Clinical study of syncope during acupuncture treatment

A bibliometric analysis of acupuncture research in Taiwan from 1988 to 2017

BACKGROUND

Since Taiwan's national health insurance system provides residents with easy and affordable access to clinical acupuncture treatment, this study sought to analyze trends in the publication of acupuncture-related research in Taiwan from 1988 to 2017, using a bibliometric method.

METHODS

Data on the scholarly literature from 1988 to 2017 were retrieved through Web of Science searches for the keywords acupunct*, acupoint*, electroacupunct*, electro-acupunct*, acupre*, auricular acupunc*, and auricular needle* in study titles.

RESULTS

A total of 539 acupuncture-related articles published from 1988 to 2017 were identified and analyzed. The articles had an h-index of 38 and were cited in subsequent studies 7250 times, meaning that Taiwan ranked sixth in the production of such publications among countries/regions globally. Among those articles, 99 (18.4%) had no subsequent citations, six (1.1%) were highly cited (over 100 citations), and 141 (26.1%) were cited 4 to 10 times. The highly cited articles discussed the possible pathways of acupuncture stimulation and efficacy, and received 1103 (15.2%) of the citations.

CONCLUSION

The China Medical University in Taichung, Taiwan, was the most active educational institution in Taiwan in terms of acupuncture-related research. Professor Lin Jaung-Geng was the leading acupuncture-related researcher, having the most publications, citations, and the highest h-index value. These results provided a context for analyzing the strengths of the existing research and informing prospective strategies for further studies.

Complications of Acupuncture

Acupuncture as a treatment modality is now more widely used by the medical profession. It behoves both practitioners and patients to be aware of possible complications, the majority of which can be avoided with cautious and prudent use of this ancient therapy.

There have been many isolated reports of complications of acupuncture in the literature. We surveyed the literature identifying all articles referring to complications of acupuncture. Our findings are presented and discussed.

The Safety of Acupuncture – Evidence from the Uk

Background

Patients are attracted to acupuncture partly by its reputation for having low risks. The safety of acupuncture should be established by positive evidence.

Methods

Two prospective surveys were conducted among different groups of professionals in the UK, including doctors, physiotherapists and practitioners primarily trained in acupuncture. Participants monitored adverse events over a defined period of time, and reported minor and significant events on purpose designed forms.

Results

A total of 652 acupuncturists reported 6733 adverse reactions including tiredness in 66 229 patients, an adverse event rate of 10.2%. The most common events were tiredness (3%) bleeding or bruising (3%), aggravation of symptoms (2%) and pain at the needling site (1%). There were no serious adverse events. A total of 86 (0.1%) of the treatments was associated with an event that the practitioner judged to be significant though without persistent consequences for the patient's health.

Conclusion

The risks associated with acupuncture can be classified as negligible, and acupuncture is a very safe treatment in the hands of competent practitioners.

A Case Series of Temporomandibular Disorders Treated with Acupuncture, Occlusal Splint and Point Injection Therapy

A treatment regime combining acupuncture, occlusal splint and point injection therapy for temporomandibular disorders (TMD) is presented. There were 89 consecutive patients treated by the regime in this case series but four patients dropped out after two to three visits. Data and treatment results of the remaining 85 patients who had treatment completed were analysed. It was found that 73 (85%) of patients with TMD had symptoms relieved within six visits under this regime. Complications were rare and minor. Acupuncture treatment, in combination with splint therapy and point injection therapy, appears to be effective for managing TMD. However, further research, using randomised controlled trials should be conducted to ascertain its effectiveness over other treatment modalities.

A Cumulative Review of the Range and Incidence of Significant Adverse Events Associated with Acupuncture

Objective

To summarise the range and frequency of significant adverse events associated with acupuncture in order to provide evidence on which to base continuing efforts to improve the safety of acupuncture practice.

Methods

Searches were conducted of computerised databases, previous reviews of case reports, population surveys, prospective surveys of acupuncture practice and relevant sections of textbooks for primary and secondary reports to indicate the range of significant adverse events associated with acupuncture. Data from prospective surveys of acupuncture were combined to estimate the incidence of serious adverse events.

Results

A total of 715 adverse events was included. There were 90 primary reports of trauma, and 186 secondary reports; the most common were pneumothorax and injury to the central nervous system. Infection accounted for 204 primary reports and 91 secondary reports. Over 60% of these cases were hepatitis B. The next most common infection was of the external ear, as a complication of auricular acupuncture. The 144 miscellaneous events mainly comprised seizures and drowsiness judged severe enough to cause a traffic hazard. There were 12 primary reports of deaths. According to the evidence from 12 prospective studies which surveyed more than a million treatments, the risk of a serious adverse event with acupuncture is estimated to be 0.05 per 10 000 treatments, and 0.55 per 10 000 individual patients.

Conclusions

The risk of serious events occurring in association with acupuncture is very low, below that of many common medical treatments. The range of adverse events reported is wide and some events, specifically trauma and some episodes of infection, are likely to be avoidable.

Acupuncture-Associated Vasovagal Response: Revised Terminology and Hospital Experience

Background: Vasovagal responses associated with acupuncture therapy are relatively uncommon adverse events, occurring in ∼0.02%-7% of treatments. The complex neurocardiovascular reflexes involved in vasovagal responses can induce a range of symptoms such as dizziness, nausea, sweating, bradycardia, hypotension, and, in some cases, syncope or convulsions. Although patients typically recover quickly with proper support, these events may be of concern and anxiety-producing for both patient and provider. Providers need to be well-versed in methods for prevention and treatment of acupuncture-associated vasovagal responses to promote safe practice environments, patient satisfaction and comfort, and cost-effectiveness. Objectives: To examine the biomedical and Traditional Chinese Medicine mechanisms of vasovagal responses, propose updated terminology, and outline steps for prevention and treatment. Methods: During an 18-month period, 281 community-style acupuncture treatments were performed on family members of admitted patients and hospital staff members at the University of Minnesota Masonic Children's Hospital. Five (1.8%) treatments resulted in documented acupuncture-associated vasovagal response (AAVR) symptoms. Results: All 5 patients recovered from their AAVR symptoms after treatment interventions. After recovery, 3 patients reported reductions in their main complaint symptoms; main complaint symptom outcomes were not recorded for the other 2 patients. Conclusions: As integrative practices become more prevalent in academic institutions and primary care environments, clear communication about, as well as prevention treatment, documentation and reporting of acupuncture-associated adverse events will become increasingly valuable. The authors recommend that clinicians in integrative practice clinical environments consider developing formal AAVR response plans as well as training students, supervising and attending providers, and ancillary staff members to ensure rapid, prepared handling and documentation of AAVR incidents.

A Review of Integrative Medicine in Gynaecological Oncology

In recent years complementary and alternative medicine (CAM) has increasingly been the focus of international research. Numerous subsidised trials (7903) and systematic reviews (651) have been published, and the evidence is starting to be integrated into treatment guidelines. However, due to insufficient evidence and/or insufficient good quality evidence, this has mostly not translated to practice recommendations in reviews by the Cochrane collaboration gynaecology group. There is nevertheless a not insignificant number of CAM providers and users. The percentage of oncology patients who use CAM varies between 5 and 90 %. Doctors have been identified as the main providers of CAM. Half of gynaecologists offer CAM because of personal conviction or on suggestion from colleagues. This must be viewed in a critical light, since CAM is mostly practiced without appropriate training, often without sufficient evidence for a given method - and where evidence exists, practice guidelines are lacking - and lack of safety or efficacy testing. The combination of patient demand and lucrativeness for doctors/alternative medicine practitioners, both based on supposed effectiveness CAM, often leads to its indiscriminate use with uncertain outcomes and significant cost for patients. On the other hand there is published, positive level I evidence for a number of CAM treatment forms. The aim of this article is therefore to review the available evidence for CAM in gynaecological oncology practice. The continued need for research is highlighted, as is the need to integrate practices supported by good evidence into conventional gynaecological oncology.

Myofascial trigger point therapy: laser therapy and dry needling

The aim of the present review is to discuss two forms of treatment for myofascial pain: laser therapy and dry needling. Although studies have reported the deactivation of myofascial trigger points with these two methods, clinical trials demonstrating their efficacy are scarce. The literature reports greater efficacy with the use of laser over dry needling. It has been suggested that improvements in microcirculation through the administration of laser therapy may favor the supply of oxygen to the cells under conditions of hypoxia and help remove the waste products of cell metabolism, thereby breaking the vicious cycle of pain, muscle spasm and further pain. While laser therapy is the method of choice for patients with a fear of needles and healthcare professionals inexperienced with the dry needling technique, further controlled studies are still needed to prove the greater efficacy of this method.

Acupuncture adverse events in China: a glimpse of historical and contextual aspects

The article by He and colleagues, "Adverse Events Following Acupuncture: A Systematic Review of the Chinese Literature for the Years 1956-2010" is an important and timely contribution. In this commentary, the article is reviewed and issues are highlighted about how to interpret and contextualize the results of their study. While their review has been well performed, certain areas have been identified where the results may be inaccurate due to problems in the reporting of original incidents. For example, potential problems were found in the reporting of the minor adverse event (AE) of fainting and the more serious AEs of pneumothorax and hepatitis. The article by He and colleagues highlights the issue that almost all AEs associated with acupuncture in the modern period are due to the administration of the therapy rather than the therapy itself. Future prospective studies can address some of the shortcomings identified in this review.

The safety of pediatric acupuncture: a systematic review

CONTEXT

Acupuncture is increasingly used in children; however, the safety of pediatric acupuncture has yet to be reported from systematic review.

OBJECTIVE

To identify adverse events (AEs) associated with needle acupuncture in children.

METHODS

Eighteen databases were searched, from inception to September 2010, irrespective of language. Inclusion criteria were that the study (1) was original peer-reviewed research, (2) included children from birth to 17 years, inclusively, (3) involved needle acupuncture, and (4) included assessment of AEs in a child. Safety data were extracted from all included studies.

RESULTS

Of 9537 references identified, 450 were assessed for inclusion. Twenty-eight reports were included, and searches of reference lists identified 9 additional reports (total: 37). A total of 279 AEs were identified, 146 from randomized controlled trials, 95 from cohort studies, and 38 from case reports/series. Of the AEs, 25 were serious (12 cases of thumb deformity, 5 infections, and 1 case each of cardiac rupture, pneumothorax, nerve impairment, subarachnoid hemorrhage, intestinal obstruction, hemoptysis, reversible coma, and overnight hospitalization), 1 was moderate (infection), and 253 were mild. The mild AEs included pain, bruising, bleeding, and worsening of symptoms. We calculated a mild AE incidence per patient of 168 in 1422 patients (11.8% [95% confidence interval: 10.1-13.5]).

CONCLUSIONS

Of the AEs associated with pediatric needle acupuncture, a majority of them were mild in severity. Many of the serious AEs might have been caused by substandard practice. Our results support those from adult studies, which have found that acupuncture is safe when performed by appropriately trained practitioners.

Safety of acupuncture practice in Japan: patient reactions, therapist negligence and error reduction strategies

Evidence-based approach on the safety of acupuncture had been lagging behind both in the West and the East, but reliable data based on some prospective surveys were published after the late 1990s. In the present article, we, focusing on 'Japanese acupuncture', review relevant case reports and prospective surveys on adverse events in Japan, assess the safety of acupuncture practice in this country, and suggest a strategy for reducing the therapists' error. Based on the prospective surveys, it seems reasonable to suppose that serious adverse events are rare in standard practice by adequately trained acupuncturists, regardless of countries or modes of practice. Almost all of adverse reactions commonly seen in acupuncture practice-such as fatigue, drowsiness, aggravation, minor bleeding, pain on insertion and subcutaneous hemorrhage-are mild and transient, although we should be cautious of secondary injury following drowsiness and needle fainting. After demonstrating that acupuncture is inherently safe, we have been focusing on how to reduce the risk of negligence in Japan, as well as educating acupuncturists more about safe depth of insertion and infection control. Incident reporting and feedback system is a useful strategy for reducing therapist errors such as forgotten needles. For the benefit of acupuncture patients in Japan, it is important to establish mandatory postgraduate clinical training and continued education system.

Convulsive Syncope: An Unusual Complication of Acupuncture Treatment in Older Patients

Vasovagal syncope is an uncommon complication during acupuncture. However, convulsive syncope during acupuncture treatment in older individuals is seldom reported in the literature. Two older patients who experienced convulsive syncope during acupuncture treatment at Taipei Veterans Hospital, Taipei, Taiwan, from January 2000 to December 2002 are reported. These cases are instructive to acupuncturists. Although acupuncture treatment is generally safe in most situations, one needs to be cautious in delivering acupuncture to older and debilitated individuals.

Clinical research on acupuncture. Part 1. What have reviews of the efficacy and safety of acupuncture told us so far?

OVERVIEW AND METHODS: This paper discusses those medical conditions in which clinical trials of acupuncture have been conducted, and where meta-analyses or systematic reviews have been published. It focuses on the general conclusions of these reviews by further examining official reviews conducted in the United States, United Kingdom, Europe, and Canada each of which examined available systematic reviews. While all reviews agree that the methodological rigor of acupuncture clinical trials has generally been poor and that higher quality clinical trials are necessary, this has not completely hampered the interpretation of the results of these clinical trials. In some conditions the evidence of efficacy has clearly reached a sufficient critical mass from enough well-designed studies to draw clear conclusions; for the rest, the evidence is difficult to clearly interpret. This paper also examines conclusions from the same international reviews on the safety and adverse effects of acupuncture. Here, conclusions are more easily drawn and there is good agreement about the safety of acupuncture.

RESULTS AND CONCLUSIONS

General international agreement has emerged that acupuncture appears to be effective for postoperative dental pain, postoperative nausea and vomiting, and chemotherapy-related nausea and vomiting. For migraine, low-back pain, and temporomandibular disorders the results are considered positive by some and difficult to interpret by others. For a number of conditions such as fibromyalgia, osteoarthritis of the knee, and tennis elbow the evidence is considered promising, but more and better quality research is needed. For conditions such as chronic pain, neck pain, asthma, and drug addiction the evidence is considered inconclusive and difficult to interpret. For smoking cessation, tinnitus, and weight loss the evidence is usually regarded as negative. Reviews have concluded that while not free from serious adverse events, they are rare and that acupuncture is a relatively safe procedure.

Convulsive syncope associated with acupuncture

Syncope is a rare but known reaction to acupuncture; however, convulsive syncope has never been previously documented as a reaction to acupuncture. This case report describes an episode of convulsive syncope, characterized by irregular clonic-tonic movements while the patient was unconscious. The episode occurred immediately after the insertion of acupuncture needles into the bilateral ST-36 acupuncture point. Here we discuss the presentation, possible causes, and prevention of convulsive syncope.

A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists

The paper describes the type and frequency of adverse events and transicnt reactions following consultations with professional acupuncturists. In a postal survey, involving 1,848 professional acupuncturists, all of whom were members of the British Acupuncture Council and practising in the UK, details of adverse events and transient reactions following treatment were recorded on standardised self-report forms. A sample size of 30,000 treatments was sought, and piloting indicated that a four-week period was required. Practitioners also provided information on themselves, including age, sex, length of training and years of practice. A total of 574 practitioners responded. 31% of the total population. These practitioners reported on adverse events and transient reactions associated with 34,407 treatments. No serious adverse events were reported, where these were defined as requiring hospital admission, prolonging hospital stays, permanently disabling, or resulting in death (95% CI: 0 to 1.1 per 10,000 treatments). A total of 43 significant minor adverse events were reported, a rate of 1.3 per 1,000 treatments (95% CI: 0.9 to 1.7). These included severe nausea and actual fainting (12), unexpected, severe and prolonged aggravation of symptoms (7), prolonged and unacceptable pain and bruising (5) and psychological and emotional reactions (4). There were three avoidable events: two patients had needles left in by mistake, and one patient had moxa burns to the skin, also caused by practitioner error. The acupuncturists also recorded 10,920 mild transient reactions occurring in 5136 treatments. 15% (95% CI: 14.6 to 15.3) of the 34,407 total. In terms of local reactions, there were reports of mild bruising (1.7%), pain (1.2%) and bleeding (0.4%). Practitioners reported that patients experienced an aggravation of existing symptoms after 2.8% of treatments. The most common mild transient reactions to treatment were feeling relaxed (11.9%) and feeling energised (6.6%). In this prospective survey of 34,407 treatments, practitioners reported no serious adverse events. This conclusion was based on data collected from one in three members of the British Acupuncture Council. Given that the whole membership delivers between one and a half and two million treatments a year, this is important evidence on public health and safety. When compared with medication routinely prescribed in primary care, the results suggest that acupuncture is a relatively safe treatment modality.

Prospective studies of the safety of acupuncture: a systematic review

PURPOSE

The objective of this review was to determine the incidence of adverse events associated with acupuncture.

SUBJECTS AND METHODS

A search for prospective surveys of the safety of acupuncture was conducted using computerized databases (Medline, Embase, the Cochrane Library, and CISCOM), inquiries to acupuncture organizations, and our own files. Data on sample, size, types of patients duration of study, types of acupuncture, definition of adverse events, method of evaluation, and findings were extracted systematically from the retrieved reports.

RESULTS

Nine surveys were located and included in the review. Their results were not uniform. The most common adverse events were needle pain (1% to 45%) from treatments, tiredness (2% to 41%), and bleeding (0.03% to 38%). Feelings of faintness and syncope were uncommon, with an incidence of 0% to 0.3%. Feelings of relaxation were reported by as many as 86% of patients. Pneumothorax was rare, occurring only twice in nearly a quarter of a million treatments.

CONCLUSIONS

Although the incidence of minor adverse events associated with acupuncture may be considerable, serious adverse events are rare. Those responsible for establishing competence in acupuncture should consider how to reduce these risks.

Incidence of adverse reactions associated with acupuncture

OBJECTIVES

To determine the type, severity, and incidence of acupuncture adverse reactions that are observed in standard practice.

DESIGN

A survey based on observation and interview by the therapists.

SETTING

Tsukuba College of Technology Clinic in Japan.

SUBJECTS

All patients who underwent acupuncture treatment during a period of 4 months from April to July 1998.

OUTCOME MEASURES

Type, severity, and incidence of acupuncture adverse reactions.

RESULTS

A total of 391 patients were treated in 1,441 sessions, involving a total of 30,338 needle insertions. The incidence of recorded systemic reactions in individual patients was: tiredness (8.2%); drowsiness (2.8%); aggravation of preexisting symptoms (2.8%); itching in the punctured regions (1.0%); dizziness or vertigo (0.8%); feeling of faintness or nausea during treatment (0.8%); headache (0.5%); and chest pain (0.3%). The incidence of recorded local reactions, expressed as a percentage of needle insertions, was: minor bleeding on withdrawal of the needle (2.6%); pain on insertion of the needle (0.7%); petechia or ecchymosis (0.3%); pain or ache in the punctured region after the treatment (0.1%); subcutaneous haematoma (0.1%); and pain or discomfort in the punctured region during the needle retention (0.03%).

CONCLUSION

Although some adverse reactions associated with acupuncture were common even in standard practice, they were transient and mild compared to cases such as pneumothorax, cardiac injury, infection, or spinal lesions reported in other studies.