Electro-­‐Acupuncture  (EA)

Safety/Adverse Events – A Review of the Literature

Electro-­‐acupuncture  (EA)  is  used  by  many  acupuncturists  as  an  adjunctive  therapy  for   conditions  associated  with  qi,  blood,  or  phlegm  stagnation.  Prior  to  the  advent  of  modern   electrical  appliances,  hand  manipulation  of  the  needles  was  used  to  strongly  stimulate  qi  flow.  

EA  is  used  to  replace  prolonged  needle  manipulation  for  conditions  in  which  there  is  an   accumulation  of  qi,  such  as  in  chronic  pain  syndromes,  or  in  cases  where  the  qi  is  difficult  to   stimulate.  (1)  

There  are  very  few  studies  of  the  potential  adverse  events  of  electro-­‐acupuncture  (EA).  One   recent  review  of  the  literature  from  1979-­‐2010  found  only  44  incidences  of  AEs  reported  during   that  time  frame  in  either  English  or  Chinese  databases.  (2)  While  a  number  of  the  AEs  were   probably  associated  with  the  acupuncture  (faintness,  hyperventilation)  a  few  were  associated   with  the  application  of  an  electrical  current  (electrical  injury,  atrioventricular  block,  dislocation   of  the  wrist  joint  from  muscle  spasm  and  others).  (2)    

A  report  from  a  one  practitioner  concluded  that  “most  of  the  safety  implications  related  to  the   application  of  EA  are  theoretical,  and  there  are  few  reports  in  the  literature  of  serious  adverse   events  that  relate  to  the  electrical  stimulus  as  opposed  to  the  trauma  of  needling.”  (3)  Zhao  et   al.  (4)  report  no  adverse  events  in  use  of  EA  in  their  report  of  60  patients  receiving  EA  therapy   for  muscle  spasticity  after  brain  injury.  

There  may  be  increased  risks  associated  with  the  needling  techniques  needed  for  EA.  A  

practitioner  must  be  aware  of  guidelines  for  insertion  depth  when  using  EA.  Both  the  depth  and   direction  of  insertion  of  the  needles  is  often  adjusted  by  practitioners  for  the  application  of  EA   in  order  to  ensure  that  the  needles  can  support  the  weight  of  the  electrical  leads  and  clips  for   the  period  of  stimulation  without  falling  out.  EA  is  often  applied  for  20–30  minutes  and  may   involve  strong  muscle  contraction.  Both  the  use  of  increased  depth  of  insertion  and  the  need  to   alter  insertion  angle  at  certain  points  require  the  practitioner  to  have  an  excellent  grasp  of  the   anatomy  underlying  the  points  in  order  for  safe  needling.  

Needle  type  and  size  is  also  important  with  EA.  Certain  types  of  metal  should  be  avoided  for  use   in  EA  such  as  silver  needles,  which  are  softer  than  stainless  steel  and  may  electrolyze  in  the   body  very  quickly  resulting  in  a  toxic  reaction.  Additional  studies  need  to  be  done  to  identify  the   best  types  of  needles  to  use  during  EA.  It  may  be  advisable  to  avoid  needles  with  a  plastic   handle  due  to  diminished  conduction;  and,  there  is  a  theoretical  concern  about  very  narrow   gauge  needles  and  possible  breakage  from  electrical  conduction.  Stainless  steel  needles  are   safe  to  use  with  electrical  stimulation.  

Excessive Current

The  current  used  for  therapeutic  EA  ranges  from  about  0.5  to  6  mA.  In  an  otherwise  healthy   subject  with  no  implanted  electrical  devices,  the  medical  literature  associated  with  the  use  of   nerve  stimulating  devices  suggests  that  this  level  of  current  should  be  safe.  (5,6)    

Higher  levels  of  current  may  cause  significant  spasms  of  local  muscles;  skeletal,  cardiac  and   smooth  muscle  fibers  can  all  be  stimulated  through  the  use  of  electrical  currents  leading  to   inadvertent  muscle  spasms.  The  level  of  electrical  stimulation  should  remain  just  below  the   level  of  pain  as  perceived  by  the  patient  and  muscle  contraction  should  be  avoided  in  most   applications  of  EA.  While  there  are  applications  of  EA  that  involve  muscle  contraction  as  part  of   the  therapy  (such  as  treatment  for  palsy),  such  treatments  need  to  be  closely  monitored.  

Anatomical Considerations

A  2008  study  of  the  safety  of  EA  reported,  “When  the  needles  are  placed  in  closely  adjacent   acupuncture  points  in  a  limb,  there  is  little  or  no  detectable  spread  of  the  currents  along  the   limb  or  into  the  chest.  By  contrast,  when  the  needles  are  placed  far  apart,  the  electrical   currents  spread  widely.”  (7)EA  should  be  avoided  in  the  following  locations  to  prevent   theoretical  AEs:  

1. Anterior  triangle  of  the  neck.  Due  to  the  location  of  the  carotid  sinus  which  regulates   blood  pressure,  the  laryngeal  muscles  associated  with  breathing,  and  the  vagus  nerve   (cranial  nerve  8),  EA  should  not  be  utilized  in  this  area.  

2. Posterior  cervical  area.  The  presence  of  the  brainstem  may  prohibit  the  use  of  EA.  

3. Crossing  the  spine.  EA  may  interfere  with  normal  nerve  conduction.  

4. Crossing  the  heart.  EA  may  affect  the  function  of  the  electrical  system  in  the  heart  and   the  contraction  of  the  cardiac  muscle.  

5. In  any  patient  with  implanted  medical  devices:  ICDs  (implantable  cardioverter   defibrillator)  and  pacemakers.  

Adverse  events  (or  potentially  adverse  events)  related  to  the  use  of  EA  have  been  reported;  

these  have  mostly  related  to  cardiac  effects  (angina,  cardiac  arrest,  interference  with  a  demand   pacemaker).  (7,8,9)  In  one  report,  however,  the  use  of  EA  in  the  limbs  in  someone  with  a   pacemaker  did  not  interfere  with  the  action  of  the  cardiac  pacemaker,  and  the  authors  of  that   study  suggest  that  this  restriction  be  re-­‐thought.  “The  results  of  this  case  study  suggest  

that  EA  might  be  a  safe  alternative  for  patients  with  a  pacemaker.  .  .  .Every  patient  should  be   considered  with  care,  individually.”  (10)  

According  to  Low  and  Reed’s  textbook  on  electrotherapy,  5  mA  direct  current  (DC)  applied  to   human  tissues  in  vivo  results  in  chemical  changes  at  the  sites  of  contact  with  the  electrodes.  A   negative  charge  at  the  cathode  results  in  an  alkaline  environment  and  liquefaction  of  proteins.  

A  positive  charge  at  the  anode  results  in  an  acidic  environment  and  coagulation  of  proteins.  

(11)  The  use  and  function  of  the  two  poles  of  EA  for  different  AOM  applications  needs  further   research  and  elucidation.  

Preventing EA Adverse Events

There  are  no  common  adverse  events  associated  with  EA  reported  in  the  English  literature.  

Uncommon  AEs  can  mostly  be  prevented  by  proper  training  and  an  awareness  of   contraindications  for  the  therapy.  

Certain  types  of  metal  should  be  avoided  for  use  in  electro-­‐acupuncture  such  as  silver  needles,   which  are  softer  than  stainless  steel  and  may  electrolyze  in  the  body  very  quickly  resulting  in  a   toxic  reaction.  Stainless  steel  needles  are  safe  to  use  with  electrical  stimulation.  (3)  

Safety Guidelines for Preventing EA Adverse Events Strongly  

Recommended   • Electrical  stimulation  should  not  be  applied  from  one  side  of  the  chest   across  to  the  other  side  of  the  chest  (front  to  back  or  side  to  side)  in  the   region  of  the  heart.  A  circuit  should  not  cross  the  midsagittal  line  of  the   patient.  

Recommended   • Avoid  applying  EA  near  the  brain  or  brainstem.  

• Avoid  crossing  the  spine  with  the  electrical  stimulus.  

• Consult  with  the  primary  physician  of  any  patient  with  a  history  of  a   seizure  disorder  before  instituting  EA.  

Injuries Due to Muscle Contraction

Excessive  electrical  current  can  cause  significant  muscle  spasms  which  may  then  cause  local   tissue  or  bone  damage.  EA  should  never  be  employed  in  such  a  manner  as  to  cause  continuous,   strong  muscle  spasms.  

Safety Guidelines for Preventing Excessive Muscle Contraction During EA

Critical   • EA  should  not  be  used  on  infants,  children,  incapacitated,sleeping  or     unconscious  persons.  

• Turn  up  the  amperage  of  the  EA  machine  slowly  and  ask  for  constant   feedback  from  the  patient  about  sensation  of  pain;  electrical  stimulation   should  be  turned  off  before  needles  are  removed  from  the  body.  

• The  level  of  stimulus  should  never  approach  the  sensation  of  pain.  

Strongly  

Recommended   • Apply  EA  in  such  a  manner  as  to  avoid  muscle  contraction  except  in  those   cases  where  muscle  stimulation  is  the  expected  outcome.  

http://www.osha.gov/dte/grant_materials/fy09/sh-18794-09/electrical_safety_manual.pdf   for  an  overview  of  electrical  safety)  

Safety Guidelines for Preventing Electrical Injury During EA

Critical   • Prevent  water,  moisture,  liquids  or  metal  objects  from  coming  in contact  with  the  patient  or  treatment  table.  Do  NOT  use  EA  in  wet  or moist  environments.

• Do  not  use  if  any  part  of  the  EA  machine  is  cracked  or  otherwise damaged.

• Do  not  use  if  the  wires  or  leads  are  not  in  good  condition.

Interference with a Cardiac Pacemaker

Electrical  stimulation  can  interfere  with  the  functioning  of  pacemakers.  Patient  histories  must   be  specific  for  ruling  out  that  your  patient  has  a  pacemaker.  

Safety Guidelines for Preventing Interference with a Cardiac Pacemaker During EA Critical   Avoid  use  of  EA  on  the  trunk  of  anyone  with  an  implanted  cardiac  device,  

including  a  pacemaker.  

Strongly  

Recommended   EA  should  not  be  used  on  any  part  of  the  body  of  patients  with   pacemakers  or  other  electronic  implants.  

References

1. Audette  JF,  Ryan  AH.  The  role  of  acupuncture  in  pain  management.  Phys  Med  Rehabil  Clin  N Am;  15  (2004)  749–77  

2. Zheng  W,  Zhang  J,  Shang  H.  Electro-­‐Acupuncture-­‐Related  adverse  events  (AE):  A  Systematic Review.  Medical  Acupuncture.  June  2012,  24(2):  77-­‐81.  doi:10.1089/acu.2011.0858.  

3. Cummings  M.  Safety  aspects  of  electroacupuncture.Acupuncture  in  Medicine  2011  Jun  29  (2):

83-­‐5  29  (2)  83-­‐5.  2011  

4. Zhao  W,  Wang  C,  Li  Z  et  al.  Efficacy  and  Safety  of  Transcutaneous  Electrical  Acupoint Stimulation  to  Treat  Muscle  Spasticity  following  Brain  Injury:  A  Double  –Blinded,   Multicenter,  RCT.  PLoS  One.  2015  Feb  2;10(2):e0116976.  doi:  

10.1371/journal.pone.0116976.  

5. Electrical  Safety  Testing  Reference  Guide.  QuadTech,  Inc.  4th  Edition,  May  2002,  P/N 030120/A4  http://www.psma.com/ul_files/forums/safety/estguide2.pdf  Accessed   December  2012  

6. Hadzic  A,  Vloka  J,  Hadzic  N,  Thys  DM,  Santos  AC.Nerve  stimulators  used  for  peripheral  nerve blocks  vary  in  their  electrical  characteristics.Anesthesiology  2003;  98-­‐969-­‐74  

7.  Thompson  JW,  Cummings  M.  Investigating  the  safety  of  electroacupuncture  with  a   Picoscope.  Acupunct  Med.  2008  Sep;26(3):133-­‐9.  

8.  Lau  EW,  Birnie  DH,  Lemery  R,  et  al.  Acupuncture  triggering  inappropriate  ICD  shocks.  

Europace  2005;7:85–6.  

9.  White  A.  A  cumulative  review  of  the  range  and  incidence  of  significant  adverse  events   associated  with  acupuncture.  Acupunct  Med  2004;22:122–133.  

http://aim.bmj.com/content/22/3/122.full.pdf  

10.  Vasilakos  DG,  Fyntanidou  BP.  Electroacupuncture  on  a  patient  with  pacemaker:  a  case   report.  Acupunct  Med.  2011  Jun;29(2):152-­‐3.  doi:  10.1136/aim.2010.003863.  Epub  2011   Mar  

11.  Low  J,  Reed  A.  Electrotherapy  Explained:  Principles  and  Practice.  Oxford:  Butterworth-­‐

Heinemann  1991.