Our standard protocol involved initially determining baseline pain level using a 0-to-10 numerical rating scale (NRS). The first needle was placed at the cingulate gyrus zone, athletes ambulated for 1 min, and then we reassessed pain level. If pain was not eliminated, this procedure was repeated using the successive needle insertion zones. As seen in Figure 2, the next ASP was placed at the thalamus point. If further treatments were requested, the succession of ASP placement proceeded to the omega 2 point for the third needle, point zero for the fourth, and Shen Men for the fifth until pain was resolved or the athletes requested cessation of treatment. If all five treatment zones were used on the first ear, needles were inserted in the contralateral ear in the same succession. Athletes were sent immediately back to training or competition. Each athlete left the ASP needles in place as designed until after the competition.
A 21-year-old male swimming athlete ruptured his anterior cruciate ligament (ACL) graft only 5 d before the Warrior Games, just after being cleared for light running for the first time since his ACL reconstruction in late 2009. He presented with a tense effusion and a knee pain score of 7/10. He did not have sufficient knee flexion (80 degrees) necessary to adequately push off the wall during turns, and he requested removal of fluid. An ultrasound-guided knee aspiration was done, revealing a large effusion with large areas of clot. Ninety milliliters of blood was aspirated; his range of motion increased to 120 degrees, and his pain decreased to a knee pain score of 4/10. One day later, he presented requesting further treatment. After three ASP needles, his pain completely resolved. He trained and competed for 3 d and won gold medals in all three of his events. As designed, the needles remained in place for the duration of competition for prolonged analgesia.
A 35-year-old male sitting volleyball athlete with chronic knee pain and effusion from a patellar cartilage injury presented with exacerbation of his pain from practice. Examination showed a tense effusion without inflammation, and he elected to undergo ultrasound-guided arthrocentesis, which produced 70 mL of clear yellow fluid. His pain remained at a knee pain score of 7/10, however, so he underwent AA. After three ASP needles, his pain completely resolved. He returned to competition for three more days and was able to win a silver medal.
A 23-year-old female swimming athlete with chronic thigh pain after surgery for a ruptured quadriceps muscle presented with acute pain due to a hamstring strain. Treatment with ice, compression, and massage were not effective; her pain was a knee pain score of 7/10. She was crying from disappointment about not being able to swim in qualifiers in a few minutes. After choosing AA, she received two ASP needles resulting in reduction of her pain to a knee pain score of 2/10, with just enough time to get on the starting platform for the race. After the race, she complained of nausea and threw up but felt better immediately. Her hamstring pain was up to a knee pain score of 4/10 and she elected to undergo further AA. After one ASP needle, her pain decreased to a knee pain score of 2/10. She continued to swim without complaint and won two medals.
A 30-year-old male sitting volleyball athlete with chronic LBP from degenerative disc disease and prior radiculopathy presented with exacerbation of his LBP. He needed to compete in 15 min. Osteopathic manipulation treatment (OMT) resulted in no change in pain, so he elected to undergo AA. After three ASP needles, his pain decreased from a knee pain score of 8/10 to a knee pain score of 1/10, and he was able to play in the championship game and won a silver medal.
A 38-year-old male sitting volleyball athlete with chronic LBP from spinal stenosis and radiculopathy culminating in two-level spinal fusion 2 years prior presented with exacerbation of his LBP, up to a knee pain score of 8/10 from his usual constant knee pain score of 6/10. After three ASP needles, his pain completely resolved. He was perplexed, having not felt complete pain relief for more than 2 years, and asked where he could get this type of treatment again. He played immediately in the championship volleyball match and won a silver medal.
A 22-year-old sprinter with posttraumatic stress disorder and chronic shoulder pain from complex regional pain syndrome presented with acute thigh pain from a new hamstring strain. He had tried ice, compression, and massage but needed to compete in a few minutes. Examination revealed this likely to be a grade 1 strain, with no ecchymosis or palpable defect and with full knee and hip range of motion but pain on full knee extension. He received three ASP needles, resulting in reduction of his pain from a knee pain score of 8/10 to a knee pain score of 1/10. He ran his event and finished without any complications.
A 35-year-old male air rifle shooter with chronic neck and LBP presented with exacerbation of his pain due to shooting all day in the characteristic position of lateral spinal curvature required for proper posture. He underwent extensive treatment with OMT, massage, and transcutaneous electronic nerve stimulation resulting in little benefit. After treatment with three ASP needles, however, his a knee pain score of 7/10 pain completely resolved, and he was able to resume competition for two more days until completion.
A 24-year-old male track sprint athlete with a history of a proximal hamstring strain 4 wk prior complained of worsening pain during practice 3 d before competition. The suspected grade 1 strain was treated during practice with ice and compression. On the day of competition, his pain level was a knee pain score of 8/10. After treatment with six ASP needles, his pain decreased to a knee pain score of 4/10. He was able to run the medal race, but the pain worsened, and although he finished, he did not receive a medal. A follow-up magnetic resonance imaging 2 wk later confirmed only a grade 1 hamstring strain.
The Table summarizes the treatment of eight athletes with AA. All but one required only three needles to achieve pain resolution or reduction to easily tolerable levels.
AA is an effective potential pain control modality, and our case series shows it can be applied successfully to athletes in competition. Dr. Niemtzow (4) developed battlefield acupuncture for use by military providers caring for Warrior athletes for rapid application in austere conditions. His first case series of nine patients treated at an outpatient clinic showed similar success rates and pain reductions as our series. Niemtzow et al. (5) published a large case series on 119 patients with acute or chronic pain. Overall, baseline pain decreased from 5.5 on a 0-to-10 NRS to 3.0 at 24 h, 3.5 at 1 wk, 3.4 at 2 wk, and 3.0 at 4 wk (all significant for improvement compared with baseline). Goertz et al. (3) performed a randomized single-blinded clinical trial on 100 patients with acute pain presenting to an emergency department. All were treated with standard Western medical treatment appropriate for their conditions. Immediate pain relief in the AA group averaged 2.33 points on the NRS but only 0.15 in the control group (P = 0.0005). Usichenko et al. (7) published a systematic review of randomized clinical trials using AA for postoperative pain in which they found AA superior to control conditions in eight of nine trials that fulfilled the inclusion criteria.
Every athlete we treated with AA during the Warrior Games was included in this case series. Our experience was one of overwhelming success in that each athlete who received AA had some positive response. As is typical for most interventions, however, we saw primarily partial responders because most athletes still reported mild residual pain after AA. Yet, when considering the outcome that mattered most to the athletes, it was their ability to compete with better pain control that would define this as a successful intervention for them. It is unclear why we saw such a dramatic magnitude of pain relief reported. Certainly, there are a host of variables that factor into the subjective reporting of pain, especially in the context of athletic competition and the desire to compete.
Other than very mild ear pain during insertion, there were no reported adverse effects among our athletes during the week of competition. One athlete vomited after competition, but it is unclear if this can be attributed to AA or simply exertion or anxiety. Another athlete (case 8) with a grade 1 hamstring strain experienced marked pain reduction after AA but returned after sprint competition with worse pain than before treatment. Though MRI later showed that it was still only a grade 1 strain, it is worthwhile to mention because one possible risk of this (and any other pain reduction modality) is masking pain to allow for further competition, which could possibly lead to worsening of an injury. This ethical dilemma pitting short-term gain against long-term injury is common in sports medicine. It requires a frank discussion between the physician and athlete, and informed consent before treatment is carried out.
Another issue warranting discussion is the feasibility of this technique in athletes who wear headgear and/or have contact with other players. While ASP needles will stay in place during vigorous activity, if they are bumped, they may fall out. While this could impact the duration of pain relief, the risk of injury to the treated athlete's ear is very low. The risk of injury to other players is extremely small because of the small size and blunted outer edge of the ASP; however, it would be prudent to cover the ear with protective headgear (e.g., as in wrestling) to limit the potential for injury or transmission of communicable disease. Anecdotally, the senior author has used AA successfully in collegiate wrestlers wearing headgear.
We found the battlefield AA technique to be highly effective and well tolerated in controlling acute pain at an athletic event. AA can be learned easily by medical professionals, requires relatively inexpensive equipment that fits easily inside a medical bag, and is rapidly effective.
The authors declare no conflict of interest and do not have any financial disclosures. The opinions contained herein are those of the authors. They do not reflect official policy of the Department of Defense, the Department of the Army, or the Uniformed Services University.
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