Review Article

Battlefield Acupuncture as a Treatment for Pain

Authors: Frank J. Salamone, BA, Daniel G. Federman, MD


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.

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1. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001–1006.   2. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain Off J Am Pain Soc 2012;13:715–724.   3. King NB, Fraser V, Boikos C, et al. Determinants of increased opioid-related mortality in the United States and Canada, 1990–2013: a systematic review. Am J Public Health 2014;104:e32–e42.   4. National Institute on Drug Abuse. Overdose death rates. Published 2020. Accessed July 7, 2020.   5. Centers for Disease Control and Prevention, National Center for Health Statistics. CDC WONDER. Accessed July 5, 2020.   6. Maeng DD, Baylor K, Bulger JB, et al. Impact of a multidisciplinary pain management program on patient care utilization and cost of care. J Pain Res 2018;11:2375–2383.   7. Niemtzow RC. Battlefield acupuncture. Med Acupunct 2007;19:225–228.   8. Xu S, Wang L, Cooper E, et al. Adverse events of acupuncture: a systematic review of case reports. Evid Based Complement Alternat Med 2013;2013:581203.   9. He W, Wang X, Shi H, et al. Auricular acupuncture and vagal regulation. Evid Based Complement Altern Med 2012;2012:786839.   10. Usichenko T, Hacker H, Lotze M. Transcutaneous auricular vagal nerve stimulation (taVNS) might be a mechanism behind the analgesic effects of auricular acupuncture. Brain Stimulat 2017;10:1042–1044.   11. Jin BX, Jin LL, Jin G-Y. The anti-inflammatory effect of acupuncture and its significance in analgesia. World J Acupunct Moxibustion 2019;29:1–6.   12. Lin W-C, Yeh CH, Chien L-C, et al. The anti-inflammatory actions of auricular point acupressure for chronic low back pain. Evid Based Complement Altern Med 2015;2015:103570.   13. Bonaz B, Sinniger V, Pellissier S. Anti-inflammatory properties of the vagus nerve: potential therapeutic implications of vagus nerve stimulation. J Physiol 2016;594:5781–5790.   14. Kong J, Fang J, Park J, et al. Treating depression with transcutaneous auricular vagus Nerve stimulation: state of the art and future perspectives. Front Psychiatry 2018;9:20.   15. Tu Y, Fang J, Cao J, et al. A distinct biomarker of continuous transcutaneous vagus nerve stimulation treatment in major depressive disorder. BrainStimulat 2018;11:501–508.   16. Wang Z, Fang J, Liu J, et al. Frequency-dependent functional connectivity of the nucleus accumbens during continuous transcutaneous vagus nerve stimulation in major depressive disorder. J Psychiatr Res 2018;102:123–131.   17. Janner H, Klausenitz C, Gürtler N, et al. Effects of electrical transcutaneous vagus nerve stimulation on the perceived intensity of repetitive painful heat stimuli: a blinded placebo- and sham-controlled randomized crossover investigation. Anesth Analg 2018;126:2085–2092.   18. Federman DG, Gunderson CG. Battlefield acupuncture: is it ready for widespread dissemination? South Med J 2017;110:55–57.   19. Jan AL, Aldridge ES, Rogers IR, et al. Does ear acupuncture have a role for pain relief in the emergency setting? A systematic review and meta-analysis. Med Acupunct 2017;29:276–289.   20. Higgins J, Thomas J, Chandler J, et al, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.0. Updated July 2019. Accessed July 7, 2020.   21. Shao X, Corcoran M, O’Bryan M. The use of battlefield acupuncture prior to botulinum toxin A administration: a 2-patient case series. Med Acupunct 2018;30:282–284.   22. Tsai S-L, Fox LM, Murakami M, et al. Auricular acupuncture in emergency department treatment of acute pain. Ann Emerg Med 2016;68:583–585.   23. Federman DG, Zeliadt SB, Thomas ER, et al. Battlefield acupuncture in the Veterans Health Administration: effectiveness in individual and group settings for pain and pain comorbidities. Med Acupunct 2018;30:273–278.   24. Federman DG, Radhakrishnan K, Gabriel L, et al. Group battlefield acupuncture in primary care for veterans with pain. South Med J 2018;111:619–624.   25. Zeliadt SB, Thomas ER, Olson J, et al. Patient feedback on the effectiveness of auricular acupuncture on pain in routine clinical care: the experience of 11,406 veterans. Med Care 2020;58:S101–S107.   26. Collinsworth KM, Goss DL. Battlefield acupuncture and physical therapy versus physical therapy alone after shoulder surgery. Med Acupunct 2019;31:228–238.   27. Estores I, Chen K, Jackson B, et al. Auricular acupuncture for spinal cord injury related neuropathic pain: a pilot controlled clinical trial. J Spinal Cord Med 2017;40:432–438.   28. Fox LM, Murakami M, Danesh H, et al. Battlefield acupuncture to treat low back pain in the emergency department. Am J Emerg Med 2018;36:1045–1048.   29. Garner BK, Hopkinson SG, Ketz AK, et al. Auricular acupuncture for chronic pain and insomnia: a randomized clinical trial. Med Acupunct 2018;30:262–272.   30. Kim M, Moss D, Crawford P. Battlefield acupuncture for post-partum pain: a randomized controlled trial. EXPLORE 2019;15:409–414.   31. Plunkett A, McCoart A, Howard RS, et al. A randomized, single-blind, prospective trial of auricular “battlefield” acupuncture for the reduction of postoperative tonsillectomy pain in adults. Pain Manag 2018;8:287–295.   32. Shah AN, Moore CB, Brigger MT. Auricular acupuncture for adult tonsillectomy. Laryngoscope 2020;130:1907–1912.   33. Linde K, Niemann K, Meissner K. Are sham acupuncture interventions more effective than (other) placebos? A re-analysis of data from the Cochrane review on placebo effects. Forsch Komplementarmedizin 2010;17:259–264.   34. Federman DG. Disastrous complication caused indirectly by the success of battlefield acupuncture. Med Acupunct 2020;32:163–165.