Overview on guidelines

Dry needling is within the scope of Physiotherapy/Physical Therapy practice. There are, however, risks associated with this type of therapy and while the incidence of risk such as induced pneumothorax are classified as rare, they are still a concern identified within research literature. These guidelines outline the essential requirements in the use of dry needling, to inform the growing number of practitioners using these techniques.

Individual States and Territories may have specific legislation applicable to dry needling, covering topics such as skin penetration and infection control. Practitioners must ensure that they comply with local State and/or Territory legislation.

Practitioners engaging in dry needling treatment are encouraged to read and follow these guidelines for general safety and maintenance of clinical standards.

Safe treatment procedures

Evidence in the effectiveness of dry needling is limited in the current literature. The benefit to risk ratio of dry needling treatment therefore needs to be considered. In the high performance sport environment, practitioners aim to use innovative and interactive treatments.

Outcomes:

1. Limit the use of needles in anatomical areas of high-risk if potential benefits of treatment are outweighed by potential side effects (this includes areas around lung fields, eyes and neurovascular structures)

2. Practitioners must have high-level knowledge of local anatomy and anatomical variations in areas of risk

Experience in needle use differs from practitioner to practitioner. Not all practitioners are skilled in use of dry needling in high-risk anatomical areas

Outcomes:

3. Where any doubt exists, practitioners should refer to or seek guidance from other practitioners with appropriate experience

4. Practitioners should stay up-to-date with current trends and research, while engaging in continued professional development to remain competent in this field of practice

Treatment consent

Consent must be obtained from the client before proceeding with any dry needling practice. A practitioner may be deemed liable for an unavoidable complication when the risks of that complication were not initially explained to the athlete.

Dry needling should not occur unless the risks of the procedure have been explained to and accepted by the patient.

Several components constitute valid treatment consent:

• Consent must be voluntarily given
• Consent must be informed; practitioners breach their duty of care if they fail to warn the athlete of the risks associated with treatments or procedures they are going to perform, and
• Consent must be obtained from those with legal capacity to do so; adults (18 years and over); children require parental or legal guardian consent [NSO coaches within the AIS daily training environment are seen as holding legal guardianship].  While common law recognises that the rights of a child to consent increases as their ability to understand and comprehend increases, caution must always be exercised.

Outcomes:

5. Consent to have dry needle techniques administered must be voluntary from the athlete

6. Information of the treatment to be given must be explained in full to the athlete

7. Informing athletes of the potential risks associated with dry needle techniques is an important and essential part of any treatment regime

8. Consent can be provided in either a verbal or written form. Where provision of consent is verbal, the obtaining of consent must be noted in the Athlete Management System (AMS) medical record at the time of treatment

An information sheet (example provided in Appendix A) must be provided to the patient receiving treatments over and around the trunk area. This sheet should detail warning signs relating to pain or treatment complications as well as the emergency procedure to follow if significant symptoms occur after treatment

Outcomes:

9. Explain adequate warning signs and management protocols if utilising skin penetration in areas over or adjacent to lung fields

10. Provide the client with an information sheet with warning signs and emergency protocols to ensure they are adequately informed of the appropriate post-treatment care

Practice specific requirements

• Any practitioner conducting dry needling in clinical practice will have undertaken an appropriate formal course of training. This includes massage therapists who must hold a nationally recognised diploma or advanced diploma (Australian Quality Training Framework standard). If dry needling has been learnt at a post-graduate workshop, practitioners must complete a minimum of 60 hours face-to-face training and 15 hours supervised clinical practice (Association of Massage Therapists Code of Practice)
• Practitioners must ensure they have appropriate indemnity insurance that covers dry needling practice
• Within certain controlled environments outside of the AIS, such as at Olympic or Commonwealth Games, practitioners will not perform dry needling unless they have received prospective approval to do so by the Medical Director and/or the Head of Physical Therapies
• It is recommended that in an NSO environment, no practitioner performs dry needling unless they have received prospective approval to do so by the Medical Director, Head of Physical Therapies and/or High Performance Director
• A greater degree of caution must be exercised in environments where there is reduced opportunity for backup support in the event of any adverse outcome from dry needling. Such environments include overseas travel and remote locations. NSOs and practitioners should consider whether dry needling is appropriate in situations where teams are remotely located and/or there is no doctor located with the team
• All dry needling treatments must be recorded in the AMS medical record.

Dry needling on the AIS campus

• All dry needling conducted within the AIS campus must follow the AIS Dry Needling Protocols, this includes treatment administered at training venues or in the athlete Residential Village
• The practice of dry needling at the AIS must at all times be conducted in accordance with government regulations pertaining to safety and hygiene. The AIS is subject to annual inspections in relation to the infection control activity license from the ACT government, specifically for the purpose of dry needling.

Sharps and body penetration procedures

These requirements are in line with the Australian Physiotherapy Association position statement on skin penetration (November 2007), ACT Health, Infection Control Guidelines for office practices and other community based services (2006) and Australian Guidelines for the Prevention and Control of Infection in Healthcare NHMRC.

• Wash hands appropriately before treatment and handling of needles, prior to insertion and removal of needles (hand washing is the first step in infection control programs)
• Treatment area must be appropriately conducted within a treatment cubicle or an area of low traffic to prevent accidental movement of needles or an athlete (particularly in the case of treatment of high-risk areas such as the thoracic spine)
• The work area must be clean and tidy
• Cover work surfaces with disposable coverings (sheet/towel/disposable covers)
• Disinfect skin in treatment region with swab (70% isopropyl alcohol or povidone-iodine)
• Sharps should be handled with care in order to prevent accidental needle stick injury
• All sharps must be immediately and appropriately disposed of in a recommended Australian Standards container after use. This applies in both clinic and team travel environments
• All practitioners performing dry needling should be immunised against hepatitis B infection
• A new swab is required to be used for each separate area of the body. For example, if needles are to be inserted into the back and the legs, a separate swab is required for the back and each leg
• All appliances used in the penetration of skin in acupuncture procedures are required to be sterile and single use only. This includes acupuncture needles, ear press needles, dermal hammers and guide tubes
• When necessary to grasp a needle shaft to facilitate insertion, the following methods must be used:
  • use a fresh pre-packaged sterile alcohol swab or fresh sterile dry swab
  • use a sterile glove
• Suction cups and other non-sharp devices applied to a skin area directly after the use of a dermal hammer, lancet or prismatic needle are required to be cleaned and disinfected or sterilised prior to being reused
• Bamboo suction cups are single use appliances and must not be reused, as bamboo is porous and difficult to clean after use.