Dry Needling and Acupuncture
Emerging Professional Issues
By Valerie Hobbs, DiplOM, LAc
Dry Needling
“Dry needling,” or “Intramuscular Stimulation (IMS),” is a term that was developed to define the technique of placing an acupuncture needle into a muscle trigger point rather than injecting the trigger point with lidocaine or cortisone. It became known as a “dry” needle since nothing was injected. Insurance allows the billing of codes for injection therapy, regardless of whether or not anything was actually injected. PTs are using code 20522 trigger point injection for 2 or less areas at $180 and 20553 trigger point injection for three or more areas at $400. Some case law has established reasonable reimbursement for 20522 at $80-90. PTs are not billing for acupuncture.
Dr. Janet Travell did the pioneering work on injection of trigger points. In the 1980s, in the Los Angeles area, Travell taught seminars with chiropractors and acupuncturists in which acupuncturists demonstrated the use of acupuncture needles to deactivate trigger points. In the early 90s, Dr. Travell and Dr. David Simons lectured at Tri State college of Acupuncture. Mark Seem, acupuncturist, president of Tri-State and himself a published author of the technique, demonstrated how he could get the same response from using acupuncture or “dry’ needles. Dr. Simons has been teaching this technique since that discovery.
In British Columbia and in Europe respectively, Chan Gunn and Peter Baldry began teaching and writing about this technique. Chan Gunn’s initial articles in the 1970s stressed that many trigger points were close to or identical to acupuncture points. His belief was that Western practitioners would better accept the technique if the point locations were described in anatomical rather than traditional Chinese medical terms.
A Google? scholar search of “dry needling” produces over 2800 hits. Some of these articles describe dry needling and acupuncture as the same technique. However, PubMed includes a MeSH (Medical Subject Heading) term of “Acupuncture therapy” for many of the articles that distinguish dry needling as a technique that is separate from acupuncture. Whether or not the technique is acupuncture is highly debatable, even in the scientific literature.
More recently Jan Dommerholt, a leading researcher and proponent of the addition of dry needling to the scope of Physical Therapy, has published several articles describing the technique. He maintains that “trigger point dry needling does not have any similarities to acupuncture other than using the same tool.” Jan Dommerholt teaches the Travell Seminar Series through an organization called Myopain Seminars.
Proponents of the technique re-define traditional Chinese medicine as being based on a traditional system of energetic pathways and the goal of acupuncture to balance energy in the body. They emphasize the channel relationship of acupuncture points, de-emphasize or completely exclude the use of ASHI points, and emphasize that acupuncture is based on the energetic concepts of Oriental medicine diagnosis. They therefore define dry needling as different and distinct from acupuncture because it is based on Western anatomy.
PT Dry Needle Training
The main courses being offered in North America are through iSTOP in British Columbia (taught by Chan Gunn), and the Travell series through Myopain Seminars in Maryland.
Canadian physical therapists are required to show 2 years of musculo-skeletal experience and hold a certificate of acupuncture through a University of Alberta course in acupuncture for Western medical practitioners or an Intermediate Diploma of Manual Therapy from the Canadian Physiotherapy Association prior to attending the iSTOP 54-hour course in dry needling. American practitioners may travel to Canada and take the 54 hour course if they can show that dry needling is in their scope of practice. No other prerequisites are required.
The Travell Series is comprised of an 80 hour course on myofascial trigger points and a 36 hour course on dry needling. The course is designed for licensed healthcare practitioners including acupuncturists.
No standards are available for dry needling education, and no college of Physical Therapy has offered a course in dry needling to date. Georgia State University is set to offer a course in the doctor of physical therapy program in spring, 2008. Information about the course has not yet been released.
In Colorado, multiple people, including LAcs, are teaching courses in the technique to PTs. There is no standard curriculum. Some courses are reported to include more than needling of triggers points, such as the use of distal points and electro stimulation. To date, most courses in Colorado have excluded acupuncturists from attending them. The reason specified for the exclusion is that acupuncturists do not know enough anatomy.
Jurisdictions that have allowed the practice
Letters of inquiry about including dry needling under physical therapy scopes of practice began to surface in multiple state boards in the 2000s. State regulatory agencies in Georgia, Kentucky, Maryland, New Hampshire, New Mexico, South Carolina, Virginia and Colorado have issued policies that the technique is within the scope of practice of physical therapy. To my knowledge, no statutory authority has been granted to physical therapists to include the technique. This means that a Board is making a policy to include the technique by a rule, rather than the physical therapy profession having to sponsor and pass a bill that explicitly changes state physical therapy law. All of the rulings have clearly specified that “dry needling” is not acupuncture.
Several jurisdictions have ruled that dry needling is not within the scope of physical therapy. Hawaii, California, and Tennessee have flatly rejected the expansion of scope. In Hawaii and California, physical therapists may not invade the skin to apply therapy and therefore the technique was not included in their scope. Tennessee ruled that the practice is acupuncture.
Several countries throughout the world allow for the practice of “dry needling” by physical therapists. The countries include Canada, Chile, Ireland, the Netherlands, South Africa, Spain and the United Kingdom. It is interesting to note that no Asian country has adopted the idea that “dry needling” is not acupuncture.
Recent Events in Colorado
In 2005, the Physical Therapy Advisory Board heard a presentation by a Colorado physical therapist who graduated from the iSTOP course and began teaching courses in Colorado on dry needling. He asked the PT Board to issue a policy statement that dry needling was within the scope of practice of physical therapists. Without any notification to other healthcare practitioners who practiced acupuncture, and without any further study beyond the original presentation, the PT Board advised the director of the Colorado Department of Regulatory Agencies to issue a policy statement that IMS or dry needling was in the scope of practice of physical therapy. In so doing the only requirements were “The Director expects physical therapists to obtain the necessary training prior to using IMS.” No certification would be required or monitored by the Colorado PT Board.
The Acupuncture Association of Colorado (AAC) began to receive complaints through its members whose patients reported that their PTs had done “acupuncture.” The AAC requested a hearing before the PT Board on the issue.
One of the unique problems in Colorado is a portion of the Acupuncture Practice Act. Colorado law defines acupuncture as:
- The insertion and removal of acupuncture needles,
- The application of traditional oriental adjunctive therapies, and
- The application of heat therapies.
There are also exclusions in the Colorado Acupuncture Practice Act. Acupuncturists are excluded from utilize X-rays, MRIs, ultrasound, osteopathic medicine, chiropractic, and – mostly poignantly – “physical therapy as defined in [the Physical Therapy Practice Act] or therapies allowed as part of the practice of physical therapy.” Should “dry needling” remain as a technique under the Physical Therapy statute and be defined as “not acupuncture” Colorado acupuncturists would be prohibited from using the technique.
A rule-making hearing allowing the practice of “dry needling” under the physical therapy statue will be held in Colorado in October. Colorado acupuncturists intend to challenge such a rule through a process called a legislative review. A legislative review is a review conducted by legislative attorneys to ensure rulings do not create a conflict with existing statutes.
The National Commission for the Certification of acupuncture and Oriental Medicine will be sending a testing expert to the October hearing. Her testimony will present the 2003 Job Analysis survey by the NCCAOM that showed that 82% of acupuncturists use needling of muscle trigger points in their practice.
Issues for the Profession to Consider
Physical therapists have been very proactive in the research involving acupuncture of muscle triggers points and are well published. Acupuncturists have been virtually silent. In allowing the practice in British Columbia in 2001, the Health Profession Council under the Ministry of Health in British Columbia found that physical therapists were within their scope of practice to use an acupuncture needle for the treatment of pain. They also clearly stated that this was distinct from the practice of acupuncture under Traditional Chinese medicine since it did not include TCM diagnosisor any knowledge of the energetics involved in traditional acupuncture. They felt that to avoid confusion of the public, they would define the technique as distinct from acupuncture.
While the debate in Colorado may involve a catch-22 exclusion in the acupuncture act, practice acts in the rest of the country do not involve such conflicts. Once an accredited PT doctoral program graduates doctors of physical therapy who have been taught dry needling in the regular course of their curriculum, additional state legislatures will be looking at and inevitably allowing the practice by PTs.
The acupuncture profession needs to step forward to assert expertise over acupuncture techniques. Research on needling of muscular trigger points must be published, and a clear consensus that ASHI acupuncture is as much a part of our medicine as energetic acupuncture needs to be established.
We live in a modern world. Dommerholt and others describe the basis of meridian acupuncture as an “arcane” and ancient system that is cumbersome and not necessary to know to effectively relieve pain. Such researchers write as if acupuncturists do not integrate Western descriptions of anatomy, and integrate any advances based on Western science is not within the basis of our medicine. In the coming decade, acupuncturists must solidly emerge as practicing an integrated rather than complimentary medicine.
Valerie Hobbs, MSOM, Dipl OM, LAc, is a Colorado acupuncturist. She is the campus director and a full professor at Southwest Acupuncture College Boulder Campus. Dr. Hobbs is working with the Acupuncture Association of Colorado and the AAAOM on the “dry needling” issue.
The AAAOM has been monitoring the spread of legislative proposals in several states to include dry needling in the scope of practice of non-acupuncturists. The following article outlines the background and current trends regarding this controversial scope of practice problem. The AAAOM recently issued a statement in support of acupuncturists in Colorado (PDF).