Adverse Events of Massage Therapy in Pain-Related Conditions: A Systematic Review

Abstract

Pain-related massage, important in traditional Eastern medicine, is increasingly used in the Western world. So the widening acceptance demands continual safety assessment. This review is an evaluation of the frequency and severity of adverse events (AEs) reported mainly for pain-related massage between 2003 and 2013. Relevant all-languages reports in 6 databases were identified and assessed by two coauthors. During the 11-year period, 40 reports of 138 AEs were associated with massage. Author, year of publication, country of occurrence, participant related (age, sex) or number of patients affected, the details of manual therapy, and clinician type were extracted. Disc herniation, soft tissue trauma, neurologic compromise, spinal cord injury, dissection of the vertebral arteries, and others were the main complications of massage. Spinal manipulation in massage has repeatedly been associated with serious AEs especially. Clearly, massage therapies are not totally devoid of risks. But the incidence of such events is low.

Full text

Review Article
Adverse Events of Massage Therapy in Pain-Related
Conditions: A Systematic Review
Ping Yin,1Ningyang Gao,2Junyi Wu,1Gerhard Litscher,3and Shifen Xu1
1Acupuncture Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai 200071, China
2Traumatology Department, Shuguang Hospital Aliated to Shanghai University of Traditional Chinese Medicine,
Shanghai 201203, China
3Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering in
Anesthesia and Intensive Care Medicine, and TCM Research Center Graz, Medical University of Graz, 8036 Graz, Austria
Correspondence should be addressed to Shifen Xu; xu teacher@.com
Received  July ; Accepted  July ; Published  August 
Academic Editor: Huang-Ping Yu
Copyright ©  Ping Yin et al. is is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Pain-related massage, important in traditional Eastern medicine, is increasingly used in the Western world. So the widening
acceptance demands continual safety assessment. is review is an evaluation of the frequency and severity of adverse events (AEs)
reported mainly for pain-related massage between  and . Relevant all-languages reports in  databases were identied
and assessed by two coauthors. During the -year period,  reports of  AEs were associated with massage. Author, year of
publication, country of occurrence, participant related (age, sex) or number of patients aected, the details of manual therapy,
and clinician type were extracted. Disc herniation, so tissue trauma, neurologic compromise, spinal cord injury, dissection of
the vertebral arteries, and others were the main complications of massage. Spinal manipulation in massage has repeatedly been
associated with serious AEs especially. Clearly, massage therapies are not totally devoid of risks. But the incidence of such events is
low.
1. Introduction
Massage, as any systematic form of touch or manipulation
performed on the so tissues of the body to provide com-
fort and promote health [–], has become popular in the
United States and the rest of the world in recent decades.
It has also been recommended by the Chartered Society of
Physiotherapy for the management of various pain-related
conditions, especially those of musculoskeletal origin [],
such as neck pain, low back pain, headache, and migraine
[–]. is is supported by numerous systematic reviews of
a large number of randomized controlled trials (RCTs) [–
]. Between  and , the -year prevalence of use of
massage by the US adult population increased from 5%(.
million) to 8.3% (. million), and massage belongs to one
of the most popular complementary and alternative medicine
(CAM) therapies in the USA []. e increased use brings
attention to the safety and quality of the modality.
Anumberoflargesurveysonthesafetyofmassagehave
been conducted. Most reported incidents have been fairly
minor, and incidence rates were low. For example, from
surveys and review articles, the risk of a serious irreversible
complication (e.g., stroke) for cervical manipulations has
been reported to vary from one adverse event in  to
one in ,, manipulations, and another review of the
articles on complications of spinal manipulation, which iden-
tied  complications, yielded estimates of vertebrobasilar
accidents from one in   patients to one per ,,
cervical manipulations and cauda equina syndrome to be less
than one per ,, treatments [–]. e authors of
these studies concluded that serious AEs seem to be rare and
massage is generally a safe intervention. So this systematic
review seeks to evaluate all published data (between  and
) about adverse eects of massage therapy. We specically
hope to help the clinician feel comfortable and informed in
conversations with their patients regarding the appropriate,
Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2014, Article ID 480956, 11 pages
http://dx.doi.org/10.1155/2014/480956

 Evidence-Based Complementary and Alternative Medicine
2246 reports in English
identified through database
searching
1036 reports in Chinese
identified through database
searching
3282 reports screened
3156 reports excluded: irrelevant
studies and duplicates
126 reports (full text
assessed for eligibility)
86 full texts excluded: unrelated to
AEs, no details reported
40 reports (138 cases)
included
F : Flow chart of the screening process.
safe, and eective use of massage, not only in pain-related
conditions.
2. Materials and Methods
2.1. Search Strategy. We searched  databases in an attempt
to locate all existing case reports (irrespective of language of
publication) with original data on AEs following any type
of massage therapy published between January  and
June  in electronic form. PubMed including MEDLINE,
EMBASE, e Cochrane Library (via Wiley), CNKI, CQVIP,
and Wanfang digital databases were searched. Search terms
were “massage, manual therapy, tuina, and chiropractic.”
ese terms were combined with “safe, safety, adverse event,
adverse reaction, side eects, complications, and risk.”
2.2. Inclusion and Exclusion Criteria. Only original case
reports of complications or AEs of massage, manual therapy,
and tuina published from January  to June  were
included in this review. All those clinical study designs
shouldbepublishedinpeer-reviewedjournals,andlike
conference proceedings, cross-sectional and other descriptive
designs and narrative reviews were excluded. Two coauthors
independently screened the titles and abstracts of all papers
found from the initial search. Disagreements between the two
authors were resolved through discussion.
We excluded multiple inclusions and analyses of the same
AEs as well as irrelevant studies. An irrelevant study was
dened as a non-case report, such as a review, commentary,
or clinical trial. Treatments not typically carried out by a mas-
sage therapist were also excluded, such as cardiac massage,
prostatic massage, or carotid sinus massage. Adverse events
related to massage oils, for example, allergies to aromatherapy
oils or to the use of ice in conjunction with massage, were also
excluded. All articles were evaluated and validated by one of
the authors according to inclusion criteria.
2.3. Data Extraction. Electronic database searches identied
a total of  articles for consideration. Aer screening, 
potentially relevant articles were identied for full review,
and  studies met inclusion criteria nally. ere were 
articles that were excluded for being unrelated to AEs or for
having no details reported (Figure ).Afulllistofexcluded
articles is available from the corresponding author. When
provided, we extracted author, year of publication, country
of occurrence, participant related information (age, sex) or
number of patients aected, the details of manual therapy,
andcliniciantypethatmighthavecontributedtotheAE,
the reported AE, and its outcome. e data were extracted
by two independent coauthors (P. Y. and NY. G.) and double
checked to ensure matching and disagreements were resolved
by consensus. Since there are no widely accepted criteria for
judging the quality of AEs reports and the current studies’
objective of describing case details, we did not assess the risk
of bias on the included studies.
3. Results
e search strategy located  articles reporting a total of 
case reports (in which the patients’ age and/or sex were given)
(Table ), and a total of  reports containing  AEs in case
series associated with massage were identied (Tab le  ). Most
cases were reported from Asia especially in China (𝑛=24,
60%oftotal)andEurope(,30%), with few cases from the
USA (, 7.5%) and Australia (, 2.5%), and more than half
of the reported patients were female. ere are  signs or
symptoms of AEs in total, and the most common problems
included disc herniation ( cases, 16.3%), so tissue trauma

Evidence-Based Complementary and Alternative Medicine 
T : Cases of AEs associated with massage therapy.
Author (year) Country Language Age, sex Details of manual
therapy Clinician type Adverse event (nature and
location) Follow-up
Jay et al. () []USA English , F Chiropractic
manipulations Chiropractor
Bilateral dissection of
vertebral arteries followed
by bilateral
occipital-parietal
hemorrhagic infarction and
visual impairment
Complete resolution ( d.)
Beck et al. () []Germany English , F Axial tension and
rotation Chiropractor Intracranial hypotension Complete resolution
conrmed by MRI
Nadgir et al. () []USA English , M Neck manipulation Chiropractor
Neck cramping (bilateral
internal carotid and
vertebral artery dissection)
Minimal residual
hemianesthesia and
dysesthesia
Oehler et al. () []Germany German , F Chiropractic neck
manipulation Unknown Bilateral dissections of
vertebral arteries Resolution
Yokota et al. () []Japan Japanese , M Chiropractic neck
manipulation
Unregistered
practitioner
Dissection of le vertebral
artery followed by Dejerine
syndrome
Unknown
Licht et al. () []Denmark English , M Cervical
manipulation
General
practitioner
Large infarction in the le
cerebellar hemisphere
(presumably due to arterial
dissection)
Complete recovery ( mo.)
Xiong () []China Chinese , M Reduction
manipulation Not mentioned Cerebral infarction Irritating cough and limb
numbness ( y.)
MaandXu()[]China Chinese , F Rotation Not mentioned Peripheral ner ve
entrapment syndrome Recovered
Yu et al. () []China Chinese , M Manipulative
reduction Not mentioned Spinal cord injury Recovered ( mo.)
Yu et al. () []China Chinese , M Manipulative
reduction Not mentioned Spinal cord injury Symptom remission ( d.)
Zhang et al. () []China Chinese , M Rotation Not mentioned
Extrusion of lumbar
intervertebral discs (lower
limb pain, incontinence,
and saddle sensation
disorders)
Pain relief aer surgery, but
residual saddle area
numbness
Zhang et al. () []China Chinese , M Rotation Not mentioned
Extrusion of lumbar
intervertebral discs (lower
limb pain, walking and
sexual dysfunction)
Muscle recovery aer
surgery, but still sexual
dysfunction ( y.)

 Evidence-Based Complementary and Alternative Medicine
T : C o nt i n u e d .
Author (year) Country Language Age, sex Details of manual
therapy Clinician type Adverse event (nature and
location) Follow-up
Izquierdo-Casas et al. ()
[]Spain Spanish , F Chiropractic Not mentioned
Dissection of vertebral
artery followed by
tetraparesis
Locked-in syndrome
Morandi et al. () []France English , F Lumbar vertebral
manipulation Physician Caudal spinal cord
ischemia Permanent neuroloss
Saxler and Barden ()
[]Germany German , F
Cervical
chiropractic
manipulation
(C/), facet joint
inltration
Not mentioned
Epidural hematoma
extending from cervical to
sacral spine
Complete resolution
Tom´
eetal.()[]Spain Spanish Not noted Chiropractic
manipulation Not mentioned Multiple cervical disc
herniation Not mentioned
Hansis et al. () []Germany German , M Chiropractic
manipulation Unknown L fracture osteoporosis Surgery
Hansis et al. () []Germany German , M Unknown Unknown Disk protrusion Surgery
Wang et al. () []Australia English , F Lumbosacral
manipulation Unknown Extradural hemorrhagic
synovial cyst, leg pain
Complete recovery aer
L–L laminectomy and
cyst removal
Wang et al. () []Australia English , F Lumbosacral
manipulation Unknown
Hemorrhagic synovial cyst
with resultant lumbar canal
stenosis and exacerbation
of severe pain in buttock
and le leg pain
L-L laminectomy and
cystremovalwithexcellent
outcome
L. Zhang and G. H. Zhang
() []China Chinese , F Rotation Not mentioned Atlantoaxial dislocation Recovered aer surgery
( wk.)
Chen et al. () []Taiwan E ng l i s h  , M Chiropractic and
massage therapy Not mentioned
Neck pain, relieved by
chiropractor, hematoma of
ligamentum avum at the
level of C-C with
hemiparesis
Complete recovery aer
laminectomy ( y.)
Suh et al. () []Korea English , F Axial tension and
rotation Chiropractor Intracranial hypotension Complete resolution aer
epidural blood patch
Schmitz et al. () []Germany English , F Cervical
manipulation
General medical
practitioner
Displaced odontoid
fracture in the presence of
an aneurismal bone cyst
Complete recovery aer
surgery
Chen et al. () []China Chinese , F Rotation Self-treatment
by her husband
Cervical myelopathy (neck
pain, dizziness, and
numbness of limbs)
Recovered ( d.)

Evidence-Based Complementary and Alternative Medicine 
T : C o nt i n u e d .
Author (year) Country Language Age, sex Details of manual
therapy Clinician type Adverse event (nature and
location) Follow-up
Jing and Yang () []China Chinese , M Rotation Not mentioned Fracture and bulge of
intervertebral discs
Nearly full recovery aer
surgery
Solheim et al. () []Norway English , M
Lumbar
manipulation
therapy
Chiropractor
Partial cauda equina
syndrome due to spinal
epidural hematoma in the
L region
Surgical evacuation of
hematoma via L and L
laminectomies,
improvement with motor
decits, but the bladder
dysfunction remained
Guo et al. () []China Chinese , F
Lumbar
manipulation
therapy
Not mentioned Ribfracture(theseventh
rib) Not mentioned
Guo et al. () []China Chinese , M Cervical
manipulation Not mentioned Lacerations of so tissues Recovered ( mo.)
Guo et al. () []China Chinese , M
Lumbar
manipulation
therapy
Not mentioned Fracture (L transverse
process fractures) Not mentioned
Guo et al. () []China Chinese , F
Lumbar
manipulation
therapy
Not mentioned Fracture (L transverse
process fractures) Not mentioned
Guo et al. () []China Chinese , F Cervical
manipulation Not mentioned Syncope Not mentioned
Guo et al. () []China Chinese , M Rotation Not mentioned Fracture (proximal humeral
fracture) Not mentioned
Yi et al. () []China Chinese , F Cervical
manipulation Not mentioned Hypochondriacal neurosis Not mentioned
Yi et al. () []China Chinese , F
Cervical spine
manipulative
reduction
Not mentioned Hypochondriacal neurosis Recovered
Jiang () []China Chinese , M Rotation
Massage
therapist
(private clinics)
Brown-Sequard syndrome
due to spinal epidural
hematoma
Near full recovery aer
surgery ( w k.)
Huang et al. () []Taiwan En g l i s h , M
Manipulation
directed at the
lumbopelvic-thigh
region and massage
Physiotherapist Ruptureofsotissuetumor
at anterior proximal thigh
Surgical tumor resection,
and neither recurrence nor
metastasis was observed 
months aer surgery
Zhu () []China Chinese , F Joint mobilization Not mentioned Hemarthrosis of knee joint Improved the joint activity
( mo.)
Jin et al. () []China Chinese , not noted Rotation Massage
therapist Dead Dead

 Evidence-Based Complementary and Alternative Medicine
T : C o nt i n u e d .
Author (year) Country Language Age, sex Details of manual
therapy Clinician type Adverse event (nature and
location) Follow-up
Tamburrelli et al. () []Italy Eng lish , M Spinal manipulation Doctor of
chiropractic
Cauda equina syndrome,
L-S extrusion
L laminotomy and L-S
discectomy,
improved, but with
persistent bowel
dysfunction, impotence,
lower extremity; pain,
paresthesias, and mild
sensory decit
Bi () []China Chinese , M Cervical
manipulation Not mentioned Dorsolateral medullary
syndrome Improved ( d.)
Zhang et al. () []China Chinese , F Rotation Massage doctor Atlantoaxial dislocation Near full recovery aer
surgery ( mo.)
Li et al. () []China Chinese , F Neck massage Not mentioned Vertebral arterial dissecting
aneurysm
Horner syndrome
disappeared and without
dysphagia ( mo.)

Evidence-Based Complementary and Alternative Medicine 
T : Case series of AEs associated with massage therapy.
Author (year) Country Language Cases Details of manual
therapy Clinician type Adverse event (nature
and location) Follow-up
Yo u n g a n d C h e n
() []Tai w a n E n g l i sh  Cervical
manipulation Chiropractor
Vertebral artery
occlusion ( case);
stenosis ( case);
slow blood ow ( case)
associated with normal
ndings ( cases)
Recovered ( mo.)
Mei et al. () []China Chinese 
Rotatory
reduction
manipulation
Not mentioned
Nausea and profuse
sweating ( cases);
headache and vertigo (
cases); upper extremity
numbness ( cases);
cervical limitation of
activity ( cases); lower
limbs motor disturbance
( cases)
 cases recovered,
 cases improved
Oppenheim et al.
() []USA English  Spinal
manipulation Chiropractor
Spinal cord injuries (
cases); cauda equina
syndrome ( cases);
radiculopathy ( cases);
pathological fracture (
cases)
 patients need
surgery, but half of
them made an excellent
recovery subsequently,
and one-third had a
good recovery
Wang (    ) [ ]China Chinese 
Rotatory
reduction
manipulation
Not mentioned Lumbar intervertebral
disc extrusion
Fully recovered (
cases);
foot prolapse ( cases);
hypoesthesia ( case)
Wang et al. ()
[]China Chinese  Neck massage Not mentioned Cervical disc herniation Recovered
Guo and Lu ()
[]China Chinese 
Rotation (
cases), tendon-
regulating
method ( cases)
Not mentioned
Simple so tissue injury
( cases);
cervical structural
damage ( cases)
Not mentioned
Qu et al. () []China Chinese  Pressing
manipulation Not mentioned
Aggravated lumbar
intervertebral disc
extrusion
Recovered (– d.)
( cases, 11.1%), neurologic compromise ( cases, 8.5%),
spinal cord injury ( cases, 8.5%), dissection of the vertebral
arteries ( cases, 6.5%), bone fracture ( cases, 5.9%),
hematoma or hemorrhagic cyst ( cases, 3.9%), syncope (
cases, 3.9%), cauda equina syndrome ( cases, 2.6%), pain
( cases, 1.3%), dislocation ( cases, 1.3%), and others. e
symptoms are frequently life-threatening, though in most
cases the patient made a full recovery. In the majority of cases,
the problems were related to spinal manipulations, including
rotational movements, which seem to be the probable cause
of the AEs.
4. Discussion
OurprimaryobjectiveinreviewingthecasereportsofAEs
associated with massage has been to identify individual cases
and outbreaks of AEs then to analyze their possible causes, in
order to minimize the massage AEs in future and enhance
the practice safety within the profession. Of the  cases
involving the AEs following massage in  references (Tables
and ), spinal manipulation has repeatedly been reported
with serious AEs especially. Collectively, these data suggest
that massage is associated with frequent, mild, and transient
AEs, but sometimes it may also be indeed associated with
serious complications which can lead to permanent disability
or even death. Although important details of most cases are
poorly reported or frequently missing, these results have clear
clinical and research related implications comparatively.
e true risk of injury due to spinal manipulation is
still not known. Yet causal inferences may be not completely
reasonable. Vascular accidents may happen spontaneously
orcouldbecausedbyfactorsotherthanmassage.ereal
serious incidence of AEs has been estimated to be ranging
from  strokes in , manipulations to . case series in
 million manipulations, and a rate of . deaths in  mil-
lion manipulations has been reported [–]. e insurance
industry claims []datasupportariskofstrokeasper
million manipulations. 99% of all chiropractors practicing in
Denmark completed a survey; they estimated that one case of
cerebrovascular accident occurred for every . million cervi-
cal treatment sessions. e occurrence increased to  in every
, treatment sessions for upper cervical manipulations,

 Evidence-Based Complementary and Alternative Medicine
and they noted that techniques using rotational thrusts were
overrepresented in the frequency of injury.
A temporal relationship is insucient to establish causal-
ity, and recall bias can further obscure the truth. Moreover,
denominators are rarely available. Smaller randomized con-
trolled trials (RCTs) are unlikely to detect rare AEs, and better
reporting of AEs is required, obviously. erefore Senstad
et al. [–] reported the data from  prospective inves-
tigations of  adults who received chiropractic spinal
manipulation indicated that 30%to55%reportedaminor
adverse event. e most common were local discomfort
(% to %), radiating discomfort (10%to23%), headache
(10%to12%), tiredness (%), or nausea; dizziness, hot
skin, or “other” reactions are uncommonly reported (<%
of reactions). And of the reported reactions, reactions were
mild or moderate in 85%to90%ofpatients.64%ofreactions
appeared within  hours of treatment, and 74%to83%had
disappeared within  hours. Interestingly, reactions are most
commonly reported by women and (for both genders) at the
beginning of the treatment series. Patients with long-lasting
problems are more likely to report treatment reactions, and
patients with no prior experience of chiropractic care do not
report more reactions than patients previously treated by chi-
ropractors. en Cagnie et al. [] recruited  new patients
treated with spinal manipulation by  physiotherapists
(Belgian). All patients were asked to complete a questionnaire
about AEs subsequently. 61%ofthepatientsreportedatleast
one AE, most of which were mild and transient, like headache
(20%), stiness (%), local discomfort (15%), radiating
discomfort (12%), and fatigue (12%). 61%oftheproblems
had started within  hours aer manipulation; 64%had
resolved within  hours. No complicationswith long-lasting
consequences were reported. Hurwitz et al. []reported
the AEs documented in a -patient RCT which compared
spinal manipulation with spinal mobilization as treatments
for neck pain. 30% reported at least one AE. Patients receiving
spinal manipulation were more likely to experience AEs than
mobilization. e most frequently noted AEs were increase
of pain, headache, tiredness, and radiating pain. 80%of
theAEsbeganwithinhoursaertreatmentandwere
mild or of medium severity. No serious complications were
noted. e three prospective case series above corroborate
the results from several earlier studies []showingthatmild
tomoderateAEsoccurinalargeproportionofpatients
receivingspinalmanipulation,buttheseAEsaretransient
and nonserious. And recently,  patients were random-
ized to one of three treatment arms in a new study [],
to investigate dierences in occurrence of adverse events
between three dierent combinations of manual treatment
techniques used by manual therapists (i.e., chiropractors,
naprapaths, osteopaths, physicians, and physiotherapists) for
patients seeking care for back and/or neck pain. And adverse
events were measured with a questionnaire aer each return
visit and categorized into ve levels. As a result, the most
common adverse events were soreness in muscles, increased
pain, and stiness. e most frequent level of adverse event in
this study was short minor lasting less than  hours and was
rated less than or equal to three on the numeric rating scale
regarding severity. No serious adverse events were reported.
Clearly, we should dierentiate between various ap-
proaches. e above cases suggest that massage by nonpro-
fessional and forceful techniques is oen associated with
AEs. In  cases the practitioners are massage therapists
(5.8% of total) and  are chiropractors (23.9%), while
in the other cases (70.3%)theyareunregisteredoreven
healthcare professionals only. So it might be unfair to assess
the AEs of spinal manipulation as practiced by well-trained
chiropractors alongside that associated with the untrained.
Obviously from above, a variety of dierent care providers
like physiotherapists, massage therapists, physicians, and
osteopaths may perform a manipulation as part of their
practice, but it should be most frequently performed by
chiropractors []. Certainly skill and experience are impor-
tant, and it is relevant to dierentiate between dierent
professions. But on the other hand, skill is a quality not easily
controlled and some therapists are more skilled than others.
Moreover,thisreviewisaimedatevaluatingtheAEsofan
intervention (massage) and not that of a profession (massage
therapist/chiropractic). at is why in this review we show
the implicated practitioners are not only chiropractors but
also physicians, physiotherapists, “bonesetters,” and general
medical practitioners.
is systematic review has several limitations. Even
though the search strategy was deemed thorough, some rele-
vant published articles might have been missed. It is possible
that not all cases were identied in our searches. Although
this paper has resulted in a few papers to review, it still had its
strengths including the thorough search of the literature to
help reduce bias in the review. We searched multiple relevant
electronic databases and used two coauthors to determine
articles for inclusion in the review and to evaluate the liter-
ature. But because of the inherent nature of case reports and
other anecdotal reports, it is impossible to make inferences
regarding cause and eect. erefore, it is not known whether
the serious AEs in cases identied in this review were caused
by massage and whether the association between therapy
and event was accidental or not. So the safety in massage
is still far from being achieved. Further investigations are
urgent to assess denite conclusions regarding this issue. In
the meantime, it should be necessary to establish a system of
risk alert for guaranteed sur veillance on this type of CAM and
safe practice guidelines are required and could continue to be
enforced.
5. Conclusions
In conclusion, although serious AEs associated with massage
in general and pain-related massage in particular are few,
massage therapies are not totally devoid of risks. Spinal
manipulation in massage has repeatedly been associated with
serious AEs especially. But the incidence of such events is
probably low. Adequate regulation could further minimize
the risks. So we recommend that not only adequate training in
biomedical knowledge for practitioners, such as anatomy and
microbiology, but also safe practice guidelines are required
andshouldcontinuetobeenforcedinordertominimize
massage AEs.

Evidence-Based Complementary and Alternative Medicine 
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
Authors’ Contribution
Ping Yin and Ningyang Gao made equal contributions to this
paper.
Acknowledgments
e work in Austria was supported by the Federal Ministries
of Science, Research and Economy and of Health (project
title: “Evidence-based high-tech acupuncture and integrative
laser medicine for prevention and early intervention of
chronic diseases”).
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