Detail of articles included about acupuncture.
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"},{slug:"intechopen-identified-as-one-of-the-most-significant-contributor-to-oa-book-growth-in-doab-20210809",title:"IntechOpen Identified as One of the Most Significant Contributors to OA Book Growth in DOAB"}]},book:{item:{type:"book",id:"5712",leadTitle:null,fullTitle:"Pure and Applied Biogeography",title:"Pure and Applied Biogeography",subtitle:null,reviewType:"peer-reviewed",abstract:'This book, Pure and Applied Biogeography, gives a very interesting report and overview about the frontiers of such parts of recent biogeographical research, which plays important roles in solving our most pressing global problems (biodiversity crisis, climate change, water issues, and sustainable agriculture). Our book consists of three sections: "Introduction", "Pure Biogeography and Global Patterns" and "Applied Biogeography and Regional Issues." After the introductory chapter, which is about the main branches and aims of biogeography in service of solving global problems, - we can find three chapters as parts of the first section. First chapter in this section is in close relation with the origin of biodiversity and conservation. The second and third chapters are about the biogeograhical aspects of climate change and biodiversity. In the second section of this book three applied biogeographical chapters can be found, which are related to agriculture, theoretical background of biological plant protection against herbivores, and regional patterns in ecological biogeography.',isbn:"978-953-51-3755-9",printIsbn:"978-953-51-3754-2",pdfIsbn:"978-953-51-3971-3",doi:"10.5772/65139",price:119,priceEur:129,priceUsd:155,slug:"pure-and-applied-biogeography",numberOfPages:176,isOpenForSubmission:!1,isInWos:1,isInBkci:!1,hash:"d1a184b4b5e457c98102c80f46f00c85",bookSignature:"Levente Hufnagel",publishedDate:"January 24th 2018",coverURL:"https://cdn.intechopen.com/books/images_new/5712.jpg",numberOfDownloads:10402,numberOfWosCitations:9,numberOfCrossrefCitations:7,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:16,numberOfDimensionsCitationsByBook:0,hasAltmetrics:1,numberOfTotalCitations:32,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 23rd 2016",dateEndSecondStepPublish:"December 14th 2016",dateEndThirdStepPublish:"September 15th 2017",dateEndFourthStepPublish:"October 15th 2017",dateEndFifthStepPublish:"December 15th 2017",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"10864",title:"Dr.",name:"Levente",middleName:null,surname:"Hufnagel",slug:"levente-hufnagel",fullName:"Levente Hufnagel",profilePictureURL:"https://mts.intechopen.com/storage/users/10864/images/system/10864.JPG",biography:"Dr. Levente Hufnagel is an associate professor and the head of the Research Institute of Multidisciplinary Ecotheology, John Wesley Theological College, Budapest, Hungary, working on ecology, biogeography, ecological research methodology, and sustainability. He has more than 20 years of experience in leading Hungarian academic institutions teaching Ph.D., MSc, and BSc students from various social and cultural backgrounds. He has more than 300 scientific publications (in both aquatic and terrestrial ecological aspects of plants, animals, and microbes at both the community and population levels) and more than 1100 independent citations to his credit. As a participant in several big ecological research and development projects, Dr. Hufnagel has significant experience in multidisciplinary collaborations (with more than 200 coauthors in different publications). He has supervised several Ph.D., BSc, and MSc theses, and served as editor in chief of an international scientific journal. Dr. Hufnagel graduated from Eötvös Lorand University with a master’s degree in Ecology and Evolutionary Biology and a Ph.D. in Hydrobiology. He also has a Ph.D. in Agricultural Science from Szent István University, Hungary, and several other degrees from the Corvinus University of Budapest and Adventist Theological College.",institutionString:"John Wesley Theological College",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"11",totalChapterViews:"0",totalEditedBooks:"6",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1412",title:"Biotechnology",slug:"agricultural-and-biological-sciences-plant-biology-biotechnology"}],chapters:[{id:"58419",title:"Introductory Chapter: The Main Directions and Tasks of Pure and Applied Biogeography in Solving the Global Problems of Our Time",doi:"10.5772/intechopen.72873",slug:"introductory-chapter-the-main-directions-and-tasks-of-pure-and-applied-biogeography-in-solving-the-g",totalDownloads:1073,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Levente Hufnagel",downloadPdfUrl:"/chapter/pdf-download/58419",previewPdfUrl:"/chapter/pdf-preview/58419",authors:[{id:"10864",title:"Dr.",name:"Levente",surname:"Hufnagel",slug:"levente-hufnagel",fullName:"Levente Hufnagel"}],corrections:null},{id:"56354",title:"Are Historical Biogeographical Events Able to Promote Biological Diversification?",doi:"10.5772/intechopen.69516",slug:"are-historical-biogeographical-events-able-to-promote-biological-diversification-",totalDownloads:1303,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"One of the goals of evolutionary biology is understanding how biological diversification change across spatial and temporal scales. Theoretically, it has been established that external (i.e., dispersals) and internal (i.e., origin of a key innovations) factors can modulate shifts in rates of species diversification. However, the role of historical events as trigger of species diversification rates have not been well understood in empirical studies. I reviewed the literature linking historical biogeographic events and species diversification in many groups. Many of studies conclude that dispersals can be associated with exceptional changes in species diversification rates in insular and mainland areas. I discuss the limitations of some approaches used to discover the link between historical biogeography and macroevolution. I propose some predictions under biogeographic scenarios to gain understanding in how historical events promote biological diversification. I suggest that future studies linking biogeography and macroevolution should incorporate ecologically-relevant traits to discern the mechanisms underlying these historical associations. Although new developments in phylogenetic comparative methods have been done, still is necessary more traditional field-based ecological and evolutionary research. The link between biogeography and diversification still remains narrative and a comprehensive approach is necessary to establish how diversification was triggered by historical events.",signatures:"Julián A. Velasco",downloadPdfUrl:"/chapter/pdf-download/56354",previewPdfUrl:"/chapter/pdf-preview/56354",authors:[{id:"110027",title:"Ph.D.",name:"Julián",surname:"Velasco",slug:"julian-velasco",fullName:"Julián Velasco"}],corrections:null},{id:"55977",title:"Ecological Responses to Climate Change at Biogeographical Boundaries",doi:"10.5772/intechopen.69514",slug:"ecological-responses-to-climate-change-at-biogeographical-boundaries",totalDownloads:1234,totalCrossrefCites:2,totalDimensionsCites:2,hasAltmetrics:1,abstract:"Temporal and spatial biogeographical boundaries are usually associated with extinction processes. However, some boundary regions seem to be places of speciation. It is unclear if boundaries are favored by generalized or specialized species. Recent studies suggest that narrow-ranging species can be strong competitors and they can replace wide-ranging species while shifting their range boundaries under the effect of climate change. In other boundary regions, the decline of both passive- and active-dispersing specialists has been observed. Core regions are also weakening. They are jeopardized mainly by extreme climate events and fragmentation and by the accompanied non-native invasions. Biodiversity loss and homogenization have been observed globally.",signatures:"Melinda Pálinkás",downloadPdfUrl:"/chapter/pdf-download/55977",previewPdfUrl:"/chapter/pdf-preview/55977",authors:[{id:"202242",title:"Ph.D. Student",name:"Melinda",surname:"Pálinkás",slug:"melinda-palinkas",fullName:"Melinda Pálinkás"}],corrections:null},{id:"56606",title:"A Synopsis of Global Mapping of Freshwater Habitats and Biodiversity: Implications for Conservation",doi:"10.5772/intechopen.70296",slug:"a-synopsis-of-global-mapping-of-freshwater-habitats-and-biodiversity-implications-for-conservation",totalDownloads:1541,totalCrossrefCites:4,totalDimensionsCites:8,hasAltmetrics:1,abstract:"Accurately mapping freshwater habitats and biodiversity at high-resolutions across the globe is essential for assessing the vulnerability and threats to freshwater organisms and prioritizing conservation efforts. Since the 2000s, extensive efforts have been devoted to mapping global freshwater habitats (rivers, lakes, and wetlands), the spatial representation of which has changed dramatically over time with new geospatial data products and improved remote sensing technologies. Some of these mapping efforts, however, are still coarse representations of actual conditions. Likewise, the resolution and scope of global freshwater biodiversity compilation efforts have also increased, but are yet to mirror the spatial resolution and fidelity of mapped freshwater environments. In our synopsis, we find that efforts to map freshwater habitats have been conducted independently of those for freshwater biodiversity; subsequently, there is little congruence in the spatial representation and resolution of the two efforts. We suggest that global species distribution models are needed to fill this information gap; however, limiting data on habitat characteristics at scales that complement freshwater habitats has prohibited global high-resolution biogeography efforts. Emerging research trends, such as mapping habitat alteration in freshwater ecosystems and trait biogeography, show great promise in mechanistically linking global anthropogenic stressors to freshwater biodiversity decline and extinction risk.",signatures:"Ryan A. McManamay, Natalie A. Griffiths, Christoper R. DeRolph\nand Brenda M. Pracheil",downloadPdfUrl:"/chapter/pdf-download/56606",previewPdfUrl:"/chapter/pdf-preview/56606",authors:[{id:"196353",title:"Dr.",name:"Ryan",surname:"McManamay",slug:"ryan-mcmanamay",fullName:"Ryan McManamay"},{id:"196355",title:"Dr.",name:"Brenda",surname:"Pracheil",slug:"brenda-pracheil",fullName:"Brenda Pracheil"},{id:"196356",title:"Dr.",name:"Natalie",surname:"Griffiths",slug:"natalie-griffiths",fullName:"Natalie Griffiths"},{id:"209046",title:"Mr.",name:"Christopher",surname:"DeRolph",slug:"christopher-derolph",fullName:"Christopher DeRolph"}],corrections:null},{id:"56726",title:"Plant Antiherbivore Defense in Diverse Environments",doi:"10.5772/intechopen.70418",slug:"plant-antiherbivore-defense-in-diverse-environments",totalDownloads:1156,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"Herbivores can damage plant productivity and fitness; plants have improved defensive traits, such as chemical defenses. Plant species produce specific defensive traits in response of diverse risk factor generated by herbivores. In this chapter, we analyze and compare the defensive traits used by plants in different habitats: aquatic ecosystems, temperate forest, and rainforest. In aquatic environments, the number of herbivores is scarce, and plants develop biomass and restrict defensive compound production. At the terrestrial environment, plants need to accumulate defensive traits for an eventual attack. But the number and quantity of those traits depend on biotic and abiotic factors. In temperate forest, plants have a low growth, and herbivore diversity is low, because there are a few number of defensive traits but in great quantity to guarantee plant survival. In contrast, at tropical forest there is a great herbivore diversity, and plants have a quick growth; thus they develop a great variety of defensive traits. There are substantial differences in plant defensive strategies at different environments. Usually, the aquatic plants use water-soluble and diffusible compounds; plants in rainforest use a plethora of chemical defenses, and in temperate forest, plants utilize physical barriers, resins, and terpenes.",signatures:"Alina Morquecho-Contreras, Carmen Zepeda-Gómez and Hermilo\nSánchez-Sánchez",downloadPdfUrl:"/chapter/pdf-download/56726",previewPdfUrl:"/chapter/pdf-preview/56726",authors:[{id:"187846",title:"Dr.",name:"Alina",surname:"Morquecho-Contreras",slug:"alina-morquecho-contreras",fullName:"Alina Morquecho-Contreras"},{id:"188445",title:"Dr.",name:"Hermilo",surname:"Sánchez-Sánchez",slug:"hermilo-sanchez-sanchez",fullName:"Hermilo Sánchez-Sánchez"},{id:"196369",title:"Dr.",name:"Carmen",surname:"Zepeda Gómez",slug:"carmen-zepeda-gomez",fullName:"Carmen Zepeda Gómez"}],corrections:null},{id:"56901",title:"Vachellia (Acacia) karroo Communities in South Africa: An Overview",doi:"10.5772/intechopen.70456",slug:"vachellia-acacia-karroo-communities-in-south-africa-an-overview",totalDownloads:2778,totalCrossrefCites:0,totalDimensionsCites:3,hasAltmetrics:1,abstract:"Vachellia karroo is a useful and widespread tree in Africa. It belongs to the family Fabaceae, which is the third largest woody plant family in southern Africa. This is an ecologically and economically important species as almost all of its parts, including bark, pods, seeds, leaves and thorns, are extremely useful to both humans and animals. Various commercial products are also obtained from the tree, and gum is one of the most important products. V. karroo in South Africa has an extensive distribution range that includes several biomes. It is very adaptable and has wide habitat tolerance, growing under many differing conditions of soil, climate, and altitude. Although it is often associated with heavy, clayey soils on the banks of rivers and streams, it also grows in bushveld, dry thornveld, grassland and woodland. V. karroo is easy to grow and as a result can become an aggressive invader of valuable farming land and grazing areas, a phenomenon usually referred to as bush encroachment. An analysis of historic data comprising 1553 relevés and 2006 species, compiled from all areas of South Africa where V. karroo is known to occur was conducted, and TWINSPAN classification produced five main vegetation types.",signatures:"Mamokete Dingaan and Pieter J. du Preez",downloadPdfUrl:"/chapter/pdf-download/56901",previewPdfUrl:"/chapter/pdf-preview/56901",authors:[{id:"203990",title:"Dr.",name:"Mamokete N.V.",surname:"Dingaan",slug:"mamokete-n.v.-dingaan",fullName:"Mamokete N.V. Dingaan"},{id:"210602",title:"Prof.",name:"Johann",surname:"Du Preez",slug:"johann-du-preez",fullName:"Johann Du Preez"}],corrections:null},{id:"58088",title:"Ecological Biogeography of West Usambara Mountains: A Study on the Influence of Abiotic Factors to Spatial Distribution of Plant and Animal Species",doi:"10.5772/intechopen.72068",slug:"ecological-biogeography-of-west-usambara-mountains-a-study-on-the-influence-of-abiotic-factors-to-sp",totalDownloads:1320,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"West Usambara Mountains, Tanzania are famous for rich biodiversity and endemic species of plants and animals. Although there have been extensive studies on plant and animals species, little attention has been given on abiotic factors influencing their spatial distribution. Given rampant degradation of vegetation and associated consequence on biodiversity, knowledge on abiotic factors influencing distribution of species along the landscape become pertinent for conservation. A study was carried out to explore abiotic factors impacting plant and animals species distribution. Soil, landform and land use/cover were studied using grids of 20 m × 20 m using FAO Guidelines for Soil Profile and Habitat Descriptions. Soils were described, sampled for laboratory analysis. Spatial distribution of plant species were determined in the grids, and along the transects, every time estimating the percent cover and describing the habitat. Distribution of animal species was studied using both small mammals and rodent burrows as proxies. Trapping was done using different traps sizes, checking daily for animal caught, counting and re-trapping. Rodent burrows were estimated in same grids by examining a width of 0.5 m from end to end of grid and total number of burrows recorded. Determination of species distribution was done using GLM regression. Results show that species are influenced by elevation, which was common to both plants and animals. Topsoil soil depth was positive to plant species whereas hillshade, surface stones, cultivation and atmospheric temperature were negatively influencing plant species. Rock outcrops, surface stones and cultivation were positively influencing small mammals distribution. It is concluded that factors influencing distribution of small mammals are elevation, surface stones, rock outcrop and cultivation. Factors influencing plant species are elevation soil depth whereas cultivation, hillshade, surface stone and rock out crops negatively impact distribution. For conservation, it is recommended that the best steps are to stop human activities leading to depletion of plant species and accelerating soil erosion and allow for self-regeneration. Control of soil erosion strongly recommended as way of plant species re-establishment.",signatures:"Joel Loitu Meliyo, Kenneth F.G. Masuki, Balthazar M. Msanya, Didas\nN. Kimaro and Loth S. Mulungu",downloadPdfUrl:"/chapter/pdf-download/58088",previewPdfUrl:"/chapter/pdf-preview/58088",authors:[{id:"181680",title:"Prof.",name:"Didas",surname:"Kimaro",slug:"didas-kimaro",fullName:"Didas Kimaro"},{id:"219833",title:"Ph.D.",name:"Joel Loitu",surname:"Meliyo",slug:"joel-loitu-meliyo",fullName:"Joel Loitu Meliyo"},{id:"221906",title:"Dr.",name:"Kenneth F.G.",surname:"Masuki",slug:"kenneth-f.g.-masuki",fullName:"Kenneth F.G. Masuki"},{id:"221909",title:"Prof.",name:"Balthazar M.",surname:"Msanya",slug:"balthazar-m.-msanya",fullName:"Balthazar M. Msanya"},{id:"221911",title:"Prof.",name:"Loth S.",surname:"Mulungu",slug:"loth-s.-mulungu",fullName:"Loth S. 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\r\n\tThis book deals with three hot topics related to the synthesis, applications, and technologies of carbon nitride. The introductory chapter deals with the synthesis and Photocatalytic properties of graphitic carbon nitride. The other chapters will cover many topics, such as Graphitic carbon nitride for high capacity hydrogen storage and synthesis and characterization of carbon nitride as coating and activation materials for organic pollutants degradation. In addition, the book will cover, Nano Composites of graphitic carbon nitride for luminescence and photocatalytic applications, Graphitic carbon nitride as catalyst support in fuel cells and water electrolyzers, and Graphitic carbon nitride composite as semiconductors and photocatalytic fibers. The new approaches such as graphitic carbon nitride-based nanocomposites, graphitic carbon nitride from melamine and uric acid, and synthesis of metal-free ultrathin graphitic carbon nitride sheet will be the synthesis for photocatalytic degradation of organic dyes. This book will encourage readers, researchers, and scientists to look further into the frontier topics of carbon nitride and open new possible research paths for further novel development.
",isbn:"978-1-80355-973-5",printIsbn:"978-1-80355-972-8",pdfIsbn:"978-1-80355-974-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,hash:"cbd79ae48d049da3e433c845d5b1ab31",bookSignature:"Prof. Nasser S Awwad and Dr. Saleh S. 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He is a permanent member of the American Chemical Society and member of the Arab Society of Forensic Sciences and Forensic Medicine.",coeditorOneBiosketch:"Dr. Saleh S. Alarfaji is the chairman of the chemistry department at King Khalid University (KKU). He got his MSc in computational chemistry from Murray State University (MSU, USA) and Ph.D. from the University of Nottingham.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"145209",title:"Prof.",name:"Nasser",middleName:"S",surname:"Awwad",slug:"nasser-awwad",fullName:"Nasser Awwad",profilePictureURL:"https://mts.intechopen.com/storage/users/145209/images/system/145209.jpg",biography:"Dr. Nasser Awwad received his Ph.D. in inorganic and radiochemistry in 2000 from Ain Shams University . Nasser Awwad was an Associate Professor of Radiochemistry in 2006 and Professor of Inorganic and Radiochemistry in 2011. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"69880",title:"Alternative Raw Materials for Pulp and Paper Production in the Concept of a Lignocellulosic Biorefinery",doi:"10.5772/intechopen.90041",slug:"alternative-raw-materials-for-pulp-and-paper-production-in-the-concept-of-a-lignocellulosic-biorefin",body:'\nSeveral successful industrial factories based on alternative raw materials for pulp and paper production already exist nowadays [1, 2]. Lignocellulose is the major structural component of plants and is by far the most abundant type of earthly biomass [1, 3]. It mainly consists of cellulose (40–60%), hemicellulose (10–40%) and lignin (15–30%), with minor amounts of extractives, proteins and inorganic compounds [1, 3]. Lignocellulose components can be found in both woody (e.g. spruce, pine, eucalypt, poplar, etc.) and non-woody biomass, the latter including vegetables (e.g. bamboo, tagasaste, kenaf, abaca, etc.) and agriculture residues from harvesting and pruning operations (e.g. barley straw, wheat straw, orange tree pruning, olive tree pruning, etc.) and from agro-food industry [e.g. bagasse, empty fruit bunches from oil palm (EFB), etc.]. Cellulose is a linear and highly ordered polymer of cellobiose (D-glucopyranosyl β-1,4-D-glucopyranose), whereas hemicellulose represents a family of branched carbohydrate polymers containing both pentoses (e.g. xylose, arabinose) and hexoses (e.g. galactose, mannose, glucose) and showing often uronic acids (e.g. glucuronic acid) and acetyl moieties as sidechain groups [1, 3]. By contrast, lignin is a three-dimensional network buildup of dimethoxylated (syringyl, S), monomethoxylated (guaiacyl, G) and non-methoxylated (p-hydroxyphenyl, H) phenylpropanoid units, derived from the corresponding p-hydroxycinnamyl alcohols, which give rise to a variety of subunits including different ether and carbon–carbon bonds [4].
\nThe main non-food use of lignocellulosic biomass is the production of cellulosic pulp from which a wide range of products can be obtained, highlighting the production of paper. At the beginning of the 1990s, there was the conviction that the arrival of new information technologies would reduce the consumption of paper; however the data of world consumption of paper and cardboard revoke this idea as it went from 240 million tonnes in 1990 to 413 million tonnes in 2016, of which 77.3 million tonnes are consumed in Europe [5]. In the past, the raw materials used in the manufacture of paper were herbaceous biomass such as flax, cotton, bamboo and cereal straw. It was not until the middle of the nineteenth century when woody materials began to be used, mainly due to the increased demand for paper because of the emergence and increased use of printing. Today, most of the cellulosic fibers used come from wood species, mainly hardwoods and softwoods [1, 2, 6]. Nevertheless, in recent years there has been an increase in consumer awareness of the need to preserve the environment, which is why they demand a more ecological production of paper, both in the use of raw materials and in manufacturing processes. With the same purpose, government bodies devote economic and human resources to research into alternative raw materials to conventional ones. For these reasons, a large number of studies on the use of non-woody materials, including agriculture residues and vegetables as alternative source for cellulosic pulp production, have emerged in recent years [1, 7, 8, 9, 10, 11, 12, 13, 14].
\nSome of the advantages of using non-woody raw materials can be mentioned: (i) in developing countries with scarce forest resources, non-woody biomass provides an effective alternative to importing wood, paper, or cellulosic pulp. In these countries, there may be a large area devoted to food crops, which would provide considerable amounts of agricultural residues and agro-food industries [1, 15]; (ii) non-woody biomass increases the added value of agri-food crops by taking advantage of their residues (traditionally used for burning or agricultural amendments) to obtain a product in great demand such as paper [1, 15]; (iii) production of special papers, whose most suitable raw materials are certain vegetable alternatives to conventional woods [1, 16]; and (iv) since the morphological characteristics of the fibers and the chemical composition of the non-woody species are very varied, a wide range of papers can be obtained by properly selecting and/or mixing these raw materials [1, 14].
\nThe availability of raw materials is very important when approaching the industrial facility for the production of cellulosic pulp. Availability is related to the production and location of the various lignocellulosic materials that can be used for the intended purpose. In the case of agricultural residues from harvesting and pruning operations, it can be said that they are very abundant in Spain. Specifically, it is estimated that the production of the most important agricultural residues, due to their abundance, such as cereal straw, sunflower stalks, vine shoots, cotton stems, olive, orange and peach tree pruning and vegetable and other similar crop wastes, represents about 50 million tonnes per year, with Andalusia contributing with more than 20% [1, 17].
\nDue to its abundance, it seems that the most recommended agricultural residue for the manufacture of paper pulp is cereal straw since it represents almost 20% of the agricultural residues considered in 2007, and the technology used in its collection is fully developed [1, 17, 18, 19]. Regarding the waste from the agri-food industry used for the production of cellulosic pulp, the bagasse from the extraction of sugar cane and waste from the palm oil industry (EFB) should be highlighted [20].
\nWith regard to alternative vegetables for cellulosic pulp production, they can be classified in three groups: (i) plants of wild nature such as bamboo, different types of cane, esparto grass, etc. [21]; (ii) plants from plantations with industrial uses, such as sorghum, abaca, sisal, jute, hemp, kenaf, flax, etc. [7, 22]; and (iii) other plants, mainly herbaceous species, grasses and legumes, which produce high biomass yields when grown in intensive plantations (tagasaste,
The prolonged storage of lignocellulosic raw materials is always necessary in the pulp and paper industry. In the case of raw materials that are harvested only at a specific period of the year, the storage is even more important. Therefore, these raw materials must be collected in order to meet the annual needs of a factory, so that it operates all year round, with the consequent better use of installed capacity. On the other hand, many alternative lignocellulosic materials are more easily deteriorated due to their non-woody special properties, such as straws, herbaceous vegetables, etc., mainly if they contain high percentages of humidity. In fact, of all the factors that influence the storage of this type of sources, the most relevant is the residual humidity. Given that these materials do not require too rigorous conservation, as they are not intended for food, the rule of allowing slightly higher humidity than the “Caurie safety” humidity obtained by adjusting the experimental data on equilibrium humidity and relative humidity of the environment of the adsorption isotherms to the Caurie equation can generally be adapted. Applying this standard and observing the experimental adsorption isotherms, it appears that wheat straw, vine shoots and cotton stems can be well conserved in environments with relative humidity below 60–70%, while other agricultural residues such as olive tree pruning or sunflower stems require lower values [26]. On the other hand, it has been verified that the recommended maximum relative humidity values, according to the standard followed in this work, coincide with those obtained experimentally when storing the different agricultural residues considered in environments with different relative humidity for 10 or 12 months. As the chemical composition of these agricultural residues is considered as well as their fibrous structure does not differ so much from other agricultural residues such as wastes from agro-food industries, forestry residues and vegetable materials in general, the above conclusions can be extended to all these alternative lignocellulosic materials.
\nTheoretically speaking any plant containing a reasonable amount of fibres can be used as a raw material for pulp and paper production. In practice, this is not the case. Besides the abundance of the plant, a steady supply and many other requirements are necessary. The fibre content of the plant is important. The plant contains in addition to fibres many non-fibrous cells, e.g. parenchyma cells. Fibres themselves vary much in different plants regarding their length, width, fine structures or microstructures, as well as their chemical composition. In one and the same plant, there are different types of fibres. The same fibre type is not equal in dimension but contains a spectrum of different dimensions. For this reason, one speaks of “average fibre length”. The length of the fibre is one of the most important parameters affecting paper strength [1].
\nChemical characterization, which gives rise to the percentages of the main chemical constituents of lignocellulosic materials (generally cellulose, hemicellulose, lignin, as well as extractives and ash), is of great interest since it can indicate their possible applications for obtaining cellulosic pulps, in terms of the most suitable process to follow and the type of pulp that can be obtained. In this characterization, the contents of holocellulose, lignin, α-cellulose, hemicellulose, and extractives in water, 1% soda and ethanol-benzene and ash are determined as the most important. For this chemical characterization, TAPPI test methods, including TAPPI T 204 om-88, TAPPI T 211 om-93, TAPPI T 222 om-88 [27], and NREL analytical methods (National Renewable Energy Laboratory NREL/TP-510-42168) are usually employed [28].
\nWhen comparing the results obtained by different authors, a good concordance is generally observed for each specific material. Sometimes discrepancies appear that can be attributed to the different procedures used as well as to the different origins and varieties of the raw materials considered. For example, the chemical characterization results obtained for rice straw were analysed and compared with (i) some agriculture residues from harvesting and pruning operations and from agro-food industry (e.g. olive tree pruning, wheat straw, sunflower stems, sorghum stems, bagasse, vine shoots, and cotton stems); (ii) some vegetables (e.g.
The value of the hot water soluble content of rice straw (7.3%) is lower than that of the rest of agricultural residues, except for bagasse and cotton stems; it is higher than the values found for the vegetables considered, except for
The value of soda extractives at 1% of rice straw (57.7%) is higher than the values corresponding to the rest of agricultural residues and vegetable considered, as well as those of pine and eucalyptus.
The content of ethanol-benzene extractives in rice straw (0.56%) is lower than that of the materials considered: agricultural and agro-food residues, vegetables, pine and eucalyptus.
The ash content of rice straw (9.2%) is higher than the values presented by the rest of agricultural residues and much higher than the values of pine and eucalyptus.
The holocellulose content of rice straw (60.7%) is similar to the value found for olive tree pruning and lower than the values found for the rest of the agricultural residues considered, as well as those of the alternative vegetables considered and those of pine and eucalyptus.
The content of α-cellulose of rice straw (41.2%) is lower than the values presented by the cotton stems,
The lignin content of rice straw (21.9%) is similar to the values corresponding to the cotton stems,
In the same way, following the same example of rice straw, the experimental data on its physical characterization, which determines the size of its fibers, are compared with those of other lignocellulosic materials such as wheat straw, sunflower stalks, vine shoots, cotton tree stalks, olive tree pruning, sorghum stalks and pine and eucalyptus woods. After a biometric analysis with the rice straw studied, it is concluded that the length of its fibers (1.29 mm) is similar to that corresponding to the stems of sorghum, superior to those of the other agricultural residues considered and to that of eucalyptus but inferior to that of pine.
\nIn summary, it can be stated that the alternative non-woody materials under consideration have acceptable chemical and physical characteristics for the production of pulp and paper [30].
\nThe manufacture of cellulosic pulp consists of the separation of cellulose fibers, which are cemented by the middle wall, composed mainly of lignin using physical or chemical methods [1, 2, 6]. In order to obtain cellulosic pulps from alternative non-woody materials, different chemical classical processes have been used (using chemical reagents such as soda, sodium sulphate and sodium sulfite) and organosolv (using organic solvents). In general, non-woody raw materials have a less density and more porous structure and, also in most of the cases, less lignin content, which means less energy and chemical requirements for fibre separation during pulp production. In addition, they have shorter growth cycles, reaching maturity faster than wood species, and in many cases the pulp yields obtained are higher [30].
\nSoda pulping is the oldest pulping processes known and consists of subjecting raw materials, cut and conditioned, to a cooking process with a given concentration of sodium hydroxide, at a specific temperature and cooking time, depending on the quality of the pulp to be obtained (chemical or semi-chemical) and the characteristics of the raw materials used [1, 2, 6]. A recovery of reagents and purification of black liquors is finally carried out. Each of these sections of the process can group together different operations. Thus, for example, in the preparation of the raw material, a debarking is carried out in the case of woody plants or pith is removed in the case of some vegetables (e.g. sunflower stalks), a cutting or reduction in size to produce chips or flakes, a cleaning to remove impurities, and so on. In the pulping section, the operations of impregnation of the raw material, cooking or delignification to separate lignin, washing of the solid fraction resulting from cooking and draining of the same to eliminate the fluid used in the washing can be integrated. In the same way, the sections of reagents recovery and purification of residual black liquors are made up of different operations.
\nSoda pulps have been obtained from different alternative raw materials, specially agriculture residues such as wheat straw [31], sunflower stalks [32, 33], vine shoots [34], olive tree pruning [35], sorghum stalks [36, 37], tagasaste [24], EFB [20, 38],
Miao et al. [22] also analysed the composition of the hemp root bast (HRT) to further subject it to a process of soda pulping and bleach it with an elemental chlorine free (ECF) bleaching sequence. These authors conclude that HRT is a suitable raw material to make paper obtaining a pulp with high viscosity and brightness (893 mL/g and 85.52% ISO, respectively). González et al. and Marrakchi et al. [41, 42] also applied soda pulping to orange tree wood and
The pulp obtained by this procedure is usually called Kraft (strong) if used for raw papers or “sulphate” if they are going to receive a further bleaching, although both denominations are used indistinctly. The name “sulphate” is due to the fact that it is the sodium sulphate, and not the sodium sulphide, the reagent that is replaced, although the real agent that acts during the reaction is the sulphide that is generated in the recovery treatment of residual black liquors [1, 2, 6]. The process can be divided into two parts: the first is the obtaining of the pulp, and the second is the recovery of the chemical reagents used from black liquors.
\nAccording to different authors [1, 2, 6], Kraft pulping process consists of the following stages:
The chips are taken to the reactor where they are cooked with white liquor (dissolution of sodium hydroxide and sodium sulphide), controlling the “liquid/solid” ratio.
Pulping takes place during the established time, under appropriate pressure conditions.
The black or residual liquor and the pulp are separated by filtration. The pulp is washed, and the black liquor is sent to the reagent recovery phase.
Once washed, the pulp goes to the bleaching stage or to the raw paper manufacturing plant.
In the reagent recovery phase, organic compounds dissolved in black liquor are used to produce energy, thus reducing the rate of polluting effluents. The stages of recovery are as follows: (i) concentration of the black liquor in the evaporators; (ii) spraying of the concentrated black liquor in the oven, where the carbon reduces the sodium sulphate to sodium sulphide; (iii) the melted solids are discharged and dissolved in water, resulting in the green liquors; and (iv) the green liquor is sent to the causticizing stage, where the sodium carbonate reacts with the calcium oxide to form sodium hydroxide [1, 2, 6].
\nSome studies have been carried out to obtain Kraft pulps using alternative materials to traditional wood, including olive tree wood [43],
Sulfite pulps are obtained by cooking the lignocellulosic material with a solution of bisulfite and sulfur dioxide [1, 2, 6]. The cooking liquor is obtained by burning sulfur to obtain sulfur dioxide which is absorbed in a base of calcium, magnesium, sodium or ammonium. The most important variables of the “sulfite” process includes impregnation of the chips with the cooking reagents, dimensions and quality of the chips, temperature, time, pressure, pH of the white liquor, concentrations of sulfur dioxide combined (total and free), “liquid/solid” ratio and raw material used. Several “sulfite” processes have been proposed, including acid sulphite, bisulphite, alkaline sulphite, multistage sulphite, high-yield sulphite, etc., to obtain dissolving pulp [1, 2, 6]. In addition to these variables, it has been proposed to use molybdate or anthraquinone as catalysts, achieving a stabilization of the polysaccharides and an acceleration in delignification.
\nThe sulfite process has been studied for several alternative raw materials but not as much as the soda and Kraft processes. Then, different studies of sulfite process with olive tree [35, 49], sunflower stalk [50], bagasse [51] and wheat straw [52] have been reported.
\nThese processes are characterized by the fact that the separation of lignin from lignocellulosic materials is achieved by solubilization with organic solvents, which are subsequently recovered for a new pulping cycle, resulting in a concentrate rich in lignin, from which different by-products can be obtained [53]. Among organic solvents used, alcohols (ethanol, methanol, butanol, etc.) and organic acids (acetic and formic acids) are commonly employed for non-woody materials [1, 2, 18, 24, 34, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66]. Nevertheless, acetone and other solvents such as phenol, formaldehyde, ethanolamine, ethylene glycol and ethanol-water have also been used for these alternative raw materials [1, 2, 19, 23, 34, 38, 60, 67, 68, 69, 70, 71], demonstrating that these materials can be used for the manufacture of pulp and paper through different processes with acceptable characteristics.
\nThese are the most widely used processes due to the selectivity that these solvents contribute to the separation of the lignin and their easy recovery by distillation. In the case of the ethanol process, the influence of the operating variables (ethanol concentration, temperature, time and liquid/solid ratio) on the characteristics of the pulp and paper sheets obtained from different alternative raw materials, including olive tree [62], wheat straw [1, 2, 18], tagasaste [24, 57], sunflower stalk and
Along with the processes that use alcohols, the processes that use organic acids are the following most used. The most common are those that use acetic acid and formic acid, and different studies have been reported with EFB [58], rice straw [63], jute [66], rapeseed straw [56], cardoon stalk [64], and wheat straw [65].
\nThe pulping of wheat straw with acetic acid and formic acid has been carried out, studying the influence of operation variables on the properties of the resulting pulps. Comparing the results obtained when operating for times ranging between 0.5 and 2 h, at temperatures of 75–125°C and 150–200°C, and with concentrations of 50–100% and 50–80% of the formic and acetic acids, respectively, it is concluded that to obtain pulp with acceptable holocellulose (88.2%), α-cellulose (40.2%) and lignin (6.4%) contents are more effective than formic acid, operating at 50% concentration, 100°C and 2 h. This fact is mainly due to it requiring less acid and lower working temperature, with the consequent savings in chemical reagents and energy for heating [65].
\nSeveral studies have been studied with acetone solvent mainly on wheat straw [1, 2, 19, 60, 67]. From these studies it is concluded that it must be operated at 200°C, for 95–100 min and with 55–60% of acetone to obtain high holocellulose and α-cellulose values and low lignin and extractives, although the yield of the pulp is low [60]. To obtain good values of breaking length (3456 m), elongation (1.42%), burst index (1.36 KN/g) and tear index (3.86 mNm2/g) of the paper sheets formed, a temperature of 200°C has to be used. On the other hand, if the brightness has to be high, it has to be operated at 140°C for 1 h with a concentration of 60% acetone [65].
\nThe refining of pulp is an operation that modifies, through the action of mechanical work and in the presence of an aqueous medium, the morphology of the fibres and their physicochemical structure, decisively changing the properties of the paper sheets obtained from the refined pulp [1, 2, 6]. Using a Sprout-Bauer refiner, the influence of refining pulp from different agricultural residues (wheat straw, sunflower stems, vine shoots, olive tree pruning, cotton stems and sorghum stems) on the corresponding pulp and paper sheets was studied [1, 2, 19, 32, 69]. In view of the results, it can be concluded that olive tree pruning pulp must be severely refined to obtain good quality paper, although the maximum values of the ring crush test (RCT) and the tear index are reached for refining grades of 45 and 55°SR, respectively. In the case of EFB soda-anthraquinone pulp, a study has been carried out in a PFI refiner, studying the influence of the cooking variables (soda concentration, temperature and time) and the number of turns in the PFI on the properties of the resulting paper sheets [20]. From this study it is deduced that under some operation conditions, 15% of soda, 170°C, 70 min and 2,400 turns in the PFI, the properties of paper sheets obtained deviate less than 12% from their optimum values (59.6 Nm/g for the traction index, 4.48% for elongation, 4.17 kN/g for the burst index and 7.20 mNm2/g for the tear index), for a degree of refining of 47.5°SR, acceptable for the formation of paper sheets. Under these conditions, reagents, energy and immobilized capital are saved with respect to the maximum values of the operating variables used [20].
\nThe bleaching of cellulosic pulps is carried out for the elimination and/or modification of some constituents that add color to the raw pulp, generally using chemical reagents in one or more stages and trying to degrade the cellulose fibers as little as possible [1, 2, 6]. The main light-absorbing substances in the pulps are lignin and resins, so in order to bleach a pulp, these substances must be chemically transformed into a solid state in order to reduce their light absorption characteristics or be oxidized, reduced or hydrolysed, to make them soluble in aqueous solutions and thus be able to be removed from the pulps.
\nThe need to reduce pollution from bleached pulp mills has led to the study of new bleaching sequences [1, 2, 6], with research focusing in three main directions: (i) bleaching processes with reagents without elemental chlorine (ECF), which consist of the total substitution of chlorinated stages by compounds such as chlorine dioxide (without elemental chlorine), regardless of whether other bleaching agents totally free of chlorine, such as oxygen, hydrogen peroxide, etc., are also used; (ii) bleaching processes with totally chlorine free reagents (TCF), using reagents such as oxygen, hydrogen peroxide and ozone, mainly [72]; and (iii) biological bleaching processes involving microorganisms or enzymes produced by them.
\nECF and TCF bleaching processes including enzymatic stages have been studied for different alternative raw materials. It is worth highlighting the TCF processes which have been studied using different chemical reagents individually (hydrogen peroxide, oxygen, ozone, sodium perborate and peracetic acid) or with OZP bleaching sequences (where Z is an ozone stage) [1, 2, 6].
\nHydrogen peroxide has been used for the bleaching of Kraft olive tree pruning pulp with a Kappa index of 21, operating at a temperature of 70°C and a consistency of 10%, and following a factorial design of experiments in which the peroxide concentration varies from 1 to 5% and the time from 30 to 210 min, finding that it is recommended to use a low-medium concentration of peroxide (1–3%) and a long time (210 min) [73]. Comparing the results with those of bleached pulps with other reagents, it is concluded that the viscosity of the pulps is higher in the case of peroxide bleached pulps than those bleached with oxygen, ozone or chlorine dioxide. To improve the Kappa index and brightness values of peroxide bleached pulp, it is desirable to combine hydrogen peroxide with oxygen or to use the combination oxygen and ozone [74].
\nFor the bleaching of abaca soda pulp with peracetic acid [75], the influence of the operating conditions on the Kappa index, viscosity and brightness of the pulp and on the breaking length and burst index of the paper sheets was studied. Following a factorial design of experiments, it is concluded that operating at 55°C, with 4.5% peracetic acid for 150 min, a brightness of 79.9% is obtained (only 6.5% lower than the maximum possible) and the maximum possible values for the breaking length (6547 m), burst index (5.0 kN/g) and viscosity (1519 mL/g).
\nPeracetic acid has also been considered in the bleaching of olive tree pruning, finding that it has to be operated at 55°C for 90 min, a consistency of 10% and an acid concentration of 2.5%, providing good values for brightness and Kappa index and improving the viscosity of the bleached pulp with respect to crude pulp [76].
\nIn the bleaching of abaca soda pulp with sodium perborate [77], the influence of the concentration of reagent (1–5%), temperature (60–80°C) and time (1–2 h) on the characteristics of the bleached pulp and the resulting paper sheets has been studied. It is concluded that in order to obtain pulp with the highest possible values of viscosity (1601 mL/g) and breaking length (5943 m), it is necessary to operate at 60°C, 1% perborate and 60 min, achieving a brightness of 62.7%, only 11.9% below the maximum possible.
\nFor abaca soda pulp, the bleaching processes using hydrogen peroxide, peracetic acid, sodium perborate and the OZP sequence were compared from the point of view of pulp yield and brightness, breaking length and burst and tear indexes of the paper sheets. Overall, the best results are achieved for peracetic bleached pulp (4.5%, at 55°C for 0.5 h), providing little loss of yield (<1%) and some values for breaking length (6.555 m), burst index (4.97 kN/g) and tear index (15.77 mNm2/g), which only decrease, with respect to those of the raw starting pulps, by 7.0, 8.8 and 20.9%, respectively, while brightness (77.4%) increases by 56.7%; with the additional advantage that by operating at a lower temperature and for less time than in the other bleaching processes considered, energy savings are produced for heating and immobilized capital for industrial installations. The pulp bleached with the OZP sequence has more brightness but loses more yield. Moreover, the characteristics of the paper sheets are worse, and the process requires higher costs of reagent, energy and immobilization [78].
\nThe OZP sequence has been applied to EFB soda-anthraquinone and diethanolamine pulps [79]. For similar Kappa index values for the two pulps (14.2 and 17.3), the paper sheets of the raw soda-anthraquinone pulp exhibit higher values for tensile (25.8 Nm/g), elongation (2.35%), burst index (1.69 kN/g) and tear index (0.50 mNm2/g) and brightness (60.6%) than the diethanolamine pulp, but the latter has a higher viscosity (659 mL/g). When OZP bleaching sequence is used, the diethanolamine pulp exhibits higher viscosity (783 mL/g), and the properties of the paper sheets are similar to or better than those of the soda-anthraquinone pulp: 22.2 as opposed to 20.4 Nm/g for the tensile index, 1.30 vs. 1.42 kN/g for the burst index, 0.71 vs. 0.70 mNm2/g for the tear index and 71.3 vs. 77.5% for brightness [79].
\nIt is worth highlighting in this section that apart from xylanases, the use of laccases has been used for the bleaching of alternative raw materials [80, 81, 82, 83, 84]. As it is known, these enzymes need a mediator to make the bleaching more effective since thanks to them they are able to oxidize not only the phenolic part but also the non-phenolic of the lignin.
\nThe work of Camarero et al. [80], who apply three different fungal laccases (from
The concept of lignocellulosic biorefinery aims at the integral use of the main components of lignocellulosic raw materials to obtain energy, chemicals and products [85]. The pulp and paper industry is an excellent initial point for the establishment of this concept as it has the best infrastructure for biomass fractionation and conversion and a great deal of practical industrial experience. Then, the classical pulp and paper industry, including Kraft, sulfite and soda technologies, has been applying this concept for a long time as it not only produces paper as the main product (cellulosic fraction) but also recovers the reagents and produces energy from the residual black liquors (lignin-rich fraction) as well as the generation of bioproducts such as tall oils, which are sold to obtain high added value products (e.g. adhesives, detergents, etc.), and lignin for the production of chemicals or materials. In the future, the extraction of hemicelluloses prior to pulping will be included in order to make maximum use of lignocellulosic materials. A general scheme, which will be developed below including also gasification of lignin, is shown in Figure 1.
\nScheme of integration of pulp and paper industry into the biorefinery concept in the future.
Using the same scheme-work of the pulp and paper industry with classical pulping methods, different organosolv pulping processes have been developed to produce cellulosic pulp and other products from different alternative raw materials such as agriculture residues [53], among them, those employing ethanol such as the Alcell© process for the production of cellulosic pulp, giving value to other biomass fractions, such as high-quality lignin in the residual black liquor with several potential industrial applications, and the Lignol© process, which also extracts lignin, as well as sugars for the production of ethanol, oligomers, furfural and acetic acid. However, one of the disadvantages of these processes lies in the incorporation of both extracts and a part of the hemicelluloses to the residual black liquors. For this reason, the possibility of carrying out a hydrolysis pretreatment of the polysaccharides with the original raw materials prior to organosolv pulping methods, using water at a high temperature (hydrothermal treatment), has been explored [53]. Then, a hydrolysis of the acetyl groups to acetic acid is produced, which acts as a catalyst solubilizing all or part of the hemicelluloses (autohydrolysis) and then resulting in a pretreatment aqueous fraction with oligomers (mainly gluco-oligosacharides and xylo-oligosacharides), sugars (glucose, xylose, arabinose), acetic, furfural or 5-hydroxymethyl-2-furfural (HMF) and some lignin. Oligomers are used as food additives or substrate for sugars, after hydrolysis and fermentation (xylose and arabinose could be fermented to ethanol or xylitol); and furfural and lignin derivatives have applications in the chemical industry [86, 87]. The disadvantage of this fractionation is the low selectivity towards cellulose, giving rise to a solid fraction structurally affected, which can limit its later use; but an adequate hydrothermal pretreatment achieves a solid fraction that can be used to obtain pulp and paper by classical or organosolv procedures, whose resistance can be improved using a relevant refining.
\nIn the pulping processes of the solid fraction coming from autohydrolysis or hydrothermal pretreatment, some residual black liquors are obtained, with lignin being the majority component. These liquors, after the separation of water and/or organic solvents used in cooking (which are recycled in the cooking process), are transformed into a concentrate rich in lignin. From these concentrates lignin can be obtained for different uses, and/or it can be subjected to gasification processes with the aim of obtaining high-quality products such as hydrogen, methanol, synthesis gas or dimethyl ether (DME) for motor applications [86, 87, 88, 89].
\nAs commented above, one of the possibilities to convert the classical chemical pulp and paper industry into a biorefinery is to extract a portion of hemicelluloses from lignocellulosic materials prior to pulping, obtaining a liquid fraction enriched in hemicellulosic carbohydrates that can be converted into ethanol and/or chemical products. One of the options for the separation of hemicellulose from lignocellulosic materials is its depolymerization by autohydrolysis, also known as hydrothermal process, which does not require the addition of acids as it is auto-generated in the process [53, 85]. In addition to the process of autohydrolysis itself, the process of steam explosion is very significant (once autohydrolysis has taken place, the mixture undergoes a sudden decompression to produce the vaporization of the water contained in the fibers and the consequent disaggregation of the lignocellulosic matrix), as well as its variants, such as the Rash, Masonite, Iotech, Siropulper and Stake processes [53, 85].
\nThese hydrothermal treatments can be carried out in a very wide range of operating conditions, with the temperature, time, solid concentration and particle size of lignocellulosic materials being the most influential variables [85]. In the case of autohydrolysis, the range of temperatures to treat lignocellulosic materials in an aqueous medium is in the range between 150 and 250°C. Under these conditions, the self-ionization of water generates protons that act as a catalyst for the hydrolysis of the hemicellulose, reacting among others the acetyl groups (present in the form of esters in the hemicellulosic heteropolymers), which are released in the form of acetic acid. Its contribution to the generation of protons is 1700 to 1,000,000 times greater than that of water, so the contribution of aqueous protons to the hydrothermal process can be neglected once acetic acid has been generated. At the same time, there is total or partial solubilization of hemicelluloses and their conversion with good yields of oligosaccharides and monosaccharides, which can be used for different purposes [53, 85].
\nOther minor reactions associated with this type of process are the formation of products such as furfural from pentoses and HMF from hexoses; the generation of carbon dioxide by decomposition of carboxyl groups present in uronic acids; the condensation of some unstable molecules that intervene as reaction intermediates; the decomposition under severe conditions of products such as furfural, sensitive to acid concentration; the decomposition of HMF to formic and levulinic acids; and condensation reactions with lignin [90].
\nDifferent studies with traditional woody materials such as eucalypt have shown a pre-extraction of hemicellulose prior to pulping process by hydrothermal processes [91, 92, 93]. In the same way, these hydrothermal processes have also been applied to alternative raw materials such as paulownia [55], sunflower stems [54], rice straw [71], tagasaste [25] and
The influence of the temperature (160–200°C) of the autohydrolysis process applied to paulownia on the composition of the resulting solid and liquid fractions has been studied [55]. It is found that the maximum concentrations of glucose, xylose, arabinose, acetic acid, furfural, HMF and oligomers of the resulting liquid fraction correspond to when operating at maximum temperature.
\nA similar study carried out with sunflower stems concludes that at 190°C the highest values are obtained for the glucose, xylose and arabinose contents of the liquid fraction of the hydrothermal treatment, with a yield of 24.5%, while the yield of the solid fraction, which can be pulping, is 72.5% [54].
\nIn the case of rice straw, the influence of temperature (150–190°C), time (0 to 20 min after reaching the working temperature) and liquid/solid ratio (6:10) on the hydrothermal treatment, on the lignin content, on the yield of the resulting solid fraction and on the composition of the corresponding liquid phase (glucose, xylose, arabinose and acetic acid) was studied [71]. It follows that in order to obtain high values of glucose (1.92 g/L), xylose (3.97 g/L), arabinose (0.99 g/L) and acetic acid (1.96 g/L) concentrations, it is necessary to operate at high temperature (190°C) and low-medium conditions for time (15 min) and hydromodule (9), which allows capital savings by not operating with the maximum time and using the maximum hydromodule value. The yield obtained for the solid fraction is 88.1%, and the lignin content is 24.43%.
\nFinally, tagasaste wood was submitted to hydrothermal treatment at 175–185°C [25]. Then, a liquor containing a substantially increased amount of oligomers (between 16.6 and 47.7% as percentages with respect to the content of the raw material in each polymer fraction) is obtained. In the case of
Hydrothermal treatments under relatively mild operating conditions (temperature and time) do not cause significant alterations in the cellulose. In this way, solid fractions susceptible to delignification or pulping are obtained [53].
\nThe solid fraction of the hydrothermal treatment of paulownia carried out at 190°C was subjected to pulping process with ethanol following a factorial design of experiments [55]. The conclusion of this work is that operating at 180°C for 30 min and an ethanol concentration of 20%, obtained pulp has acceptable values of Kappa index and viscosity, and their corresponding paper sheets have a brightness of 27.4% ISO, a tensile index of 28.87 Nm/g, a burst index of 1.22 kPam2/g and a tear index of 1.23 kNm2/g.
\nIn the case of sunflower stems [54], the solid fraction of a treatment carried out at 180°C is cooked with ethanol (70%, 170°C for 2 h and a hydromodule of 8) giving rise to a pulp with properties (36.3% of pulp yield, 69.1% cellulose, 12.6% hemicellulose, 18.2% lignin, 551 mL/g viscosity, 3.8 km breaking length, 1.23% elongation, 1.15 kN/g burst index and 2.04 mNm2/g tear index) similar to that obtained by the soda process.
\nThe influence of operating conditions (temperature from 160 to 180°C, time from 30 to 90 min and concentration of diethanolamine from 60 to 80%) on the pulping process of the solid fraction obtained from a hydrothermal treatment of rice straw (carried out at 190°C) on the characteristics of the pulp (yield, Kappa index, viscosity and degree of refining) and of the paper sheets obtained from them (length of rupture, elongation, burst index, tear index and brightness) was also studied [71]. It is deduced that it is convenient to operate at 162.5°C, 60 min and 70% of diethanolamine, since paper sheets present characteristics that deviate little from the optimal ones (less than 8% in the worst case), saving chemical reagents, energy for heating and immobilized capital for the installation, when operating with values of time and the concentration of diethanolamine medium and medium-low temperature, with respect to the maximums considered; likewise the values found for the yield and Kappa index deviate less than 14% with respect to the optimal values.
\nAutohydrolysed tagasaste wood was also submitted to ethanol and soda pulping procedures [25]. The autohydrolysis prior to ethanol pulping increases yields (53–60%); reduces Kappa index (28.8–34.6), but also viscosity (755–857 mL/g); and decreases paper strength (2.97–5.22 kNm/kg). However, applying a refining process to tagasaste pulp is found to improve its strength-related properties more markedly than in soda pulp from the same material (tensile index of 44 kNm/kg). In the case of
The valorization of lignin-rich black liquors generated from pulping processes is another transition path from the traditional pulp and paper industry to future biorefineries. Generally, residual lignins from black liquors are used to obtain energy for processing plants, mainly by combustion. However, the aromatic structure of lignin makes it a potential source for the production of new bio-based high-value products and chemicals, increasing the sustainability and competitiveness of this pulp and paper industry [86]. Other different fractions of lignin and compounds such as various polysaccharides present in these black liquors, which may not have specific applications or their transformation into high value-added products may not be profitable, can also be valorized by gasification process [89].
\nPulp and paper industry is estimated that moves around 70 million tonnes of lignin annually [95], of which only just over 1 million tonnes are currently marketed, corresponding to lignosulfonates, and which have an established market for use in various uses such as plasticizers and dispersion agents, whereas Kraft lignins are used in the recovery tanks of products from the paper plants themselves and only market around 100.000 tonnes per year. Finally, only a few hundred tonnes of lignins from the soda process come onto the market each year, although this quantity is expected to rise rapidly to around 10,000 tonnes due to the fact that an increasing number of small paper mills, which use agricultural waste and non-wood species to produce cellulose, are introducing lignin recovery processes as the only way to meet environmental effluent treatment specifications.
\nDepending on the biomass feedstock, pulping technology and conditions and isolation procedures, lignin has distinct features that may render them useful for different applications. Purity, molar mass and chemical functionalities are some of the characteristics to take into account [96]. So, a detailed knowledge of lignin structure, composition and purity is required in order to determine its behaviour in different potential applications. In this sense, characterization of residual lignins from Kraft and soda-anthraquinone pulping of agriculture residues such as olive tree pruning [97] and wheat or barley straw [98], as well as vegetables like
Among the different characteristics of lignin, its high heterogeneity is one of the most important, which not only affects its structure but also its high distribution of molecular weights (range from 1.000 to 300.000 Da for the same sample) [101]. Therefore, fractionation is one of the ways of obtaining reactive lignins. The preparation of lignin with a defined molecular weight distribution can be carried out by means of different processes: ultrafiltration, selective extraction with solvents and differential precipitation.
\nThe technique of ultrafiltration and nanofiltration is one of the methods being investigated today, with the dual intention of on the one hand reducing the organic load contained in the digestion solution, for its subsequent reincorporation into the pulping process without the loss of inorganic reagents, and on the other obtaining valuable organic resources for use in the development of high-value-added materials. By means of ceramic membranes capable of filtering the residual liquor until the separation of substances smaller than 1 kDa, low molar lignin fractions (1000 g/mol maximum) are obtained. After suitable purification processes, these lignins have a high phenolic hydroxyl content (and/or acid groups), high reactivity and low processing and handling temperatures. In this way, Toledano et al. [102] propose ultrafiltration as a fractionation process to separate different molecular weight lignin fractions from olive tree pruning organosolv black liquor.
\nSolvent extraction of lignin can be carried out primarily in two ways. In one case, lignin is extracted by a single solvent or a sequential use of multiple solvents. In the other case, a solvent is used to dissolve lignin and then precipitated using chemical (mainly with acids) treatments. Then, Domínguez-Robles et al. [103] used different proportions of acetone (40 and 60%) in water for lignin fractionation of two different sources (organosolv and soda wheat straw lignins), obtaining different fractions with different molar masses and functional groups. Finally, fractionation of the lignins by differential precipitation consists of extracting different lignin samples as the pH of the solution is gradually lowered. It is the most commonly used method because the simple addition of a strong acid is sufficient, compared to the high costs of the other two methods. However, it has a disadvantage derived from the formation of colloids during precipitation, which can greatly complicate the filtration process. In this sense, Domínguez-Robles et al. [104] have proposed an acid precipitation of wheat straw lignin from soda black liquor using three different inorganic acids (phosphoric, sulphuric and chloride acids) at three different concentration levels, achieving pH values from 11 to 2.
\nDifferent lignin applications have been suggested depending on its properties. Then, poorly degraded lignin is employed as dispersants, surfactants and thermoplastic blends or copolymers [105, 106, 107] or as an aromatic compound platform to obtain fine chemicals such as polyols, benzene, xylene, toluene, vanillin, ferulic acid, etc. [87]. In contrast, extensively depolymerized lignin, therefore, with a high phenolic content, is suitable for coating, adhesives and composites [108, 109, 110, 111]. In this sense, some examples of lignin valorization from alternative raw materials have been reported. Then, Borrero-López et al. [112] showed the possibility to produce olegels from soda lignin obtained from solid state fermented wheat straw; Tejado et al. [113] assayed soda-anthraquinone flax lignin and ethanol-water wild tamarind lignin to phenol-formaldehyde (PF) resin production; Domínguez-Robles et al. [103] investigated the use of soda wheat straw lignin as natural adhesive for the production of high-density fibre board; and Domínguez-Robles et al. [98] analysed Kraft, soda and organosolv wheat straw lignins as a binder material for electrodes in rechargeable lithium batteries.
\nAny proportion of the agricultural raw material non-suitable for pulp and paper production, in addition to lignin and other compounds such as various polysaccharides obtained in lignin separation processes, may be converted—via pyrolysis—into several types of fuels and petrochemical substitutes [1, 88].
\nAs commented above, different fractions of lignin and other compounds such as various polysaccharides can be obtained in lignin separation processes. Some of these fractions may not have specific applications, or their transformation into high-value-added products may not be profitable, so they may be suitable for a gasification process [89]. This consists of the partial oxidation of the lignocellulosic residues to obtain carbon monoxide, hydrogen, methane, nitrogen and carbonic anhydride mainly, in proportions that depend on the raw material considered and the conditions of the process. Three types of processes can be distinguished: (i) exothermic, using oxygen or air to obtain carbon monoxide or a mixture of carbon monoxide and nitrogen (lean gas); (ii) endothermic, which use water vapor to obtain carbon monoxide and hydrogen (synthesis gas); and (iii) balanced or mixed, using oxygen and water vapor or air and water vapor to obtain carbon monoxide and hydrogen or a mixture of carbon monoxide, hydrogen and nitrogen.
\nGasification gases can be used as fuels or to obtain chemicals. Among the latter, those obtained from carbon monoxide (methyl formate, formamide, formic acid, carbonyls, acrylic acid, etc.) and those obtained from carbon monoxide and hydrogen (ammonia, nitric acid, hydrazine, urea, hydrocyanic acid, aldehydes, explosives, etc.) can be distinguished. For example, pyrolysis of soda
The availability and concentration of wood in areas of easy access, the elevated fibre content, the cost of transport, the ease of storage as well as the stability of the raw material and its performance during the pulping process have supported the use of the wood in the pulp and paper industry. However, due to the numerous advantages of certain alternative raw materials (low-cost fibers, fast growth, low lignin content and fiber morphology, among others), they have proved to be a viable option as a starting raw material for the production of a wide range of different papers. On the other hand, taking into account the concept of lignocellulosic biorefinery, the pulp and paper industry is a good starting point since from its beginnings it not only produced pulp for paper but also energy. However, this industry needs different innovations to adapt even more to this concept. These innovations include the valorization of the extractives and hemicellulosic fractions through extraction prior to the pulping process, the valorization of black liquors through gasification or purification, the valorization of lignocellulosic waste through gasification or other processes such as saccharification and fermentation and also the introduction of new alternative raw materials to wood, as summarized in this work.
\nThe authors are grateful to Spain’s DGICyT, MICINN, for funding this research by Projects CTQ2016-78729-R and RTI2018-096080-B-C22 and the National Program FPU (Grant Number 454 FPU14/02278). The authors would also like to thank the Community of Madrid (Spain) for funding research through the project P2018/EMT-4348 (SUSTEC-CM).
\nThe authors declare no conflict of interest.
\nMuscular pain is a very common pathology in the physiotherapy treatment of outpatient care. The invasive techniques for treating these patients have aroused great interest, there are many reviews made in recent years about its effectiveness but none with conclusive results [1, 2, 3, 4, 5, 6]. Articles about post-needling pain [7, 8] and adverse side effects that may occur due to dry needling are being published until this day.
Dry needling is a minimally invasive technique into the most hypersensitive area/point of a tense band in a skeletal muscle (called myofascial trigger point), without the addition of any drug (Figure 1). It can be classified as deep or superficial [9]. There is not much evidence about which of the two options is better, it seems that deep dry needling has shown greater effectiveness due to penetrating the myofascial trigger point while the superficial dry needling penetrates the skin and the subcutaneous cellular tissue [10, 11]. In the same way, the appearance of local twitch response would guarantee its effectiveness [12, 13].
Myofascial trigger point.
These myofascial trigger points present a high equivalence with the ashi points of acupuncture, corresponding to approximately 71% as Melzack introduced [14]. Acupuncture is based on a traditional and invasive Chinese technique of thousand years of age based on metaphysical concepts of "Ch\'i" (Qi), the body energy flows through channels called "meridians" that has hypersensitive areas called ashi points (Figure 2). Its treatment also consists in the insertion of a needle in these points without any type of drugs [15].
Acupuncture Meridians.
On the other hand, injections have also been the subject of many reviews, [16, 17] they have combined the effects of needling with the effect of local anesthetics. However, in 1943 Lewit [18] demonstrated that the true effectiveness of the infiltrations was due to the mechanical effect generated by the insertion of the needle itself and not the anesthetic.
The objective of this study is to summarize the articles published in relation to adverse effects of needling therapies to promote a good practice and knowledge.
A review of the literature was carried out in Pubmed, Web of Science, Medline and PEDro databases. The search was limited to studies on adverse effects and possible complications due to invasive/needling techniques: acupuncture, injections and dry needling in English and Spanish.
The keywords in English first introduced separately were: "acupuncture", "injection", "dry needling" and "adverse effect/event". In a second time, in order to limit the article sample, 12 searches were added: 1–3: “acupuncture/dry needling/injection” AND "complication"; 4–6: “acupuncture/dry needling/injection” AND "iatrogenic"; 7–9: “acupuncture/dry needling/injection” AND "safe practice" and 10–12: “acupuncture/dry needling/injection” AND "academic training". A manual search of the references of pre-selected articles was also carried out.
The search fields were title/abstract of the keywords of the studies publishes by the journals indexed in Pubmed during the period between 2000 (January) AND 2020 (January). In Web of Science the search fields were TS (theme)/TI (title). In Medline search field was TI (title) and in PEDro a simple search was done. The manuscripts selected for this systematic review met the following inclusion criteria: (i) articles that report the adverse effects and/or complications of invasive/needling techniques; (ii) reviews of such complications; (iii) articles in English and Spanish and (iv) articles with protocols or recommendations on the safe practice of these techniques. We excluded theoretical articles on the application of these techniques and articles that were not published in English or Spanish.
A summary of the findings of the included studies was performed, structured in the incidence/frequency of adverse effects, most prevalent adverse effects, type of intervention, type of population and other associated diseases which could influence the results (Tables 1–3). Each article was named by the author and date; they have a brief description of the intervention, the type of the adverse effect and the conclusion/resolution of the inconvenience.
The initial search provided 4.034 potential reports, after applying the inclusion and exclusion criteria, the sample consisted of 2.169 articles from Pubmed, 814 articles from Web of Science, 781 articles from Medline, 270 from PEDro and 9 found manually through preselected references from the Google Scholar database (Figure 3). After duplicated were excluded, 1.881 articles were selected. Both reviewers screened abstracts in a first time. In a second time, articles selected had a more detailed evaluation and 46 articles were excluded by the language, being letters to the editor or comments on other articles. Finally, 102 articles considered valid (93 from the initial search and 9 found manually). Detailed characteristics of the included studies are described in Tables 1–3 in relation to acupuncture, injection or dry needling respectively.
Flow chart for different stages of the review.
Author/year | Description |
---|---|
Tandon, S. (1998) [19] | 48-year-old male suffering from bronchial asthma. Pneumothorax following acupuncture with electrical stimulation in the third and fourth intercostal spaces. |
Peuker, ET. (1999) [20] | To review the traumatic injuries after acupuncture and discuss how to avoid these adverse effects. |
Kirchgatterer, A. (2000) [21] | 83-year-old female. Syncope and cardiogenic shock after acupuncture into the sternum. |
Lao, L. (2003) [22] | 1965-1999 review: 202 incidents in 98 papers from 22 countries. |
Ha, KY. (2003) [23] | 68-year-old female. Low back pain and sciatica aggravated by acupuncture. Chronic inflammatory granuloma with compression of the lumbar fourth nerve and dural sac. |
Chang, SA. (2004) [24] | 68-year-old male. Death for massive hematemesis resulting from aortoduodenal fistula caused by acupuncture. |
Saw, A.(2004) [25] | 55-year-old female, diabetic. Necrotising fasciitis due to acupuncture in a knee osteoarthritis. |
Lee, WM. (2005) [26] | 36-year-old female. Bilateral pneumothorax after acupuncture. |
Ryu, HJ. (2005) [27] | Clinical manifestations and treatment for Mycobacterium abscessus due to acupuncture. |
Kung, YY. (2005) [28] | 2 elderly patients: 72-year-old male and 63-year-old female. Between 2000 and 2002: syncope after acupuncture. |
Chauffe, RJ. (2006) [29] | Since 1985: 9 pneumothorax cases after acupuncture. 27-year-old student seeking acupuncture at levator scapular. |
Su, J. (2007) [30] | 52-year-old female with chronic coughing. Acupuncture at BL131: paravertebral point at the level of the spinous process of the third vertebra: bilateral pneumothorax. |
Lee, S. (2008) [31] | 79-year-old male (hypertension and diabetes). Bacterial aortitis with pseudoaneurysm formation after acupuncture. |
Hwang, JK. (2008) [32] | 25-year-old female: Pneumoretroperitoneumen after acupuncture in right psoas muscle. |
Juss, JK. (2008) [33] | 50-year-old female. Pneumothorax by acupuncture at scapulothoracic region. |
Jindal, V. (2008) [34] | Acupuncture to prevent postoperative nausea in children and to inhibit chemotherapy vomiting in adults. |
Tsukazaki, Y. (2008) [35] | 32-year-old female (recurrent headache). Subarachnoid hemorrhage following acupuncture. |
Witt, CM. (2009) [36] | Review of acupuncture for osteoarthritis knee or hip, low back pain, neck pain or headache, asthma, rinitis or dysmenorrhoea. 229.230 patients: 19.726 suffered at least one adverse effect. |
Kim, JH. (2009) [37] | 55-year-old female. Hemopericardium after acupuncture. |
Kuo, HF. (2010) [38] | 39-year-old female with paresthesia and soreness at popliteal fossa. Fistula arteriovenous: vascular complication after acupuncture. |
Ernst, E. (2010) [39] | Systematic review of cardiac tamponade due to acupuncture. 5 Databases, no restrictions in time or language. 26 cases (14 fatal consequences). |
Nam, KH. (2010) [40] | 4 cases of epidural hematomas after facet block, acupuncture and epidural injections. |
Inayama, M. (2011) [41] | 37-year-old female. Pneumothorax and pleural fluid collection after acupuncture on neck and upper back. |
Hsieh, RL. (2011) [42] | 44-year-old female (aplastic anemia). Staphylococcus infection after acupuncture at right calf. |
He, W. (2012) [43] | Chinese review of 167 papers: 1.038 cases (35 deaths). |
Xu, S. (2012) [44] | Frequency and severity of adverse events of acupuncture, moxibustion and cupping between 2000-11: 117 reports with 308 adverse effects from 25 countries. |
Lee, JH. (2012) [45] | 47-year-old female: epidural abscess at C1-C3 after acupuncture and cupping. |
Tagami, R. (2013) [46] | 69-year-old male: bilateral pneumothorax after acupuncture at upper back. |
Stenger, M. (2013) [47] | 64-year-old male: pneumothorax after acupuncture for lumbar pain and sciatica. |
82-year-old female: pneumothorax after acupuncture for herpes zoster. | |
Lee, SW. (2014) [48] | 47-year-old female with abdominal pain after acupuncture. Endoscopy: needle in the posterior wall of the antrum. |
Hamptom, DA. (2014) [49] | 43-year-old female with chronic neck pain. Pneumothorax after acupuncture. |
Peuker, E. (2014) [50] | 38-year-old female. Pneumothorax after acupuncture at subacromial region (BL13), paravertebral point at the spinous process of the third thoracic vertebrae. |
Chun, KJ. (2014) [51] | 48-year-old female, (breast cancer 7 years before). Cardiac tamponade after acupuncture at fourth intercostal space. |
Peuker, E. (2014) [52] | Review of traumatic lesions after acupuncture. |
Wu, J. (2014) [53] | Chinese review of adverse effects between 1980 and 2013. 3 databases: 182 incidents in 133 relevant papers. |
Ji, GY. (2014) [54] | 54-year-old female; 38-year-old female and 60-year-old male: 3 cases of hemiplegia after cervical paraespinal needling (intramuscular stimulation, acupuncture or lidocaine) in 2002-2013 in Korea. |
Schar, ML. (2015) [55] | 39-year-old female with peripheral neuropathy history. Pneumothorax and broken needle in her chest. |
Karavis, MY. (2015) [56] | 37-year-old female. Haemothorax after acupuncture for neck and right upper back pain. |
Callan, AK. (2015) [57] | 15-year-old female with scoliosis. Periscapular abscess after acupuncture due to instrumentation. |
White, A (2015) [58] | 715 adverse effects: 90 trauma (186 secondary reports); 204 infections (91 reports); 144 miscellaneous (12 deaths). |
Brogan, RJ. (2015) [59] | 66-year-old male. Left pneumothorax after acupuncture (paraespinal, infrascapular and axillary regions bilaterally) for low back pain secondary to arthritis. |
Wigger, O. (2015) [60] | 51-year-old female with breast pain and dyspnea. Cardiac perforation due to acupuncture. |
Yao, Y. (2015) [61] | 54-year-old male. Epidural abscess at C4-T2 due to acupuncture. |
Huisma, F. (2015) [62] | 53-year-old female. Pneumothorax after acupuncture at posterior left hemithorax medial to the scapula. |
Kim, JS. (2016) [63] | Review between 2011 and 2015: 17 pneumothoraxes (1 bilateral and 16 unilateral). |
Ehgbal, K. (2016) [64] | 74-year-old female. Quadriparesis and sensory deficit due to cervical subdural hematoma at C4-C6 after acupuncture at neck and shoulder. |
Li, X. (2017) [65] | Meta-analysis of 33 randomized controlled trials about dry needling and manual acupuncture until February 2016. 33 trials with 1.692 patients. |
Kim, D. (2017) [66] | 55-year-old female. She died by acute peritonitis three days after acupuncture. |
Domenicucci, M. (2017) [67] | 64-year-old male. Hematoma epidural spinal C2-T12 (hemiparesis and paresthesias) after acupuncture for lumbosciatic pain. |
Lee, HJ. (2017) [68] | Retrospective observational study (2010-2014): 10 pneumothorax and 2 pneumoperitoneum. |
Sia, CH. (2018) [69] | 50-year-old women. Pneumothorax after acupuncture for neck pain. |
Lin, SK. (2019) [70] | Pneumothorax incidence after acupuncture in Taiwan (1997-2012) 411.734 patients, 5.407.378 treatments. |
Lee, H. (2019) [71] | 80-year-old male. Retroperitoneal abscess after lumbar acupuncture. |
Lin, SK. (2019) [72] | Cellulitis after acupuncture incidence in Taiwan (1997-2012). 407.80 patients, 6.207.378 treatments. |
Liu, ZH. (2019) [73] | 42-year-old male. Broken needle in retroperitoneum after acupuncture treatments 2 years ago. |
Tucciarone, M. (2019) [74] | 36-year-old male. Abscess in prevertebral muscles after acupuncture. |
Ullah, W. (2019) [75] | Old man. Pericarditis secondary to acupuncture after Staphilococus aureus infection. |
Priola, SM. (2019) [76] | 47-year-old female. Epidural intracraneal abscess after acupuncture. |
Ullah, W. (2019) [77] | Systematic review about cardiac complications after acupuncture. 30 articles: 8 infections, 22 cardiac tamponades. |
Corado, SC. (2019) [78] | 79-year-old female. Pneumothorax 2 days after interscapular acupuncture. |
Detail of articles included about acupuncture.
Author/year | Description |
---|---|
Antoni, RO. (1961) [79] | Review of 226 cases between 1955 and 1959: 71 iatrogenic pneumothoraxes. |
Shafer, N. (1970) [80] | 29-year-old female with severe neck pain with radiation into her right arm and limitation of motion. Pneumothorax after injection. |
Cheng, J. (2007) [81] | Review from 1966 to November 2006: 35 papers. Infections, nerve injury, pneumothorax, embolism. |
Usman, F. (2011) [82] | 37-year-old female, 20 weeks pregnant. Retrosternal abscess after injection at sternoclavicular joint. |
Ahiskalioglu, EO. (2016) [83] | 25-year-old female. Pneumothorax after 4ml injection of lidocaine at thoracic region for neck and low back pain. |
Soriano, PK. (2017) [84] | 39-year-old male. Hipokalemic paralisis after injection guided by ultrasound in iliopsoas. |
Choe, JY. (2017) [85] | 70-year-old male (diabetic and cardiac history). Descending necrotizing mediastinitis after lidocaine injection at upper trapezius. Death by septic shock. |
Lee, DG. (2018) [86] | 38-year-old male. Scapular neuropathy after 1% lidocaine injection and 6ml of saline. |
De la Torre-Canales, G. (2019) [87] | Systematic review about adverse effects of botulinum toxin A for masticatory muscles. 16 articles. |
Camões-Barbosa, A. (2019) [88] | 33-year-old female. Weakness after botulinum toxin A injection for spasticity. |
Mozafari, N. (2019) [89] | 55-year-old male. Cutaneous necrotic lesion after interferon beta 1-b injection. |
Yurük, D. (2019) [90] | Rhabdomyolysis after epidural steroid injection. |
Marcus, F. (2019) [91] | 4 cases of Nicolau Syndrome: rare complication after intramuscular injections. |
Kang, HY. (2019) [92] | Systemic toxicity after cervical epidural steroid injection guided (February 2016-October 2017) 11 patients. |
Park, HB. (2019) [93] | Possible association between injections and calcification in lateral epicondylitis. |
Al-Omari, AA. (2019) [94] | 78-year-old male. Avascular necrosis after one intra-articular injection. |
Lobaton, GO. (2019) [95] | 62-year-old male. Vertebral osteomyelitis after epidural steroid injection. Permanent neurological injury. |
Quincer, E. (2019) [96] | 5-year-old male. Nicolau Syndrome after intramuscular injection in deltoid muscle. |
Anderson, SE. (2019) [97] | Adverse effects after intra-articular corticosteroid injections (2000-2016), 1.708 patients, 104 adverse effects. |
Kim, BR. (2019) [98] | Review of adverse events of intra-articular facet joint injections. (2007-2017). 11.980 procedures, 101 adverse events in 99 patients. |
Wang, RN. (2019) [99] | 61-year-old female. Oculo-motor nerve palsy after epidural lumbar injection. |
Petrin, Z. (2019) [100] | 87-year-old female. Paralysis without hematoma after lumbar epidural steroid injection. |
Rensma, HG. (2019) [101] | 33-year-old male. Nicolau syndrome after elbow injection. |
Hu, Y. (2019) [102] | Optic perineuritis after hyaluronic acid injections. |
Lee, JH. (2019) [103] | 81-year-old female. Osteonecrosis after intra-articular corticosteroid injection. |
Ali, D. (2019) [104] | 72-year-old female. Ischaemic stroke after cervical transforaminal injection. |
Rouientan, A. (2019) [105] | 22-year-old male. Complication after botulinum toxin A. |
Jani, P. (2019) [106] | Iatrogenic adrenal suppression after facet joint injection. |
Desai, K. (2019) [107] | Review of 354 cases about iatrogenic peripheral nerve injuries. |
Park, CW. (2019) [108] | 68-year-old male. Iatrogenic injury of sciatic nerve after intramuscular injections. |
Ali, SS. (2019) [109] | Iatrogenic spinal epidural hematoma and intracranial hypotension after thoracic epidural injection. |
Sencan, S. (2019) [110] | 3 males treated with transsacral blocks. Neuropatic sciatic after gluteal injection. |
Detail of articles included about injections.
Author/year | Description |
---|---|
Lee, JH. (2011) [111] | 58-year-old female with neck and upper extremity pain. Acute cervical epidural hematoma (C3-T1) after dry needling. |
McCutcheon, L. (2011) [112] | Techniques modifications to avoid pleura and lung. Understanding anatomy and its variants. Safe technique for training physiotherapists. |
Brady, S. (2014) [113] | 2 questionnaires for 10 months. 39 physiotherapists and 1463 adverse effects. Safe technique. |
Halle, JS. (2016) [114] | To evaluate benefits/risks of these techniques to minimize them. |
Halle, JS. (2016) [115] | Adequate training and education: safe and effective technique. To inform patients via informed consent. |
McManus, R. (2018) [116] | 27-year-old female, secretary. Neurapraxia of radial nerve after dry needling. |
Berrigan, WA. (2018) [117] | 62-year-old female. Epidural hematoma and broken needle after dry needling. |
Uzar, T. (2018) [118] | 36-year-old male. Pneumothorax after dry needling for pain in back muscles. |
Kim, DC. (2018) [119] | 16-year-old male. Local abscess after dry needling at the thigh for pain after a knee injury. |
McDowell, JM. (2018) [120] | Safety of acupuncture and dry needling in pregnant women. 124 responses: only 60 needle pregnant women and a 60% of them feel safety. |
Detail of articles included about dry needling.
102 articles met the inclusion criteria of the research in the period between 2000 (January) and 2020 (January) in form of original articles, case reports and reviews.
From these 102 articles selected, 23 refer to pneumothorax including more than 120 cases (19 of acupuncture, 3 of injection and 2 of dry needling); 4 articles refer to cardiac tamponade with more than 25 cases (both of acupuncture), 21 in relation to infections, abscesses or hemorrhages (14 of acupuncture, 6 of injection and 1 of dry needling) and other 7 articles refer to adverse effects such as syncope and cardiogenic shock (acupuncture), 3 pneumoperitoneo (acupuncture), 9 hematoma (6 of acupuncture, 1 of injection, 2 of dry needling), hemiplegia (acupuncture), cardiac perforation (acupuncture), hypokalemic paralysis (injection), 6 neuropathies (injection), 1 neuroapraxia (dry needling) and 12 cutaneous lesions/Nicolau syndrome/necrosis (3 of acupuncture, 9 of injection). In 11 articles there already was an existing disease, in other 4 the needle was broken and unfortunately in 4 articles the consequences were fatal. It has also collected 21 review articles of these needling therapies (more than 21.000 adverse effects described). Finally, 6 articles have synthetized information about benefits, risks, perception of security and even modifications of the application of these techniques (Figure 4).
Prevalence of most common adverse events.
Considering the outpatient care treatment, adverse effects are possible complications that can occur during or even after the application of these techniques. In more cases there has little importance such as pain, a slight bleeding or a small bruise that disappears quickly. However, other adverse effects without a clear cause can suppose a serious risk for the patient.
These risks have always been present, but in recent years publications have increased considerably. There is no consensus about the classification of these adverse effects. Some authors [111] categorized them into four groups: delayed or missed diagnosis, adverse effects during treatment, bacterial or viral infections, or tissue or organ trauma.
The incidence/frequency of these adverse effects is not clear. Acupuncture seems to have an incidence of 2/125.000 cases [30]; White et al. [58] estimated the risk of a serious adverse event with acupuncture at 0.05 per 10.000 treatments, and 0.55 per 10.000 individual patients, Lin et al. [70] reported a pneumothorax incidence of 0.87 per 1.000.000 acupuncture treatments and 1.75 per 1.000.000 in anatomical risk areas; these authors also showed a cellulitis incidence [72] about 64.4 per 100.000 treatments.
In relation to injections, Anderson et al. [97] explained an incidence of 5.8% of adverse effects. Kim et al. [93] introduced the incidence separately in relation with the case: 0.84% and 1.63% in relation to the patient; on the other hand, the procedure had an incidence of 0.07% and the administrated drug 0.15%. Finally, the unknown etiology had a 0.63% for this author [93] and for other authors it is unknown [121].
Data about incidence of dry needling procedures has not been found.
The most reviewed articles refer isolated cases and not a periodicity, but other authors have published several reviews that try to synthesize this information. Considering these 3 needling techniques, acupuncture leaves a clear superiority in relation to the number of publications with adverse effects.
Peuker et al. [20] investigated the traumatic wounds caused by acupuncture and discuss how these complications could be avoided. Lao et al. [22] reviewed 98 publications (1965–1999) and they found 202 complications (infections, tissue/organ damage and nerve injury). Cutaneous disorders, hypotension, fainting and vomiting were some adverse effects described. Chauffe et al. [29] found 9 cases of pneumothorax since 1985. Witt et al. [36] reviewed acupuncture studies in chronic osteoarthritis pain of the knee or hip, lumbar, cervical, head, allergic rhinitis, dysmenorrhea and asthma. Out of 229.230, 19.726 reported at least 1 adverse effect (bleeding, pain, vegetative symptoms). The longest duration of these adverse effects was 180 days (nerve injury). Ernst et al. [39] conducted a review of cardiac tamponade after acupuncture: 26 cases were found and 14 with fatal complications. He et al. [43] reviewed 167 articles with 1.038 cases (35 deaths) from Chinese literature. 468 cases were syncope, 307 pneumothorax, and 64 subarachnoid hemorrhage. Xu et al. [44] checked the frequency and severity of these effects (2000–2011): 117 articles with 308 adverse effects in 25 countries (294 for acupuncture, 4 moxibustion and 10 cupping). Peuker et al. [52] reviewed the traumatic lesions after acupuncture. Wu et al. [53] performed a review in China (1980–2013), finding 182 incidents in 133 papers (internal organ, tissue and nerve injury are the major complications). The adverse effects included were syncope, infection, hemorrhage, allergy, burn, aphonia, hysteria, cough, thirst, fever, somnolence and broken needles. White et al. [58] found 715 incidents in their review: 90 reports of trauma and 12 reports of death. In Taiwan, Lin et al. [70, 72] published 2 reviews (1997–2012) about pneumothorax and cellulitis incidence respectively. They evaluated 411.734 patients with 5.407.378 treatments of acupuncture [70] and 407.802 patients with 6.207.378 acupuncture treatments [72]. In both articles the authors emphasized the importance of the previous medical history. Ullah et al. [77] reviewed 133 articles and selected 30 cases with relevant cardiac complications: 8 were infective complications and 22 cardiac tamponades.
Regarding injections, 8 articles have been found. Antoni Ro et al. [79] reviewed 226 cases (1955–1959), finding 71 cases of pneumothorax and Cheng et al. [81] performed a review (1966–2006) explaining the complications of this technique: “infections, spinal cord injury and peripheral nerve injuries, pneumothorax, air embolism, pain or swelling at the site of injection, chemical meningism, granulomatous inflammation of the synovium, aseptic acute arthritis, embolia cutis medicamentosa, skeletal muscle toxicity, and tendon and fascial ruptures”. De la Torre et al. [87] introduced a review about the adverse effects caused by botulinum toxin A in masticatory muscles. They used 436 citations and concluded with 16:7 were myofascial pain and 9 were trigeminal neuralgia. The most frequent adverse effects were “temporary regional weakness, tenderness over the injection sites and minor discomfort during chewing”. Most of them had a spontaneous resolution. Marcus et al. [91] found a very rare complication due to injections (diclofenac, dexamethasone and benzathine penicilin): Nicolau Syndrome. They found 4 cases (2016–2018). Park et al. [93] investigates an association between steroid injection and calcification in lateral epicondylitis. They evaluated 110 patients (February 2016-October 2018) and concluded that the injections history and the number of them has a significative association with soft tissue calcifications. A review (January 2000-April 2016) about adverse events due to intra-articular corticosteroid injections was made by Anderson et al. [97] 1.708 patients from 3 regional hospital participated: 99 patients had 104 adverse effects within 90 days post-injection. The most prevalent symptom was flare (78 patients) and 10 patients had skin reactions. There were no infections. Years before, Kim et al. [98] had reviewed 11.980 injections in 6.066 patients (January 2007-December 2017). There were 101 facet-joint injections and 99 patients developed adverse effects. 7 patients had an infectious spondylitis, 1 patient died of an uncontrolled infection and 2 patients had partial recovery of their neurological condition. Finally, Desai et al. [107] published a review of 17 years where reflected the iatrogenic peripheral nerve injuries due to injections. They included “intramuscular injections, brachial nerves procedures, subclavian and jugular venous cannulation and routine intravenous injections”. The most frequents symptoms were pain, paresthesia and sensory-motor deficits. 190 patients needed surgical intervention, 164 had any sequel or no recovery and 9 had neurological deterioration with weakness.
There is not standard data on the incidence of these events. Unfortunately, the huge diversity of pathologies, interventions, therapists… makes difficult a generalization.
There is no consensus about the most frequent adverse effect in the literature. Some of them are pneumothorax, cardiac tamponade, air embolism, spinal epidural haematoma/abscess, abdominal visceral injury, median and fibular nerve injury and infection [20, 36, 75, 77, 81, 87, 111].
Some authors reflected that pneumothorax is the most cited adverse effect, [50, 63] while for others is infection [44]. White et al. [58] agree with both theories being the most common complication pneumothorax and injury to the central nervous system and infection will be in second place. Ullah et al. [77] concluded that cardiac tamponade is the most frequent complication.
It seems that invasive techniques on the thorax are related to a high incidence of pneumothorax [118]. There are some investigations in different countries (United Kingdom, Japan, Czechoslovakia, Switzerland, Germany, Japan and Taiwan) about it. The incidence of these cases is low, less than 1/10.000. However, there have been more than 100 cases reporting iatrogenic pneumothorax due to acupuncture and dry needling, including cases of death [112]. Lin et al. [70] showed an incidence of 0.84/1.000.000 and 1,75/1.000.000 at risk anatomical areas. Most iatrogenic pneumothorax used to be unilateral, but there are bilateral cases too [26, 30]. In this article there are 23 articles related to pneumothorax [19, 26, 29, 30, 33, 46, 47, 49, 50, 55, 56, 59, 62, 63, 68, 69, 70, 78, 79, 80, 83, 112, 118].
Other incidents (less frequent) reported in the literature but not less important are cardiac tamponade [21, 39, 51, 75, 77], granulomas [23], fistulas [24, 38], necrosis [25, 42, 85], infections [27, 57, 119], abscesses [27, 45, 61, 71, 74, 76], pneumoretroperitoneum [32], hemorrhages [35], hemopericardium [37], haematomas [40, 64, 67, 109, 111, 117], chilotorax [41], organ perforation [48, 60], needle rupture [53, 55, 117], hemiplegia [54], hemothorax [56], peritonitis [66], cellulitis [72], hypokalemic paralysis [84], nerve injury [86, 99, 102, 107, 108, 110, 116], weakness [88], necrosis [89, 90, 94, 103], Nicolau Sydrome [91, 96, 101], toxicity…[92] Almost all had a complete resolution of the symptoms. However, publications with fatal and irreversible consequences have also been found [24, 37, 98].
There are several aspects must be considered when carrying out these techniques in the treatment of muscular pain in outpatients. These incidents, even taking caution may occur; therefore, it is important to obtain a complete clinical history highlighting possible underlying pathologies [70, 71, 72]. Several articles have found patients with asthma [19], diabetes [25, 85], anemia [42], herpes zoster [47], cancer [51], miastenia gravis [55] and scoliosis [57] and sclerosis [89]. These pathologies could influence the appearance or greater probability of developing a complication.
The age of the patients is other aspect to discuss. A review performed in children (acupuncture to prevent postoperative nausea) has been published without conclusion about its effectiveness [34]. Quincer et al. [96] showed the case of a 5-year-old boy who developed a Nicolau Syndrome after an intramuscular injection in deltoid. Besides, cases of elderly people who have suffered syncope’s due to acupuncture have also been described [28]. These patients (the most prevalent population in the outpatient) may be more debilitated and suffer more adverse effects even taking precautions.
There are some types of population could be considered “at risk” when using these needling techniques, like pregnant women. We have found an article that exposes a retrosternal abscess due to sternoclavicular joint injection with resolution [82]. McDowell et al. have developed a review on the safety of acupuncture and dry needling in pregnant women in New Zealand. They conclude that of 124 responses obtained, only 60 therapists needle pregnant women and only 66% of them express safety. More training is needed in this field, particularly on dry needling [120].
In relation to sex, only one article showed major incidence in men than in woman [70].
It seems that the most frequent application of these techniques is analgesia, including analgesic blocks [40], but there are other applications such hyaluronic acid in eyebrow [102], botulinum toxin A for axilar hiperhidrosis [105] and aesthetics for rejuvenation have also presented adverse effects [122, 123].
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.
Language was the first limitation, several articles have been found in France [124, 125], Portugal [126], Russia [127], Germany [128], Italy [129], Denmark [130], and Iceland [131] that have not been included in the revision due to its original language. 3 reviews in Chinese [132], German [128] and Danish [133] respectively were excluded for the same reason. The first two expose a synthesis or classification of adverse effects and the third, is a review on acupuncture in children in Denmark. Letters and comments were also excluded; however, we highlight the case of acupuncture in the disease of behgets [134]; a letter to editor where they expose a case of pneumothorax during a demonstration of dry needling in the thoracic iliocostal [135] and a needle broken as a complication of acupuncture [136]. Neither has been taken into account articles on practical applications, effectiveness of such techniques or superiority of some over others.
Acupuncture seems to have the most adverse effects reported throughout the literature, while injections and dry needling are increasing their publications, probably due to the increase in popularity especially of the second [114, 115]. Nowadays adverse effects seem to be common, but complications are rare. All authors of these articles agree in some tips to take in consideration:
The anatomy of the area to treat should be familiar to the healthcare professionals before undertaking the procedure.
Communication with the patient via informed consent is needed.
Aseptic conditions during the procedure are necessary.
The appropriate time to apply the treatments correctly becomes essential for a good practice and an adequate achievement of the results.
A correct training and continuous formation of healthcare practitioners are necessary.
This is a brief summary of the adverse effects found in the literature. There is no clear consensus about incidence, the most prevalent adverse effect, the intervention protocols, or experience of the therapist… As a conclusion, needling therapies are usual techniques in the outpatient care and complications are possible even considering all the precautions. Therapists have to know how to react, recognize the adverse effects and correct them as far as possible or refer the patient to the corresponding service, being always updated to new advances and familiar to the normal and variants of anatomy of the patients to avoid complications as much as possible. Caring the aseptic conditions and the communication with the patient to inform them about all the parts of the treatment with needling therapies are essential.
None declared.
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