Stimulated by Lin et al, Kim et al, and Wei et al 2023.[1–3] NHIRD – National Health Insurance Research Database (Taiwan)CI – confidence intervalCVA – cerebrovascular accidentNF1 – neurofibromatosis type 1 This week I am highlighting 3 papers with different...
Stimulated by Lin et al, Kim et al, and Wei et al 2023.[1–3]
Treatment protocol for lymphoedema from one of the trials in Kim et al 2023.[2]
NHIRD – National Health Insurance Research Database (Taiwan)
CI – confidence interval
CVA – cerebrovascular accident
NF1 – neurofibromatosis type 1
This week I am highlighting 3 papers with different methods but linked by the theme of avoiding, or learning from, adverse effects.
The first is another of the huge retrospective cohort studies from Taiwan – this time investigating the incidence of nerve injury following acupuncture and any comorbidities that influence the rate of such injury, as well as the most common locations of injury.
One part of the NHIRD now includes the insurance records of a sample of 2 million patients over a 19-year period (2000 to 2018). Of this sample, the authors found records of 14 507 847 acupuncture treatments in 886 753 patients. 756 patients were excluded because they sustained accidents, trauma, or invasive medical procedures between the acupuncture and the diagnosis of nerve injury. Finally, there were 8361 nerve injuries after acupuncture – an incidence rate of 5.76 per 10 000 acupuncture treatments.
The incidence rate showed a marked decline after 2005, reducing from over 10 per 10 000 to just over 5 in 2007 and subsequent years. The authors note that this corresponds to a change in licencing of acupuncturists and a media campaign on adverse events.
The 2 sites with the highest incidence of injury were the spinal cord (44%) and the upper limb (37%). Other sites were less than 5%, but notably the optic nerve featured in 2.1% of cases, reflecting a much greater use of points in the orbit than we see in the West. Having said that, spinal cord injury via acupuncture needles is also likely to be much rarer in the West.
Moving on to the other factors that influence the incidence of nerve injury, perhaps it is no surprise that the number of sessions is a factor, particularly when >36 sessions is compared with 6. The odds ratio for the higher number of sessions is 3.95 (95% CI: 3.64 to 4.28). A variety of comorbidities are associated with a modestly increased risk of nerve injury: diabetes; hypothyroidism, liver cirrhosis; chronic kidney disease; rheumatoid arthritis; systemic lupus erythematosus (all 1.34 to 1.45). Marginally higher rates were associated with dementia (1.47) and CVA (1.65).
The second paper is a systematic review examining the role and safety of using acupuncture as a treatment for breast cancer related lymphoedema. It includes 8 studies but only 189 patients in total, which is clearly insufficient to detect rare events. For example, the incidence of cellulitis after acupuncture in Taiwan is around 1 in 10 000 treatments. This is derived from the figure 64.4 per 100 000 treatment courses from a past blog: Acupuncture and cellulitis risk. Subsequently, I have read that a typical treatment course in Taiwan is 6 rather than 10 sessions – the latter is from China and equates to treatment every weekday for 2 weeks. The incidence of skin infection from the biggest prospective safety survey in the West is closer to 1 in 70 000.[4]
The total number of treatments in the review was just under 3000 and less than half of these treatments involved needling the area affected by lymphoedema. The increased risk of infection associated with lymphoedema is estimated to be 80:1 (in the leg),[5] so if these studies were carried out in Taiwan, we might have expected to see a handful of cases of infection, but in the west perhaps only 1.
The authors of the review conclude that acupuncture in the lymphoedematous region does not increase the risk of infection or the progression of lymphoedema, which may be marginally overstepping matters considering the size of their dataset.
Finally, the last paper is a rather unusual case of a bleeding-related adverse event following acupuncture in a patient with neurofibromatosis – NF1. The patient was receiving acupuncture treatment for insomnia and subsequently developed a very large haematoma in the region of her right scapula. A small percentage of patients with NF1 can have vascular anomalies related to one or more of their neurofibromas (0.4% to 6.4%). In this case there were multiple large and tortuous arteries in the region, which were not obvious until after the patient was subjected to angiography. Subsequently, the offending damaged artery was embolised and the haematoma removed.
References
1 Lin C-L, Chern A, Wang M-J, et al. Incidence of nerve injury following acupuncture treatments in Taiwan. Complement Ther Med. 2023;103007.
2 Kim JK, Loo C, Kim JS, et al. Can Acupuncture be a Part of the Treatment for Breast Cancer-Related Lymphedema? A Systematic Review of the Safety and Proposed Model for Care. Lymphology. 2023;56:27–39.
3 Wei W, Yang L, Zhu Y, et al. Massive Hemorrhage Following Acupuncture Treatment in a Neurofibromatosis Type 1 Patient. Cureus. 2023;15:e47825.
4 Witt CM, Pach D, Brinkhaus B, 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.
5 Dupuy A, Benchikhi H, Roujeau JC, et al. Risk factors for erysipelas of the leg (cellulitis): case-control study. BMJ. 1999;318:1591–4.