Dear Acupuncture Today Editor, I have followed with interest the discussion of dry needling in the March 2019 issue, beginning with Dr. Steven Collins'; article "We Are Fighting the Wrong Battle," followed by several Letters to the Editor.
The Washington, D.C. Board of Medicine has adopted a thoughtful and pragmatic approach to this issue that might be of interest to the community. In their Guidance Statement for the practice of dry needling by physical therapists (https://dchealth.dc.gov/release/policy-statement-guidance-dry-needling-practice-physical-therapy), the D.C. Board of Medicine permits properly trained physical therapists to use filiform needles for dry needling; however, the Guidance Statement indicates that physical therapists performing dry needling should include in their informed consent form "... a clearly and conspicuously written statement that the patient is not receiving acupuncture" [emphasis added].
This approach achieves two important goods. First, it gives patients the benefit of dry needling at their physical therapist';s office—which can be helpful to patients when delivered by a properly trained physical therapist (more on training below). In some cases, dry needling can enhance the effectiveness of standard physical therapy protocols by resolving a muscle knot before proceeding with exercises and/or manipulation. Also, for physical therapy patients with a muscle knot, it may be less burdensome to be dry needled as part of their physical therapy visit, vs. scheduling an entirely separate appointment with an acupuncturist to put a needle into the muscle knot.
At the same time, the D.C. Board of Medicine';s approach protects the profession of acupuncture from encroachment by health care practitioners who are trained not in acupuncture, but in a very simplistic, limited needling technique that we call Ah Shi needling (and they call dry needling). By the informed consent language cited above, the Board of Medicine makes it clear to patients that they cannot get acupuncture from their physical therapist. This protects the integrity of our medicine. It also ensures that patients who want acupuncture will seek out a licensed acupuncturist. Similarly, physicians who wish to refer their patients for acupuncture know that only licensed acupuncturists can provide acupuncture treatment.
Regarding dry needling training, the acupuncture profession has a substantial, and legitimate, interest in adequate training standards for physical therapists practicing dry needling, as dry needling accidents may give the public the perception that filiform needles themselves are unsafe. Part of the reason people feel comfortable receiving acupuncture is the stellar safety record of filiform needle use by licensed acupuncturists. Acupuncturists have a strong interest in making sure the safety record of the filiform needle is sustained, in perception as well as in reality.
The physical therapy profession shares (or should share) this interest in safety. Developing training and safety standards for dry needling provides an excellent opportunity for genuine collaboration between acupuncturists and physical therapists, in pursuit of our common interest in patient welfare. Collaboration among disciplines for the benefit of patients is the very essence of integrative health care. We advance our profession by doing this well, often, and in a variety of contexts.
Training standards for non-acupuncturists using filiform needles must ensure that patients are protected from the risk of muscle, organ, and nerve damage, as well as infection. Based on my personal experience taking a dry needling "weekend course," while the didactic material was excellent and the instructors highly skilled, the amount of time allocated for actual needling by needle-naïve students is probably not sufficient to ensure safety, in my view. I believe additional hours of clinical supervision should be considered for the basic dry needling certification.
A student stands over a patient, needle poised. They have a “perfect” prescription: a textbook combination of points harvested from a lecture slide on chronic lower back pain. But as the needle meets the skin, the student hesitates - the symptom of a quiet habit that has taken hold of our profession. We routinely say we “prescribe” points. It sounds efficient. It echoes the authority of biomedical culture and fits neatly into the insurance field. But vocabulary is never neutral; repeated long enough, it dictates behavior.
Acupuncture can be highly effective in cases of nasal congestion so common in allergy presentations; so much so that I often treat such issues using acupuncture protocols alone. In cases of seasonal allergies with highly predictable causes such as obvious elevations of environmental allergens, I use a skeleton acupuncture prescription that can easily be fleshed out to target potential underlying patterns and effectively customized to the patient.
The field of acupuncture in the U.S. continues to grow in visibility, patient demand and clinical effectiveness. Yet behind the curtain, many acupuncturists are quietly struggling to keep their doors open. While the profession is rooted in centuries of healing tradition, modern economic pressures – particularly those driven by insurance limitations, low reimbursement rates and job-market saturation – are making it increasingly difficult for licensed acupuncturists to thrive.
