Council of Colleges of Acupuncture and Oriental Medicine

P.O. Box 65120 • Baltimore, MD 21209

Telephone: 410.464.6041 • Fax: 410.464.6042

 

Written Statement to the Virginia Board of Physical Therapy (February 23, 2017)

 

This statement is submitted by the Council of Colleges of Acupuncture and Oriental Medicine (Council) in opposition to the proposed regulation of the Virginia Board of Physical Therapy to expand the scope of practice for physical therapy to include “dry needling,” a treatment domain that is equivalent to acupuncture practice. The Council since 1982 has been the national membership association for accredited acupuncture colleges and programs in the U.S. (www.ccaom.org). The Council’s membership currently consists of 57 such colleges in 21 states, all of which have been approved by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM), the national accrediting agency for acupuncture and Oriental medicine programs recognized by the U.S. Department of Education (www.acaom.org).    

The Council opposes the proposed regulation for the following reasons:

1. Dry Needling is Acupuncture.

Dry needling is an invasive procedure that uses acupuncture needles, is indistinguishable from acupuncture, and is part of the armamentarium of acupuncture. In its Position Paper on Dry Needling,[1] the Council, which consists of higher education faculty, active practitioners, and administrators, documented the collective work of scholars and physicians over centuries and the work of modern practitioners showing decisively that the claims by physical therapists concerning the alleged “differences” between acupuncture and dry needling do not exist and that acupuncture historically and scholastically/academically encompasses all dry needling.[2] This is especially true of the recent attempts by physical therapists to redefine acupuncture as based on “meridians” and “energy flows.” While some acupuncture locations are located on meridians, these are only one classification of acupuncture locations based on a single theory. Additional locations, commonly referred to as “extra points” are not located on meridians. Trigger points, referred to historically as “ASHI” points are fully included in historical and modern acupuncture theory and are also not on meridians. By superimposing a definition that is not comprehensive, physical therapists not only attempt to separate themselves from acupuncture regulation, they also seek to limit a profession over which they have no knowledge or jurisdiction.

2.Acupuncture uses biomedical terminology; therefore, use of biomedical language cannot be a basis for defining dry needling as distinct from acupuncture.

The Council has taken the position that any intervention utilizing dry needling is the practice of acupuncture, regardless of the language used to describe the procedure. Physical therapists have misled the public by attempting to claim that their use of biomedical terminology distinguishes dry needling from acupuncture practice. The curriculums of the Council’s member acupuncture colleges make no such distinction. National acupuncture accreditation and certification bodies require the study of biomedicine, evidenced-informed practice, and bioscience courses such as anatomy and physiology as part of standard training for modern acupuncture practice. In addition, the national certification agency for the profession (NCCAOM) provides a national certification examination in biomedicine. The idea that acupuncturists use energetic language that is different from the biomedical terminology used by physical therapists, and that for this reason dry needling through the use of an acupuncture needle is not acupuncture, is false and has no correlation to actual standards of practice and education in the acupuncture field. It is therefore inaccurate and inappropriate that the Virginia Board of Physical Therapy makes any statements about any procedure or practice of acupuncture or attempt in any way to “declare” that dry needling is distinct from the practice of acupuncture.

 

1. Dry needling may not be within the scope of practice for physical therapists in Virginia because as an incisive procedure, such needling may be prohibited surgery.

The use of an acupuncture needle for purposes of dry needling or for any other purpose is an incisive procedure inasmuch as the documented presence of bleeding after acupuncture and the risk for nerve injury and pneumothorax indicate that acupuncture involves puncturing body tissues.[3] Accordingly, the inherently incisive nature of dry needling raises an issue whether the proposed regulation is consistent with Virginia statute § 54.1-3473, which prohibits physical therapists from using “surgical purposes.”  There is no indication in the current law that the Virginia legislature intended to allow physical therapists to insert acupuncture needles, an inherently invasive procedure. Therefore, the Physical Therapy Board lacks the authority to expand the physical therapy scope. A similar opinion has recently been released by the New Jersey Attorney General.[4]

 

1. There is no national standard in the physical therapy profession for the provision of education and training for dry needling, and the lack of such a national standard has resulted in public harm.

In the U.S., dry needling is taught to physical therapists in continuing education courses for which there is no regulation of content. Providers of continuing education for physical therapists are teaching techniques indistinguishable from what is commonly practiced as acupuncture, in some instances teaching acupuncture meridians and points, and renaming classical acupuncture points as “homeostatic points.” Moreover, continuing education instruction for dry needling is usually carried out during a 24 or 27-hour weekend seminar with no supervised clinical time.

 

In view of reports of serious adverse events caused by physical therapists and other non-acupuncturist providers performing dry needling, including pneumothorax,[5][6] the physical therapy board of Virginia must exercise its duty to protect the public by refusing to allow the practice until adequate educational standards are in place. A 2016 report from the physical therapy malpractice insurers documents a 500% increase in serious harm requiring surgery from dry needling from 2011 to 2015.[7] In published comments to the Virginia Regulatory Town Hall on Dry Needling Guidelines, acupuncture practitioners Janet Borges[8] and Jodi Knauer[9] report separate instances of pneumothoraxes occurring after dry needling in Virginia, and one of the cases is reported to be known to the Virginia Physical Therapy Board.

 

Since the proposed regulations do not specify any standard for training, physical therapists in Virginia may engage in an invasive practice which has already demonstrated harm to the public with no minimum training whatsoever.

 

1. Attendance in dry needling courses is not limited. A doctorate in physical therapy is not a prerequisite to taking a dry needling course.

The physical therapy lobby claims that because physical therapists are trained at the doctoral level, they already have the competencies to learn invasive techniques such as dry needling. Only an estimated 32% of licensed physical therapists are trained at the doctoral level.[10] [11] [12] [13] [14] [15] An expansion of scope on the basis of physical therapists’ attainment of doctoral-level degrees does not apply to 68% of physical therapists in practice. Since dry needling education courses are not limited to doctorally-trained physical therapists, and less than a third of currently licensed physical therapists have attained doctoral level education, this advanced educational rationale cannot be used to support the proposed expanded scope expansion for all licensed physical therapists.

 

While new graduates are at the doctoral level, currently licensed physical therapists may be at the bachelor or masters level of education. However, because there is no regulatory requirement for dry needling education, dry needling continuing education programs for physical therapists do not restrict attendees to providers trained at the doctoral-level. Further, current education, upon which the guidance document underlying the proposed regulation is based, has failed to prevent practitioners from improperly needling through clothing or treating patients far beyond the defined scope of dry needling practice. Regular postings of needling through clothing and unsafe insertion of needles up to the handle are found on social media in the U.S.

 

1. Physical therapy regulators must specify adequate training.

The Federation of State Boards of Physical Therapy commissioned the Analysis of Competencies for Dry Needling by Physical Therapists, which is also known as the HumRRO Report.[16] This document is cited by the board as its reason to eliminate any required training. The HumRRO Report is unusual in its non-disclosure that five of the seven Task Force members[17] [18] [19] [20]used to develop the report have a financial interest as instructors or owners in for-profit providers of dry needling education for physical therapists. The report, and testimony by physical therapists in support of their continued use of inadequate weekend-length programs, concluded that 86% of the competencies needed to perform dry needling are competencies contained in existing physical therapy programs. These competencies involve the general evaluation and delivery of care and have no relevance to dry needling. As the ability to take a patient history and evaluate a patient for physical therapy does not confer knowledge or skill about needling therapies, the comparative statement that physical therapists lack only 14% of dry needling competencies is meaningless. Additional problems with the report include the following:

 

1. The basic definition of dry needling adopted by the report[21] is not restricted to trigger point therapy and could include every needling technique in acupuncture, including auriculotherapy and microsystems such as scalp acupuncture as long as they are defined in biomedical terms. Therefore, the definition of dry needling adopted by the report is overly broad and vague. It is impossible to define all the competencies needed under an overly broad definition because without a content standard, all the related job tasks and knowledge competencies cannot be reliably identified.

 

1. The report identifies 16 dry-needling-specific knowledge competencies that comprise the 14% of the additional competencies that must be gained in post-graduate coursework. It is important to note that when physical therapists are testifying that they already have within their programs 86% of the competencies needed, they have completely left out any competencies related to the attainment of skills or supervised clinical experience necessary to perform dry needling. All of the deficient competencies are knowledge-based. In a single footnote, the report states that “although additional training is needed for the development of psychomotor skills…there does not appear to be widespread agreement regarding the minimum of practice hours necessary…Variation across individuals in terms of their aptitude, education, experience, and clinical specialization results in different rates of development.”[22] In other words, the report fails to identify ANY hours that are needed for skill attainment. With the insertion of 3-inch needles into a human body as the core skill being taught, the failure to identify the amount of clinical practice necessary underscores the inherent bias in the report.

 

1. The report is based on doctoral-level competencies. As discussed under item #5 above, only an estimated 32% of licensed physical therapists are trained at the doctoral level. Since dry needling education courses are not limited to doctorally-trained physical therapists, and less than a third of currently licensed physical therapists have attained the educational level upon which the report is based, the report cannot be used to support the proposed expanded scope expansion for all licensed physical therapists. The attainment of a DPT degree is not required for licensure in Virginia. Therefore, the Board must rectify the reality of current training of its licensees by mandating a minimum requirement to attain this advanced skill.

 

1. Independent certification bodies usually carry out the development of a job task analysis and competencies for professional practice in order to avoid bias. Since this report relies on for-profit vendor experts, avoids altogether the issue of a lack of an educational standard in the field, and fails to set any minimum hours for skills training, none of its conclusions can be depended upon for policy-making to promote public safety.

 

1. Physical therapy regulators must conduct adverse event monitoring.

In spite of documentation of life-threatening adverse events, the Council is not aware of a call within the physical therapy community to monitor adverse events through appropriate reporting. The Council believes the absence of such a call in the presence of known life-threatening injury calls into question whether the motivation in the proposed scope expansion is in the best interest of the profession and the safety of its patients.

 

1. In many states where similar dry needling regulations have been adopted, physical therapists have practiced far beyond the intended scope of the regulations free from any disciplinary consequences.

In Colorado, where regulations also define dry needling as a technique applied to trigger points, physical therapists have advertised services for cosmetic dry needling. Social media sites advertise treatment of headaches by using acupuncture points on the hand and dry needling treatment of sinusitis. Placing the responsibility on the physical therapist rather than on the board for proper adherence to scope of practice may lead to a similar breach of scope inVirginia.

 

The CCAOM is very aware that acupuncture is effective and that there are many patient benefits derived from acupuncture treatments. It is incumbent on the physical therapy profession, however, not to mislead the public when the profession seeks to expand its scope of practice, to seek appropriate legislative authority for an expansion of scope into a well-established domain of practice belonging to another profession, and above all to set appropriate training standards to protect the public.

 

Sincerely,

 

Valerie Hobbs, Dipl.O.M., L.Ac, Co-Chair, Legislative Committee

Dennis Moseman, M.S., D.C., L.Ac. (Dipl. Ac. NCCAOM), Co-Chair, Legislative Committee

Council of Colleges of Acupuncture and Oriental Medicine

P.O. Box 65120

Baltimore, MD 21209

 

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[1] See http://www.ccaom.org/downloads/CCAOM_Position_Paper__May_2011_Update.pdf.

[2] See Zhou, K, Ma Y, Brogan MS, Acupunct Med “Dry needling versus acupuncture: the ongoing debate.” Published Online First: 6 November 2015 doi:10.1136/acumed-2015-010911: http://aim.bmj.com/content/33/6/485.full?sid=b148da55-4902-4ec2-b4e7-4823a5ef8e05; and Arthur Yin Fan and Hongjian He. Letter: Dry needling is acupuncture. Acupunct Med Published Online First: 15 December 2015. Doi:10.1136/acumed-2015-011010. http://aim.bmj.com/content/early/2015/12/15/acupmed-2015-011010.full.

[3] See Council of Colleges of Acupuncture and Oriental Medicine, Clean Needle Technique (CNT) Manual—Best Practices for Acupuncture Needle Safety and Related Procedures (7th ed. 2015), at 3-23.

[4] http://www.thsu.edu/wp-content/uploads/2017/02/Dry-Needling-opinion-NJ-AG-2.9.17.pdf.

[5] National Center for Acupuncture Safety and Integrity. 2015. 10 Facts You Should Know [Brochure]. http://acupuncturesafety.org/10-facts-you-should-know/

[6] U.S. Food and Drug Administration. March 25, 2013. MAUDE Adverse Event Report: Acupuncture Needle. MDR Report Key 3122096. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=3122096.

[7] http://www.thsu.edu/wp-content/uploads/2017/02/Dry-Needling-opinion-NJ-AG-2.9.17.pdf, pages 19 and 22.

[8] http://www.townhall.virginia.gov/l/viewcomments.cfm?commentid=47827

[9] http://www.townhall.virginia.gov/L/viewcomments.cfm?commentid=48189

[10] This estimate was drawn from currently available statistics. The various state boards of physical therapy may keep an exact number of licensed DPTs, but this data is not readily available to the public. Between 2001-2014, there were 49,405 graduates of DPT programs. The Federation of State Boards of Physical Therapy (FSBPT) reports that 1% of graduates fail to pass licensing exams. Therefore the number of graduates who were eventually licensed can be reduced by 494 to 48,911. This number is reduced by 2.5% for attrition to an estimated number of currently practicing DPTs at 48,170. Added to this are the 15,000 graduates of tDPT programs for a total of 63,170. The American Physical Therapy Association estimates the number of licensed PTs at 198,000. Therefore the number of all licensed physical therapists who are doctorally trained would be 63,170/198,000 or 32%.

[11] http://www.capteonline.org/AggregateProgramData/Archive/

[12] https://www.fsbpt.org/FreeResources/NPTEPassRateReports/NPTEGraduationYearReports.aspx

[13] http://www.apta.org/WorkforceData/. The PT profession has not gathered statistics on attrition. They have used figures of 3.5%, 2.5% and 1.5% to calculate projections of surplus/shortage in projected workforce. The middle number was used here.

[14] http://www.apta.org/PostprofessionalDegree/TransitionDPTFAQs/. Number 13.

[15] http://www.apta.org/WorkforceData/

[16] See https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Dry_Needling/AnalysisCompetenciesforDryNeedlingbyPT.pdf [hereinafter cited as HumRRO Report].

[17] http://myopainseminars.com/directors-faculty/. Joe Donnelly and Michelle Layton are instructors for Myopain Seminars.

[18] http://www.kinetacore.com/physical-therapy/Keri-Maywhort-PT-DPT/page233.html

[19] http://www.kinetacore.com/physical-therapy/JJ-Thomas-MPT-CMTPT/page287.html

[20] http://www.kinetacore.com/physical-therapy/Edo-Zylstra-PT-DPT-MS-OCS-IMSp/page240.html

[21] HumRRO Report at 1.

[22] Id. at 13.