Stimulated by Shah et al 2019.
Well it has been a slow week for acupuncture research, but it was unusual to see the journal Laryngoscope come up on my searches. I worked in ENT as a junior and then again in a part-time staff position whilst developing a portfolio career in the southwest. So I was curious enough to look at the paper.
It turned out to be a reasonably large (n=134) trial of BFA (BattleField Acupuncture) for post-op pain following tonsillectomy. I knew the day would come when I would have to address the phenomenon of BFA on this blog, so it might as well be now!
The term was coined in the aftermath of the 9/11 terrorist attacks by Richard Niemtzow, a physician and medical acupuncturist in the US military. BFA or the battlefield protocol is a set of 5 points on the ear where ASP semi-permanent needles are placed. The points are called (from top to bottom): Omega-2, Shenmen, Point Zero, Thalamus and Cingulate Gyrus. ASP needles are tiny barbed devices that are about 1.4mm in diameter at their widest point. They are inserted with a small plastic device with an integral plunger. 1.4mm sounds rather wide for a needle, but they are tiny devices. Whenever they have been used on me I have not felt much, but at odd times I have felt a lot from finer needles, so positioning may be critical – more on that later.
Here are some ASP needles magnified so you can see their shape.
BFA has become very popular in the US military, and of late has been popping up in trials in the medical literature. In some areas it has been adopted in routine practice, as the service woman below writing on social media illustrates.
The study by Shah et al used BFA or a non-penetrating sham control as an adjunctive technique aimed at reducing post tonsillectomy pain. There was a significant effect on the day of surgery, but not thereafter.
I found two relevant systematic reviews on ear acupuncture: one specifically on post-operative pain; and the other on immediate pain relief, which included treatment of migraine, biliary colic, various emergency department (ED) pain presentations, and procedural pain (egg collection within IVF), as well as post-operative pain. Both concluded that ear acupuncture was a promising technique with the usual caveats.
There were no trials on BFA in these reviews. Such trials have been published over the last 2 years. Two were in the journal edited by Richard Niemtzow himself, and both drew positive conclusions.[5,6] Others have not all been positive. A trial on lower limb surgery in Military Medicine concluded:
The use of modified battlefield acupuncture protocol does not change pain opioid use or quality of life in those with lower extremity surgery.
Another one on post-partum pain also failed to demonstrate any significant benefits.
But the news from the ED is more hopeful, and a small feasibility trial of BFA for back pain presentations concluded that BFA was feasible and may be efficacious. Although this trial only included 15 patients in each arm, and had an open design. It also attracted some criticism concerning the reporting and analysis of pain outcomes.
By contrast with these trials, those on post-operative pain from Taras Usichenko’s team are all positive. There are differences in the approach of course, with TU carefully selecting ‘reactive’ points on the pinna in certain regions of the ear, as opposed to using a protocol based on anatomical landmarks. The advantage of the latter is that a lot of practitioners can be trained in a relatively short time, as have been in the BFA protocol, and the disadvantage with the careful selection of points for individuals is that this may be operator dependent (personal communication TU).
I guess time will tell, but either way, these approaches do have potential, and we (the BMAS) will have to keep teaching ‘Ears’ on our foundation training course.
On the topic of needling protocols or as I like to call it when I’m in Barcelona: ‘making it up’ acupuncture. I have a few protocols that I have invented, one of which I have seen in published literature from China in recent years. These protocols are not attributed to me by name. I like to think of them as being attributed to mechanisms and logic, but I will always settle for the rather iconoclastic: ‘making it up’ acupuncture.
1 Shah AN, Moore CB, Brigger MT. Auricular acupuncture for adult tonsillectomy. Laryngoscope Published Online First: 11 October 2019. doi:10.1002/lary.28338
2 Niemtzow RC. Battlefield Acupuncture: My Story. Med Acupunct 2018;30:57–8. doi:10.1089/acu.2018.29077.rcn
3 Usichenko TI, Lehmann C, Ernst E. Auricular acupuncture for postoperative pain control: a systematic review of randomised clinical trials. Anaesthesia 2008;63:1343–8. doi:10.1111/j.1365-2044.2008.05632.x
4 Murakami M, Fox L, Dijkers MP. Ear Acupuncture for Immediate Pain Relief-A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Med 2017;18:551–64. doi:10.1093/pm/pnw215
5 Garner BK, Hopkinson SG, Ketz AK, et al. Auricular Acupuncture for Chronic Pain and Insomnia: A Randomized Clinical Trial. Med Acupunct 2018;30:262–72. doi:10.1089/acu.2018.1294
6 Collinsworth KM, Goss DL. Battlefield Acupuncture and Physical Therapy Versus Physical Therapy Alone After Shoulder Surgery. Med Acupunct 2019;31:228–38. doi:10.1089/acu.2019.1372
7 Crawford P, Moss DA, Crawford AJ, et al. Modified Battlefield Acupuncture Does Not Reduce Pain or Improve Quality of Life in Patients with Lower Extremity Surgery. Mil Med 2019;184:545–9. doi:10.1093/milmed/usy277
8 Kim M, Moss D, Crawford P. Battlefield Acupuncture for Post-Partum Pain: A Randomized Controlled Trial. Explore (NY) Published Online First: 22 May 2019. doi:10.1016/j.explore.2019.05.001
9 Fox LM, Murakami M, Danesh H, et al. Battlefield acupuncture to treat low back pain in the emergency department. Am J Emerg Med 2018;36:1045–8. doi:10.1016/j.ajem.2018.02.038
10 Wee TC, Tan YL. Observations regarding battlefield acupuncture to treat low back pain in the emergency department? Am J Emerg Med 2019;37:151. doi:10.1016/j.ajem.2018.04.065