**4.6 Reviews about safety**

Among all reviews a meta-analysis of 33 randomized controlled trials was found. The authors conclude that acupuncture and dry needling are effective techniques, but more research on the safety of them is needed [65]. McCutcheon et al. [112] also reviewed the safety of acupuncture and dry needling, suggesting modifications of these techniques to avoid pleura and the lung. However, there are no conclusive results.

Considering the severity of these techniques, Brady et al. [113] conducted a study to check the adverse effects of dry needling. They filled in 2 questionnaires for 10 months to 39 physiotherapists and regrouped 1.463 adverse effects (common/less common/rare). They showed that it was a safe technique. Similarly, Halle et al. have published 2 articles [114, 115]. They assessed the risk/benefit of these techniques to minimize them, proposed an adequate education, knowledge of anatomy, training and to inform the patient via informed consent.

Guided techniques should be an interesting option to reduce these complications, but several articles do not support this affirmation [92, 110]. More investigation in this line is needed. On the other side, if dry needling seems to be safe, maybe it would be chosen instead injections to avoid the possible events effects derivate to the administered drugs like Kim et al. [93] exposed.
