: Even though widely used in today's clinical practice, acupuncture has remained a controversial subject. Many reviews are currently available but most lack a critical stance and some are overtly promotional. The aim of this overview is to provide a balanced, critical analysis of the existing evidence. Some of the original concepts of traditional acupuncture are not supported by good scientific evidence. Several plausible theories attempt to explain how acupuncture works but none are proved beyond doubt. The clinical effectiveness of acupuncture continues to attract controversy. Many controlled clinical trials and numerous systematic reviews of these studies have been published. Considerable problems are encountered when interpreting these data. Heterogeneity is a significant drawback of both clinical trials and systematic reviews. Some of the controversies may be resolved through the use of the new ‘placebo needles’ which enable researchers to adequately control for placebo effects of acupuncture. The majority of studies using such devices fails to show effects beyond a placebo response. Acupuncture has been associated with serious adverse events but most large‐scale studies suggest that these are probably rare. Nonserious adverse effects occur in 7–11% of all patients. In conclusion, acupuncture remains steeped in controversy. Some findings are encouraging but others suggest that its clinical effects mainly depend on a placebo response.

Objective: To identify adverse effects of spinal manipulation.Design: Systematic review of papers published since 2001.Setting: Six electronic databases.Main outcome measures: Reports of adverse effects published between January 2001 and June 2006. There were no restrictions according to language of publication or research design of the reports.Results: The searches identified 32 case reports, four case series, two prospective series, three case-control studies and three surveys. In case reports or case series, more than 200 patients were suspected to have been seriously harmed. The most common serious adverse effects were due to vertebral artery dissections. The two prospective reports suggested that relatively mild adverse effects occur in 30% to 61 % of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effect. The survey data indicated that even serious adverse effects are rarely reported in the medical literature.Conclusions: Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.

Acupuncture is commonly used for pain control, but doubts about its effectiveness and safety remain. This review was aimed at critically evaluating systematic reviews of acupuncture as a treatment of pain and at summarizing reports of serious adverse effects published since 2000. Literature searches were carried out in 11 databases without language restrictions. Systematic reviews were considered for the evaluation of effectiveness and case series or case reports for summarizing adverse events. Data were extracted according to predefined criteria. Fifty-seven systematic reviews met the inclusion criteria. Four were of excellent methodological quality. Numerous contradictions and caveats emerged. Unanimously positive conclusions from more than one high-quality systematic review existed only for neck pain. Ninety-five cases of severe adverse effects including 5 fatalities were included. Pneumothorax and infections were the most frequently reported adverse effects. In conclusion, numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain. Serious adverse effects continue to be reported. Numerous reviews have produced little convincing evidence that acupuncture is effective in reducing pain. Serious adverse events, including deaths, continue to be reported.

Objectives. After many years out of the limelight, massage therapy is now experiencing a revival. The aim of this systematic review is to evaluate its potential for harm. Methods. Computerized literature searches were carried out in four databases. All articles reporting adverse effects of any type of massage therapy were retrieved. Adverse effects relating to massage oil or ice were excluded. No language restrictions were applied. Data were extracted and evaluated according to predefined criteria. Results. Sixteen case reports of adverse effects and four case series were found. The majority of adverse effects were associated with exotic types of manual massage or massage delivered by laymen, while massage therapists were rarely implicated. The reported adverse events include cerebrovascular accidents, displacement of a ureteral stent, embolization of a kidney, haematoma, leg ulcers, nerve damage, posterior interosseous syndrome, pseudoaneurism, pulmonary embolism, ruptured uterus, strangulation of neck, thyrotoxicosis and various pain syndromes. In the majority of these instances, there can be little doubt about a cause–effect relationship. Serious adverse effects were associated mostly with massage techniques other than ‘Swedish’ massage. Conclusion. Massage is not entirely risk free. However, serious adverse events are probably true rarities.