CRD summary

This review assessed the risks associated with acupuncture. The authors' concluded that acupuncture appears to be a safe procedure with minimal adverse reactions. The strength of this conclusion is limited because it is based solely on English language, published case reports which are unlikely to provide a reliable estimate of the occurrence of adverse outcomes.

Authors' objectives

To assess the risks associated with acupuncture.

Searching

MEDLINE, CISCOM, EMBASE (Excerpta Medica), Cardiff School of Biosciences (BIOSI), CINAHL, International Pharmaceutical Abstracts, Science Citation Index Expanded, the Cochrane Complementary Medicine Field Trials Registry, and the University of Maryland's CAMPAIN database were searched; the search terms were listed in the review. In addition, information was obtained from the Safety Record of Acupuncture of the National Commission for the Certification of Acupuncturists. Studies published in English between 1965 and 1999 were included.

Study selection

Assessment of study quality

The authors did not state that they assessed validity.

Data extraction

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction. Numbers of patients with complications or adverse events were extracted, together with long-term patient outcomes where available.

Methods of synthesis

Results of the review

Two hundred and two cases, identified from 98 papers, were included.

Infections.

Between 1974 and 1988, hepatitis was the most common complication. In all 94 cases, unsterile techniques were employed. No cases were identified post 1988. Nine cases of auricular infection were reported between 1975 and 1987. No information on sterilisation was available; however, needles were left in the pinna for weeks. Fifteen additional cases of infection that were possibly related to acupuncture were also identified. The diagnoses were human immunodeficiency virus infection, staphylococcal septicaemia (2), spinal infection with prolapsed disc, chronic osteomyelitis, bacterial endocarditis, pseudoaneurysm, posterior tuberculous spondylitis, bacterial meningitis and epidural haematoma, glenohumeral pyarthrosis, cervical spinal epidural abscess, and peritemporomandibular abscess.

Internal organ or tissue injuries.

Twenty-six cases of pneumothorax were associated with acupuncture. Thirteen cases of spinal cord and nerve injury were identified, the majority of which were linked with a Japanese needling technique that involved the permanent insertion of needles into paraspinal subcutaneous tissues. Twenty-one further cases of injury were reported. In some the Japanese method of embedding needles was used, while four were the result of self-puncturing.

Other complications.

Eleven other complications were detailed in the case reports, of which two were third-degree burns and two were asthmatic attacks.

Adverse reactions.

Between 1972 and 1991, 7 cases of contact dermatitis were found. Upon testing, 6 of these cases were found to be allergic to certain metals used in acupuncture needles. In addition, 6 individuals treated with acupuncture reported petechiae, cutaneous herpes, interference with a cardiac pacemaker, hypotension, fainting or recurrent fainting, vomiting and sweating.

Overall, of the 144 cases for which follow-up information was available, there were 7 deaths and 25 suffered permanent consequences. The frequency of reported complications and adverse effects appears to be declining over time.

Authors' conclusions

The authors concluded that if clean needle procedures and proper needling techniques are followed, acupuncture appears to be a safe medical procedure with minimal adverse reactions.

CRD commentary

The research question of the review was clearly reported, as were the inclusion criteria relating to the outcomes and study design. No attempt to locate unpublished reports was mentioned in the search strategy; hence, publication bias may have influenced the results. In addition, the included studies were limited to those published in English; language bias is likely given the subject matter of the review. Details of the included studies were presented, although with some inconsistency that was possibly related to the availability of information in the original case reports. The narrative synthesis was appropriate and clearly organised. The steps taken to minimise bias in the review process were not reported. Two key limitations need consideration when interpreting the authors' conclusions. A review based solely on English language, published case reports is unlikely to provide a reliable estimate of the occurrence of adverse outcomes associated with such a diverse intervention. As to the cases that were included, there was insufficient evidence of a thorough investigation of causality.

Implications of the review for practice and research

Practice: The authors stated that the risks can be minimised through the use of disposable needles and clean needle techniques by licensed acupuncturists. They further stated that patients should inform practitioners of any bleeding problems, anatomical variations, or use of anticoagulant medication or pacemakers. The authors also recommended that a mechanism be established by practitioners for the daily documentation of adverse events and complications; a list of criteria was given.

Research: Where further research into acupuncture is carried out, the authors suggested that any adverse events and complications be documented.

Funding

Maurice Laing Foundation and Thera Trust.

Bibliographic details

Lao L, Hamilton G R, Fu J, Berman B M. Is acupuncture safe: a systematic review of case reports. Alternative Therapies in Health and Medicine 2003; 9(1): 72-83. [PubMed: 12564354]

Other publications of related interest

Ernst E, White AR. Prospective Studies of the safety of acupuncture: a systematic review. Am J Med 2001;110:481-5.

Indexing Status

Subject indexing assigned by NLM

MeSH

Acupuncture Therapy /adverse effects /standards /trends; Hepatitis /etiology; Humans; Hypotension /etiology; Nausea /etiology; Needlestick Injuries /prevention & control; Pain /etiology; Patient Satisfaction; Risk Factors; Skin Diseases /etiology; Syncope /etiology; Vomiting /etiology

AccessionNumber

12003000346

Database entry date

31/05/2004

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.