Editing Acupuncture (section)

=== Adverse events ===
Acupuncture is generally safe when administered by an experienced, appropriately trained practitioner using clean-needle technique and sterile single-use needles.<ref name="nciacupuncture">{{cite web|title= Acupuncture&nbsp;– for health professionals (PDQ)|url= http://www.cancer.gov/about-cancer/treatment/cam/hp/acupuncture-pdq#section/_71|publisher= [[National Cancer Institute]]|date= 23 September 2005|access-date= 16 July 2015|archive-date= 17 July 2015|archive-url= https://web.archive.org/web/20150717182155/http://www.cancer.gov/about-cancer/treatment/cam/hp/acupuncture-pdq#section/_71|url-status= live}}</ref> When improperly delivered it can cause adverse effects.<ref name="Xu S"/> Accidents and infections are associated with infractions of sterile technique or neglect on the part of the practitioner.<ref name="nciacupuncture"/> To reduce the risk of serious adverse events after acupuncture, acupuncturists should be trained sufficiently.<ref name="Ernst 2011">{{cite journal | vauthors = Ernst E, Lee MS, Choi TY | title = Acupuncture: does it alleviate pain and are there serious risks? A review of reviews | journal = Pain | volume = 152 | issue = 4 | pages = 755–64 | date = April 2011 | pmid = 21440191 | doi = 10.1016/j.pain.2010.11.004 | s2cid = 20205666 | url = http://www.dcscience.net/Ernst-2011-AcupunctAlleviatePainRiskReview.pdf | access-date = 20 January 2017 | archive-date = 20 September 2017 | archive-url = https://web.archive.org/web/20170920124317/http://www.dcscience.net/Ernst-2011-AcupunctAlleviatePainRiskReview.pdf | url-status = live }}
*Comment in: {{cite journal | last=Hall | first=Harriet | title=Acupuncture's claims punctured: Not proven effective for pain, not harmless | journal=Pain | publisher=Ovid Technologies (Wolters Kluwer Health) | volume=152 | issue=4 | year=2011 | issn=0304-3959 | doi=10.1016/j.pain.2011.01.039 | pages=711–712| pmid=21440190 | s2cid=4472996 }}</ref> A 2009 overview of [[Cochrane Collaboration|Cochrane reviews]] found acupuncture is not effective for a wide range of conditions.<ref name=Ernst2009>{{cite journal | vauthors = Ernst E | title = Acupuncture: what does the most reliable evidence tell us? | journal = Journal of Pain and Symptom Management | volume = 37 | issue = 4 | pages = 709–14 | date = April 2009 | pmid = 18789644 | doi = 10.1016/j.jpainsymman.2008.04.009 | doi-access = free }}</ref> People with serious spinal disease, such as cancer or infection, are not good candidates for acupuncture.<ref name=Berman2010/> [[Contraindication]]s to acupuncture (conditions that should not be treated with acupuncture) include coagulopathy disorders (e.g. hemophilia and advanced liver disease), warfarin use, severe psychiatric disorders (e.g. psychosis), and skin infections or skin trauma (e.g. burns).<ref name=Berman2010/> Further, electroacupuncture should be avoided at the spot of implanted electrical devices (such as pacemakers).<ref name=Berman2010/>

A 2011 systematic review of systematic reviews (internationally and without language restrictions) found that serious complications following acupuncture continue to be reported.<ref name="Ernst 2011"/> Between 2000 and 2009, ninety-five cases of [[serious adverse event]]s, including five [[deaths]], were reported.<ref name="Ernst 2011"/> Many such events are not inherent to acupuncture but are due to [[Medical malpractice|malpractice]] of acupuncturists.<ref name="Ernst 2011"/> This might be why such complications have not been reported in surveys of adequately trained acupuncturists.<ref name="Ernst 2011"/> Most such reports originate from Asia, which may reflect the large number of treatments performed there or a relatively higher number of poorly trained Asian acupuncturists.<ref name="Ernst 2011"/> Many serious adverse events were reported from developed countries.<ref name="Ernst 2011"/> These included Australia, Austria, Canada, Croatia, France, Germany, Ireland, the Netherlands, New Zealand, Spain, Sweden, Switzerland, the UK, and the US.<ref name="Ernst 2011"/> The number of adverse effects reported from the UK appears particularly unusual, which may indicate less under-reporting in the UK than other countries.<ref name="Ernst 2011"/> Reports included 38 cases of infections and 42 cases of organ trauma.<ref name="Ernst 2011"/> The most frequent adverse events included [[pneumothorax]], and [[bacterial infection|bacterial]] and [[viral infection]]s.<ref name="Ernst 2011"/>

A 2013 review found (without restrictions regarding publication date, study type or language) 295 cases of infections; [[mycobacterium]] was the [[pathogen]] in at least 96%.<ref name=Gnatta2013/> Likely sources of infection include towels, hot packs or boiling tank water, and reusing reprocessed needles.<ref name=Gnatta2013/> Possible sources of infection include contaminated needles, reusing personal needles, a person's skin containing mycobacterium, and reusing needles at various sites in the same person.<ref name=Gnatta2013/> Although acupuncture is generally considered a safe procedure, a 2013 review stated that the reports of infection transmission increased significantly in the prior decade, including those of mycobacterium.<ref name=Gnatta2013/> Although it is recommended that practitioners of acupuncture use disposable needles, the reuse of sterilized needles is still permitted.<ref name=Gnatta2013/> It is also recommended that thorough control practices for preventing infection be implemented and adapted.<ref name=Gnatta2013>{{cite journal | vauthors = Gnatta JR, Kurebayashi LF, Paes da Silva MJ | title = Atypical mycobacterias associated to acupuncuture: an integrative review | journal = Revista Latino-Americana de Enfermagem | volume = 21 | issue = 1 | pages = 450–58 | date = February 2013 | pmid = 23546331 | doi = 10.1590/s0104-11692013000100022 | doi-access = free }}</ref>

==== English-language ====
A 2013 systematic review of the English-language case reports found that serious adverse events associated with acupuncture are rare, but that acupuncture is not without risk.<ref name="Xu S"/> Between 2000 and 2011 the English-language literature from 25 countries and regions reported 294 adverse events.<ref name="Xu S"/> The majority of the reported adverse events were relatively minor, and the incidences were low.<ref name="Xu S"/> For example, a prospective survey of 34,000 acupuncture treatments found no serious adverse events and 43 minor ones, a rate of 1.3 per 1000 interventions.<ref name="Xu S"/> Another survey found there were 7.1% minor adverse events, of which 5 were serious, amid 97,733 acupuncture patients.<ref name="Xu S"/> The most common adverse effect observed was infection (e.g. mycobacterium), and the majority of infections were bacterial in nature, caused by skin contact at the needling site.<ref name="Xu S"/> Infection has also resulted from skin contact with unsterilized equipment or with dirty towels in an unhygienic clinical setting.<ref name="Xu S"/> Other adverse complications included five reported cases of [[spinal cord injuries]] (e.g. migrating broken needles or needling too deeply), four brain injuries, four peripheral nerve injuries, five [[heart]] injuries, seven other organ and tissue injuries, bilateral hand [[edema]], [[granuloma|epithelioid granuloma]], [[pseudolymphoma]], [[argyria]], pustules, [[pancytopenia]], and scarring due to hot-needle technique.<ref name="Xu S"/> Adverse reactions from acupuncture, which are unusual and uncommon in typical acupuncture practice, included syncope, galactorrhoea, bilateral nystagmus, pyoderma gangrenosum, hepatotoxicity, eruptive lichen planus, and spontaneous needle migration.<ref name="Xu S">{{cite journal | vauthors = Xu S, Wang L, Cooper E, Zhang M, Manheimer E, Berman B, Shen X, Lao L | title = Adverse events of acupuncture: a systematic review of case reports | journal = Evidence-Based Complementary and Alternative Medicine | volume = 2013 | pages = 1–15 | year = 2013 | pmid = 23573135 | pmc = 3616356 | doi = 10.1155/2013/581203 | doi-access = free }}</ref>

A 2013 systematic review found 31 cases of vascular injuries caused by acupuncture, three causing death.<ref name=Bergqvist/> Two died from pericardial tamponade and one was from an aortoduodenal fistula.<ref name=Bergqvist>{{cite journal | vauthors = Bergqvist D | title = Vascular injuries caused by acupuncture. A systematic review | journal = International Angiology | volume = 32 | issue = 1 | pages = 1–8 | date = February 2013 | pmid = 23435388 | url = http://www.minervamedica.it/en/journals/international-angiology/article.php?cod=R34Y2013N01A0001 | access-date = 1 March 2014 | archive-date = 1 March 2014 | archive-url = https://web.archive.org/web/20140301091317/http://www.minervamedica.it/en/journals/international-angiology/article.php?cod=R34Y2013N01A0001 | url-status = live }}</ref> The same review found vascular injuries were rare, bleeding and pseudoaneurysm were most prevalent.<ref name=Bergqvist/> A 2011 systematic review (without restriction in time or language), aiming to summarize all reported case of [[cardiac tamponade]] after acupuncture, found 26 cases resulting in 14 deaths, with little doubt about cause in most fatal instances.<ref name=Ernst-Zhang/> The same review concluded that cardiac tamponade was a serious, usually fatal, though theoretically avoidable complication following acupuncture, and urged training to minimize risk.<ref name=Ernst-Zhang>{{cite journal | vauthors = Ernst E, Zhang J | title = Cardiac tamponade caused by acupuncture: a review of the literature | journal = International Journal of Cardiology | volume = 149 | issue = 3 | pages = 287–89 | date = June 2011 | pmid = 21093944 | doi = 10.1016/j.ijcard.2010.10.016 }}</ref>

A 2012 review found that a number of adverse events were reported after acupuncture in the UK's [[National Health Service (England)|National Health Service]] (NHS), 95% of which were not severe,<ref name=Wheway2012/> though miscategorization and under-reporting may alter the total figures.<ref name=Wheway2012/> From January 2009 to December 2011, 468 safety incidents were recognized within the NHS organizations.<ref name=Wheway2012/> The adverse events recorded included retained needles (31%), dizziness (30%), loss of consciousness/unresponsive (19%), falls (4%), bruising or soreness at needle site (2%), pneumothorax (1%) and other adverse side effects (12%).<ref name=Wheway2012/> Acupuncture practitioners should know, and be prepared to be responsible for, any substantial harm from treatments.<ref name=Wheway2012/> Some acupuncture proponents argue that the long history of acupuncture suggests it is safe.<ref name=Wheway2012/> However, there is an increasing literature on adverse events (e.g. spinal-cord injury).<ref name=Wheway2012>{{cite journal | vauthors = Wheway J, Agbabiaka TB, Ernst E | title = Patient safety incidents from acupuncture treatments: a review of reports to the National Patient Safety Agency | journal = The International Journal of Risk & Safety in Medicine | volume = 24 | issue = 3 | pages = 163–69 | date = January 2012 | pmid = 22936058 | doi = 10.3233/JRS-2012-0569 }}</ref>

Acupuncture seems to be safe in people getting [[anticoagulant]]s, assuming needles are used at the correct location and depth,<ref name=Mcculloch2014/> but studies are required to verify these findings.<ref name="Mcculloch2014">{{cite journal | vauthors = Mcculloch M, Nachat A, Schwartz J, Casella-Gordon V, Cook J | title = Acupuncture safety in patients receiving anticoagulants: a systematic review | journal = The Permanente Journal | volume = 19 | issue = 1 | pages = 68–73 | year = 2014 | pmid = 25432001 | pmc = 4315381 | doi = 10.7812/TPP/14-057 }}</ref>

==== Chinese, Korean, and Japanese-language ====

A 2010 systematic review of the Chinese-language literature found numerous acupuncture-related adverse events, including pneumothorax, fainting, [[subarachnoid hemorrhage]], and infection as the most frequent, and cardiovascular injuries, subarachnoid hemorrhage, pneumothorax, and recurrent cerebral hemorrhage as the most serious, most of which were due to improper technique.<ref name=Zhang-2010/> Between 1980 and 2009, the Chinese-language literature reported 479 adverse events.<ref name=Zhang-2010/> [[Prospective survey]]s show that mild, transient acupuncture-associated adverse events ranged from 6.71% to 15%.<ref name=Zhang-2010/> In a study with 190,924 patients, the prevalence of serious adverse events was roughly 0.024%.<ref name=Zhang-2010/> Another study showed a rate of adverse events requiring specific treatment of 2.2%, 4,963 [[Incidence (epidemiology)|incidences]] among 229,230 patients.<ref name=Zhang-2010/> Infections, mainly [[hepatitis]], after acupuncture are reported often in English-language research, though are rarely reported in Chinese-language research, making it plausible that acupuncture-associated infections have been underreported in China.<ref name=Zhang-2010/> Infections were mostly caused by poor sterilization of acupuncture needles.<ref name=Zhang-2010/> Other adverse events included spinal epidural hematoma (in the cervical, thoracic and lumbar spine), chylothorax, injuries of abdominal organs and tissues, injuries in the neck region, injuries to the eyes, including orbital hemorrhage, traumatic cataract, injury of the oculomotor nerve and retinal puncture, hemorrhage to the cheeks and the hypoglottis, peripheral motor-nerve injuries and subsequent motor dysfunction, local allergic reactions to metal needles, stroke, and cerebral hemorrhage after acupuncture.<ref name=Zhang-2010/>

A causal link between acupuncture and the adverse events cardiac arrest, pyknolepsy, shock, fever, cough, thirst, aphonia, leg numbness, and sexual dysfunction remains uncertain.<ref name=Zhang-2010>{{cite journal | vauthors = Zhang J, Shang H, Gao X, Ernst E | title = Acupuncture-related adverse events: a systematic review of the Chinese literature | journal = Bulletin of the World Health Organization | volume = 88 | issue = 12 | pages = 915–21C | date = December 2010 | pmid = 21124716 | pmc = 2995190 | doi = 10.2471/BLT.10.076737 }}</ref> The same review concluded that acupuncture can be considered inherently safe when practiced by properly trained practitioners, but the review also stated there is a need to find effective strategies to minimize the health risks.<ref name=Zhang-2010/> Between 1999 and 2010, the Korean-language literature contained reports of 1104 adverse events.<ref>{{cite journal | vauthors = Shin HK, Jeong SJ, Lee MS, Ernst E | title = Adverse events attributed to traditional Korean medical practices: 1999–2010 | journal = Bulletin of the World Health Organization | volume = 91 | issue = 8 | pages = 569–75 | date = August 2013 | pmid = 23940404 | pmc = 3738306 | doi = 10.2471/BLT.12.111609 }}</ref> Between the 1980s and 2002, the Japanese-language literature contained reports of 150 adverse events.<ref>{{cite journal | vauthors = Yamashita H, Tsukayama H | title = Safety of acupuncture practice in Japan: patient reactions, therapist negligence and error reduction strategies | journal = Evidence-Based Complementary and Alternative Medicine | volume = 5 | issue = 4 | pages = 391–98 | date = December 2008 | pmid = 18955234 | pmc = 2586322 | doi = 10.1093/ecam/nem086 }}</ref>

==== Children and pregnancy ====
Although acupuncture has been practiced for thousands of years in China, its use in [[pediatrics]] in the United States did not become common until the early 2000s. In 2007, the [[National Health Interview Survey]] (NHIS) conducted by the [[National Center for Health Statistics|National Center For Health Statistics]] (NCHS) estimated that approximately 150,000 children had received acupuncture treatment for a variety of conditions.<ref>{{cite web |url = https://nccih.nih.gov/sites/nccam.nih.gov/files/news/nhsr12.pdf |title = Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007 |date = 10 December 2008 |website = National Center for Complementary and Integrative Health |publisher = NCHS |last = Barnes |first = Patricia M. |access-date = 5 February 2016 |archive-date = 16 March 2016 |archive-url = https://web.archive.org/web/20160316075748/https://nccih.nih.gov/sites/nccam.nih.gov/files/news/nhsr12.pdf |url-status = live }}</ref>

In 2008, a study determined that the use of acupuncture-needle treatment on children was "questionable" due to the possibility of adverse side-effects and the pain manifestation differences in children versus adults. The study also includes warnings against practicing acupuncture on infants, as well as on children who are over-fatigued, very weak, or have over-eaten.<ref>{{cite journal | vauthors = Jindal V, Ge A, Mansky PJ | title = Safety and efficacy of acupuncture in children: a review of the evidence | journal = Journal of Pediatric Hematology/Oncology | volume = 30 | issue = 6 | pages = 431–42 | date = June 2008 | pmid = 18525459 | pmc = 2518962 | doi = 10.1097/MPH.0b013e318165b2cc }}</ref>

When used on children, acupuncture is considered safe when administered by well-trained, licensed practitioners using sterile needles; however, a 2011 review found there was limited research to draw definite conclusions about the overall safety of pediatric acupuncture.<ref name="Adams 2011"/> The same review found 279 adverse events, 25 of them serious.<ref name="Adams 2011"/> The adverse events were mostly mild in nature (e.g., bruising or bleeding).<ref name="Adams 2011"/> The prevalence of mild adverse events ranged from 10.1% to 13.5%, an estimated 168 incidences among 1,422 patients.<ref name="Adams 2011"/> On rare occasions adverse events were serious (e.g. [[cardiac rupture]] or [[hemoptysis]]); many might have been a result of substandard practice.<ref name="Adams 2011">{{cite journal | vauthors = Adams D, Cheng F, Jou H, Aung S, Yasui Y, Vohra S | s2cid = 46502395 | title = The safety of pediatric acupuncture: a systematic review | journal = Pediatrics | volume = 128 | issue = 6 | pages = e1575–87 | date = December 2011 | pmid = 22106073 | doi = 10.1542/peds.2011-1091 }}</ref> The incidence of serious adverse events was 5 per one million, which included children and adults.<ref name="Adams 2011"/>

When used during pregnancy, the majority of adverse events caused by acupuncture were mild and transient, with few serious adverse events.<ref name="Park-2014"/> The most frequent mild adverse event was needling or unspecified pain, followed by bleeding.<ref name="Park-2014"/> Although two deaths (one stillbirth and one neonatal death) were reported, there was a lack of acupuncture-associated maternal mortality.<ref name="Park-2014"/> Limiting the evidence as certain, probable or possible in the causality evaluation, the estimated incidence of adverse events following acupuncture in pregnant women was 131 per 10,000.<ref name="Park-2014">
{{cite journal | vauthors = Park J, Sohn Y, White AR, Lee H | title = The safety of acupuncture during pregnancy: a systematic review | journal = Acupuncture in Medicine | volume = 32 | issue = 3 | pages = 257–66 | date = June 2014 | pmid = 24554789 | pmc = 4112450 | doi = 10.1136/acupmed-2013-010480 | type = Systematic review }}
</ref>

Although acupuncture is not contraindicated in pregnant women, some specific acupuncture points are particularly sensitive to needle insertion; these spots, as well as the [[abdomen|abdominal region]], should be avoided during pregnancy.<ref name="Berman2010"/>

==== Moxibustion and cupping ====
<!-- Traditional acupuncture involves moxibustion and cupping. -->
Four adverse events associated with moxibustion were bruising, burns and cellulitis, spinal epidural abscess, and large superficial basal cell carcinoma.<ref name="Xu S"/> Ten adverse events were associated with cupping.<ref name="Xu S"/> The minor ones were [[keloid]] scarring, burns, and [[bulla (dermatology)|bullae]];<ref name="Xu S"/> the serious ones were acquired hemophilia A, stroke following cupping on the back and neck, factitious [[panniculitis]], reversible cardiac hypertrophy, and [[iron deficiency anemia]].<ref name="Xu S"/>