VISUAL VIGNETTE

Battlefield Acupuncture: An
Emerging Method for Easing Pain
Charles E. Levy, MD, Nicholas Casler, BS,
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and David B. FitzGerald, MD

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hronic pain is a serious problem for combat veterans and

C soldiers. In a sample of 2597 soldiers who had served in
Afghanistan and Iraq, 44% reported pain lasting for more than
3 months, half of whom reported pain for 1 year or more.1
Pain medications, including opioids, often have limited ef-
ficacy and may impose unwanted adverse effects. These limits
explain the Department of Defense and the Veterans Adminis- FIGURE 1. Placement of a BFA dart. The gold dart can be seen at the
tration's interest in nonpharmacologic interventions including distal end of the applicator.
acupuncture.2 As traditionally practiced, acupuncture involves
a complex assessment and individualized treatment by trained
providers (300 hrs required for physicians), which are barriers
to widespread implementation in military and veteran settings.
In 2001, Niemtzow3 developed “battlefield acupuncture”
(BFA), a form of auriculotherapy where a sequence of gold ai-
guille semipermanent needles (Sedatelec, Irigny, France) are
placed at up to five specific sites in one or both ears. Battlefield
acupuncture is purported to influence central nervous system
pain processing through its effects on a somatotopic organiza-
tion of the body represented in the auricle. It has been suggested
that auricular therapies cause the release of β-endorphins to
elicit short-term analgesia or anti-inflammatory cytokines for
long-term effects.4 The BFA needles (more accurately described
as tiny conical darts) pierce the ear in designated locations in a
particular order (Figs. 1 and 2 show the technique and the
locations of needle placement). They stay in place until they
fall out typically within 3–4 days.2
Although there is some support for auricular therapy in
general, the evidence base for BFA is relatively meager.2,4 Re-
gardless, the Defense and Veterans Center for Integrative Pain
Management and the Veterans Health Administration National
Pain Management Program Office recently completed a 3-yr
$5.4 million acupuncture education and training program,
which deployed certified BFA trainers to receptive Department
of Defense and Veterans Administration medical centers. Over
FIGURE 2. The left ear with BFA darts in place. The darts can be seen in
2800 providers were trained to provide BFA. At the author's the prescribed locations, in order in which they are placed: (A) cingulate
gyrus, (B) thalamus, (C) omega 2, (D) point zero, (E) Shen Men.
From the Physical Medicine and Rehabilitation Service, and Center of Innovation
on Disability and Rehabilitation Research, North Florida/South Georgia Veterans
Health System, Gainesville, Florida (CEL); Department of Occupational Therapy,
and Center for Arts in Medicine, University of Florida, Gainesville, Florida (CEL); Veterans Administration facility, approximately 60 practitioners
Florida State University College of Medicine, Tallahassee, Florida (NC); Neu- have been trained, producing approximately 2500 patient BFA
rology Service and the Brain Rehabilitation Research Center, Rehabilitation
Research and Development Service, Office of Research and Development, encounters in the past 2 yrs. In the first author's experience with
Department of Veteran Affairs, North Florida/South Georgia Veterans Health nearly 30 veterans, BFA has reduced pain for those with head-
System, Gainesville, Florida (DBF); and Department of Neurology, University aches, acute and chronic back and musculoskeletal pain, and
of Florida, Gainesville, Florida (DBF).
All correspondence should be addressed to: Charles E. Levy, MD, Physical Medicine neuropathic pain.
Service, North Florida/South Georgia Veterans Health System, 1601 SWArcher Besides obvious questions regarding the mechanisms of
Rd (#117), Gainesville, FL 32608.
Financial disclosure statements have been obtained, and no conflicts of interest have
action, the comparative efficacy, and duration of effects, the
been reported by the authors or by any individuals in control of the content of Department of Defense and Veterans Health System embrace
this article. of BFA presents an opportunity to study the adaption and im-
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115 plementation of this most fascinating complementary tech-
DOI: 10.1097/PHM.0000000000000766 nique into traditional western practice. If the promise of BFA

e18 www.ajpmr.com American Journal of Physical Medicine & Rehabilitation • Volume 97, Number 3, March 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 Volume 97, Number 3, March 2018 Visual Vignette

holds true, it will add an important treatment option in physiat-
rists' arsenal to treat acute and chronic pain.
REFERENCES
1. Toblin RL, Quartana PJ, Riviere LA, et al: Chronic pain and opioid use in US soldiers after
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2. Walker PH, Pock A, Ling CG, et al: Battlefield acupuncture: opening the door for
acupuncture in Department of Defense/Veteran's Administration health care. Nurs Outlook
2016;64:491–8
3. Niemtzow R: Battlefield acupuncture. Med Acupunct 2007;
19:225–8
4. Yeh CH, Chiang YC, Hoffman SL, et al: Efficacy of auricular therapy for pain
management: a systematic review and meta-analysis. Evid Based Complement

combat deployment. JAMA Intern Med 2014;174:1400–1 Alternat Med 2014;2014:934670

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.