Indications, contraindications, and dangers related to dry needling
SECTION I
Indications of Dry Needling
Dry needling is another tool in the armory of physiotherapist. When used purposefully with sound clinical reasoning dry needling works well in various musculoskeletal and neuromuscular conditions. Suggested Indications are:
- Trigger points: Releases trigger points
- Pain of muscular origin, e.g. muscular component of acute spinal pain: for analgesia, control of muscle spasm.
- Musculoskeletal pains: e.g. osteoarthritis: works like pain killers, provides temporary relief
- Referred pains: works like pain killers, provides temporary relief
- Pathologies of soft tissue origins: e.g. tennis elbow, plantar fascitis, shin splints- appears to improve tensigrity, accelerates healing
- Spasticity: as a Part of multidisciplinary treatment approach
APTA outlines the following indications:
DN may be incorporated into a treatment plan when myofascial TrPs are present, which may lead to impairments in body structure, pain, and functional limitations. TrPs are sources of persistent peripheral nociceptive input and their inactivation is consistent with current pain management insights. DN also is indicated with restrictions in range of motion due to contractured muscle fibers or taut bands, or other soft tissue restrictions, such as fascial adhesions or scar tissue. TrPs have been identified in numerous diagnoses, such as radiculopathies, joint dysfunction, disk pathology, tendonitis, craniomandibular dysfunction, migraines, tension-type headaches, carpal tunnel syndrome, computer-related disorders, whiplash associated disorders, spinal dysfunction, pelvic pain and other urologic syndromes, post-herpetic neuralgia, complex regional pain syndrome, nocturnal cramps, phantom pain and other relatively uncommon diagnoses such as Barré Liéou syndrome or neurogenic pruritus among others.
Absolute Contraindications:
- In a patient with needle phobia
- Unwilling patient – patient beliefs, fear etc
- Unable to give consent – age-related, communication, cognitive
- History of untoward reaction to needling (or injection) in the past
- Medical emergency
- Into a muscle or area in patients on anticoagulant therapy or with thrombocytopenia, where haemostasis by manual compression cannot be carried out appropriately e.g. psoas, tibialis posterior
- Into an area or limb with lymphoedema as patients with lymphoedema maybe more susceptible to infection. In addition it is not advisable to needle a limb after surgical lymphectomy.
Relative contraindications
- Abnormal Bleeding Tendency
- Compromised Immune System
- Diabetes
- Epilepsy
- Frail Patients
- Vascular Disease
- Infection
- Pregnancy
Dangers of Dry Needling
Dry needling poses certain potential risks to the patient and therapists which are not associated with traditional non-invasive physiotherapy.
Pneumothorax
- Dry needling may puncture pleura and cause pneumothorax.
- DN should be performed with special precautions around thorax.
- Needling is done obliquely and superficially. Emphysematous patients have maximum risk.
- A pincer grip should be utilized as in the case of the upper trapezius. In other cases target tissue can be fixed over bone (scapula and ribs) to protect the lung.
- The risk of a pneumothorax is very small if proper needling techniques are employed.
Clinical features
- Sudden and sharp chest pain
- Breathing difficulty
- Tight chest
- Early fatigue
- Tachycardia/diminished chest sounds
- Low O2 tension
- Low BP
Blood Vessels
- With DN there is a potential of injury to blood vessels.
- Palpate for pulse to locate an artery prior to DN to minimize risk.
- With normal bleeding and clotting time it is highly unlikely to have serious bleeding.
Nerve
Special consideration needs to be given in relation to the spine and in the posterior sub occipital area as the brain stem is accessible through the foramen magnum.Siz o
It is not unlikely to have accidentally inserted a needle in a peripheral nerve. This is characterized by a tingling distal to the needling site along the course and distribution of the peripheral nerve. While care must be taken to avoid this, immediate withdrawal of the needle is all that is necessary.
Organs
Anatomical knowledge of internal organs is important as with DN there is potential for injury to internal organs such as the kidney or penetration into the peritoneum cavity.
Others
- Stuck, bent, broken needle.
- Forgotten needle, forgotten patient.
- Euphoria
Minor adverse effects
- Bleeding
- needling pain
- aggravation of symptoms
- faintness, drowsiness
Patient instructions
- Regarding activity
- Regarding decision making!
Rare but serious traumatic complications could be avoided if practitioners had better anatomical knowledge, applied existing anatomical knowledge better, or both (Peuker and Gronemeyer 2001).
SECTION II
SECTION III
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