1. Academic perspective

In terminology, dry needling (DN) is a synonym to acupuncture, just a different English translation from the original Chinese term?? (Zhen Ci). In China, DN is a common name of acupuncture for over 200 years.(11,17)  In West, DN has become popular since 1980s, especially since late 1990s, for replacing the term acupuncture by some traditional and medical acupuncturists, medical doctors, as a step “toward acceptance of acupuncture by the medical profession”. (23,36, 61)

DN is the use of dry needles alone, either solid filiform acupuncture needles or hollow-core hypodermic needles, to insert into the body for the treatment of muscle pain and related “myofascial” pain syndrome; a.k.a. intramuscular stimulation, trigger points (TrP) acupuncture, TrP DN, myofascial TrP DN, or biomedical acupuncture. In West, DN is a form of over-simplified acupuncture using biomedical language in treating “myofascial” pain, a contemporary development of a portion of Ashi point acupuncture from traditional acupuncture. It seeks to redefine acupuncture by reframing its theoretical principles in a Western manner. Current DN protocol using filiform acupuncture needles is exact same as the acupuncture used by medical doctors in West since 1821, and same as part of Ashi point acupuncture in traditional acupuncture used in East over 2,000 years. (36,61) It is a medical therapy and a form of acupuncture practice, not just a technique on inserting a dry needle.

For the business of the commercial seminars, many DN educators have covered up their acupuncture background, and have intentionally denied the fact that DN is acupuncture. However, in in other situations, they did tell the truth. The Mother of DN, Dr. Janet Travell admitted to the general public that DN is acupuncture when she stated in a newspaper that “the medical way of saying it is ‘acupuncture’. In our language that means sticking a needle into somebody", (37,61) and acupuncture professionals practice DN as acupuncture therapy and there are several criteria in the acupuncture profession to locate TrPs as acupoints.(13)

2. The Problems DN caused

Firstly, DN promotors have caused great confusion to academic scholars, healthcare professionals, administrators, policymakers, and the general public. As acupuncture professionals and researchers, they clearly know DN is acupuncture-just in different name. However, some of them made stories to fool people DN is different from acupuncture, and “discovered” or “developed” by themselves, or at least a “rediscovery” by western medical doctors. For example, Dr. Travell, a clinical researcher involved with acupuncture work and used to participate in the planning of acupuncture conferences (37,62) described a complicated DN “discovery processes” in her books--from injecting therapy with local anesthesia medication to  inserting injecting needle without medication--performing injecting needle DN, to using acupuncture needling; and used TrPs to rebrand acupoints. In fact, before had done all of these, in a newspaper she admitted to the general public that DN is acupuncture. This actually causes a problem in their academic integrity, although these DN promoters and educators are known scholars.

Secondly, in order to promote their “own” academic theory, commercial education business, and other objectives, DN educators have developed commercial courses for continuing education taught “DN techniques” to a large number of students, including PTs and other customers without acupuncture credentials in non-regulated seminars. While PTs programs do not include in any content in needling therapy,(63,64) the national organizations of PT profession, such as APTA(1) and FSBPT(52) started to support DN around 2010, currently there are more PTs involving the DN teaching and practice than other professionals.(53,54) Not recognized DN as a part of acupuncture, PT professionals, nevertheless, made a great effort to promote DN practice in the past ten years in the U.S. While elevating their education level to a doctoral degree, PTs as a profession probably want to expand their scope of practice and take over DN, even "the physiological basis for DN treatment of excessive muscle tensionare often licensed acupuncturists.

Thirdly, DN has mainly been taught in continuing education level courses of 20-30 hours (proposed to increase to 54 hours in future in some program).(1, 53,54,65,66)  This lack of adequate professional training increases the risk of patient’s injury and can be a threat to public health and safety. Reports of serious injuries associated with DN or acupuncture by PTs are not uncommon. (67-70) Under current healthcare regulations and system, a patient has no way to know if his or her DN practitioner has sufficient training and what is the risk of being injured when treated by “dry needlers” who received minimal training. More often, patients are not likely to know the practitioners’ experience level when DN technique is applied; nor will the patient know if the PT chooses to use needles for purposes beyond typical DN practice. Dr. David Simmons, a pioneer of TrPs, stated: "Your problem is largely one of semantics so the simple answer is to change the playing field and the semantics that go with it. If you... use the different terminology you leave other side without an argument".(71)

How can anyone practices acupuncture under the name of DN and say it is not acupuncture therapy? The public has a right to expect certain hard-earned standards of accredited education and licensing for those professionals who are using acupuncture needles on them therapeutically. In most of the states of the U.S., for becoming a certified MDs acupuncturist, physician or medical acupuncturists (after they get their MD license after their western medical education and at least three years of residency) are required to get a minimum of an additional 300 educational hours in a board -approved acupuncture training institution (American Board of Medical Acupuncture, ABMA) and have 500 cases of clinical acupuncture treatments; For licensed in  acupuncture, the candidates are required to attain an average of 3,000 educational or training hours via an accredited school or program (such as The Accreditation Commission for Acupuncture and Oriental Medicine, ACAOM). (59,60,65) So far, there is no comparable requirements and regulations for PTs to study needling therapy and perform DN in the U.S. (18) As noted that, even Dr. Travell opposes PTs to perform DN. (62)

In addition to public risk, PT dry needlers’ denial of acupuncture recognition has created a big tension between the acupuncture profession and PTs, as well as among other professionals who are seeking to provide acupuncture by calling acupuncture in a different name. If law-makers and regulators are to decide to allow PTs and others to provide acupuncture to citizens based on only 20-30 hours of training, they can certainly do that. The historic record shows however that these lawmakers should know that they are granting them the right to practice acupuncture. (18)

3. The Solution

In short, the evidence shows clearly that currently, at least in the U.S., DN practitioners intent to bypass the legal regulations to practice acupuncture in the name of DN.(18,44)  At last, here is a quote of the position letter on DN from American Medical Association (AMA):

“DN is indistinguishable from acupuncture”, physical therapists and other non-physicians practicing DN should – at a minimum – have standards that are similar to the ones for training, certification and continuing education that exist for acupuncture.  It emphasizes that "for patients' safety, practitioners should meet standards required for licensed acupuncturists and physicians". (60)

REFERENCES

61. Fan AY, Xu J, Li YM. Evidence and expert opinions:  dry needling versus acupuncture (II). Chin J Integr Med 2017; 23:83-90.

62. DeLorme L. Letter to Washington State Department of Health Sunrise Reviews, Re: Sunrise Review Panel Draft Recommendations. October 10, 2016. In: Washington State Department of Health. Information Summary and Recommendations Physical Therapy Dry Needling Sunrise Review. Page 688-694. Available at: http://www.doh.wa.gov/Portals/1/Documents/2000/DryNeedlingFinal2016.pdf Accessed Jan. 17, 2017.

63. University of Maryland Eastern Shore. Physical therapy, credit hours and approximate tuition. Available at: https://www.umes.edu/Physical-Therapy/Pages/Admissions/Estimated-Costs/ Accessed December 26, 2016.

64. University of Maryland School of Medicine. Doctor of Physical Therapy (DPT) tuition, fees and living expenses budget. file:///C:/Users/Arthur%20Fan/Downloads/2015-2016_DPT_Tuition_and_Educational_Expenses.pdf Accessed December 26, 2016.

65. Fan AY, Jiang J, Faggert S, Xu J. Discussion about the training or education for “dry needling practice”. World J Acupunct Moxibust 2016;26:6-10.

66. Ma YT. Dr. Ma’s integrative dry needling. Available at: http://integrativedryneedling.com/ Accessed December 12, 2016.

67. Cummings M, Ross-Marrs R, Gerwin R. Pneumothorax complication of deep dry needling demonstration. Acupunct Med 2014;32:517-519. doi: 10.1136/acupmed-2014-010659. Epub Sep 19,2014.

68. Almloff L. Opposed two reported cases of pneumothorax by PT in Virginia have been dismissed by Board. Available at: http://www.townhall.virginia.gov/L/viewcomments.cfm?commentid=48669. Accessed December 12, 2016.

69. Knauer J. Pneumothorax from a physical therapist performing dry needling in virginia.

Available at: http://www.townhall.virginia.gov/L/viewcomments.cfm?commentid=48189. Accessed December 12, 2016.

70. Terrell W. Pneumothorax Caused by Dry Needling of Intercostal. Available at https://www.youtube.com/watch?v=EWb69O__NiE. Accessed December 12, 2016.

71.Simmons DG. Letter to the editor. J Man Manip Ther 2007t;15:246.

Copy from: FAN AY, XU J, LI YM. Evidence and Expert Opinions: Dry Needling versus Acupuncture (?):—The American Alliance for Professional Acupuncture Safety (AAPAS) White Paper 2016.Chin J Integr Med 2017 Mar;23(3):163-165.