Original Research

Battlefield Acupuncture vs Ketorolac for Treating Pain in the Emergency Department

Fed Pract. 2023 April;40(4):110-115 | doi:10.12788/fp.0369

References

2. Nahin RL. Severe pain in veterans: the effect of age and sex, and comparisons with the general population. J Pain. 2017;18(3):247-254. doi:10.1016/j.jpain.2016.10.021

3. Motov S, Strayer R, Hayes BD, et al. The treatment of acute pain in the emergency department: a white paper position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2018;54(5):731-736. doi:10.1016/j.jemermed.2018.01.020

4. Samcam I, Papa L. Acute pain management in the emergency department. In: Prostran M, ed. Pain Management. IntechOpen; 2016. doi:10.5772/62861

5. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the use of opioids in the management of chronic pain. Accessed February 15, 2023. https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOpioidsCPG.pdf

6. Davis MT, Mulvaney-Day N, Larson MJ, Hoover R, Mauch D. Complementary and alternative medicine among veterans and military personnel: a synthesis of population surveys. Med Care. 2014;52(12 suppl 5):S83-590. doi:10.1097/MLR.0000000000000227

7. Goertz C, Marriott BP, Finch FD, et al. Military report more complementary and alternative medicine use than civilians. J Altern Complement Med. 2013;19(6):509-517. doi:10.1089/acm.2012.0108

8. King HC, Hickey AH, Connelly C. Auricular acupuncture: a brief introduction for military providers. Mil Med. 2013;178(8):867-874. doi:10.7205/MILMED-D-13-00075

9. Niemtzow RC. Battlefield acupuncture. Medical Acupunct. 2007;19(4):225-228. doi:10.1089/acu.2007.0603

10. Collinsworth KM, Goss DL. Battlefield acupuncture and physical therapy versus physical therapy alone after shoulder surgery. Med Acupunct. 2019;31(4):228-238. doi:10.1089/acu.2019.1372

11. Estores I, Chen K, Jackson B, Lao L, Gorman PH. Auricular acupuncture for spinal cord injury related neuropathic pain: a pilot controlled clinical trial. J Spinal Cord Med. 2017;40(4):432-438. doi:10.1080/10790268.2016.1141489

12. Federman DG, Radhakrishnan K, Gabriel L, Poulin LM, Kravetz JD. Group battlefield acupuncture in primary care for veterans with pain. South Med J. 2018;111(10):619-624. doi:10.14423/SMJ.0000000000000877

13. Garner BK, Hopkinson SG, Ketz AK, Landis CA, Trego LL. Auricular acupuncture for chronic pain and insomnia: a randomized clinical trial. Med Acupunct. 2018;30(5):262-272. doi:10.1089/acu.2018.1294

14. Fox LM, Murakami M, Danesh H, Manini AF. Battlefield acupuncture to treat low back pain in the emergency department. Am J Emerg Med. 2018; 36:1045-1048. doi:10.1016/j.ajem.2018.02.038

15. Woo A, Lechner B, Fu T, et al. Cut points for mild, moderate, and severe pain among cancer and non-cancer patients: a literature review. Ann Palliat Med. 2015;4(4):176-183. doi:10.3978/j.issn.2224-5820.2015.09.04

16. Motov S, Yasavolian M, Likourezos A, et al. Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Ann Emerg Med. 2017;70(2):177-184. doi:10.1016/j.annemergmed.2016.10.014

17. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad Emerg Med. 2003;10:390-392. doi:10.1111/j.1553-2712.2003.tb01355.

Results

Sixty-one patients received BFA during the study period: 31 were excluded (26 received adjunct treatment in the ED, 2 had active cancer documented, 2 had an indication other than pain, and 1 received BFA outside of the ED), leaving 30 patients in the BFA cohort. During the study period, 1299 patients received ketorolac. These patients were selected using a random number generator and then screened to determine inclusion or exclusion in the study. We continued to randomly select patients for the ketorolac group until we had a similar number in each treatment group. Of these 148 patients who were randomly selected to be reviewed, 116 were excluded: 48 received adjunct treatment in the ED, 24 had no postintervention NRS pain score documented within 6 hours, 18 received ketorolac doses other than 15 mg, 12 received ketorolac outside the ED, 9 had no baseline NRS pain score documented, 3 presented with a NRS pain score of ≤ 3, and 2 had active cancer documented. The ketorolac cohort comprised 31 patients.

Baseline characteristics were similar between the 2 groups except for the average baseline NRS pain score, which was statistically significantly higher in the BFA vs ketorolac group (8.7 vs 7.7, respectively; P = .02). The mean age was 51 years in the BFA group and 48 years in the ketorolac group. Most patients in each cohort were male: 80% in the BFA group and 71% in the ketorolac group. The most common types of pain documented as the chief ED presentation included back, lower extremity, and head.

Ten patients in the BFA group and 3 in the ketorolac group presented with lower extremity pain (P = .02) (Table 1).

Endpoints

The mean difference in NRS pain score was 3.9 for the BFA group and 5.1 for the ketorolac group. Both were clinically and statistically significant reductions (P = .03 and P < .01), but the difference between the intervention groups in NRS score reduction was not statistically significant (P = .07).

For the secondary endpoint of outpatient prescriptions written at discharge, there was no significant difference between the groups except for oral NSAIDs, which were more likely to be prescribed to patients who received ketorolac (P = .01).

Patients who received BFA were more likely to receive oral muscle relaxants or topical analgesics, but the difference between the groups was not statistically significant (Table 2). There was no difference in the number of patients who received no prescriptions at ED discharge. Patients who received ketorolac were more likely to be admitted to the hospital (P = .049) (Table 3).

No AEs were observed in either treatment group during the study.

Subgroup Analysis

An analysis was performed for subgroups classified by baseline NRS pain score (mild: 4; moderate, 5 - 6; severe, 7 - 9; and very severe, 10). Data for mild pain was limited because a small number of patients received interventions. For moderate pain, the mean difference in NRS pain score for BFA and ketorolac was 3.5 and 3.8, respectively; for severe pain, 3.4 and 5.3; and for very severe pain, 4.6 and 6.4. There was a larger difference in the preintervention and postintervention NRS pain scores within severe pain and very severe pain groups.

The mean difference in NRS pain score reduction between the intervention groups was not statistically significant for any subgroup (Figure).

A subgroup analysis also was performed comparing pain locations, although no statistically significant difference was found among the subgroups (Table 4).

Discussion

Both interventions resulted in a significant reduction in the mean NRS pain score of about 4 to 5 points within their group, and BFA resulted in a similar NRS pain score reduction compared with ketorolac 15 mg. Because the baseline NRS pain scores were significantly different between the BFA and ketorolac groups, a subgroup analysis revealed that BFA reduced mean NRS pain score in patients with severe and very severe pain but appears to be less beneficial for moderate pain, unlike the ketorolac results that showed a large reduction in all pain groups except for the small sample of patients with mild pain.

References

1. Cantrill SV, Brown MD, Carlisle RJ, et al. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012;60(4):499-525. doi:10.1016/j.annemergmed.2012.06.013

2. Nahin RL. Severe pain in veterans: the effect of age and sex, and comparisons with the general population. J Pain. 2017;18(3):247-254. doi:10.1016/j.jpain.2016.10.021

3. Motov S, Strayer R, Hayes BD, et al. The treatment of acute pain in the emergency department: a white paper position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2018;54(5):731-736. doi:10.1016/j.jemermed.2018.01.020

4. Samcam I, Papa L. Acute pain management in the emergency department. In: Prostran M, ed. Pain Management. IntechOpen; 2016. doi:10.5772/62861

5. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the use of opioids in the management of chronic pain. Accessed February 15, 2023. https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOpioidsCPG.pdf

6. Davis MT, Mulvaney-Day N, Larson MJ, Hoover R, Mauch D. Complementary and alternative medicine among veterans and military personnel: a synthesis of population surveys. Med Care. 2014;52(12 suppl 5):S83-590. doi:10.1097/MLR.0000000000000227

7. Goertz C, Marriott BP, Finch FD, et al. Military report more complementary and alternative medicine use than civilians. J Altern Complement Med. 2013;19(6):509-517. doi:10.1089/acm.2012.0108

8. King HC, Hickey AH, Connelly C. Auricular acupuncture: a brief introduction for military providers. Mil Med. 2013;178(8):867-874. doi:10.7205/MILMED-D-13-00075

9. Niemtzow RC. Battlefield acupuncture. Medical Acupunct. 2007;19(4):225-228. doi:10.1089/acu.2007.0603

10. Collinsworth KM, Goss DL. Battlefield acupuncture and physical therapy versus physical therapy alone after shoulder surgery. Med Acupunct. 2019;31(4):228-238. doi:10.1089/acu.2019.1372

11. Estores I, Chen K, Jackson B, Lao L, Gorman PH. Auricular acupuncture for spinal cord injury related neuropathic pain: a pilot controlled clinical trial. J Spinal Cord Med. 2017;40(4):432-438. doi:10.1080/10790268.2016.1141489

12. Federman DG, Radhakrishnan K, Gabriel L, Poulin LM, Kravetz JD. Group battlefield acupuncture in primary care for veterans with pain. South Med J. 2018;111(10):619-624. doi:10.14423/SMJ.0000000000000877

13. Garner BK, Hopkinson SG, Ketz AK, Landis CA, Trego LL. Auricular acupuncture for chronic pain and insomnia: a randomized clinical trial. Med Acupunct. 2018;30(5):262-272. doi:10.1089/acu.2018.1294

14. Fox LM, Murakami M, Danesh H, Manini AF. Battlefield acupuncture to treat low back pain in the emergency department. Am J Emerg Med. 2018; 36:1045-1048. doi:10.1016/j.ajem.2018.02.038

15. Woo A, Lechner B, Fu T, et al. Cut points for mild, moderate, and severe pain among cancer and non-cancer patients: a literature review. Ann Palliat Med. 2015;4(4):176-183. doi:10.3978/j.issn.2224-5820.2015.09.04

16. Motov S, Yasavolian M, Likourezos A, et al. Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Ann Emerg Med. 2017;70(2):177-184. doi:10.1016/j.annemergmed.2016.10.014

17. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad Emerg Med. 2003;10:390-392. doi:10.1111/j.1553-2712.2003.tb01355.

Battlefield Acupuncture vs Ketorolac for Treating Pain in the Emergency Department

Author disclosures

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Ethics and consent

References

Results

Endpoints

Subgroup Analysis

Discussion

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