Acupuncture-related adverse events: a systematic review of the Chinese literature
Zhang et al. · Bulletin of the World Health Organization · 2010
Evidence Level
MODERATEOBJECTIVE
Systematically review the Chinese literature on adverse events related to traditional acupuncture
WHO
479 cases of adverse events in patients aged 2 to 73 years
DURATION
Analysis of articles published between 1980-2009 (30 years)
POINTS
Main: Jianjing (GB-21), Feishu (BL-13), Fengchi (GB-20), Yamen (GV-15)
🔬 Study Design
Traumatic Events
n=296
cases of pneumothorax, hemorrhage, organ injury
Infectious Events
n=11
bacterial and viral infections
Other Events
n=172
syncope, allergic reactions, stroke
📊 Results in numbers
Total deaths
Most common event
Articles included
Rural acupuncturists involved
Percentage highlights
📊 Outcome Comparison
Distribution of adverse events by category
This study analyzed cases of acupuncture complications reported in China over 30 years. Although serious events are rare, most occurred due to improper technique. Acupuncture is safe when performed by well-trained professionals.
Article summary
Plain-language narrative summary
This study represents the first comprehensive systematic review of the Chinese literature on adverse events related to acupuncture, analyzing three decades of data (1980-2009) from Chinese medical databases. The investigators identified 115 articles reporting 479 cases of adverse events following traditional needle acupuncture, including 14 deaths. Events were classified into three main categories: traumatic (296 cases), infectious (11 cases), and other (172 cases). Pneumothorax was the most frequently reported adverse event, with 201 cases and four associated deaths.
Other serious events included subarachnoid hemorrhage (35 cases, 3 deaths), cardiovascular injuries, and abdominal organ perforations. The acupuncture points most frequently associated with adverse events were Jianjing (GB-21), Feishu (BL-13), Fengchi (GB-20), and Yamen (GV-15), especially when needled at excessive depth. The analysis revealed that 68% of traumatic events were caused by acupuncturists practicing in rural clinics or rural hospitals, where formal training is limited. Infections resulted mainly from inadequate aseptic technique and insufficient needle sterilization.
The study identified significant disparities between urban and rural acupuncturists in China, with rural practitioners rarely receiving formal education at medical schools. Syncope was the most common non-traumatic adverse event, occurring primarily in patients receiving acupuncture for the first time, especially when points were applied to the head or neck. The clinical implications of this study are significant for the global practice of acupuncture. Although serious adverse events are rare considering the volume of treatments performed in China, the majority are preventable through appropriate training, proper technique, and safety measures.
Limitations include the absence of a precise denominator for the total number of treatments, possible underreporting of events in the Chinese literature, and variability in the quality of case reports. The study highlights the need for standardization of acupuncture training and improvement of safety practices.
Strengths
- 1First comprehensive systematic review of the Chinese safety literature
- 230-year data analysis with detailed event classification
- 3Identification of specific patterns related to inadequate technique
- 4Substantial case sample with risk factor analysis
Limitations
- 1Absence of a denominator to calculate true incidence
- 2Possible underreporting in the Chinese literature
- 3Variable quality of included case reports
- 4Selection bias favoring more severe cases
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
The safety of acupuncture is an issue that every physician who recommends or practices the procedure needs to understand clearly. This 30-year systematic review of the Chinese literature offers a robust mapping of the technique's real risk profile, classifying 479 adverse events as traumatic, infectious, and other. Pneumothorax emerges as the most frequent event — 201 cases with four deaths — concentrated at points such as Jianjing and Feishu, which require strict control of depth and angulation. Subarachnoid hemorrhage associated with Fengchi and Yamen reinforces the need for solid anatomical knowledge when addressing the posterior cervical region. For the physician who integrates acupuncture into a pain and rehabilitation service, these data allow precise communication of risk to the patient, selection of points with a wider anatomical safety margin, and the structuring of protocols that clearly separate low-risk indications from those requiring greater technical experience.
▸ Notable Findings
The most striking finding of this review is that 68% of traumatic events occurred in rural Chinese clinics and hospitals, where formal training is limited — a pattern that is not restricted to geography but reflects the direct relationship between technical qualification and the incidence of serious complications. The distribution of events by anatomical point is clinically revealing: Jianjing, Feishu, Fengchi, and Yamen account for the most severe cases, all in regions where vital structures are in immediate proximity to the needle. Infections — only 11 cases over three decades — show that, with proper asepsis and single-use needles, infectious risk is low. Syncope was the most prevalent non-traumatic event, with a higher occurrence in treatment-naive patients and when points are applied to the head and neck, which has direct implications for the management of initial sessions.
▸ From My Experience
In my practice in the pain and rehabilitation service, the data from this review confirm what we have learned empirically over the years: the vast majority of adverse events are technique-related, not inherent to acupuncture itself. I never needle Feishu with the patient seated without first confirming the thoracic body type — in very thin patients or those with a narrow thorax, I prefer alternative points or reduce depth to less than 15 mm. For Fengchi and Yamen, I adopt mandatory angulation toward the nose, never pointing toward the foramen magnum — a routine I pass on to all the residents in the service. I tend to observe vasovagal syncope mainly in the first and second session, especially in anxious patients undergoing cervical or cranial point treatment — that is why I begin initial sessions with the patient in the supine position, and only progress to more rostral points from the third session onward, when the autonomic response is already calibrated. Debilitated, hypotensive patients or those on anticoagulants warrant an adapted protocol from the first consultation.
Full original article
Read the full scientific study
Bulletin of the World Health Organization · 2010
DOI: 10.2471/BLT.10.076737
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.
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