Acupuncture, IMS, and trigger point needling are all dry needling techniques used in the practice of Physiotherapy. The assessment, techniques, and rationale for use vary between physiotherapists based on their training and competence, but all techniques have the common goal of trying to have a positive effect on the patient’s condition.
The first confirmed system of acupuncture dates back approximately 2,500 years ago in China. There has been a large evolution in the use of acupuncture needles since then, and it is now common for many professions to use dry needling in practice. Physiotherapists focus on using dry needling to create effects in the musculoskeletal system. They do not use needles to create changes in your liver, gall bladder, hormone systems or for anything pregnancy-related (unless you are injured or in pain during your pregnancy).
In 2014, the College of Physiotherapists of Alberta requested the Health Quality Council of Alberta perform a review of adverse outcomes due to dry needling to gauge the risk of dry needling and to improve the quality and safety of this practice. Since then, the College of Physiotherapists of Alberta has built on those recommendations and today’s article will take you through the latest information on adverse events in needling and provide you with what you can expect from your physiotherapist if you receive dry needling in Alberta.
First, let's talk about what you can expect from your physiotherapist when they suggest dry needling as a treatment option.. Informed consent is a huge topic in health care and constitutes one of the most important aspects of providing care to a patient. The physiotherapist must:
- Describe the treatment: You should be told the basics of the treatment including what it involves, what you should feel during and after needling, and what the expected outcome of the treatment should be.
- Emphasize your role in making the decision to get treated with dry needling: Whether you ask about needling, or your physiotherapist suggests it as an option, you make the final decision to receive the treatment or not.
- Discuss alternatives to needling: Not all patients need dry needling as a treatment. Physiotherapy can provide many alternative forms of treatment and many different avenues of care to achieve your goals.
- Discuss the risks involved: There are risks with dry needling, which we discuss later in this article. You can expect that your physiotherapist will explain the risks in general and any risks unique to you.
- Answering questions: You may or may not have questions depending on how well everything was explained, but you should be given the opportunity to have your questions about the treatment answered before the physiotherapist asks for your consent.
- Obtain your consent: You make the final decision about receiving needling and that decision needs to be made without you feeling like you’ve been pressured or talked into anything.
Once the physiotherapist has taken you through the steps above and you feel comfortable receiving treatment, then they may present you with a consent form to sign or ask for your verbal consent. You should only sign this form or grant consent after they have addressed everything in points 1-6 to your satisfaction.
Importantly, consent needs to be ongoing. Each time you see your physiotherapist, the physiotherapist MUST ask if you wish to continue with needling. They may not have to go through all the initial details they did in the first session, but they should be constantly checking in to see how you are doing, if you have any questions, if there are any changes that could affect the treatment’s safety or effectiveness, and if you are willing to continue.
It is also important to note that consent can be revoked at any time. Just because you agreed to something at the start, does not mean you have to continue with it if you have changed your mind. Many things can alter your opinion on whether you wish to receive a treatment, but you are able to withdraw from one part or from all treatment at any time. You can expect that your physiotherapist:
“Respects the autonomy of clients to question, decline options, refuse, and/or withdraw from services at any time.” Consent Standard of Practice
Now that you have had the treatment explained to you, we are going to go through the potential risks associated with dry needling from the more common “minor” issues to the more serious adverse events, however this is not an exhaustive list. Each one of us have different views on how risky something is, so we have presented this from someone’s (me) point-of-view who has been using needling in practice for several years.
Some of the more common (and typically minor) incidents that you can experience when being treated with a form of dry needling include bruising, bleeding, and discomfort.
When a needle penetrates the skin and goes past the level of the dermis, it may encounter blood vessels on the way to the targeted site. If the needle pierces the blood vessel, there can be a droplet or two of blood that comes after the needle is removed. Generally, the blood clots quickly due to the small gauge of the needle and your blood’s ability to clot. However, usually after a blood vessel has been hit, a small bruise may form and can be anywhere from smaller than a dime, to as large as a loonie depending on the type of needling performed, the gauge of the needle, and your body’s ability to clot quickly. Bruising is what occurs when blood vessels are damaged and small amounts of blood pool under the skin.
Discomfort or sharp pain can occur during and after needling treatments. These types of reactions are reported more frequently and can be a normal reaction to having acupuncture needles inserted into the muscles and tissue of the body. Some patients feel better immediately, while others may be sore for an hour or two, and up to a day or two. It is typically mild discomfort, but if you are concerned that there may be something wrong, contact your physiotherapist to discuss your response, or follow the plan your physiotherapist discussed with you if concerns arise following your departure from the clinic.
On the spectrum of risks associated with dry needling, we will move onto the slightly more concerning vaso-vagal response. The vaso-vagal response is experienced by most people as feeling faint or light-headed. Reports of dizziness, sweating, nausea, increased heart rate or a drop in blood pressure are rare, occurring in 0.2-7% of patients receiving treatment1. Most often, patients recognize that they have had these reactions before to the sight of blood, or their own personal experience with immunizations, drawing blood for testing, or from previous treatments involving acupuncture needles.
Recovery from this response usually takes 20-30 minutes and is helped with a little snack and some water or juice. There are no long-term issues with having a vaso-vagal response, but if it does occur, it is usually a good idea to follow-up with your family doctor to make sure nothing else is going on that may have triggered this response.
Infection and pneumothorax are two of the more significant adverse events when it comes to having a physiotherapist insert a needle into your body. Bacterial infections after needling are rare but if they do occur, it is usually because of microorganisms on the surface of the skin. Symptoms would include pain, redness, swelling, and heat in the area of the infection. Most infections can be easily treated with a visit to a doctor.
The last and rarest of potential adverse events we will talk about is a pneumothorax. A pneumothorax is also known as a collapsed lung and occurs when an abnormal collection of air forms in the space between the lung and the chest wall. A pneumothorax can occur during dry needling if a needle enters the lung tissue, but thankfully this is quite rare, occurring in approximately one out of a million treatments.2 While shortness of breath is often thought of as the main symptom, other symptoms may include anxiety, cough and chest pain increasing while taking a deep breath in. Although quite rare in occurrence, if you do have these symptoms, please go straight to the emergency department as an x-ray is needed for diagnosis and you will require medical treatment.
Now that we have talked about the potential adverse events that can occur during an acupuncture or dry needling treatment, let’s talk about what you should expect if any of these occur while you are receiving treatment.
- The physiotherapist performing the treatment should be told of any symptoms you are having so they can help you through the situation
- If you get symptoms after you have left the clinic, phone the physiotherapist so they can walk you through the next steps, whether you’re experiencing pain, dizziness, and/or shortness of breath.
- The physiotherapist should have a plan that they walk you through whether you are in the clinic or away. This plan should involve whatever immediate care is necessary depending on the adverse event and appropriate follow-up to ensure your concerns have been addressed.
The use of dry needles in practice should be presented to you in a way that weighs the potential benefits and risks of the treatment, as well as why the physiotherapist thinks it would be an appropriate treatment option. The potential risks should be explained thoroughly in a way that you understand, and your questions should be answered to your satisfaction. Your consent must be voluntary and ongoing. Trust is built over time, and it is ok to tell the physiotherapist that you might not be ready to get needling treatments done by them. As a professional, they should respect your decision and provide alternatives to treatment. Physiotherapy should never be a one-treatment-for-everyone practice, so expect your physiotherapist to provide you with alternatives that you are comfortable with.
- Christensen KA, Gosse BJ, Hildebrand C, Gershan LA. Acupuncture-associated vasovagal response: Revised Terminology and Hospital Experience. Med Acupunct 2017: 29(6): 366-367.
- Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, et al. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komp. 2009:16(9): 1-7.