This document provides information on a needling workshop covering topics such as harm minimization when needling sensitive areas like the lung fields, health and safety practices, myofascial trigger points, and various needling techniques. It discusses regulatory requirements, contraindications for certain areas and patient populations, infection control protocols, and assessing treatment outcomes. An overview is given of integrating needling into osteopathic practice along with case examples of how needling could be applied.

1. Dr Stiofán Mac Suibhne

2.  Harm minimisation - Needling anatomically
‘sensitive’ areas – with particular reference to
the lung fields.
 Health and safety - including infection control
and risk management.
 MyofascialTrigger Points
 NeedlingWorkshop CV17 GB30 GB21 GB20 BL44
SI 12 SI13TE15 – Cervical,Thoracic and sacral
Spinal / Paraspinal points

3.  Taxonomy of NeedlingTechniques
 Introduction to the Conceptual Basis ofWestern
Medical Acupuncture
 Integration of Needling into Osteopathic Practice
 Overview of Osteopathy Australia’s Practice Briefing
 Regulatory & Insurance Requirements
 Assessment & PostWorkshop Exercise

4.  Auricular, facial and anterior cervical areas
are excluded from this workshop.
 After the workshop & completing the
practical needling assessment and theoretical
assessment you will be equipped with the
knowledge and skills to safely & competently
needle in practice.
 Optional exercise - complete treatment logs.

5.  In the UK Osteopaths may use dry-needling &
acupuncture related techniques in practice
 MUST have adequate indemnity insurance
 Acupuncture and relating needling
techniques are not restricted activities in law
 The use of the title ‘Acupuncturist’ is
restricted

6.  When needling anywhere over the pleura & lung
fields caution is required.
 Make sure you are confident on the surface
anatomy of the lungs, pleura, and mediastinum.
 Needle depth key. Be aware of defects of
ossification in sternum & scapula
 Pneumothorax & CardiacTaponade rare but
catastrophic outcomes

7.  Superiorly: extends up to 3 cm above clavicle
(needling MTrPs in the upper trapezius / GB21
most frequently associated with
pneumothorax).
 Posteriorly: lung extends to rib 10
 Antero-laterally: rib 6 mid-clavicular line to
rib 8 mid-axillary line
Review this material in the eFolio

8.  Antero-laterally: 2 ribs below the lung fields
 Rib 8 mid-clavicular line down to rib 10-12
laterally (mid-axillary line)
 Posteriorly: pleura down to rib 12 at lateral
border of erector spinae – caution therefore
required when needling in the erector spinae

9.  Needling over joint margins requires particular
care.
 Penetrating joint spaces risks the introduction of
bacteria. Cases of septic arthritis have been
associated with needling techniques, both single
joints proximal to the needle site and polyarticular
 Osteopaths need to be confident of the surface
anatomy of joints and be able to locate needles so
they do not penetrate joint spaces.

10.  Care should be taken to avoid needling into blood vessels
 Avoid needling into varicose veins, acutely inflamed areas,
leg ulcers or any tissue you suspect may be infected.
 Where there are lumps and bumps in the subcutaneous
tissue or skin lesions it is not acceptable to needle in the
area.
 Vigorous needling will result in damage to the target
tissues to a lesser or greater extent and serious injuries
through damage to vascular structures and infections
have been known

11.  It is not permissible to needling a limb affected by
lymphoedema, regardless of the cause as it increases
the risk if cellulitis developing.
 Where women have had lymphatic structures
removed or destroyed through treatment for breast
cancer and lymphoedema results it not acceptable to
need in the affected areas.
 Likewise patients in heart failure or with abdominal
masses preventing lymph return from the lower
extremities, it is not acceptable to needle
oedemtatous tissues.

13.  Hyper-irritable spots in skeletal muscle that
are associated with palpable nodules in taut
bands in muscle fibres
 The trigger point (MTrP) model holds that
unexplained pain radiates from these points
of local tenderness to broader areas usually
distant to the trigger point itself

15.  Advocates of DN claimTravell & Simons identified
consistently referred pain patterns associate with
MTrPs.
 No standard methodology for diagnosis of trigger
points & an absence of theory to explain how they
arise, why they produce specific patterns of referred
pain.
 Nevertheless theTravell & Simons Maps may be
useful finding points to needle

16.  Surface Anatomy of theThorax
 Palpation for MTrPs
 NeedlingOver Lung Fields
Variables:
 Depth of needle penetration
 Angle of needle penetration
 Needle diameter / length & Brand / Quality
 Location, location, location

18.  Direct Deep Needling into the MTrP. Very often
not located in the first thrust. Repeated lift and
thrust in a fan like pattern or pistoning. Aim to
elicit a twitch response.
 Superficial Needling. Simply insert the needles
over the MTrPs / tender areas. Safer & better
tolerated by patients.
 EA & Classical points in the area.

22.  Hand hygiene is important. Hands must be
washed and or alcohol hand rub used
 Universal Precautions are important
 Consider being vaccinated for Hepatitis B
 There is no consensus on swabbing site of
insertion or wearing gloves - review the
codes of practice OCNZ BMAS APA OA

23.  A healthy person requires a threshold of viable infectious
agents to be introduced into their system before an
infection can be established and swabbing reduces the
surface inoculum of skin commensals and other.
 The patient’s skin generally requires no preparation prior
to needling.
 Swabbing with a isopropropyl alcohol skin wipe (medi-
wipe) prior to needle is probably unnecessary from the
perspective of infection control.
 Swabbing has become customary as it is borrowed from
blood letting and immunisation procedures.

24.  BMAS advises caution when using needling technique in immuno-
suppressed patients.
 If needling over an area that is particularly susceptible to infection such
as a joint or bursa the skin should be sterilised. Apply Betadine (iodine)
or a chlorohexidine preparation to pre-swab the area. This is effective in
removing most, if not all, surface bacteria and is particularly appropriate
if using periosteal acupuncture adjacent to a joint.
 If needling techniques are used in such patient skin sterilisation is
recommended for patients who have a deficiency in their immune
system regardless of the point of needle insertion.
 Immuno-compromised patients include those with malignancies,
autoimmune (lupus,AIDS or rheumatoid disease, post organ transplant).
These patients may get an infection from a much smaller number of
infectious agents. Disinfection may not remove enough organisms to
prevent infection, hence their skin needs to be sterilised.

25.  Infection control is an important
consideration in acupuncture and related
needling techniques.
 Re-usable needles are absolutely forbidden -
Only sterile, single use disposable needles are
acceptable.
 A needle must either be in its packet, in a
patient or in a disposal bin for clinical waste.
Set up your work areas first.

26.  Manual stimulation (Lift &Thrust / Flicking /
Skewering / Kebabing)
 GuideTubes
 PeriostealAcupuncture
 Electro-acupuncture (not covered)
 Moxibustion (not covered)

27. Manual stimulation of acupuncture needles may elicit
a phenomenon known as de qi (der chi).
A composite of unique sensations. According to the
Chinese tradition, deqi experienced by patients is
described as: dull aching or soreness, numbness or
tingling, pressure, heaviness
And it is felt by the acupuncturists (needle grasping)
as tense, tight, and full. It is believed that deqi may be
an important variable in the studies of the mechanism
and efficacy of acupuncture treatment.

28.  Brocken needle – mark the insertion point
with a pen and seek urgent medical
attention.
 Stuck needle – leave for a few minutes and
try to remove. Gently needle adjacent site.
 Forgotten needle – count them in : count
them out. Apologise
 Faints – make patient comfortable and stay
with them. Reassure.

29. LayeringTechnique is a rationale not a menu:
 Peripheral Effects
 Segmental Effects
 Supraspinal Effects
 Sympathetic Outflow
 Central Sympathetic Effects
 Immune Effects
Also considerTrigger Points / Perisoteal / EA /Auricular / Prolotherapy
Review the LayeringTechnique paper by Lindsey Bradnum

30. If No: Needle away from injured tissue
IfYes:Which points or needle directly into
tissue you want to influence. Use few needles
and stimulate gently to maximise local
effects.

31. If No: Needle tissues with different segmental
nerve (extra-segmental) supply to that of
damaged tissue
IfYes: Do you want to needle into the damaged
tissue?
IfYes: Choose local points situated anatomically
near or in the damaged tissue
If No: Choose points in other tissues that are
supplied by the same myotome, scleratome or
dermatome as the damaged tissue. If choosing a
myotome choose a muscle that is hypertonic

32. Acute Nociceptive pain use fewer needles in segment with gentle
stimulation.
Chronic Nociceptive pain – use more needles in segment
PLUS Choose a distant point in the disturbed segment, in either
dermatome, myotome or scleratome. If treating for pain a point in
a bordering segment could be chosen as a distant point as
nociceptive stimuli will affect bordering segments
Needle for 10-20 minutes
Add a layer

33. If No: needle for 10-15 minutes with moderate
stimulation.
Choose segmental points to damaged tissues and do
not use “big” points.
IfYes: Choose extra-segmental points and “big points” of
hands and feet. Needle for 20-40minutes with strong
stimulation. Activates descending inhibitory systems
from hypothalamus and possibly diffuse noxious
inhibitory controls (DNIC)

34. When condition not improving with somatic treatment
If No:Think somatic nerve supply and treat according to above principles
IfYes: Choose segmental level of tissue you want to influence and needle paraspinal
point at that spinal level. Sympathetic outflow to head and neck is C8 toT4,
Upper limb isT5-T9 and Lower Limbs areT10-L2. PLUS:
Choose a distant point in tissues innervated with the same sympathetic segmental
nerve supply as the tissue you wish to influence. Needle strongly for at least 10
minutes to increase sympathetic outflow, or gently to decrease outflow
Add a layer: Choose a spinal point that influences the segment sharing the nerve
supply as the spinal level - e.g.
Expand: Huatuo Jiaji point, Bladder point, or facet joint in cervical spine. Needle for
10-20 minutes

35. Autonomic nervous system control by
hypothalamus.
Stimulated in same manner as
analgesic supraspinal effects. Choose
big points, hands and feet and stimulate
strongly for 20-40 minutes

36. Mumbo jumbo? Surprisingly not
Use Points at segmental level of spleen, lung,
thymus.
Use general strong points that influence
hypothalamus and regulate autonomic outflow
(hands and feet). RepeatTreatments, strong
stimulation, 30 minutes.
Auricular Points affecting vagal efferent activity

37. Big as in powerful:
 Liver 3 (Lr3)
 Spleen 6 (Sp6)
 Stomach 36 (St 24)
 Large Intestine 4 / 10 / 11 (Li 4/10/11)
 Pericardium 6 (PC6)
 Gall Bladder 21 / 20 (GB 20/21)
Anatomical Inch.
These are useful points mainly between the
knees and feet and elbow and hands.

38. Safety considerations:
Cord
Spinal nerves
Cauda equina
Lung fields
Need to have excellent recall of spinal anatomy

39. Safety considerations:
Cord
Spinal nerves
Cauda equina
Lung fields
Need to have excellent recall of spinal anatomy
Periosteal Pecking

44. The posterior rami innervates the
muscles skins & joints of the back.
Hilton’s Law
Sherrington’s law – reciprocal
innervation

55.  Acute Lsp Disk Presentation
 Chronic LBP
 Sciatic Pain
 Elbow Pain
 OA Knee
 Hip Pain
 Acute Ankle sprain

56.  Auricular acupuncture is a system of diagnosis and treatment
limited to the ear. The system was devised in France in the 1950s
by Nogier.
 BMAS does not advocate the use of indwelling semi-permanent
needles in ear cartilage due to the risk of chondritis (infection of
the cartilage of the pinna).The cartilage has a relatively poor
blood supply and this makes the tissue more vulnerable to
infection and should an infection be introduced it responds poorly
to antibiotic.
 Osteopaths should consider using the proprietary small metal
balls or seeds on adhesive strips as an alternative to needling.

57. Biomesotherapy group of therapies using
needles. It may involve injection of sterile saline
using very fine hyperdermic needles, or the
injection of homeopathic solution, or inserting
acupuncture through blebs of homeothpathic
liquid.
There has been a recently well documented
case in South Australia of mycobacterial agents
being introduced into patients by this approach.

58. As with biomesotherapy, prolotherapy is term
that represents a wide range of approaches. It
involves injection therapy, the aim may be to
sclerose ligaments or encourage proliferation
through injecting growth factors.
Some procedures may require ultrasound
guidance or prescription only
medicines. The American Osteopathic
Association has a training programme .

59.  Perineural InjectionTreatment (also known as Neural
Prolotherapy or Subcutaneous Prolotherapy in initial
published studies) was developed by New Zealander Dr
John Lyftogt.
There is some evidence to support its effectiveness in the
treatment of painful conditions due to sport and
occupation or other chronic non-malignant pain related
issues.
The treatment consists of a series of small injections
immediately under the skin targeting painful and sensitive
nerves with dextrose (glucose) or Mannitol (polyol-sugar).