Systematic Review of Adverse Effects: A Further Step towards Modernization of Acupuncture in China
Wu et al. · Evidence-Based Complementary and Alternative Medicine · 2015
Evidence Level
STRONGOBJECTIVE
Analyze the frequency and severity of acupuncture complications and adverse events reported in China between 1980-2013
WHO
182 cases of adverse events identified in the Chinese scientific literature
DURATION
33-year retrospective analysis (1980-2013)
POINTS
Various points involved, mainly cervical, thoracic, and abdominal
🔬 Study Design
Adverse event cases
n=182
Retrospective analysis of case reports
📊 Results in numbers
Injury to internal organs, tissues, or nerves
Pneumothorax
Central nervous system injuries
Mortality rate
Percentage highlights
📊 Outcome Comparison
Most frequent types of complications
This study analyzed rare cases of acupuncture complications in China over 33 years. Although acupuncture is generally safe, it is important to be aware of these rare risks and to always seek qualified practitioners. Most complications occurred due to a lack of adequate training of practitioners.
Article summary
Plain-language narrative summary
This study represents a comprehensive analysis of adverse events associated with acupuncture in China over a 33-year period (1980-2013), contributing significantly to the understanding of the safety of this long-standing practice. The investigators conducted a systematic review of case reports published in three major Chinese databases (CQVIP, CNKI, and Wanfang), identifying 182 incidents reported in 133 relevant articles. The rigorous methodology included only first-hand reports to avoid duplications, excluding reviews and case-control studies. The results reveal that injuries to internal organs, tissues, or nerves represent the main category of complications (115 cases, 63.2%), with pneumothorax being the most frequent individual complication (30 cases), followed by central nervous system injuries (37 cases).
Other significant complications included peripheral nerve injuries (8 cases), organ injuries (22 cases), other tissue injuries (18 cases), syncope (18 cases), infections (17 cases), hemorrhages (10 cases), broken-needle complications (7 cases), and other adverse reactions (15 cases). Among the 182 cases analyzed, 25 resulted in death, mainly related to pneumothorax and central nervous system hemorrhages. The temporal analysis shows a downward trend in the most serious complications since the 2000s, possibly due to increased licensing requirements and formal training for acupuncturists. Most serious accidents occurred in the 1980s and 1990s, when many practitioners in rural areas performed acupuncture without adequate anatomical knowledge.
The study identified important risk factors, including overly deep puncture, incorrect acupoint location, lack of anatomical knowledge, excessive stimulation, and inadequate hygiene conditions. Pneumothorax complications were more common at points on the thorax, supraclavicular fossa, and back, while central nervous system injuries were primarily associated with cervical acupoints. Syncope, although less severe, represented a common adverse event, often related to factors such as hunger, thirst, nervousness, or patient intoxication. Infections, including cases of tetanus, were more prevalent in rural health centers with low hygiene standards — a problem that decreased significantly with the introduction of single-use needles.
The clinical implications of this study are substantial for the modernization and standardization of acupuncture. The authors emphasize the urgent need for systematized training and standardization of clinical acupuncture operations. They recommend better anatomy education for acupuncturists, the establishment of continuing education courses on safety, the creation of an adverse event reporting system, and mandatory safety certification requirements for licensure. Limitations include possible underreporting of adverse events due to the absence of a formal registration system, concentration only on the Chinese literature, and variability in the quality of case reports.
Despite this, the study provides valuable data on the safety of acupuncture and informs strategies to minimize future risk.
Strengths
- 1Comprehensive analysis of 33 years of data
- 2Rigorous methodology with multiple Chinese databases
- 3Detailed classification of adverse event types
- 4Temporal analysis showing safety improvement trends
Limitations
- 1Possible underreporting of adverse events
- 2Concentration only on the Chinese literature
- 3Variable quality of the original case reports
- 4Absence of a population denominator to calculate true incidence
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
For those who incorporate acupuncture into the therapeutic arsenal in a pain and rehabilitation service, this 33-year survey offers a precise cartography of the real risks of the practice. Pneumothorax — 30 identified cases, predominantly associated with thoracic, supraclavicular fossa, and back points — remains the most severe and preventable individual complication. Central nervous system injuries, 37 cases linked primarily to cervical acupoints, reinforce the need for rigorous anatomical mastery before working in this region. The temporal analysis is clinically encouraging: the progressive reduction in serious complications from the 2000s onward parallels the tightening of certification criteria, demonstrating that formal training requirements have a direct impact on patient safety. In practical terms, the adoption of single-use needles has virtually eliminated the serious infections that predominated in previous decades.
▸ Notable Findings
The 25 deaths recorded over 33 years reveal that poorly performed acupuncture can be lethal, and the mechanisms are identifiable: pneumothorax and central nervous system hemorrhages concentrate the mortality. The distribution of the 182 complications by category shows that structural injuries — organs, tissues, nerves — account for 63.2% of events, far outweighing systemic complications such as syncope and infection. Syncope, although benign when properly managed, appears in 18 cases and maintains a clear association with states of hypoglycemia, dehydration, anxiety, and ethanol intoxication — variables that the physician controls during pre-session screening. Another striking finding: the concentration of infectious complications in rural centers using reusable needles confirms that basic biosafety protocols, now universalized in hospital and outpatient settings, are decisive for the safety of the technique.
▸ From My Experience
In my practice in the pain service, the adverse event profile described in this article corresponds to what we have learned to avoid with systematic training in surface anatomy and ultrasound. I routinely emphasize to residents that points on the upper back and posterior cervical region require oblique angulation and controlled depth — two correctable technical errors that account for most of the serious complications described here. I see vasovagal syncope occasionally, generally in the first session of anxious or fasting patients; we now routinely check eating and hydration before starting. The finding regarding the reduction in complications after mandatory certification is consistent with what we have observed in Brazil after the regulation of acupuncture as a medical specialty: serious cases that used to arrive at the emergency room with pneumothorax have virtually disappeared from my clinical radar. For patients on anticoagulants or with coagulopathies, I maintain heightened caution, especially in regions with large vascular plexuses.
Full original article
Read the full scientific study
Evidence-Based Complementary and Alternative Medicine · 2015
DOI: 10.1155/2015/432467
Access original articleScientific 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.
Related articles
Based on this article’s categories