What is the scope of practice for acupuncturists and physical therapists?
You might be surprised to find that although physical therapists around the country are performing dry needling, they may be doing so illegally. Each profession has a scope of practice that is determined by each state. State by state the SOP (scope of practice) changes. There are multiple states where physical therapists are not allowed to perform dry needling and many states where the practice was a grey area in their SOP but was overturned and is now illegal.
So what does the SOP here in Colorado say about physical therapists who perform dry needling?
"Dry needling (also known as Trigger Point Dry Needling) is a physical intervention that uses a filiform needle to stimulate trigger points, diagnose and treat neuromuscular pain and functional movement deficits; is based upon Western medical concepts; requires an examination and diagnosis, and treats specific anatomic entities selected according to physical signs. Dry needling does not include the stimulation of auricular or distal points."..." have practiced for at least two years as a licensed Physical Therapist, and have successfully completed a dry needling course of study that consists of a minimum of 46 hours of in-person (i.e. not online) dry needling training."…"Physical Therapists performing dry needling in their practice must have written informed consent for each patient where this technique is used."
Previously the law stated that physical therapists were not allowed to use acupuncture needles. The FDA section 880.5580 states that an acupuncture needle is a solid medical device that is intended to pierce the skin for the purposes of the therapy acupuncture. This device must be labeled as an acupuncture needle and it must be sterile. So physical therapists became clever. Several companies, Myotech in particular, found a loophole in the language. Myotech branded needles, identical in all ways to an acupuncture needle, but labeled it as a "dry needle", not an "acupuncture needle". Most physical therapists used these Myotech needles to get around the law. However, because no one is cracking down on physical therapists practicing outside their SOP, they became more and more liberal with their usage of needles. Check out this website which sells needles to physical therapists. All the needles sold to PTs except for the one Myotech brand are clearly labeled "acupuncture needles".
Furthermore, in the state of Colorado for SOP for licensed acupuncturists, it clearly states that in order to practice acupuncture you must be licensed through DORA (department of regulatory affairs) and you must hold a diploma from bonafide acupuncture and oriental medicine school with proof of training. It is clear that although PT's are trying to find the loophole in their SOP law that says they cannot practice acupuncture, and they cannot use acupuncture needles, they still very clearly are. As a side opinion, I wonder how many patients are given an actual mandatory disclosure about dry needling which includes the benefits and potential risks, and states that person's credentials. I wonder how many patients actually receive this document and can review it before pressured into a therapy they know nothing about. Most of the patients I have spoken with who have received dry needling have no knowledge that their PT practicing dry needling was even in a gray area of their SOP much less illegal in many states.
The other concerning area of this SOP that is being encroached on is the clear law stating that no PT using dry needling may insert needles into distal points or auricular points. In acupuncture, acupuncturists use what's called distal points which are designated acupuncture points that stimulate certain nerves, blood vessels, and other neurological and chemical processes. These are distinct from trigger points which are knots in the belly of a muscle. It is not uncommon to hear about PT's inserting needles into distal points. This is THE MAJOR difference between dry needling and acupuncture.
Trigger points are classified as "non-segmental" because they are simply found where there is pain or muscle adhesion (knots) and are not necessarily along with areas that correspond to spinal nerves or muscle nerve pathways (segmental points). When a needle is inserted into subcutaneous muscle tissue the muscle will grip the needle causing the muscle to stretch. Needling these non-segmental tender trigger points produces considerable pain relief from nociceptors (pain receptor pods). In trigger point dry needling, originally, the needle was only meant to be like a knife dicing up that trigger point. In dry needling, the needle is moved up and down and forcefully used like a saw to physically break up that muscle knot (trigger point). In fact, the doctor who discovered trigger points, Janet Travell, used hypodermic needles because of their similarity to a scapula and better ability to cut through tissue.
The primary difference with acupuncture is our use of distal points. Distal points for the most part are not in a muscle belly but instead lay near major nerve or blood vessel bundles called A or C fibers. In fact there are exactly 309 acupuncture points situated on or very close to nerves,
and 286 are on, or very close to, major blood vessels, which are surrounded by small nerve bundles, called Nervi vasorum. Unlike needling trigger points, needling these points provides far more stimulation. Local connective tissue and fibroblasts undergo an expansion and remodeling up to several centimeters away from the site of distal needling. This shows us that the fibroblasts and collagen can grasp the needle, pulling nearby structures and then inducing measurable peripheral sensory modulation. Acupuncture has also proven to produce localized vasodilation that lasts for several days. General acupuncture points, when needled, will affect the quantity of IgG, IgA, IgM, and influences humoral immune system response, involving B-cell lymphocytes, immunoglobulins, and the secretory immune system. The acupoint Stomach 36, is a well-known "immunotonic," In addition, it goes above this basic response and actually increases the number of natural killer cells, as well as the number of the T-cell lymphocytes, monocytes, macrophages, and the numbers of leukocytes, and neutrophils. Acupuncture has also shown to have an immense anti-inflammatory effect. This anti-inflammatory effect, unlike when breaking up trigger points, stimulate TNF-a (tumor necrosis factor) , IL-6 (interleukin-6 anti-inflammatory), CRP (c-reactive protein, mostly liver inflammation), and NOS (nitric oxide).
This information regarding the difference between dry needling and traditional acupuncture is largely what my 106-page doctoral dissertation encompassed. There is overwhelming, undeniable evidence that trigger point needling and acupuncture produces different effects, and that the two can ideally be used together, and undoubtedly can not be used interchangeably. Which is why there is such a debate on this topic. It is clear dry needling isn't acupuncture. However, the effects of acupuncture are so profound that physical therapists are desperate to get a piece of their acupuncture pie no matter if they are practicing illegally or not. But mostly, physical therapists are taking the very complicated and comprehensive medicine of acupuncture and trying to fast food their way into the field. My frustration is that trigger point dry needling is a very useful therapy but often too overlooked or never even taught to acupuncturists!
Dr. Christina Fick
4. Filshie J, White A. Medical Acupuncture: A Western Scientific Approach. London, UK: Churchill Livingstone; 2006: 84
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8. Filshie J, White A. Medical Acupuncture: A Western Scientific Approach. London, UK: Churchill Livingstone; 2006: 98.
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