Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans

An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management

STUDY OBJECTIVE

Acute musculoskeletal pain in emergency department (ED) patients is frequently severe and challenging to treat with medications alone. The purpose of this study was to determine the feasibility, acceptability, and effectiveness of adding ED acupuncture to treat acute episodes of musculoskeletal pain in the neck, back, and extremities.

METHODS

In this pragmatic 2-stage adaptive open-label randomized clinical trial, Stage 1 identified whether auricular acupuncture (AA; based on the battlefield acupuncture protocol) or peripheral acupuncture (PA; needles in head, neck, and extremities only), when added to usual care was more feasible, acceptable, and efficacious in the ED. Stage 2 assessed effectiveness of the selected acupuncture intervention(s) on pain reduction compared to usual care only (UC). Licensed acupuncturists delivered AA and PA. They saw and evaluated but did not deliver acupuncture to the UC group as an attention control. All participants received UC from blinded ED providers. Primary outcome was 1-hour change in 11-point pain numeric rating scale.

RESULTS

Stage 1 interim analysis found both acupuncture styles similar, so Stage 2 continued all 3 treatment arms. Among 236 participants randomized, demographics and baseline pain were comparable across groups. When compared to UC alone, reduction in pain was 1.6 (95% confidence interval [CI]: 0.7 to 2.6) points greater for AA+UC and 1.2 (95% CI: 0.3 to 2.1) points greater for PA+UC patients. Participants in both treatment arms reported high satisfaction with acupuncture.

CONCLUSION

ED acupuncture is feasible and acceptable and can reduce acute musculoskeletal pain better than UC alone.

Multi-level exploration of auricular acupuncture: from traditional Chinese medicine theory to modern medical application

As medical research advances and technology rapidly develops, auricular acupuncture has emerged as a point of growing interest. This paper delves into the intricate anatomy of auricular points, their significance and therapeutic principles in traditional Chinese medicine (TCM), and the underlying mechanisms of auricular acupuncture in contemporary medicine. The aim is to delve deeply into this ancient and mysterious medical tradition, unveiling its multi-layered mysteries in the field of neurostimulation. The anatomical structure of auricular points is complex and delicate, and their unique neurovascular network grants them a special status in neurostimulation therapy. Through exploration of these anatomical features, we not only comprehend the position of auricular points in TCM theory but also provide a profound foundation for their modern medical applications. Through systematic review, we synthesize insights from traditional Chinese medical theory for modern medical research. Building upon anatomical and classical theoretical foundations, we focus on the mechanisms of auricular acupuncture as a unique neurostimulation therapy. This field encompasses neuroregulation, pain management, psychological wellbeing, metabolic disorders, and immune modulation. The latest clinical research not only confirms the efficacy of auricular stimulation in alleviating pain symptoms and modulating metabolic diseases at the endocrine level but also underscores its potential role in regulating patients' psychological wellbeing. This article aims to promote a comprehensive understanding of auricular acupuncture by demonstrating its diverse applications and providing substantial evidence to support its broader adoption in clinical practice.

Immediate efficacy of auricular acupuncture combined with active exercise in the treatment of acute lumbar sprains in 10 minutes: Protocol of a randomized controlled trial

BACKGROUND

Acute lumbar sprain (ALS) is common musculoskeletal disorder characterized by severe low back pain and activity limitation, which significantly impacts the patient's work and life. Immediate relief of pain and restoration of mobility in a short period of time are the main needs of patients when they visit the clinic. This study aims to evaluate the immediate efficacy of this combined treatment for ALS within 10 minutes.

METHODS

This is a single-center, prospective, randomized clinical trial. 128 eligible patients with ALS will be randomly allocated in a 1:1 ratio to either the auricular acupuncture (AA) group or the sham auricular acupuncture (SAA) group. All patients will receive a single 10-minute treatment. The primary outcome will be the change in pain intensity after 10 minutes of treatment. The secondary outcomes include changes in pain intensity at other time points (2, 5 minutes), changes in lumbar range of motion (ROM) at different time points, blinded assessment, treatment effect expectancy scale evaluation, and treatment satisfaction scale evaluation. All participants will be included in the analysis according to the intention-to-treat principle.

DISCUSSION

This is the first randomized controlled trial to assess the immediate efficacy of AA combined with active exercise for ALS. The findings of this study are expected to provide a simple and rapid treatment for ALS in clinical.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2400083740. Registered 30 April 2024.

Bibliometric analysis of auriculotherapy research trends over the past 20 years

OBJECTIVES

Auriculotherapy has long been used to treat various diseases. We analyzed and visualized auriculotherapy's geographical distribution, key contributors, and thematic trends over the past 20 years to provide current trends in auriculotherapy field and to offer recommendations for future research directions.

DESIGN/SETTING

We searched for relevant studies in the Web of Science between January 10, 2003, and December 31, 2022. A bibliometric analysis was performed using VOSviewer for annual publications, journals, countries, institutions, authors, and keywords.

RESULTS

A total of 800 studies were included in the analysis, and the number of studies steadily increased over the 20 examined years. In 2018, there was a noteworthy rise in publications, nearly twice as many as the preceding year. Integrative & complementary medicine was the most researched area, with most articles published in Evidence-Based Complementary and Alternative Medicine. China was the country with the most published research, and the most active organization was Guangzhou University of Chinese Medicine in China, followed by Kyung Hee University in South Korea. The most prolific author was Yeh Mei-ling, who reported the effects of auriculotherapy on dysmenorrhea and smoking cessation. Keyword analysis revealed four clusters: pain, mental health, obesity, and smoking cessation.

CONCLUSION

Auriculotherapy research primarily focused on clinical studies related to pain, obesity, smoking cessation, and depression. Future research should place greater emphasis on verifying the mechanisms of auriculotherapy for specific ailments and may require efforts to enhance the robustness of clinical trials. Through visual analysis, our study may serve as a foundational resource, offering valuable insights into the trajectory of auriculotherapy research.

Battlefield Acupuncture for the Treatment of Chronic Migraines

A 70-year-old man presented with worsening migraines and was referred to a neurologist by their primary care doctor for further workup. Imaging and lab work were benign. The patient then underwent several trials of various first and second-line medications and anti-migraine devices to no avail. It was not until one session of battlefield acupuncture, where five needles were placed in the patient's ear for a few days, that the patient had a resolution of his symptoms.

Changes in Pain Among Housed and Unhoused U.S. Veterans After Receiving Battlefield Acupuncture at One Medical Center

This study reports on 54 homeless and 53 stably housed veterans who received battlefield acupuncture (BFA) between September 2018 and October 2022. Linear mixed-effects regressions were used to examine change in overall pain score and how pain impacted four areas: (1) activity, (2) sleep, (3) mood, and (4) stress over the course of 8 weeks from the baseline visit at one BFA clinic. Results indicated significant reductions in the impact of pain on activity, sleep, and stress among both homeless and housed veterans. Although overall pain levels were not significantly impacted, further research on the impact of BFA on homeless populations is warranted.

Battlefield acupuncture for chronic musculoskeletal pain in cancer survivors: a novel care delivery model for oncology acupuncture

Introduction

Battlefield Acupuncture (BFA), a standardized auricular acupuncture protocol, is widely used for pain in the military but is not well-studied in oncology. This study examined cancer survivors who received BFA for pain.

Methods

This is a secondary analysis of a randomized trial that compared the effectiveness of BFA and electroacupuncture vs. usual care for chronic musculoskeletal pain in cancer survivors. This study focused on participants randomized to BFA. Participants received 10 weekly treatments. Needles were placed until one of these stop conditions were satisfied: ten needles were administered; pain severity decreased to ≤1 out of 10; patient declined further needling, or vasovagal reaction was observed. Pain severity was assessed using Brief Pain Inventory. Responders were those with ≥30% pain severity reduction. We examined pain location, BFA stop reason, and pain reduction of participants during the first session. We also examined which factors predicted responder status after the first session (week 1) or the full treatment (week 12).

Results

Among 143 randomized to BFA, most common pain locations were lower back (30.8%) and knee/leg (18.2%). Of 138 who initiated treatment, 41 (30.0%) received ten needles; 81 (59.1%) achieved pain ≤1; 14 (10.2%) declined further needling; and 1 (0.7%) had vasovagal reaction. BFA reduced pain severity by 2.9 points (95% CI 2.6 to 3.2) after the first session (P < 0.001). After adjusting for baseline pain severity, responders at week 1 were 2.5 times more likely to be responders at week 12, compared to those who were non-responders at week 1 (AOR 2.5, 95% CI 1.02 to 6.11, P = 0.04). Among those who achieved pain ≤1, 74% were responders at week 12, a higher proportion compared to the proportion of responders among those who received ten needles (39.5%), those who declined further needling (50%), and those with vasovagal reaction (0.0%) (P = 0.001). Those with pain in proximal joints had a higher proportion of responders at week 12, compared to those with pain in distal joints (64.2% vs. 20%, P = 0.008).

Conclusion

Specific factors may predict the likelihood of achieving meaningful pain reduction from BFA. Understanding these predictors could inform precision pain management and acupuncture delivery models.

Battlefield Acupuncture as a Treatment Option for Chronic Tinnitus: A Pilot Study

INTRODUCTION

There is no cure for tinnitus, which is a highly prevalent condition in service members and veterans. Battlefield acupuncture (BFA) can be used to manage pain and stress-related symptoms. We investigated BFA as a safe, low-cost treatment for tinnitus perception and coping in eight chronic tinnitus patients who were followed for 6 months after two BFA treatments to identify changes in tinnitus severity or impact.

MATERIALS AND METHODS

Patients completed case history, Tinnitus Screener, Tinnitus Functional Index (TFI), Tinnitus Reaction Questionnaire (TRQ), and Hospital Anxiety and Depression Scale (HADS) questionnaires at baseline, at two BFA treatment sessions (2 weeks apart), and at four follow-up sessions (at 1, 2, 4 and 6 months after treatment). Questionnaire score changes were evaluated over time by using restricted maximum likelihood hierarchical regression modeling from baseline to 1-, 2-, 4-, and 6-month post-treatment follow-ups.

RESULTS

TFI and TRQ group means were both significantly reduced at 1 month after treatment, and these reductions persisted through the 2- and 4-month follow-ups. The TRQ group mean remained significantly reduced after 6 months.

CONCLUSIONS

Findings from eight chronic tinnitus sufferers who received two BFA treatment sessions are reported here, suggesting at least short-term treatment benefits observed as reductions in tinnitus-related psychological distress and impact. Although these findings are constrained by the study's small sample size and limited treatment period, its findings underscore the need for further research to determine the potential benefits of BFA for individuals who suffer from chronic tinnitus. Future research should consider the possibility of more lasting benefits through extended BFA treatment, with a comparison of BFA treatment against other treatment methods.

Electroacupuncture for abdominal pain relief in patients with acute pancreatitis: A three-arm randomized controlled trial

BACKGROUND

Electroacupuncture (EA) may reduce the severity of acute pancreatitis (AP) and provide additional pain relief in patients with chronic pancreatitis. However, the ability of EA to relieve pain in patients with AP has not been well documented.

OBJECTIVE

This study was undertaken to compare the pain-relieving effects of EA and conventional treatment in patients with AP.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

This study was conducted using a randomized, controlled, three-arm, parallel-group and multi-center design. Patients diagnosed with AP were randomly and equally assigned to EA1, EA2 or control groups. All participants received conventional standard-of-care therapy for AP. Local EA alone was administered in EA1, and local plus distal EA was given in EA2. Local EA included two abdominal acupoints, while distal EA included twelve peripheral acupoints. EA groups underwent one session of EA daily for 4 days (days 1-4), or until pain was resolved or discharged.

MAIN OUTCOME MEASURES

The primary outcome measure was the change in the visual analogue scale (VAS; 0-100) pain score between baseline and day 5.

RESULTS

Eighty-nine participants were randomized into EA1, EA2 and control groups, and 88 (EA1, 30; EA2, 29; control, 29) were included in the full-analysis set. VAS score change (median [interquartile range]) on day 5 was (12.3 ± 22.5) in the EA1 group, (10.3 ± 21.5) in the EA2 group, and (8.9 ± 15.2) in the control group. There were not significant differences in the change in VAS score among treatments (P = 0.983). However, time to food intake was significantly shorter in the EA group (EA1 + EA2) than in the control group (median 2.0 days vs 3.0 days), with a hazard ratio of 0.581 (P = 0.022; 95% CI, 0.366-0.924). No significant adverse events occurred.

CONCLUSION

EA treatment did not significantly reduce pain after 4 days of treatment in patients with AP-associated abdominal pain but significantly reduced time to first food intake.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03173222. Please cite this article as: Jang DK, Lee JK, Jung CY, Kim KH, Kang HR, Lee YS, Yoon JH, Joo KR, Chae MK, Baek YH, Seo BK, Lee SH, Lim C. Electroacupuncture for abdominal pain relief in patients with acute pancreatitis: A three-arm randomized controlled trial. J Integr Med. 2023; 21(6): 537-542.

Gulf War Illness: A Randomized Controlled Trial Combining Mindfulness Meditation and Auricular Acupuncture

Background

Many Gulf War (GW) Veterans report chronic symptoms including pain, fatigue, and cognitive impairment, commonly defined as Gulf War Illness (GWI). Complementary and integrative health (CIH) therapies may potentially improve multiple symptoms of GWI.

Objective

To examine the effectiveness of combining 2 commonly available CIH therapies, mindfulness meditation and auricular acupuncture, in improving health-related functioning and multiple symptom domains of GWI (e.g., pain, fatigue).

Methods

This study was a randomized controlled trial in which Veterans with GWI were randomly assigned to either the intervention group (n = 75), wherein they received 2 distinct CIH therapies - mindfulness meditation and auricular acupuncture, or the active control group, wherein they received a GW Health Education (GWHE) program (n = 74), each lasting 8 weeks. Self-report health measures were assessed at baseline, endpoint, and 3 month follow-up.

Results

In the intention-to-treat analyses, there were significant between-group differences for mental-health related functioning, fatigue, depression symptoms, and Kansas total severity scores for symptoms in which the CIH group had improved scores for these outcomes at endpoint compared to the GWHE group (all P ≤ .05). The CIH group also had significant reductions in pain interference at endpoint and follow-up compared to baseline (estimated marginal mean difference: -2.52 and -2.22, respectively; all P = .01), whereas no significant changes were observed in the GWHE group. For pain characteristics, the GWHE group had a worsening of pain at endpoint compared to baseline (estimated marginal mean difference: +2.83; P = .01), while no change was observed in the CIH group.

Conclusion

Findings suggest a possible beneficial effect of combining 2 CIH therapies, mindfulness meditation and auricular acupuncture, in reducing overall symptom severity and individual symptom domains of fatigue, musculoskeletal, and mood/cognition in Veterans with GWI.

Trial Registration

Clinical Trials identifier NCT02180243.

Association Between Exposure to Complementary and Integrative Therapies and Opioid Analgesic Daily Dose Among Patients on Long-term Opioid Therapy

OBJECTIVES

To describe the association between exposure to selected complementary and integrative health (CIH) modalities and the trajectory of prescribed opioid analgesic dose within a national cohort of patients receiving long-term opioid therapy (LTOT) in the Veterans Health Administration (VHA).

MATERIALS AND METHODS

Using national data from VHA electronic health records between October 1, 2017 and September 30, 2019, CIH use was analyzed among 57,437 patients receiving LTOT within 18 VHA facilities serving as evaluation sites of VHA's Whole Health System of Care. Using linear mixed effects modeling controlling for covariates, opioid dose was modeled as a function of time, CIH exposure, and their interaction.

RESULTS

Overall, 11.91% of patients on LTOT used any of the focus CIH therapies; 43.25% of those had 4 or more encounters. Patients used acupuncture, chiropractic care, and meditation modalities primarily. CIH use was associated with being female, Black, having a mental health diagnosis, obesity, pain intensity, and baseline morphine-equivalent daily dose. Mean baseline morphine-equivalent daily dose was 40.81 milligrams and dose decreased on average over time. Controlling for covariates, patients with any CIH exposure experienced 38% faster dose tapering, corresponding to a mean difference in 12-month reduction over patients not engaging in CIH of 2.88 milligrams or 7.06% of the mean starting dose.

DISCUSSION

Results support the role of CIH modalities in opioid tapering. The study design precludes inference about the causal effects of CIH on tapering. Analyses did not consider the trend in opioid dose before cohort entry nor the use of other nonopioid treatments for pain. Future research should address these questions and consider tapering-associated adverse events.

From patient outcomes to system change: Evaluating the impact of VHA's implementation of the Whole Health System of Care

OBJECTIVE

To describe how a partnered evaluation of the Whole Health (WH) system of care-comprised of the WH pathway, clinical care, and well-being programs-produced patient outcomes findings, which informed Veterans Health Administration (VA) policy and system change.

DATA SOURCES

Electronic health records (EHR)-based cohort of 1,368,413 patients and a longitudinal survey of Veterans receiving care at 18 WH pilot medical centers.

STUDY DESIGN

In partnership with VA operations, we focused the evaluation on the impact of WH services utilization on Veterans' (1) use of opioids and (2) care experiences, care engagement, and well-being. Outcomes were compared between Veterans who did and did not use WH services identified from the EHR.

DATA COLLECTION

Pharmacy records and WH service data were obtained from the VA EHR, including WH coaching, peer-led groups, personal health planning, and complementary, integrative health therapies. We surveyed veterans at baseline and 6 months to measure patient-reported outcomes.

PRINCIPAL FINDINGS

Opioid use decreased 23% (31.5-6.5) to 38% (60.3-14.4) among WH users depending on level of WH use compared to a secular 11% (12.0-9.9) decrease among Veterans using Conventional Care. Compared to Conventional Care users, WH users reported greater improvements in perceptions of care (SMD = 0.138), engagement in health care (SMD = 0.118) and self-care (SMD = 0.1), life meaning and purpose (SMD = 0.152), pain (SMD = 0.025), and perceived stress (SMD = 0.191).

CONCLUSIONS

Evidence developed through this partnership yielded key VA policy changes to increase Veteran access to WH services. Findings formed the foundation of a congressionally mandated report in response to the Comprehensive Addiction and Recovery Act, highlighting the value of WH and complementary, integrative health and well-being programs for Veterans with pain. Findings subsequently informed issuance of an Executive Decision Memo mandating the integration of WH into mental health and primary care across VA, now one lane of modernization for VA.

Development and Assessment of an Abbreviated Acupuncture Curriculum for Pediatricians

OBJECTIVE

Acupuncture has been shown to improve pain and other health outcomes in children and is well tolerated. However, use of acupuncture by pediatric medical providers is rare, in part due to the cost and time associated with formal training. We aimed to develop an abbreviated acupuncture curriculum and assess its impact and acceptability with academic pediatricians.

METHODS

In this pilot study, pediatricians received instruction in 2 acupuncture protocols for treating acute and chronic pain (Battlefield Acupuncture and Four Gates) during a 10-hour course developed by board-certified medical acupuncturists. Learning methods included an online module with videos and articles, 2 live workshops, and additional home practice. Participants completed a skills-based exam and pre- and post-tests measuring knowledge and attitudes about acupuncture treatment.

RESULTS

Forty-five physicians (divided among 3 cohorts) began the acupuncture training course, and 38 (84.4%) completed all components. The course significantly increased participants' perceived efficacy of acupuncture for acute and chronic pain. Participants showed significant improvement in acupuncture knowledge. All participants agreed that the course would influence their current medical practice, and all participants felt confident utilizing basic acupuncture. Additionally, all participants indicated that they would recommend the abbreviated acupuncture curriculum to a colleague.

CONCLUSIONS

Pediatricians became proficient in 2 acupuncture protocols with a 10-hour curriculum and found the format and content highly acceptable. Future plans include studying acupuncture implementation and expanding the course to other departments and institutions.

Justice and equity in pragmatic clinical trials: Considerations for pain research within integrated health systems

Introduction

Methods

Results

Conclusions

Effectiveness of Electroacupuncture or Auricular Acupuncture vs Usual Care for Chronic Musculoskeletal Pain Among Cancer Survivors: The PEACE Randomized Clinical Trial

Importance

The opioid crisis creates challenges for cancer pain management. Acupuncture confers clinical benefits for chronic nonmalignant pain, but its effectiveness in cancer survivors remains uncertain.

Objective

To determine the effectiveness of electroacupuncture or auricular acupuncture for chronic musculoskeletal pain in cancer survivors.

Design, Setting, and Participants

The Personalized Electroacupuncture vs Auricular Acupuncture Comparative Effectiveness (PEACE) trial is a randomized clinical trial that was conducted from March 2017 to October 2019 (follow-up completed April 2020) across an urban academic cancer center and 5 suburban sites in New York and New Jersey. Study statisticians were blinded to treatment assignments. The 360 adults included in the study had a prior cancer diagnosis but no current evidence of disease, reported musculoskeletal pain for at least 3 months, and self-reported pain intensity on the Brief Pain Inventory (BPI) ranging from 0 (no pain) to 10 (worst pain imaginable).

Interventions

Patients were randomized 2:2:1 to electroacupuncture (n = 145), auricular acupuncture (n = 143), or usual care (n = 72). Intervention groups received 10 weekly sessions of electroacupuncture or auricular acupuncture. Ten acupuncture sessions were offered to the usual care group from weeks 12 through 24.

Main Outcomes and Measures

The primary outcome was change in average pain severity score on the BPI from baseline to week 12. Using a gatekeeping multiple-comparison procedure, electroacupuncture and auricular acupuncture were compared with usual care using a linear mixed model. Noninferiority of auricular acupuncture to electroacupuncture was tested if both interventions were superior to usual care.

Results

Among 360 cancer survivors (mean [SD] age, 62.1 [12.7] years; mean [SD] baseline BPI score, 5.2 [1.7] points; 251 [69.7%] women; and 88 [24.4%] non-White), 340 (94.4%) completed the primary end point. Compared with usual care, electroacupuncture reduced pain severity by 1.9 points (97.5% CI, 1.4-2.4 points; P < .001) and auricular acupuncture reduced by 1.6 points (97.5% CI, 1.0-2.1 points; P < .001) from baseline to week 12. Noninferiority of auricular acupuncture to electroacupuncture was not demonstrated. Adverse events were mild; 15 of 143 (10.5%) patients receiving auricular acupuncture and 1 of 145 (0.7%) patients receiving electroacupuncture discontinued treatments due to adverse events (P < .001).

Conclusions and Relevance

In this randomized clinical trial among cancer survivors with chronic musculoskeletal pain, electroacupuncture and auricular acupuncture produced greater pain reduction than usual care. However, auricular acupuncture did not demonstrate noninferiority to electroacupuncture, and patients receiving it had more adverse events.

Trial Registration

ClinicalTrials.gov Identifier: NCT02979574.

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.