A needle penetrates the epidermis and deeper structures.
Consider superficial structures visible on the skin's surface.
Consider deeper structures beneath muscles, blood vessels, organs, and bone.
Risks include infection and damage to internal organs and structures.
Mnemonics for safe needling: ADD
A: Anatomy (superficial and deep) in the region being needled.
D: Danger (superficial and deeper structures to be cautious of).
D: Safe Depth and Direction of needling to avoid danger.
Knowledge of anatomy is crucial; consult an anatomy textbook if needed.
Good knowledge of surface anatomy is essential; review bony landmarks, tissue contours, and major blood vessel and nerve locations.
Anatomical variability must be remembered.
Assess for potential dangers in superficial and deep structures, including epidermis, dermis, adipose tissue, lymphatics, fascia, blood vessels, bones, the central & peripheral nervous systems, and visceral structures.
Record the direction of needling for safety and medico-legal reasons.
Needle Penetration Depth at Different Angles
50mm needle at 60 degrees ≈ 43mm perpendicular insertion
30mm needle at 60 degrees ≈ 26mm perpendicular insertion
30mm needle at 20 degrees ≈ 10.3mm perpendicular insertion
Oblique insertions (e.g., 20 degrees) may be chosen to target superficial structures and avoid deeper dangers.
Patient Selection Considerations
Thoroughly question patients to assess individual safety.
Consider absolute and relative contraindications to assess individual risk.
Use recommended guidelines for obtaining appropriate informed consent; a standard consent form is in Appendix A of the manual.
Essential Components of Informed Consent
Informed: Patients must receive sufficient information to make a decision, including the nature of dry needling, benefits, alternatives, and material risks.
Voluntary: Consent must be freely and voluntarily given, with the patient having the right to choose between treatment options and to withdraw consent at any time.
Timing: Consent must occur before the procedure begins.
Specific: Consent must be specific to the dry needling procedure and not part of a generic consent for all treatments.
The consent form is a record of the discussion, not the consent itself.
Consent is valid as long as there is no change in the patient's condition or the nature/extent/reason for treatment; obtain new consent for different areas.
Discuss new treatment options with the patient.
A parent or guardian must give consent for patients under 18 (age varies by state).
Absolute Contraindications
Conditions requiring medical management (outside physiotherapy scope).
Severe clotting disorders (e.g., hemophilia, von Willebrand's disease, warfarin, Xarelto) due to risk of uncontrolled haemorrhage.
Current COVID-19 diagnosis (particularly in the viral shedding phase) to prevent viral spread.
Lymphedema due to risk of infection.
Organ transplant recipients due to risk of infection.
Severe needle phobia.
Allergy to stainless steel.
Points on the scalp of infants (open fontanels), eyes, ears, or dental areas.
Unstable epilepsy.
Pacemakers (for electro-acupuncture).
Overexcited or fatigued patients due to unpredictable systemic response.
High-dose steroids or immunosuppressants (increased infection risk).
Rheumatoid arthritis, lupus, Addison's disease, or ME (increased infection risk).
Frail or systemically unwell patients.
Low white blood cell counts (neutropenia) or following chemotherapy/bone marrow transplants.
Psychologically labile patients/panic attack history (unpredictable response).
Needling over the pregnant uterus (absolute); relative contraindication in 1st trimester or needling hand/foot/lumbar spine during pregnancy (TCM literature suggests risk of miscarriage).
Cancer (increased infection risk, potential for muscle spasm/guarding).
Patients prone to syncope/fainting.
Bloodborne infections (HIV, hepatitis B); use universal precautions.
Lung conditions (asthma, emphysema, cystic fibrosis); avoid needling over lung area (pneumothorax risk).
Hives with dry needling; screen for increased immune response.
Assess general medical risk (fever, colds, skin condition, healing times, MRSA history, comorbidities).
Educate patients about symptoms of severe complications (shortness of breath, chest pain) and when to seek immediate medical attention.
Actual Dry Needling Treatment: Clinical Reasoning
Dry needling can be applied alone or as an adjunct to physiotherapy interventions.
It is based on Western medicine approaches.
It addresses musculoskeletal conditions presenting with pain, articular/muscular dysfunction, and functional impairment.
Involves an orthopedic situation for muscle, joint, and neural conditions.
Assessing Patient Beliefs
Assess the individual's belief in dry needling.
Respect patient's belief system and address alternative treatments.
Some patients refuse due to negative experience (deep dry needling or aggressive needling).
Others equate dry needling with traditional Chinese medicine acupuncture, challenging their belief system.
Assessing Suitability
Assess the severity (mild, moderate, or very painful) and irritability of the condition.
Consider the proper dry needling approach for the patient based on your clinical assessment.
Assess local needling (myofascial trigger points or tender regions).
In person with referred pain, consider treating them along their neural pathway, myotomes, dermatomal distribution, or a combined approach
Consider the location of treating depending on assessment (Local vs Remote).
Assess the proper position of patient and needle depth based on the area of treatment.
Assess diameter and length of needle for the area of treatement.
Consider the number of needles for sensitivity level (One needle for sensitive areas)
Blind Needling
The treatment assessment is similar to those employed in physiotherapy and other manual therapy approaches.
Recommend Mnemonic DOCTOR MINARS.
(D) Diagnose or have a provisional diagnosis following the assessment of what the patient's condition could be.
(O) Reevaluate.
(C) Myofascial trigger points, active or latent.
(T) Injured areas such as tender points or taut bands.
(O) Peripheral nerves, especially with peripheral pain addressing neural pathways and the region of the dermatomes and microtomes and the fascia.
(R) Activities such as functions such as, I mentioned, running or kicking a football.
(M)The somatosensory cortex or the brain where pain is perceived and modulated.
Treatment
Consider the number of needles that you may insert, which would depend on that patient's condition, such as if it was acute or chronic or if they were an anxious patient and what the treatment response could be.
Consider also the needle duration. We consider with dry needling, a needle retention of one second to two minutes and progressed as indicated by the patient's response.
Then consider the application of the needle. If it's very acute or irritable, you may needle in situ.
Application can include stimulation like clockwise or anticlockwise or whether it is appropriate to reproduce a twitch response, which would be based on their condition, their irritability, addressing the safety considerations that Jane discussed, the patient's presentation whether they're anxious or not, and what you predict the treatment response could be.
An acute irritable condition - use less needles, insert superficially, avoid stimulation, retain for a shorter time, and possibly needle remote from the pain region.
Non irritable condition- dry needling can be performed superficially or deep with or without stimulation or reproduce a twitch response. Needling can be local or remote depending on the patient's presentation, condition, and history of past needling treatments.
Actual Dry Needling Treatment: Treatment Grades
Grade one: Superficial at the entrance of the muscle for acute pain and hyperalgesia.
Grade two: Mid depth, just nudging at the entrance of the trigger point for subacute pain or irritable conditions.
Grade three: Deep through the myofascial trigger point for ongoing or nonirritable conditions.
Grade four: Deep to in range for ongoing and nonirritable conditions.
Guidelines for Progressing Treatment
There are no recipes or points to be needle, the patient's history and your skill of examination and palpation is important.
Improved - repeat the treatment of the last treatment and reassess to not overtreat.
Marginally improved- you may possibly increase the time of needle retention, or you might consider increasing the depth. You might do grade one to grade two minus, or you might insert another needle to allow the nervous system to respond.
Day Two Same - Ask yourself some questions and repeat the treatment of Day 1. Consider adding a needle or depth and reassess.
Day Two Worse - Revaluate the patient's presentation. Consider whether you would apply dry needling that day. And if you do, explain to the patient of your treatment progression or regression. Consider regression treatements options (Reduced needle, time, stimulation. Maybe remove needles.
In relation to treatment regression, you may consider reducing the number of needles, reducing the treatment time, using a final needle, using minimal or no stimulation, exercising due care with treatment and reassessing the responses, or refer to a medical practitioner if indicated.
When you progress your treatment, you can perform in situ needling from one minute to forty five minutes with an average duration of twenty minutes.
Patients will improve, or remain, the same, or get worse on the 24 hours.
Consider alternative treatments such as exercise, soft tissue, mobilization and education.
Prognosis:
Pathololgy - look at biomechnical changes.
Patient expectation to their sport
Look at past contribution factors and change them in a modifiable way.
The How: Practical Procedure
Skin Penetration Hygiene Procedures:
Adopted the Australian guidelines for the prevention and control of infection healthcare from 2019.
Check in your facility in which you work, which guidelines you fall under. But if there are none, the Australian guidelines are the ones you have to abide by.
One hands free hand washing sink or an alcohol based hand hygiene station MUST be onsite.
Hand Hygiene:
Posters available include: World Health Organization posters available for educating proper hand cleaning.
A hand rub is best if you hands are dry and can be use with an alcohol based sanitizer. This is convinient if you do not have access to soap and water.
Soap MUST be used if hands are visibly soiled.
Making sure that you rub your palms together, the backs of your hands, then you put your palm to palm and do the tips of your fingertips and then your thumbs and then wait for it to dry.
Gloves: Do not use as an alternative for washing hands
According to Australia guidelines the user need not wear gloves if both patience and practitioner have intact skin and expect no bleeding, follow other and state guidelines if they indicate otherwise. Single use, gloves are required if bleeding is expercted or in other situations.
Skin Preparation:
There is no need to swab if you see skin as visibly clean.
If using alcohol swab, let area dry before puncturing the skin.
If adding extra infection control, a betadine skin swab may be used to reduce infection. Puncture wet or wait for site to dry based on facility preference.
A Betadine skin swab is recommended if the patient is in a fetal joint, you are using press needle of they are immunocompressed, or if the patient is already soiled, or they have been massaged earlier.
Equipment
Minimum legal requirement in Australia is pre sterilised, single use, solid Filiform stainless steel needles. - Check expiry date on each sterile package.
Different brands of needles will feel slightly more quality oriented during needle insertion.
Shaft of the needle is generally stainless steel, and then the handle of the needle, which could be plastic, it could be stainless steel or it could be copper.
Different needles have different release mechanisms from the encasing plastic guide tube and this will be demonstrated how you actually release the needles with the different release mechanisms.
When written to the packet, The diameter of the needle for dry needling is generally 0.3 millimetres.
Select proper needle length (30 mm vs 50mm etc) based on the palpated area to puncture after sterile cleaning, and select patient population (BMI etc).
Kidney dishes (for cleaning), varying sharps supply and needles, hand sanitizer, gloves, jelly beans (for syncope and other nausea treatment), tweezers, stethoscopes are all highly recommended close in reach during treatment.
Patient Considerations
Consider comfort, safety and warmth during treatment.
Appropriate post treament (dryness, breathing issue or infection)
Check in the area to feel before the treatment of patient and what needs to be done.
Safe Insertation
Palpate to indentify target point.
Clean with proper antibacterial tools before opening sterile tools for less risk and injury.
Needles can be glued (break the glued region whilst holding the needle perpendicular with a bit of pressure against the guide tube so that if you then pull the guide tube out of the packet, you still have control of the needle) or use a plastic plastic stopper jamming (remove the plastic stopper whilst the structure is still parallel) .
Tap needle with enough force and speed to puncture skin, then leave needle in for safe direction for given direction.
Removal of Punctured Area
Using a clean dry cotton follow in the insertion site after and remove from patient slowly.
Place needles in proper sharps container and store.
Use proper first aid as universal for proper medical attention of bleeding.
Must keep Hep B current as a certified physisican.
Adverse Events
One adverse event per 633 consultations. Fainting is seen most.
Increased pain (496 events reported) compared to Non- medical (573 events).
UK/ NOR gave a 10 perscent adverse effect. Symptoms are haematoma, slight haemorrhage, dizziness, nausea and tiredness.
Post treatment drowsiness
Stuck in bed needles.
Management of More Serious Symptoms
Pneumothorax or heamothoax
Convulsions
Complex Regional Pain Syndrome
Infection.
Visceral or Neural Damage
Psychiatric Disturbance
General Magement Principles:
Implement doctor s ABCD, where A-assess and B-breathing where CPR is used if indicated in most cases, be knowledgeable about any medical complications.
Know First Aid and prescribe based on each.
Know anatomy and the surface landmarks of where the patient is getting treated.