Corie Tillman Wolf

Executive Director

Board of Physical Therapy

Department of Health Professions

9960 Mayland Drive, Suite 300
Richmond, VA 23233

February 24, 2017

Ms. Wolf:

The Maryland Acupuncture Society (“MAS”) writes to express our concerns regarding Proposed Regulations 18VAC112-20-121. Practice of dry needling submitted by the Board of Physical Therapy currently under review.

We OPPOSE these regulations as written and offer below amendments to the process.

The State of Maryland has recently undergo a similar rulemaking process to clarify the practice of dry needling; one which has been ongoing since 2009 when our Attorney General issued an opinion directing our Board of Physical Therapy Examiners that they must undergo the formal rulemaking process if the practice of dry needling were to carry legal effect.

Over the many years of this process, multiple draft regulations were proposed by the board and rejected because it was agreed by the Secretary of our Department of Health and Mental Hygiene that the insufficiencies of the regulations constituted a risk to public safety.

Having reviewed your current regulations, we have grave concern that your regulations as written will at best cause patients to receive ineffective treatment from undertrained professionals and at worst cause a significant increase in life-threatening injuries.

Dry Needling is a style of needling treatment within the greater field of acupuncture. The practice of “acupuncture” includes any insertion of an acupuncture needle for a therapeutic purpose.  Anatomically, “trigger points” and “acupuncture points” are synonymous, and acupuncture has targeted trigger points for over 2,000 years. “Dry needling” is indistinguishable from acupuncture since it uses the same FDA-regulated medical device specifically defined as an “acupuncture needle,” treats the same anatomical points, and is intended to achieve the same therapeutic purposes as acupuncture.

As such, we feel that permitting physical therapists to perform an invasive procedure for which they do not receive education in their primary schooling constitutes a scope expansion that only the legislature, not the Board of Physical Therapy, has the authority to permit.

We also feel that any such scope expansion that is permitted by the legislature must include certain safeguards which these regulations lack.

Such safeguards should include but not be limited to:

• Minimal Training: a minimal number of training hours which include both didactic classroom training and hands-on supervised practice should be specified in any regulations concerning the acupuncture practice of dry needling.  It is our understandings that acupuncturists in Virginia are required to obtain a minimum of 1,365 hours of acupuncture-specific training including 705 hours of acupuncture-specific didactic material and 660 hours of supervised clinical training.

We strongly suggest that any legislature condoned scope expansion include regulations that specify minimum hours of training, all of which should be completed subsequent to completion of physical therapy schooling as the anatomy and physiology training a physical therapist completes in school is not sufficient for knowledge of performing invasive, internal procedures such as needling.The mechanical devices taught in physical therapy schooling are used either on the surface, and do not penetrate the skin barrier, or are used to remove dead tissue from the surface of the skin. None of their regular coursework includes intervention that breaks the skin barrier into live muscular and intramuscular tissue.

• Adequacy of Training and Demonstration of Competency:  As the procedure of needling carries such risks as infection and organ and nerve damage, it is essential that training courses for the acupuncture procedure known as dry needling are accredited and offered by providers of an advanced skill level. 

Over the many years that Maryland has worked to better regulate this procedure, we have witnessed “dry needling” classes that constitute less than 12 – 24 hours of large group lecture with little to no hands-on supervised practice.Class participants are then given needle packages at the end of the weekend and encouraged to immediately begin offering this service in their own clinics.These classes are often offered in the Washington DC metro area, and it is no doubt to us that your own licensees in the Northern Virginia area may be drawn to taking such insufficient training courses.

We suggest that your regulations include a requirement that coursework and practicum supervision be offered only through accredited programs; that instructors have practiced this procedure for a minimum length of time, and that examinations administered outside the required training hours be passed before any providers is permitted to perform this procedure.

• Registration: In Maryland, all health occupations, including physicians, wishing to perform any form of acupuncture needling are required to submit proof of completion of their training and passage of any required competency examinations to their respective board and specifically register for a certification in addition to the license they already have.  This safeguards the public in two ways.  First, it assures that providers are actually completing the necessary educational requirements before offering the service, and allows the board to penalize those providers who advertise this service without having completed the essential training.  Secondly, it allows our licensing boards to better track injuries that occur as a result of this type of needling.  With such information, the boards are better able to assess if improvements to the standards for training are needed.

• Restrictions: As previously mentioned the procedure referred to as “dry needling” is identical to one specific form of acupuncture within the greater body of the practice of acupuncture and Chinese medicine.  It is our contention that practicing one procedure of a medicine without knowledge or understanding of the greater body of knowledge will lead to unintentional consequences.  We have witnessed youtube videos, conference lectures, and articles published in physical therapy journals encouraging physical therapists to expand the practice of “dry needling” beyond the acupuncture trigger points used in the procedure to the use of distal points that fall further along the nerve or muscle channels.  These are described by the physical therapy community as points which are “linked” to the neuromuscular impairment, however we recognize them as traditional acupuncture points.  As acupuncturists, we understand that these distal acupuncture points are effective because we have spent considerable time learning the entirety of the full body neuromuscular and central nervous system response that occurs when a particular point in the connective tissue is stimulated by a needle, and we therefore have advanced training in recognizing the “link” to neuromuscular impairment.  However, such training is not included in the standard dry needling courses.

We therefore strongly recommend that your regulations restrict licensees from performing additional needling procedures that extend into the broader field of acupuncture.  We ask that you redefine the definition of dry needling to more specifically restrict dry needling to only neuromuscular trigger points rather than anywhere “linked” to neuromuscular or musculoskeletal impairments.

As research continues to confirm the evidence based benefits of acupuncture needling procedures, so too will the desire of the health occupations wishing to offer this effective service to their patients grow.  We have no doubt that you will receive multiple comments encouraging you to pass these regulations because the writer has experienced a benefit from "dry needling" because we know that dry needling is acupuncture; and we know that acupuncture works! 

But it is critical to protect the health and safety of our citizens by assuring that anyone who offers acupuncture needling, by any name, is sufficiently trained to do so.

Thank you,

David Blaiwas                                                                       Tracy E. Soltesz

President                                                                             Vice President of External Affairs

Maryland Acupuncture Society                                              Maryland Acupuncture Society