Inspired by Kao et al 2022,[1] and the protocol by Liu et al 2022.[2]
BCT – blunt chest trauma
key to acronyms
NRS – numerical rating scale
FRS – face rating scale
SMI – sustained maximal inspiration
HRV – heart rate variability
HR – heart rate
MAP – mean arterial pressure
Two papers from Taiwan appeared recently and both tested different forms of acupuncture for acute analgesia in patients with blunt chest trauma (BCT). I guess most patients had rib fractures with or without lung injuries.
BCT – blunt chest trauma
Kao et al (n=72) used a simple protocol of distant points: 3 in the legs (GB36, GB34, ST36); and 3 in the arms (LI4, LU7, TE5). Pyonex needles of 0.20×0.60mm were applied and retained for 4 days. Placebo pyonex needles were used in the control group – these look exactly the same but have no needle protruding from the tiny plastic button in the middle of the circular adhesive.
There was a baseline difference in hypertension comorbidity, but this is unlikely to be relevant to the outcomes. There was little difference in NRS on rest, deep breathing, coughing, or turning over (the main outcomes), but there was a difference in the FRS in favour of the real indwelling needles.
The power calculation for this trial was based on a similar trial from 2014; however, this trial used deep oblique needling into the abdomen and or lumbar region with the needles taped down and retained for 6 hours per day, compared with a non-penetrating control (n=58).[3]
Liu et al (n=120) used a 3-arm design with manual acupuncture compared with laser or sham laser at the same set of points. Patients with rib fractures were treated daily for 3 days at bilateral points in the arms (LI4, TE6) and in the legs (ST36, GB34).
An average NRS during deep breathing, coughing, and turning over was used as the study outcome and this was assessed daily, after the intervention, for 3 days.
Average NRS and NRS on deep breathing were significantly reduced in the active groups on day 2 and day 3 when compared to the sham laser group. However, there were no significant differences in the use of analgesics or any of the more objective secondary outcomes: SMI; salivary cortisol; HRV; HR; MAP. There was a trend in favour of manual acupuncture in terms of sleep quality on day 3.
So, adding all this together, what should we recommend in practice and for further research? Well, I do like the convenience of the pyonex needles, but I suspect that you get a bigger stimulus from the older spinex indwelling needles, as used by Kotani et al in 2001.[4] These are 6mm long and are usually inserted obliquely through the epidermis. They can be fixed by applying adhesive tape over them, or as in a recent paper by Usichenko et al, by placing a placebo pyonex over them.[5]
over the rib at the site of the fracture
all indwelling spinex and pyonex
bilateral segmental paraspinal
bilateral auricular
Ho et al took the site of maximal tenderness of each rib but then inserted the acupuncture needle distally on a horizontal line transecting the umbilicus. I might place 3 spinex needles over the rib at the site of the fracture (perhaps 20mm apart) and combine this with bilateral segmental paraspinal points (spinex again) in the style of Kotani.[4] Auricular points could be added with pyonex needles in the style of Usichenko.[5,6] All these needles could be left in place for several days. If the chest trauma was not closed, we could still probably find space for the indwelling paraspinal needles, and of course the auricular needles may also be possible.
References
1 Kao P-Y, Lottering B, Lu T-Y, et al. Press Tack Needle Stimulation for Blunt Chest Trauma: A Randomized Double-Blind Control Trial. Interact Cardiovasc Thorac Surg 2022;:ivac158. doi:10.1093/icvts/ivac158
2 Liu C-T, Hsieh T-M, Wu B-Y, et al. Acupuncture Analgesia in Patients With Traumatic Rib Fractures: A Randomized-Controlled Trial. Front Med 2022;9:896692. doi:10.3389/fmed.2022.896692
3 Ho H-Y, Chen C-W, Li M-C, et al. A novel and effective acupuncture modality as a complementary therapy to acute pain relief in inpatients with rib fractures. Biomed J 2014;37:147–55. doi:10.4103/2319-4170.117895
4 Kotani N, Hashimoto H, Sato Y, et al. Preoperative Intradermal Acupuncture Reduces Postoperative Pain, Nausea and Vomiting, Analgesic Requirement, and Sympathoadrenal Responses. Anesthesiology 2001;95:349–56. doi:10.1097/00000542-200108000-00015
5 Usichenko TI, Henkel BJ, Klausenitz C, et al. Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial. JAMA Netw Open 2022;5:e220517. doi:10.1001/jamanetworkopen.2022.0517
6 Usichenko TI, Dinse M, Hermsen M, et al. Auricular acupuncture for pain relief after total hip arthroplasty – a randomized controlled study. Pain 2005;114:320–7. doi:10.1016/j.pain.2004.08.021
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