Is dry needling therapy dangerous? This is an important question given the rising popularity of Dry Needling training for Manual Therapists and the demand by patients for this relatively new and invasive technique, aimed at treating pain arising from Myofascial Trigger Points (MTrP’s).

As Manual Therapists we have an obligation to our patients, our employers, regulatory bodies, professional indemnity insurers, private health insurers, our respective professions and colleagues to ensure that whatever treatment or intervention we offer, and our patients subsequently agree to, it does not expose them to harm.

Manual Therapists from every profession, regardless of geography accept and abide by, even swear by The Hippocratic Oath, whether they do this consciously or passively by implicit default. The oath is actually best known for its corpus or the body of work by Hippocrates, widely accepted as the Greek “Father of Medicine”. This collection of Ancient Greek Medical works is thought to be the first example of Medical ethics.

Contrary to popular belief, the aphorism, “first do no harm” or “primum nil nocere” does not actually appear in the Hippocratic oath or the Hippocratic corpus (Hippocrates wrote in Greek, not Latin). In fact the phrase is thought to have been coined by the English Physician and author Thomas Sydenham (1624-1689), according to a book by Thomas Inman: Foundation for a New Theory and Practice of Medicine (1860). Sydenham rose to fame in the late seventeenth century and was known as the English Hippocrates.

Dry Needling Therapists like all Health Professionals have taken on the established dictum of our predecessors, avoiding any intervention that could likely cause harm, but are we doing enough to ensure that we achieve the highest possible standards of safety?

Is it possible to offer our patients an invasive therapeutic solution without the risk of harm, and provide certainty to Dry Needling therapists? The certainty that they will never be put in a position which jeopardises their right to practice through an adverse event, following a patient treatment.

To answer the question of whether Dry Needling is dangerous or not, we must first ask what makes a treatment dangerous. Surely no treatment should be dangerous. There are certainly treatment approaches that carry greater risk of harm but a dangerous treatment implies poor training, false clinical reasoning, inadequate knowledge, insufficient practice, and or patient selection. All of these considerations fall back into the responsibility of the therapist, and not the inherent nature of the treatment itself.

It’s easy to blame the therapist when things go wrong

It is however very easy to blame practitioners for adverse reactions following treatment; it’s an obvious response to blame the person who provided the treatment.

This easy target approach is unfair and simplistic. It’s like blaming the school kid who fails to achieve the expectations of his parents and teachers in their final year exams, who is really to blame?

Like any therapeutic intervention, whether it’s taught at undergraduate or post-graduate level, every question about risk, safety and danger of harm must start with the standard of the initial training and education.

Above all, the most important factor that determines the value of a Dry Needling course is a culture of safety within the teaching organisation. Everything that is presented must have safety as the overriding consideration before implementation.

Education is where and how we learn any skill, whether we are learning a sport or a new treatment technique, the process is the same. Process is the key word here, every skill that is performed perfectly follows a process or a system, a defined order of events with an aim and objective, designed to achieve a certain goal.

In the case of a therapeutic intervention like Dry Needling, the goal is to solve a problem, the problem maybe pain or restriction of motion, and often a combination of both.

Dry Needling training is like most other continuing professional development training. It involves the study of important theoretical knowledge as well the practice of manual needling skills. This teaching format is a fairly standard process.

The structure of a Dry Needling course must contain certain components that make it safe, for those participants who attend the training and the patients or clients who are subsequently treated.

Dry needling educators must not fail their students

Dry Needling educators fail their students when they fail to mitigate risk. Risk is inherent in any treatment intervention; whether it’s the risk of a skin irritation after applying sports tape or indeed an iatrogenic pneumothorax following a Dry Needling treatment. These adverse reactions are at different ends of the scale but have one thing in common, a failure to manage and mitigate risk.

The problem with failing to mitigate risk when it comes to Dry Needling is that the consequences are much greater than in non-invasive techniques.

Dry Needling is very different from any other skilled therapeutic intervention taught to Manual Therapists, it is an invasive technique that requires a strong pre-requisite understanding of surface and clinical anatomy.

It is unlike non-invasive treatments, where the therapist is afforded the luxury of perhaps safely applying their manual skills to an area, region or group of muscular tension or joint restriction. Not only is Dry Needling different with respect to the precision in which it is applied, but also in the way in which the treatment is recorded.

Instead of treating the extensor surface of the forearm with soft tissue techniques aimed at reducing the muscle tension in the wrist and finger extensors, a Dry Needling therapist must know exactly which muscles, and wherein that muscle they inserted the needle.

In addition, they must also know the location of important structures that lie in the path of the needling technique. By knowing this information, the Dry Needling therapist may now be able to accurately record several key references about their treatment including the name of the muscle they treated, the location within that muscle where the needle was inserted, the needling depth, the gauge and length of the needle, as well as the therapeutic outcome.

This vital information provides the therapist with the confidence that their treatment was accurately recorded and provides them with a reference point in case of adverse reactions or events. The other important benefit of such precise note taking is that one is then able to modify their treatment according to a patient’s response, based on a detailed understanding of their prior treatment.

Dry Needling is not just another post-graduate course

Therapists who attend a Dry Needling course for the very first time should be aware that things will now change, as soon as they successfully complete their training, not only will their anatomical knowledge be refreshed, it will take centre stage in their clinical reasoning and patient management from now on as Dry Needling therapists.

These days there are so many ways to refresh and review the anatomical knowledge required for safe Dry Needling practice, whether we watch videos, read books, download an App or attend courses. The issue that we have is not the availability or access to the content, although both of these factors are important, what’s important is the messenger. The ability of a teacher to first explain the need for learning the required knowledge, or the problem, then to offer a solution based on safe training methods with adequate checks and balances cannot be overemphasised.

The training process must be based on sound reasoning rather than dogma. All Dry Needling educators should respect the fact that they are teaching their peers who are adult learners, and not at school anymore. Adults learn in different ways but they learn more quickly and retain more information when the teacher is able to explain a reason behind every instruction or required skill acquisition.

The reasoning behind the way we do things at a given course must be transparent and open to scrutiny by the therapists who attend a course, and accrediting bodies.

Systems and processes are important foundations for any skill. If educators do not teach the steps that make up the systems and processes, and more importantly the reasoning behind them, mistakes happen, the system breaks down, because there’s no process. Adverse events usually occur when a therapist is confounded by stress, they are running late, they are too busy, they’re tired and of course poor communication. The risk of being affected by these variables is greatly increased when the initial training is poorly delivered. Risk is minimised if a therapist is trained using systems and processes built on a culture of safety.

These safety systems and processes create a series of trampolines designed to catch you if you fall, the more mistakes you make, the more metaphorical trampolines you need to save you from hitting the ground. This strategy is used in almost every type of training, not only in health and medical education, but also in the aviation industry, armed forces and construction. The trampolines are built in redundancies that reduce risk. Only by asking what if, can we know which redundancies to build and how.

A Dry Needling course that cares about the safety standards of those who invest their time and money into their education is one that has asked those questions of itself then built a secure teaching process that protects the learner.

Gambling with safety never works

A culture of safety starts with the very first interaction between learner and educator, this builds trust and confidence, which grows with practice and experience.

Comparison between Dry Needling courses is not easy for practitioners who wish to study Dry Needling. Very often the decision to start training with an education provider is based on the price of the course and the numbers of continuing education points or hours earned.

While these are no doubt important considerations, we as training providers need to educate our demographic about which factors are worthy of equal, if not, greater consideration when choosing a Dry Needling education provider.

One of these other factors is the way in which high-risk muscle needling techniques are taught. Having presented over 400 Dry Needling courses in the past 5 years and helped over 4500 practitioners achieve their goal of becoming a Dry Needling therapist; the most important feedback is this: “I now feel safe using these techniques.”

All high-risk muscles should be taught using a 1:1 student to presenter ratio. This teaching strategy has a number of benefits including, learning from others in the class, repeat observation of the technique, building a muscle memory, and populating a library of visual and proprioceptive cues.

NEED to know versus MUST know knowledge

Every course whether it’s about Dry Needling, exercise prescription, Pilates or a class you took at school, has NEED to know information and MUST know information.

Dry Needling students should focus on the MUST know information, especially when it comes to muscles that have important caution points like the pleurae, arteries, nerves, and abdominal contents.

Nothing confuses a new student to a discipline more that the colour grey. Grey is a threat to safety and compliance.

Acupuncturist is a protected title under the National Law (1), however, the law does not prevent the use or acupuncture terms or practices. Only practitioners registered with the Chinese Medicine Board of Australia may use the title. There are potentially severe financial penalties for ‘holding out’ and misleading patients.

Don’t muddy the waters

The law rightly protects Acupuncturists, as one would expect, but unfortunately, it has also allowed the use of Acupuncture terms, nomenclature and even the use acupoint selection to creep into the language of Dry Needling courses. The law has not gone far enough to protect Acupuncture itself.

This situation creates confusion and does nothing to establish Dry Needling as a separate treatment intervention, distinct from Acupuncture. It has also trivialised the rich and complex principles of treatment and diagnosis that Acupuncturist take years to develop and understand.

Would be Dry Needling therapists should look for courses that use the language of myofascial pain and scientific research to describe their course content, rather than that of traditional Chinese Medicine.

Terms such as local twitch responses, hyperirritable nodules, taught bands, referral patterns, pistoning, and the integrated hypothesis of trigger point formation are all important terms and definitions consistent with a contemporary understanding of Dry Needling.

You may ask why not use these terms given the abundant evidence for the overlap of trigger point location and acupoints in the literature. The answer to that is once again safety and compliance.

If a therapist attends a course and is taught to needle trigger points in adductor pollicis but is also taught that needling this “point” may be called LI 4 or He Gu, what should the therapist write in their notes in order to record their treatment?

If they write that they treated LI 4, worse still they record that they did this in order to treat a headache in an attempt at a quasi-acupuncture diagnosis and treatment, compliance and safety concerns should be raised.

The muddying of the waters continues even within professional practice guidelines for Dry Needling therapy by manual therapists. These advisory publications fail to distinguish between two completely separate disciplines and the resultant message becomes opaque and threatens safety.

If one compares the requirements we are obliged to meet with respect to maintaining our first aid certificate to that of the refresher requirements for Dry Needling therapists, it’s clear to see that there’s a crack in the system.

The likelihood of having to perform CPR on one of your patients is very slim but the ability and knowledge required to save their life cannot be taken for granted. We should be ready to apply first aid as health professionals or members of the public, which is why the obligation to stay current is important and justified.

The likelihood of a Dry Needling therapist injuring a patient is reported to be quite low. In a study by Brady et al (2013), 39 physiotherapists participated and 1463 (19.18%) mild adverse events were reported in 7629 treatments with trigger point dry needling. No significant adverse events were reported giving an estimated upper risk rate for significant adverse events of less than or equal to (≤) 0.04%. (2)

Pneumothorax after unsafe Dry Needling is a more common adverse event than you think

A serious adverse event related to Dry Needling therapy includes an iatrogenic traumatic pneumothorax. On face value, these figures appear quite comforting. The problem is, that, as with all research, the results must be taken in context.

In the study (2), 183 physiotherapists were invited to take part. Of these, 51 volunteered to participate, and 39 actually took part.

The other issue is one that will affect all research into the risks of adverse reactions due to dry needling therapy. Many serious adverse reactions, including pneumothorax go unreported and are missing from any literature reviews.

Pneumothorax as a result of Dry Needling does happen, but it can be completely avoided together with all the other serious adverse events with the right training from the right course.

So, to answer the original question; is Dry Needling dangerous, certainly NOT!

Not if the initial training ticks the boxes with respect to safety, process, checks and balances. There’s nothing new about this approach, it has stood the test of time.

What features should you look for in a Dry Needling Course?

Let’s look at what makes a trusted education provider that teaches safe Dry Needling techniques…

• Do they exhibit a culture of safety in how they structure and present their courses?
   
• What are the systems and processes that are built in to guarantee the safety of participants and their patients/clients?
   
• Is the provider someone who has completed a Dry Needling course just like you’re about to join, or someone who has teaching experience and a Dry Needling Certification?
   
• How is dry needling to high risk muscle trigger points taught?
   
• Which muscles are covered in the Introductory Course? Is there a gradually increasing degree of challenge and a slow introduction of challenging muscles as you move from Introductory to Advanced Levels of training?
   
• What are the support mechanisms in place to help practitioners before and after their Dry Needling course?
   
• Which accrediting bodies have recommended a Dry Needling course?
   
• Whether we remember taking the Hippocratic oath or not, is irrelevant. What is relevant is that we must ask ourselves, is what I have learned or what I would like to learn based on the highest level of safety in order to manage & mitigate risk?

Only by asking this question can we avoid harm and the potential for adverse events.

References
1. Using a protected title, such as ‘acupuncturist’, under the National Law. http://www.chinesemedicineboard.gov.au/Codes-Guidelines/Position-statements/using-a-protected-title.aspx
2. Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. Brady S, McEvoy J, Dommerholt J, Doody C. J Man Manip Ther. 2014 Aug; 22(3): 134-40. doi: 10.1179/2042618613Y.0000000044.

By - Dr Wayne W Mahmoud
(Osteopath & Acupuncturist)
M.App Sci (Acupuncture)
Certified Myofascial Trigger Point Therapist (USA)
Director - CPD Health Courses