Adverse event

Comment

Pain

Occurring during DN: if the pain is unexpected (i.e. not the pain of trigger point referral) the needle should be removed. If the pain persists after the treatment the patient can use heat or ice over the area.

Post-needling soreness: this is the most common AE (Simons, 1999b). Patients should be warned that they may experience post-needling soreness and that they can apply ice or heat to the area to decrease the pain.

Haematoma

Avoidance of blood vessels when DN is necessary. It is good practice to apply haemostasis to the area, using a cotton wool swab, on removing the needle. If bleeding continues, apply further pressure and ice the area to minimize the bruising.

Fainting or

autonomic

response

This may occur as a result of excessive needle stimulation, pain, psychological stress, fatigue, incorrect patient positioning or in a patient who is autonomically labile. It is necessary to explain the DN procedure prior to its application, preferably place the patient in the lying position during needling and avoid over needling on first treatment. Should the patient faint remove all needles, lie the patient down - if they are not already lying – and raise their legs. Offer water or something sweet and possibly something to eat. Reassure the patient and monitor. With time the symptoms should terminate, however if there are concerns a medical assessment should be sought.

Needle issues

Stuck needle: A muscle may spasm around the needle making it difficult to move, twisting the needling too much or only moving the needle in one direction. To release it leave the needle for a short time, turn it in opposite direction, use massage or ice on the muscle to encourage release.

Bent needle: this may occur from the needle hitting a bone or a strong muscle contraction bending the needle. When removing follow the path of the bend in the needle. Patient must remain still and muscle can be encouraged to relax as described above.

Broken needle: this is very unlikely to occur when using disposable needles however should it happen the patient must be instructed to not move. If the broken needle is visible use tweezers to remove the needle. If it is not visible, gently depress the skin around the needle to expose the needle and remove with tweezers. If the needle cannot be reached, medical attention must be sought for surgical removal. Mark the area of the needle to facilitate further treatment.

Infection

To prevent infection the area to be DN should be cleaned with alcohol prior to treatment and aseptic techniques must be utilised. Avoid needling skin that shows signs of infection.

Excessive

drowsiness

Should the patient report feeling drowsy or excessively relaxed they should refrain from driving until returned to an awake state. For future treatments, avoid excessive stimulation or needle time.

Pneumothorax

Only clinicians with adequate training may needle the thorax.

Symptoms include:

- Shortness of breath – may only occur on exertion

- Chest pain

- Dry cough

- Decreased breath sounds on auscultation

These may be immediate or delayed. Special caution must be taken in patients who will be undergoing altitude changes e.g. flying or scuba diving. Immediate referral to an accident and emergency department for further assessment is necessary. Please see anatomical considerations for further detail.

Trauma to

internal organs

This may occur via a haematoma or due a needle penetrating the gastrointestinal tract or bladder. Symptoms are variable. The patient must be assessed for shock. If it is suspected that a hollow organ has been penetrated, sepsis and peritonitis may ensue and requires immediate appropriate referral to an accident and emergency department.

Nerve injury [21]

DN may cause nerve injury either through direct trauma or indirectly via a hematoma. Most commonly neuropraxia results, however axonotmesis may also occur, but rarely neurotmesis. Neuropraxia: When the axon is intact but the myelin sheath is damaged this may cause interruption of nerve conduction with temporary loss of function, which is normally restored within hours to months (approximately 6-9 weeks).

Axonotmesis: Where the axon is damaged, but the epineurium is maintained. This can result in motor, sensory and autonomic paralysis. Prognosis is good but rehabilitation may take months.

Neurotmesis: When the nerve sustains injury from contusion, stretch or laceration, the axon and the connective tissue around the nerve is damaged and continuity is lost.

Nerve reinnervation occurs at 1 mm per day, thus the patient should be adequately informed about prognosis.

Needle stick

injury

Should the clinician sustain a needle stick injury the area must immediately be washed with warm water, soap and disinfected with 70% alcohol. Allow the area to bleed, do not suck the site. The patient and the clinician should be tested for HIV/AIDS, Hepatitis B and C (if the status is not already known). Immediate referral to an accident and emergency department for post exposure prophylaxis (PEP) is required. It is good practice for a clinician to know their own status regarding HIV/AIDS and to have Hepatitis B immunization.