915

Research

Bull World Health Organ 2010;88:915–921C | doi:10.2471/BLT.10.076737

Introduction

Acupuncture is popular in most countries, but nowhere more than in China. Because its use is so widespread, safety is an im-portant issue that deserves close attention. Serious adverse events resulting from acupuncture, including pneumothorax, cardiac tamponade, spinal cord injury and viral hepatitis, have been identified in previous literature reviews.1–4 Prospective surveys to determine the frequency of acupuncture-related adverse events have been conducted in Germany,5,6 Norway7 and the United Kingdom of Great Britain and Northern Ireland.8,9 These studies have shown an incidence of mild, transient acupuncture-related adverse events that ranges from 6.71% to 15%. The most com-mon adverse events of this type were local pain from needling (range: 1.1–2.9%) and slight bleeding or haematoma (range: 2.1–6.1%). In a prospective observational study of 190 924 patients, the incidence of serious adverse events (death, organ trauma or hospital admission) was about 0.024%.5 Another large-scale observational study showed a rate of adverse events requiring specific treatment of 2.2% (4963 incidents among 229 230 subjects).6 Studies such as these have shown that in extremely rare cases acupuncture can lead to serious, sometimes life-threatening complications, in addition to mild and transient adverse events.

Because most reports on the safety of acupuncture have been published outside China, the objective of this article was to summarize the Chinese literature on the subject of acupuncture-related adverse events and determine the possible reasons that such events occur.

MethodsInclusion/exclusion criteriaIn December 2009 we searched the following electronic data-bases: Chinese Biomedical Literature Database (1980–2009), Chinese Journal Full-Text Database (1980–2009) and Weipu Journal Database (1989–2009). The search terms were: (acu-puncture OR needle) AND (induce OR cause OR adverse event OR adverse reaction OR side effect OR complication OR harm OR risk OR mistake OR infection OR injury OR fainting OR haemorrhage OR bleeding OR death OR pneumothorax OR pain). We searched for these terms (in Chinese) as free text in the title or abstract, and we also hand-searched the reference lists of all reports located through the electronic searches.

Case reports, case series, surveys and other observational studies were included in the review if they reported factual data on complications related to acupuncture. Review articles, transla-tions and clinical trials were excluded. The search was limited to Chinese-language papers.

Different types of acupuncture can lead to different adverse events. To present clear results, we only included reports on traditional needle acupuncture, defined as a procedure in which stainless steel filiform needles are inserted into acupoints – acu-puncture points located throughout the body that are associated with specific therapeutic effects – and manipulated in place. Other types of acupuncture, such as electroacupuncture, laser acupuncture and auricular acupuncture, were excluded.

Two authors (Zhang and Shang) independently examined the titles and abstracts of all papers found through the search to determine if they fulfilled the inclusion criteria outlined

Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة.

Objective To systematically review the Chinese-language literature on acupuncture-related adverse events.Methods We searched three Chinese databases (the Chinese Biomedical Literature Database, 1980–2009; the Chinese Journal Full-Text Database, 1980–2009; and the Weipu Journal Database, 1989–2009) to identify Chinese-language articles about the safety of traditional needle acupuncture. Case reports, case series, surveys and other observational studies were included if they reported factual data, but review articles, translations and clinical trials were excluded.Findings The inclusion criteria were met by 115 articles (98 case reports and 17 case series) that in total reported on 479 cases of adverse events after acupuncture. Fourteen patients died. Acupuncture-related adverse events were classified into three categories: traumatic, infectious and “other”. The most frequent adverse events were pneumothorax, fainting, subarachnoid haemorrhage and infection, while the most serious ones were cardiovascular injuries, subarachnoid haemorrhage, pneumothorax and recurrent cerebral haemorrhage.Conclusion Many acupuncture-related adverse events, most of them owing to improper technique, have been described in the published Chinese literature. Efforts should be made to find effective ways of monitoring and minimizing the risks related to acupuncture.

Acupuncture-related adverse events: a systematic review of the Chinese literatureJunhua Zhang,a Hongcai Shang,a Xiumei Gaoa & Edzard Ernstb

a Research Centre of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Road, Tianjin, 300193, China.b Peninsula Medical School, University of Exeter, Exeter, England.Correspondence to Junhua Zhang (e-mail: zjhtcm@gmail.com).(Submitted: 9 February 2010 – Revised version received: 21 July 2010 – Accepted: 4 August 2010 – Published online: 27 August 2010 )

Bull World Health Organ 2010;88:915–921C | doi:10.2471/BLT.10.076737916

Junhua Zhang et al.Review of acupuncture-related adverse events in ChinaResearch

above. The full texts of potentially rel-evant articles were retrieved for detailed assessment. Disagreements between the two authors were resolved by discussion.

Information on author, patient, acu-puncturist, acupuncture site, adverse event, treatment and outcome was extracted from the primary articles and entered into a pre-formulated spreadsheet. Acupoints were described by pinyin name (i.e. the Latinized spelling of traditional Mandarin Chinese names) and code according to a standard nomenclature developed by the World Health Organization.10,11 These data have been summarized in three tables according to the type of adverse event.

ResultsOur inclusion criteria were met by 115 articles (98 case reports and 17 case series) (Fig. 1). We noted no clear trend in the frequency of reports of acupuncture-re-lated adverse events over the past 30 years.

In total, 479 cases of acupuncture-related adverse events were reported. Patients ranged in age from 2 to 73 years. The first authors of the papers were members of medical departments, court jurisdictions and police depart-ments. Only 20% of these authors were the acupuncturists who performed the procedure that caused the adverse event. The reported acupuncture-related adverse events were classified into three categories: traumatic (Table 1, avail-able at: http://www.who.int/bulletin/volumes/88/12/10-076737), infectious (Table 2) and “other” (Table 3).

Traumatic eventsTraumatic injuries were reported in 87 articles (73 case reports and 14 case series) and totalled 296 cases. The events were classified into seven subgroups according to the type and site of the injury.

Arachnoid and spinal dura materNine cases of spinal epidural haematoma (in the cervical, thoracic and lumbar spine) were reported. No further informa-tion was provided.

Subarachnoid haemorrhage was reported in 35 patients, 3 of whom died. The others recovered after 1 to 8 weeks of treatment. One of the deceased patients had a history of hypertension and cerebral haemorrhage and died 10 days after the acupuncture. The other two patients died within 30 minutes of having undergone the acupuncture, perhaps as a result of injury to the medulla oblongata.

The acupoints most frequently in-volved in cases of subarachnoid haemor-rhage and spinal epidural haematoma were Fengchi (GB20), Yamen (GV15), Fengfu (GV16), Dazhui (GV14) and Tianzhu (BL10). In several cases, the needles were inserted to a depth of 4 to 5 cm below the skin’s surface, and such deep insertion is suspected to have led to injury.

Thoracic organs and tissuesWith a total of 201 cases, pneumotho-rax was the most frequently reported acupuncture-related adverse event. Four patients died from it and the others recov-ered after 2 to 30 days of treatment. One

patient was a 70-year-old woman with a history of chronic bronchitis, emphysema, cor pulmonale and heart failure who died from pulmonary infection, heart failure and pneumothorax. Two more women died after not receiving timely treatment for pneumothorax caused by needling at the Jianjing (GB21) and Tianding (LI17) acupoints. The fourth patient died from tension pneumothorax but no further information was provided.

The acupuncture sites in these cases were primarily in the shoulder and scapu-lar regions (64%) and in the chest (24%). In two cases, the Tianding (LI17) point in the neck area had been needled. The most frequently used acupoints were Jianjing (GB21; 30%), Feishu (BL13; 15%), Quepen (ST12; 10%) and Tiantu (CV22; 10%). Other acupoints were Ganshu (BL18), Shenshu (BL23), Ti-anding (LI17), Jiuwei (CV15), Juque (CV14), Jianzhen (SI9), Quyuan (SI13) and Dingchuan (EX-B1).

Chylothorax was reported after needling at the Feishu (BL13) point in a 21-year-old man with a malformed thoracic duct. Right ventricular injury was reported in four cases, two of which recovered after surgical treatment. The other two patients died from right ven-tricular puncture complicated by cardiac tamponade and multiorgan dysfunction syndrome. One case of aortic artery rup-ture was reported after needling at the Qi-men point (LR14) at a depth of 4 cm; the patient died within 15 minutes. Coronary artery injury with cardiac tamponade was reported in a man who treated himself for chronic bronchitis and lost the needle at the Zhongfu point (LU1).

Abdominal organs and tissuesInjuries of abdominal organs and tis-sues were reported in 16 patients, all of whom recovered after surgery. These instances included perforations of the gallbladder, of the bowels and of the stomach, frequently complicated by peritonitis. A 2-year-old boy suffered intestinal wall haematoma with intes-tinal obstruction after acupuncture treatment for diarrhoea.

The acupoints associated with such adverse events were Tianshu (ST25), Zhongwan (CV12) and Qimen (LR14). Most of the patients underwent acupunc-ture for abdominal pain, attributable mainly to appendicitis or cholecystitis. Deep needling accounted for most of the abdominal injuries.

Fig. 1. Flow diagram for systematic review of the Chinese-language literature on adverse events related to traditional needle acupuncture, 1980–2009

Records identified from database(n = 1810)

Potentially relevant articles(n = 247)

Articles assessed for eligibility(n = 141)

Included articles(n = 115)

98 case reports;17 case series

Duplicates, articles not about acupuncture(n = 1563)

Reports unrelated to adverse events,duplicates, reviews and translations

(n = 106)

Articles about acupoint injection,electroacupuncture and related measures

(n = 26)

Bull World Health Organ 2010;88:915–921C | doi:10.2471/BLT.10.076737 917

Junhua Zhang et al. Review of acupuncture-related adverse events in ChinaResearch

Neck areaSix cases of injuries in the neck region were reported, including neural injuries (4), a false aneurysm of the carotid artery (1) and thyroid haemorrhage (1). One patient died after acupuncture at the Tiantu point (CV22); the needle had been inserted to a depth of 6 cm.

EyesFive articles reported injuries to the eyes, including orbital haemorrhage (3), trau-matic cataract (1), injury of the oculomo-tor nerve (1) and retinal puncture (1). One case of optic atrophy accompanied by haemorrhage and traumatic cataract resulted in visual impairment.

The acupoints in the above cases were Jingming (SL1), Qiuhou (EX-HN7) and Chengqi (ST1). When needling acupoints in the area of the orbital cavity, bleeding is difficult to avoid, even for the experienced acu-puncturist. Deep needling can also injure the oculomotor nerve, the retina and neighbouring tissues.

Peripheral nerves, vessels and other tissuesThree cases of haemorrhage were reported after acupuncture on the cheeks and the hypoglottis. One case of calf haematoma complicated by diabetic foot was caused by needling at the Tiaokou (ST38) and Chengshan (BL57) acupoints.

Four cases of peripheral motor nerve injuries and subsequent motor dysfunc-tion were reported. Three children suffered adductor muscle fibrosis and ad-duction deformity of the thumb as a result of local vascular and muscular injuries from needling at the Hegu point (LI4).

The acupoints most frequently involved in the injuries were Taiyang (EX-HN5), Neiguan (PC6) and Hegu (LI4). Forceful needle manipulation at these points, which are quite superficial, can cause injury to peripheral nerves, capillaries and muscle fibres.

Needling site pain and broken needleFour cases of pain at the needling site were reported in two articles. An intra-abdominal lump turned out to be caused by an acupuncture needle fragment that had broken off 15 years earlier.

Infectious eventsNine cases of bacterial infection and two cases of viral infection were reported. Ta

ble

2. C

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g JG

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pace

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tracr

ania

l inf

ectio

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used

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gol J

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n M

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gion

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tracr

ania

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inly

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QL,

Wu

TY. T

hree

ther

apeu

tic a

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nctu

re e

rrors

. Clin

Misd

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Mist

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ritis

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Bull World Health Organ 2010;88:915–921C | doi:10.2471/BLT.10.076737918

Junhua Zhang et al.Review of acupuncture-related adverse events in ChinaResearch

Tabl

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Acu

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M. F

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2007

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g du

ring

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in 6

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n J

Misd

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2007

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ke a

fter a

cupu

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rst-

aid

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and

less

on. J

ilin M

ed In

f 199

4;7:

29.

72, f

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Adv

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M

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orrh

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Trad

Ch

in M

ed 1

993;

2:34

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quel

a of

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ebra

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ST3

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tc.

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bral

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emor

rhag

eDe

ath

Prob

ably

Song

QL,

Wu

TY. T

hree

ther

apeu

tic a

cupu

nctu

re e

rrors

. Clin

Misd

iag

Mist

her

2001

;14:

73.

58, m

ale

Sequ

ela

of c

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ral

haem

orrh

age

KI1

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bral

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ably

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Y. Ac

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ctur

e-in

duce

d fa

tal h

aem

orrh

agic

stro

ke. X

injia

ng J

Trad

Ch

in M

ed 1

985;

4:24

–5.

59, m

ale

Sequ

ela

of s

troke

EX-H

N5, G

V20,

GB

20Ce

rebr

al

haem

orrh

age

Deat

hPr

obab

ly

Ma

ZH. A

cupu

nctu

re-in

duce

d ca

rdia

c ar

rest

. Heb

ei J

Trad

Chi

n M

ed 2

005;

27:5

89.

28, m

ale

Tic

doul

oure

uEX

-HN5

, LI4

, SJ5

Card

iac

arre

stRe

cove

ryPr

obab

lyZh

ang

CY, Z

heng

SM

, Pei

YF.

Acci

dent

al in

jury

to in

tern

al o

rgan

s ca

used

by

impr

oper

ac

upun

ctur

e in

5 c

ases

. Hei

long

jiang

J Tr

ad C

hin

Med

199

2;1:

38.

39, m

ale

Asth

ma

BL13

Shoc

kRe

cove

ryCe

rtain

ly

Wan

g L.

Acu

punc

ture

-indu

ced

petit

mal

epi

leps

y. Ch

in A

cu M

oxib

ustio

n 20

04;S

1:96

.35

, mal

eCh

eira

lgia

Pain

ful s

pot

Pykn

olep

syRe

cove

ryPr

obab

lyGa

n ZZ

. Acu

punc

ture

at T

aiya

ng p

oint

cau

sed

seve

re o

rbita

l hae

mor

rhag

e. C

hin

J Oc

ular

Trau

ma

Occu

p Ey

e Di

s 20

00;2

2:24

6.46

, fem

ale

Cold

, hea

dach

eEX

-HN5

Orbi

tal

haem

orrh

age

Reco

very

Prob

ably

Li J

S. A

cupu

nctu

re-in

duce

d fe

ver.

Chin

Acu

Mox

ibus

tion

2000

;10:

639.

52, m

ale

Sequ

ela

of b

rain

co

ncus

sion

GV20

, GB2

0, L

I11,

LI

4, e

tc.

Feve

rRe

cove

ryPr

obab

ly

Shan

g YT

. Adv

erse

eve

nts

caus

ed b

y ac

upun

ctur

e in

2 c

ases

. New

J Tr

ad C

hin

Med

20

06;3

8:76

.65

, fem

ale

Faci

ople

gia

GB14

, LI4

Coug

hRe

cove

ryPr

obab

ly46

, fem

ale

Obes

ityST

25, S

P15

Thirs

tRe

cove

ryCe

rtain

lyW

ang

SF, L

an Y

H. A

cupu

nctu

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t Nei

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Bull World Health Organ 2010;88:915–921C | doi:10.2471/BLT.10.076737 919

Junhua Zhang et al. Review of acupuncture-related adverse events in ChinaResearch

All patients recovered after appropriate treatment.

Infections were mainly due to poor sterilization of acupuncture needles. Acupoints on the head became infected most often, perhaps because hair makes it difficult to implement aseptic technique. Two cases of facial abscess may have been caused by acupuncture to relieve toothache.

Other adverse eventsA total of 172 acupuncture-related adverse events that were neither due to trauma nor to infection were reported. Local allergic reactions occurred after acupuncture in four patients with an al-lergy to metal needles.

In our review, fainting was the most common adverse event associated with acupuncture, and it occurred primarily in patients receiving acupuncture for the first time. In total, 150 cases of fainting were reported. In one report of 82 cases, 60% (49) of the patients fainted during the first treatment. Of these 49 fainting spells, 83% occurred when acupuncture was being applied to the head or neck.

Stroke after acupuncture was re-ported in five patients (aged from 58 to 73 years). One case of stroke occurred in a 72-year-old woman who received acupuncture on her arm. The other four patients had a history of stroke and hyper-tension. Three patients died from cerebral haemorrhage that was considered to be causally related to the acupuncture.

Other adverse effects included cardi-ac arrest, pyknolepsy (epileptiform attacks resembling petit mal), shock, fever, cough, thirst, aphonia, leg numbness and sexual dysfunction. However, the existence of a causal link between acupuncture and these adverse events is uncertain.

DiscussionMany types of acupuncture-related ad-verse events have been identified in the Chinese literature. Injuries and infections appear to be related to inappropriate technique, whereas other types of adverse events are not. Fainting is vasovagal in origin and minor bleeding is sometimes inevitable.

Infections result primarily from poor aseptic procedure and insufficient knowledge on the part of acupuncturists, who often disinfect reusable acupuncture needles with alcohol instead of steril-izing them. The use of disposable sterile

acupuncture needles and guide tubes is strongly recommended.12

Most traumatic events are caused by improper manipulation in high-risk acupoints. The depth of needle insertion is crucial. The lung surface is about 10 to 20 mm beneath the skin in the region of the medial scapular or midclavicular line.2 This may explain the high incidence of pneumothorax during needling in this area. Other traumatic complications, such as subarachnoid haemorrhage, car-diovascular injuries or perforation of the gallbladder, can also be caused by exces-sively deep needle insertion.

The patient’s condition also needs to be considered. Cardiovascular trauma occurred most frequently in patients with cardiomegaly. Patients with abdominal pain that has no clear diagnosis are at increased risk of trauma or infection from acupuncture at abdominal acupoints. Symptomatic treatment of abdominal pain with acupuncture can also delay effective therapy. During needling at pe-ripheral acupoints on the legs, arms and face, manipulation should be carefully executed to avoid damaging nerves and blood vessels.

Some adverse events are inevitable but could be minimized through pre-ventive measures. Fainting, which is a reflex caused by vagal excitation, is the most common adverse event during acu-puncture.13 Its incidence can be reduced by preparing patients and positioning them properly; the patient should not be hungry or tired and should preferably be placed in the supine, lateral or prone position.

Of the 87 articles reporting traumatic events, 59 (70%) provided information about the acupuncturists. Of these 59 articles, 68% (40) indicated that the acupuncturists were practising in village clinics or rural hospitals when they per-formed the procedures that caused the traumatic events. All infections reported were caused by acupuncturists in rural areas. In China, acupuncturists in rural and urban hospitals have a great disparity in clinical skills. Acupuncturists practising in rural hospitals, township health centres or village clinics rarely receive formal edu-cation in medical colleges. It follows that training for the practice of acupuncture needs to be unified and improved.

Several serious adverse events were identified through a review of case re-ports,14 but very few were found in surveys7–9 or prospective observational

Refe

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Bull World Health Organ 2010;88:915–921C | doi:10.2471/BLT.10.076737920

Junhua Zhang et al.Review of acupuncture-related adverse events in ChinaResearch

studies.5,6 This suggests that serious acu-puncture-related adverse events are rare. Bleeding and pain during needling are re-ported less often in the Chinese-language than in the English-language literature, perhaps because practitioners in China consider such events too trivial to report. Infections (primarily hepatitis) after acu-puncture are reported frequently in the English-language literature1 but relatively rarely in the Chinese-language literature, even though non-disposable acupuncture needles are still used in China. It is pos-sible that in China acupuncture-related infections are underreported.

Of the 87 articles reporting traumatic injuries, 72 (about 70%) were authored not by the acupuncturists themselves, but by the physicians who treated the adverse events. None of the articles reporting infec-tions were authored by the acupuncturists, as opposed to 16 of the 20 (80%) reports of adverse events other than trauma or infection. Again, we suspect that under-

reporting of such events in the Chinese-language literature is much higher than in the English-language literature.

Our review has several limitations. Although our search strategy was compre-hensive, we cannot guarantee that all rel-evant articles were identified. Many of the reports lacked detail, so that cause–effect relationships are often uncertain. In the absence of a denominator (i.e. the total number of acupuncture treatments prac-tised over the study period), the reported adverse events do not lend themselves to generating incidence figures. There are 2688 hospitals of traditional Chinese medicine in China.15 If we assume, for instance, that each hospital receives 50 to 100 visits for acupuncture per day (a con-servative figure), the annual number of acupuncture treatments would total from 50 to 100 million. This would suggest that the incidence of acupuncture-related adverse events is negligible. However, the true incidence remains unknown and can-

not be accurately estimated. Collectively these factors limit the conclusiveness of our findings.

ConclusionVarious types of acupuncture-related adverse events have been reported in China. Similar events have been reported by other countries,1–9 usually as a result of inappropriate technique. Acupuncture can be considered inherently safe in the hands of well trained practitioners. How-ever, there is a need to find effective ways to improve the practice of acupuncture and to monitor and minimize the health risks involved. ■

AcknowledgementsThe authors thank YY Xu, X Zhang and WK Zheng for their help with the litera-ture search.

Competing interests: None declared.

ملخصاآلثار الضائرة املرتبطة بالوخز اإلبري: مراجعة نظامية لألدبيات الصينية

بالوخز املرتبطة الضائرة اآلثار الصينية حول اللغة أدبيات مراجعة الغرض اإلبري مراجعة نظامية

وهي صينية بيانات قواعد ثالث يف بالبحث الباحثون قام الطريقة وقاعدة 1980-2009؛ الصينية، البيولوجية الطبية األدبيات بيانات )قاعدة بيانات وقاعدة 1980-2009؛ الصينية، للمجالت الكاملة النصوص بيانات جريدة ويبو Weipu، 1989-2009(، من أجل تحديد املقاالت الواردة فيها البحث تضمن ولقد التقليدي. اإلبري الوخز سالمة حول الصينية باللغة تقارير حالة، وسلسلة للحاالت، مع مسوحات وسائر الدراسات القامئة عىل املراقبة، حال احتوائها عىل معطيات واقعية، وقد استبعدت مقاالت املراجعة،

واملقاالت املرتجمة والتجارب الرسيرية.املجودات لبت 115 مقالة معايري اإلدراج يف الدراسة )98 تقارير حالة، و17 سلسلة من الحاالت( واشتملت عىل إجاميل 479 حالة تعرضت لآلثار

اآلثار ولقد صنفت مريضا. 14 وتويف اإلبري، الوخز استخدام بعد الضائرة الضائرة املرتبطة بالوخز اإلبري إىل ثالث فئات: رضحي، ومعٍد، وأخرى. وكانت أكرث اآلثار الضائرة تكراراً عىل اإلطالق اسرتواح الصدر، واإلغامء، والنزف تحت العنكوبتية، والعدوى، بينام كانت اآلثار األكرث تفاقام هي تلك التي ارتبطت الصدر، واسرتواح العنكوبتية، تحت والنزف الوعائية، القلبية باإلصابات

وتكرار النزف الدماغي.العديد من األحداث الصينية املنشورة عىل االستنتاج احتوت األدبيات الخاصة باآلثار الضائرة املرتبطة بالوخز اإلبري، وكان أكرثها يعود إىل استخدام التقنية الخاطئة. ومن ثم، يتوجب بذل الجهود من أجل إيجاد طرق فعالة

للمراقبة والرصد وتقليص املخاطر املرتبطة بالوخز اإلبري.

Resumé

Événements indésirables liés à l’acupuncture: une évaluation systématique de la documentation chinoiseObjectif Évaluer systématiquement la documentation en langue chinoise sur les événements indésirables liés à l’acupuncture.Méthodes Nous avons fait des recherches dans trois bases de données chinoises (la base de données sur la documentation biomédicale chinoise, 1980–2009, la base de données en texte intégral du Journal chinois, 1980–2009 et la base de données de la revue Weipu, 1989–2009) afin d’identifier les articles en langue chinoise qui abordent le thème de la sécurité de l’acupuncture traditionnelle pratiquée avec des aiguilles. Les observations, les séries de cas, les enquêtes et d’autres études d’observation ont été prises en compte lorsqu’elles rapportaient des données factuelles, mais les articles, les traductions et les essais cliniques ont été exclus.Résultats Les critères d’inclusion concernaient 115 articles (98 observations et 17 séries de cas) qui signalaient au total 479 cas

d’événements indésirables après acupuncture. Quatorze patients étaient décédés. Les événements indésirables liés à l’acupuncture étaient classés en trois catégories : traumatiques, infectieux et «autres». Les événements indésirables les plus fréquents étaient le pneumothorax, l’évanouissement, l’hémorragie méningée et l’infection, les plus graves étant les lésions cardiovasculaires, l’hémorragie méningée, le pneumothorax et l’hémorragie cérébrale récurrente.Conclusion De nombreux événements indésirables liés à l’acupuncture, dont la majorité était due à une technique incorrecte, ont été décrits dans la documentation chinoise publiée. Des efforts sont indispensables afin de trouver des moyens efficaces de contrôler et de réduire les risques liés à l’acupuncture.

Bull World Health Organ 2010;88:915–921C | doi:10.2471/BLT.10.076737 921

Junhua Zhang et al. Review of acupuncture-related adverse events in ChinaResearch

Resumen

Acontecimientos adversos relacionados con la acupuntura: revisión sistemática de la bibliografía chinaObjetivo Realizar una revisión sistemática de la bibliografía en chino sobre los acontecimientos adversos relacionados con la acupuntura.Métodos Se realizaron búsquedas en tres bases de datos chinas (Biomedical Literature Database, 1980–2009; Chinese Journal Full-Text Database, 1980–2009 y Weipu Journal Database, 1989–2009) con el fin de identificar los artículos en lengua china sobre la seguridad de la acupuntura tradicional con agujas. Se incluyeron casos clínicos, series de casos, encuestas y otros estudios de observación que presentaran datos documentados, pero se excluyeron los artículos de revisión, las traducciones y los ensayos clínicos.Resultados Los criterios de inclusión se cumplieron en 115 artículos (98 casos clínicos y 17 series de casos) que, en total, informaron sobre

479 casos de efectos adversos tras la acupuntura. Catorce pacientes fallecieron. Los acontecimientos adversos relacionados con la acupuntura fueron clasificaron en tres categorías: traumáticos, infecciosos y «otros». Los acontecimientos adversos más frecuentes fueron: neumotórax, desmayo, hemorragia subaracnoidea e infección; mientras que los más graves fueron: lesiones cardiovasculares, hemorragia subaracnoidea, neumotórax y hemorragia cerebral recurrente.Conclusión En la bibliografía china publicada se han descrito muchas reacciones adversas relacionadas con la acupuntura, debidas en su mayor parte a una técnica inadecuada. Debemos esforzarnos para encontrar formas eficaces de controlar y reducir al mínimo los riesgos relacionados con la acupuntura.

References1. Norheim AJ. Adverse effects of acupuncture: a study of the literature for the

years 1981–1994. J Altern Complement Med 1996;2:291–7. doi:10.1089/acm.1996.2.291 PMID:9395661

2. Peuker ET, White A, Ernst E, Pera F, Filler TJ. Traumatic complications of acupuncture. Therapists need to know human anatomy. Arch Fam Med 1999;8:553–8. doi:10.1001/archfami.8.6.553 PMID:10575398

3. Yamashita H, Tsukayama H, White AR, Tanno Y, Sugishita C, Ernst E. Systematic review of adverse events following acupuncture: the Japanese literature. Complement Ther Med 2001;9:98–104. doi:10.1054/ctim.2001.0446 PMID:11444889

4. Ernst E, Sherman KJ. Is acupuncture a risk factor for hepatitis? Systematic review of epidemiological studies. J Gastroenterol Hepatol 2003;18:1231–6. doi:10.1046/j.1440-1746.2003.03135.x PMID:14535978

5. Endres HG, Molsberger A, Lungenhausen M, Trampisch HJ. An internal standard for verifying the accuracy of serious adverse event reporting: the example of an acupuncture study of 190,924 patients. Eur J Med Res 2004;9:545–51. PMID:15689300

6. Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S et al. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed 2009;16:91–7. doi:10.1159/000209315 PMID:19420954

7. Norheim AJ, Fønnebø V. Acupuncture adverse effects are more than occasional case reports: Results from questionnaires among 1135 randomly selected doctors, and 197 acupuncturists. Complement Ther Med 1996;4:8–13. doi:10.1016/S0965-2299(96)80049-5

8. White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001;323:485–6. doi:10.1136/bmj.323.7311.485 PMID:11532840

9. Macpherson H, Scullion A, Thomas KJ, Walters S. Patient reports of adverse events associated with acupuncture treatment: a prospective national survey. Qual Saf Health Care 2004;13:349–55. doi:10.1136/qshc.2003.009134 PMID:15465938

10. A proposed standard international acupuncture nomenclature: report of a WHO scientific group. Geneva: World Health Organization; 1991.

11. WHO standard acupuncture point locations in the Western Pacific Region. Geneva: World Health Organization; 2008.

12. Guidelines on basic training and safety in acupuncture. Geneva: World Health Organization; 1999.

13. He J, Tang QF, Zhuang LX. Clinical analysis of the therapeutic effect of fainting during acupuncture and preliminary study of the mechanism. Chin Acu Moxibustion 2004;24:553–5.

14. Lao L, Hamilton GR, Fu J, Berman BM. Is acupuncture safe? A systematic review of case reports. Altern Ther Health Med 2003;9:72–83. PMID:12564354

15. Ministry of Health of the People’s Republic of China [Internet]. Beijing: Ministry of Health; 2010. Available from: http://www.moh.gov.cn [accessed 11 August 2010]. Chinese.

ABull World Health Organ 2;87:fpage–lpage | doi:10.2471/BLT.07.043125

Junhua Zhang et al. Review of acupuncture-related adverse events in ChinaResearch

Tabl

e 1.

Tra

umat

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vent

s af

ter a

cupu

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s id

entifi

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roug

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syst

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aem

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J Z

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Acu

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Sha

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Chen

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J P

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987;

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5.Ji

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, et a

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nap

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Anh

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hin

Med

Col

l 199

6;15

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Li L

F, Co

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, Jin

QW

. Acu

punc

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u po

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ause

d su

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aem

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Chi

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u M

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08;2

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2.Li

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. Acu

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hae

mor

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hanx

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J 1

980;

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.Li

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, Xia

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, Liu

JS,

et a

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Peo

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984;

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Liu

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atom

a. M

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Lia

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92;6

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Mi X

H, L

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Sha

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Trad

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989;

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mag

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rac

J M

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harm

200

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:932

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Sha

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Wu

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. One

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Chi

nJ F

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Yang

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Lia

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Trad

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.Yu

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Acu

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ape

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ause

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bara

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aem

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cas

es. J

Apo

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rv D

is 19

86;3

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W. A

cupu

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J S

ichua

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hin

Med

198

8;10

:52.

Li Y

Q, C

hen

GW. A

cupu

nctu

re c

ause

d ep

idur

al h

aem

orrh

age

in c

ervic

al s

pine

. Chi

n Co

mm

Doc

tors

200

3;19

:46–

7.Sp

inal

epi

dura

l hae

mat

oma

(9 c

ases

)–

9 re

cove

ries

Liu

FY. A

cupu

nctu

re a

t Fen

gchi

poi

nt c

ause

d su

bdur

al h

aem

atom

a. M

ed J

Lia

onin

g 19

92;6

:25.

Zhan

g J.

Dia

gnos

is a

nd tr

eatm

ent o

f spi

nal e

pidu

ral h

aem

atom

a ca

used

by

acup

unct

ure.

Mod

Med

Hea

lth 2

006;

22:2

924–

5.Ab

dom

inal

org

ans

and

tissu

esZh

ang

JH. A

cupu

nctu

re a

t abd

omin

al a

cupo

ints

cau

sed

4 ca

ses

of p

erito

nitis

. Chi

n Ru

ral D

octo

r 199

7;4:

20–1

.Pe

riton

itis

(2 c

ases

)–

Reco

very

Zhen

g BS

, Zha

o M

L. L

esso

ns fr

om 2

cas

es o

f gal

lbla

dder

per

fora

tion

com

plic

ated

with

bile

per

itoni

tis c

ause

d by

acu

punc

ture

. Chi

n J

Clin

198

3;3:

44.

Wu

DP, H

e RL

. Gal

lbla

dder

per

fora

tion

com

plic

ated

with

bile

per

itoni

tis, 2

cas

es c

ause

d by

acu

punc

ture

. Sha

nxi J

Trad

Chi

n M

ed 1

981;

S1:4

4.Ba

i XF.

Acup

unct

ure-

indu

ced

gallb

ladd

er p

erfo

ratio

n w

ith b

ile p

erito

nitis

. Inn

er M

ongo

lia M

ed J

199

1;11

:80.

Liu

JC, L

iu H

Y. Ga

llbla

dder

per

fora

tion,

2 c

ases

cau

sed

by a

cupu

nctu

re. C

hin

J Ba

ses

Clin

Gen

Sur

g 20

01;8

:226

.Pe

rfora

ted

gallb

ladd

er

(7 c

ases

, 5 w

ith p

erito

nitis

)ST

25, C

V12

Reco

very

Duan

QL,

Wan

g SR

. Sev

ere

com

plic

atio

ns c

ause

d by

acu

punc

ture

in 3

cas

es. H

ebei

J Tr

ad C

hin

Med

198

4;1:

36–7

.In

test

inal

per

fora

tion

(5 c

ases

, al

l with

per

itoni

tis)

–Re

cove

ry

Wan

g M

Y. Se

rious

con

sequ

ence

s of

acu

punc

ture

at a

bdom

inal

acu

poin

ts in

2 c

ases

. Peo

ple’

s. M

il Su

rg 1

985;

6:61

–2.

Zhan

g JH

. Acu

punc

ture

at a

bdom

inal

acu

poin

ts c

ause

d 2

case

s of

per

itoni

tis. C

hin

Rura

l Doc

tor 1

997;

4:20

–1.

Xiao

XT.

Gast

ric p

erfo

ratio

n ca

used

by

acup

unct

ure.

Chi

n J

Clin

198

5;1:

9.Ga

stric

per

fora

tion

(1 c

ase,

w

ith p

erito

nitis

)CV

12Re

cove

ry

Liu

WG,

Dua

n LJ

, Sun

DT.

Acup

unct

ure

at T

ians

hu p

oint

cau

sed

inte

stin

al o

bstru

ctio

n. C

hin

J In

t Tra

d W

est M

ed 1

992;

3:14

7.In

test

inal

wal

l hae

mat

oma

with

obs

truct

ion

(1 c

ase)

ST25

Reco

very

B Bull World Health Organ 2;87:fpage–lpage | doi:10.2471/BLT.07.043125

Junhua Zhang et al.Review of acupuncture-related adverse events in ChinaResearch

Body

site

and

refe

renc

eaAd

vers

e ev

ent (

no. o

f ca

sesb )

Acup

oint

(cod

ec or

site

)Ou

tcom

e

Thor

acic

org

ans

and

tissu

esCh

ang

JY. A

cupu

nctu

re a

t bac

k ac

upoi

nts

caus

ed h

aem

opne

umot

hora

x. H

ebei

J Tr

ad C

hin

Med

198

4;3:

48.

Pneu

mot

hora

x (2

01 c

ases

)GB

21, B

L13,

BL

18, B

L23,

LI1

7,

ST12

, CV2

2,

CV15

, CV1

4, S

I9,

SI13

4 de

aths

; 197

re

cove

ries

Ding

WY.

Acup

unct

ure

at c

hest

and

bac

k po

ints

cau

sed

10 c

ases

of t

raum

atic

pne

umot

hora

x. C

entra

l Pla

ins

Med

J 1

986;

4:39

.Du

JY.

Repo

rt of

10

case

s of

pne

umot

hora

x ca

used

by

acup

unct

ure.

Cen

tral P

lain

s M

ed J

198

1;2:

22.

Duan

QL,

Wan

g SR

. Les

sons

from

3 c

ases

of s

ever

e co

mpl

icat

ions

of a

cupu

nctu

re. H

ebei

J T

rad

Chin

Med

198

4;1:

36–7

.Ga

o CG

. Tw

o ca

ses

of b

ilate

ral p

neum

otho

rax

caus

ed b

y ac

upun

ctur

e. J

Pra

ct M

ed 1

984;

3:38

–9.

Hu D

R. T

raum

atic

pne

umot

hora

x ca

used

by

acup

unct

ure

in 7

cas

es. J

iang

xi J

Trad

Chi

n M

ed 1

981;

4:29

–30.

Hu Q

X, Z

hang

HY.

Acup

unct

ure

caus

ed 9

cas

es o

f tra

umat

ic p

neum

otho

rax.

Clin

Med

(Nor

thfie

ld, I

L) 1

987;

7:33

1–3.

Hu Y

A. A

cupu

nctu

re a

t che

st a

cupo

ints

cau

sed

13 c

ases

of p

neum

otho

rax:

X-r

ay d

iagn

osis

and

ana

lysis

. Nei

Mon

gol J

Trad

Chi

n M

ed 1

995;

S1:5

1.Ji

ang

DG. A

cupu

nctu

re a

t Jiu

wei

poi

nt c

ause

d pn

eum

otho

rax.

Cho

ngqi

Med

J 1

980;

6:47

.Ji

n BR

. Acu

punc

ture

at Q

uyua

ni p

oint

cau

sed

pneu

mot

hora

x. S

hang

hai J

Acu

Mox

ibus

tion

1987

;3:4

5.Ji

n PL

. Acu

punc

ture

-rel

ated

acc

iden

ts a

nd th

eir p

reve

ntio

n. C

hin

J Pr

act C

hin

Mod

Med

200

5;8:

765.

Li Y

C. C

linic

al a

nalys

is o

f 25

case

s of

acu

punc

ture

-indu

ced

pneu

mot

hora

x. C

hin

Com

m D

octo

rs 1

995;

12:3

7–8.

Li Y

Y, Ch

eng

XL. O

ne c

ase

of p

neum

otho

rax

caus

ed b

y ac

upun

ctur

e. J

Han

dan

Med

Col

l 199

7;10

:72–

3.Li

u LY

. One

cas

e of

hae

mop

neum

otho

rax

caus

ed b

y ac

upun

ctur

e. J

Cha

ngch

un U

niv T

rad

Chin

Med

200

7;23

:58.

Lu B

, Tia

n XH

. One

cas

e of

trau

mat

ic te

nsio

n pn

eum

otho

rax

caus

ed b

y ex

cess

ively

deep

acu

punc

ture

. Gui

zhou

Med

J 1

993;

17:1

25.

Ma

WT.

Anal

yses

of 1

4 ca

ses

of tr

aum

atic

pne

umot

hora

x in

duce

d by

acu

punc

ture

. Anh

ui M

ed J

199

3;14

:41.

Ma

L, Z

hang

CJ.

Clin

ical

ana

lysis

of a

cupu

nctu

re-in

duce

d pn

eum

otho

rax.

J C

lin A

cu M

oxib

ustio

n 19

97;1

3:40

.M

a BZ

. Acu

punc

ture

-indu

ced

traum

atic

pne

umot

hora

x in

one

cas

e. Q

ingh

ai M

ed J

200

7;37

:41.

Ou Q

, Ji J

C. A

cupu

nctu

re a

t sho

ulde

r acu

poin

ts c

ause

d 5

case

s of

pne

umot

hora

x. J

Trad

Chi

n Or

thop

Trau

mat

ol 1

997;

9:54

.Qi

n M

X, A

o W

H. Im

prop

er a

cupu

nctu

re c

ause

d pn

eum

otho

rax.

Clin

Misd

iag

Mist

her 2

003;

16:7

6.Ru

an K

Y, Qi

KJ,

Mou

ZC.

Acu

punc

ture

at p

oint

s in

sup

racl

avic

ular

foss

a ca

used

hyd

ropn

eum

otho

rax.

New

J Tr

ad C

hin

Med

199

2;4:

33.

Shi Y

K. L

esso

ns fr

om 3

8 ca

ses

of p

neum

otho

rax

caus

ed b

y ac

upun

ctur

e. P

eopl

e’s.

Mil

Surg

198

0;10

:53.

Song

BZ,

Xu

JS. O

ne c

ase

haem

opne

umot

hora

x ca

used

by

acup

unct

ure

at le

ft Ji

anjin

poi

nt. J

Anh

ui Tr

ad C

hin

Med

Col

l 198

7;6:

45.

Song

QL,

Wu

TY. T

hree

ther

apeu

tic e

rrors

of a

cupu

nctu

re. C

lin M

isdia

g M

isthe

r 200

1;14

:73.

Wan

g DS

. Acu

punc

ture

at e

piga

striu

m c

ause

d pl

eura

l effu

sion

. Peo

ple’

s. M

il Su

rg 1

982;

10:7

3.W

ang

YL. O

ne d

eath

from

pne

umot

hora

x ca

used

by

acup

unct

ure

at b

ilate

ral T

iand

ing

poin

ts. J

For

ensic

Med

199

9;15

:47–

8.Xi

a C.

Tre

atin

g ac

upun

ctur

e-in

duce

d ac

cide

nts.

J C

lin A

cu M

oxib

ustio

n 19

93;2

:75–

6.Ya

n ZC

. Acu

punc

ture

at T

iant

u po

int c

ause

d se

vere

pne

umot

hora

x. N

ew C

hin

Med

198

5;16

:655

.Zh

a CH

. Ide

ntifi

catio

n of

hae

mop

neum

otho

rax

afte

r acu

punc

ture

from

pie

rcin

g of

the

left

lung

. Chi

n J

Fore

nsic

Med

200

6;21

:75–

6.Zh

ang

SP. A

cupu

nctu

re c

ause

d ha

emop

neum

otho

rax.

Sha

ngha

i J A

cu M

oxib

ustio

n 19

86;4

:21.

Zhan

g CY

, Zhe

ng S

M, P

ei Y

F. Fi

ve c

ases

of a

ccid

enta

l inj

ury

of in

tern

al o

rgan

s ca

used

by

impr

oper

acu

punc

ture

. Hei

long

jiang

J Tr

ad C

hin

Med

199

2;1:

38.

Zhao

DY,

Zhan

g GL

. Clin

ical

ana

lysis

of 3

8 ca

ses

of p

neum

otho

rax

indu

ced

by a

cupu

nctu

re o

r inj

ectio

n at

acu

poin

t. Ch

in A

cu M

oxib

ustio

n 20

09;2

9:23

9–42

.Zh

eng

PD, P

ang

SH. A

cupu

nctu

re c

ause

d se

vere

hae

mop

neum

otho

rax.

J Tr

ad C

hin

Med

198

3;5:

32.

Zhu

ZH, S

hen

H. A

ccid

enta

l pne

umot

hora

x ca

used

by

acup

unct

ure

ther

apy.

Int J

Em

erg

Crit

Care

Med

200

5;2:

992–

5.Zo

ng W

J. P

neum

otho

rax

caus

ed b

y ac

upun

ctur

e in

5 c

ases

. Sha

ngha

i J A

cu M

oxib

ustio

n 19

84;1

:24.

Yang

ST.

Acup

unct

ure

at F

eish

u po

int c

ause

d ch

yloth

orax

. J C

lin A

cu M

oxib

ustio

n 19

91;4

:19.

Chylo

thor

ax (1

cas

e)BL

13Re

cove

ryHu

o SH

, Tia

n YP

, Ma

QL, e

t al.

Acup

unct

ure

caus

ed c

ardi

ac in

jury

with

pne

umot

hora

x. C

hin

J Cr

it Ca

re M

ed 2

007;

27:9

08.

Righ

t ven

tricu

lar p

unct

ure

(4 c

ases

)CV

15, 2

nd–3

th

ICR

near

ste

rnal

ed

ge; p

reco

rdia

l re

gion

; und

er ri

ght

brea

st

2 de

aths

; 2

reco

verie

sLu

o YZ

, Don

g L,

Yua

n HS

, et a

l. Ac

upun

ctur

e ca

used

pul

sus

tard

us a

nd c

ardi

ac ta

mpo

nade

. Chi

n J

Clin

Tho

rac

Card

iova

sc S

urg

2006

;13:

343.

Zhu

WT,

Li X

S, Z

hang

YT,

et a

l. Ac

upun

ctur

e ca

used

dea

th fr

om c

ardi

ac ru

ptur

e. J

For

ensic

Med

200

8;24

:312

.Xi

e JZ

, Lin

WZ.

Acu

punc

ture

cau

ses

deat

h fro

m c

ardi

ac in

jury

. Chi

n J

Inte

gr Tr

ad W

est M

ed In

t Crit

Car

e 20

03;1

:51.

Zhu

J. A

cupu

nctu

re a

t Qim

en p

oint

indu

ced

deat

h fro

m a

ortic

hae

mor

rhag

e. S

hang

hai J

Acu

Mox

ibus

tion

1990

;2:3

1.Ao

rtic

arte

ry ru

ptur

e (1

cas

e)LR

14De

ath

Gen

JQ. S

ucce

ssfu

l man

agem

ent o

f acu

punc

ture

-indu

ced

coro

nary

arte

ry in

jury

with

acu

te c

ardi

ac ta

mpo

nade

. J C

lin C

ardi

ol 2

005;

21:3

92.

Coro

nary

arte

ry p

unct

ure

with

ca

rdia

c ta

mpo

nade

(1 c

ase)

LU1

Reco

very

CBull World Health Organ 2;87:fpage–lpage | doi:10.2471/BLT.07.043125

Junhua Zhang et al. Review of acupuncture-related adverse events in ChinaResearch

Body

site

and

refe

renc

eaAd

vers

e ev

ent (

no. o

f ca

sesb )

Acup

oint

(cod

ec or

site

)Ou

tcom

e

Neck

are

aZh

u J.

Acu

punc

ture

at T

iant

u po

int c

ause

d on

e de

ath.

Jia

ngsu

J Tr

ad C

hin

Med

198

6;2:

28.

Inju

ry o

f inf

erio

r lar

ynge

al

nerv

e an

d tra

chea

(1 c

ase)

CV22

Deat

h

Gao

LW. A

cupu

nctu

re a

t Fut

u po

int c

ause

d dy

spno

ea. C

hin

J Tr

ad C

hin

Med

Pha

rm 1

989;

2:50

.Vo

cal c

ord

para

lysis

; su

bcut

aneo

us e

mph

ysem

a (1

cas

e)

LI18

Reco

very

Zhou

LZ,

Zha

o DG

, Pen

g L.

Opi

nion

s re

gard

ing

acup

unct

ure-

indu

ced

hoar

sene

ss. S

hang

hai J

Acu

Mox

ibus

tion

2005

;27:

27.

Hoar

sene

ss (1

cas

e)Na

pe a

rea

Reco

very

Yan

BX. A

cupu

nctu

re a

t bra

chia

l ple

xus

caus

ed p

hren

ic n

erve

inju

ry. S

haan

xi J

Trad

Chi

n M

ed 1

994;

15:5

13.

Inju

ry o

f phr

enic

ner

ve

(1 c

ase)

Bico

ngRe

cove

ry

Cai X

J. A

cupu

nctu

re c

ause

d th

yroi

d ca

psul

e ha

emor

rhag

e w

ith a

sphy

xia. M

ed J

Chi

n Pe

ople

’s Li

bera

tion

Arm

y 19

91;6

:494

.Th

yroi

d ha

emor

rhag

e;

infe

ctio

n (1

cas

e)Ne

ck a

rea

Reco

very

Chen

SM

. Acu

punc

ture

cau

sed

traum

atic

car

otid

arte

ry a

neur

ysm

. J Tr

ad C

hin

Med

198

0;7:

49.

Fals

e an

eury

sm o

f car

otid

ar

tery

(1 c

ase)

Neck

are

aRe

cove

ry

Eye

area

Jin

PL. A

dis

cuss

ion

of a

cupu

nctu

re-r

elat

ed a

ccid

ents

and

thei

r pre

vent

ion.

Chi

n J

Prac

t Chi

n M

od M

ed 2

005;

8:76

5.Or

bita

l hae

mor

rhag

e (3

cas

es)

SL1,

EX-

HN7

2 re

cove

ries;

1

Visu

al

impa

irmen

tXu

RZ.

Acu

punc

ture

at J

ingm

ing

poin

t cau

sed

exop

htha

lmos

: pre

vent

ion

and

coun

term

easu

res.

J C

lin A

cu M

oxib

ustio

n 20

03;1

9:22

.Ya

ng G

, Wan

g SL

. Blin

dnes

s ca

used

by

acup

unct

ure.

Tia

njin

J Tr

ad C

hin

Med

199

6;13

:6.

Yang

G, W

ang

SL. B

lindn

ess

caus

ed b

y ac

upun

ctur

e. T

ianj

in J

Trad

Chi

n M

ed 1

996;

13:6

.Tr

aum

atic

cat

arac

t (1

case

)Su

perc

iliary

ac

upoi

nts

Visu

al

impa

irmen

tXu

LH,

Liu

AH.

Ocu

lom

otor

ner

ve in

jury

cau

sed

by a

cupu

nctu

re. C

hin

J Oc

ular

Trau

ma

Occu

p Ey

e Di

s 19

97;1

9:22

6.In

jury

of o

culo

mot

or n

erve

(1

cas

e)ST

1Re

cove

ry

Liu

BS, L

i ZX,

Lei

F. A

cupu

nctu

re-in

duce

d re

tinal

det

achm

ent.

Chin

J O

cula

r Tra

uma

Occu

p Ey

e Di

s 19

88;1

:43–

4.Re

tinal

inju

ry (1

cas

e)Ey

elid

Reco

very

Perip

hera

l ner

ves

and

bloo

d ve

ssel

sDi

ng X

Y, Li

u SY

. Acc

iden

t due

to c

linic

al a

cupu

nctu

re. C

hin

Acu

Mox

ibus

tion

2008

;28:

817–

8.Le

g, h

aem

orrh

age;

dia

betic

fo

ot (1

cas

e)ST

38, B

L57

–

Xia

C. T

reat

ing

acup

unct

ure-

indu

ced

acci

dent

. J C

lin A

cu M

oxib

ustio

n 19

93;2

:75–

6.Ch

eeks

, hae

mat

oma

(1 c

ase)

ST5

Reco

very

Han

LX. A

cupu

nctu

re a

t Lia

nqua

n po

int c

ause

d su

blin

gual

fold

hae

mat

oma.

Sha

ngha

i J A

cu M

oxib

ustio

n 19

94;1

3:10

7.Hy

pogl

ottis

, hae

mat

oma

(2 c

ases

)CV

23Re

cove

ryW

ang

NR. A

cupu

nctu

re a

t Lia

nqua

n po

int c

ause

d su

blin

gual

hae

mat

oma.

J C

lin A

cu M

oxib

ustio

n 19

96;7

:89.

Ou L

S, L

iu D

C, T

ian

LY, e

t al.

Acup

unct

ure

at H

egu

poin

t cau

sed

thum

b ad

duct

ion

defo

rmity

in 1

2 ch

ildre

n. J

Anh

ui Tr

ad C

hin

Med

Col

l 198

9;8:

40.

Addu

ctio

n de

form

ity o

f th

umb

(3 c

ases

)LI

4Re

cove

ry

Wan

g SF

. Acu

punc

ture

at T

aiya

ng p

oint

cau

sed

adve

rse

reac

tions

from

impr

oper

man

ipul

atio

n in

2 c

ases

. Cen

tral P

lain

s M

ed J

198

2;3:

135.

Inab

ility

to c

lose

eye

(1 c

ase)

EX-H

N5Re

cove

ryW

ang

SF. A

cupu

nctu

re a

t Tai

yang

poi

nt c

ause

d ad

vers

e re

actio

ns fr

om im

prop

er m

anip

ulat

ion

in 2

cas

es. C

entra

l Pla

ins

Med

J 1

982;

3:18

5.In

abilit

y to

shu

t mou

th

(1 c

ase)

EX-H

N5Re

cove

ry

Wan

g L.

Acu

punc

ture

at N

eigu

an p

oint

indu

ced

hand

mus

cle

cont

ract

ure.

Sha

ngha

i J A

cu M

oxib

ustio

n 19

91;2

:45.

Palm

ar m

uscl

e co

ntra

ctur

e (2

cas

es)

PC6

Reco

very

Need

ling

site

Feng

B, H

uang

YX.

Adv

erse

eve

nts

caus

ed b

y im

prop

er a

cupu

nctu

re. J

Clin

Acu

Mox

ibus

tion

1996

;12:

42.

Pain

(4 c

ases

)SI

3, L

I11,

han

d ac

upoi

nts

Reco

very

Shi G

P, Ch

en Z

M. A

nalys

is o

f 3 a

ccid

ents

cau

sed

by a

cupu

nctu

re. J

Clin

Acu

Mox

ibus

tion

1994

;10:

38.

Li S

L, C

ui X

M. F

ract

ured

acu

punc

ture

nee

dle

caus

ed in

tra-a

bdom

inal

lum

p. S

hang

hai J

Acu

Mox

ibus

tion

1992

;3:3

2.Br

oken

nee

dle

(1 c

ase)

–Re

cove

rya A

ll re

fere

nces

in th

is ta

ble

are

in C

hine

se. T

he E

nglis

h-la

ngua

ge p

aper

and

jour

nal t

itles

are

free

tran

slat

ions

. The

orig

inal

Chi

nese

-lang

uage

title

s ca

n be

obt

aine

d fro

m th

e co

rresp

ondi

ng a

utho

r.b O

nly

case

s of

trad

ition

al n

eedl

e ac

upun

ctur

e ar

e in

clud

ed. T

his

expl

ains

any

dis

crep

ancy

bet

wee

n th

e nu

mbe

r of c

ases

in th

is c

olum

n an

d th

e tit

le o

f the

cor

resp

ondi

ng re

fere

nce.

c Ref

eren

ces10

,11 .