Strongly Oppose Poor Definitions, Inadequate Training, and Health Risks in Regulations 18 VAC 112 – 20 for Dry Needling 

Dear Board of Physical Therapy,  

As a medical practitioner and a Virginia resident, I strongly oppose these regulations for dry needling in Virginia that grossly mislead the general public and present a grave risk to public health and safety. The new proposed regulations do not define dry needling, have no defined practice standards, and fall short of requiring any third-party testing of training competencies. These regulations as proposed will only increase the number of undertrained and poorly qualified dry needling practitioners in the state of Virginia.   

Both the American Medical Association (AMA) and the American Academy of Physical Medicine and Rehabilitation (AAPMR) have acknowledged that “dry needling as an invasive procedure and should only be performed by practitioners with standard training and familiarity with routine use of needles in their practice, such as licensed medical physicians and licensed acupuncturists.” (1, 2)  

I am a board-certified Doctor of Acupuncture in the Commonwealth of Virginia and have been a Virginia resident for 20 years. I have a Bachelor of Science in Biology (Pre-Medicine), a Masters of Science in Acupuncture and a Doctorate in Acupuncture. I am legally allowed to practice needling in Virginia only because I have graduated from an accredited acupuncture school that required over 2,600 hours of clinical and didactic training, culminating in a year-long supervised clinical internship, a clean needling technique exam, and three separate national board exams to include point location, eastern medicine theory and western biomedicine. Over the past decade, chiropractors and medical doctors, including surgeons have had the option of taking 200/300 hours of training to legally and safely practice basic acupuncture techniques in Virginia. For-profit corporations with no agreed-upon competency standards are now offering weekend courses in dry needling, making the claim that allied health professionals can learn to safely needle patients in as short as a two-day weekend training course, also claiming that the practitioner can then “offer this to their patients the next day.” It is ethically imperative that those making the regulatory decisions for 18 VAC 112 – 20 continue to disclose any direct vested interest in these for-profit dry needling companies as the proposed regulations continue to lean heavily towards supporting the dry needling companies who under these regulations are not required to adhere to any defined practice standards.  

This minimal training approach has great potential to harm patients, and I have seen that harm firsthand. In May 2015, a chiropractor in Virginia who had completed a weekend dry needling course treated a corporate client of mine, a 30-year-old woman with dry needling. After the dry needling treatment, the patient experienced shortness of breath and called the practitioner to express concern that she could not breathe. The practitioner told the patient that she would be fine, but thirty minutes later called the patient back and told her to go to the emergency room. The patient experienced a penetrating right lung injury, which resulted in a traumatic pneumothorax. She was treated for the pneumothorax at the emergency department of Inova Fairfax Hospital in Falls Church, Virginia. She was admitted to the hospital that same day and was hospitalized for six hours. The practitioner told the patient that the collapsed lung was the patient’s fault since her muscle "inappropriately jumped." The practitioner was never disciplined. Needless to say, the patient was emotionally and physically traumatized by her dry needling experience. She had a reasonable expectation that her health care provider was appropriately trained in safely inserting needles into the tissues of the body, and this expectation was clearly violated. This practitioner only completed a weekend dry needling course instead of the 200 hours required under their practice laws. That the practitioner could call it “dry needling” and thus circumvent the mere 200-hour acupuncture training required of chiropractors to become “qualified in acupuncture” is a stark warning call that illustrates the risks inherent in the ambiguity of this proposed regulation.   

In addition to the aforementioned case, I am aware of two other reported cases of medical negligence by unqualified and undertrained therapists performing dry needling resulting in pneumothoraxes in Virginia.(3) To my knowledge, none of these therapists were ever disciplined.  I have also seen patients in my clinic whose dry needling experience was intensely painful, led to increased intensity of pain for a sustained duration, and caused nerve damage.  

Internal injuries beyond nerve damage or organ puncture can occur by a dry needling practitioner with limited training. Human beings do not walk this Earth as muscles alone--the body functions as a whole. To presume that the muscular system is independent of the functioning physiological body when using an acupuncture needle is medical ignorance and a dangerous rationale. Physiological changes that occur at the muscular level and in the fascia during and after trigger point release affect the entire body. It is evident that physical therapists are beginning to realize this, and many have expanded beyond the intent of dry needling as a trigger point release therapy and are needling distal points on the body to treat allergies, headaches and sinus issues, using e-stem and retaining needles.   

Dry needling is contraindicated in many circumstances for babies, children, pregnant patients, elderly persons, cancer patients, emphysematous, hydronephrosis, lymphedema, splenomegaly and hepatomegaly patients, and additional cases based on systemic effects of the needles that extend beyond the muscular system.   

The AMA CPT committee on October 30, 2018 defined dry needling as indistinguishable from trigger point acupuncture. The new codes will become active January 1, 2020.(4) Codes describing the procedure of needling with no needle retention are to be created and will be placed in the medical-surgical section of the code set.

Even surgeons are required to obtain an additional 300 hours of training in acupuncture beyond his/her surgical training per the American Academy of Medical Acupuncture (AAMA). Physical therapists should be held to a standard that exceeds the AAMA standard of care.     

I am deeply disheartened that the physical therapy board has chosen to continue to ignore the recommendations of the professional acupuncture community as well as that of many in the medical community here in Virginia. These recommendations include the standardization of training hours, a definition of dry needling that is not identical to the scope of practice of acupuncture, and third-party psychometric testing to ensure safe, ethical and appropriate training for dry needling practitioners.   

As highly trained medical professionals in our respective fields, we have an obligation to the public and to our patients to represent ourselves in a way that upholds state laws and educational standards within the boundaries of our respective professional licenses. The physical therapy board is fully aware of the national education and certification standards to utilize acupuncture in practice. The board’s statements that “dry needling is not acupuncture” and their belief that this declaration suffices to meet acceptable practice standards is absurd. As it stands now, this regulation poses a grave, unacceptable risk to the public. 

Sincerely,

Dr. Jodi Knauer, D.Ac., L.Ac., Dipl. Ac.

Doctor of Acupuncture

1.   http://www.asacu.org/wp-content/uploads/2017/06/AMA-Dry-Needling-Policy.pdf

2.   http://www.asacu.org/wp-content/uploads/2016/09/AAPMR-Position-on-Dry-Needling1.pdf

3.   https://www.acupuncturesafety.org

4.    https://www.ama-assn.org/sites/default/files/media- browser/public/physicians/cpt/september-2018-summary-panel-actions.pdf