To determine the adverse effects of acupuncture.

The author searched MEDLINE (1981-1994) using the keywords 'acupuncture adverse effects'. There were no language restrictions, however the English abstract was used as the only source of information for reports in languages other than English, Norwegian, German, French, Spanish, or Russian.

Study designs of evaluations included in the review

Case reports of adverse effects of acupuncture.

Specific interventions included in the review

Acupuncture including Japanese acupuncture (where the needles are inserted 2cm into the body, cut off, and left in the body for up to 30 years), moxibustion with acupuncture, hot needle acupuncture and electroacupuncture.

Participants included in the review

Patients undergoing treatment by acupuncture. Ninety-six (96) patients were European, 27 were Asian, 66 were American, and 4 were Australian or African.

Outcomes assessed in the review

Any adverse effects of acupuncture which were classified into 3 categories: mechanical organ injuries, infections, and other adverse effects.

How were decisions on the relevance of primary studies made?

The author does not state how the papers were selected for the review, or how many of the reviewers performed the selection.

The author does not report the method used to assess quality, or how the quality assessment was performed.

The author does not state how the data were extracted for the review, or how many of the reviewers performed the data extraction.

How were the studies combined?

The reports are combined in a narrative discussion of the outcome measures with totals given for each adverse effect.

How were differences between studies investigated?

The author does not state how differences between the studies were investigated. However, the author does acknowledge very different contents in the case reports and different definitions for the acupuncture procedure.

Seventy-eight studies were included in the review with 193 patients.

Thirty-three (33) studies report 42 occurrences of mechanical organ injuries including pneumothorax (17 studies, 23 patients), pseudoaneurysm (1 study, 1 patient), compartment syndrome (1 study, 1 patient), deep venous thrombophlebitis (1 study, 1 patient), medulla spinalis injury (10 studies, 13 patients), nerve injury (1 study, 1 patient) and upper urinary tract injury (2 studies, 2 patients).

Thirty-one (31) articles report 129 occurrences of infections including hepatitis (11 studies, 100 patients), auricular chondritis (8 studies, 16 patients), bacterial endocarditis (4 studies, 4 patients), myelitis (3 studies, 3 patients), staphylococcal sepsis (2 studies, 3 patients), HIV (1 study, 1 patient), psoas abscess (1 study, 1 patient), and lymphocytoma cutis (1 study, 1 patient).

Sixteen (16) articles report 22 occurrences of 'other adverse effects' including asthmatic death (1 study, 1 patient), contact dermatitis (3 studies, 3 patients), prurigo pigmentosa (1 study, 1 patient), reduced bowel movements (1 study, 2 patients), hypotension/fainting (2 studies, 2 patients), increased pain (1 study, 1 patient), argyria (2 studies, 5 patients), Behcets syndrome (1 study, 1 patient), eschars and scarring (1 study, 1 patient), and problems from implanted needles (3 studies, 5 patients).

There were 3 deaths reported: one from bilateral pneumothorax, one from endocarditis, and one from severe asthma while under acupuncture treatment.

Most adverse effects of acupuncture seem to be a result of incorrect treatment (due to insufficient basic medical knowledge, low hygienic standard, and inadequate acupuncture education) rather than adverse effects after correctly performed acupuncture. The study confirms the adverse effects of acupuncture under certain circumstances. Serious adverse effects, however, are few, and acupuncture can generally be considered as a safe treatment.

The author has stated the research question but no inclusion criteria for the review. The literature search is poor because the author has searched only the MEDLINE database which may have missed relevant studies published outside the USA.

The author has not reported on how the articles were selected, or how the quality of the included studies was assessed and there is no report as to who, or how many reviewers, selected the articles or extracted the data. The studies are not statistically combined which was appropriate. However, the included studies have no controls so the determination of causality for the adverse events is questionable. The authors also do not report any data on the type of patients included, the types of acupuncture used in each case, and why that acupuncture treatment was used. The author's conclusions should therefore be viewed with caution.

Practice: The author states that adequate acupuncture education, especially insertion technique, and the practical use of basic medical knowledge should effectively prevent adverse effects of acupuncture.

Research: There are no stated implications for further research.

Norwegian Research Council.

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.