Essentials of Complementary and Alternative Medicine (June 1999)

TRAUMA
The insertion of an acupuncture needle represents a tissue trauma. Depending on the anatomic site, this may lead to serious complications or, as in the majority of 
cases, be of no consequence at all.
Numerous cases of pneumothorax have been reported. In total, well over 100 cases have been published (
2
, 
5
, 
26
). In most cases, a direct causal link to acupuncture 
is indisputable. In Germany, one well-documented fatality through pneumothorax is on record (
3
). A 63-year-old woman suffering from asthma went to a heilpraktiker 
(i.e., a nonmedically trained complementary therapist) who had a reputation as an acupuncturist. He used acupuncture points on the thorax to treat the chronic 
asthma. During therapy, the patient felt acute breathlessness and died within 20 minutes. The postmortem diagnosis was bilateral pneumothorax.
There are also several reports of cardiac tamponade through acupuncture (
27
, 
28
 and 
29
). One patient's heart was pierced by an acupuncturist through a foramen in 
the sternum (
30
). The patient died within 2 hours, and cardiac tamponade was confirmed at autopsy. Congenital sternal foramina can be found in 10% of the male and 
4% of the female populations. Others have commented on this case that the acupoint in question must be punctured obliquely to the sternum, which would prevent 
cardiac tamponade (
31
).
Several authors have reported trauma of the spinal cord by acupuncture needles (
32
, 
33
, 
34
, 
35
 and 
36
). Recently, a rare case of transverse myelopathy after 
acupuncture was published (
37
). These complications can occur when needles are inserted into the paraspinal musculature and penetrate as far as the spinal cord.
Traumatic injury of a blood vessel often results in a hematoma, which is a frequent complication of acupuncture (
5
). However, hematomas are rarely severe. A recent 
report described a case in which an acupuncture needle caused a false aneurysm of the popliteal artery (
38
). The patient presented with rupture of the aneurysm and 
was saved by arterial repair.
OTHER ADVERSE EFFECTS OF ACUPUNCTURE
Other adverse effects of acupuncture range across a wide array of conditions and symptoms (
39
). A fatality was observed in Japan (
40
) in which a patient received 
acupuncture for his chronic asthma. An acute asthma attack was triggered by acupuncture, and the patient died during treatment. As is often the case with anecdotal 
reports, it is difficult to decide whether the fatality was causally related to acupuncture or whether this was a mere temporal coincidence. In one report (
41
), the 
electromagnetic interference of an electroacupuncture device suppressed a demand cardiac pacemaker; in another report, manual needle acupuncture was 
apparently followed by cardiac arrhythmias in a 70-year-old woman who carried a cardiac pacemaker (
42
).
In addition to these rare and serious adverse effects, there are more frequent but less serious problems (
Table 9.1
). In our own survey, 13% of acupuncture users 
reported mild adverse effects of which the most frequent was “aggravation of symptom” (
43
). In a much larger Australian survey of approximately 2000 practitioners, a 
total of 3177 adverse events of acupuncture were reported; the most frequent was fainting during treatment (
2
).

Table 9.1. Frequent Complications of Acupuncture
Although these surveys represent first attempts to estimate the size of the problem, we cannot yet give reliable prevalence figures at present. Thus, all we can state 
with certainty is that properly delivered acupuncture seems relatively safe but does lead to adverse effects which, at times, can be severe and even life-threatening.
C
HAPTER
 R
EFERENCES
1.
Ernst E, White AR. Life threatening adverse reactions after acupuncture? A systematic review. Pain 1997;71:123–126.
2.
Bensoussan A, Myers SP. Towards a safer choice. Sydney, Australia: Southern Cross University, 1996.
3.
Brettel HF. Akupunktur als Todesursache. Münch Med Wschr 1981;123:97–100.
4.
Huang K Ch. Acupuncture. The past and the present. New York: Vantage Press, 1997.
5.
Rampes H, James R. Complications of acupuncture. Acupunct Med 1995;11:26–33.
6.
Boxall EH. Acupuncture hepatitis in the West Midlands. J Med Virol 1978;2:377–379.
7.
Stryker WS, Gunn RA, Francis DP. Outbreaks of hepatitis B associated with acupuncture. J Fam Pract 1986;22(2):155–158.
8.
Kent GP, Brondum J, Keenlyside RA, et al. A large outbreak of Acupuncture-Associated Hepatitis B. Am J Epidemiol 1988;127(3):591–598.
9.
Slater PE, Ben-Ishai P, Leventhal A, et al. An acupuncture-associated outbreak of hepatitis B in Jerusalem. Eur J Epidemiol 1988;4(3):322–325.
10.
Hussain KK. Serum hepatitis associated with repeated acupunctures. Br Med J 1974;3:41–42.
11.
Kobler E, Schmutziger P, Hartmann G. Hepatitis nach akupunktur. Schweiz Med Wschr 1979;109(46):1828–1829.
12.
Kiyosawa K, Tanaka E, Sodeyama T. Transmission of hepatitis C in an isolated area in Japan. Gastroenterol 1994;106:1596–1602.
13.
Kiyosawa K, Gibo Y, Sodeyama T, et al. Possible infectious causes in 651 patients with acute viral hepatitis during a 10-year period (1976–1985). Liver 1987;7:163–168.
14.
Shimoyama R, Sekiguchi S, Suga M, et al. The epidemiology and infection route of asymptomatic HCV carriers detected through blood donations. Gastroenterol Japan 1993;28:1–5.
15.
Phoon WO, Fong NP, Lee J. History of blood transfusion, tattooing, acupuncture and risk of hepatitis B surface antigen among Chinese men in Singapore. AJPH 1988;78(8):958–960.
16.
Vittecoq D, Mettetal JF, Rouzioux C, et al. Acute HIV infection after acupuncture treatments. N Engl J Med 1989;320(4):250–251.
17.
Castro KG, Lifson AR, White CR. Investigation of AIDS patients with no previous identified risk factors. JAMA 1988;259:1338–1342.
18.
Scheel O, Sundsfjord A, Lunde P, Andersen BM. Endocarditis after acupuncture and injection treatment by a natural healer. JAMA 1992;267:56.
19.
Jeffreys DB, Smith S, Brennand-Roper DA, Curry PVL. Acupuncture needles as a cause of bacterial endocarditis. Br Med J 1983;287:326–327.
20.
Lee RJE, Mc Ilwain JC. Subacute bacterial endocarditis following ear acupuncture. Int J Cardiol 1985;7:62–63.
21.
Pierik MG. Fatal staphylococcal septicemia following acupuncture: report of two cases. RI Med J 1982;65:251–253.
22.
Izatt E, Fairman M. Staphylococcal septicaemia with DIC associated with acupuncture. Postgrad Med J 1977;53:285–286.
23.
Doutscu Y, Tao Y, Sasayama K. A case of staphyloccus aureus seopticemia after acupuncture therapy. Kansenshogaku Zasshi 1986;60:911–916.
24.
Hirose K, Tajimak I, Fujikira N, et al. AIDA/HIV related knowledge, attitude and behaviour of acupuncturists in Aichi Prefecture. Jap J Publ Health 1995;42:269–279.
25.
Ernst E, White A. Acupuncture: safety first. Training programmes should include basic medical knowledge and experience. Br Med J 1997;314:1362.
26.
Norheim AJ, Fonnebo V. Adverse effects of acupuncture. Lancet 1995;345:1576.
27.
Schiff AF. A Fatality due to acupuncture. Medical Times 1965;93(6):630–631.
28.
Nieda S, Abe T, Kuribayashi R, et al. Cardiac trauma as complication of acupuncture treatment; a case report of cardiac tamponade resulting from a broken acupuncture needle. Japan J 
Thorac Surg 1973;26:881–883.
29.
Hasegawa J, Noguchi N, Yamasaki J, et al. Delayed cardiac tamponade and hemothorax induced by an acupuncture needle. Cardiology 1991;78:58–63.
30.
Halvorsen TB, Anda SS, Levang OW. Fatal cardiactamponade after acupuncture through congenital sternal foramen. Lancet 1995;345:1175.
31.
Carneiro NM, Shih-Minl. Acupuncture technique. Lancet 1995;345:1577.
32.
Kataoka H, Sakata M. Nerve injury due to an acupuncture treatment. Geka 1958;20:578–82.
33.
Kondo A, Koyama T, Ishikaway K. Injury to the spinal cord produced by acupuncture needle. Surg Neurol 1979;11:155–156.
34.
Shiraiski S, Goto I, Kuroiwa Y. Spinal cord injury as a complication of an acupuncture. Neurology 1979;229:1180–1182.
35.
Isu T, Iwasaki Y, Sasaki H. Spinal cord and root injuries due to glass fragments and acupuncture needles. Surg Neurol 1985;23:255–260.
36.
Sato M, Yamane K, Ezima M. A case of transverse myelopathy caused by acupuncture. Rinsko Shinkeigaku 1991;31:717–719.
37.
Ilhan A, Alioglu Z, Adanir M. Transverse myelopathy after acupuncture therapy. Acupunct Electro Therap Res Int J 1995;20:191–194.
38.
Lord RV, Schwartz P. False aneurism of the popliteal artery complicating acupuncture. Austr New Zealand J Surg 1996 ;66:645–647.
39.
Ernst E. The risks of acupuncture. Int J Risk Safety Med 1995;6:179–186.
40.
Ogata M, Kitamura O, Kubo S, Nakasono Q. An astmatic death while under Chinese acupuncture and moxibustion treatment. Am J Forensic Med Pathol 1992;13:338–341.
41.
Fujiwara H, Taniguchi K, Ikezono E. The influence of low frequency acupuncture on a demand pacemaker. Chest 1980;78:96–97.
42.
White AR, Abbot NC, Ernst E. Self-reports of adverse effects of acupuncture included cardiac arrhythmia. Acup Med 1996;14:121.
43.
Abbot NC, White AR, Ernst E. Complementary medicine. Nature 1996;381:361.

CHAPTER 10. A
DVERSE
 E
FFECTS OF
 S
PINAL
 M
ANIPULATION
Essentials of Complementary and Alternative Medicine
CHAPTER 10. A
DVERSE
 E
FFECTS OF
 S
PINAL
 M
ANIPULATION
Edzard Ernst
Spinal Manipulative Therapies
 
Direct Adverse Effects
 
Comparative Safety
 
Indirect Risks
Contraindications to SMT
Chapter References
SPINAL MANIPULATIVE THERAPIES
Osteopathy and chiropractic can be categorized as spinal manipulative therapies (SMT), which are aimed at restoring spinal joint function through adjustments of 
spinal motion segments. Chiropractic often involves high-velocity thrusts that seem to be particularly burdened with serious complications.
Direct Adverse Effects
Recent narrative (
1
) and systematic reviews (
2
) report a multitude of direct adverse reactions to SMT. The latter located 295 case reports, including 165 
vertebrobasilar accidents (25 of which were fatal), 61 cases of disk herniation or progression to cauda equina syndrome, 13 cerebral complications other than 
vertebrobasilar accidents, and 56 other types of complications. Of the documented 295 adverse events, 135 had occurred at the hands of chiropractors. 
Vertebrobasilar accidents occurred most frequently after upper cervical spinal manipulation with a rotational component (
3
). Their cause is usually arterial dissection 
at the atlantoaxial joint with intimal tear, intramural bleeding, or pseudoaneurysm that leads to thrombosis or embolism (
4
). Cauda equina syndrome seems to occur 
considerably less frequently, typically after lumbar SMT (
5
). The risk factors for these complications are summarized in 
Table 10.1
. The list comprises entities that are 
not normally detectable by chiropractors.
Table 10.1. Risk Factors for Complications of SMT
Estimations as to the incidence rates of adverse events after SMT are inconsistent and widely variable (
Table 10.2
). The variation can only partly be explained by the 
differences in type of adverse reactions. Obviously, mild adverse effects are more frequent than serious ones.
Table 10.2. Estimated Incidence Rates of Complications and Adverse Effects after SMT
Several other complications of SMT have been recorded (
Table 10.3
). They all seem to be extremely rare events (
1
, 
6
, 
7
, 
8
 and 
9
), and some have been observed 
only after cranial-sacral treatment, a variation of SMT.
Table 10.3. Rare Complications of SMT
There are no systematic investigations of the adverse effects of SMT; most of our knowledge is based on case reports (
10
). However, several published surveys have 

shed more light on this issue. In our own survey (
11
), 16% of users of SMT reported having experienced adverse effects; fortunately, most were mild. When United 
States neurologists were asked whether they had seen complications of SMT during the last 2 years, a large proportion claimed to have witnessed mostly serious 
complications, including 50 cases of stroke (
12
). Based on the results of a survey of 226 members of the Danish Chiropractors' Association, it was calculated that 
cerebrovascular accidents occurred 1 in 120,000 cervical treatment sessions (
13
).
Comparative Safety
Chiropractors are keen to point out that SMT is much safer than other (conventional) treatment options for the same complaint (
14
). It should be stressed, however, 
that such comparisons are problematic on methodological grounds. First, they compare one treatment (e.g., nonsteroidal antiinflammatory drugs [NSAIDs]), for which 
proper postmarketing surveillance techniques (often unreliable in themselves) are in place, with SMT, for which no such systems exist. Thus, it is to be expected that 
relatively fewer adverse effects are on record for SMT. Second, they compare incidence rates of adverse effects following a single SMT treatment with incidence rates 
related to prolonged drug therapy (
14
). This could be an unfair comparison—for example, contrasting one tablet of aspirin with one series of SMT. Third, they 
compare SMT for which the benefit is far from established (
15
) with treatments of documented efficacy. Thus, comparative evaluations of risk–benefit ratios are highly 
complex issues that are not resolved by the data available to date and will be extremely difficult to resolve in the future.
Indirect Risks
I
MMUNIZATION
Some chiropractors advise their clients against immunization of their children (
16
). If this were to happen on a large scale, not only would it put the child at risk, but it 
could endanger the herd immunity of entire populations. This is a good example of how complementary practitioners can hinder their clients' access to effective 
orthodox treatments.
U
SE OF
 X-R
AYS
Another indirect risk is the excessive use of x-rays by chiropractors. A survey of 48 members of the British Chiropractic Association showed that 82% of them had 
x-ray facilities in their clinics. Of 1598 patients with low back pain, 71% had been x-rayed (
17
). A more recent survey from the same source recorded that 74% of 
chiropractors had their own x-ray equipment, but no data on the frequency of x-ray use were provided (
18
). Pederson sent questionnaires to all chiropractors working 
in the European Union (
19
). X-rays were used in 72% of the patients with low back pain. Of all the patients seen by chiropractors, 64.4% were x-rayed. A survey of a 
random sample of members of the American Chiropractic Association suggested that 96.3% of new patients and 80% of patients at follow-up visits were x-rayed (
20
). 
A 1992 survey of 60 licensing boards in the United States and Canada (
21
) showed that full spine, skull, soft tissue, barium, and topography studies were permitted in 
100%, 98.1%, 96.2%, 36.0%, and 56.3%, respectively, by the boards. A survey of all the members of the Netherlands' Chiropractors Association indicated that 80% of 
chiropractors would often or always use x-rays for a new patient (
22
). Only 6% would employ it seldom or never, and virtually all thought that it was “desirable” or 
“absolutely desirable” to have access to x-ray equipment. In a recent clinical trial of various treatments of back pain, 208 practitioners of various types were randomly 
selected from six strata (
23
). Plain spine x-rays were used more frequently by the chiropractors (in 67% of all patients) than by any other profession.
Within the chiropractic profession, “there is currently no agreement regarding indications for taking x-rays” (
19
). Osteoporosis is a relative contraindication for several 
chiropractic techniques (
Table 10.4
). Plain x-rays of the spine (the type usually taken by chiropractors) do not help in diagnosing osteoporosis unless it is in very 
advanced stages (
24
, 
25
). Chiropractors could therefore use x-rays to detect malignancies, fractures, infections, inflammatory spondylarthropthies, and other 
contraindications (
19
). Yet, “bone disease is not immediately revealed by X-rays” (
26
), and unsuspected pathological findings on routine lumbar radiographs are as 
infrequent as 1 in 2500 (
27
). Many chiropractors employ x-rays for diagnosing misalignment or subluxation of the spine (
28
). Yet “subluxation of the vertebra as 
defined by chiropractic.... does not occur” (
29
) and “minor misalignments of vertebrae are normal and not necessarily a sign of trouble” (
30
) and such irregularities 
“show up on almost anyone's X-ray” (
31
). Thus, the question of why chiropractors so frequently use x-rays amounts to a serious safety issue that needs addressing.
Table 10.4. Contraindications of SMT
CONTRAINDICATIONS TO SMT
The list of contraindications of SMT in 
Table 10.4
 is impressive. It raises questions as to the validity of these items, particularly because there seems to be no 
agreement among authors as to what constitutes a contraindication of SMT. It also raises questions regarding the ability and competence of nonmedically trained 
practitioners to diagnose these conditions.
In conclusion, SMT does produce adverse effects, some of which are serious. Their incidence is not completely known, and estimates vary enormously. In addition, 
important indirect safety issues need to be addressed, particularly in relation to the chiropractic profession.
C
HAPTER
 R
EFERENCES
1.
Ernst E. Cervical manipulation: is it really safe? Int J Risk Safety Med 1994;6:145–149.
2.
Assendelft WJJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. J Fam Pract 1996;42:475–480.
3.
Terrett AGJ. Vascular accidents from cervical spine manipulation: report on 107 cases. J Aust Chiropractors Assoc 1987;17:15–24.
4.
Frisoni GB, Anzola GP. Vertebrobasilar ischemia after neck motion. Stroke 1991;22:1452–1460.
5.
Malmivaara A, Pohjola R. Cauda equina syndrome caused by chiropraxis on a patient previously free of lumbar spine symptoms. Lancet 1982;2:986–987.
6.
Segal DH, Lidov MW, Camins MB. Cervical epidural hematoma after chiropractic manipulation in healthy young women: case report. Neurosurgery 1996;39(5):1043–1045.
7.
McPartland JM. Craniosacral iatrogenesis. Side-effects from cranial-sacral treatment: case reports and commentary. J Bodywork Movement Ther 1996;1(1):2–5.
8.
Oware A, Herskovitz S, Berger AR. Long thoracic nerve palsy following cervical chiropractic manipulation. Muscle-Nerve 1995;18(11):1351.
9.
Peters M, Bohl J, Thömke F, et al. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995;45:2284–2286.
10.
Shekelle PG. Spine update: spinal manipulation. Spine 1994;19(7):858–861.
11.
Abbot NC, White AR, Ernst E. Complementary medicine. Nature 1996;381:361.
12.
Lee KpH, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation. Neurology 1995;45:1213–1215.
13.
Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part II: treatment to the upper neck and the rate of cerebrovascular incidents. J Manipulative Physiol Ther 
1996;19(9): 563–569.
14.
Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther 1995;18(8): 530–536.
15.
Ernst E. Complementary medicine: the facts. Phys Ther Rev 1997;2:49–57.
16.
Ernst E. The attitude against immunisation within some branches of complementary medicine. Eur J Pediatr 1997;156:513–515.
17.
Breen AC. Chiropractors and the treatment of back pain. Rheumatol Rehabil 1977;6: 207–218.
18.
Huisman M. Chiropractic practice in Britain. Undergraduate project, Anglo-European College of Chiropractic, Bournemouth, 1989.

19.
Pedersen P. A survey of chiropractic practice in Europe. Eur J Chiropractic 1994;42:3–28.
20.
Plamindon RL. Summary of 1994 ACA statistical study. J Am Chiropractic Ass 1995;32:57–63.
21.
Lamm LC, Wegner E, Collord D. Chiropractic scope of practice: what the law allows. J Manipulative Physiol Ther 1995;18:16–20.
22.
Assendelft WJJ, Pfeifle ChE, Bouter LM. Chiropractic in the Netherlands: a survey of Dutch chiropractors. J Manipulative Physiol Ther 1995;18:129–139.
23.
Carey T, Garrett J, Jackman A, et al. The outcome and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopaedic surgeons. N Engl 
J Med 1995;333:913–917.
24.
Kane WJ. Osteoporosis, osteomalacia, and Paget's disease. In: Frymoyer JW, ed. The adult spine. New York: Raven Press, 1991:637–659.
25.
Michel BA, Lanc NE, Jones HH. Plain radiographs can be used in estimating lumbar bone density. J Rheumatol 1990;17:528–531.
26.
Grieve GP. Incidents and accidents of manipulation and allied techniques. In: Grieve, GP, ed. Grieve's modern manual therapy. Edinburgh: Churchill Livingstone, 1994:679.
27.
Brodin I. Product control of lumbar films. Läkartidningen 1975;72:1793–1795.
28.
Sanders M. Take it from a D.C. Med Econ 1990;67:31–32.
29.
Crelin ES. A scientific test of the chiropractic theory. Am Scientist 1973;61:574–580.
30.
Chiropractors. Consumer Reports 1994;59:383–390.
31.
Fultz O. Chiropractic, what can it do for you? Am Health 1992;11:41–43.

CHAPTER 11. A
YURVEDIC
 M
EDICINE
Essentials of Complementary and Alternative Medicine
CHAPTER 11. A
YURVEDIC
 M
EDICINE
D. Vasant Lad
Background Information
 
Definition
 
History and Development
Principal Concepts