I have a patient with history of right great toe surgery in December to remove/replace cartilage, but post op developed burning/stinging pain in the medial arch of her foot and both dorsum & plantar surface of her toe. She had L3/L4 sympathetic nerve blocks — 2 of them. Pain is much better since the second one. Only has it now if she is standing for longer periods of time. The top of the foot is red when she wakes up in the morning, while most other times it looks more normal. She reports “ROM is still really limited, but it doesn’t hurt anymore.” Describes symptoms as stinging pain in the top of the foot — occasional dull pain on the medial aspect of the foot. Usually, symptoms are 2/10 with 4/10 at worst.
We tried one session of dry needling. Her QST was high 13/16. I did a total of 5 needles – 3 in her tibial nerve distribution muscularly, 1 at the tibial nerve and 1 beneath the retinaculum for the medial plantar nerve. They were left in situ for 10 minutes as she had only a mild dull ache in the retinaculum needle during the treatment. She had a reaction of nausea which started about 20 minutes after the needling and lasted until the next day. Other than that no increase in symptoms, also no change in her foot so far. She has not been back in because she is going away for the weekend, so I’m not sure what muscularly she is feeling from a tenderness standpoint.
Sounds like with your suggestions I was WAY too aggressive????… Clearly, I influenced the parasympathetic nervous system, but was it a normal reaction or over reaction?
Going forward, what would you recommend in terms of dosage. Stick with only the homeostatic points? Less needles? Less time?? Repeat what I did & see how she responds??
Any feedback you could provide would be greatly appreciated. I’ve been seeing some really good results with other patients so far, but this was the first adverse reaction. The patient is willing to try again, but was just concerned that the second session could ramp up those symptoms?? I thought, more likely they would be less severe with more exposure but was not 100% certain. (sorry I posted this in two places -- I'm new to the forum and wasn't sure if I should post on my own).
Christina,
I would have needled proximally at the common fibular nerve based on your description of her distribution on pain on the dorsum of the foot. The dosage was appropriate and very low- I would say her response was strong for the dosage provided and nausea is no always a bad thing ( other than the obvious) but does show a autonomic response in a system that is already heightened. Hard to give going forward thoughts as you do not know how she is currently doing- When she comes back focus on proximal at common fibular distribution - If she does well with that I would add 1-2 Hz estim to the region - Then work more distally as she tolerates- in situations like hers we recommend proximal first then move to the involved region-
Frank
I agree with Frank.
Her pain pattern is more consistent with the fibular nerve distribution.
In terms of how she responded, there are other external factors that could be influencing her sensation of nausea. Does she have low blood pressure, what position was she in when you needled her? Does she have a fear of needling? Had she eaten that day? Was she dehydrated? These are all things that can contribute to nausea with any dosage of needling treatment.
Your dosage was low, and I think you did not make a bad choice with your initial dosage. However, given her initial response, you want to make sure her next needling experience is a positive one.
I'd start with education and discussing how needling dosage can be modified to make an effective but somewhat enjoyable treatment and how you plan on modifying it that day to reduce the risk of nausea. I find that makes people less nervous moving forward. In terms of next treatment, I'd recommend utilizing half inch needles, and needling the proximal homeostatic points. This is less likely to cause any adverse reaction. Then you can progressively increase the intensity of her treatment.
Happy needling!
Natalie
Thank you both for your responses.
In terms of positioning -- she was prone for her needling. Not sure if she ate that morning, but I would think yes based upon what I know of her & her general health. She is not averse to needling again & was not upset by the situation (other than not really liking being nauseous). I will definitely modify for next time with the homeostatic common fibular nerve & go with the 1/2" needles. Thanks! I will update when she returns. 🙂
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