Dry needling: balancing benefit and the mitigation of risk
Gillian Sheppard and Scott Shelly of Barry.Nilsson. Lawyers discuss a clinical scenario where a patient has suffered adverse results from dry needling treatment and provide some safeguards to prevent this from happening.
Physiotherapists, podiatrists and other allied health practitioners may practise any of the following forms of acupuncture: traditional acupuncture, Western acupuncture and dry needling.
In recent years, dry needling has increasingly been used in physiotherapy settings to alleviate pain and increase motion for patients.
In contrast to traditional and Western acupuncture, dry needling is applied to altered or dysfunctional tissue to improve or restore function.
Dry needling is an invasive technique and performing it may be the first time a practitioner penetrates a patient’s skin.
Naturally, this creates the potential for hazards and complications, especially in relation to bloodborne pathogens.
The act of puncturing the skin may also result in a number of predictable adverse events, including bruising, bleeding and pain during or following treatment.
These outcomes are common and are mild in nature.
A physiotherapist may consider these normal side effects of treatment.
However, from the patient’s perspective, they may be considered adverse, particularly if the patient has not been educated about the risks.
Health practitioners have a duty to make the care of patients their primary concern, to practise effectively and safely and to ensure that the risk of injury is minimised.
Although dry needling is very safe if practised appropriately, there have been documented fatalities as well as other serious adverse effects such as pneumothorax and local or systemic infections.
It is incumbent on the practitioner to ensure that the training they have received meets appropriate standards and that the use of dry needling to treat patients:
- is within the practitioner’s scope of practice
- includes a diagnosis based on clinical reasoning
- is part of an overall management approach.
When considering and performing dry needling, it is important to be particularly cognisant of:
- needle hygiene
- obtaining informed consent
- high-risk areas (ie, those close to vulnerable structures) that require extra consideration and/or caution
- ensuring that relevant questions are put to the patient to determine whether they are at higher risk (eg, if they are taking anticoagulants or have an acute immune disorder)
- managing adverse events and serious complications, including the most common serious side effect, pneumothorax.
Clinical scenario one
Sarah attends for an appointment with her physiotherapist for a sports-related chest and shoulder injury she sustained during a particularly tough game of water polo.
After a number of treatment sessions, the level of improvement is not as expected.
Her physiotherapist suggests that dry needling may be of assistance.
Following discussion, Sarah provides consent, stating that she is ready to ‘give anything a go’ to alleviate her pain and get back to training.
Sarah is taken into the treatment room and prepared for the procedure.
She is advised by the physiotherapist to let her know should she experience pain or discomfort at any time.
The physiotherapist inserts the first needle and everything seems to be going well.
When the last needle is inserted, Sarah winces a little.
The physiotherapist asks Sarah if she is okay and she responds, ‘That one felt a little deeper and a little sore but I’m okay’.
The physiotherapist notes in Sarah’s file that some pain was experienced with the last needle and records their conversation.
Exercises are given for home therapy and Sarah is asked to telephone should she have any concerns.
Several days later, the physiotherapist is advised that Sarah started experiencing some shortness of breath.
After a number of tests she is diagnosed with pneumothorax, a small puncture in the lung located exactly at the site of the last needle.
Fortunately, Sarah makes a full recovery.
The first step in mitigating risks for both yourself and your patient is to ensure that fully informed consent is obtained.
While uncommon, pneumothorax is possible.
If Sarah has provided fully informed consent (which is clearly documented) and has been warned about symptoms to watch out for after treatment, the physiotherapist is well placed to respond to a complaint, if made.
Clinical scenario two
Max comes to see his podiatrist as a result of shin and calf soreness.
Testing leg strength results in pain, as does other muscle testing of the leg.
After a number of treatments, the podiatrist decides to try dry needling to release the local muscle tension.
During the course of the dry needling procedure the needle breaks.
In this situation, you should:
- stay calm for your and your patient’s sake
- if possible, attempt to remove the needle
- if unsuccessful, transport the patient carefully to a hospital with a safety pin over the area to assist radiographers.
Learnings and safeguards
How would many of us survive the microscopic scrutiny of our actions on one of our less successful days, when things could or should have gone better?
Adverse events happen.
The important thing is to make sure that you are well placed to, and do, respond appropriately.
Effective communication, informed consent and detailed records can prevent claims and complaints from being made.
This will also put you in the best position to respond to an adverse event.
Safeguards to avoid breaching professional obligations include:
- ensuring that you are communicating appropriately with your patients. Review the relevant code of conduct and, in particular, the provisions regarding informed consent
- ensuring that fully informed consent is obtained and documented and that your clinical notes contain details of those communications
- remembering that consent is an ongoing process. In subsequent dry needling treatments, it is necessary to remind patients about the risks and, where appropriate, educate patients on self-management of adverse events should they occur
- only acting within the scope of your practice. Refer if you need to refer. If a patient is refusing to accept your advice, consider whether to recommend that they consult another practitioner
- avoid taking a defensive position—‘I did the right thing. No, I am not refunding your money; make a complaint’—if an adverse outcome occurs or a patient complains. Review the treatment and seek assistance from your association, your insurer or a senior colleague
- considering what you can do to remedy the situation if an error has occurred
- continuing to maintain and update your education on dry needling.
Remember that while the use of dry needling may be an attractive and effective alternative to traditional muscle/myofascial release techniques, it is not for every patient.
The APA Acupuncture and Dry Needling national group strongly recommends completing the APA Safety in Acupuncture and Dry Needling module every five years. The Dry Needling Level 1 course addresses how to avoid these adverse events. Annual CPD is required in dry needling to mitigate risk in clinical practice. Click here and keyword search ‘Needling’.
This article is part of the risk management series facilitated by APA’s trusted insurance partner BMS and written by leading health law firm Barry.Nilsson. Lawyers.
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