The Use of Battlefield Acupuncture Prior to Botulinum Toxin A Administration: A 2-Patient Case Series

Background

Botulinum toxin type A injection is a common and safe procedure used for the treatment of overactive muscles through local injection by inhibiting the release of acetylcholine in the neuromuscular junction.^1,2 The benefits usually last only 3–6 months, and this requires reinjection of the toxin. The procedure, however, can be difficult if a patient's spasticity or pain prevent easy access to the muscles for injection, or if a patient has anxiety related to needles and is unable to remain still.

Acupuncture has been used for more than 5000 years, originating in China. This modality has been shown to have both local and distant effects within the body through the release of neurotransmitters and effects on the brain, as demonstrated on functional MRI. ³ Battlefield Acupuncture (BFA)—an auricular acupuncture technique developed by Richard C. Niemtzow, MD, PhD, MPH, in 2001, while he was on active duty in the United States Air Force—is a form of auricular acupuncture using a very specific sequence of needles inserted into the ears; BFA has been shown to reduce pain in a few minutes with few potential side-effects.^4–6

Case #1

A 70-year-old male veteran had a history of left middle cerebral artery strokes in 1991 and 1994, resulting in right upper-extremity spasticity with hand contractures. These contractures caused chronic recalcitrant pain. This patient was referred for local Botulinum toxin A injections. However, he was unable to have his upper extremity positioned for the injections due to his pain. After written informed consent was obtained from this patient, BFA was performed with gold Aiguille semipermanente needles being placed in the bilateral Cingulate Gyri and Thalami points on his ear, which reduced his spasm and decreased his pain level to facilitate the positioning needed for the for Botulinum toxin A injections. The patient reported that his pain went from a 6/10 to a 4/10 after BFA. Botulinum toxin A injections were then performed, with 75 units in the extensor carpi radialis, 25 units in the flexor digitorum profundus (FDP) superficial, 25 units in the FDP deep, 50 units in the flexor digitorum superficialis, and 25 units in the flexor pollicis brevis. This patient tolerated each injection. The remaining 3 points of BFA were then performed bilaterally on him, and he reported his pain level as 1/10.

Case #2

A 69-year-old male veteran with a history of a right pontine stroke in 1999, with likely two additional strokes since, had resulting right-sided spastic hemiplegia, leading to chronic right-sided posterior knee pain secondary to spasticity. The pain and spasticity had previously been well-treated with Botulinum toxin A; therefore, he was referred for repeat local toxin injections. During prior treatments, this patient had been very anxious while receiving the injections, leading to the concern that he would move during the repeat injections. While giving written informed consent, this patient remarked repeatedly about his fear of the injection needles. BFA was performed with gold ASP needles placed in the bilateral Cingulate Gyri and Thalami points. This patient tolerated the BFA with no anxiety or adverse events. He became mildly sedated and reported having less pain. He then tolerated the Botulinum toxin A injections, with 100 units in the biceps femoris in 2 locations, 100 units in the semimembranosis in 2 locations, and 100 units in the semitendinosis in 2 locations, without any movement.