An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management

Abstract

ImportanceAcute musculoskeletal pain is challenging to treat in the Emergency Department (ED), a novel setting to incorporate nonpharmacologic interventions, such as acupuncture, to reduce chronic pain.ObjectiveDetermine effectiveness of ED acupuncture for treating acute musculoskeletal pain.DesignPragmatic two-stage adaptive randomized clinical trial over one year. Stage 1 identified whether auricular acupuncture (AA) or peripheral acupuncture (PA) was more feasible and efficacious in the ED. Stage 2 assessed effectiveness of selected ED acupuncture intervention(s) on 1-hour pain reduction compared to no acupuncture (NA).SettingAcademic tertiary-care ED.ParticipantsAdults with acute (≤7 days) musculoskeletal pain in neck, back and/or extremities. Of 911 patients screened, 491 met inclusion criteria, 247 enrolled, 11 withdrew, and 236 were randomized (68 NA, 84 AA, 84 PA).InterventionsAA places ear needles based on battlefield acupuncture. PA places needles in head, neck, and extremity sites distal to pain. Acupuncture was delivered by licensed acupuncturists. All three arms received usual care from blinded ED providers.Main OutcomesPrimary outcome: 11-point Numeric pain rating scale at 1-hour. Secondary outcomes: Satisfaction with treatment; ED opioids given.ResultsInterim analysis at end of Stage 1 found both acupuncture styles similarly feasible and efficacious, so Stage 2 continued all three arms with unequal allocation (from 1:1:1 to 1:2:2 NA:AA:PA). All three arms had similar demographics (mean age 46.1 years ±16.5 SD, 56.2% female, and 53.6% Black), ED baseline pain scores (AA 7.0 ± 2.3, PA 7.2 ± 2.3, NA 6.9 ± 2.2) and pre-baseline ED administration of opioid and non-opioid analgesics. Both AA (2.1 ± 2.9) and PA (1.6 ± 2.0) produced significantly greater 1-hour pain reductions than NA (0.4 ± 1.9).Conclusions and RelevanceTwo different styles of ED acupuncture effectively reduce acute musculoskeletal pain better than usual care alone. Acupuncture is feasible, acceptable, and effective for treating pain in historically underserved populations in the emergency department setting.Clinicaltrials.govregistrationEmergency Department Acupuncture for Acute Musculoskeletal Pain Management ID#:NCT04290741; URL:https://clinicaltrials.gov/ct2/show/NCT04290741Key PointsQuestionWhat is the effectiveness of acupuncture for reducing acute musculoskeletal pain in an emergency department (ED) population?FindingsIn this pragmatic randomized clinical trial of 236 adults, ED patients receiving auricular acupuncture had a mean (± SD) pain score reduction of 2.1 ± 2.9 points, those receiving peripheral acupuncture had a reduction of 1.6 ± 2.0 points, while those who did not receive acupuncture had no change in pain (0.4 ± 1.9), which was a significant difference between no acupuncture and both acupuncture groups.MeaningAcupuncture can be added to usual care to effectively improve acute musculoskeletal pain in the ED.