Stimulated by Eucker et al 2025 and Neilsen et al 2026.[1,2]
ED – emergency department
IF – impact factor
RCT – randomised controlled trial
MSK – musculoskeletal
BFA – battlefield acupuncture
NRS – numerical rating scale
EA – electroacupuncture
ABVN – auricular branch of the vagus nerve
NTS – nucleus tractus solitarius– key to acronyms
This is another paper based in the ED, plus a coincident review paper on the same topic. I recognised the names of both first authors, and one stimulated me to review previous blogs to find that I have been waiting for this trial to be published since 2024 (see Acupuncture in the ED 2024).
Both papers are from the US, but from different places. The trial I should have been expecting is from Duke University, North Carolina, and the review paper authors are spread around from New York to California via Ohio.
The paper I highlighted in 2024 was published in Annals of Emergency Medicine (IF 5.4),[3] and the current trial is published in Pain Medicine (IF 3.0).[1] I am on the editorial board for the latter journal (which I have mentioned previously; see APA in cLBP 2025), so I wondered why I hadn’t been invited to review the paper. On checking my records, I see that I did indeed review it. My excuses for forgetting this include the following: the time lapse between review and publication; the number of papers I review annually; and the time that has lapsed since my own birth.
I was pleased to see that my suggestion from peer review had been adopted, which is not at all guaranteed. I cannot say what it was here, but it might just come up at the webinar on Wednesday.
So, this is the second report of a 2-phase adaptive pragmatic RCT set in the busy academic tertiary care ED at Duke University Hospital. Patients arriving with acute MSK pain during the daytime (an 8 hour period between 8am and 8pm) were enrolled and randomised to usual care or usual care plus one of 2 acupuncture interventions. Abdominal and chest pain were excluded for obvious reasons. The acupuncture was either auricular application of Seirin Pyonex needles using the BFA protocol or manual acupuncture to peripheral points in the arms, legs, head and neck. Acupuncture patients were offered twice weekly follow-up treatment in a small group setting for one month.
The primary outcome was a pain NRS, which was recorded at baseline, 1 hour, and 1 month. Values at arrival to the ED were also reported as discussed in the prior blog (see Acupuncture in the ED 2024). The 1-hour outcomes demonstrated a similar (clinically relevant) pain reduction in both acupuncture groups, so all 3 groups were continued. The current paper discusses the 1-month outcomes. 599 patients were randomised with just over 400 receiving acupuncture in addition to usual care and just under 200 receiving usual care alone.
Unfortunately, only a minority of patients attended the follow-up sessions due to work and time commitments, and so there was no real difference in NRS at 1 month. 121 patients had 6 or more sessions and 478 had less than 6 (this includes the usual care / no acupuncture group). The pain reduction at 1 month was 66% versus 44% respectively. This difference was significant, but since this was not a planned analysis, conclusions are necessarily cautious.
It seems rather spooky that the review paper discusses both manual acupuncture and auricular acupuncture in an ED setting.[2] I guess it is logical to discuss auricular acupuncture since the BFA technique has been promoted heavily in the US, and it is a very convenient technique compared with say 30 minutes of EA (my preferred approach for maximum analgesia).
The review is published in the journal Integrative Medicine Research (IF 3.0), which I have mentioned here previously (see Acupuncture and mortality in IHD 2025). It is a comprehensive review with 151 references and full of compelling questions and subtitles, such as:
- What is an acupuncture point?
- What is de qi?
- Point specificity
The authors do not actually address these topics head-on, but their discussion is useful and mostly research orientated. I pick up a fondness for fascia, which is common in the contemporary acupuncture world as well as a famous old university in northern Italy that MC visited last year for the first time.
When it comes to auricular acupuncture there is a rather heavy focus on the ABVN and an implicit assumption that the sensory fibres all end up in the NTS rather than the trigeminal nucleus, which is the usual terminus for somatic sensory fibres from the head and neck.
On that last point I poured over my copies of Gray’s Anatomy to try to find a quote that is stuck in my memory… I know I have it safely tucked away somewhere. Then I went for the more contemporary approach of quizzing ChatGPT 5.2. I’ll let you know the results on Wednesday evening.
References
1 Eucker SA, Glass O, Knisely MR, et al. Acupuncture for Acute Musculoskeletal Pain in the Emergency Department and Clinic: A Pragmatic Randomized Trial. Pain Med. 2025;pnaf165. doi: 10.1093/pm/pnaf165
2 Nielsen A, Dyer NL, Faryar K, et al. Therapeutic mechanisms of acupuncture therapy for acute pain in the emergency department. Integr Med Res. 2026;15:101283. doi: 10.1016/j.imr.2025.101283
3 Eucker SA, Glass O, Knisely MR, et al. An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management. Ann Emerg Med. 2024;84:337–50. doi: 10.1016/j.annemergmed.2024.03.014
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