Case of the Month

Read real cases and their outcomes

When Acupuncture Goes Very, Very Wrong

Nov 13, 2018

The Case

The College received a complaint from a patient who sustained bilateral pneumothoraces (collapsed lungs) as the result of acupuncture treatment she received from her physiotherapist.

The patient had attended physiotherapy treatment regularly for almost 10 years before returning for neck, shoulder and upper back pain. The physiotherapist who treated her previously recommended both acupuncture and ultrasound to treat the pain during the patient’s final visit.

During acupuncture treatment, the patient indicated that the insertion of one of the needles was so painful that she cried out and the PT then moved it.

The patient laid with the needles inserted for approximately 20 minutes before they were removed by a physiotherapist assistant (PTA). The patient was then given ultrasound treatment followed by a heat pack applied for 10–15 minutes in an effort to alleviate her pain.

The patient said that she had undergone acupuncture treatments numerous times but had never felt the level of pain that she did on this occasion. The day after her appointment she met with her family physician who recommended x-rays. The x-rays revealed bilateral pneumothoraces—a diagnosis that was subsequently confirmed by a surgeon in a hospital emergency room two days later. The patient said she was not made aware of the potential risks of acupuncture treatment at any time during her appointment.

In a written submission to the College the physiotherapist indicated that she assessed the patient and concluded that her symptoms and objective findings were consistent with a diagnosis of myositis affecting the neck and upper back, plus possible underlying degenerative changes at the cervical spine. She noted that the patient’s history included: sarcoidosis, anemia, kidney dysfunction and a splenectomy, and observed that she had kyphosis of the thoracic spine.

According to the physio, the patient suffered a similar condition previously which was successfully treated with acupuncture, ultrasound and cervical traction, so she proceeded with the same course of treatment. She noted that the patient had responded favourably to acupuncture in the past and it accounted for the majority of her treatment at the clinic.

There was no record of the physiotherapist discussing the possible risks associated with acupuncture with the patient in the chart, and the PT did admit that she asked a physiotherapist assistant to remove the acupuncture needles as she was busy with another patient.

The Standards

The Working with Physiotherapist Assistants Standard restricts physiotherapists from assigning any part of acupuncture treatment to a PTA—this includes removing needles.

A crucial element of the consent process is a conversation between the physiotherapist and the patient and the physiotherapist needs to ensure that the patient has a clear understanding of their treatment. In this case, the patient was unaware of the potential risks associated with acupuncture and there was no note in the chart to indicate that informed consent had been obtained.

Additionally, it’s a physiotherapists responsibility to consider the overall health of the patient, as well as any contraindications or risks associated with the treatment before proceeding.

When a PT selects a particular treatment, they must provide clinical justification for their decision.

In this case, the physio chose to mirror the patient’s previous treatments but neglected to consider whether conditions including sarcoidosis and kyphosis were contraindications to the use of acupuncture.

The Outcome

The physiotherapist was not permitted to provide acupuncture treatments until successfully completing an educational course focused on safe and effective acupuncture practice as part of a Specified Continuing Education and Remediation Plan (SCERP). This information now appears permanently on the Public Register.

More about Consent

Working with Physiotherapist Assistants Standard

Record Keeping Standard

Physiotherapist Essential Competencies

Leave a comment
  1. Graeme | Jan 07, 2019
    This is a good example of the risks far outweighing potential benefit and those risks not being made known to the client. 
  2. College of Physiotherapists | Dec 18, 2018

    Thanks everyone for your comments. Unfortunately we are unable to share any more details about the case due to privacy concerns. 

    The goal of Case of the Month is to raise awareness of the issues that the College is seeing and ensure that physiotherapists are aware of the risks. All PTs are encouraged to read the cases and reflect on their own practice to ensure that they're meeting the standards of the profession and delivering high-quality, competent patient care.

    If ever in doubt please contact our Practice Advice team at  

  3. Derek | Dec 18, 2018
    As long as you have done the AA1 and AA2 certification (or like certs) there is no reason a physiotherapist cannot competently practice acupuncture. Its not rocket science .. physiotherapists have years of anatomy education especially if paired with a kinesiology degree.  know your points well and when to use them and outcomes will be positive.  
  4. Laura | Dec 17, 2018

    I too would like to know more information as to what points caused the pneumothoraces. Acupuncturists are trained very thoroughly on needling angles and depths to avoid pneumothorax, so it's disheartening to hear of acupuncture needles being used this way.

  5. Sara | Dec 14, 2018
    This is precisely why no body but Registered Acupuncturists should be allowed to needle and practice Acupuncture. 
  6. Cathy | Nov 15, 2018
     Ditto.  As per Carolan's questions.
  7. Carolan | Nov 13, 2018

    I very much want to know what points caused the pneumothoraces. And at what angle the needles were used on those points. And how long ago this physio was acupuncture trained. This information would help all physios who provide acupuncture services to understand better how things can go wrong. 

    For instance, GB 21 used to be needled perpendicularly in the past, but for a number of years it has no longer been taught in this way due to the risk of pneumothorax. The needle is now most often angled horizontally through the point site, in no way vertically angling down into the danger zone. 

    So the physio in this case may have practiced with older training for a vertical needle with no issue for a long time, until this client, who may not have had enough "padding" between the needle and the lung as the physio had been accustomed to.

    Or it may have been a completely different point and acupuncture issue. I would like to know. Thank you.  

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