Dear Board of Physical Therapy,

I am a board certified, licensed acupuncturist in the Commonwealth of Virginia, and I oppose the draft regulations for dry needling in Virginia. I have a Bachelors of Science in Biology (Pre-Medicine), a Masters of Science in Acupuncture and I am a Doctoral Candidate in Acupuncture. I am only legally allowed to practice acupuncture in Virginia because I have graduated from an accredited acupuncture school which included over 2,200 hours of clinical and didactic training which culminated in a year long supervised clinical internship, passed a clean needle technique exam and three separate national board exams to include acupuncture with point location, acupuncture theory and western biomedicine.

I am re-submitting my comments from the first regulatory review period from 2016 with additional response. During the first comment period in 2016 there were 1,266 comments opposing dry needling and 230 in support. The vast majority of the comments were in opposition to the proposed regulations.

The American Medical Association came out with a position paper on dry needling in June 2016. In their press statement from 6.15.16, the American Medical Association states that “dry needling is indistinguishable from acupuncture.” “Delegates agreed that the practice of dry needling by physical therapists and other non-physician groups should include at a minimum the benchmarking of training and standards to already existing standards of training, certification and continuing education that exist for the practice of acupuncture. The AMA also recognizes dry needling as an invasive procedure and maintains that dry needling 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.”

https://searchpf.ama-assn.org/SearchML/searchDetails.action?uri=%2FAMADoc%2FHOD-410.949.xml

In addition, the American Association of Medical Acupuncturists and the American Academy of Physical Medicine and Rehabilitation have both released position papers opposing dry needling:

medicalacupuncture.org/Portals/2/PDFs/AAMADryNeedlingPolicyOct15.pdf

https://www.aapmr.org/practice/resources/positionpapers/AAPMR%20Documents/AAPMR-Position-on-Dry-Needling.pdf 

1. Dry Needling is the Unlicensed and Illegal Practice of Acupuncture in Virginia by Physical Therapists.

The APTA definition of “dry needling” is very similar to the definition of “acupuncture” according to Virginia law. The definition of acupuncture by the State of Virginia is: "Practice of acupuncture means the stimulation of certain points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or to normalize physiological functions.” 

The APTA definition of “dry needling” is: "Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments.” 

Dry needling constitutes the practice of acupuncture under Virginia law. The practice of acupuncture includes but is not limited to acupuncture physical medicine, trigger point acupuncture, orthopedic acupuncture, sports medicine acupuncture, classical acupuncture, facial acupuncture, auricular acupuncture, traditional Chinese acupuncture, Kiiko Matsumoto acupuncture, Dr. Tan acupuncture, and more. When a board certified licensed acupuncturist releases a trigger point using an acupuncture needle, the physiological mechanism and palpation of the muscle fibers is the same as in dry needling.

A 2015 article in a peer-reviewed, international medical journal also makes the case that dry needling is acupuncture:

http://aim.bmj.com/content/early/2015/12/15/acupmed-2015-011010.long

2. ZERO Hours of Training in Dry Needling is Substandard Patient Care and Bypasses Acupuncture Laws for State Licensure

The new proposed regulations have taken out any training requirements for dry needling with the claim that dry needling is taught in all Physical Therapy schools. This is false. Dry needling has historically only been taught post graduation by for profit companies over a weekend with no benchmarks in clinical experience, didactic training or third party testing for competency.

A board certified licensed acupuncturist is trained in appropriate needle depth, contraindications and technique to safely pierce the skin of a patient with an acupuncture needle. Contraindications on needle placement, depth and treatment strategy are taught in all accredited acupuncture schools throughout the United States. 

Physical therapists are highly trained professionals who perform manual manipulation of muscle tissues and therapeutic strengthening exercises. Many of my pain patients include physical therapy as part of their treatment plan. These patients are benefitting from an integrative approach to their care.

Human beings cannot walk this earth as muscles alone. The body functions as a whole. To presume that the muscular system is independent of the entire functioning physiological body when using a filiform 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. Acupuncture functions as a whole, and thus dry needling, which is the crude practice of acupuncture, will affect the entire gross anatomy beyond the musculoskeletal system.

Internal injuries beyond nerve damage or organ puncture can occur by a dry needling practitioner with extremely limited training. For example, a licensed acupuncturist can read pulses to ascertain the potential pregnancy of a patient often before an hCG Blood test or any over the counter urine test reads positive. This practitioner has the knowledge to avoid needling into certain muscles that if aggressively needled can, not only cause harm to the surrounding tissue, but also has the potential for causing a miscarriage. Furthermore, aggressive needling such as dry needling is contraindicated or used rarely with extreme caution in many circumstances for babies, children, 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.

3. Dry Needling with ZERO Hours of Training is NOT safe.

I have seen pictures of hazardous dry needling through clothing, a video of a dry needling instructor causing a Pneumothorax while teaching the technique to students, and pictures of dry needling angle, depth and placement that put patients at unnecessarily high risk for adverse events.

I have a client who in 2015 experienced a collapsed lung from an allied health professional performing dry needling in Virginia. After the dry needling treatment, the patient experienced shortness of breath and called the non-licensed acupuncturist to express concern that she could not breathe. The practitioner told the patient that she would be fine. Thirty minutes later the practitioner called the patient back and told her to go to the emergency room. The patient was admitted to the emergency room and intensive care unit and diagnosed with a life threatening Pneumothorax. 

Upon that first call from her patient, the practitioner should have told her to immediately go to the emergency room, as shortness of breath following a dry needling treatment is an immediate red flag for all licensed acupuncturists and physicians and a basic standard of care protocol. The practitioner also told the patient that the collapsed lung was the patient’s fault since her muscle "inappropriately jumped." The practitioner was never disciplined. The patient has been emotionally and physically traumatized since her dry needling experience. The patient 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.

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 largest company insuring physical therapists recently called dry needling “an emerging area of risk” and documented numerous dry needling injuries. 

The unregulated practice of Dry Needling opens the door to any non-licensed acupuncturist and allied health professional to practice medicine without the appropriate license.

The FDA regulates the sale of acupuncture needles, a Class II medical device, to be sold to qualified licensed acupuncturists as determined by state law. It is my understanding that physical therapists are purchasing and using acupuncture needles in the state of Virginia even though it is illegal to purchase these needles per state law and FDA regulations.

4. Separating Dry Needling from Acupuncture is Confusing to the General Public and Affects the Credibility of Acupuncture

The large discrepancy in training standards between what board certified acupuncturists requires and the basic training physical therapists receive before practicing what they define as dry needling is confusing to the public, as patients expect that their practitioner be appropriately trained. My patients ask me quite often about dry needling. The public is confused.

When I first opened my private practice I had two office locations. One of my offices shared space with physical therapists who practiced dry needling. I had envisioned an integrative and collaborative experience at this wellness center. All of these practitioners were considerate medical professionals and no doubt highly skilled in manual therapy and exercise therapy. However, after I had to explain to my patients on more than one occasion why the person in the room next to my patient was screaming in pain from a dry needling treatment, I decided sharing this space was no longer in the best interest of my patients or myself as a health care professional. I was also told by several physical therapists that if they were not able to dry needle they would no longer have a medical practice. The majority of those physical therapy patients received primarily dry needling. I question how physical therapists (who are not licensed acupuncturists) ethically bill for dry needling, as a CPT insurance code for dry needling does not exist. Dry needling by physical therapists in Virginia is illegal unless the therapist also holds an acupuncture license.

I have seen advertisements for dry needling as a treatment for sinusitis/allergy complaints and facial rejuvenation, as well as a video of a physical therapist dry needling “Hegu” (an acupuncture point on the hand) for headaches. Dry needling courses are being taught using acupuncture point locations. And now there is “passive dry needling” where the needles are retained for 20 minutes. These are examples of the illegal practice of internal medicine, dermatology and acupuncture by physical therapists without proper medical licensing credentials.

An appropriate and honorable checks and balances system needs to address these gross discrepancies in educational standards in Virginia outside of financial interests or personal gain. Superior, patient-focused medical care does not exist in isolation, but rather in collaboration. A mutual respect among professions is warranted. I am not opposed to physical therapists practicing acupuncture with an appropriate level of training. However, zero hours of training is not sufficient. The educational standard to practice as a licensed acupuncturist in Virginia, to include the trigger point release physical therapists are attempting to separate from acupuncture by calling it dry needling, is to graduate from an accredited acupuncture school with appropriate clinical training, a one-year supervised clinical internship and pass three NCCAOM Board Exams. While physical therapists would almost certainly receive transfer credit for much of their western medicine training when they attend acupuncture school, it is their responsibility as medical professionals to complete this training—and a grave, unacceptable risk to patients if they do not.

Sincerely,

Jodi Knauer, M.S., L.Ac., Dipl. Ac.

Doctoral Candidate, 2018