AAPM&R Position on Dry Needling
Dry needling is the use of solid needles (contrasted with the use of hollow hypodermic needles that are used for injections) to treat muscle pain by stimulating and breaking muscular knots and bands. Unlike trigger point injections used for the same purpose, no anesthetics are used. There is controversy regarding the definition of dry needling. Licensed medical physicians and licensed acupuncturists consider dry needling as Western Style Acupuncture or Trigger Point Acupuncture whereby the insertion sites are determined by tender painful areas and tight muscles. These sites may be treated alone or in combination with known acupuncture points. Other practitioners take the position that dry needling is different from acupuncture in that it is not a holistic procedure and does not use meridians or other Eastern medicine paradigms to determine the insertion sites. However, dry needling is taught in American acupuncture schools as a form of treatment for individuals using acupuncture needles.
Dry needling is an invasive procedure. Needle length can range up to 4 inches in order to reach the affected muscles. The patient can develop painful bruises after the procedure and adverse sequelae may include hematoma, pneumothorax, nerve injury, vascular injury and infection. Post procedure analgesic medications may be necessary (usually over the counter medications are sufficient).
There has been controversy in the United States as to who is qualified to practice dry needling. Since it is an invasive procedure using needles, many take the position that it should only be performed by licensed acupuncturists or licensed medical physicians (M.D. or D.O.). There are other practitioners performing this procedure who have taken a course or courses in this technique but do not routinely use needles otherwise in their practices.
The American Academy of Physical Medicine and Rehabilitation recognizes dry needling as an invasive procedure using acupuncture needles that has associated medical risks. Therefore, the AAPMR maintains that this procedure should only be performed by practitioners with standard training and familiarity with routine use of needles in their practice, such as licensed acupuncturists or licensed medical physicians.
AAMA Policy on Dry-Needling
The American Academy of Medical Acupuncture (AAMA) is the premier North American organization of physician acupuncturists. The AAMA is committed to insuring public health and safety by ensuring that all persons practicing any type of medicine, including acupuncture, are properly trained and educated. It is imperative that courts and medical bodies maintain and preserve strict standards of education and training in acupuncture before any person undertakes inserting a needle into a patient. An ill-trained practitioner could, as a result of lack of education or ignorance, cause substantial medical injury.
Acupuncture, like Western Medicine is a complex subject. It cannot be mastered in a weekend or in a month. All AAMA members, in addition to four (4) years of medical school (MD or DO), must have 300 hours of didactic and clinical acupuncture education and training. In most states, a non-physician must have in excess of 2,000 hours of clinical and didactic education and training before they can become certified to treat patients.
Dry needling, like acupuncture, involves the use of solid needles (contrasted with the use of hollow hypodermic needles that are used for injections) to treat muscle pain by stimulating and breaking muscular knots and bands. Unlike trigger point injections used by physicians and licensed acupuncturists for the same purpose, no anesthetics are used in dry needling. There is controversy regarding the definition of dry needling. Licensed medical physicians and licensed acupuncturists consider dry needling as Western Style Acupuncture or Trigger Point Acupuncture whereby the insertion sites are determined by tender painful areas and tight muscles. These sites may be treated alone or in combination with known acupuncture points. Other practitioners take the position that dry needling is different from acupuncture in that it is not an holistic procedure and does not use meridians or other Eastern medicine paradigms to determine the insertion sites.
Regardless of the theory, it is incontrovertible that dry needling is an invasive procedure. Needle length can range up to 4 inches in order to reach the affected muscles. It is critical to understand that dry needling, in the hands of minimally educated practitioners can cause extreme harm. Any invasive procedure has associated and potentially serious medical risks and is safe only if performed by a properly educated, trained and experienced health professional. The technique of dry needling frequently involves needling of muscular structures that may be deep and/or hidden under layers of other muscles and tissues and close to sensitive structures and organs including blood vessels, nerves and organs as, for example, the lungs. The patient can develop painful bruises after the procedure and adverse sequelae may include hematoma, pneumothorax, nerve injury, vascular injury and infection. Angle the needle incorrectly and, for example, the lung may be punctured. Post procedure analgesic medications may be necessary (usually over the counter medications are sufficient). In the worse case scenario, vital organs can be pierced, resulting in complex medical situations or even death.
Physical therapy is not a field that has historically included the use of needles. The recent trend of some physical therapists to embrace dry needling under the umbrella of physical therapy practice is one that marks a distinct departure from traditional physical therapy practice. The fact that many physical therapists receive only minimal hours of training speaks to the potential danger of their practice.
To include dry needling into the scope of practice by physical therapists is unnecessarily to expose the public to serious and potentially hazardous risks. Because of this we feel a duty to inform legislators and regulating bodies about the inherent danger to the public of this practice.
Therefore, the AAMA strongly believes that, for the health and safety of the public, this procedure should be performed only by practitioners with extensive training and familiarity with routine use of needles in their practice and who are duly licensed to perform these procedures, such as licensed medical physicians or licensed acupuncturists. In our experience and medical opinion, it is inadvisable legally to expand the scope of physical therapists to include dry needling as part of their practice.
Statement of World Federation of Chinese Medicine Societies: Dry Needling is within the Scope of Acupuncture and Moxibustion of Traditional Chinese Medicine
It is known that some practitioners are applying a method of treatment, called dry needling, in their medical practices. This method of treatment refers to puncturing trigger points in the myofascial tissue with acupuncture needles, so as to release statues, such as pathological muscle tension, and to treat diseases, such as myofascial pains. These trigger points are actually channel points, extra points and Ashi points in acupuncture and moxibustion of traditional Chinese medicine. Besides, puncturing manipulations and needles of dry needling are the same as those of acupuncture and moxibustion of traditional Chinese medicine. Therefore, dry needling is actually ‘re-discovery’ of acupuncture and moxibustion of traditional Chinese medicine, and is a component of different kinds of traditional and modern acupuncture therapies.
World Federation of Chinese Medicine Societies acknowledges that, dry needling is a component of the therapy of Chinese acupuncture and moxibustion, and it cannot be developed independently without medical principles of Chinese acupuncture and moxibustion.
World Federation of Chinese Medicine Societies advocates, in the course of utilizing the achievement of acupuncture and moxibustion of traditional Chinese medicine, practitioners should respect the fact that dry needling is within the scope of acupuncture and moxibustion of traditional Chinese medicine, respect acupuncture theories and traditional culture of acupuncture and moxibustion of traditional Chinese medicine, so as to promote the worldwide development of acupuncture industry in a healthy and orderly way.
February 22nd, 2016
ASA Position on Dry Needling
The American Society of Acupuncturists (“ASA”) opposes the illegal and unsafe practice of acupuncture. “Dry needling” is a pseudonym for acupuncture that has been adopted by physical therapists, chiropractors, and other health providers who lack the legal ability to practice acupuncture within their scope of practice. This strategy allows these groups to skirt safety, testing, and certification standards put into place for the practice of acupuncture. Dry Needling is a style of needling treatment within the greater field of acupuncture. The practice of “acupuncture” includes any insertion of an acupuncture needle for a therapeutic purpose. Acupuncture training has always included both traditional and modern medical understandings.
Anatomically, “trigger points” and “acupuncture points” are synonymous, and acupuncture has targeted trigger points for over 2,000 years. “Dry needling” is indistinguishable from acupuncture since it uses the same FDA-regulated medical device specifically defined as an “acupuncture needle,” treats the same anatomical points, and is intended to achieve the same therapeutic purposes as acupuncture.
The US Food and Drug Administration (FDA) defines the acupuncture needle as a Class II medical device, and has explicitly stated that the sale of acupuncture needles “must be clearly restricted to qualified practitioners of acupuncture as determined by the States.” As “dry needling” is acupuncture, it presents the same inherent risks including but not limited to perforation of the lungs and other internal organs, nerve damage, and infection. Recent reports of serious and potentially life-threatening injuries associated with “dry needling” include pneumothoraces and spinal cord injury. These and other injuries support the statement that “dry needling” presents a substantial threat to public safety when performed without adequate education, training, and independent competency examination. Adequate training and competency testing are essential to public safety.
In addition to biomedical training, licensed acupuncturists receive at least 1365 hours of acupuncture-specific training, including 705 hours of acupuncture-specific didactic material and 660 hours of supervised clinical training. Further, many states also require even physicians wishing to practice acupuncture to have substantial training. The American Academy of Medical Acupuncture (AAMA) has set the industry standard for a physician to practice entry level acupuncture at 300 hours of postdoctoral training with passage of an examination by an independent testing board. This standard presumes extensive, pre-requisite training in invasive procedures , the differential diagnosis of presenting conditions, clinical infection-control procedures in the context of invasive medicine, management of acute office and medical emergencies, and advanced knowledge of human physiology and evidence based medicine. The AAMA expects that physicians choosing to incorporate acupuncture into practice will pursue lifelong learning, including formal and self-directed programs.
In contrast, there are no independent, agency-accredited training programs for “dry needling,” no standardized curriculum, no means of assessing the competence of instructors in the field, and no independently administered competency examinations.
Neither physical therapy nor chiropractic entry-level training includes any meaningful preparation for the practice of invasive therapeutic modalities such as the insertion of acupuncture needles. Training in these programs is generally limited to external therapeutic modalities. In some states, however, physical therapists and others have begun inserting acupuncture needles and practicing acupuncture with 12-24 hours of classroom time and little to no hands-on training or supervision. This is being done under the name “dry needling.”
Physical therapists and chiropractors without acupuncture included in their state practice acts have, in some cases, been authorized to perform dry needling by their own regulatory boards’ non-binding guidelines or through administrative rulemaking. Such actions often occur even when the statutory practice act adopted by the state legislature lacks any legislative intent to authorize invasive procedures such as the insertion of needles.
All health care providers without acupuncture formally included in their state practice act should be prohibited from the practice of acupuncture, even when described as “dry needling,” unless their practice act is legally expanded to include the practice of acupuncture and provide the same level of clinical and classroom training required for the licensure of acupuncturists.
AMA Annual June 11-15, 2016 Report
Dr. Susan Hubbell, AAPM&R Delegate to the AMA, introduced the following resolution:
Resolution 223: Dry Needling is an Invasive Procedure. This resolution asked our AMA to “recognize dry needling as an invasive procedure and maintain that dry needling should only be performed by practitioners with standard training and familiarity with routine use of needles in their practice, such as licensed medical physicians and licensed acupuncturists.”
Our resolution was adopted. We received many thanks for bringing this resolution to the meeting.