SECTION I
Dry needling as a modiality is not a new phenomenon. In fact, it turns out to be at least three quarters of a century old if we consider the paper of Brav and Sigmond in 1941 as the beginning of modern day dry needling where they claimed pain could be relieved by simple needling without injecting any substance. However, the popularity of dry needling has reached its maximum only in recent times. It is now evident that dry needling has become more than just a passing fad and is turning out to be a mainstream physiotherapeutic treatment. That day is probably not so far when our universities start incorporating dry needling in their syllabus. Before that an important task remains to be accomplished though, which is standardizing the process of dry needling.
Here we discusses sixteen key components that are identified while reviewing the available national and international guideline pertaining to needling. For ease of the practitioner those components are arranged in a singled sheet of paper, which constitutes the dry needling assessment form.
The Need
Because of its invasive nature dry needling has certain potential risks to the patient and therapists which are not associated with most other physiotherapy modality. The dangers range from minor hazards to rare but life threatening complications. As the number of the physiotherapists practicing dry needling increases so will the number of hazards. Practice of a standardized needling procedure will go a long way prevent these potential adverse effects.
Moreover a streamlined procedure will aid in recording the sessions, improve reproducibility of the results, help in conducting research and benefit billing and insurance related issues.
Existing Resources
Quite a few guidelines exist which are aimed at streamlining dry needling, the APTA resource paper on dry needling being most popular. FSBPT’s “Analysis of competencies for dry needling by physical therapists” is another excellent source. The Australian society for acupuncture physiotherapists (ASAP) and health quality council of Alberta (HQCA) have their own set of guidelines respectively. Physiotherapy Alberta has also come out with their practice guidelines related to critical event management during dry needling. Back home we have a “Handbook of safe injection practices” from national centre for disease control (NCDC), govt of India, which, though not directly related, has a lot of relevant information.
Key Components and Dry Needling Assessment Form (DNA-F)
A review of the above guidelines delineates sixteen key components of safe and effective practice of dry needling. These are organized in an orderly fashion in the dry needling assessment form (DNA-F) to make the process safe, easy, systematic and reproducible.
The first key component (I) is the aim of dry needling. Commonest use of dry needling is to obtain analgesia, healing or in treatment of trigger point. In the DNA-F they can be mentioned by ticking the check boxes. In case the goal is a different one then it can be mentioned in the other column.
Once the aim is recorded the next step (II) is to establish if the patient has prior experience with dry needling, as per the FSBPT guideline. Following this the contraindications (III) has to be ruled out. Twenty two of the common contraindications which are featured in the existing resources are mentioned in the DNA-F check boxes. This ensures that the obvious contraindications are not missed during assessment. The dotted line next to some of them means the therapist who assesses the patient is supposed to mention the relevant details. If any other contraindication is present that too is needed to be mentioned.
In case there are one or more relative contraindications, and the therapist still decides to go ahead with the treatment, the precautions (IV) are necessary. Whenever possible the referring doctor’s opinion (IVA) should be sought. This is important as there is a dearth of objective guideline on when to proceed with needling in case of an existing clinical condition (like diabetes). In such a scenario if the responsibility of whether to go ahead with needling is shared it is best for all parties involved. Whenever there are concerns with hemostasis it is prudent to check bleeding time, blotting time or International normalized Ratio (IVB).If any other precautions are necessary they must be mentioned.
Precautions against pneumothorax
Pneumothorax is a potentially life threatening complication arising from dry needling. A six step guideline with an acronym SPIDER is being advocated to protect against needling induced pneumothorax. Here S stands for surface anatomy. Before needling a therapist should always review the surface anatomy of the area to be needled to identify and avoid potentially vulnerable structure (pleura in this case). P is for position and both patient’s position and the position of the needle has to be chosen carefully. I indicates incidence angle, the angle at which the needle enters the body. It is important to recognize that at the same point of entry a wrong incidence angle can easily reach the pleura and create problem, for example, whie needling the thoracic multifidus in the ‘safe needling zone’ if the needle is angled laterally (instead of the recommended medial direction) it will definitely puncture the pleura. D stands for depth. The needler should have a fair bit of idea about the depth of the tissue, choose the length of the needle accordingly and the needle should be advanced no further than necessary. E is for patient education and R is for recording of the needling session.
Glove as a precaution
Use of gloves definitely add an extra layer of safety. However, it takes away sensory feedback from the practitioner’s hand. What do the guidelines say about it?
The APTA guidelines advocate using gloves whereas according the Australian guidelines (ASAP) use of glove is not mandatory. The injection guidelines of NCDC and the glove pyramid of WHO both mentions gloves are not necessary during routine IM injections, a procedure much similar to dry needling.
Jan Dommerholt advises wearing gloves in the non needling hand which is then used to stop bleeding, should it occur. The OSHA guidelines that APTA advocates says the glove needs to be changed once the procedure is over or while treating a different patient.
Precaution against infection: Skin preparation & Hand hygiene
Dry needling being a clean field technique skin preparation only constitutes cleaning the area with alcohol based solution suffices. This procedure is similar as used in IM injection and the NCDC guidelines (70% spirit solution) can be followed. The same guideline advises washing hands during the first procedure and cleaning them with alcohol based sanitizers between the procedure, unless there is visible dirt or chances of contamination, in that case the hands need to be washed again. Do remember there are certain non alcohol based sanitizers, which should probably be avoided.
Following the precautions the patient needs to be educated (V) which involves giving the patient a basic knowhow about dry needling, patient rights, exposure and related privacy issues, expected sensations, usual reactions and potential adverse effects. The patient also needs to know the activity guidelines related to dry needling, how to identify serious adverse effects and what to do in such a scenario. This is important as pneumothorax sometimes occurs hours after the dry needling session is over. The patient should recognize the symptoms (sudden sharp chest pain, breathing difficulty) and act accordingly. Usually a small pneumothorax does not need any treatment. A large pneumothorax needs aspiration or ICDT.
The next step is to obtain informed consent (section VI). After discussing these and satisfying patient’s queries the final call on whether the patient can be safely needled has to be taken. If the decision is to go ahead then therapist needs to obtain patient’s informed consent.
Next the structures (VII) that are to be needled are identified. The presenting pain/symptoms (VIII) are expressed in numerical rating as well as in body chart. The local precautions e.g. femoral artery(X) and patient’s position (XI) are mentioned.
With all these details in place the needling is performed. The techniques and needle details (XII & XII) are mentioned, e.g. for piriformis, 50mm needles X 2, DDN, 80% inserted, angled away from sciatic nerve can be mentioned. Section XIV records the duration of needling and XV records patient’s symptoms after needling.
The sections VII-XV has five rows, so they can be used either to needle five structures or to needle the same structure for five sessions.
The last section and one of the most important key components is recording of adverse reactions. Apart from pneumothorax other major adverse effects can be injury to internal organs, e.g. urinary bladder, these conditions need immediate medical attention. Minor adverse effects include minor bleeding, aggravation of symptoms etc which needs only reassurance from the therapist.
Needle-stick Injury
One of the adverse reactions that affect the therapist is needle stick injury. The needle stick injury happens due to improper needle handling techniques and it is best prevented. Alongside the therapist who practices dry needling should be vaccinated against hepatitis B. If needle-stick injury happens then the area should be washed with soap in flowing water and post exposure prophylaxis (PEP) needs to be initiated at the earliest. Compressing /sucking the punctured area should never be done.
In conclusion
Standardizing the process of dry needling is essential for multitude of reasons. Sixteen key components were identified while reviewing existing national and international guidelines. They were organized to form DNA-F to assist in safe and effective dry needling. As per the author’s knowledge no tool has been developed till now that simplifies the process of dry needling. On this regard the DNA-F is one of a kind. If used with clinical wisdom and common sense DNA-F will be a useful supplement to the regular assessment while dry needling.
SECTION II
SECTION III
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