As a licensed acupuncturist in Virginia, who also maintains licensure by the California Acupuncture Board, I strongly object to the proposed drafting of "dry needling" regulations as they are outlined in Guidance Document 112-9.  Since it was written, this grossly flawed and misleading document has created an environment that is a serious threat to public safety.  It does so by not only blatantly confusing the healthcare consumer, but authorizes physical therapists to perform invasive procedures clearly outside their scope of practice as codified by the Commonwealth of Virginia.   Specifically, “dry needling” is being misrepresented as a manual therapy technique, which it is not.  “Manual therapy” is clearly defined in the scope of practice for physical therapists, as codified in § 54.1-3473, and acupuncture is not part of that code.

It is indisputable that “dry needling”, also known as “trigger point dry needling” is acupuncture; a treatment modality that is codified in § 54.1-2900 as: "… the stimulation of certain points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or to normalize physiological functions, including pain control, for the treatment of certain ailments or conditions of the body…” To maintain the sophomoric argument that ‘“dry needling” is not acupuncture’ for the purposes of allowing physical therapists to practice what is in fact acupuncture, is irresponsible medical practice. To request that patients sign a disclosure wherein they acknowledge they are not receiving acupuncture, and then proceeding to treat them with…acupuncture, is confusing and deceptive.

Virginia citizens deserve better.  Patients should be assured that the highest standards for acupuncture practice are being met and enforced.

Much of my practice deals with the treatment of pain and sports injuries.  This includes regular referral to physical therapists, with whom I work in tandem toward our mutual goal of eliminating pain and reestablishing functional movement for the patient. I am certainly not opposed to the style of “dry needling” trigger point acupuncture, as I regularly treat referred pain patterns via trigger points, with much success. I am opposed to the lack of oversight, lack of regulation standards, no standard measurement of competency, and absence of clinical hours that comprises the 54-hour training, which is currently used as a basis for physical therapists to administer “dry needling” in Virginia. I am also opposed to the lack of professional integrity illustrated by overwhelming evidence that physical therapists and others are practicing beyond the supposed intent of “trigger point dry needling” and are expanding into overt acupuncture practice.

I first became aware of serious a “dry needling” patient injury in Virginia during February of 2014. A Virginia colleague shared a case, documented with photographs. Her patient suffered pneumothorax as a direct result of “dry needling” performed by a physical therapist. The photographs clearly showed deep perpendicular needling in the region of the upper thoracic spine. The needles were inserted all the way to the shaft, and 7 of the 8 needles appeared to be at least 1.5 inches in length (based on my observation of the color of the plastic needle shaft, which is, to my knowledge, uniform across needle manufacturers). This type of needle insertion is completely counter to the training that even a first semester acupuncture student learns. While this incident was documented and reported to the Virginia Board of Physical Therapy in 2014, no disciplinary action was taken.  The lack of disciplinary action implies (to me) that the Virginia Board of Physical Therapy is not taking responsibility for the health and safety of the public as it pertains to “dry needling.”

This case, and numerous others nationally, have resulted in serious patient injury. In my own practice, many patients have reported painful outcomes following “dry needling” by physical therapists. Sadly there is no shortage of photographs and video in national circulation showing failed and injurious results by physical therapists.  These failures repeatedly demonstrate a woeful lack of training and knowledge regarding the real risks associated with needling of any type, such as: blood vessel, nerve and organ injury from inappropriate acupuncture needle angle and depth of insertion, inappropriate acupuncture needle manipulation, infection and cross infection from non-sterile acupuncture needles, and inadequate skin preparation.

It is also increasingly clear, by way of anecdotal evidence from my own patients and that of my colleagues, as well as from volumes of reports circulating nationally, that physical therapists are, in fact, expanding into overt acupuncture practice and not limiting themselves to “trigger point dry needling.” The above referenced photographs and video show acupuncture meridians and acupuncture points being clearly identified (as in: drawn on the patient), and needled. These practitioners with minimal training are promoting treatment in physical therapy settings for, among other things: “cosmetic dry needling,” “dry needling for sinus infections,” “dry needling for chronic migraine,” etc. Just two days ago a patient told me about a friend who had received painful “dry needling” from a physical therapist for digestive issues. There are even photos of physical therapists needling patients through clothing.  This is a travesty, which degrades both licensed acupuncturists and physical therapists, and ultimately does not serve the patient.

While the overwhelming enthusiasm for the beautiful modality of acupuncture is heartening, the seeming willingness of some physical therapists to practice outside their realm of competency is deeply disturbing and a grave danger to the public.  This trend toward bad practice by some physical therapists must be stopped in the Commonwealth of Virginia.  Guidance Document 112-9 would do just the opposite.

There are other possible safety considerations specific to this proposed regulation. The first is that the recent changes in “Direct Access Provisions” for physical therapists, as I understand it, potentially provides a loophole by which a patient can receive “dry needling” acupuncture without the medical referral or supervision that was previously referenced as part of Guidance Document 112-9.

Another consequence of this proposed regulation that results from “Trigger Point Dry Needling” being falsely referenced as “not acupuncture” is that other healthcare providers, such as chiropractors, now increasingly practice “dry needling” in Virginia with merely 54 hours (or less) of training. This circumvents the original 200-hour requirement (50 hours of which is clinical supervision) currently in the Virginia regulations for chiropractors, medical doctors and others to be “qualified” (referring here to the term “qualified” as differentiated in Virginia regulations from “licensed acupuncturists”) to add the modality of acupuncture to their clinical practice. This loophole inviting poor practice and further patient injury must be closed. 

The professional landscape in Virginia, as well as nationally, pertaining to this issue has changed dramatically since the 2007-2008 drafting of Guidance Document 112-9, which was written with no opportunity for public or professional comment. This is most certainly not a turf war between competing professions. It is about ensuring patient safety and protecting the integrity of the acupuncture profession as well as that of the physical therapy profession. Many licensed acupuncturists work closely with physical therapists with much success. However, permitting a profession to practice an invasive procedure that is outside of their documented scope, with inadequate training and education, is inexcusable, illegal, and a risk to the public. I encourage the Department of Health Professions and the Board of Physical Therapy to promote responsible regulation and quality medical practice by rejecting the current regulation proposition.