Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com
In today’s episode of the PT on ICE Daily Show, our dry needling division leader, Paul Killoren, talks about how and why patients may faint during a dry needling session as well as the approach to take if this happens in your session. Take a listen to learn how to better serve this population of patients & athletes.
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EPISODE TRANSCRIPTION
0:00 – Dr. Paul Killoren, PT, DPT
Morning team, welcome back to the PT on Ice Daily Show. I’m your host for the day, Paul Killoren. It is clinical Tuesday. If we’ve never met, I’m the head of the dry needling division. So today we’ll talk some dry needling. Very excited to discuss fainting during dry needling today. Not a topic many people want to talk about until an event occurs. And actually, what kind of prompted the topic this morning was one of the techniques that we teach, one of the go-to techniques that we teach on our upper dry needling course, is a seated position. And I think it’ll be a topic for another day, the advantages of this position, allowing access to post here and anterior, honestly getting a more supported, more comfortable position for the shoulder. But what that post, the expected response from certain camps out there, the expected response was, aren’t you afraid that your patients are going to faint? And I 100% know if any of you were trained out there by other organizations, honestly, up to current day, but anytime in the past decade or so, you were probably told, we always needle prone or supine on the first visit. That’s how I was trained. That’s how I taught for a long time. But I’m going to challenge that today. Before we get deep into the positions for dry needling, the topic for today will just be fainting from dry needling. We’ll talk about some of the numbers. We’ll talk about if there’s some things we can do to avoid it. But let’s talk about fainting. And first of all, to qualify, what is a fainting event from dry needling? It’s vasovagal sympathy, syncope, not sympathy. We are sympathetic to their syncope. But it is a hypotensive, it’s an autonomic nervous system, hypotensive. Basically, your heart rate drops, bradycardia, and your blood pressure drops at the same time, which causes a very brief loss of blood flow cerebrally. So I mean, if we say fainting, it’s not just feeling dizzy or feeling faint or nauseous, it is a loss of consciousness, which can occur. But I think we have to immediately qualify how likely is it to occur. First of all, my own sample size. I personally have had two of my patients faint in the past decade. I’ve been dry needling since 2011. I mean, you can do some napkin math there. I’ve been teaching dry needling courses since 2014. And I’ve probably seen a handful more, maybe five to seven people, actually lose consciousness. So quick napkin math, we’re getting upwards of maybe 10,000 people that I’ve seen being needled. And I have less than 10 that have fainted. So first of all, we can’t say that it’s impossible. But I think we have to immediately qualify, what is the risk? People can faint. Some more data, there are 12 billion injections done throughout the world every year, we’re talking injections. And honestly, most of our needle phobic or needle related vasovagal events, our blood draws, there is something slightly more autonomic to our vessels and some of our nerves like our median nerve, tibial nerve. So we can immediately say, if we have a large needle like a hypodermic, and we’re intentionally puncturing a vein, the risk of an autonomic nervous system or a vasovagal event is probably slightly higher. People faint when they give blood. Most people are aware of that, if that’s them. First of all, let’s qualify that we use a smaller needle and we’re doing our best to avoid vessels. So immediately just the mechanisms of a vasovagal event, we should assume would be slightly less with our dry-neeling procedure. But we also have to say there is a large psychosomatic, psychological aspect to this. Rough numbers, I went off on a tangent and just looked at all these vasovagal fainting events, but just needle related phobia and needle related events research. So broad strokes, there’s about 10% of us, of people in the general public, who have a needle related phobia. And honestly, if you’ve been dry-needling long enough, or it doesn’t take very long, you probably know this. Whether we’re actually screening them or not with our words or with our intake questionnaires, I’d say one in 10 people probably do say like, all right, I hear you’re the dry-needle guy, I really don’t like needles, but I’m here to give it a shot. I think that kind of fits. I think one in 10 makes sense. But let me dive into some more, I won’t even say dry-needling because some of it’s acupuncture, but some more monofilament data as far as feeling faint or actually fainting from dry-needling. First of all, McPherson in 2001, this is acupuncture, but it’s European acupuncture, which includes some physical therapists, 0.22% feeling faint out of 34,000, not actually fainting. I say that because Boice 2020, which is American dry-needling, American physical therapists, over 20,000 treatment sessions, 0.78% of patients, which categorically they said was a minor adverse event, 0.78% felt faint. Only four people out of those 20,000 sessions, so 0.02, actually slightly less, actually fainted. So again, I think we need to acknowledge this can occur, but I’m immediately going to say that is a very rare risk. And again, what I’m trying to get to is should this risk of fainting guide our practice patterns, should that very low percentage that I just mentioned to you mean that we should always needle prone in supine on the first visit? I’m going to say no. I’m going to say there are a handful, there is a large majority of my patients where I feel very comfortable doing a comfortable seated dry-needling procedure on the first visit. And I’ll talk about that a little more as we get through this. One more publication, because I thought it was actually kind of funny. It was, again, it was acupuncture. Christensen was the author in 2017. They actually surveyed, retrospectively, over 18 months, all of these people that had acupuncture treatment, and they finally found eight people that had said they fainted from acupuncture. So over a year and a half, they finally found eight people who fainted. What’s unique is they kind of tapped into duration of symptoms. Almost all of them were very transient, recovering almost spontaneously. As soon as there was a loss of consciousness, they immediately regained it. What’s unique here, and what I wanted to point out, is that of those eight, three people actually said when they came to, when they regained consciousness, their primary pain complaint was improved. I think that’s a great stat. I mean, I think we’re going to say fainting or feeling faint, a vasovagal event, we’re going to call that an adverse event for sure. That’s not our goal, but I think it’s also pretty amazing to say nervous system responded for sure. We’re saying it’s an adverse response, but it responded, and that massive adverse response actually decreased the pain experience for those patients. I just wanted to throw that in there, because we’ll talk through now about how to avoid it, and what we can do clinically, but I think we always have to say that nervous system response has benefit, or we should at least screen the patient for saying that was a pretty intense response. How do you feel right now? And don’t be surprised if some of those patients feel better. So first of all, this is probably going to be obvious data, but who are the patients out there fainting? Again, going through some big systematically reviewed stuff, age is a component. So younger, younger patients faint more often, and we’re talking kiddos getting injections. Number of attempts was a significant correlation for venue puncture. So they’re trying to draw blood. A lot of you have probably had similar experiences of like you’re in the hospital, it takes the nurse three or four attempts to truly get that IV into the vein. Number of attempts was directly correlated to fainting events. And then the last one is probably the most obvious, but probably the most important, and I’ll come back to this, is that if there was a history of a needle phobic or an adverse event from needling, if they had fainted previously, the risk of fainting again was significantly higher. So age, number of attempts, and history. So those are probably obvious things as far as risk factors, but I’m going to immediately parlay into that and say, are we screening our patients? And again, the challenge that the contest that I’m trying to put out against kind of the typical conservative narrative is I’m okay treating my patients first visit, first time being needled seated, if I do some screening questions of have you ever felt nauseous? Have you ever felt faint or actually fainted from a needling procedure, from giving blood, honestly, anything from a piercing to blood draw to a tattoo? And if they’re like, Nope, never had an issue. I feel much more comfortable versus that person that says, Oh yeah, I mean, I’m pretty anxious to be here because yeah, every time I get my blood drawn or every time I get a vaccination, you know, I get a little dizzy and I feel like I’m going to pass out or I have passed out. Those are the patients where I think that 10 to 30 seconds screening verbal screening says, okay, that’s cool. Good news is the needles we’re using today are much smaller, much different. I’m also trying to avoid all of the large nerves and vessels. But you know, it’s your first time let’s start supine or prone. I think that simple mechanism of a screening question, you can do it written on your consent form. But basically, have you had an event or not? Or I guess to add into it, if it’s a kiddo, maybe we start them supine or prone. The absence of all of that, the absence of a previous event or the admission of feeling faint from previous needle procedures, as well as age makes me feel very comfortable to needle that person seated, visit one. And again, that is challenging a narrative out there that says, we would never do that. What if your patient faints? That’s why we always do it supine and prone. I don’t think we have to do that. First of all, the data, the incidence rate doesn’t support it. Second of all, what I just said is that if we have a simple screening process, we can pick out the people that are much higher risk of fainting. And the last thing I’ll add here is that I already mentioned that the majority of this adverse event data fainting like vasovagal response needle born data is from injections and blood draws. And any of you that have had an injection or blood draw recently know how it goes. You walk in, they don’t overly sensitize, honestly overly screen you. They also don’t put you supine or prone. You’re seated in a chair. And I mean, you depending on how compassionate your nurse is, she’s probably, you know, putting the little strap on your arm saying, you ever get squeamish from needles? And then half of us are like, yeah, a little nervous and they proceed anyways. So let’s just, I’d like to infuse a little bit of that. I don’t even know the right words, not cavalier. It’s not aggressive. I just want to apply a little bit of that mindset to our dry needling. And again, if we’re picking up answers or body language that they’re highly anxious about needling, then we can lay them supine or prone. But the truth is injections, vaccinations, blood draws are all done seated. And that’s one of the reasons I think we should be more willing earlier on to do seated dry needling. But let’s say, let’s say you subscribe to anything I’m saying right now. I was like, okay, I’m going to try, or if you’ve taken our upper dry needling course, you know that one of those go-to setups is the seated prop position. So let me put a few barriers, buoys in the water for that initial session coming in for shoulder pain. Maybe they’re post-op surgical or post-surgical shoulder pain. We’re going to prop them up on a chair. And first of all, I think a few buoys worth putting in the water. I like using a stable chair, so not a wheelie stool. It’s a chair with legs. It has armrests. It has a firm back. So they are more or less able to completely relax. They’re putting, you know, my sarcastic script is I want you so comfortable, like you could take a nap here. Like I don’t want you holding yourself up. I don’t want you feeling imbalanced. I want you comfortable, stable, but honestly relaxed. You should be able to stay here for five minutes, 10 minutes, 15 minutes. So that is very helpful. Secondly, I think if we reduce the number of needles, so again, if it is their first session, we’ve done kind of a brief screening. We’re not picking up on anything, but it’s still their first session being needled. We’re probably not going to put six, eight, 10 needles in that patient, in that seated position on that first visit. So maybe two needles, maybe four needles. And not that we want to think worst case scenario, but how quickly could you take those needles out if an event occurred? Again, they’re in a bailout position. They’re seated, but they’re supported against a table in a chair with an armrest. Those shoulder needles, could you take those two to four needles out in two to three seconds? The answer is probably yes. So I think the environment, so the table, the chair, the patient position, and then the number of needles really makes us more willing to go to a seated position quicker, even in the event of fainting. One more thing I’ll add is that if we said that potential vessel interaction or nerve interaction might slightly increase the chances of fainting, I’ll add what I add to most discussions these days is that if we minimize the amount of mechanical needle work, if we minimize pistoning, that anxious, that sensitized, and that kind of psychological aspect of the needling will be less. If we piston less, the risk of almost every adverse event goes down, and that applies to fainting. So I think if we follow those rules, and so far I’m saying the data doesn’t support us always being supiner prone, I think we can go seated quicker if we screen better. Is there a history? Is there an age or any other reason why that patient might faint? And I guess I’ll add one more anecdotally. It’s not from the research, but both of my NF2, both of my patients that fainted in my clinic, first of all they were early 20s, very fit Division 1 soccer guys. Both of them were either late morning, early afternoon sessions where they hadn’t had breakfast. I think there might be a blood sugar component to this as well. That wasn’t from the literature, but I think if we’re talking about an autonomic or a nervous system response, because I think you guys, if you haven’t seen it before, I mean the symptoms that are going to key you into vasovagal syncope are diaphoretic, so kind of cold, sweaty, very pale, so paler or green skin, feeling nauseous, bradycardia. If you take their heart rate it’ll actually be lower and their blood pressure will be lower. So those are the symptoms that are like, you don’t look so good. And again the data will say that there’s going to be a few people that have that feeling faint, feeling dizzy without actually fainting. The number of people that actually faint from dry dealing acupuncture is very, very low. But let’s say it happens. What do you do with the patient in the clinic if they faint, if they lost consciousness? Honestly, whether they’re seated or if they’re supine or prone, what do you do? This is legitimately an algorithm from a publication, and I say that because it’s going to seem like such obvious stuff that we don’t need to cover it, but here is the algorithm. And first of all, this was dry needling. It’s international. It was actually from the Turkish Journal of PT, but they specifically said what is the algorithm and what are the positional considerations for trigger point dry needling in the context of patients fainting of vasovagal events? And first of all, they were talking upper trap needling and levator needling. They said that yeah, you can do it prone. There might be an orthostatic component to this vasovagal, this hypotensive event, but they actually said that’s probably unnecessary. You can do this seated just like all the other injections and blood draws in the world. But what they said is if a patient faints, the response should, number one, create a safe environment. So again, I think that just speaks to, I guess, not the extreme opposite of doing this anywhere unsafe. Maybe that speaks to what I said of not being in a stool with wheels, but being in a chair with legs, with a back rest, and creating a safe environment. To say it another way, a bailout position. If this patient fainted right now, where are they going to go? That answer should be there. Or if they’re prone or supine, there. They’re in a bailout position. We’re not standing. We’re not, again, on, I don’t know, I’m trying to, crazy clinical apparatus. We’re not needling on a Swiss ball the first visit. So safe environment is number one. Number two, it says clinicians should not overreact. There is a major psychological component to this. Whether the patient faints or is near fainting, the reassurance from a clinician not overreacting to that situation or seeing the sympathetic responses actually reverses course. So if they’re like, oh, how you feeling? They’re like, I don’t feel so good. Like, okay, take the needles out. Let’s just rest here for a minute. That quick reassurance, that not overreacting, very quickly reverses course for our patients. If the patient loses consciousness, if it’s convenient, you can elevate the legs. Again, we’re trying to get central blood flow restored quickly, but otherwise safe position. And then depending on how long they have lost consciousness, we turn their head to a side to just help breathing, depending on the size of your patient. But again, all of that’s pretty obvious stuff. That’s the algorithm, those four things. This publication said that almost all of these events recover almost immediately, spontaneously. Perhaps we should take vitals in the clinic, again, being at least heart rate and blood pressure. Perhaps if there was a true loss of consciousness, there should be an observation period. Depending on your clinical setup, it’s like, hey, do you mind hanging out here for a little bit, 20 minutes, 30 minutes or an hour before you drive, just to, you know, you did lose consciousness for a second. I just want to make sure you’re okay before you head out. But that’s it. I mean, rarely, I only have one event that really lasted more than a few seconds throughout my teaching, driveling courses for a long time. And that time we did keep, we kept monitoring, we did alert EMS and they showed up. So they did the leads and all of that, the patient was discharged immediately. So I think there’s a medical diligence here, but it’s a pretty obvious one that if they lose consciousness for a second or two, then they recover. First of all, you’ll see that they recover pretty quickly. Maybe we can do some of the orange juice, the snack, just resting there. Again, if there does seem to be a blood sugar component, but really they recover very quickly. And really, I mean, that’s all I have for today. So my challenge for you is based on the incidents of vasovagal events and fainting, how willing should we be to treat seated initially? I would say we should do it initially, as long as we screen well, which could be just a verbal, like if you ever had a reaction to needling, if you ever fainted from a blood draw injection, piercing anything else. I think we need to have a control environment. Really, that’s just the chair, the setup, maybe having a table to support the arm in, reduce the number of needles and pistoning. And then I guess just knowing how to respond, but really that response should be reassuring, if anything, and then positional if needed, knees up, head to the side, that sort of thing. So I’m sure that prompts more questions. If you’ve ever had a patient faint, maybe it looked a little different. When we talk about nervous system responses, it could have not just been fainting, it could have been anything else from voiding bladders, that sort of thing. If you have other questions, send me a message and that can be at DPT with needles or at Icephysio, it’ll get funneled to me. But thanks for jumping on this morning to talk about fainting with dry needling. There will probably be a follow-up series, maybe more so as to why we’d like not just, um, avoiding adverse events from needling seated, but what are the benefits. I think the benefits far outweigh the risks that we discussed this morning. So thanks for tuning in, and I’ll see you down the road.
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