This article discusses the evidence basis for the use of acupuncture in lower back pain, osteoarthritis of the knee, and traumatic brain injury (TBI). It reviews research and clinical application of acupuncture in a military setting. Finally, it demonstrates how a physician may apply the same acupuncture techniques the military is using on the battlefield to treat a sports injury in an austere environment. The introduction section reviews recommendations for pain control in an austere environment and risks associated with certain pain medications. Then it outlines a brief history, discusses the proposed mechanisms of action, and reviews the safety of acupuncture. Finally, it discusses acupuncture training requirements and difficulties in study design.
Sports medicine physicians are increasingly working in austere environments. Ultramarathons, adventure races, mountain bike races, and multiday endurance events are gaining popularity, but these events tend to be located far from definitive medical care, requiring medical management for several days (29). A recent article published in Current Sports Medicine Reports entitled “Pain Control in Austere Settings,” describes ways to provide adequate analgesia through the use of comfort care, PRICE therapy (protection, rest, ice, compression, and elevation), and medications. The article defines the ideal pain medication as easy to transport, stable in all environments, nonsedating, having minimal side effects, and able to be used on a patient regardless of injury or hemodynamic status (29).
Nonsteroidal anti-inflammatory medications have traditionally been first-line medications for acute musculoskeletal injuries. However, they are associated with gastrointestinal side effects and acute renal injury in dehydrated patients (9,26). There is limited evidence on the bleeding risk with nonsteroidal anti-inflammatory use in acute trauma (29). The other frequently used analgesic, acetaminophen, may cause acute liver injury in high doses. Physicians may prescribe opiates for severe pain, but common side effects include nausea, constipation, and sedation with respiratory depression (3). Certain countries require legal approval to administer opiates. Intramuscular analgesia is easily administered with a rapid onset of action, but the discomfort from the injection and local site reaction may limit use. For ongoing, severe pain, intravenous analgesia is commonly used, but administration can be difficult in an austere setting given the need for special equipment, the provider skill, and the risk of contamination (29).
Physicians may use acupuncture as an alternative or adjunct to medication. It is a discipline of traditional Chinese medicine that involves the insertion of fine needles in specific points on the body to treat pain or systemic symptoms. Several styles exist: traditional Chinese medicine-based acupuncture, French energetic acupuncture, Korean hand acupuncture, auricular acupuncture, myofascially based acupuncture, and Japanese style acupuncture. Knowledge and practice of acupuncture began in the United States in the 1970s, after James Reston, a reporter who traveled with President Nixon during his trip to China in 1971, noted improvement with acupuncture for postoperative pain (13). In 1997, the National Institutes of Health published a consensus statement that concluded there was clear evidence that needle acupuncture can treat postoperative and chemotherapy-induced nausea and vomiting, nausea and vomiting during pregnancy, and postoperative dental pain (22). Acupuncture may be effective as an adjunct therapy, an acceptable alternative, or a comprehensive treatment program for a number of other pain-related conditions such as lower back pain, tennis elbow, headache, and fibromyalgia (22). The National Center for Complementary and Integrative Health was created in 1998 with the goal of conducting and supporting research and providing information on complimentary health products and practices including acupuncture (37).
Acupuncture’s physiological basis for pain relief reportedly occurs through several mechanisms. The most robust data involve endorphin and monoamine mechanisms described in studies done between the 1970s to the 1990s. They demonstrate that acupuncture activates inhibitory mechanisms in the ascending pain pathway and stimulates the descending analgesic pathway (6,17,21). Functional magnetic resonance imaging (fMRI) studies demonstrate that acupuncture modulates cortical, subcortical, and brainstem pathways involved in pain processing (4,14,23).
Acupuncture is extremely safe when performed by well-trained practitioners. The U.S. Federal Drug Administration regulates needles and considers them medical devices for use only by licensed practitioners. They must be sterile, nontoxic, and labeled for single use (37). Common adverse events from acupuncture include mild pain with insertion, minor bleeding, and bruising. Less commonly, a patient may feel lightheaded or experience nausea, headache, drowsiness, or vasovagal syncope. Acupuncture may aggravate the medical condition (34). Serious complications are rare, occurring in less than 0.05 per 10,000 treatments. They include retained needle, organ puncture, infection, pneumothorax, seizure, drowsiness sufficient enough to cause an automobile accident, and death (30).
Despite its relative safety, easy transportability, and demonstrated effectiveness, medical acupuncture requires specialized training, which may not be feasible for a practicing physician. The American Board of Medical Acupuncture requires physicians to complete a 300-credit-hour course in medical acupuncture. They must dedicate 200 credit hours to class study and 100 credit hours to clinical practice. For board certification, there are additional requirements such as passing the board examination and submission of 500 clinical cases. Each state has specific licensing requirements (1).
Finally, acupuncture is inherently difficult to study because it is almost impossible to create a true randomized controlled trial. Finding a control group is challenging because fMRI studies demonstrate that “sham” acupuncture (needling nonacupuncture points) is still physiologically active, although less so than true acupuncture (14,33). In a randomized controlled trial, practitioners should use the same acupuncture points and needle stimulation techniques for all patients in the study. In clinical practice, treatments are individualized. Palpation of tender points and a traditional Chinese medicine diagnosis aid in point selection.
Evidence Basis for Common Sports Medicine Injuries
Growing evidence supports acupuncture treatment for several common sports medicine injuries. Acupuncture, used as a primary or adjunct treatment, may be associated with fewer side effects compared with medications. The following section focuses on the current evidence for acupuncture treatment for lower back pain, osteoarthritis of the knee, and TBI. A physician will commonly encounter these conditions in an austere environment.
Lower Back Pain
Back pain is one of the most common medical complaints, estimated to affect up to two-thirds of the U.S. population at some point in their lifetime. In an epidemiological study of active U.S. military members, Knox et al. (15) investigated 13,754,261 person-years of data and concluded that the incidence of lower back pain was 40.5 per 1,000 person-years. Current recommendations for medication treatment of nonspecific lower back pain include nonsteroidal anti-inflammatories, muscle relaxants, and opiates. Studies that investigate the efficacy of these medications are moderate quality at best (5).
Manheimer et al. (18) published a meta-analysis evaluating acupuncture for the treatment of lower back pain in 2005. Thirty-three randomized controlled trials were included, evaluating acupuncture versus sham acupuncture, no additional treatment, medications, manipulation, massage, and transcutaneous electrical nerve stimulation. Twenty-two trials concluded that acupuncture was significantly more effective than sham treatment and no additional treatment for short-term treatment of chronic lower back pain. No studies suggested that acupuncture was more effective than other active therapies for chronic lower back pain.
Furlan et al. (11) published a systematic review in 2005 of 35 randomized controlled trials demonstrating that acupuncture was more effective for pain relief and function than no treatment or sham treatment for chronic lower back pain. However, researchers only found these effects immediately after treatment and at short-term follow-up. The study concluded that acupuncture was not more effective than other conventional and “alternative” treatments but may be effective as an adjunctive treatment.
Yuan et al. (35) published a meta-analysis in 2008 on the effectiveness of acupuncture for lower back pain. Twenty-three studies were included with six considered high quality. Results noted moderate evidence that acupuncture was more effective than no treatment and strong evidence of no significant difference between acupuncture and sham acupuncture for short-term pain relief. Acupuncture may be beneficial as an adjunct to other treatments, but there is insufficient evidence to compare the effectiveness of acupuncture to other conventional therapies.
Finally, Lee et al. (16) published a systematic review of the literature on the use of acupuncture to treat acute and subacute lower back pain in 2013. The review included 11 randomized controlled trials from 1980 to 2011, focusing on outcomes of symptom and functional improvement. The study only considered randomized trials comparing needle acupuncture with a control. It excluded trials using acupuncture-related techniques (acupressure, moxibustion, laser, and magnetic device) and trials that compared different forms of acupuncture against each other. Five studies noted that compared with nonsteroidal anti-inflammatories, acupuncture may more effectively relieve symptoms of acute lower back pain; however, three of the five studies had a high risk of bias. For pain alone, there was inconsistent evidence that acupuncture was more effective than nonsteroidal anti-inflammatories. In two studies, one acupuncture treatment appeared more effective than sham at relieving acute lower back pain, but after 3 to 12 treatments, the effectiveness was similar. Finally, acupuncture appears to be associated with fewer side effects than nonsteroidal anti-inflammatories, but evidence is limited.
Osteoarthritis of the Knee
In 2007, Manheimer et al. (19) conducted a meta-analysis of 11 randomized controlled trials. The study noted clinically relevant short- and long-term benefits of acupuncture for pain and function compared with waiting list controls. However, the true benefit from acupuncture for short-term improvement in pain for osteoarthritis of the knee was irrelevant compared with sham acupuncture.
That same year, White et al. (31) published a meta-analysis of 13 randomized controlled trials. Acupuncture that met the criteria for adequate treatment was significantly superior to sham acupuncture and no additional intervention to improve pain and function in patients with chronic knee pain. Nevertheless, authors noted that further research was necessary because there was high heterogeneity of results.
Recently, Corbet et al. (7) published a systematic review and network meta-analysis comparing acupuncture and other physical treatments for pain relief from osteoarthritis of the knee. Authors used 112 trials covering 22 treatments with 9,709 patients. Acupuncture produced a clinically significant reduction in pain compared with standard care. They performed a sensitivity analysis of satisfactory and good quality studies and found that acupuncture (11 trials) and muscle strengthening exercises (9 trials) were significantly better than standard care, with acupuncture more so than muscle strengthening exercises (standard mean differences [SMD], 0.49; 95% credible interval, 0.00–0.98). Nevertheless, they cautioned that many of the studies in the systematic review and network meta-analysis were of poor quality.
Lastly, a systematic review conducted by Manyanga et al. (20) evaluated acupuncture treatment for osteoarthritis of the knee. Twelve randomized controlled trials were included from 1989 to 2013. The primary outcome was pain intensity, and the secondary outcomes were functional mobility and health-related quality of life. Authors concluded that acupuncture provided a statistically significant reduction in pain intensity, improvement in functional mobility, and improvement in health-related quality of life. However, they considered 75% of the studies to have unclear or high risk of bias.
A systematic review in 2012 by Wong et al. (32) evaluated four randomized controlled trials (294 patients) on the use of acupuncture for TBI. Three of the studies used electroacupuncture, and the fourth used manual acupuncture. The trials evaluated acupuncture against sham or acupuncture with standard treatment against standard treatment alone. Outcomes suggest that acupuncture is effective for acute treatment and rehabilitation of TBI. However, many of the studies included had low methodological quality.
In another small study in 2012, researchers evaluated 24 patients with insomnia secondary to TBI for improvement of insomnia after acupuncture. Patients receiving acupuncture showed an improvement in perception of sleep, measured by the Insomnia Sleep Index; however, there was no significant difference in sleep time compared with the control group as measured by the ActiGraph (36). They also measured cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status and Paced Auditory Serial Addition Test. Cognitive function improved to a significant degree for the acupuncture treatment group (Z = −2.81, P < 0.01) (36). Finally, a cohort study in Taiwan in 2013 compared the use of emergency care and hospitalization in patients with TBI with and without the addition of acupuncture treatment. Acupuncture was associated with decreased risk of emergency care visits and hospitalization the first year after injury (27).
Military Research and Clinical Application
The U.S. Military has taken a significant interest in acupuncture over the last 15 years. Currently, the military is using acupuncture in austere locations at the point of injury, at remote clinic locations for acute and routine same-day care, during a medical evacuation process, and at forward deployed hospitals. However, it is clear that more research is needed using sound methodological design on the use of acupuncture in the military population.
Colonel (retired) Richard Niemtzow (24) developed battlefield acupuncture in 2001 as an auricular technique for the rapid treatment of acute pain. It uses five acupuncture points on the ear: cingulate gyrus, thalamus, omega 2, shenmen, and point zero (24). Training is standardized and requires a half-day training session. Niemtzow, with the assistance of a Samueli Institute, has been training physicians in the military on this technique for the past 12 years. They are now training nonphysician medical providers to provide treatment at the point of injury. A recent pilot program at Camp Lejeune trained 37 special operations duty corpsman and allied healthcare personnel on the technique with the goal of gathering objective data in Afghanistan and Camp Lejeune (2). A recent 2013 feasibility and observational study evaluated battlefield acupuncture before medical evacuation of patients from Landstuhl Regional Medical Center, Germany, to Joint Base Andrews, Maryland. The study determined that the battlefield acupuncture technique was easy to learn, did not interfere with provider preflight duties, and provided significant pain relief (2).
In 2009, the Air Force Surgeon General and Deputy Surgeon General approved a pilot program to train 44 active duty military physicians in medical acupuncture through the Helms Medical Institute (25). The goal of the program was to determine whether acupuncture was effective in reducing pain, decreasing reliance on narcotic analgesics, and facilitating earlier assessment of TBI. Additionally, the program evaluated the overall effectiveness and practicality of using acupuncture in a deployed environment. Because of its success, the program is still ongoing (25).
Application to Sports Medicine Practice in an Austere Environment
Few studies describe the use of acupuncture to treat sports medicine injuries in an austere or wilderness environment (10). However, lower back pain, exacerbations of chronic knee pain, and TBI are sports injuries physicians can expect to see in an austere environment, and there is increasing evidence that acupuncture may be an effective treatment. Additionally, military acupuncture studies are often conducted in austere locations and can serve as a guide for further sports medicine research.
Commander Alan Spira (U.S. Navy) published a descriptive study in 2008 describing acupuncture treatment of sailors during Operation Iraqi Freedom. During the 9-month deployment, 132 patients received 435 acupuncture treatments. The majority of conditions treated were orthopedic, relating to the spine. Eighty percent of patients did not take medications for their condition after receiving acupuncture on the basis of the advice of the medical advisor. The troops, when asked why they chose acupuncture, stated that it was difficult to comply with medications in an austere environment, they could avoid side effects of medications, and treatments were easy and beneficial for their condition. Fifty-four percent of patients reported significant symptom improvement, 28% improvement, and 18% no improvement. There were no infections noted. A cost analysis demonstrated that acupuncture was cost-effective compared with nonsteroidal anti-inflammatories. In addition, one patient who declined acupuncture developed acute gastrointestinal discomfort requiring 24-h hospitalization due to nonsteroidal anti-inflammatory use (28).
Auricular acupuncture may be a preferred acupuncture technique for a physician in an austere location because of the ease of use and simplified training requirements. A patient’s ears are typically readily accessible, and cleansing the skin is only required for gross contamination. A trained physician can perform a treatment in less than 30 min. Needles are either standard acupuncture needles removed at cessation of treatment or semipermanent needles that fall out within 3 to 7 d (Figure). Needles are sterile, easily transported, and environmentally stable, and can be used on patients regardless of hemodynamic status. Patients typically note pain relief within minutes to the first hour after treatment and may return to play after treatment. Risks include infection, pain with needle placement, fatigue, contact dermatitis with semipermanent needles, and vasovagal symptoms. A physician may repeat treatment daily to weekly depending on the needle type used. Finally, physicians can attend a shortened training for certification, typically 2 to 7 d.
In 2006, Military Medicine published a study on the use of auricular acupuncture to treat acute pain syndromes. It was a randomized controlled trial comparing the effects of standard emergency medical care to acupuncture plus standard emergency medical care for patients with acute pain syndromes. Patients in the acupuncture group had a 23% reduction in pain compared with the standard medical care group whose pain remained essentially unchanged (P < 0.0005). However, at the 24-h follow-up, both groups noted similar reduction in pain. The study concluded that more research was needed, particularly trials that compared acupuncture with a sham acupuncture control (12).
The use of acupuncture on the “sidelines” of sports fields is an increasing topic of interest. Physicians can easily use the same techniques in an austere location. Many athletes present to their physicians with acute injuries or exacerbations of chronic pain wanting immediate relief of pain so they may continue their sport. A recent case series in Current Sports Medicine Reports evaluated the use of auricular acupuncture on athletes during the 2010 Warrior Games (8). Physicians offered auricular acupuncture to athletes who did not respond to initial standard therapy. Eight patients received auricular acupuncture for the presenting complaints of lower back pain, hamstring strain, and knee pain. Each athlete reported some positive response to treatment and was able to return to competition (8).
Acupuncture techniques such as Chinese Scalp Acupuncture and Tendinomuscular Meridian treatments demonstrate positive results for the treatment of insomnia and headaches related to TBI and acute musculoskeletal pain. Physicians can rapidly use these techniques in an austere environment as well. However, most of the evidence supporting these techniques is clinical observation. The medical community needs additional research before recommending formal training in these techniques for use in an austere environment.
There is low to moderate quality evidence that acupuncture is effective for treatment of lower back pain and osteoarthritis of the knee. There is weak, emerging evidence that acupuncture is effective for symptoms associated with TBI. Military research demonstrates favorable results on acupuncture use in the austere setting to treat acute and chronic pain. In particular, physicians can rapidly perform auricular acupuncture to treat acute pain with possibly fewer side effects compared with medications. This technique also has shortened training requirements. The current research and clinical application of acupuncture is promising. It suggests that training in and use of certain acupuncture techniques may be beneficial as a sole or adjunct treatment for common sports medicine injuries in an austere environment. However, despite these promising results, noninferiority trials comparing acupuncture with standard care are lacking. It is clear that the medical community needs high methodological quality research on acupuncture in the military and civilian setting.
The views expressed in this abstract/manuscript are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.
The authors declare no conflict of interest and do not have any financial disclosures.
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