| Action | Practice of dry needling |
| Stage | Proposed |
| Comment Period | Ended on 7/26/2019 |
 |
Fan et al7 pointed out that a significant overlap in clinical practice between PTs and acupuncturists might be the origin of the DN debate. Before 2000, DN was mainly practiced and advertised by licensed acupuncturists in the US. Later, some acupuncturists developed commercial courses for continuing education and recruited a large number of PTs as students and customers. Other acupuncturists were hired by PT schools to introduce acupuncture to their students and faculty. Still others of these acupuncturist educators attended PT schools to gain doctoral degrees. It was acupuncturists, not dry-needlers or PTs, who taught most DN courses, at least in the early stages of the practice.
Fan et al7 also pointed out that the first person in the US. who used filiform needles (acupuncture needles) under the name of DN to treat patients was Mark Seem. Seem claims that he expanded the classical Chinese acupuncture approach via integrating the work of Travell in acupuncture needling for myofascial pain. He stated that he shared with Travell the classical acupuncture technique in treating a chronic, complex whiplash syndrome to release such TrPs.24 Seem also authored A New American Acupuncture, which was published in 1993 and covers DN. He taught this acupuncture method (DN) internationally for over 25 years before his retirement.24
Ma has published several books related to DN. Among these are Scientific Acupuncture for Health Professionals33 and Biomedical Acupuncture for Sports and Trauma Rehabilitation: Dry Needling Techniques.34 Ma, as a member of the Acupuncture International Standard Working Committee in the World Federation of Acupuncture-Moxibustion Societies, is a licensed acupuncturist, and he practiced DN under his acupuncture license in the US.
Even though he taught DN techniques to many PT students without any acupuncture education or background, Ma admitted that DN is the practice of acupuncture, using biomedical language for musculoskeletal pain management. Like Ma, other important authors in the field—including Giles Gyer, Jimmy Michael, and Ben Tolson—also indicated that DN is acupuncture; however, some of them insisted that DN was developed by PTs.2 Ma did say “DN originated in traditional Chinese methods and has developed from the ancient empirical approach to become a modern, evidence-based practice.”34 Recently, he proposed another modern interpretation of acupuncture and called it “Ma’s integrative dry needling.”35 It’s clear that all of these DN-related terms are simply different translations of acupuncture, which is called Zhen Ci (??) in original Chinese text.
Seem29 emphasized that Travell, in her seminars, indicated that “myotherapists ran the parallel training for PTs in the manual-therapy-technique sections of that course, where physicians taught the TrP injection techniques.” He indicated that “according to Travell’s discussions in her seminars, PTs—who are licensed to practice ischemic compression, which can be almost as effective as TrP injections and much less risky than using thick 3-5 inch-long syringes—were very pleased with those powerful manual techniques that they are licensed to practice based on the same manuals (Current authors note: Myofascial pain and dysfunction: the trigger point manual, two volumes.).Seem also stated that “Travell and Simons’ two-volume seminal text on PT practice provides options for a manual-therapy ischemic-compression technique. There is no reason for any …physical therapist who takes such a 50-75 hour program practicing on peers to ever need to learn needling techniques. Travell didn’t favor needling techniques being taught to any medical professionals other than medical doctors, dentists, and osteopathic physicians, given the danger of hitting nerves and important organs when needling over the torso on the front, back, or side.”
Travell not only recognized DN as acupuncture,8 but she clearly stated her opposition to PTs performing DN in a letter to Steven J. Finando, dated November 11, 1991, saying: “I hope that the New York State Board will maintain its ban on the right of PTs to perform fine-needle insertion into TrPs (DN).”25
Jin et al6 stated that “any modalities, as long as they apply needles to puncture certain locations at the body surface, belong to acupuncture, in spite of how and where the locations of stimulation are determined by either western neuro-anatomy or traditional Chinese medicine meridians….The mechanism of DN and acupuncture are one and the same…(achieving) efficacy via neural reflex arcs.” Jin et al also indicate that “DN has de-meridian attributes, but it uses acupuncture needles and techniques; therefore it does not have de-acupuncture attributes. In other words, as long as DN applies filiform needles to stimulate TrPs, it’s in the scope of acupuncture….To protect the public safety of patients seeking acupuncture, we refute the de-acupuncture claim by DN educators.” The current authors note that the term “de-meridian” identifies modalities that do not use the term “meridian” but use another term for the same factor, and acupuncture using “de-meridian” theory isn’t equivalent to “de-acupuncture”, because that kind of acupuncture still have all acupuncture characteristics 5,6,19-21 mentioned by NIH,27 CMS,28 and WHO 29. A person who changed his cloth is still that person, is not another person.
Fan et al32 pointed out that most of the states in the US, when comparing the education required to practice needling for licensed acupuncturists, require students to attain an average of 3000 educational or training hours via an accredited school or program, such as one accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) before they apply for a license. Physicians or medical acupuncturists, after they get their MD licenses after western medical education and at least 3 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 treatment to be certified in medical acupuncture. However, a typical DN education course runs only 20-30 hours, often over one weekend, and the participants may receive a DN certificate, without any examination or additional licensure.
The American Academy of Physical Medicine and Rehabilitation (AAPM&R)36 states that “DN is taught in American acupuncture schools as a form of treatment for individuals using acupuncture needles.”
NCCAOM, the certifying board for licensed acupuncturists, reported an analysis in 2003 that documented the prevalence of DN techniques in the practices of licensed acupuncturists. Of the acupuncturists responding, 82% used needling of TrPs in patients that presented with pain. Of patients receiving acupuncture treatment, an estimated 56% presented with TrPs pain.4
WHO’s Guidelines on Basic Training and Safety in Acupuncture37 mentions that nonphysician providers, to practice acupuncture, need a minimum of 1500 hours of training, including acupuncture theory, in which 1000 hours must be clinically supervised acupuncture practice and 500 hours must be biomedical courses.
DISCUSSION: USE BY NON-ACUPUNCTURISTS
Clearly, DN is a simplified form of acupuncture focused on limited myofascial conditions, is an invasive medical practice, and is not within the scope of PTs’ practice.7-10,22,38
DN has been developed simply by rebranding acupuncture with another name and has been promoted by some traditional and medical acupuncturists, medical doctors, and researchers—with different purposes—who are not PTs.7,10 To promote their “own academic theory” based on a fascia hypothesis and their commercial courses and to obtain other objectives, DN educators have taught DN techniques to a large number of students, including PTs and other customers without acupuncture credentials in nonregulated seminars. The national organizations of the PT profession, such as APTA1 and FSBPT13 started to support DN around 2010. Currently more PTs are involved in the teaching and practice of DN than are other professionals.39,40
Not recognizing DN as a part of acupuncture, PT professionals nevertheless have made a great effort to promote DN practice in the past 10-15 years in the USA. While elevating its educational level to a doctoral degree, the PT profession probably wanted to expand their scope of practice and take over DN. APTA states that, “the physiological basis for DN treatment of excessive muscle tension, scar tissue, fascia, and connective tissues is not well-described in the literature.”1
As noted, DN educators in both continuing education courses and in schools are often licensed acupuncturists. DN has mainly been taught in continuing-education courses of 20-30 hours—proposed to increase to 54 hours in the future for some programs—although some states have specific requirements for training hours to practice while others have no minimum requirements.1,32,35,39,40 This lack of adequate professional training increases the risk of patient injury and can be a threat to public health and safety.
Some states don’t regulate DN, nor do some regulations have minimum training and education requirements. Reports of serious injuries associated with DN or acupuncture by PTs aren’t uncommon.41-44 Under current healthcare regulations, a patient has no way to know if his or her DN practitioner has sufficient training and if he or she risks being injured when treated by dry needlers who have received minimal training. More often, patients don’t know the practitioners’ experience level when the DN technique is applied, nor do they know if the PT chooses to use needles for purposes beyond typical DN practice. 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 a different terminology, you leave the other side without an argument.”45
DN is an interpretation of traditional acupuncture focusing on musculoskeletal disorders by using one form of biomedical language. How can anyone who practices acupuncture under the name of DN 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. For becoming a certified MD acupuncturist and licensed acupuncturist, strict requirements exist in acupuncture (needling) education, including studies in national accredited educational institutions and several hundred to thousands of educational hours in most states of the US.22,32,36 So far, no comparable requirements and regulations exist for PTs to study needling therapy and perform DN in the US.7
In addition to public risk, PT dry needlers’ denial of acupuncture recognition has created tension between the acupuncture profession and PTs as well as among other professionals who are seeking to provide acupuncture by calling acupuncture by a different name. If lawmakers 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 with minimal training.7 Lawmakers should also pay attention to what both national and international health organizations have stated in terms of dry needling being under the scope of acupuncture and not to be practiced by those who are not licensed acupuncturists.
The evidence clearly shows that DN practitioners, at least in the U.S., intend to bypass the legal regulations required to practice acupuncture under the guise of DN.7,25 Finally, the position letter on DN from American Medical Association (AMA) states,
“DN is indistinguishable from acupuncture”; physical therapists and other nonphysicians practicing DN should—at a minimum—have standards that are similar to the ones for training, certification and continuing education acupuncture. It emphasizes that “for patients’ safety, practitioners should meet the standards required for licensed acupuncturists and physicians.”22
CONCLUSIONS
Acupuncturists and physician acupuncturists must complete extensive acupuncture training in accredited programs and pass national examinations to become licensed or certified to practice acupuncture. However, a typical DN course runs only 20-30 hours, often over the course of one weekend, and the participants may receive a DN certificate without any national examination being required. For the safety of patients and professional integrity, the research team strongly suggests that all DN practitioners and educators should have to meet the same basic standards as those required for licensed acupuncturists or physicians.
References
1. American Physical Therapy Association. Description of dry needling in clinical practice: An educational resource paper. 2013, http://www.apta.org/StateIssues/DryNeedling/, accessed April 23, 2019.
2. Ma YT. What is dry needling? 2010, http://www.acupuncture.ca.gov/about_us/materials/20100819_10e.pdf, accessed April 23, 2019.
3. Dommerholt J. Dry needling-IMS, FAQ. 2017, http://www.bethesdaphysiocare.com/pdf/faq_dryneedling.pdf Accessed December 23, 2017.
4. Council of Colleges of Acupuncture and Oriental Medicine. Position paper on dry needling. 2011. http://www.ccaom.org/downloads/CCAOM_Position_Paper__May_2011_Update.pdf, accessed December 23, 2017.
5. Zhou K, Ma Y, Brogan M. Dry needling versus acupuncture: the ongoing debate. Acupunct Med. 2015; 33(6):485-490. doi: 10.1136/acupmed-2015-010911. Epub 2015 Nov 6.
6. Jin GY, Jin LL, Jin BX. Dry Needling: a de-meridian style of acupuncture. World J Acupunct Moxibustion 2016; 26(2):1-5.
7. Fan AY, Zheng L, Yang G. Evidence that dry needling is the intent to bypass regulation to practice acupuncture in the United States. J Altern Complement Med 2016; 22:591-593.
8. Fan AY, Xu J, Li YM. Evidence and expert opinions: Dry needling versus acupuncture (I). The American Alliance for Professional Acupuncture Safety (AAPAS) white paper 2016. Chin J Integr Med. 2017; 23(1):3-9. doi: 10.1007/s11655-016-2630-y.
9. Fan AY, Xu J, Li YM. Evidence and expert opinions: Dry needling versus acupuncture (II). Chin J Integr Med. 2017; 23 (2):83-90.
10. Fan AY, Xu J, Li YM. Evidence and expert opinions: Dry needling versus acupuncture (III) : -The American Alliance for Professional Acupuncture Safety (AAPAS) White Paper 2016. Chin J Integr Med. 2017; 23 (3):163-165. doi: 10.1007/s11655-017-2542-x.
will be continued...