|Action||Practice of dry needling|
|Comment Period||Ends 12/30/2015|
Dear Members of the State Board of Physical Therapy,
I am a licensed Acupuncturist in the States of New York and Maryland for the past three decades and more. I developed a classical Chinese acupuncture approach to integrating acupuncture needling of myofascial pain and related disorders, where release of tight knotted muscles, often called ‘trigger points’ after the work of Dr. Janet Travell. I shared this classical acupuncture technique with her by treating a complex old whiplash syndrome for her Myotherapy traveling companion and friend who was an expert at acupressure to release such trigger points, when Travell taught with Maryland neurologist Robert Gerwin, MD in 1990, who had never seen acupuncture needling of trigger points before, nor had Dr. Travell. He wondered what he was doing lecturing to a group of half acupuncturists, and I asked contrariwise how he felt comfortable teaching physical therapists, who had no required training in the use of such solid filiform needles in their entry-level programs there. He was not able to make the demonstration I did that night for Dr.Travell and her trigger-point bodywork expert colleague as he had a dinner to go to. Whenever I successfully needled in classical Chinese style muscle channel shallow technique, with a 1 inch needle inserted half way into the soft tissue that I had compressed with my non-needling hand as the Japanese often do, easing up now and again to give the deeper muscle room to react, it would twitch often dramatically that was visible to Dr. Travel and me and very palpably experienced by her colleague who even remarked that it felt just like deep trigger point injections done by Dr. Gerwin who directed the training in the Travell Seminar Series when elderly Dr. Travell was no longer able. Myotherapists ran the parallel training for physical therapists in the manual therapy technique sections of that course, where physicians taught the trigger point injection techniques. Physical therapists, according to Travell’s instructions, who are licensed to practice ischemic compression that can be almost as effective as trigger point injections, and much less risky than using thick 3-5 inch long syringes, were very pleased with these powerful manual techniuques hey are licensed to practiced based on the same manuals. Medicare and Medicaid standards for coding for trigger point injections call for coding for a few, or multiple, trigger point injection sites; as well as coding for what medication filled the syringe - usually lidocaine or even cortisone as the case may be, and sometimes homeopathic solutions that medical doctors and their ‘physician extenders’ use as well.
Travell and Simons’ 2 volume seminal text on this practice always provide manual therapy ‘ischemic compression’ technique options, so there is no reason for any well trained physical therapist who takes such a 50-75 hour program practicing on peers to ever need to learn needling techniques, which Travell did not favor ever being taught to other than medical doctors, dentists and osteopathic physicians given the danger of hitting nerves and also important organs when needling over the torso on the front, back or side.
After Dr. Gerwin heard Dr. Travell and her colleague report on the similarity in efficacy of my one acupuncture session to trigger point injection, and he saw the thin short Japanese Serein needles I gave him to check out, he looked for externs and found an osteopathic resident trained in such acupuncture release of trigger points. Subsequently he met and partnered eventually with a physical therapist who claims to have learned such needling with acupuncture needles in the Netherlands where he is from. I taught that technique to physical therapists in the Netherlands who were the main licensed providers, along with physicians in my classical acupuncture seminars for the Anglo-Dutch Institute comprehensive acupuncture and traditional Chinese medicine program, as well as to physical therapists and physicians in rehabilitative medicine in the UK, and they all concurred no one should do acupuncture treatment of such myofascial conditions without proper acupuncture training. They also agreed that ‘dry needling’, which is to say the use of an empty syringe with no medication was nonsensical, even though Dr. Hong, an acupuncturist who like Dr. Gunn went on to become a physical and rehabilitation medicine physician, dropping any reference to that earlier acupuncture training as Dr. Baldrey in the UK, and Dr. Ma in Colorado have done, to cover up their original comprehensive acupuncture training. Hong’s research study had 3 options – actual trigger point injections of lidocaine into myofascial trigger points; injection of saline solution instead; and dry needling with no fluid injected. While no insurance company would ever provide coverage for such dry-needling, Hong was able to show that all 3 techniques worked equally well, with post-injection soreness the mildest as expected in those who received lidocaine, an anesthetic, and greater for those who were injected with cortisone, and the greatest with those injected with a ‘dry’ syringe.
Travell and Simons had already come to the conclusion that the twitching evoked in acute myofascial trigger point conditions was the actual therapeutic mechanism, as the twitching stretched the tight contracted muscle fibers [trigger points] within the sorest part of such muscles, and so stretching created by the injection, accompanied by some soothing fluid, even saline solution, with lidocaine seeming to make that stretching release last the longest, explained the mechanism for such often dramatic relief.
While a more time consuming technique, ischemic compression release which all entry-level physical therapists have learned, allows them to approximate the release from the more risky trigger point injections, at a fraction of the cost of such surgically coded injections. They can also use electro-stimulation techniques on such trigger points conditions with equally good results, and there are even ultra-sound, and laser devices hey are licensed to use.
The only reason physical therapists could possibly have for wanting to use acupuncture needles, then, since they are not at a loss for their own manual therapy techniques and FDA legal regulated devices, is to be able to tell their patients who ask if what they do is as effective as the ever more popular 2000 year old originally Chinese acupuncture, where no potentially harmful medications are ever ‘injected’, making it a primary nonpharmacologic therapy among those physical and occupational therapists are licensed to practice, as appeared for pain management conditions in the accreditation manual update of the Joint Commission that accredits some 20,500 mainstream and integrative medicine hospital and integrative medicine outpatient facilities and programs, where acupuncture was also on that list, where physical therapy does not figure, for behavioral healthcare, mood and mental disorders, including psychosomatic and organ functional problems like IBS or Reflux that physical therapists are not trained to treat.
In short, unless the Board would consider it appropriate for licensed acupuncturists to be able to practice all of the licensed manual therapy techniques a trained physical therapist may practice, since we learn our own East Asian acupressure-related techniques, or the same licensed chiropractic and osteopathic manipulations those providers may practice, if we learn far simpler release techniques within our acupuncture scope of practice, without the same level of osteopathic or chiropractic training in their required entry-level well supervised training treating the public that the short trigger point [acupuncture] dry-needling courses may never provide for legal reasons, I submit that the approval for physical therapists to practice using FDA regulated medical devices known as acupuncture needles, for those licensed in acupuncture to use such needles or for licensed surgeons, is irresponsible in the extreme and opens the Pandora’s box for all licensed therapists to start using other licensed therapist’s FDA regulated techniques and devices.
Finally, the high likelihood that the 20,000 licensed acupuncturists in this country will have had enough, and will file a federal class-action suit with the FDA to penalize these poorly trained self-professed trigger point ‘dry-needlers’ [illegal acupuncturists] is high and poses a serious risk for the Board and for each physical therapist the state licenses, where the implicit final determination of entry-level competence in physical therapy does not include national or state training, standards or assessment of any level of competence in such lucrative CEU short courses that are only good for the course owners themselves.
I suspect that passing such a bill will leave licensed acupuncturists no choice but to mount a powerful full disclosure pubic relations attack on your Board and on any physical therapists who practice such shoddily learned acupuncture techniques without a license in acupuncture. And the door will be open for them to advertise that they practice physical therapy acupuncture and trigger point needling, beating the physical therapists at their own game while legally billing for what physical therapists must be illegally checking off as a manual [rather than intramuscular] therapy, which is another kind of fraud altogether that your Board would do well to investigate.
I thank you for considering these comments based on 38 years teaching, supervising and practicing licensed acupuncture, after what is now a masters degree accredited 3 year program of some 1906 hours of training minimum, with 500 hours in the practice of acupuncture.
Mark Seem, PhD, LAc.
Founder and Past President, Tri-State College of Acupuncture