Adverse effects of acupuncture: Which are clinically significant?
Chung et al. · Canadian Family Physician · 2003
Evidence Level
MODERATEOBJECTIVE
Review potentially serious adverse events associated with acupuncture treatment
WHO
Patients from various studies receiving acupuncture from physicians and physical therapists
DURATION
Analysis of studies from 1966 to 2002
POINTS
Various points, with emphasis on precautions at CV-17 and thoracic points
🔬 Study Design
Study Review
n=100000
Analysis of adverse events across multiple acupuncture studies
📊 Results in numbers
Minor adverse events
Bleeding at needle site
Pain at needle site
Pneumothorax (rare)
Fainting
Percentage highlights
📊 Outcome Comparison
Adverse events by frequency of occurrence
This study shows that acupuncture is generally safe, with most side effects being mild — such as small bleeding or pain at the needle site. Serious events are very rare, but they can occur if the treatment is not performed properly by trained professionals.
Article summary
Plain-language narrative summary
This systematic review study, published in 2003 in Canadian Family Physician, represents a comprehensive analysis of the safety of acupuncture based on decades of medical literature. The authors conducted an extensive search of multiple medical databases from 1966 to 2002, examining case reports, prospective studies, and retrospective reviews to identify adverse events associated with acupuncture treatment. The research was motivated by the growing interest of both the public and health professionals in complementary and alternative medicine, particularly in acupuncture, which has been increasingly integrated into multidisciplinary clinics for the treatment of pain, addictions, and various other symptoms. The study reveals that minor adverse events are relatively common, occurring in 6% to 15% of treatments.
The most frequent effects include bleeding at the needle insertion site (3.1% of cases), pain at the puncture site (1.1%), and temporary aggravation of symptoms (about 1%). Other minor events include nausea, dizziness, fatigue, and fainting, the latter occurring in up to 0.3% of cases. Interestingly, the study notes that 86% of patients with symptom aggravation subsequently experienced improvement, suggesting a possible 'healing crisis' — a therapeutic process in which there is temporary exacerbation before improvement. Serious adverse events are significantly rarer but can be potentially fatal.
The analysis identified cases of pneumothorax (lung puncture) with an incidence of approximately 1 in 70,000 treatments, spinal cord injuries, serious infections including hepatitis B and septicemia, and even two deaths related to infection. Cases of broken needles, including needles intentionally left in the skin and accidental breakages, resulted in 48 adverse events during the period studied. The study emphasizes that specific risk factors increase the likelihood of complications. Patients with coagulation disorders such as hemophilia, advanced liver disease, or those taking anticoagulants present a higher risk of prolonged bleeding.
Immunocompromised individuals, including those with HIV, diabetes, transplant recipients on immunosuppressants, or those on high-dose steroid therapy, face an elevated risk of infections. The study also highlights the importance of proper technique and anatomical knowledge, citing cases in which unfamiliarity with anatomical variations, such as congenital sternal foramina, resulted in serious complications. An Australian analysis cited in the study clearly demonstrates the relationship between training and safety: practitioners with less than one year of training reported 2.07 adverse events per year, while those with 49-60 months of training reduced this rate to 0.92 events per year. This finding underscores the critical need for standardization of acupuncture training.
The authors conclude that, although acupuncture is relatively safe when compared to medications routinely prescribed in primary care, all health professionals should be aware of the potential risks. They recommend that patients be informed about possible adverse effects, that a complete medical history be performed to identify risk factors, and that only properly trained professionals practice acupuncture. The study represents an important milestone in the documentation of acupuncture safety and establishes fundamental guidelines for the safe practice of this therapeutic modality.
Strengths
- 1Comprehensive systematic review of multiple databases
- 2Analysis of a large volume of treatments (>100,000)
- 3Clear identification of risk factors
- 4Establishment of safety guidelines
Limitations
- 1Possible underreporting of adverse events
- 2Limited data on non-physician practitioners
- 3Variability in the quality of included studies
- 4Lack of standardization in adverse event criteria
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
The safety profile of acupuncture is information that every physician who integrates it into the therapeutic arsenal must master with precision — not out of fear, but to guide clinical decision-making and informed consent honestly. This review, covering more than 100,000 treatments over 36 years of literature, consolidates data that allow the clinician to stratify risk before indicating the procedure. Patients with coagulopathies, those on anticoagulants, the immunosuppressed, or those with poorly controlled diabetes deserve individualized evaluation before needling. The incidence of pneumothorax of 1 in 70,000 treatments, although low, reinforces the need for solid anatomical knowledge in the thoracic and cervical regions. For the physician working in a multidisciplinary pain clinic, these data support the indication of acupuncture as a low-risk procedure compared to nerve blocks, opioids, or prolonged anti-inflammatory use.
▸ Notable Findings
The finding that deserves special attention is that 86% of patients who presented initial aggravation of symptoms subsequently evolved with clinical improvement. This has direct implications for the conduct of the follow-up visit: what appears to be a therapeutic failure in the first sessions may be part of the response process. The training-dose relationship also stands out — practitioners with less than 12 months of training reported 2.07 adverse events per year, while those with 49 to 60 months of training reduced this rate to 0.92. The difference is clinically relevant and supports the institutionalization of structured medical training programs in acupuncture. Fainting, occurring in 0.3% of cases, is a manageable and preventable event with appropriate positioning and triage of patients who are fasting or have a vasovagal history.
▸ From My Experience
In my practice at the pain clinic, we routinely perform formal coagulation screening and verify anticoagulant use before any needling in deep paravertebral or thoracic regions — a routine that became even more solid after reading series such as this. The initial aggravation that the article describes corresponds well to what we observe in about 10 to 20% of patients in the first two sessions, especially in chronic myofascial syndromes with active trigger points. I make it a habit to warn explicitly about this at the first visit, as it prevents early treatment dropout. In general, the relevant clinical response appears between the third and fifth session; for chronic pain cases, we work with cycles of 8 to 12 sessions before reassessing the therapeutic plan. Immunosuppressed patients receive needling with a rigorous checklist of hygiene and traceable-lot disposable needles, without exception.
Indexed scientific article
This study is indexed in an international scientific database. Check your institutional access to obtain the full article.
Scientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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