"Comparatively, This Won't Hurt..."—Acu in the ED
"Comparatively, This Won't Hurt..."Acu in the ED
Abstract & Commentary
By Russell H. Greenfield, MD
Synopsis: Results of this small pilot trial suggest that acupuncture analgesia in the ED may be both effective in managing pain associated with minor extremity trauma as well as feasible. While the conclusions are welcome, they serve more to advance the notion that further study is warranted than to promote application of acupuncture in the acute setting.
Source: Arnold, AA, et al. Efficacy and feasibility of acupuncture for patients in the ED with acute, nonpenetrating musculoskeletal injury of the extremities. Am J Emerg Med 2009;27:280-284.
This small pilot trial was designed to assess the efficacy and feasibility of acupuncture (Acu) analgesia for ED patients presenting with minor extremity trauma. A convenience sample of patients aged 18-60 years who presented to a Level I Trauma Center with nonpenetrating extremity trauma occurring within 36 hours of arrival were eligible for participation (a total of 20 enrolled, 14 of whom were males, the median age being 33 years). Attending physicians were instructed not to provide conventional pain relief measures to patients before or during Acu aside from ice, elevation, and immobilization; however, if pain medication was requested by the patient, such treatment would be offered and the patient removed from the study.
Acu was performed by one of three licensed acupuncturists and was based in traditional Chinese medical theory. Efficacy of treatment was measured using a visual analog scale (VAS) before treatment, immediately after Acu (time 0), and every 30 minutes thereafter. A numerical rating score (NRS; 0-10) was employed at discharge and during phone contact that was initiated within three days of ED discharge to ascertain pain levels, development of complications, and patient satisfaction with Acu. Markers of feasibility included average time spent in the emergency department (TID) for those receiving Acu vs. a control group who did not receive Acu (control group data obtained from database of similarly afflicted patients).
Of the 47 patients approached during the 2.5 year trial only 20 chose to participate, and three of the participants requested pain medication immediately following Acu (interestingly, their VAS scores had decreased markedly as a result of Acu even though medication was requested), while one other requested pain medication 60 minutes into the trial for a headache (data included in VAS analysis). Median pre-acupuncture VAS (n = 17) was 57 mm. At time 0 (n = 16) median VAS decreased to 36.5 mm. From pre-acupuncture to time 1 (n = 8) median VAS change was 19 mm, but there were no further significant data beyond time 1. Median NRS both at time of ED discharge and at follow-up was 3, while that of the control group was 2.5. Median TID was 135 minutes, but only 90 minutes for controls (reportedly not a statistically significant difference). Only minor complications were reported. Patient satisfaction (1-5, with 5 being highest; n = 12) was 5, with a range of 3-5. The study authors conclude that Acu can be an effective analgesic intervention in the ED for patients with acute extremity injury and does not increase patients' TID.
Commentary
This paper has value as a "test of concept," as proposed by the authors, but little beyond that. The researchers are due praise for stepping out of the realm of "Acu only for chronic disease" and attempting its application in the often crazed setting that is the ED, but the flaws in the trial are undeniable, and even some of the conclusions drawn are questionable at best.
Only relatively minor extremity trauma was considered appropriate for assessment (mainly sprains and contusions), potential subjects were excluded if they had chronic disease (no explanation provided), there were no VAS data for the control group, and the sample size was very small. It is interesting to note that it took 2.5 years to accrue 20 subjects who would participate in the study. There are likely many reasons for this, but one of them is that most people who find themselves in acute pain desire relief from a trusted pain reliever, and are not willing to forego medication in the furtherance of medical research and an intervention that "might" be effective. Most patients do not yet believe in the potential for Acu to help them acutely. Another point of interest is that it is unclear whether patients received pain medications, either guidance with respect to OTC aids or prescription drugs, for home use.
This editor is open to seeing the application of select CAM therapies in the ED, including Acu where appropriate, but the statements regarding feasibility are also disappointing. The authors state that the difference in TID for those receiving Acu vs. the controls was not statistically significant, but any ED nurse or doctor can attest to the impact of an additional 45 minutes in department with regard to at least nursing duties and patient flow.
Another point of interest is a methodological weakness perceived by the authors. They state that future studies should employ perhaps a single acupuncturist using a standardized Acu approach for minor extremity trauma. There is value to this approach, especially for conventional medical practitioners who might be able to employ select acupoint stimulation in specific settings, but part of the beauty of Acu from the perspective of traditional Chinese medicine is precisely that treatment is individualized and not standardized, adding to the complexity of studying this form of care.
CAM therapies such as Acu might have a place in the ED, but this study does little more than whet one's appetite for sound research to help answer questions of both efficacy and feasibility.
Results of this small pilot trial suggest that acupuncture analgesia in the ED may be both effective in managing pain associated with minor extremity trauma as well as feasible. While the conclusions are welcome, they serve more to advance the notion that further study is warranted than to promote application of acupuncture in the acute setting.Subscribe Now for Access
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