A Severity-Based Classification Framework for Dry Needling Unintended Responses and Adverse Events: An Expert Consensus Delphi Publisher Pubmed



Kearns G A ; Sheldon A ; Barrett T ; Puentedura E ; Brismee J M ; Dommerholt J
Source: Musculoskeletal Science and Practice Published:2026

Abstract

Objective To develop an expert-derived, consensus based framework for defining and classifying unintended responses (UR) and adverse events (AE) following dry needling (DN) through an exploratory, descriptive modified Delphi process. Methods One hundred DN experts were invited to participate in a 3-round electronic Delphi. Eligibility required ≥3 years of DN practice, ≥5 years of clinical experience, and DN-related teaching and/or scholarship. A-priori consensus criteria were ≥80% agreement, median ≥3, and interquartile range ≤1. Round-1 used open-ended questions exploring UR and AE definitions and classifications. Rounds 2 and 3 required participants to rate agreement with statements derived from thematic analysis on a 4-point Likert scale. Descriptive statistics and Kendall's coefficient of concordance and Wilcoxon rank-sum tests were calculated. Results Sixty-five experts met inclusion criteria and completed Round 1. Fifty-two participants (80%) from nine countries completed all three rounds. Key consensus findings included: (1) UR categories including bleeding/bruising, neurologic responses, and autonomic responses; (2) classification of AE along a severity spectrum; (3) prioritizing severity and functional impact over response type when distinguishing UR from AE; and (4) four operational AE categories ranging from Minor Expected to Severe. Notably, pain and discomfort did not achieve consensus as an UR category. Conclusion This exploratory Delphi produced a preliminary, expert-derived framework for defining and classifying DN AE along a severity spectrum, pending prospective validation. Emphasizing severity and functional impact over prescriptive event typologies, this framework may support more consistent clinical documentation, patient communication, and research reporting. © 2026 Elsevier Ltd.