Currently in TN there are a number of licensed Physical Therapists openly advertising and offering the service of “Dry Needling”. In the American Physical Therapy Association’s 2012 Educational Resource Paper, “Physical Therapists & the Performance of Dry Needling” defines Dry Needling as follows:
“Dry Needling sometimes referred to as trigger point dry needling or intramuscular manual therapy is an invasive technique used by physical therapists to treat myofascial pain that uses a dry needle, without medication or injection, which is inserted into areas of the muscle known as trigger points.
The term Dry Needling was first used by Dr Janet Travell, MD in her landmark publication: Myofascial Pain and Dysfunction, the Trigger Point Manual, 1983. Dr Travell, a cardiologist, was particularly interested in whether there was a pathological relationship between myofascial trigger points in the pectoralis muscles and non-specific chest pain. Dr Travell defined these Trigger Points as: “hyperirritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers”
The earlier stages of her research involved the injection of substances, saline, procaine, etc. into these points to determine their effect on relieving muscle contraction and its associated pain. Although her work with injectable solutions supported her hypothesis, over time she determined that the needle itself was providing most of the remedial effect, not the injected substrate. Consequently, experiments using a hypodermic needle without injection required the development of the term Dry Needling to distinguish it from the Wet Needle injection technique.
In her book she discusses the relationship between Trigger Points and Acupuncture points, stating: “The distinction between Trigger Points and Acupuncture points for the relief of pain is blurred for a number of good reasons… There is a high degree of correspondence between published locations of Trigger Points and classical acupuncture points for the relief of pain” According to her studies at that time there was an approximate 71% correlation between Acupuncture points and myofascial trigger points.
A 2008 study by the Mayo Clinic’s Department of Physical Medicine and Rehabilitation, entitled “Trigger Points and Classical Acupuncture Points”, (P.T. Dorsher, J. Fleckenstein) further explores the relationship of Acupuncture points to myofascial trigger points. It concludes that myofascial trigger point regions were demonstrated to have 93.3% anatomic correspondences with classical acupuncture points. Further, that trigger points most likely represent the same physiological phenomenon as Acupuncture points in the treatment of pain disorders.
In essence, both sources are saying that, with respect to myofascial pain management, trigger points and acupuncture points are substantially the same points. Trigger points, being fewer in number, are then a subset of the catalog of acupuncture points as published by the World Health Organization (WHO). By logical inference, using a needle to puncture a trigger point is substantially the practice of Acupuncture.
By extension, Dry Needling of Trigger Points is a form of Acupuncture. Although Dry Needling proponents claim it is more scientific than acupuncture and is therefore a different technique, choosing to describe classical Acupuncture in Western biomedical terms does not make it a different science, just a more elucidated one.
Acupuncture, once the target of skeptics, has now been demonstrated in contemporary western studies to have significant impacts on pain management. Consequently, the interest in its use has increased in recent years. Several classes of healthcare practitioners would now like to include needling techniques in their scope of their practice. Amongst these is the membership of the American Physical Therapy Association.
The APTA seeks to include Dry Needling into the scope of practice of Physical Therapists on a national basis. In its 2010 Resource Paper the APTA adopts the position held by the American Academy of Orthopedic Manual Physical Therapists (AAOMPT) that “dry needling is within the scope of physical therapy practice”. In Appendix B of this paper, the Federation of State Boards of Physical Therapy (FSBPT) states that “Although the FSBPT Model Practice Act does not specifically mention intramuscular manual therapy there is nothing to specifically exclude the technique.”
The APTA Resource Paper is designed as a resource for state Physical Therapy boards to consult as they make a determination whether to approve Dry Needling/Intramuscular Manual Therapy for inclusion in the scope of practice for Physical Therapists. It is concerning that there is a movement to persuade state boards that Dry Needling is already in the scope of practice for Physical therapists, yet there is no substantial, uniform regulatory requirement for education of Dry Needling proposed. In the Resource Paper it is stated: “Currently dry needling is not specifically included in entry‐level education for physical therapist”. They further state that the therapist must be competent to perform this intervention but fail to state what level of education is necessary to gain this competency.
At present, two main sources of outside training have sprung up to offer certification classes in Dry Needling. Kineticore, a Physical Therapist education company in Colorado offers a Level 1 and Level 2 course, which when combined total 55 hours of instruction. Another company, Myopain Seminars, offers weekend certification classes across the country. Completion of all the modules of this program total 104 hours of training. These courses are designed for practitioners who have never had any previous training in the insertion of a surgical needle into a human body.
These seminars purport to adequately train individuals to perform this technique. However, it is not clear from the AAMA statements whether all or only part of this instruction constitutes adequate training to be competent; this is apparently left to the state board to decide. Moreover, the inadequate number of hours does not meet the level of competency or safety which is deemed necessary by regulations governing the practice of Acupuncture in the state of Tennessee. The APTA claims that the basic PT curriculum already includes gross anatomy and physiology, which they claim is a sufficient pre-requisite for the Dry Needling certification offered by these outside vendors. However, it is noteworthy that in most states even MDs are required to have 200-300 hours of approved training in this invasive needle technique.
Acupuncture is considered safe when performed by a well-trained practitioner. Serious risks and adverse events are avoided when practitioners have been prepared to a high level of competency. Licensure to practice Acupuncture in Tennessee requires that candidates meet the standards set forth by the National Certification Commission on Acupuncture and Oriental Medicine (NCCAOM ). These standards currently include 1490 hours of training in Acupuncture, of which 660 hours must be clinical hours supervised by a licensed acupuncturist. Successful completion of board examinations for Foundations, Diagnostics, Point Location, and Western Biomedicine award the practitioner advanced standing in our field. Successful completion of the Clean Needle examination through the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) meet eligibility requirements to practice Acupuncture in the United States.
Competency and safety should be the standard when decisions of the public interest are being interpreted. Training has to meet the standard set forth by the Tennessee Code Annotated, Title 63, Chapter 6, Part 10; 63-6-1001, and, the Acupuncture Certification Process; Rule 0880-12-.02 in the General Rules and Regulations Governing The Practice Of Acupuncturists.
The Acupuncture Act of Tennessee, TCA:63-6-1001, part 10, et seq., sets active certification in acupuncture by the National Commission for the Certification of Acupuncturists and Oriental Medicine as the presumptive standard of education and training for safe practice in this field.
On the websites of both the aforementioned companies offering Dry Needling certification are statements that the State of Tennessee Physical Therapy Board has approved Dry Needling for Physical Therapists. (http://www.kinetacore.com/physical-therapy/-/page63.html). The physical therapy practice act for the State of Tennessee does not specify that the insertion of any needle lies within the scope of practice for physical therapists. In August, 2011, the Tennessee Physical Therapy Board convened to propose, by administrative rule, that the practice of ‘Dry Needling’ by a licensed physical therapist be upheld by the board and signed into rule by the Attorney General. An email to the Board of Physical therapy requesting information on the adoption of any rule allowing Dry Needling received the following response:
The Practice Act has not changed in any way. The Board’s understanding is that ‘Dry Needling’ is and has always been in the Scope of Practice for physical therapists in the state of Tennessee.
In its 2012 position paper on Dry Needling, the APTA stated that Dry Needling is now within the Scope of Practice for PT’s in Tennessee. However, it is important to note this change from its 2001 annual executive update which reported that Dry Needling fell beyond the PT’s scope of practice in the state of Tennessee and that any practice of an invasive technique was deemed illegal.
The foregoing appears to echo the AAMA language, and presumes that the practice of Dry Needling is already in the scope of practice for Physical Therapists in Tennessee. Given that a significant number of physical therapists are openly advertising and practicing Dry Needling in Tennessee, one must conclude that they are either in flagrant violation of the law, or that they are basing their right to practice the insertion of Acupuncture needles on the approval of their board, which is probably more reasonable.
(Note: Dry Needling, as practiced by Physical Therapists, utilizes a solid, filiform needle, not a hypodermic needle as the technique was first developed. The filiform type of needle is presently classified and regulated by the FDA as an Acupuncture needle.)
Following is a sample list of Physical Therapy websites offering Dry Needling services in the State of Tennessee:
In conclusion, there are several states across the nation that are in the middle of legal battles over whether the Board of Physical therapy has the authority to presume Dry Needling already in the scope of practice. North Carolina, Maryland, and Oregon courts have issued temporary injunctions. Mississippi, Louisiana, Illinois, and South Carolina are in the beginning stages of legal action on this issue. Currently, South Carolina requires the any discipline practicing Acupuncture must meet all of the academic and clinic requirements set forth by the NCCAOM. At this time, no Physical Therapist has within its scope of practice the ability to insert a needle into the skin for therapeutic purposes.
It is the opinion of the Tennessee Acupuncture Advisory Committee to the Medical Board that a further investigation should be conducted as to the jurisdiction under which the regulation of Dry Needling should fall.
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