Dry Needling: Averting a Crisis for the Profession
By John Amaro, LAc, DC, Dipl. Ac.(NCCAOM), Dipl.Med.Ac.(IAMA)
To date, there have been a multitude of articles published nationally in opposition to what may very well be perceived as the number-one threat to the existence of the acupuncture profession – what is known as "dry needling." Dry needling is being practiced by hundreds of physical therapists across the nation and in every state.
It has achieved a great deal of notoriety and popularity within the PT community, and in particular the general public, who have embraced it and are actively seeking the services of those who utilize this procedure.
When practiced by a physical therapist, the procedure is more often than not covered through medical insurance plans and may command as much or more than $200 per treatment. Unfortunately, the practice of acupuncture by licensed and state board-regulated LAc's does not fall within the same financial parameters the PT is receiving by billing for trigger-point therapy or other similar codes.
The entire acupuncture profession, from the individual practitioner to the national organizations, have launched direct and impassioned protests against this practice. Acupuncture organizations have stated emphatically that the PT who is inserting acupuncture needles into the skin to deactivate trigger points is infringing upon the practice acts of state board-licensed and regulated acupuncturists, as the procedure is clearly acupuncture.
Physical therapists, on the other hand, respond by saying that they are not using any belief system, academia or philosophy of Traditional Chinese Medicine or any particular thought process that deals with what is commonly known as the practice of acupuncture, regardless of what Asian country it may have been developed in. They explain their procedure as simply isolating trigger points, as described by Travell, Simons, and others as far back as 1947 and expounded upon in the mid-1960s. They go on to say that what they are doing is absolutely not acupuncture.
Trigger points are hyperirritable spots in skeletal muscle which are painful on deep palpation and can give rise to referred pain and motor dysfunction. They are found in palpable, taut bands of skeletal muscle and are responsible for a host of maladies affecting especially the musculoskeletal system, from pain in a body area to dysfunction of the area. Acupuncturists counter that this is what we refer to as "Ah Shi," "Ah So" points, which is a classic method of acupuncture known universally.
Palpating the area of pain, which may be known as "Surround the Dragon," will elicit specific tender points that may be needled by the acupuncturist in a classically and globally utilized approach. The physical therapist utilizes the identical approach by palpating and finding the trigger points, which are exquisitely tender; and then inserting an acupuncture needle into the area in what is described by them as "dry needling."
As such, PTs state that they are doing nothing more than utilizing a procedure that has been described in medicine for more than 50 years.
Acupuncturists say they utilize the same procedure,s which are over 5,000 years old, and that what they are doing is in fact acupuncture!
Recently I received an e-mail from the National Commission for the Certification of Acupuncture and Oriental Medicine (NCCAOM) with a plea to contribute money to fund the upcoming "legal battle and to be used for a public awareness campaign to achieve our objective to stop PTs doing dry needling in AZ."
The letter also details the intent "to protect the public's health safety, welfare and to stop all insufficiently trained and unlicensed practitioners from unsafe acupuncture." The letter continues with, "in order to stop this serious threat to public health, safety and our profession, we have formed the Coalition of Arizona Acupuncture Safety (CAAS) and we need your immediate support. There is a pressing need to hire legal counsel and spread the word to all Asian medical practitioners and to the general public nationwide as soon as possible."
In reviewing the Arizona Acupuncture Board of Examiners' minutes from its last meeting (I served on the board in its development for three years), the tone and direction were the same, from an esteemed president of a well-known and respected acupuncture college to comments from the American Association of Acupuncture and Oriental Medicine (AAAOM), to a well-known and respected practitioner, to an attorney representing the Arizona Society of Oriental Medicine. The message could be summed up by all is that the PTs who are utilizing dry needling are practicing acupuncture and are untrained, and thus pose a danger to the public. They all felt that the amount of education the PTs had to utilize dry needling was totally inadequate and not consistent with the education of LAc's doing the same procedure.
The unfortunate part of this whole scenario is that if you ask 100 people on the street to list from top to bottom the medical professionals who have the most education, respect and acceptance by the general public and the entire medical community, from universities to hospitals, to insurance companies and anyone else who deals with the health and welfare of the community; I am afraid to report that LAc's come out on the very bottom and far down the list from physical therapists.
I actually conducted this survey on 100 people by listing MD, DDS, PT, RN, DC and LAc, and asking people to rate them from highest to lowest in esteem and education. The order as shown above is the exact way it was voted on, with the exception of two people who ranked the DC at the bottom.
I personally feel that the national acupuncture organizations, and all those who have allowed their emotion to get the best of them, are without question approaching this issue form the wrong direction. While physical therapists are laughing at the acupuncture profession for launching a "we're trained and your not" mentality, they continue to practice "dry needling" by using acupuncture needles into trigger points calling it intramuscular dry needling and exposing that it is not acupuncture.
The general public and the PT profession have embraced dry needling because they see that it is effective and referrals are high for this procedure. Besides that, ask another 100 people about their dry needling experience by a PT; more than 85 percent are extremely happy with the results and have referred or would refer others for the procedure. This is to the obvious dismay of the acupuncturists, who are seeing their patient base being stolen by another profession doing the exact same work.
In the meantime, our national acupuncture organizations are attempting to launch a public-awareness campaign, which will obviously cost thousands upon thousands of dollars, to try and discredit the physical therapist. I predict that unfortunately, this will fall upon totally deaf ears. The only people who are going to hear this message is us – and we already know the issue.
Some in the profession are saying that in order to use dry needling, the physical therapist must go through the legislative process to add this dimension into their practice. In the meantime the PT hierarchy simply rolls their eyes at the prospect. At this point, they are in the driver's seat and regardless of how much finger pointing, name calling, lack-of-education accusations, danger to the public cries and other similar outrage, the issue is not going to be resolved.
So, what is the answer? To me, it is very obvious and I fail to understand why our professional leaders as a whole are not seeing this, but the facts are very clear.
When a PT, or any other professional, is performing "dry needling," this is in stark contrast to "wet needling." Travell and Simons, in their 1981 book, Myofascial Pain and Dysfunction – the Trigger Point Manual, discussed (among other methods to deactivate a trigger point) hypodermic needle injection of a variety of chemicals. This discussion included the precise method of injection of the agent into the trigger point. The book has hundreds of illustrations of hypodermic needle injection into the trigger points.
It was discovered that virtually all substances injected via the hypodermic needle had a positive effect, including simple saline solution. They also wondered what would happen if nothing were injected and just the hypodermic needle were introduced, creating a mechanical effect to deactivate the trigger points. It was discovered that it worked in the same fashion and that injection of a chemical, even though still popular with many practitioners, was not necessary. However, the analgesic effect of the chemical did provide an additional effect in harmony with the presence of the needle itself.
Due to the fact that it was shown to be imperatively easier to simply insert a dry hypodermic needle into the area to achieve the "twitch response" than the actual "wet needle" approach, "dry needling" became very popular. The only true negative was the fact that the procedure was extremely painful with the introduction of a relatively large gauge needle into a very tender point on the body. Patients were not pleased with the pain inflicted by multiple insertions of the hypodermic needle into extremely tender points.
When acupuncture as a practice, and profession developed in North America and solid, filiform, thin, disposable, sterile needles were introduced, various practitioners (primarily physical therapists) began to add them to their practice and began to call it "dry needling." The PT worked side by side with pain-management physicians and anesthesiologists in hospital settings, who were the ones who used trigger-point hypodermic needle injections of chemicals and were quite familiar with the procedure.
The primary issue here is that today, virtually every physical therapist practicing "dry needling" utilizes "acupuncture needles," as they are thin, sterile, effective and do not cause the searing pain of a large hypodermic needle. The problem is that it cannot be called "dry needling," in that the procedure is specifically designated to be used with a hypodermic needle. Therefore, it absolutely cannot be termed "dry needling," as specific acupuncture needles are being used. If a PT or anyone else is using a thin, filiform needle into a body part, it must be classified as the practice of acupuncture. Other than suturing the skin and or tissues, there is no place in medicine or any medical procedure which uses a solid, thin needle other than the practice of acupuncture. Any application of a needle for any purpose is always a hollow hypodermic needle.
In order for the physical therapist to refer to the procedure as "dry needling," it must be practiced with a hypodermic needle. If the PT were judicially judged to be mandated to use hollow bore hypodermic needles, I feel the procedure would go into oblivion, as the pain and discomfort would be primary to the patient.
Bear in mind that the state boards and legislature, in developing the practice of acupuncture in each of the states, all have specific definitions as to what is acupuncture:
Arizona states that "acupuncture" means puncturing the skin by thin, solid needles.
Colorado states that the "practice of acupuncture" means insertion and removal of acupuncture needles.
Texas states that "acupuncture" means the nonsurgical, non-incisive insertion of acupuncture needles.
Florida states that "acupuncture" shall include, but not be limited to, the insertion of acupuncture needles.
The four examples I illustrated here are just a few of the states, of course; virtually all states have similar, if not exact wording. Thus, acupuncture is described by the state legislature of each of these states as the insertion of "acupuncture needles." Should any practitioner utilize an acupuncture needle for any purpose to treat a person, they are practicing acupuncture as described by the legislature and must be held accountable.
My suggestion to acupuncture leaders is to change the tactic from trying to discredit the physical therapist as unqualified, untrained and danger to society, and go after the real issue: Anytime a PT uses what they are calling "dry needling" with an acupuncture needle, they are outside of their scope of practice and into ours, and must be held accountable through the courts and via state board disciplinary action.
If the profession will do this, we are assured that this very serious problem will go away."Dry needling" can only be called dry needling when it is used with a hypodermic needle, which is how it has been classically described in the texts describing the procedure. Few if any PTs will maintain their enthusiasm when their patient is probed with a hollow hypodermic in which 3-5 acupuncture needles can fit down the shaft.
Acupuncture has too much to offer and our practitioners have sacrificed too much to lose it to another profession that is clearly operating outside of its scope of practice.
All the best for saving the acupuncture profession from this crisis. Let's unite and appeal to our state boards and leaders to begin taking immediate judicial action. Instead of stating, "We're trained and they're not," let's go for a solid approach and state: "We're licensed by the state board of examiners and they're not."
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