The Rose Has a New Name

By Valerie Hobbs, DiplOM, LAc

When I walked into the treatment room last Tuesday night, the last thing in my mind was whether or not the most effective treatment for my patient would be considered as dry needling or as acupuncture.

I teach in an acupuncture college, and I work in an OB-Gyn acupuncture clinic twice a week. Like most acupuncturists, even with a specialty designation, the patients I see frequently present me with musculo-skeletal complaints. One of my patients on that Tuesday was a 27 year old primigravida at 14 weeks gestation. She was seeking acupuncture treatment for the first time. Her chief complaints were fatigue, morning sickness, and back and hip pain.

While the Chinese medical diagnoses of spleen qi vacuity, liver and stomach disharmony, and qi stagnation in the taiyang and shaoyang channels were emerging, I was also assessing trigger points in the quadradus lumborum, gluteus minimus, and gluteus medius. I was thinking in both Western anatomic and Chinese medical terms because what I do, what I have been trained to do, is to practice an integrated system of medicine. Although the gluteus medius points were mildly tender to deep palpation, the gluteus minimus points were tender and taut. However the quadratus lumborum trigger points were the most tender and taut. My patient’s pelvis was normally aligned with neither an anterior or posterior tilt nor a right to left or left to right rotation. Palpation of distal meridian points and pulse diagnosis confirmed the underlying Chinese medical diagnosis of spleen qi vacuity with liver and stomach disharmony.

To needle the QL trigger points, I would need to disperse points in close proximity to the kidney organ back shu points. Because of the early pregnancy status, the moderate nature of the muscle spasm, the Chinese medical implications of the location of the points, and also because the patient was seeking treatment the first time, I chose not to deeply needle the muscle trigger points. I chose instead to use a distal point technique. A point 1 cun distal to Lung 5, which was also ropy, tight, and painful to palpation was needled ipsolateral to the back pain. The needle was inserted to a depth of 2-2.5 cm until a qi sensation was felt, and the muscle fibers in the area of needling released. The patient was standing and was asked to gently extend and flex at the waist. The pain relief in the quadratus lumborum with an increased range of motion was immediate. QL trigger points that were previously taut and tender were no longer taut and no longer painful. The rest of the treatment commenced to fortify the spleen and harmonize the liver and stomach.

The previous week a 34 year old woman with a chief complaint of lateral hip pain sought treatment in her 28th week of her second pregnancy. For years she had played softball in the catcher position and had developed hip pain in her first pregnancy, which became very problematic. It had been described as a 6/7 out of 10 on a pain scale, disrupting both activity and sleep. Trigger points were palpated bilaterally in the piriformis. Trigger points and motor points in the piriformis muscle were needled deeply into the piriformis. Fasciculation was not elicited per se. What I felt, and what I wanted to elicit, was the anatomic sensation of muscular release, with the underlying TCM “deqi” sensation. The relief was again immediate.

I had learned the techniques I used in my first diploma degree program in traditional Chinese medicine in 1994. I learned this technique from acupuncturist Jim Skioen, based on the work of Janet Travell, and learned further refinements of the technique most recently through post graduate education with acupuncturists Whit Reaves, Matt Callison, Michael Young and physical therapist Cary Gold. Had a viewer from another planet been observing the technique, it would have been indistinguishable from dry needling. Had a viewer from the psychic network been observing both my treatment and that of a physical therapist, he or she would have had an equally difficult time discerning any difference in thought pattern concerning the Western anatomical assessment and application of treatment.

The debate about the emergence of dry needling and its relationship with acupuncture continues. In my opinion, it is a highly sociological, perhaps even anthropological, but not necessarily a medical, debate. Proponents of dry needling, as well as some acupuncturists, describe a definition of acupuncture as an energetic balancing system based on classic principles.

This definition of acupuncture is a modern Western invention. Western medical non-acupuncturist practitioners seek to describe their recent “discovery” of what acupuncturists have long known, that is, that the insertion of a needle into the body can alleviate pain. Because the Western researchers describe the phenomenon in Western medical terms, skipping the complex of Asian medical diagnostics and acupuncture point and meridian energetics, they claim that they are doing something quite distinct from practitioners who trace their lineage of knowledge from Asian medical sources. In a way this Western approach is isolating the subset of acupuncture techniques that they perceive as what “really works” or that subset which can be described and measured in Western medical terminology. The contention is, then, that a single technique is being adopted, not the entire medical system. Since that technique is described in Western terms, by Western practitioners who claim no knowledge of Asian medicine, it has become a new and distinct area of medical practice.

Some modern Western acupuncturists have also embraced the trend to define themselves as practicing a medicine that encompasses an energetic balancing, and this is reflected is some state’s practice acts. This trend does not follow World Health Organization definitions, which tends to define the practice of acupuncture by technique. The most recent document on the subject from the WHO, Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials by Xiaorui Zhang, describes the system of acupuncture treatment in this way: “the term ‘acupuncture’ is used in its broad sense to include traditional body needling, moxibustion, electric acupuncture (electro-acupuncture), laser acupuncture (photo- acupuncture), microsystem acupuncture such as ear (auricular), face, hand and scalp acupuncture, and acupressure (the application of pressure at selected sites).”1 The most recent successfully enacted acupuncture practice act in the U.S. is from the state of Michigan in 2006. Public Act 30 defines acupuncture in this way: “Acupuncture’ means the insertion and manipulation of needles through the surface of the human body at specific locations on the human body for the prevention or correction of disease, injury, pain, or other condition.”2

In adopting language that describes Asian medicine as an energetic balancing system, what acupuncturists may be attempting to do, independently or in response to medical practitioners who isolate and adopt single techniques, is to distinguish what they are doing as a system-based approach to health care rather than being defined by the individual technique. This more global language also embraces the larger scope of Asian medicine that extends beyond physical medicine into internal medicine. Certainly, as an acupuncturist, I know that what I did in my Tuesday night clinic was not simply to needle the piriformis muscle. The needling of the piriformis was performed in the context of a comprehensive treatment based on the presentation of the entire individual. However, if I were to define my scope of practice as providing healthcare by utilizing an ancient energetic system of balance, would I someday find myself sacrificing the scope of acupuncture defined in Western medical terms to a biomedical practitioner?

Sticking points
Articles on dry needling and its disassociation with acupuncture continue to be published3, and the ramifications from the most recent legal debate in Colorado are still emerging. What follows are a distillation of what I am calling sticking points—those areas of debate that reveal the contrast in the points of view from those promoting dry needling by biomedical practitioners based on their knowledge of Western anatomy and the acupuncture community.

Contrasting Approaches
There are inherent differences in a Western medicine approach and an Asian medicine approach when diagnosing and treating disease. Western medicine has been and continues to be focused on the single component that describes or treats a medical condition or disease. We have therefore mapped the human genome, discovered viruses, and extrapolated active ingredients to create Western pharmacology. Asian medicine, while recognizing and utilizing the single component, describes the environment in which that single component manifests. Therefore, while the physical therapist may dry needle a trigger point in the infraspinatus, the acupuncturist treats the person whose infraspinatus muscle is in spasm. Whether it is the needle in the trigger point that provides relief or it is the global needling of the entire system that provides relief remains an area of fascinating study.

Exclusive Use of Western Medical Terminology
What proponents of dry needling claim is that since they are thinking in Western anatomic terms, that their technique is distinct from techniques performed by a licensed acupuncturist even though the instrument employed, and that location on the body, and manipulation is exactly the same. In other words, dry needlers are suggesting that the scope of practice be defined by what is in the mind of the practitioner. What is most dangerous about this assertion is the subsequent drawing of a distinction in the regulatory environment that everything in Asian medicine must be couched in terms of ancient origin. This is contrary to the educational and regulatory advancements to date in the United States for the licensing of qualified trained practitioners of Asian medicine.

In discussing the need to provide clarification of authority to diagnose in Western medical terms, The Little Hoover Commission, in its 2004 report to the California legislature concluded, “interactions with other health care providers, including collaboration and referrals, as well as with many members of the public, benefit from the use of common, Western-based diagnostic terminology.”4

The move to expand the physical therapy scope by drawing a distinction through use of language and the thought process of the practitioner is quite chilling. Asian medicine has never been, nor is it now, a static system of medicine. While based in classic literature of unprecedented history, 2000 years of interpretation have resulted in many, many advancements and reinterpretations. I am quite sure that Zhang Zhongjing himself would have been fascinated by culturing bacteria in the course of what he described as an internal heat invasion and would have gone on to describe when and how to properly apply broad-spectrum antibiotic therapy, undoubtedly within the context of additional herbal medicinals to mitigate its side effects and enhance its efficacy.

At no time in human history have we had this current benefit of global instantaneous communication and integration of knowledge. The impact of this globalization is greatly felt within the practice of Asian medicine. There are many changes and advancements occurring as a result of this unprecedented integration. Some of these advancements are a direct result of Western scientific inquiry and analysis. My Tuesday night patients are absolutely safer and enjoy much more efficacious treatment than they could if I were to be restricted only to a system of healing based solely on pre-scientific Asian medical diagnostics and systems of treatment. In fact, educational and professional mandates have been promoted by the profession and embodied within the laws that govern my practice. While basic diagnoses may be derived from the medicine as it was practiced in past centuries, I work as an independent provider of health care in the United States in the 21st century. I must integrate both systems and not be relegated to only one. Janet Travell’s seminal work is as much a basis for my daily practice as it is for the physical therapist.

Equal Status in the Health Care System
The reason I characterize the debate about dry needling and its relationship to acupuncture as a sociological debate is because the debate emerges in and is highly shaped by Northern European and Northern-European derived cultures. There is certainly no confusion about the integration of Asian medicine and Western medicine or whether or not dry needling is acupuncture in the countries of origin of acupuncture, namely China, Japan, Korea, Vietnam, etc.

A concerted effort was undertaken in the 1970s by biomedical practitioners in Northern-European derived cultures to distance themselves from acupuncture and to do so by creating new descriptions in Western science terms. As Chan Gunn, a founder of dry needling, wrote in 1976, “As a first step toward acceptance of acupuncture by the medical profession, it is suggested that a new system of acupuncture locus nomenclature be introduced, relating them to known neural structures.”5

The dry needling regulatory debate has been centered in health care systems dominated by Western culture and Western medicine. The professions engaged in that debate are unfortunately in disparate positions in that health care system. Insurance parity becomes a primary issue, with physical therapists being reimbursed at 3-10x the rate of an acupuncturist for virtually identical treatments. (And that is if the insurance company will reimburse the acupuncturist at all.) In many states, the medical acupuncturist may receive payment, but the licensed acupuncturist is excluded.

The practice of Asian medicine encompasses much more than the treatment of musculo-skeletal pain. However, the proportion of practitioners in the United States that utilize trigger point therapy is 82%.6 Therefore, the impact of physical therapists entering the field with readily available insurance reimbursement (with virtually a long weekend’s worth of education) does indeed infringe on the practice of licensed acupuncturists.

Lack of Independent Certification
At the heart of this debate is the wide gulf between the receptive professions’ views of the certification criteria necessary to inform the public or ensure some measure of public safety. Acupuncturists practice under specific and widely proscriptive educational criteria. The American Physical Therapy Association does not consider dry needling an entry-level technique, and they neither promote nor intend to promote educational standards for techniques that they do not consider entry-level techniques.

In the physical therapy profession, many invasive techniques such as joint manipulation, wound debridement, and dry needling are all learned in post-graduate courses for which there is no educational standard. MyoPain Seminars, led by Mr. Dommerholt, requires extensive training in myofascial trigger point identification before they teach dry needling. A certification exam is also offered. But this is not the only course offered, and in Colorado at least two other providers have emerged who teach considerably less hours in weekend courses. No clinical hours are required on actual patients. In fact, in Colorado no registration of educators offering courses or of physical therapists using the technique is required at all.

It was recently reported to me that a Colorado physical therapist treated a patient for the pain of a partial tear of a tendon by inserting acupuncture needles near the area of pain. The Colorado physical therapy rule allows for a broad definition to insert a filiform needle to treat pain and is not relegated to trigger point therapy only. It would seem that any acupuncture technique that treats pain, as long as it does not involve distal or auricular points, is within the scope of physical therapy after a weekend of education in the technique. With no monitoring of either education or the physical therapist, who is to say what further acupuncture techniques physical therapists will apply?

True collaboration
If those who promote dry needling techniques for any medical practitioner truly believe that dry needling falls within the larger scope of acupuncture, then meeting the Institute of Medicine’s call for collaboration among providers of both conventional and complementary medicine means active collaboration and referral. This would suggest that researchers and promoters of dry needling learn, as all acupuncturists learn, why and when to refer to a practitioner with a different set of skills. In other words, when the physical therapist sees that intervention with acupuncture might be effective, but their dry needling technique is not effective or appropriate, a referral to an acupuncturist is in order. A place to start would be a call to all trainers of physical therapists to cease their exclusion of acupuncturists from dry needle training. While Dommerholt should be commended for his non-exclusion of such practitioners, many dry needling trainers in the U.S. and throughout Europe exclude acupuncturists. A second place to start would be to stop the distancing of one profession from another and a concerted effort to cease all publication about how dry needling can’t be and is not acupuncture would be reflective of a beginning of collaboration.

Continuing Concerns
The concerns about physical therapists and other Western medical practitioners who promote dry needling continue. These concerns may be summarized as:

Smelling the Roses
For the past year, I have been very engaged in the political issues surrounding physical therapy and dry needling and how to best professionally represent the concerns of Colorado acupuncturists. I am still very concerned about the impact of scope definition and whether or not practitioners of Asian medicine will be freely able to practice integrated medicine.

I have read with interest Mr. Dommerholt’s willingness to listen, and I acknowledge his openness and equally hope for a working relationship of mutuality. Yet when I walk into the treatment room next Tuesday, I have to admit I’m going to leave this debate at the door. What really matters to me, and to most practitioners I expect, is that I call upon myself to learn all that I can to the best of my ability to increase the efficacy of what I do for the benefit of my patients. I’m sure that physical therapists do this as well. Immersing oneself in one’s own profession, being very clear about educational and certification standards to protect the public, seeking to recognize and remove bias, and calling one another to accountability when we don’t is the way the professions will come to common understanding.

In treatment, this means that sometimes I’m going to choose a point that is based on pre-science, and sometimes it means I’m going to choose a point with only modern science in mind. What I know is that the medicine I have chosen to practice contains both of these paradigms and isn’t well suited to reduction into parts. I know that how it works is still immeasurable in Western terms, and that like the dao itself, to try to capture and describe it, means to move away from it.

As acupuncturists, the validation comes from our patients, not from a health care or legal system. As we gain the respect of the former, the latter will follow. We need to be sure to recognize that all the time we debating the name of a rose, we are still infused with its perfume. It’s still acupuncture, and it still works.

1. Zhang, Xiaorui Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials, www.who.int
2. Michigan Public Act 30 Part 165, Section 16501.
3. See Amaro, John A, When Acupuncture Becomes Dry Needling, Dynamic Chiropractic, June 3, 2008, Vol 26, Issue 12.
4. Milton Marks “Little Hoover” Commission on California State Government Organization and Economy by the UCSF Center for the Health Professions, Acupuncture in California: Study of Scope of Practice, May 2004, pg. 13
5. Gunn, CC, Ditchburn FG, King MH, Renwick GJ, Acupuncture loci: a proposal for their classification according to their relationship to known neural structures, Am J Chin Med, 1976 Summer; 4(2): 183-95.
6. Fabrey Lawrence, Cogdill Kimberly, Kelley Jeffrey, A National Job Analysis: Acupuncture and Oriental Medicine Profession, Applied Measurement Professional, Inc, August 2003, Appendix B