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Re: Battlefield acupuncture added no benefit as an adjunct analgesic in emergency department for abdominal, low back or limb trauma pain

Dear Editor, We read with interest the trial report by Jan et al. and commiserate with their neutral findings. We have some comments that we hope may inform future research. Whenever using acupuncture techniques in sham controlled trials, we feel it is essential to maximise the physiological difference between real and sham groups. In this regard the sham technique was good, but the active technique was not optimal. Mechanistic research suggests that local and segmental acupuncture are likely to be the best approach in acute pain. Surgical pain is a different matter since local needling would not be possible, and in this situation, indwelling needles in segmental points and ear points has proven successful. Measuring pain as an outcome in a situation where conventional pharmacologic pain relief is provided clearly risks a ceiling effect. In their systematic review of randomised controlled trials of acupuncture for post-operative pain relief, Sun et al. reported cumulative opioid requirements that could avoid this risk, measuring opioid requirements 8–72 h following surgery. In the ED, there are a number of outcomes that could be measured to avoid the ceiling effect on subjective pain measures, for example time to mobilisation, time in the department, additional analgesic requirements following the intervention. Regarding the intervention, Battlefield acupuncture (BFA) is clearly a rather blunt tool designed for situations where resources are limited, but in the ED of a private hospital we feel a more sophisticated approach may have proved more successful. It only takes a few days to train regulated healthcare professionals in the principles and safe practice of Western medical acupuncture, and this approach is likely to be much more versatile and effective in the ED. In the cases where local or segmental needling is not suitable, and ear acupuncture is considered, we recommend careful point selection based on tenderness and lowered impedance. In addition, the use of the sterile New Pyonex needles would be considerably cheaper and safer than the Aiguille Semi-Permanent needles used in BFA. Regarding the BFA point protocol, only one of the five points is close to the region of the ear innervated by the auricular branch of the vagus nerve, and stimulation of this nerve is compatible with the current model of analgesic effects of auricular acupuncture. The most commonly used five-point protocol (NADA) has two points within the cymba conchae, which was innervated by the vagus nerve in 100% of ears examined by Peuker et al. In summary, we recommend that healthcare professionals in the ED are trained more comprehensively in a variety of acupuncture techniques and that acupuncture is offered as an alternative to pharmacological interventions in suitable cases. We encourage Jan et al. to persevere in testing acupuncture in the ED and gladly offer our advice on future protocols if that would be well received. Competing interests