Battlefield Acupuncture and Physical Therapy Versus Physical Therapy Alone After Shoulder Surgery

A scoping review of mechanisms of auricular acupuncture for treatment of pain

OBJECTIVES

Auricular acupuncture (AA) is becoming increasingly common in primary care clinics, emergency departments and peri-operatively for pain relief. Over the last decade, since the last comprehensive reviews were published, the literature has expanded. In this scoping review, we seek to document the efficacy of AA in treating both acute and chronic pain, describe the mechanism of action of AA in treating pain, and discuss how AA has been integrated into Western medicine to date.

METHODS

The authors performed a MEDLINE search inclusive of articles from 1966 to June 2023 including articles written in English identifying literature. We included human studies when more than 3 patients were included. Three hundred and fourteen unique articles were identified and 152 were selected by title screen. After abstract review, 117 were chosen for full-text review. Following full-text review, 33 articles were excluded and 21 added from references, totaling 105 articles included in our scoping review.

RESULTS

AA reduces pain severity in patients with both acute and chronic pain. The best studies in the acute settings have occurred in the peri-operative setting where sham AA is employed, multiple sessions of AA are given, and medication dosing is carefully monitored. In these cases, AA reduced pain and post-operative medications. In patients with chronic pain, multiple sessions of AA resulted not only in pain relief but also in improvements in function and disability. Literature suggests that AA works through multiple mechanisms with the most compelling data coupled to the autonomic nervous system and neuroendocrine system. Curriculums designed to teach AA and aid in implementation have been published.

CONCLUSION

AA is an accessible, effective means of pain relief. AA is relatively straightforward to learn, and protocols and curriculums exist to teach healthcare professionals this valuable skill. Overcoming implementation barriers, including patient education, are essential next steps.

Effectiveness and safety of auricular acupuncture on adjuvant analgesia in patients with total knee arthroplasty: a randomized sham-controlled trial

Objective

This study aimed to evaluate the effectiveness and safety of auricular acupuncture (AA) on postoperative analgesia, the degree of postoperative nausea, and the effect of inflammation after total knee arthroplasty (TKA).

Methods

This was a single-center, placebo-controlled, randomized clinical trial. In total, 96 patients were randomly divided into an AA group with an indwelling intradermal needle (n = 48) and a sham auricular acupuncture (SAA) group with a non-penetrating placebo needle (n = 48). Intra-spinal anesthesia was adopted in both groups during surgery, and an epidural analgesic pump was implanted after surgery for 48 h. The primary outcome was the post-surgery visual analog score (VAS) of resting and movement states (at 6, 12 h and 1, 2, 3, 5, and 7 days). The secondary outcomes included additional doses of analgesic injection during the treatment, C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), and white blood cell (WBC) count on the 1st, 3rd, and 7th day after the operation, nausea on the 1st, 2nd, and 3rd day after the operation, the Hospital for Special Surgery Knee Score (HSS) on the 2nd and 12th week after the operation, and adverse events.

Results

The VAS in the AA group at 6 h, 12 h, 2, 3, and 5 days after surgery were lower than those of the SAA group (p < 0.05). Among the secondary outcomes, the total dose of additional analgesic injection after surgery in the AA group was lower than that in the SAA group (p < 0.05). The serum CRP on the 1st day after operation in the AA group was lower than that in the SAA group (p < 0.05). The degree of nausea on 2nd day after surgery in the AA group was lower than that in the SAA group (p < 0.05). There was no significant difference in other outcomes (p > 0.05).

Conclusion

In this study, AA was shown to be an effective and safe complementary and alternative therapy for pain relief after TKA, which was able to reduce the total postoperative dose of additional painkillers, decrease serum CRP 1 day after surgery, and improve the degree of postoperative nausea.

Clinical trial registration

www.chictr.org.cn, ChiCTR2100054403.

Personalized checkpoint acupuncture can reduce postoperative pain after abdominal surgery-a STRICTA-conform pilot study

BACKGROUND

Optimal pain management is one of the core elements of Enhanced Recovery After Surgery (ERAS®) protocols and remains a challenge. Acupuncture (AC) is an effective treatment for various pain conditions. Systematic and personalized allocation of acupoints may be decisive for efficacy.

METHODS

Based on the predominant pressure sensitivity of six gastrointestinal (GI) checkpoints (G1-G6), we devised a method to detect personalized patterns of pain and a corresponding set of acupoints. We performed a single AC treatment with semi-permanent needles and assessed the visual analogue scale (VAS) score, pain threshold based on pressure algometry (PA), and temperature changes on abdominal skin areas before and 5 min after AC.

RESULTS

Between April and June 2021, thirty-eight patients were prospectively included in this pilot study. The mean reduction in subjective pain sensation as assessed by VAS was 86%, paralleled by an augmentation of the pain threshold as measured by PA by 64%. A small but significant increase in the skin temperature was observed above the abdominal surface. These effects were independent of the type of surgery.

CONCLUSION

Checkpoint acupuncture may be a complementary tool for postoperative pain management. Further investigations are needed to explore this analgesic effect.

The Opioid-Sparing Effect of Acupuncture After Abdominal Surgery: A Systematic Review and Meta-Analysis Protocol

Purpose

Routine overprescribing of postoperative opioid analgesics may induce side effects and correlate with chronic opioid use following surgery. This review aims to evaluate the effectiveness and safety of acupuncture for opioid-sparing effects in patients who underwent abdominal surgery.

Methods

Eleven databases in different languages, including English (Ovid MEDLINE, CENTRAL, EMBASE, CINAHL), Chinese, Korean, and Japanese, will be searched. Randomized controlled trials using acupuncture for postoperative pain control in adult patients undergoing abdominal surgery will be screened. All randomized controlled trials comparing acupuncture with no treatment, sham acupuncture, and conventional treatments will be included. The Cochrane risk of bias tool will be used to assess the risk of bias. The primary outcome will consist of a cumulative opioid consumption. Additionally, the number of cumulative opioid analgesic demands/requests, the time to initial opioid analgesic usage, postoperative pain, opioid-related side effects, and adverse events of acupuncture will be assessed. The mean differences or risk ratios with a 95% confidence interval will be calculated to estimate the pooled effect of acupuncture when it is possible to conduct a meta-analysis.

Results

This study could confirm the effect of opioid-sparing on acupuncture after abdominal surgery.

Conclusion

This study would evaluate the evidence on the effectiveness of acupuncture after abdominal surgery with a focus on opioid intake. It provides evidence to support decision-making on applying acupuncture for postoperative management.

Registration Number

CRD42022311155.

Treating pain using acupuncture for nonacupuncturists

ABSTRACT

Battlefield acupuncture is a specific auricular acupuncture protocol that can be performed by nonacupuncturists in military and civilian clinical settings. Battlefield acupuncture is purported to be efficacious in controlling pain, is quickly administered, and requires minimal postadministration observation. With very low risk and a negligible adverse reaction profile, this technique can be used as an alternative or complement to manage pain. More large randomized controlled trials are needed to compare acupuncture with standard therapy in military and civilian settings.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Background

Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.

Methods

This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.

Results

A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.

Conclusions

This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Relationships between physical therapy intervention and opioid use: A scoping review

OBJECTIVE

To synthesize available evidence that has examined the relationship between physical therapy (PT) and opioid use. TYPE: Scoping Review LITERATURE SURVEY: Data sources including Google Scholar, Embase, PubMed, Cochrane Library, and CINAHL were searched for English articles up to October 24, 2019 using terms ("physical therapy"[Title/Abstract] OR physiotherapy[Title/Abstract] OR rehabilitation[Title/Abstract]) AND (opiate*[Title/Abstract] OR opioid*[Title/Abstract]).

METHODOLOGY

Included studies evaluated a PT intervention and reported an opioid-use outcome. Data were extracted to describe the PT intervention, patient sample, opioid-use measurement, and results of any time or group comparisons. Study quality was evaluated with Joanna Briggs checklists based on study design.

SYNTHESIS

Thirty studies were included that evaluated PT in at least one of these seven categories: interdisciplinary program (n = 8), modalities (n = 3), treatment (n = 3), utilization (n = 2), content (n = 3), timing (n = 13), and location (n = 2). Mixed results were reported for reduced opioid-use after interdisciplinary care and after PT modalities. Utilizing PT was associated with lower odds (ranging from 0.2-0.8) of using opioid medication for persons with low back pain (LBP) and injured workers; however, guideline-adherent care did not further reduce opioid use for persons with LBP. Early PT utilization after index visit for spine or joint pain and after orthopedic surgery was also associated with lower odds of using opioid medications (ranging from 0.27-0.93). Emergency department PT care was not associated with fewer opioid prescriptions than standard emergency department care. PT in a rehabilitation center after total knee replacement was not associated with lower opioid use than inpatient PT.

CONCLUSIONS

The relationship between timing of PT and opioid use was evaluated in 13 of 30 studies for a variety of patient populations. Eight of these 13 studies reported a relationship between early PT and reduced subsequent opioid use, making the largest sample of studies in this scoping review with supporting evidence. There is limited and inconclusive evidence to establish whether the content and/or location of PT interventions improves outcomes because of heterogeneity between studies.

Battlefield acupuncture added no benefit as an adjunct analgesic in emergency department for abdominal, low back or limb trauma pain

OBJECTIVES

To ascertain whether ear acupuncture (modified Battlefield technique) as an adjunct (Adj-BFA) to standard analgesia care (SAC) significantly reduces pain scores compared with sham acupuncture (Adj-Sham) or SAC alone, when delivered by medical and nursing practitioners in an ED.

METHODS

A randomised controlled trial using a convenience sample of 90 patients attending an ED with acute abdominal, limb trauma or low back pain were allocated to three treatment arms: Adj-BFA, Adj-Sham and SAC. The primary outcome of change in pain scores out-of-10 (NPRS-10) from triage were assessed immediately after intervention and at 1 and 2 h post-intervention. Secondary outcomes were the percentage of patients reporting 'adequate analgesia' or ≥30% reduction in pain score, analgesic medication use (in morphine equivalent dose [milligrammes]), analgesics and needle costs (Australian dollars), adverse effects and patient satisfaction (Likert scale).

RESULTS

There was no significant difference in pain scores (P = 0.582) or secondary outcomes measures between Adj-BFA, Adj-Sham and SAC.

CONCLUSION

The present study on 90 patients did not show a significant difference in analgesia outcomes in the first 2 h using Adj-BFA for acute pain in the ED, and there were no significant differences for secondary outcomes between treatment arms. Given the mixed results of recent BFA trials, further research using the original BFA technique on different painful conditions, as either stand-alone or as-adjunct to non-opioid analgesia are needed before BFA can be recommended as a technique for acute pain management in the ED.

Battlefield Acupuncture as a Treatment for Pain

This study evaluated both randomized and nonrandomized trials of battlefield acupuncture for the treatment of both acute and chronic pain. Studies published between May 2016 and November 2019 were found through PubMed, the Cochrane Library, or Scopus, concerned with the treatment of pain using auricular acupuncture in accordance with battlefield acupuncture protocol. Search terms were battlefield acupuncture AND pain or auricular acupuncture AND pain. Case reports, literature reviews, meta-analyses, and expert opinions were not included. Bias risk was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We found 12 studies with a combined sample size of 12,326. All five of the included nonrandomized trials reported positive outcomes, while five of seven of the included randomized trials reached statistical significance in their primary outcome. Six of the randomized trials were considered to have a high risk of bias resulting from the lack of blinding. The one randomized trial with moderate bias risk was a positive study. No severe adverse events were reported. Clinicians may consider battlefield acupuncture as a safe treatment for pain while the evidence base grows; however, we conclude that widespread adoption of battlefield acupuncture will require further high-quality studies drawing from diverse settings and patient populations. In addition, future studies should attempt to achieve blinding.

Battlefield Acupuncture for Adult Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Pain is a major public health problem, causing heavy social and economic burdens to patients and society while consuming tremendous medical resources at the same time. Thus, there is a critical need to find low-cost, efficacious, and therapeutic approaches to help manage pain. While acupuncture is increasingly recognized as a promising pain-relieving method, less is known about a specific form of auricular acupuncture known as Battlefield Acupuncture (BFA). The BFA technique involves the sequential placement of semi-permanent, single-use, French ASP[Formula: see text] golden needles to five specific acupoints in one or both ears, where they are left in place for 3-4 days or longer [Niemtzow, R.C., Battlefield acupuncture. Med. Acupunct. 19: 225-228, 2007]. The BFA needles (more accurately described as tiny conical darts) pierce the ear in designated locations in a particular order [Levy, C.E., N. Casler and D.B. FitzGerald. Battlefield acupuncture: an emerging method for easing pain. Am. J. Phys. Med. Rehabil. 97: e18-e19, 2018.]. (Figs. 4 and 5) It was developed by Dr. Richard C. Niemtzow in 2001, as a subgroup form of an auricular acupuncture technique based on the somatotopic arrangement of an inverted fetus pattern on the external ear [Romoli, M. Ear acupuncture: historical abstract-differences of ear cartography between the east and the west. Dtsch. Z. Akupunkt. 53: 24-33, 2010.]. Currently, BFA is widely used in the US military, but to our knowledge, there is no review which comprehensively synthesizes the current publications surrounding pain management. This review aims to investigate the effects and safety of BFA in adults with pain. Electronic databases were searched for randomized controlled trials (RCTs) published in English evaluating efficacy and safety of BFA in adults with pain, from database inception to September 6, 2019. The primary outcome was pain intensity change, and the secondary outcome was safety. Nine RCTs were included in this review, and five trials involving 344 participants were analyzed quantitatively. Compared with no intervention, usual care, sham BFA, and delayed BFA interventions, BFA had no significant improvement in the pain intensity felt by adults suffering from pain. Few adverse effects (AEs) were reported with BFA therapy, but they were mild and transitory. BFA is a safe, rapid, and easily learned acupuncture technique, mainly used in acute pain management, but no significant efficacy was found in adult individuals with pain, compared with the control groups. Given the poor methodological quality of the included studies, high-quality RCTs with rigorous evaluation methods are needed in the future.

The effectiveness of battlefield acupuncture in addition to standard physical therapy treatment after shoulder surgery: a protocol for a randomized clinical trial

INTRODUCTION

There is a large incidence of shoulder instability among active young athletes and military personnel. Shoulder stabilization surgery is the commonly employed intervention for treating individuals with instability. Following surgery, a substantial proportion of individuals experience acute post-operative pain, which is usually managed with opioid pain medications. Unfortunately, the extended use of opioid medications can have adverse effects that impair function and reduce military operational readiness, but there are currently few alternatives. However, battlefield acupuncture (BFA) is a minimally invasive therapy demonstrating promise as a non-pharmaceutical intervention for managing acute post-operative pain.

METHODS

This is a parallel, two-arm, single-blind randomized clinical trial. The two independent variables are intervention (2 levels, standard physical therapy and standard physical therapy plus battlefield acupuncture) and time (5 levels, 24 h, 48 h, 72 h, 1 week, and 4 weeks post shoulder stabilization surgery). The primary dependent variables are worst and average pain as measured on the visual analog scale. Secondary outcomes include medication usage, Profile of Mood States, and Global Rating of Change.

DISCUSSION

The magnitude of the effect of BFA is uncertain; current studies report confidence intervals of between-group differences that include minimal clinically important differences between intervention and control groups. The results of this study may help determine if BFA is an effective adjunct to physical therapy in reducing pain and opioid usage in acute pain conditions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04094246 . Registered on 16 September 2019.

Lessons Learned in Teaching Battlefield (Ear) Acupuncture to Emergency Medicine Clinicians

Background: Acupuncture, in general, is being proclaimed as an alternative analgesic amid the opioid crisis, and along with this, within emergency departments (EDs) there is a specific interest in a form of ear acupuncture called Battlefield Acupuncture (BFA). It is expected that BFA will be used more widely in emergency medicine as it is easy to learn and can be applied both promptly and easily. Teaching programs will be required to sustain this increased demand and upskill emergency clinicians in this skill. Objectives: This article provides experiences and recommendations, based on faculty experiences from teaching BFA in Australia to ED clinicians combined with formal participant feedback. Main Points: BFA courses were adjusted to suit ED doctors and nurses, along with their unique case mix and associated challenging environment. The content of the BFA courses included evidence, pain indications, contraindications, application, safety, mechanism of action, and how to negotiate barriers of credentialing. Workshops used the latest and most effective teaching methods that encompassed problem-based learning, infotainment, simulation, "four stage skills teaching," and "teaching on the run." Conclusion: It is hoped that the experiences gained, and lessons learned in educating this new frontier of BFA to emergency clinicians will assist others in teaching BFA and its related techniques as a viable analgesic alternative in emergency medicine.