The australian physiotherapy association

Australian Society of Acupuncture Physiotherapists Inc
GUIDELINES FOR
SAFE ACUPUNCTURE
AND DRY NEEDLING
PRACTICE
JULY 2007
CONTENTS
Management of Needle Accidents & Adverse Reactions pg 12 Waste Disposal Advise for Needles or Bodily Fluids pg 17 ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
This document is designed to be used as a guide to safe acupuncture practice for physiotherapists practicing acupuncture in Australia. Acupuncture practice by physiotherapists may include Traditional Acupuncture, Western Acupuncture or Dry Needling. The guideline was constructed via consultation with various Australian and International acupuncture guidelines, including the minimum standards set by the International Acupuncture Association of Physical Therapists (IAAPT). The federal governments Infection Control Guidelines (January 2004) was also considered along with the National Health and Medical Research Council’s Australian Immunisation Handbook (2003) and the Standards of Practice for Acupuncture: Health (Infectious Diseases) Regulations (1990). Consultation was also sought from the Australian Medical Acupuncture College and The Australian Acupuncture & Chinese Medicine Association. Relevant journal based literature was also considered. The guidelines will be reviewed and revised by the ASAP as required. It should be noted that individual states and territories around Australia will have varying guidelines on skin penetration and infection control and physiotherapists are urged to view the relevant information from their local governing bodies. Physiotherapists are also advised to refer to any relevant legislation set by individual state physiotherapy registration boards. This document was produced by the ASAP working party which included; Leigh McCutcheon BAppSc (Physio) Grad Cert (Orth Manip Ther) Post Grad Dip (Acupuncture) Master Musculoskeletal (Hons) Member APA, ASG, ASAP, MPA, SPA, NZSP, PAANZ. Paula Raymond-Yacoub B Phty. Dip Shiatsu. Acup Cert (APA) M Clin Prac Member APA, ASG (PD course co-ordinator), ASAP Andrew Hutton BAppSc (Physio) Titled Sports Physiotherapist Member APA, ASG, ASAP, SPA, MPA Peter Selvaratnam BAppSc (Physio) Grad Dip (Manip Ther) Post Grad Dip (Acupuncture) Ph.D (Anatomy) Member APA, MPA, SPA, ANZAOP, Asoc.Prof.(clinical)Univ.Melb. Libbie Nelson Dip (Physio) Acup Cert (APA) Dip (Herbal Med & Homeopath) Member APA, ASG (Chairperson), ASAP, SPA, GG Doug Cary BAppSc (Physio) Post Grad Dip (Manip Ther) Grad Dip (Clinic Acupuncture) Member APA, MPA, ASG Virginia Ruscoe BAppSc (Physio) Acup Cert (APA) Member APA, ASG (Assistant course co-ordinator), ASAP, SPA APA – Australian Physiotherapy Association ASAP – Australian Society of Acupuncture Physiotherapists SPA – Sports Physiotherapy Australia PAANZ – Physiotherapy Acupuncture Association of New Zealand MPA – Musculoskeletal Physiotherapy Australia NZSP – New Zealand Society of Physiotherapists GG – Gerontology Group ANZAOP - Australia/New Zealand Academy of Orofacial Pain ASG – APA Acupuncture Study Group ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
INTRODUCTION
Physiotherapists may practice acupuncture under any of the following paradigms;
Traditional Chinese Acupuncture1, Western Acupuncture2 or Dry Needling3. For the
use of this safety document Acupuncture and Dry Needling are defined as follows;


1. Traditional Acupuncture: Utilisation of meridian or extra points based on
a Traditional Chinese Medicine approach which includes diagnosis and
clinical reasoning using various Chinese medicine assessment methods and/or
paradigms. Utilisation within the context of physiotherapy will include a
diagnosis based on clinical reasoning as part of an overall management
approach.
2. Western Acupuncture: Western acupuncture utilises meridian points but
applies it to western reasoning with particular consideration to
neurophysiology and anatomy. It does not utilise any traditional Chinese
medicine assessment methods or paradigms. Utilisation within the context of
physiotherapy will be based on clinical reasoning as part of an overall
management approach.

3. Dry Needling: Needling to altered or dysfunctional tissues in order to
improve or restore function. This may include (but is not limited to) needling
of myofascial trigger points, periosteum and soft tissues. Utilisation within the
context of physiotherapy will be based on clinical reasoning as part of an
overall management approach.

The basic introductory training necessary for a physiotherapist to practice acupuncture
or dry needling competently depends on the paradigm being employed. For a
Traditional Acupuncture approach a 150 hour course is recommended by the
ASG as a basic introduction. The current APA ASG Level 1 Acupuncture course is
based on an Oriental Medicine paradigm and equates to 150 hours of study including
self directed study and face to face teaching. It should be noted that the APA ASG has
run an introductory Traditional Acupuncture course which is APA accredited since
1979. For Dry Needling or Western Acupuncture a 2 day course is considered
adequate as a basic introduction. The length of the minimum training required for
dry needling or western acupuncture is based on the fact that the clinical reasoning
basis for dry needling and western acupuncture does not differ from the anatomical
and neurophysiology knowledge that physiotherapists already possess. Two days is
considered minimum with respect to training safety issues in relation to skin
penetration. This is also in line with other western nations where physiotherapists
practice Dry Needling or Western Acupuncture, such as the United Kingdom, New
Zealand and Canada. Following the minimum training requirements physiotherapists
are advised to complete 30 hours of continuing professional development in
physiotherapy acupuncture over a three year period to remain competent in this
field of practice.
ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
PRINCIPLES OF SAFE PRACTICE
1. Physiotherapists should confine their use of acupuncture to treatment of
conditions within the scope of practice of physiotherapy for which they
have training and experience. Physiotherapists should practice
acupuncture with respect to the level of training they have received and
should attend further training if they wish to extend the use of
acupuncture within their practice. This is particularly pertinent for any
needling in the trunk, thorax or cervical regions.

2. Physiotherapists should only implement needle insertion techniques after
attending a two day training course.

3. Physiotherapists must comply with current legislation of any local, state
or federal governing bodies (e.g. local, state or federal governments and
state registration boards).
4. Physiotherapists should keep clearly documented records describing the
acupuncture procedure. Warnings given and informed consent should be
noted. For consent of a child less than 16 years of age a parents or
guardians consent should be gained. It may be pertinent to document
both the parents and the childs consent, especially if the child is in the 14-
16 year age group.
5. Warnings and consent should include contraindications and precautions
and possible adverse outcomes. Verbal consent is usually sufficient but in
some cases it may be pertinent to gain written consent.
6. Physiotherapists should comply with the management of needle accidents
and adverse reactions guidelines as outlined in this guide.
7. Physiotherapists should comply with the hygiene requirements as outlined
in this guide. Physiotherapists should be aware of any further hygiene
requirements of employers (e.g. hospital department guidelines).
8. Physiotherapists should comply with the waste disposal guidelines for
needles or bodily fluids as outlined in this guide. Physiotherapists should
be aware of additional requirements for waste disposal of needles or
bodily fluids as set by local governing bodies.
9. Physiotherapists should recognize and comply with the safety guidelines
for moxibustion, cupping/spooning and the application of auricular
needles, press needles and beads as outlined in this guide.
ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
PATIENT EXPLANATION
The patient should be told of the proposed treatment and what it entails. This explanation will possibly include: ¾ The procedure of the needle insertion into the skin. ¾ Inform the patient that sterile, single use, disposable needles will be used. ¾ A brief explanation of how the type of acupuncture that is being ¾ If using additional stimulation of the needle, such as manual stimulation, electrical stimulation or moxa, this should be discussed with the patient. ¾ The possibility of transient symptoms during and/or after the treatment, such as fatigue, light headedness or temporary aggravation of the symptoms should be considered. ¾ Any advice following the treatment that may be pertinent for the individual patient, such as care with driving long distances after any needling treatment or in regards to the use of heat or local ice following Dry Needling. The physiotherapist must remain within hearing distance so that they are immediately accessible to the patient and can monitor treatment and make any appropriate checks of the patient. ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
CONTRAINDICATIONS AND PRECAUTIONS FOR ACUPUNCTURE AND
DRY NEEDLING

1. PROHIBITED AREAS FOR NEEDLING
Prohibited areas for physiotherapists using acupuncture techniques include nipples,
the umbilicus, external genitalia.
Scalp areas of infants before the frontanelles have closed are also contraindicated.

2. DANGEROUS OR VULNERABLE POINTS
The following are useful points in the body which may not be needled until
appropriate training is undertaken;
• GB21 (trapezius), BL 11, LU 1 and any other point in the thorax due to the relative risk of pneumothorax. Needling in this region should be shallow
and/or away from lung tissue and/or over bone or cartilage.
Note lung and pleura anatomy.
Lung fields:
ƒ Superiorly: extends 2-3 cm above clavicular line (hence GB21 being most
frequent point documented with pneumothorax – thus sufficient minimum training is required to needle this point) ƒ Anterior-laterally: lung rib 6 mid clavicular to rib 8 mid axillary line Pleura:
ƒ 2 ribs below i.e. rib 8 mid-clavicular line down to rib 10-12 laterally (mid-
ƒ Posteriorly: lung extends to rib 10, and pleura down to rib12 (at lateral • Orbit of the eye points including BL 1, ST 1 and Ex Pt. (qiuhou) are generally considered to be contraindicated for physiotherapists. • Neck points including CV 22 (anterior neck), LI 18 (lateral neck over the major vessels), SI 17 (lateral neck over the baroreceptors), GV 15 (over the spinal cord), and GV 16 (over the brain stem). • ST 21 which lies over the gall bladder on the right should be needled • CV 17 (over the sternum) and SI 11 (over the infrascapular fossa) should be needled superficially and/or obliquely due to congenital foramen (holes) in these boney structures which are evident in a percentage of the population. • Ah Shi (tender points) points close to vulnerable structures. ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
• Avoid needling into vulnerable pathological sites including varicous veins, acutely inflamed areas, areas of unhealthy tissue or infected tissue. • Avoid needling into a limb affected by lymphoedema or needling directly into breast tissue. Japanese acupuncture using non-insertion techniques may be utilized in this case.
3. PREGNANCY
Acupuncture should be used with caution on pregnant patients. Acupuncture points
that should be avoided include LI 4, SP 6, BL 60, BL 67 and LV 3, points over the
abdomen, ear points for the endocrine & genitor-urinary system and scalp points for
the genital & foot motor sensory areas. Needle GB 21 with caution. The upper lumbar
spine should be needled with caution. Strong electro-acupuncture and over simulation
of points should be avoided during pregnancy.
As one in four to five pregnancies naturally abort especially in the first trimester, the
risk of acupuncture should be fully outlined and it may be advisable to seek written as
well as verbal consent prior to acupuncture treatment.

4. DIABETES
Due to poor peripheral circulation care must be taken when needling diabetic patients
and the relative risk of needling peripheral regions should be considered.

5. PACEMAKERS
Patients with pacemakers should not receive electro-acupuncture.

6. CONFUSED PATIENTS
The patient must be able to consent o the proposed treatment. Should the patient
appear disorientated or confused then acupuncture treatment is not advisable. Children
under the age of 16 require the consent of their parents.
7. CHILDREN
Parental consent must be gained when treating children under the age of 16.
Physiotherapists should also consider gaining consent from both the parent and the
child, especially if the child is in the 14-16 year age group.

8. BLEEDING DISORDERS
Naturally occurring hemorrhagic diseases are a relative contraindication to treatment
(e.g. Haemophilia, Von Willebrands). If needling techniques are implemented the
lighter stimulation and smaller gauge needles would be indicated.
9. ANTICOAGULANTS
Patients on high levels of blood thinning medications such as Plavix or Warfrin may
not be suitable for acupuncture. Care should be taken when needling patients on
ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
anticoagulants (consider finer gauge needles) and it is advisable to apply pressure to
the site of insertion after withdrawing the needle. Avoid needling into joints to
minimise the risk of haemarthrosis.

10. CANCER
Due to the immunicological risks extra care should be taken when needling patients
with cancer.

11. BLOOD BORNE DISEASES
Patients may be questioned as to their awareness of having a blood borne disease.
Care should be taken when needling any patient in reference to their likelihood of
having a blood borne disease. Gloves are not usually worn when needling a patient
however some institutions may have guidelines that require the physiotherapist to don
a pair of gloves particularly when removing the needles when the risk of a bleed is
greater. Physiotherapists should also consider current legislation of any local, state or
federal governing bodies (e.g. local, state or federal governments and state registration
boards) which may have guidelines concerning the use of gloves when practicing
acupuncture.

12. ACUTE IMMUNE DISORDERS
Patients with acute immunological disorders (e.g. acute states of rheumatoid arthritis
or systemic lupus erythema) have an increased risk of infection and therefore and
should be considered a relative precaution and care should be taken when needling
such patients.

13. INCOMPETANT HEART VALVE OR VALVE REPLACEMENTS
Patients with an incompetent heart valve or valve replacement have an increased risk
of infection and therefore should be considered a relative precaution and should be
needled with care. It may be pertinent to seek advice (in terms of consent or antibiotic
prescription) from the patient’s general practitioner or cardiac specialist.

14. ALLERGY TO METALS
Patients allergic to metals may react to acupuncture needles and relative risks should
be discussed prior to treatment.

15. UNSTABLE EPILEPSY
Patients with epilepsy, especially unstable epilepsy, should be needled with care. The
number of needles, strong points, stimulation of the needles and length of time that
the patient that the patient is needled should be considered when needling such
patients.
ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
16. FRAIL PATIENTS
Patients with a weak constitution after prolonged chronic illness may tolerate
acupuncture poorly. Minimal treatment (reduced number of needles, reduced
treatment times, finer gauge needles and minimal stimulation of the needles) should
be considered.

17. MEDICATIONS

Due to the effect on the autonomic system patients may have reactions that effect their
current medications. Consequently as a result of the homeostatic action of needling an
over correction of a patient’s medical condition may occur. This is particularly
pertinent for patients on blood pressure or diabetic medications. It is advisable for the
physiotherapist to consider this possibility and it may be prudent to discuss this with
the patient.
18. TREATMENT EXTERNAL TO CLINICAL ROOMS
Care should be taken when needling patients at an external setting (such as on a home
visit or at a sporting venue) to ensure that patients are adequately positioned to
prevent injury should fainting occur. Patients skin should also be examined to ensure
that it is clean prior to treatment (see Hygiene Requirements on page 12).
ADDITIONAL CONTRAINDICATIONS AND PRECAUTIONS FOR
ELECTROACUPUNCTURE (EA)
¾ Patients with heart pacemakers should not receive EA. ¾ All contraindications and precautions of manual acupuncture should be ¾ Extra care must be taken if patients have bleeding disorders or are on anti- coagulant therapy as the muscle contraction and the movement of the needle may create a significant bleed. ¾ It is recommended that EA is not applied across the spinal cord. ¾ Use a biphasic stimulator, designed for EA. Direct current (DC) must be avoided in order to prevent polarisation of the needles due to electrolysis. The unit used must be battery (not mains) operated. ¾ Do not use needles with a plastic hilt/handle. ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
ADDITIONAL CONTRAINDICATIONS AND PRECAUTIONS
FOR MOXIBUSTION
¾ It is essential to check sensitivity to heat before commencing. ¾ Used with great caution in hirsute (hair covered) areas of the body. ¾ Do not use moxibustion on broken or damaged skin. ¾ Use with care with children or frail patients. ¾ Where possible shield the skin with a protective guard to protect against burns. ADDITIONAL CONTRAINDICATIONS AND PRECAUTIONS
FOR CUPPING AND SPOONING/GUA SHA
¾ Not be used in hirsute areas of the body. ¾ It is not unusual for bruising due to prolonged or strong cupping to occur. Blistering due to prolonged strong cupping may occur. It is advisable to draw patients attention to any bruising that has occurred. Use a mirror if necessary, so they are not surprised when they get home. ¾ It is essential to check state of skin before commencing. Do not use on broken ¾ Use with care with children or frail patients. ¾ Avoid the sacral area or abdomen of pregnant women. ¾ Avoid using cupping or spooning on patients who have bleeding disorders or ¾ Be aware that some brands of suction cups have an inbuilt magnet, which contacts the skin. If the suction is too strong this magnet can press too strongly against the engorged tissue and break the skin creating a potential infection risk. ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
ADDITIONAL CONTRAINDICATIONS AND PRECAUTIONS FOR
AURICULAR NEEDLES; PRESS NEEDLES AND BEADS
¾ All contraindications and precautions of manual acupuncture should be ¾ Clean the ear with an alcohol swab or soap and water to remove dead ¾ In the case of press needles/beads sterilise the skin with 2% solution of iodine ¾ In the case of press needles/beads, after applying a sterile disposable press needle/bead, apply 2% iodine in flexible colloden solution, or 2% iodine and cover with “Op-Site”. This seals the press needle/bead and reduces the risk of infection. ¾ These needles/beads may remain in place for 7-10 days. In humid conditions needles/beads should be left in-situ for much shorter periods. ¾ Press needles/beads may remain in place for 7-10 days. In humid conditions press needles/beads should be left in-situ for much shorter periods. ¾ At the time of removing the press needles check the tissue and assess whether an antiseptic ointment or antibiotic ointment is required to be applied to the needle site. ¾ Extra precautions must be taken with all ear acupuncture because the cartilage has a very poor blood supply. Therefore, if this becomes infected, it is difficult for the body to mount an immune response to the invading bacteria. Do not use press (semi-permanent) needles if there are obvious lesions on the ear or the patient has an immune deficiency disease. ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
MANAGEMENT OF ADVERSE REACTIONS IN ACUPUNCTURE

PAINFUL TREATMENT
If pain persists while the needle is inserted it should be removed. If pain persists
following a treatment, the patient can be advised to apply heat or ice.
HAEMATOMA
Care should be taken to avoid injuring blood vessels, however if bleeding does occur,
apply pressure to the area with a cotton swab after the needle has been withdrawn. Ice
can be used locally to minimize the bruising.
FAINTING
This may be caused by nervous tension, hunger, fatigue, incorrect positioning,
excessive stimulation of the needles or if the patient is autonomically labile. To avoid
fainting explain the acupuncture procedure before treatment, treating the patient in a
lying position may be preferable, don’t insert too many needles and use minimal
stimulation on the first treatment. If fainting occurs stop needling and remove all
needles, make sure the patient is lying down and consider raising their legs, offer
water, warm tea or something sweet to eat and reassure the patient. Symptoms should
abate after resting.
STUCK NEEDLE
A stuck needle may occur due to spasm of the local muscle after insertion of the
needle, twisting the needle with too much amplitude or in only one direction causing
the muscle fibres to bind, or if the patient alters their position whilst the needles are
in-situ. To avoid, position the patient in a relaxed manner, avoid excessive twisting of
the needle and avoid needling tendinous muscle tissue. If the needle is stuck due to
over rotation, then rotate the needle in the opposite direction and remove. If it is stuck
due to muscle tension, leave the needle in for a short period of time, relax the tissue
around the needle with massage, ice massage or by inserting 1-2 needles around the
stuck needle, then remove the needle.
BENT NEEDLE
A bent needle may occur if the needle strikes hard tissue, there is a sudden change in
the patient’s posture, or strong contraction of the muscle occurs during trigger point
needling. To prevent a bent needle occurring, insert the needle carefully with the
patient in a comfortable position. If a bent needle occurs instruct the patient not to
move, relax the local muscle and remove the needle slowly following the course of
the bend.
BROKEN NEEDLE
This may occur due to poor quality of the needle, strong muscle spasm, sudden
movements by the patient when the needle is in place or by withdrawing a bent
needle. The likelihood of a broken needle is very rare with the use of single use sterile
needles as there is no metal fatigue from repeated use and autoclaving. The patient
should be advised to remain calm to avoid the needle from going deeper. If the broken
needle is exposed remove the broken section with tweezers, if it is not exposed press
the tissue around the insertion site until the broken section is exposed and remove
ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
with tweezers. If the needle can’t be remove in the clinic, medical attention must be
sought so that the needle can be removed surgically.
INFECTION
The skin in the region to be needled should be inspected and if infection is suspected
needling should be deferred and medical advice sought. Care should be taken when
needling very thin or fragile skin due to the relative infection risk.

EXCESSIVE DROWSINESS
A small percentage of patients may feel excessively relaxed and sleepy after
acupuncture treatment. They should be advised not to drive until they have recovered.
For patients that this occurs with, it is advisable not to leave the needles in for a
significant amount of time or to over stimulate the needles.
PNEUMOTHORAX
When needling around the thoracic region patients should be warned of the rare
possibility of a pneumothorax. Care should be taken when needling GB 21 (upper
trapezius) and any other points over the thoracic region which could inadvertently
create a pneumothorax. Where possible angle the needle away from the underlying
lungs and/or needle over bone or cartilaginous tissue. Practitioners must have attended
adequate training programs to needle in the thoracic region. The symptoms and signs
of a pneumothorax may include shortness of breath on exertion, chest pain, dry cough,
and decreased breath sounds on auscultation. These symptoms may not occur until
several hours after the treatment and patients need to be cautioned of this especially if
they are going to be exposed to marked alterations in altitude such as flying or scuba
diving. If a pneumothorax is suspected then the patient must be sent urgently for an x-
ray and medical management.

NEEDLING OVER THE SPINAL CORD
Care should be taken when needling between the spinous processes of vertebrae or
over the nerve roots (Governing Vessel or the inner Bladder channel). The distance
from the skin to the spinal cord or the roots of the spinal nerves varies from 25 to 45
mm in different individuals. The spinal cord terminates around the L1 to L2 level of
the vertebral column. To avoid infection do not puncture deeply in this region.

NEEDLING OVER ABDOMINAL ORGANS
All abdominal organs, including the kidney, liver, spleen, intestines and urinary
bladder are potentially at risk, when needling directly over organs. The risk is greater
with anatomical variance or enlarged organs. Do not needle deeply over organs.

MISCARRIAGE
Take care when needling pregnant women, especially in the first trimester when
miscarriage may be more common due to chance and a causal connection may be
assumed. Avoid needling over the abdomen. Points to be avoided during pregnancy
include LI 4, SP6, BL 60, BL 67 and LV 3. Needle GB 21 with caution. Avoid
prolonged needling or strong stimulation during pregnancy.


ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
NEEDLE STICK INJURY
Needle stick injury occurs when the therapist is inadvertently pricked by the needle
after it has been withdrawn from the patient. If this does occur, wash well around the
site of penetration, encourage bleeding and have blood tests for Hepatitis B and C and
HIV/AIDS. The patient may also be requested to have the same blood analysis
performed. If the patient is HIV positive the physiotherapist should urgently seek
medical advice concerning anti-viral medications. All practitioners should consider
being vaccinated for Hepatitis B. Only therapists trained in acupuncture or dry
needling techniques are permitted to remove needles from a patient.

HAND WASHING & GLOVES
Hands should be washed before needling a patient for at least 30-60 seconds. Soap or
alcohol based hand rub (ABHR) may be used. When using ABHR the manufacturer’s
guidelines should be followed. Hand moisturisers should be at regular intervals to
help maintain the physiotherapist’s skin condition.
Cuts, abrasions or lesions on the skin of the therapist are a possible source of
pathogens and should be covered by water resistant occlusive dressing or disposable
latex or nitrile gloves should be worn.
In the absence of skin lesions the choice of wearing gloves lies with the
physiotherapist. Wearing gloves may protect against direct contact with blood and can
decrease the risk of infection should a needle stick injury occur. It is however
acknowledged that various forms of acupuncture needling requires the ability of the
physiotherapist the feel the reaction of the tissue that is being needled and gloves may
inhibit the ability to do this. Reactions to latex gloves have been reported by health
care workers. Additionally the risk of contacting blood is considered minimal in
acupuncture procedures. As the risk of blood contact occurs only when needles are
removed physiotherapists may consider wearing gloves when removing needles.
Alternatively when dry needling physiotherapists may consider wearing a glove on
their non-dominant hand.
Hands should also be washed after needling a patient or after removal of gloves.
NOTE: In some Australian states or territories laws concerning skin penetration may
require the therapists to glove when needling.
SKIN PREPARATION
No skin preparation is usually required unless needling into an area that is particularly
susceptible to infection, such as a joint or bursa. Swab with an alcohol wipe and allow
to dry for at least 1-2 minutes or use Betadine (iodine) to pre-swab the area. If the
patient’s skin does not appear clean (e.g. if they have been working outdoors or
walking on the beach) you may request the patient to wash their skin prior to
administering the acupuncture treatment.
NOTE: In some Australian states or territories laws concerning skin penetration may
require swabbing prior to needling.
ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
HYGIENE REQUIREMENTS
¾ Physiotherapists must ensure that hands and nails are clean prior to giving ¾ Hands should be washed with soap and water for at least 30-60 seconds before ¾ Cuts, abrasions or lesions on the skin of the therapist are a possible source of pathogens and should be covered by a water resistant occlusive dressing or disposable gloves worn. ¾ The patient’s skin in area to be needled must also be clean. If the patients does not present with clean skin, the area to be needled may be cleaned with soap and water, or by using isopropropyl alcohol skin wipe.
The ABOVE procedures will disinfect skin, which is sufficient for Acupuncture
procedures, and is the required MINIMUM STANDARD.
SKIN STERILISATION

Skin sterilisation is recommended for patients who have a deficiency in their immune
system, or when needling into a joint space (e.g. shoulder, knee).
¾ A sterilising solution such as 2% iodine in 70% alcohol should be used and left on the skin to dry for a minimum time of two minutes. (for those allergic to iodine, chlorhexadine in alcohol is suitable). ¾ Immuno-compromised patients include those with malignancies, autoimmune problems such as S.L.E, AIDS or R.A. and those on immune suppressive drugs e.g. organ transplant recipients. These groups of people can get an infection from a much smaller number of infectious agents than those with an intact immune system. Disinfection may not remove enough organisms to prevent infection, hence their skin needs to be sterilised.
The background to this policy is that in a normal healthy person a certain amount of
infectious agents (bacteria, viruses) have to be introduced to the host’s system before
the body’s defences are overwhelmed and an infection takes place. To reduce the
number of bacteria or viruses below this infective agent is to disinfect. To completely
remove all forms of life from the skin is to sterilise.
EAR STERILISATION
The ear consists of a cartilage structure covered by skin. While the skin has a normal
nerve and vascular presence, the cartilage is largely devoid of these. Consequently, if
an infective agent is introduced in the cartilage, infection may ensue because of the
inability of the tissue to mount a response mediated via the blood vessels and nerves.
ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
This makes attention to skin sterilisation very important - even more important if “semi-permanent” press needles are to be used. ¾ When using “semi-permanent” needles it is suggested that the skin is prepared in the usual way, using a 2% solution of iodine in 70% alcohol, and the needle covered and held in place by plastic skin (flexible collodion). This reduces the chances of getting infection around the needle site with time. ¾ After the needle has been removed, if the site looks red and inflamed, then the application of an antibiotic ointment (e.g. Mupirocin), twice daily, may reduce the likelihood of any local infection. ¾ If the ear appears to be infected, and is not responding rapidly to topical ointment, then medical advice and treatment should be sought.
HYGIENE ESSENTIALS

1. Use only sterile, disposable needles.
2. Wash your hands thoroughly with soap and water before needling every patient.
3. Cleanse the skin of the recipient if necessary.
4. Use 2% iodine in 70% alcohol and leave for two minutes before needling only if
complete sterilisation is required. This is recommended for immuno-compromised
patients or joint penetration.
5. Dispose of needles carefully in a “sharps container”. Therapists need to avoid
“needle stick” injury as they are the ones at risk!

ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
WASTE DISPOSAL ADVISE FOR NEEDLES OR BODILY FLUIDS
¾ The treatment area should be clean, private if possible and have washing ¾ Wet surfaces should be disinfected regularly. ¾ All discarded needles must be disposed of in a sharps box clearly marked “Medical Sharps Waste”. These should either be incinerated via a needle collection service or a biological waste disposal contractor, or disposed of according to the Local Health Authority’s’ protocol/policies. ¾ The use of disposable needles is essential. It would be difficult to defend the
use of re-usable or re-sterilised needles in a case of acupuncture induced infection. All the major infections reported in the acupuncture literature, including HIV, but more frequently, Hepatitis B, have resulted from errors in sterilisation of re-usable needles. ¾ Care must be taken to avoid contact with the patient’s blood, should bleeding occur. A dry cotton wool ball should be used to absorb it and disposed of into an appropriate container marked “Contaminated Material” and disposed of by incineration or according to Local Health Authority practice. ¾ Linen contaminated with blood or other body fluids should be treated with Hypochlorite solution (Bleach) before laundering. MANAGEMENT OF BLOOD AND BODILY FLUIDS SPILLS

Large blood and bodily fluid spills are unlikely in acupuncture practice however
if a spill occurs then it is recommended to;

1. Wear personal protective equipment. Heavy duty utility gloves are advised. 2. Absorb the spill with dry disposable paper towels. Since most disinfectants are less active, or even ineffective, in the presence of high concentrations of protein as are found in blood or serum, the bulk of the spilled liquid should be absorbed prior to disinfection. 3. Confine waste in a disposable waterproof bag. 4. Clean the spill site with detergent and water, rinse and dry. 5. Disinfect the spill site using a chlorine-generating disinfectant if bare skin will contact the spill site or if it a difficult to clean surface in the clinical area. 6. Surfaces that cannot be cleaned (in carpet) adequately may need replacement. 7. Disinfectants should be left in contact with the surface for 10 minutes. 8. Sodium hypochlorite solutions must be freshly prepared. 9. Sodium hypochlorite may be irritating to skin therefore protective gloves must 10. Sodium hypochlorite may corrode metal and damage other surfaces. ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
11. Liquid household bleach usually contains 4-5% available chlorine, diluted with tap water 1:100 gives 5000 ppm approximately which will inactivate Hepatitis B in 10 minutes and HIV virus in 2 minutes. 12. Flood the spill site or wipe down the spill site with disposable towels soaked in disinfectant to make the site “glistening wet”. 13. Absorb the disinfectant solution with disposable materials. Alternatively, the 14. Rinse the spill site with water to remove any noxious chemicals or odours. Dry the spill site to prevent slipping or further spills. 15. Materials used to absorb spillage should be placed in impermeable waste bags ASAP Guidelines for Safe Acupuncture and Dry Needling Practice
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