Welcome to the second part of the dry needling (DN) and acupuncture discussion with Dr. Peter Selvaratnam. Last week we looked at some of the distinguishing features that differentiate each technique. This week focus our discussion around patient selection, precautions & contraindications, risk factors, and safety procedures. All of these features are vital in being able to clinically reason when DN and acupuncture is going to be an appropriate treatment modality for your clients. The technique of DN is a skill that needs to be learnt and practiced, but deciding when to use DN is often the greater challenge.

Q: What type of patients benefit from these two treatments?

For acupuncture - all systems of the body can be treated, hence which it is called an alternative medicine. Acupuncture is commonly used in chronic pain, hormonal problems, nausea, vomiting, headaches, migraines, and other systemic conditions.

For dry needling - musculoskeletal conditions, neurological conditions, nerve irritation, and Bell's palsy. For Physiotherapists, who are much more likely to treat musculoskeletal conditions, sports injuries, back and neck pain, and neurological conditions, dry needling is often a better choice of treatment. Dry needling can also be used in both acute and chronic injuries. Often the primary reason is due to a neuromuscular condition which could be acute or not responding musculoskeletal therapy/exercise, and there may be myofascial trigger points that are contributing to impaired body structure, pain and functional limitation.

Acute: wry neck, sports injuries, work-related injuries, motor vehicle accidents, headaches, jaw pain and nerve root pain.

Chronic: sports injuries, work-related injuries, motor vehicle accidents, chronic pain regional syndrome type 1 (RSD), multiple myofascial trigger points, migraines and headaches.

Another point to remember is that acupuncture and DN don't have to be used in isolation and often can be combined with other treatment methods, such as exercise, manipulation, joint mobilisation, and self-management strategies, to further enhance treatment outcomes (ACCP, 2014).

Both acupuncture and dry needling are commonly used in the treatment of lower back pain. Image courtesy of Google Images — Both acupuncture and dry needling are commonly used in the treatment of lower back pain. Image courtesy of Google Images

Q: What are the contraindications and precautions for DN and acupuncture?

Acupuncture is an alternative medicine and many people view alternative medicines as a safer option, but 'natural' doesn't always mean safer.

There are some absolute contraindications to be aware of which exist for both acupuncture and DN (APTA, 2016; ASAP; 2007; ASAP, 2013):

Conditions which need medical management
Severe clotting disorders and patients with abnormal bleeding tendencies
Haemophilia
Patients on anticoagulant medication
Patients with cancer, blood borne diseases, and acute immune disorders
Von Willebrand's disease
Lymphedema of the limb
Allergy to needles and metal
Fontanelles on the scalp of infants
Unstable epilepsy
Overexcited or fatigued individual
Intoxicated individual
Patients with clear signs of active infection
Confused or phobic patients
Untrustworthy patients
Frail patients and elderly patients as there is a risk of infection and these patients are often on multiple medications and have multiple comorbities that alters their cardiovascular system, immunity, and haemodynamic states.
Children - DN is not recommended for children under 12 and parental and child consent should always be obtained.
Patients with a significant cognitive impairment who may be unable to fully understand the treatment parameters and intervention.
Severe hyperalgesia or allodynia which may interfere with the treatment
It is prohibited for Physiotherapists using acupuncture techniques to include the nipples, the umbilicus, and external genitalia (first line in the ASAP guidelines under CIs).

There are also relative contraindications and precautions to consider:

Insufficiency of heart valve
Coronary artery stents
Joint replacements - particularly TKR due to the risk of injection (Najama, et al., 2010)
Unstable spine
Advanced liver disease as this can compromise production of clotting factors
High dose of steroids which can suppress the immune system
HIV infection as these patients can be immunocompromised
Open skin wounds and/or vulnerable tissues such as varicose veins
Skin cellulitis and inflamed areas of skin are at increased risk of infection
Patients who are unable to communicate directly with the therapist due to language barrier
Someone who is not willing to receive that type of treatment
Someone who is unable to give consent for treatment
Diabetes is a consideration due to poor peripheral sensation, cardiovascular changes and reduced healing.
Pacemakers - patients with pacemakers should not receive electro-acupuncture

Q: What are the possible side effects and risks?

"Relatively few complications from using acupuncture have been reported. Still, complications have resulted from use of non sterile needles and improper delivery treatments. When not delivered properly, acupuncture can cause serious adverse effects, including infections, punctured organs, pneumothorax, and injury to the central nervous system" (National Centre for Complementary and Integrative Health, 2016). This statement applies to DN as well as the risks are related to needle use and placement.

Prospective studies on 65,482 acupuncture sessions in Japan reported in 1999, and 66,000 acupuncture sessions in the UK reported in 2001 demonstrated that there were no major adverse events (BAcC).

More common side effects which are less severe are post treatment drowsiness, bruising, nausea, fainting, and temporary exacerbation of symptoms.

Dry needling for more vulnerable or high risk areas such as the upper trapezius takes training and practice to perform safely. Image courtesy of Google Images

In regards to infection, there a risk of local infection, but if your patient has any other comorbidity which makes them immunocompromised, there can be significant impacts on blood pressure, liver function, full body immunity and healing. Infection can be caused by re-using needles, using needles that aren't sterilised and not cleaning the treatment area before use.

Something to consider is the relative risk that is associated with each treatment site, as there are some areas that are much more dangerous and vulnerable to treat. The upper trapezius, the anterior neck, lateral neck over major vessels, in the lumbar spine you need to careful of the position of the kidneys vs erector spinae and quadratus lumborum (ASAP, 2007).

The use of gloves is recommended for both treatment techniques to improve the hygiene of the treatment environment. Image courtesy of Google Images

Q: what steps can be taken to reduce the risk of side effects?

Hygiene requirements:

The first way to reduce risk is to wash your hands. The ASAP recommend that Physiotherapists wash their hands at least 30-60 seconds before and after treatment, with soap.
A good tip is to be mindful of what doors and surfaces you touch after you wash your hands. If there isn't a basin in the room, set everything up and then leave the door slightly ajar when you go wash your hands so you can open and close it with elbows or feet.
Clean the patient's skin with soap and water or alcohol skin wipes - and let the alcohol completely dry prior to commencing treatment.
Cover cuts and lesions with a water resistant dressing.

Sharps container for disposing of needles. Image courtesy of Google Images

Sterilisation:

Use sterile and disposable needles.
Dispose of needles carefully in a sharps container.
If when you open a needle, it has detached from the side and puncture the package with the needle tip exposed to the outside environment, it is no longer sterile and should be discarded.

Conclusion

I'd like to thank again Dr. Peter Selvaratnam for contributing his knowledge to Rayner & Smale. When I read over this blog I can see that there is a long lists of 'don't do it when... and the bad outcomes are...' but remember that when we make decisions based on clinical reasoning and careful examination, these risks are significantly reduced. And if you wrote a list of all the conditions that benefit from this treatment approach - it would be much longer than the contraindications.

There are many people who will sing the praises of both acupuncture and DN and personally, I have great results in the clinic. But the key take home message is picking the right person rather than just using it as a treatment for everyone. Be thorough in your subjective evaluation, check for contraindications, and use your clinical knowledge and reasoning to decide what the best treatment modality is for each client.

Sian & Peter

Further resources & references:

Australian Society of Acupuncture Physiotherapists Inc (ASAP) - guidelines for safe acupuncture and dry needling in practice

American Physical Therapy Association - Dry Needling Resource

AACP - Integrating Evidence-Based Acupuncture into Physiotherapy for the Benefit of the Patient

The British Acupuncture Council is the leading self-regulatory body for the practice of tractional acupuncture in the UK. We are a member-led organisation; with over 3000 members. The BAcC is the home of traditional acupuncture in the UK, led by an elected governing board and driven by a specialist staff team.
Fact Sheets & Information about traditional acupuncture

Combined Health Information Database (CHID)

National Institute of Health

National Centre for Complementary and Alternative Medicine (NCCAM) Acupuncture Information Resources

National Centre for Complementary and Integrative health - Acupuncture: in Depth

Australian Health Practitioners Regulation Agency (AHPRA) ADNG - Infection prevention and control for acupuncture practice