By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Summary Points
- This randomized trial compared electroacupuncture (inserted needles stimulated by electricity) vs. auricular acupuncture (needle insertion into the outside of the ear) vs. usual care for pain control in 360 cancer survivors with musculoskeletal pain.
- Compared with usual care after 12 weeks, weekly electroacupuncture treatment was associated with reduced pain severity of 1.9 points (P < 0.001) on the Brief Pain Inventory (BPI), and weekly auricular acupuncture was associated with reduced pain severity of 1.6 points (P < 0.001) on the BPI.
- While 10.5% of patients in the auricular acupuncture arm discontinued treatment because of adverse effects, such as pain and dizziness, only 0.7% of those in the electroacupuncture arm discontinued treatment because of adverse effects; P = 0.001.
SYNOPSIS: This randomized clinical trial involves 360 cancer survivors and found that two types of acupuncture demonstrated superior pain control compared to usual care during a 12-week follow-up period.
SOURCE: Mao JJ, Liou KT, Baser RE, et al. Effectiveness of electroacupuncture or auricular acupuncture vs. usual care for chronic musculoskeletal pain among cancer survivors: The PEACE randomized clinical trial. JAMA Oncol 2021;7:720-727.
The population of cancer survivors in the United States topped 18 million in 2022, and this figure is projected to rise annually.1 Pain affects up to 50% of cancer survivors; unfortunately, up to 20% of these patients report inadequate pain management. Poor sleep, fatigue, poor productivity, mental health problems, and decreased quality of life are among the unwanted outcomes associated with this state.1,2
One side effect of the opioid crisis has been a surge of interest in nonpharmacological pain control. Acupuncture, a key component of traditional Chinese medicine, has gained traction and acceptance in the Western world and often is used for pain control. Studies have definitively indicated the efficacy of acupuncture for pain control in non-cancer pain, but studies looking at pain in cancer and survivors of cancer have been less robust and more difficult to generalize.3
Mao et al designed a controlled study aimed at comparing the efficacy of two distinct acupuncture methodologies — electroacupuncture and auricular acupuncture — against the standard care approach among a diverse population of cancer survivors experiencing chronic musculoskeletal pain. In the event that both acupuncture procedures demonstrated significant statistical superiority over usual care, the study protocol called for a test of “noninferiority” of auricular acupuncture vs. electroacupuncture to verify whether auricular acupuncture was at least as effective as the more widely studied electroacupuncture technique.
The 360 participants in the study were recruited from a registry database at Memorial Sloan Kettering in New York City, resided in the surrounding area, had previous diagnoses of cancer, had no evidence of disease at entrance to the study, and musculoskeletal pain with a self-reported intensity of at least 4 on a scale of 1-10 for at least three months prior to the start of the study.
Exclusion criteria included inflammatory arthritic conditions, phantom limb pain, and pending disability claims. Eligible patients were randomized in a 2:2:1 ratio into an electroacupuncture arm, auricular acupuncture arm, or usual care, which included physical therapy, analgesic medications, and glucocorticoid injections.
Acupuncture, a therapeutic procedure where a trained practitioner inserts hair-thin needles to stimulate specific parts of the body, has been practiced for pain relief for more than 2,500 years. In the last 40 years, this ancient technique has become increasingly popular in the Western world, with more than 10 million acupuncture treatments administered annually in the United States.
Electroacupuncture is a type of acupuncture that combines an electrical current with needling, thereby enhancing endogenous opioid release. Licensed practitioners with formal training in acupuncture are required to administer this intervention effectively and safely.4,5
Auricular acupuncture, a variation of traditional acupuncture where needling only occurs on the external ear, has the potential to be more available to a wider range of patients, in part because providers without formal acupuncture training may perform this technique. Although “ear acupuncture” was a recognized therapy in ancient China, it was not until the 1950s that systemic research in this area grew.
French physician Dr. Paul Nogier generally is recognized as “the father of modern ear acupuncture” because of his extensive work mapping regions of the ear connected to specific areas of the body. More recently, the U.S. military has offered training to providers in “battlefield acupuncture,” which incorporates a specific auricular acupuncture protocol to address pain in veterans.6,7
In the Mao et al study, electroacupuncture and auricular acupuncture were administered by the same group of trained acupuncturists. Each group received 10 treatments over 10 weeks.
The Brief Pain Inventory (BPI), a standardized tool to measure average pain severity and composed of four questions related to pain severity, was administered at baseline and at 12-week follow-up. Responses on the BPI range from 0 to 10 indicating “no pain” to “worst pain ever.” A mean of these four scores was calculated to determine average pain severity, which was the primary outcome measured in this study.
RESULTS
After screening for eligibility, 360 patients were enrolled in this study — 145 were randomized to the electroacupuncture arm, 143 to the auricular acupuncture arm, and 72 to usual care. Table 1 presents the primary outcome results of this study. While both electroacupuncture and auricular acupuncture were associated with a significant decrease in pain vs. usual care, the difference between these two interventions was not significant enough to demonstrate noninferiority of auricular acupuncture over electroacupuncture.
Table 1. Compilation of Results Comparing Change in Severity of Average Pain After 12 Weeks of Treatment |
|||
| Type of Care | Change in BPI Pain Severity Scale Week 12 (95% CI) | Difference from Usual Care in Change from Baseline | Difference from Electroacupuncture and Auricular Acupuncture |
Usual care |
-0.48 (-0.85 to -0.10) |
N/A |
N/A |
Electroacupuncture |
-2.39 (-2.66 to -2.12) |
-1.92 (P < 0.001)* |
0.36; P = 0.55 |
Auricular acupuncture |
-1.92 (-2.43 to -1.40) |
-1.56 (P < 0.001)* |
N/A |
*Statistically significant value BPI: Brief Pain Inventory; CI: confidence interval |
|||
While adverse effects, such as bruising, were reported as mild to moderate among all acupuncture participants, ear pain among the auricular acupuncture group was significant enough to result in discontinuation of treatment by 10.5% of this population. In contrast, only one (0.7%) of the participants in the electroacupuncture group discontinued treatment because of an adverse effect.
COMMENTARY
Mao et al bring rigor to the field of acupuncture and pain control. In this randomized clinical trial, it is shown that both electroacupuncture and auricular acupuncture are associated with greater pain reduction than usual care in patients with pain after cancer recovery. Additionally, the results indicate that auricular acupuncture may be associated with more side effects and discontinuation when compared with electroacupuncture.
Some of the limitations on generalization of these findings include a relatively small sample size of participants drawn from one geographic area. Enlarging the sample size and extending recruitment for such studies into rural and inner-city areas will be important in the future to help determine factors affecting likelihood of response.
It is notable that Medicare presently provides coverage for acupuncture treatments specifically for low back pain.8 Additional studies are needed to confirm the benefit of acupuncture overall as well as the efficacy of different acupuncture techniques for managing other types of pain, including pain after cancer remission.
There also is a need for studies to examine results when healthcare providers, who are not trained acupuncturists but certified in specific techniques (like auricular acupuncture), administer the treatment. Regardless, the Mao et al investigation lays a solid foundation for such studies.
For now, the integrative provider stands on solid ground recommending patients with chronic pain post-cancer recovery consider acupuncture as a potential method for pain relief.
While the availability of trained providers may pose a barrier in some communities, it is hoped that the growing demand for this therapeutic intervention could ignite the establishment of more training programs. This, in turn, could result in a wider availability of competent acupuncturists, thereby making this ancient form of treatment more attainable.
REFERENCES
- American Cancer Society. Cancer Treatment & Survivorship Facts & Figures. American Cancer Society; 2022.
- Gallaway MS, Townsend JS, Shelby D, Puckett MC. Pain among cancer survivors. Prev Chronic Dis 2020;17:190367.
- Patil S, Sen S, Bral M, et al. The role of acupuncture in pain management. Curr Pain Headache Rep 2016;20:22.
- Hao JJ, Mittelman M. Acupuncture: Past, present, and future. Glob Adv Health Med 2014;3:6-8.
- Yin X, Li W, Liang T, et al. Effect of electroacupuncture on insomnia in patients with depression: A randomized clinical trial. JAMA Netw Open 2022;5:e2220563.
- Wirz-Ridolfi A. The history of ear acupuncture and ear cartography: Why precise mapping of auricular points is important. Med Acupunct 2019;31:145-156.
- King HC, Hickey AH, Connelly C. Auricular acupuncture: A brief introduction for military providers. Mil Med 2013;178:867-874.
- Medicare.gov. Acupuncture. https://www.medicare.gov/coverage/acupuncture
This randomized clinical trial involves 360 cancer survivors and found that two types of acupuncture demonstrated superior pain control compared to usual care during a 12-week follow-up period.
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