Murakoshi Yusuke, et al. Japanese Acupuncture and Moxibustion; 2024; Vol.18: 1–7

Original Research

Survey on adverse events associated with acupuncture among American
football players
MURAKOSHI Yusuke1,2), FUJIMOTO Hideki1,3)
1) Graduate School of Tokyo Ariake University of Medical and Health Sciences
2) Department of Acupuncture and Moxibustion, Niigata University of Health and Welfare3) Department of Acupuncture and Moxibustion, Tokyo Ariake University of Medical and Health Sciences

Abstract[Objective] This study aimed to conduct a survey among American football players regarding the adverse events
associated with acupuncture in athletes.
[Methods] The participants of this study included 73 American football players (29.3 ± 9.6 years old). A
questionnaire survey of adverse events related to acupuncture was conducted in 20XX（February to July, August
to December) among athletes who had received acupuncture owing to sports injuries. The study period was one
year, and a Google survey form was used to conduct the survey at the end of the season. The players who agreed
to participate in the study received the survey questions online, and the responses were obtained anonymously.
The players were asked about the type of adverse events and whether it affected their physical performance. The
acupuncture records, method of acupuncture, and any adverse events identified immediately after acupuncture werealso recorded.
[Results] A total of 39 players underwent acupuncture during the study period. Among them, 33 responded(84.0%). A total of 117 acupuncture treatments were performed during one season. Thereafter, the number of valid
responses were analyzed. No adverse events consequent to acupuncture were reported by 60.6% (n=20) of the
respondents. However, 39.3% (n=13) of the players reported adverse events. The most common adverse event wasskin itching in 18.2% of players (n=6). This was followed by muscle weakness in 6.1% (n=2), needle pain after
removal of needles in 6.1% (n=2), bleeding in 6.1% (n=2), and anemia in 3.0% (n=1). Only one player (3.0%)
reported a negative effect on physical performance. A therapist-confirmed adverse event, bleeding, was reported
in case of 3.4% (n=4) of the 117 treatments.
[Discussion and Conclusion] Most adverse events of acupuncture were minor, and there were no reports of serious
adverse events that warranted medical treatment. According to the acupuncture records, 117 acupuncture
procedures were performed throughout the season, and bleeding was confirmed in four cases (3.4%). According
to the results of the questionnaire survey and treatment record analysis, athletes may be aware of adverse events
that the practitioners cannot confirm.
Key words: Sports, Acupuncture, Adverse events, Safety, American football

I. Introduction
Acupunctureandmoxibustion
therapyarecommonly used to treat sports injuries in Japan1-3) .
The efficacy of these treatments for athletes has beenreported previously1-3) . In 2020, 42 randomized
controlled trials presented evidence on the effects ofacupuncture, moxibustion, and massage in sports
medicine. These studies provided clear indications of
the efficacy of acupuncture and moxibustion
treatments4) . In addition to efficacy, information on

safety is important for athletes5).
An adverse event is typically defined as "anundesirable medical event that occurs during or after
treatment regardless of causality6) ". Reported adverse
events of acupuncture have been studied at universityaffiliated clinics7-9). These studies reported many minor
adverse events as a result of acupuncture. Conversely,reports of adverse events associated with acupuncture
specific to the field of sports are lacking. The adverse
events of acupuncture may also contain those specificto athletes. A previous cross-sectional study on the

Corresponding author: Murakoshi Yusuke, Department of Acupuncture and Moxibustion, Niigata University of Health andWelfare, 1398 Shimami-cho, kita-ku, niigata-shi, Niigata 950-3198, JAPANReceived 25 Mar, 2023 Accepted 18 Apr, 2024

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Murakoshi Yusuke, et al. Japanese Acupuncture and Moxibustion; 2024; Vol.18: 1–7

adverse events of acupuncture in 841 athletes reported
that 47.6% of athletes experienced adverse events
because of acupuncture5,10) . In addition, 4.0% of
athletes reported negative effects on physicalperformance because of acupuncture10) . There havebeen reports of relatively severe adverse events,
including a case of broken needles that reached thepelvic cavity during the acupuncture treatment of an
athlete11) . The occurrence of adverse events has also
been reported in publications related to studies
examining the effects of acupuncture on athletes. In a
study on 345 sailing athletes, acupuncture caused
adverse events in one athlete12). In another study with163 triathlon athletes, six athletes experienced adverse
events associated with acupuncture13) . A review ofcase reports on acupuncture in athletes also reported
three incidents of minor adverse events, including
bleeding, pain, and numbness14). Therefore, there is aneed for safer acupuncture for athletes, and clarifying
the adverse events associated with acupuncture inathletes is necessary. However, very few studies haveinvestigated the adverse events of acupuncture forathletes. Based on these backgrounds, this study
carried out a survey targeting a specific sports
competition. The topic of this research focused on
American football. It is commonly acknowledged as
one of the sports with the highest incidence of sports
injuries15) . Therefore, it is presumed that acupuncture
therapy is frequently employed in the care andrehabilitation of American football players16).
This study aimed to conduct a survey among
American football players regarding the adverse
events of acupuncture in athletes.

II. Methods
1. Study participants
The participants of this study included 73 adult
American football players （29.3±9.6 years old). In
20XX （February to July, August to December), a
questionnaire survey of adverse events related toacupuncture was conducted among these athletes who
had received acupuncture owing to sports injuries.
The study period was one year, and the survey began
in February 20XX and continued through December.
Over the course of one season, the acupuncture
treatments and the names of the players treated wererecorded. At the end of the season, the names of theplayers were extracted from the treatment records, anda questionnaire survey was provided to the subjects.
2. Survey methods
A survey was conducted using Google survey form
at the end of the season. The players who agreed tothe study received the survey online. The responses
were obtained anonymously. This study was approvedby the Ethical Review Committee of Tokyo Ariake
University of Medicine and Health Sciences（no.261）.
The authors have no conflict of interest to declare.
The UMIN clinical trial number is UMIN000046933.
3. Questionnaire items (Table.1)
The following questionnaire items were used:(1) Questions for sports activities associated withacupuncture1)-1 What was the purpose of your acupuncture?
(Multiple answer).

Murakoshi Yusuke, et al. Japanese Acupuncture and Moxibustion; 2024; Vol.18: 1–7

1)-2 What effects did you feel after the acupuncture?
(Multiple answer).
1)-3 In which area did you receive acupuncture?
(Multiple answer).
1)-4 When did you receive acupuncture? (Multiple
answer).
1)-5 Did acupuncture exert a positive effect on yourphysical performance? (Single answer). A fourpoint scale was used to evaluate whether
acupuncture had a positive effect on the physicalperformance of the player.
1)-6 Did the acupuncture stimulation make you feelthe effect of the treatment? (Single answer).
1)-7 What was the amount of stimulation during theacupuncture? (Single answer). The amount ofstimulation during acupuncture was evaluated atfour levels.
1)-8 How many times did you receive acupunctureduring this season? (Single answer).
1)-9 Did the sensation of stimulation throughacupuncture remain after the treatment? (Multiple
answer).
(2) Questions for adverse events associated withacupuncture2)-1 Did you experience any health problems after
receiving acupuncture? (Multiple answer).
2)-2 Did the acupuncture affect your physicalperformance negatively? (Single answer).
4. Acupuncture records
Acupuncture is used to treat sports injuries. Prior to
the acupuncture treatment, the head trainer and team3

physician assesses the injury. Acupuncture treatment
is then performed on players that were deemed to bein need of acupuncture, by an acupuncturist withmore than 10 years of acupuncture experience. The
acupuncture recorded the treatment and any adverse
events that were identified immediately afterward.
5. Data representation and statistical processing
Data for both single answer and multiple answers
are expressed as a value (percentage) divided by the
number of valid responses from participants who
underwent acupuncture treatment during the season.
III. Results
1. Number of valid responses
Thirty-nine players received acupuncture during thestudy period. Of the 39 players who received
acupuncture, 33 responded (84.0%) to the survey (Fig.
1). A total of 117 acupuncture treatments were
performed during one season. Therefore, the numberof valid responses were analyzed. Table 2 shows the
background of the 33 survey respondents.
2. Questionnaire results(1) Questions for sports activities associated withacupuncture
The most common purpose of acupuncture waspain relief at 93.9% (n=31). This was followed bymuscle tone relief at 45.5% (n=15), fatigue relief at
33.3% (n=11), range of motion improvement at
24.2% (n=8), conditioning at 9.1% (n=3), prevention

Figure 1. Survey method
The participants of this study included 73 adult American football players. A questionnaire wasdistributed among these athletes who had received acupuncture and moxibustion consequent tosports injuries, and a survey of adverse events related to these treatments was conducted in 20XX
（February to July, August to December). The study period was one year.

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Murakoshi Yusuke, et al. Japanese Acupuncture and Moxibustion; 2024; Vol.18: 1–7

of injury at 9.1% (n=3), and rehabilitation assistanceat 3.0% (n=1). The most common effect ofacupuncture observed by the players was pain relief
at 78.8% (n=26). This was followed by muscle tone
relief at 60.6% (n=20), improvement in range of
motion at 30.3% (n=10), fatigue relief at 24.2%(n=8), conditioning at 9.1% (n=3), rehabilitation
assistance at 3.0% (n=1), and ineffective treatment at
0% (n=0). The most common region of acupuncture
was the lower back at 54.5% (n=18). This wasfollowed by the buttocks at 27.3% (n=9), neck at
21.2% (n=7), knee joint at 21.2% (n=7), hip joint at
15.2% (n=5), ankle joint at 12.1% (n=4), shoulder
joint at 12.1% (n=4), and thigh at 9.1% (n=3). The
most common point of time to receive acupuncture
was post training or match, at 39.4% (n=13). Thiswas followed by within 24 h of training or match at
36.4% (n=12), 2-3 days pre training or match at
36.4% (n=12), more than 3 days pre training or
match at 18.1% (n=6), and during the training or
match at 12.1% (n=4). It was reported as very
effective by 27.3% (n=9), effective by 33.3% (n=11),
slightly effective by 33.3% (n=11), and ineffective by
6.1% (n=2) of the participants. Among the total
respondents, both stimulation sensation and treatment
effects were experienced by 75.8% (n=25); 21.2%(n=7) could confirm treatment effects but notstimulation sensation, 3.0% (n=1) could confirm
stimulation sensation but not treatment effects, andneither stimulation sensation nor treatment effects
were experienced by 0.0% (n=0). It was reported asvery strong by 3.0% (n=1), strong by 12.1% (n=4),
moderate by 84.8% (n=28), and weak by 0% (n=0).
The number of acupuncture treatments a player
received in a season was reported as one by 21.2%(n=7), 2-5 by 57.6% (n=19), 6-10 by 18.2% (n=4),
and more than 10 by 3.0% (n=1). The stimulation
sensation felt immediately after receiving acupuncture
was reported to disappear soon by 81.8% (n=27),
within 24 h by 15.2% (n=5), within 2-3 days by
3.0% (n=1), and after 3 days by 0% (n=0).
(2) Questions for adverse events associated withacupuncture

Adverse events because of acupuncture were notreported by 60.6% (n=20) of the respondents.
However, 39.3% (n=13) of the players reported
appearance of adverse events. The most common
adverse event was skin itching at 18.2% (n=6). Thiswas followed by muscle weakness at 6.1% (n=2),
pain after needle removal at 6.1% (n=2), bleeding at
6.1% (n=2), and anemia at 3.0% (n=1) (Fig.1).
Regarding adverse events of acupuncture treatment
related to physical performance, only one player(3.0%) reported acupuncture-associated negative effecton physical performance; however, it did not impede
the performance of 97.0% of the respondents (n=32)(Fig.2).
3. Acupuncture records
The most common body parts that received
acupuncture were the lower back for 30.7% (n=36)
and hamstrings for 30.7% (n=36) of the respondents.
This was followed by the ankle joint, hip joint, lower
leg, buttocks, knee joints, front of the thigh, and wrist
joints for 13.6% (n=16), 7.6% (n=9), 6.8% (n=8),4.2% (n=5), 2.5% (n=3), for 1.7% (n=2), and 1.7%(n=2), respectively, of the respondents. The timing oftreatment was pre training or match for 29.0% (n=34)
and post training or match for 70.9% (n=83) of the
respondents. The most common acupuncture method
was electroacupuncture for 46.1% (n=54) of the
respondents. This was followed by a single needlingtechnique for 45.2% (n=53), exercises acupuncture17)
for 15.3% (n=18), needle retention for 10.2% (n=12),
and scattered needling for 4.2% (n=5) of the
respondents. The therapist-confirmed adverse event
was bleeding, reported in 3.4% (n=4) of the 117
treatments.
IV. Discussion
This study aimed to conduct a survey among
American football players regarding the adverse
events of acupuncture in athletes. The results of thesurvey revealed the occurrence of adverse events
associated with acupuncture through a questionnaireMurakoshi Yusuke, et al. Japanese Acupuncture and Moxibustion; 2024; Vol.18: 1–7

survey of the athletes. Not all adverse events required
medical treatment. Only one player (3.0%) reported anegative effect of acupuncture on physicalperformance. The acupuncture records showed
bleeding as the only adverse effect. However, adifference was observed between the athletes'
responses and the acupuncture records.
In this study, 13 of the 33 athletes (39.3%)
experienced adverse events. In a previous study of
841 athletes, 47% experienced adverse events5) . The
results of this study were almost similar to those ofprevious studies. Thus, our data supports the findingsof the previous studies. In this study, itchy skin was
the most common adverse event (18.0%). Thissuggests that itchy skin may be an adverse event thatis specific to acupuncture in American football
players. This is because in a survey of adverse events
conducted at a university-affiliated acupuncture clinic,
only 4 of the 391 patients (1.0%) who received
acupuncture complained of itching after thetreatment7) . Acupuncture has been reported to cause
microscopic tissue damage at the treatment site18) .
Accordingly, itching may be triggered by acupuncture.
However, the acupuncture records contained no eventsof skin itching. This result shows that it is unlikely
to have occurred immediately after acupuncture.
Itching may have appeared during or after the
exercise. Itchy skin is a condition in which the barrier
function of the skin is compromised, and itchinesscan be induced by external stimuli, whether physical,
chemical, or biological19) . In sports, external stimuli
act easily owing to sweat. Therefore, sweat or otherstimuli at the acupuncture site may have excited thenerve fibers in the epidermis and caused itching of
the skin. Endo et al. reported skin contact injury
owing to alcohol disinfection20) . They also reported

5

two types of allergic reactions, immediate anddelayed20). This suggests that itching may have been
induced by alcohol as well as acupuncture needles.
Only one player reported a negative effect ofacupuncture on physical performance. The player also
complained of itchy skin and had been receiving
acupuncture before training or match. Therefore, theuncomfortable sensation with itching may be an
adverse event associated with acupuncture having anegative effect on physical performance. However, theprobability of occurrence of the adverse event issimilar to that reported in previous study10) . In a
survey conducted by Fujimoto et al., 4.0% of theplayers reported a negative effect of acupuncture on
physical performance10) . Furthermore, itching may be
an adverse event that. According to our survey, theplayer who had a negative effect on physicalperformance received acupuncture in the 24 hours
prior to the practice at the neck and lower back (Fig.
3). Thus, when athletes receive acupuncture within 24
hours before practice, adverse events such as itchyskin may ensue.
In this study, adverse event of "muscle weakness"
was observed. A case of weakness consequent toacupuncture before a game resulted has beenreported12) . Two similar cases were reported in thepresent study, and this is an adverse event that should
be considered during in athletes. One of the twoathletes received strong acupuncture stimulation in the
24 hours before practice. Thus, strong stimulation
may induce muscle weakness.
Acupuncturists may have to consider the amount ofstimulation when treating athletes. The results of thisstudy were comparable to those of previous studies,in that the stimulus sensation was experienced by
players. An adverse event study of acupuncture at a

Figure 2. Adverse events after acupuncture treatment (Multiple answers)
20 players did not experience adverse events. 13 players reported having experienced adverse
events. The number of adverse events was the number that occurred during the season and did
not represent the frequency of occurrence.

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Murakoshi Yusuke, et al. Japanese Acupuncture and Moxibustion; 2024; Vol.18: 1–7

Figure 3. A case of negative performance because of acupuncture (Single answer)
Only one player (3.0%) reported a negative effect of acupuncture on physical performance. This player also
reported that he had "itchy skin" as an adverse event.

university-affiliated clinic in Japan reported that asensation of irritation remained in 3.5% of patients8).
The frequency of residual acupuncture stimulation
sensation reported in this study was comparable tothose reported in previous studies.
The only adverse event that acupuncturists wereable to identify throughout the season was bleeding.
Interestingly, there was a difference in the number ofadverse events revealed based on the athletes'
questionnaire survey and acupuncture records. Thus, it
is important to enquire with both players andacupuncturists because adverse events in athletes may
occur during or after exercise rather than immediately
after the treatment. This may lead to a difference
between the acupuncture records and athletes'
responses.
The study has limitations. The survey was
conducted anonymously. This was because the aim
was to increase the number of responses and reducebias. However, recall bias cannot be reduced to zero,even with anonymous responses. Additionally, owing
to the absence of names, it was not possible to checkthe results of the survey against the acupuncturist
treatment chart. Therefore, in the future, correlating
the participants' experience and the acupuncturerecords is important. This study results do not imply
that acupuncture is unsafe in athletes. We believe thatthe results of this study are not specific to American
football players but are applicable to many sports.
Future studies on adverse events of acupuncture
treatment in various athletes are needed, andcomparisons between sports are warranted.

V. Conclusion
This study aimed to conduct a survey in American
football players regarding the adverse events ofacupuncture for. Acupuncture was performed for one
season, and the following results were obtained:
1. "Itchy skin" was the most common adverse eventof acupuncture in this study, reported by 18.2%(n=6) of the respondents, followed by muscle
weakness by 6.1% (n=2) and pain after needle
removal by 6.1% (n=2). These adverse events wereconsidered as athlete characteristics.
2. Only one player (3.0%) reported a negative effectof acupuncture on physical performance.
3. Most adverse events of acupuncture were minor,
and there were no reports of serious adverse events
that needed medical treatment.
4. According to the treatment records, 117
acupuncture procedures were performed throughout
the season, and bleeding was confirmed in fourcases (3.4%).
5. From the results of the questionnaire survey andthe treatment records, we conclude that athletes
may be aware of adverse events that theacupuncturists cannot confirm.
Acknowledgment
We thank the players who participated in thisstudy. We would like to thank Editage for English
language editing.
Conflict of interest
The authors report no conflicts of interest.

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