Physiotherapists who perform dry needling i must ensure plans are in place to manage any critical or unexpected events (including adverse events ii). When developing plans for managing dry needling critical events, physiotherapists must consider safety literature and resources describing adverse events of dry needing.

This Guideline is intended to assist physiotherapists who perform dry needling meet expectations set out in Physiotherapy Alberta’s Standards of Practice.

View the Dry Needling Critical Event Management Guideline as a PDF.

Elements of a Critical Event Management Plan

The Health Quality Council of Alberta’s Patient Safety Framework for Albertan’s (page 8-9) outlines four distinct elements which provide the foundation for managing a critical event:

  • Proactive identification of risks to patient safety.
  • Effective response to adverse events and close calls when they do occur.
  • Implementation of strategies based on the learnings from a review of adverse events and their causes.
  • Evaluation of implemented recommendations.

To create a comprehensive practice-specific dry needling critical event management plan, physiotherapists must consider the people, equipment, processes and data available in their practice setting and decide who is doing what, when.

A critical event management plan will identify how an organization will:

  • Monitor risks to patient care and utilize appropriate reporting and response systems.
  • Provide education for all employees on patient safety and adverse event response processes.
  • Provide all employees with a critical path for managing and reporting events when patients are seriously harmed by the health system or experience a close call.
  • Outline a process to investigate an adverse event or close call to understand underlying factors and implement changes to reduce the chance of recurrence.
  • Engage in other safety improvement processes (as required) to deliver safe patient care.

To help with developing needling-specific safety plans, the following resources should be accessed:

Constructing Critical Event Protocols

When constructing critical event management protocols, physiotherapists must give consideration to:

  • Management strategies for when the patient is in the clinic.
  • Management strategies for when the patient leaves the clinic, including whether it is safe for the patient to function in the community. If the post-treatment symptoms such as fatigue or drowsiness impairs ability to drive, then protocols would include plans for arranging alternate transportation for the patient from the clinic to their next destination.
  • Procedures for timely communication with the treating therapist informing them that their patient has contacted the clinic for guidance on how to manage a symptom after leaving the clinic, and for the treating therapist to provide a timely response to the patient’s inquiries.
  • Regular review of safety protocols with staff.

Considerations when developing Dry Needling Critical Event Management Plans

When considering critical events associated with dry needling be mindful that:

  • Dry needling adverse events have often been classified into mild/significant/serious.
  • According to studies, 8.6%22 of patients receiving acupuncture and 19%1 of patients receiving trigger point dry needling experience an adverse event. [More information on adverse event rates is found in the FAQ document.]
  • Most adverse events associated with dry needling are mild (e.g., bleeding, bruising, pain before and after needling).2,17-21
  • Only a small proportion of dry needling adverse events require medical intervention to manage the event.20
  • 39.4% of adverse events in a study occurred during treatment.22
  • 60.6 % of adverse events in a study occurred after treatment.22
  • Systemic reactions vary in presentation and severity and can affect level of alertness and ability to function or render one unconscious. Management protocols must address the patient while they are in the clinic and advise on how to manage symptoms as they return to the community.1,3,9-11,20,24
  • Serious adverse events are preventable and can be attributed to faults in practitioner technique or judgement.3,19,20,22
  • Pneumothorax is the most frequent serious adverse event associated with dry needling and has occurred following needling for pain in the shoulder, neck, thoracic and back, as well as asthma and breathing problems.4,10-12,18-22 Iterative reports indicate that physiotherapists have attributed patient's symptoms of pneumothorax as being related to musculoskeletal pain.

Questions to ask when scanning your practice

  • What adverse events are associated with the dry needling technique I perform?
  • What protocols for managing dry needling adverse events do I have and what protocols must be developed?
  • What equipment (including personal protective equipment) do I need to manage an event when it happens?
    • Where is the safety equipment located relative to where the dry needling treatment is delivered?
    • Who is responsible for ensuring the equipment is regularly checked, replenished and available should an event happen?
  • Who are the persons (patients, support workers, administrative staff, physiotherapists) involved in managing an event and what do I want them to do should an event occur?
  • Does the patient have a role in preventing or managing an event? What are the key messages that need to be communicated to the patient prior to and after dry needling?
  • In follow-up sessions do I routinely inquire about adverse reactions to dry needling?
    • If a patient has persistent pain following needling in the chest, neck, low back or shoulder and/or feels unwell, have I ruled out a pneumothorax?
  • What skills do I have to manage the event and what skills do I need to acquire?
  • What skills do the other staff who will assist with managing the event have and what do they need?
  • Where are dry needling adverse event protocol documents housed? How many of the staff know where to access the protocols if required?
  • How often are the management protocols reviewed? Do we practice these protocols?
  • What communication systems are in place to ensure that new staff understand and review safety policies?
  • Do I have a plan for addressing patients who call back with concerns including ensuring that I, the treating physiotherapist, or my designate will be immediately informed about the inquiry?
  • Do I have a tracking system that examines events and use them for further learning?

Appendix A: Sample Dry Needling Critical Event Management Plans

Protocols can be structured using a variety of formats. The examples provided herein use a suggested format. Physiotherapists are welcome to use their own safety planning templates.

Example - Bleeding Haematoma

Adverse Event Protocol #1 Bleeding/Haematoma
Purpose
  • This protocol addresses the prevention and management of bleeding/haematoma as an expected side effect of dry needling or when it is significant and considered an adverse outcome.
Management Strategy
  • Patient screened for bleeding disorders, anti-coagulant medication.
  • Post treatment, apply pressure with cotton swab/ball following removal of needle.
  • Force and time of pressure application sufficient to ensure that bleeding has ceased prior to patient leaving.
  • For visible haematoma post treatment - inspect area and provide relevant post clinic management instructions.
  • Consider using anti - bruising topical product following treatment.
Equipment (type and location)
  • Cotton swab/ball, gloves located on counter, waste disposal container located within reach oftreatment table
Personnel involved
  • Physiotherapist
  • Patient
Patient strategies
  • Informed of the potential for bleeding or bruising.
  • Assists with application of pressure post treatment.
  • Follows post treatment instructions – may include topical products, application of ice or heat.
Follow-up
  • Monitor progression of haematoma in follow-up appointments and address any patient concerns as needed.
  • Monitor for other adverse symptoms and need for further medical management or referral to other health care provider(s).
  • Record in chart as appropriate.

Example: Vasovagal Syncope (private treatment room with equipment stored in multiple cupboards)

Adverse Event Protocol #2 Vasovagal Syncope/Fainting
Purpose
  • This protocol addresses the prevention and management of vasovagal syncope/fainting. 
Management strategy
  • Patient history/assessment identifies past situations where pain or site of blood triggered syncope.
  • Following needling insertion if patient complaints of dizziness, or light-headedness or loses consciousness, remove needles.
  • Lay patient supine if patient not already positioned so. Consider elevating their feet.
  • Consider resuscitation strategies you have learned (i.e., Needling GV 26 is preferred over acupressure to upper lip).
  • Keep patient warm – consider using blanket.
  • Monitor vital signs – pulse, blood pressure.
  • With alert patient, consider providing liquids to restore blood glucose and invigorate sympathetic nervous system.
  • Assess for and manage injuries sustained at time of collapse.
  • Once recovered monitor patient for other signs of autonomic nervous system physiological dysfunction nausea, dizziness, fatigue, confusion.
  • Ensure patient alertness and full function before allowing them to leave clinic.
  • If alertness or ability to operate a vehicle are impaired, arrange for alternate methods of transportation home.
  • Consider referral to other medical providers if response is severe and patient is anxious about the severity of their response.  
Equipment (type and location)
  • Patient warning bell/call system distributed.
  • Sharps disposal container within reach of treatment table for quick removal of needles.
  • Blanket readily available in far right lower cupboard.
  • Blood glucose restoration kit (e.g., cookies/juice) kept in treatment area, top left cupboard above sink.
Personnel involved
  • Physiotherapist
  • Support personnel work in concert with the physiotherapist:
    • Responding immediately to therapists request for assistance
    • Assisting with moving patient
    • Monitoring patient
    • Locating blankets and ancillary equipment
    • Arranging alternate transportation
    • Routinely monitoringand replenishing contents of blood glucose restoration kit
Patient strategies
  • Informed of the risk of fainting.
  • Patient ensures they have eaten prior to needling treatment (prevention of low blood glucose).
  • Informed that they must activate call bell/contact physiotherapist immediately if symptoms of dizziness, or light-headedness occur anytime during needling.
  • Reassured and educated that symptoms may persist for a few hours.
  • Educated to disclose to other providers of needling (e.g., blood donation) of this adverse reaction. 
Follow-up
  • Timely follow-up with patient to ensure recovery.
  • Monitor for other adverse symptoms and need for further medical management or referral to other health-care provider(s).
  • Update clinical record.
  • Complete incident reports if required.
  • Review event, action taken and act on improvements if required. 

Example: Pneumothorax

Adverse Event Protocol #2 Pneumothorax
Purpose
  • This protocol outlines steps for preventing, managing and monitoring for pneumothorax. 
Management strategy

Signs and symptoms:

  • Shortness of breath, difficulty breathing, wheezing, dry hacking cough
  • Various presentations of pain varying from mild to intense indicative of an injury to the lung (e.g., unexpected or persistent pain in chest region, radiating pain into shoulder or back)
  • Feeling unwell
  • Cyanosis, changes in vital signs
  • Delayed onset of any of these signs and symptoms

During treatment:

  • Remove needles
  • Monitor vital signs
  • Arrange for transportation to hospital for further medical assessment

Patient has departed from the clinic and then made contact expressing concerns about breathing, persistent chest pain or unexpected malaise:

  • Contact treating physiotherapist immediately
  • Physiotherapist to contact patient back in timely manner and provide advice
  • If physiotherapist unavailable or it is deemed to be a medical emergency, advise patient to obtainassistance with transportation and present to emergency department or physician for further medical assessment
Equipment (type and location)
  • Patient warning bell/call system distributed when patient is left in cubicle/room.
  • Sharps disposal container within reach of treatment table for quick removal of needles.
  • Stethoscope kept in middle third drawer-grey workstation-main treatment area.
  • Blanket readily available in treatment area. 
Personnel involved
  • Physiotherapist
  • Support personnel work in concert with physiotherapist
    • Responding immediately to physiotherapist's request for assistance
  • Administrative Staff – attentive to patient contact and ensures communication to treating physiotherapist if patient contacts clinic with concern
Patient strategies When needling has been performed in chest, neck, back area patient informed to alert physiotherapist if:
  • Intense or persistent pain in chest area, with or without radiation to arms, back
  • Shortness of breath, unexplained cough
  • Difficulty breathing
  • Unexpected feeling of malaise
Follow-up
  • Timely follow-up with patient to ensure further medical assessment and to learn what actions taken by other health-care providers.
  • Update clinical record.
  • Complete incident reports if required.
  • Review event, action taken and act on improvements if required. 

References

References are listed in the Dry Needling Resources Reference List.

Footnotes

  1. Dry needling includes acupuncture, intramuscular stimulation, trigger point needling and other forms of needling with a solid filament style needle (i.e., Gokavi technique, motor point needling).
  2. Adverse event: An unexpected and undesired incident directly associated with the care or services provided to the patient; an incident that occurs during the process of providing health care and results in patient injury or death; or an adverse outcome for a patient, including an injury or complication.
  3. A critical event planning template is found in the Guideline.