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Acupuncture and Dry Needling- What’s the Big Deal?

I have held off on speaking publicly about “dry needling” because, to be honest, until recently I hadn’t yet formulated a concrete opinion. This week, however, I came across some disturbing new information that has led to an uneasy feeling that I can’t seem to shake. While I support the idea of dry needling by other well trained professionals, I can no longer stand back and watch while patients are put at risk and my profession is demeaned. With this blog post, I hope to educate the general public about what is going on behind the scenes with the “dry needling” epidemic. Forewarning: this will be long.

First, some background:

What is Dry Needling?

It depends on who you ask. Technically, “dry needling” is a term that dates back to the mid 1900s. Janet Travell, MD, found that inserting empty hypodermic needles into trigger points could help release those points (empty meaning without liquid like one would get in a shot, hence the “dry”). These days, physical therapists and other “dry needlers” use acupuncture needles. If you ask an acupuncturist, you’ll likely hear that “dry needling” is, in fact, acupuncture. We have been palpating and needling trigger points to relieve pain for thousands of years. Patients may have heard their acupuncturist talk about trigger points as “Ashi” points- “Ashi” means “ah, yes!” as this is the sound we often hear when we find the sweet spot. The World Health Organization agrees with the acupuncturists on this one. In the 2007 WHO International Standard Terminologies, the WHO defines “trigger point needling” as “a type of acupuncture in which the trigger points are needled for therapeutic purposes.” (Note: the American Physical Therapy Association states that “trigger point needling” is another name for “dry needling” here.)

The educational requirements for dry needling certification and acupuncture certification or licensure are also very different, with acupuncturists having a minimum of 660-870 hours of hands-on, supervised training (in addition to 1245-1755 hours of training in diagnosis, biomedicine, ethics, and other topics). Acupuncturists must also maintain continuing education. Dry needling certification courses for PTs often require only 27-72 hours of training, with no universal requirement for supervised patient treatments.

With that out of the way, let’s delve into the issues behind “dry needling” by PTs and other providers.

Potential Risks- Incorrect Insertion

I will be the first person to tell you that physical therapists know their anatomy. Their high level of study in to the body’s musculature is the main reason that I disagree with some of my colleagues who argue that PTs should be required to undergo the several thousand hours of training in acupuncture that a Licensed Acupuncturist does. However, understanding the body’s anatomy and understanding how to safely needle into that anatomy are two completely different things.

Physical therapists learn anatomy from a manual therapy framework, whereas acupuncturists learn it with an eye on potential risks for needle insertion. For example, back in my first semester of graduate school, we learned not only to trace the trapezius muscle along its origin and insertion points, but also exactly how the trapezius overlies the lung and pleural (chest) cavity. We learned where the lung was closest to the muscle and also where it curved away, making it safer to needle a little deeper.

Now, I’m not saying that physical therapists and other medical professionals aren’t aware of the trapezius overlying the lung. Even someone without training in anatomy would probably be able to see the relationship there. However, the context in which acupuncturists learn anatomy is always with the idea of inserting a needle into that part of the body. Every time I look at a certain muscle, I cannot help but think of the underlying organs and exactly how the muscle overlies them. This is an incredibly important skill for my job, as I am inserting needles all over the body on any given day. This is also not a way of looking at the body that can be taught in a weekend course. Learning and viewing the body from a manual therapy standpoint and then trying to go back and look at it from the perspective of someone inserting needles can lead to errors in the way needles are inserted, as demonstrated below.

All of these photographs were retrieved off of Instagram in the last week by searching for the tag “#dryneedling.” I have removed the identifying information on each of them to protect the posters’ privacy. The red circles on each picture indicate where the needle appears to have been inserted at the wrong angle. (I say “appears to” here because I cannot speak with 100% certainty unless I were to see the needle angle in person. However, it’s pretty clear that something is incorrect when a needle is supposed to be going straight up and down but the photo shows it at an angle, or when the needle should be pointed toward the spine but is pointed away from it in the photo.) Inserting a needle at the incorrect angle could lead to potential organ or nerve puncture.

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In the third photo above, not only do some of the needles appear to be inserted at an incorrect angle, but even more importantly, they are also inserted to the hilt. This is a no-no as an acupuncturist because the hilt is considered the weakest spot of the needle. Pressure on the hilt increases the risk of the needle shaft breaking off inside the body.

DNClothing

In this photo,  needles are inserted through clothing. This goes against Clean Needle Technique, which states that clothes should be removed and the point swabbed with alcohol before needle insertion.

Potential Risks- Contraindications

Improper needle insertion is not the only risk with “dry needling” by someone with too little training. In an effort to differentiate their tactics from acupuncture, most “dry needling” courses do not discuss the non-neuromuscular actions of the acupoints. This is problematic, as any acupuncturist worth their salt knows that some points should not be needled on particular patients. For example, several acupoints are known to cause uterine contractions and therefore contraindicated on pregnant patients (unless the patient is seeking help with labor induction). I recently spoke to a PT friend of mine who is certified in dry needling, and she was unable to tell me which points should not be utilized in pregnancy.

Even more alarming is that these points are, in fact, being “dry needled” on pregnant patients right here in my city. I saw a new patient last week with pain in her trapezius muscle. She had undergone dry needling the month prior and reported that it helped “a little.” Upon further questioning, it became clear that her PT had inserted a needle into and stimulated the point Gallbladder 21 (GB 21 for short). GB 21 is one of the points on the body that is both an acupoint and a trigger point. It is also a point that is KNOWN TO CAUSE UTERINE CONTRACTIONS. This patient is very fortunate that she did not experience any negative side effects.

Other points on the body are considered contraindicated in certain cases including low blood pressure, diarrhea, or in the elderly. Again, judging from the outlines provided by multiple courses, these contraindications appear to be rarely (if ever) taught in a typical “dry needling” certification course.

The Politics- Scope of Practice and Beyond

This is where the heart of the matter lies. For any medical profession, the scope of that profession’s providers can vary by state and is ultimately determined by the state’s legislating bodies. This can turn into a “behind the scenes” turf war that the public often knows nothing about. When physical therapists began practicing “dry needling” in greater numbers, acupuncture boards in many states challenged their right to do so, essentially arguing that “dry needling” is, in fact, just acupuncture with a new name. Lobbyists were brought in on both sides and the fight played out differently in various states. Currently, physical therapists are NOT ALLOWED to practice dry needling in the following states: California, Idaho, South Dakota, Tennessee, Florida, Pennsylvania, New York, and Hawaii. In all other states, legislative bodies have determined that “dry needling” is within the scope of physical therapists, or they have not yet made a ruling on the matter.

So, what’s the big deal with PTs being allowed to dry needle? Other than the safety issues stated above, I don’t personally take issue with it. Acupuncture (and therefore “dry needling”) is an extremely effective tool for relieving pain and the more practitioners that utilize it, the better. I do wish that further education was required for PTs and other practitioners who want to perform “dry needling”, again due to the safety issues mentioned previously. However, assuming practitioners are properly trained in trigger point needling, I think it’s great that more people will have access to this wonderful modality.

Notice how I highlighted the term “trigger point needling” above. This is important. According to the American Physical Therapy Association,

Dry needling is a technique physical therapists use (where allowed by state law) to treat myofascial pain. The technique uses a “dry” needle, one without medication or injection, inserted through the skin into areas of the muscle, known as trigger points. Other terms commonly used to describe dry needling, include trigger point dry needling, and intramuscular manual therapy.

Dry needling is not acupuncture, a practice based on traditionalChinese medicine and performed by acupuncturists. Dry needling is a part of modern Western medicine principles, and supported by research.

There are two issues I have with this definition. First and foremost, it seeks to diminish the validity of acupuncture by insinuating that acupuncture is not a part of Western medicine principles and is not supported by research. This is a common theme amongst dry needling proponents. Our own Kentucky One Health system states the following on their website:

The only similarity between this technique and acupuncture is the type of needle used. Dry Needling evaluations include a subjective and objective examination of the neuromuscular system. Needle insertion points are based on assessment and knowledge of neuroanatomy to deactivate hyperirritable spots within the muscle with a goal of decreasing pain and restoring function. This technique is just one small part of the treatment session. It enhances the patient’s ability to perform corrective exercises and/or the therapist’s ability to perform other manual therapy techniques to restore normal function.

Acupuncture evaluates the tongue and pulses. Needle insertion is along Meridians to balance energy.

Do you see the problem here? These statements show an utter lack of understanding about what a modern acupuncturist does. I have been trained at a graduate level on various orthopedic tests and utilize them on a daily basis to determine which muscles or parts of the body are responsible for a given symptom. Western neuroanatomy is also an important part of my training and influences the points I choose. Yes, we do utilize energy and meridians, but that is only a part of our medicine. Our understanding of the science behind acupuncture grows every year, and negating that growing area of research is both unsound and irresponsible. In fact, even the tongue and pulse have their place in western medicine. I recently had a pregnant patient who complained of back pain. During her intake, I noticed that her pulse was not forceful and her tongue was paler than it should have been, indicating what acupuncturists call a blood deficiency. After treating her for pain, I gave her a dietary handout based on blood deficiency that included multiple iron rich foods. Two weeks later she was diagnosed with low iron by her OB.

The second issue I have with the APTA’s definition of “dry needling” is that it is hypocritical. Here is an excerpt from the Federation of State Boards of Physical Therapy Dry Needling Resource Paper:

PTs using dry needling:

  • do not and cannot claim to practice acupuncture,
  • do not use acupuncture traditional Chinese medicine theories, meridian acupoints and terminology,
  • do not use acupuncture diagnosis like tongue and pulse

And here’s where the hypocrisy comes in:

DNAcupoints

The photo above, again from Instagram but substantiated by a PT I know who underwent “dry needling” certification, shows drawings of the Chinese Meridians and even labeled acupoints.

Also, remember that “trigger point needling” definition I highlighted above? That’s been thrown out the window by many PTs. PTs across the country are now offering “dry needling” for non muscular conditions. Here is a link to “Cosmetic Dry Needling” by a physical therapist in Colorado.  And here we have a PT treating sinus congestion:

DNSinuses

This is not “dry needling.”

Finally, much of the research supporting dry needling is actually research supporting acupuncture. From the website of one of the certification programs for dry needling

Brain imaging studies have demonstrated that needling of “key” distal points (not trigger points), that are not “onsite” with the patient’s symptoms, stimulates the descending pain inhibitory systems or cortical areas of the brain that are involved in pain control. Furthermore, much of the literature that “dry needling” draws from uses the term “acupuncture” in its title, and many of these studies have used both traditional acupuncture points and myofascial trigger points in their treatment regimes. Thus, a foundational knowledge of the nomenclature and the location of several key traditional acupuncture points will be discussed on this course to help the clinician understand and interpret the existing biomedical acupuncture and dry needling literature within the context of neuromusculoskeletal conditions.

This indicates that not only are they utilizing acupuncture studies to support dry needling while stating that acupuncture and dry needling are different, but they are also using points OUTSIDE OF TRIGGER POINTS. Again, hypocritical.

In Conclusion

As you can see, my medicine, my profession, is being pulled out from under me. To add insult to injury, these same people are devaluing what I do and describing it only in terms of “energy” and “meridians.” Some of them are also potentially putting their patients at risk. I can no longer stand by and watch this happen. In sharing this post, my goal is not to start a turf war or demean the field of physical therapy, a field I often refer my own patients to. Instead, my goal is to inform you, the public, about what “dry needling” really is and the impact it is having on our profession. If you value acupuncture, please share this with your friends. Change can only come if we educate the public.