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Background: Pneumothorax is a very rare but serious complication associated with acupuncture and dry
needling around the thoracic region. Physiotherapists and other health practitioners should be aware of the
risks associated with needling in this region and should take care to minimize the possibility of an iatrogenic
pneumothorax.
Findings: An awareness of the signs and symptoms of a pneumothorax is necessary for practitioners using
acupuncture and dry needling in the thoracic region. Understanding the normal anatomy and its variants
can minimize risk associated with needling practices in this region. Various technique modifications are
suggested so that the pleura or lungs are avoided while using acupuncture or dry needling in the thoracic
region.
Discussion/Conclusion: Acupuncture and dry needling in this region administered by well-trained
physiotherapists and other health practitioners is very safe; however, to maximize safety therapists should
consider the relevant anatomy and not practise using advanced acupuncture and dry needling techniques
without adequate competency-based training.
Keywords: Acupuncture, Education, Iatrogenic disease, Medical error, Pneumothorax
pulmonary disease (COPD), tuberculosis, sarcoido- pneumothorax due to acupuncture and dry needling
sis, cystic fibrosis, severe asthma, idiopathic pulmon- reported in the research literature, including four
ary fibrosis, malignancy, necrotising pneumonia and cases of death.25,27,28,30–34 Most iatrogenic pneu-
HIV associated Pneumocyctis carinii pneumonia.1,15 mothoraces associated with acupuncture and dry
Secondary spontaneous pneumothorax has also been needling are unilateral, although case studies of
associated with connective tissue disorders including bilateral iatrogenic pneumothoraces have been
rheumatoid arthritis (RA), ankylosing spondylitis reported.16,35
(AS), scleroderma, systemic lupus erythematosus Large prospective investigations into the incidence
(SLE), polymyositis, catamenial pneumothorax and of acupuncture-induced iatrogenic pneumothorax
Ehlers–Danlos syndrome.1–2 The use of oral corti- have been conducted in the United Kingdom,
costeroids has also been associated with spontaneous Japan, Czechoslovakia, Switzerland, and Germany.
pneumothorax.16 During the survey of adverse events following
The incidence of primary spontaneous pneu- acupuncture studies in the United Kingdom over
mothorax is 7.4–24/100 000 in men and 1.2–10/ 66 000 consultations were performed by medical
100 000 in women.1,13,17 Primary spontaneous pneu- practitioners and physiotherapists and there were
mothorax occurs predominantly in adults in their no pneumothoraces.36–39 Similarly in Japan, no
second and third decades of life.12 The incidence of pneumothoraces occurred during a 6-year survey of
secondary pneumothorax is 6.3/100 000 in males and 65 482 consultations conducted by acupuncture
2.0/100 000 in females;17 however, in individuals with therapists.40,41 In Czechoslovakia, the incidence of
COPD the incidence increases to 26/100 000 with a acupuncture-induced iatrogenic pneumothorax was 2
3.5-fold increase in mortality associated with second- in 139 988 equating to 1 in 69 994 consultations by
ary spontaneous pneumothorax.12 Secondary spon- hospital-based medical physicians.42 German acu-
taneous pneumothorax has been shown to peak in puncture trials (GERAC) have been the largest
incidence in the 60- to 65-year age bracket.12 prospective studies into the efficacy, effectiveness,
Traumatic pneumothorax may be iatrogenic or non- and safety of acupuncture by well-trained medical
iatrogenic. Causes of non-iatrogenic pneumothorax practitioners to date. From the initial 763 900
include penetrating or non-penetrating traumatic inju- consultations reviewed during GERAC, Melchart
ries, rib fractures, and high risk professions or sports et al.43 reported an incidence of 1/381 950 consulta-
including diving or flying. The common causes of tions; however, after 2 338 146 consultations, Witt
iatrogenic pneumothorax include transthoracic needle et al.44 reported the incidence of iatrogenic pneu-
biopsy, central venous subclavian vein catheterization, mothorax to be 1/1 170 000. The programme for
thoracentesis, transbronchial lung biopsy, pleural evaluation of patient care with acupuncture (PEP-Ac)
biopsy, intercostal nerve block, suprascapular nerve
provided further analysis of the GERAC trials,
block, tracheostomy, nasogastric feeding tube place-
summating that in over 4 000 000 acupuncture
ment, nephrectomy, gastrostomy, cardiopulmonary
consultations by medical practitioners three pneu-
resuscitation, and positive pressure ventilation.1,18–20
mothoraces occurred equating to a risk of 1/
Iatrogenic pneumothorax has also been reported to
1 300 000 consultations.45,46 However not all of the
occur with medical research utilizing electromyography
consultations included in the above cited prospective
fine wiring to assess activation of muscles including
studies involved needling in the thoracic region. It is
levator scapulae, trapezius, serratus anterior, rhom-
important to establish if a pneumothorax is sponta-
boids, the diaphragm, cervical and thoracic paraspinal
neous or iatrogenic because with primary spontaneous
muscles, intercostals, pectoralis major and minor,
pneumothorax, the risk of recurrent pneumothorax is
supraspinatus, infraspinatus, and subscapularis.21–23
increased while with iatrogenic pneumothorax this risk
Similarly injections of prolotherapy solutions, botuli-
is not increased.17
num toxin, anaesthetic, or cortisone into ligaments and
muscles in the thoracic region have been associated with Clinical features
iatrogenic pneumothoraces.21,24,25 A good working knowledge of the clinical features of
pneumothorax is vital to physiotherapists and other
Acupuncture- and Dry Needling-induced
Iatrogenic Pneumothorax health practitioners practising acupuncture or dry
Incidence needling in and around the thoracic region. This
Acupuncture and dry needling has been identified as facilitates its early recognition and may improve the
an additional cause of iatrogenic pneumothorax.26 information and consent processes for these proce-
The incidence of acupuncture-induced pneumothorax dures. It also aids the diagnosis of spontaneous
is less than 1/10 000,27,28 which is classed as very rare pneumothorax masquerading as a thoracic muscu-
by the WHO classification.29 There have however loskeletal condition in patients with thoracic region
been in excess of 100 case reports of iatrogenic pain presenting for acupuncture or manual therapy.
Figure 3 Needling levator scapulae by winging the scapula off the chest wall in side lying with the ipsilateral arm elevated or
alternatively the patient lies on their contralateral side with their ipsilateral arm held behind their back. Note: Do not attempt to
needle the origin of levator scapulae if the medial border of the scapulae is not able to wing off the chest wall.
Figure 4 Angle of inclination alters with arm position when the needle is left in situ in upper trapezius (Gall Bladder 21). A
degree of cephalad obliquity should be maintained at all times and patients should be advised that they can alter their arm
position only by elevating their arms.
region, without completing adequate training by re- 27 Juss JC, Speed CA, Warrington J, Mahadeva R. Acupuncture
inducued pneumothorax – a case report. Acupunct Med 2008;
cognized educational bodies. 26:193–6.
28 Peuker ET, White A, Ernst E, Pera F, Filler TJ. Traumatic
complications of acupuncture. Therapists need to know human
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