As a licensed acupuncturist in Virginia, who also maintains licensure by the California Acupuncture Board, I strongly object to the proposed drafting of "dry needling" regulations as they are outlined in 18VAC112-20-121. I objected strongly to the draft that preceded this one in the first comment period ending December 2015. Since the original guidance document was written in 2007/8, which preceded the promulgation of the proposed regulation, the Physical Therapy Board has blatantly disregarded scores of comments from healthcare practitioners, including physicians, opposing the illegal practice of “dry needling” by physical therapists. Reports of patient injury have been dismissed. This is irresponsible medical practice and has created an escalating threat to public safety in Virginia, which has resulted in numerous reports of injury to patients. This mirrors similar challenges with public safety respective to “dry needling” nationally.

In my opinion, neither the Virginia Department of Health Professions or the Physical Therapy Board have taken this seriously, and the Physical Therapy Board has ignored numerous requests from other stakeholders to formulate standards that meet those of recognized standards of acupuncture practice in this country. Those standards, as practiced by medical doctors and licensed acupuncturists, have collectively been on the books for well over 35 years.  Physical therapists have instead chosen to circumvent the process of legislation to change their scope of practice, instead using regulation as a means by which to add the invasive modality of acupuncture, or “dry needling” into their regulations. As many others have commented, this effectively constitutes the illegal practice of acupuncture.

This makes it necessary for physical therapists to hold to the fallacy that “dry needling” is not acupuncture, despite the fact that every instructive text on “dry needling” references acupuncture. Even a slight amount of critical thinking leads one to realize that it is impossible to explain the therapeutic rationale for “dry needling” without referencing acupuncture. And of course, evaluation of therapeutic rationale and clinical outcomes are necessary for insurance reimbursement. Even the American Physical Therapy Association (APTA) website has a document produced in 2013 by their “public policy and professional affairs unit” entitled “Description of Dry Needling in Clinical Practice.” http://www.apta.org/StateIssues/DryNeedling/ClinicalPracticeResourcePaper/

A quick glance at that document yields several references to acupuncture research:

#31: Langevin HM, Bouffard NA, Badger GJ, Churchill DL, Howe AK. Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: Evidence for a mechanotrans-duction-based mechanism. J Cell Physiol. May 2006; 207(3):767-774.

#41: Ge HY, Fernandez-de-Las-Penas C, Yue SW. Myofascial trigger points: spontaneous electri- cal activity and its consequences for pain induction and propagation. Chinese Medicine. 2011;6:13.

#51: Baldry PE. Acupuncture, Trigger Points and Musculoskeletal Pain. Edinburgh: Churchill Livingstone; 2005.

#52: Ceccherelli F, Rigoni MT, Gagliardi G, Ruzzante L. Comparison between superficial and deep acupuncture in the treatment of lumbar myofascial pain: a double-blind randomized controlled study. Clin J Pain. 2002;18:149-153.

#64: Fu ZH, Wang JH, Sun JH, Chen XY, Xu JG. Fu’s subcutaneous needling: possible clinical evidence of the subcutaneous connective tissue in acupuncture. J Altern Complement Med. Jan-Feb 2007;13(1):47-51.

If an invasive procedure such as acupuncture were originally intended to be within the scope of practice for physical therapists, it would have been included in all 50 state statutes, would have been taught in PT education programs for decades, and there would have been a CPT code for insurance reimbursement. Instead none of those things happened, and physical therapists again are skirting the legal bounds by misrepresenting “dry needling” as a manual therapy technique, which is clearly defined in the scope of practice for physical therapists, in § 54.1-3473. The modality of acupuncture is not part of that code. Despite this, physical therapists are billing patients for manual therapy, neuromuscular re-education, or injection (even though nothing has been injected). This information is not difficult to find. A quick search for “billing for dry needing” yields many opinions on how best to work the system. 

It is worth mentioning that the issues surrounding physical therapists and “dry needling” have created a contentious environment between two professions that should, and historically have, worked in tandem for the benefit of the patient. Personally, I was employed as a physical therapy assistant and chiropractic assistant years before my training in traditional Chinese medicine, and before I became a licensed acupuncturist. This made for a natural inclination to refer to physical therapists after my licensure. In fact when the “dry needling” debate was first brought to my attention in 2009 while serving on the Board of the American Association of Acupuncture and Oriental Medicine (AAOM), I incorrectly believed there could possibly be a “threat” to this long-standing relationship between the two professions. Further, in today’s insurance driven landscape, the typical manner of treatment for pain goes like this: After consulting with an MD or orthopedic specialist to obtain a diagnosis, and likely medication, the patient is often referred to a physical therapist, in order to rule out a purely muscular / soft tissue scenario that is the cause for strain / pain. This is a cost saving measure (for the insurance company), rather than obtaining imaging first, such as an MRI, to determine if the issue is instead structural. The physical therapist is now in a situation that requires them to alleviate the pain in a short course of treatment. The licensed acupuncturist faces the same situation.

This is why acupuncture, aka “dry needling” has been such a game changer for PTs, who often get poor compliance from patients who are supposed to do their exercises regularly, and why so many patients have reported miraculous return to function. HOWEVER. These patients have in fact been receiving orthopedic acupuncture, also known as “myofascial trigger point acupuncture,” “classical fascia needling,” “motor point needling,” “trigger point needling” which are all STYLES OF ACUPUNCTURE, as codified in § 54.1-2900, that are employed by licensed acupuncturists across the country. 

Licensed acupuncturists have successfully worked alongside other allied health professionals for decades. If I am being generous, I could imagine that the inclusion of the stipulation in the original guidance document, requiring that patients sign a statement acknowledging they “are not receiving acupuncture” was an effort to appease the one licensed acupuncturist that was on the “task force” when the document was created.  However, to request that patients sign a disclosure wherein they acknowledge they are not receiving acupuncture, and then proceeding to treat them with…acupuncture, is confusing and deceptive. I speculate that this misconception has become so ingrained within the PT profession that they actually do not realize the wild absurdity of this argument.

Physical therapists reportedly have been doing dry needling in Virginia since 2003, historically in the context of a physical therapy practice. Despite the glowing reports from patients who have been miraculously cured with this acupuncture treatment that is “not acupuncture,” this has not been with a 100% safety record, even with the vague requirement for medical referral and supervision. Indeed one reason this regulation is being promulgated is that American Academy of Medical Acupuncturists in 2015 sent a letter to the governors of several states, including Virginia, who were considering the expansion of the physical therapy scope to “acupuncture under the guise of dry needling.” The current draft of the proposed regulation may make it more convenient for the Board of Physical Therapy to protect itself by enforcement of a regulation in the case of public complaint or injury, but it does not protect the public from harm.

Widely overlapping treatment strategies amongst professions have further confused the issues at hand. Patients report a “great massage” from their physical therapist, and “exercise instruction” from their chiropractor. Recently in Colorado, a physical therapist was sanctioned for performing “cosmetic dry needling,” which was found to be “generally not meeting the accepted standards of physical therapy practice.”  There are numerous examples across the country of physical therapists advertising dry needing services for a wide range of medical complaints, including internal medicine, outside of the generally recognized pain spectrum. This is another obvious risk to the pubic, that will only continue to increase in Virginia and elsewhere as more physical therapists take interest in needling practices, along with occupational therapists, athletic trainers, and others. There is no safeguard to prevent this risk in the proposed regulations, as they are currently written.

The fact remains that many patients and the general pubic is confused, and if this draft of regulations stands, they are not safe. We as practitioners, with a shared interest of helping our patients, should not allow that to happen. The Department of Health Professions and the Virginia Board of Physical Therapy should not allow that to happen. I appeal to this Board to revise the current draft, and to consider the counsel of licensed acupuncturists and other medical professionals in doing so, in order to provide additional safeguards for the public via clear competency and certification requirements for physical therapists. Additionally I am appealing to cease using the argument that patients are not receiving acupuncture as a means by which to circumvent the drafting of more rigorous guidelines.

Virginia citizens deserve better, and should be assured that the highest standards for needling practices are being met and enforced. I encourage the Department of Health Professions and the Board of Physical Therapy to promote responsible regulation and quality medical practice and reject the current rules proposition.