Dry Needling and Acupuncture 2015 – The State of the Profession

Dry Needling wins again – it receives “the greatest threat to the profession” practitioner’s choice award.

In recent years, Acupuncturists have devoted more resources to this issue than to any other.

A (fairly accurate) review of legal and regulatory actions shows that we’re not having much success. (Here’s another review, APTA’s Dry Needling Resource Paper.)

Even our wins have been temporary. For example –

– the Georgia Acupuncture Board added language stating that Dry Needling is acupuncture. The PT’s then added Dry Needling to their scope via legislation. (Could Georgia PT’s now advertise they’re doing acupuncture?)

– the October 2014 ruling in Washington State against dry needling was widely celebrated. Now the PT’s have introduced bills which would add Dry Needling to their scope. With almost 5,000 PT’s in the state, and about 1,100 LAcs, it’s likely they’ll eventually succeed.

We say the PT’s:

  • are stealing our medicine! (But we don’t own it.)
  • are illegally expanding their scope. (The majority of states have ruled it is in the PT scope. Modifications to scope are common in health care.)
  • are using Regulation to do what should be done Legislatively. (Scope clarification is often done via Regulation, which gives the public and other professionals the opportunity to weigh in and is preferable to politically driven legislative action. The public is protected through regulation. The PT’s have been successful in passing Legislation allowing dry needling.)
  • are pursuing this because their own techniques don’t work. (Even if true, 1) why does that matter, and 2) does the argument apply to us when we add techniques lasers, essential oils, e-stim, herbs –  to our scope?)
  • can’t possibly know enough to do this technique safely. (Many clearly do.)
  • can’t possibly be providing good treatments. (Their patients disagree.)
  • wrongly say that dry needling isn’t acupuncture. (Is it better if they say it is? Is there a legal reason our definition should prevail?)
  • make the public fear acupuncture. (Insisting this technique is acupuncture will contribute to the problem. Don’t we have the same problem when we use the technique?)
  • should use hypodermic needles. (Does that show concern for public safety?)

We can continue the fight to stop dry needling – getting caught in the cycle of suit (complaint) (never-mind the SCOTUS ruling) and counter-suit (NC PT lawsuit). We can fight state by state, and attack any Acupuncturist who suggests anything other than “the PT’s must be stopped.” We can keep insisting that if we just devote more resources and fight harder, we’ll win.

Or, we can learn from our history and the history of all of the other professions that have fought to maintain a monopoly on technique or turf.

We could be fighting for strong regulations. Mandated adverse effect reporting, strict definitions of what dry needling is and what it isn’t (other than whether or not it is acupuncture), requiring direct supervision for all clinical hours, requiring PT’s to post their hours of training, requiring registration with the PT Board, requiring physician referral for dry needling – all of these are possible.

A PR campaign promoting acupuncture and helping the public find an Acupuncturist? That’s possible too. Supporting ease of licensure so that people in every state can find an LAc? We can work for that. Support for new practitioners so that the public can actually find an Acupuncturist? That’s a great goal. Building collaborative relationships with other professionals who want to decrease pain and suffering? That would serve everyone.

Putting our energy into stopping dry needling? Not so much. It’s our obsession with stopping dry needling that is the greatest threat to the profession.



17 Foundational Beliefs of The Acupuncture Observer

Embracing the season of gratitude and thanks, it’s time for The Acupuncture Observer to take a step back and share some of her foundational beliefs about the medicine, the profession, and life.

  1. Acupuncture/OM works. The unique situation of the patient and the unique skills of the provider influence effectiveness. No single tradition provides all of the answers or benefits.
  2. Acupuncture/OM has fewer negative side effects and risks than conventional treatment for many conditions.
  3. Access is a necessary precursor to effective treatment.
  4. Effective treatment will increase wellbeing and could decrease health care costs.
  5. Every means to increase access carries trade-offs. Those trade-offs must be understood as we determine our path forward. We should learn from the experiences of other professions.
  6. Understanding and explaining the mechanism of acupuncture from the knowledge base of modern biology and physiology is useful and interesting, but is not necessary for acceptance by the medical establishment.
  7. The current “science-based” understanding of health is known to be limited. Insisting that Acupuncture/OM be taught, thought of, or explored only in the language of modern medicine/science is unscientific and risks centuries of experience and wisdom.
  8. Consumers should have significant freedom of choice in health care. Understandable and clear information about potential benefits and risks, as well as an exploration of the costs (financial and otherwise) is necessary for good decision-making.
  9. Self-serving thinking leads to hypocrisy. Special attention is needed when an argument for patient protection creates an economic benefit for particular providers.
  10. Simple, easily learned treatments can be effective and safe.
  11. There is the potential for growth and success within the acupuncture/OM profession.
  12. Many acupuncture programs do not provide sufficient or accurate information about post-graduation life and do a poor job of teaching business skills. This can be changed easily and inexpensively.
  13. The financial and karmic ROI (Return on Investment) of positively promoting our profession is superior to that of engaging in political/regulatory battles with others.
  14. The future of the medicine and of the profession are interconnected but not identical.
  15. Thoughtful and respectful analysis can identify areas of common ground.
  16. Focusing on areas of common ground decreases factionalism, and builds unity, understanding, and participation.
  17. The profession lacks venues for respectful dialogue on these issues. As a result, many scholars and potential leaders within the profession avoid involvement.

Do we agree on some of these? Can respectful dialogue increase the areas of agreement? What if we read the Tao Te Ching, the I Ching, and The Art of War first? What if we go deeper than our Wei level response to some of these issues? I believe it is possible that we’ll be able to find a new path forward, one we can walk together, with our hair flowing free. After all, I’m an acupuncturist.

A Practical Next Step

Okay, I’ve heard the critics — too much blaming the profession and focusing on mistakes, not enough positive things we can do now.  So, here goes —

A very practical next step, or maybe the most important thing to do to prepare for a next step, is getting your bearings. Any confusion about where you are now and your next steps might be in the wrong direction.  So let’s take a look at where we are with our old friend Dry Needling —

On January 23, 2014, the Court of Appeals of the State of Oregon issued a ruling regarding the practice of dry needling by Chiropractors. Surfing the web I’ve read “the issue came down to whether chiropractors could perform dry needling after having 24 hours of training,” and “The Oregon Court of Appeals ruled “dry needling” is acupuncture and not within the scope of practice of chiropractic medicine” and “This ruling sets a precedent which can have far-reaching effects beyond Oregon. It becomes part of the record for each state acupuncture Association to use in it’s own fight for appropriate licensure, training, and practice.”

It is certainly correct that the ruling does set a precedent, so let’s be sure we understand what that precedent is. I encourage all of you to read the ruling, linked above.  It isn’t long and it is interesting. You can see a nice summary here. Most critically —

  1. The ruling does not say that dry needling is acupuncture.  I don’t believe it includes any mention of the word acupuncture.
  2. The ruling does not consider how much training is necessary to practice this technique safely. Hours of training are irrelevant to this ruling.
  3. Patient safety is not explored or addressed in this ruling.

The Court focuses on the Chiropractic Board’s argument that Dry Needing is Physiotherapy and rules that it is not, based on the understanding of the word in 1927, when Physiotherapy was added to Chiropractic scope in Oregon.   (The Court clearly states that it does not find that Physiotherapy is the same as Physical Therapy.)

So, if you are in a state in which the PT Board or Chiropractic Board has argued that Dry Needling is Physiotherapy, and if Physiotherapy was added to that Board’s scope in the late 1920’s, this ruling sets a very important precedent.  I’m guessing the ruling may not quite live up to its reputation as a game-changer.

In other news, while NCASI is celebrating the Utah DOPL’s decision that dry needling is outside the scope of practice for Physical Therapists, there is a bill (HB 367) moving through the Utah House that would add Dry Needling to the Physical Therapy scope. (There are fewer than 100 LAcs in Utah, and several thousand PT’s). Similarly, Arizona S.B. 1154, legislatively adding dry needling to Physical Therapy scope has passed the Senate.

So, that’s where we are. And if you don’t buy my argument that knowing where we are counts as a practical next step, here, on its one year anniversary, but so relevant it could have been written today, are not ten, but ELEVEN, positive, practical, and fulfilling next steps.

Who is a Word-Trickster?

Will Morris, in Acupuncture Today, writes — ” ‘Word-tricksters’ – as I like to call them – change language in order to gain personal advantage.”

I haven’t received much input on my questions about nomenclature, but in my conversations with practitioners around the country I haven’t found any agreement or clarity about where acupuncture begins or ends.

I do have a question for Dr. Morris and the others who have been so insistent that the other professions should use “acupuncture” rather than “dry needling” or any other term. Would folks be happy with an outcome in which all professions agreed to use the term acupuncture for anything that used a filiform needle, but in which the LAc community still had no say in the regulations, education requirements, and scope for those professions?

The acupuncture community would not see that as a win. I believe that the people arguing for the global use of the term acupuncture are doing so because they think it will give them control over the procedure — that is, to gain personal advantage.  Doesn’t that make us the Word Tricksters?

In the meantime, based on youtube videos and discussions on various list serves, my colleagues are very interested in being able to draw distinctions between how they use needles and how the PT’s and others use needles.  Wouldn’t insisting on the use of the term “Dry Needling” help?



A Rose, Redux!

Again, there has been an issue with my last post not being sent to subscribers or showing up on the media sites.  Because I want community feedback before posting part 2 I’m hoping this attempt will fly through cyberspace as intended.  Thanks for your patience.

A Rose?

I would love to leave the TPDN/Dry Needling issue behind. I also believe that if we explore why what we’ve been doing hasn’t been working we’ll end up empowered rather than defeated.

Many colleagues have been referring to this Will Morris article in AT. I hope you’ll bear with more frequent posts over the next few days as we spend some time pondering his points.

A question for the community – is a key factor here the use of an acupuncture needle?

When an MD injects cortisone into a sore spot, is that acupuncture?  Is a vaccination acupuncture? What if a syringe is used to draw fluid out of an area – is that acupuncture?  Is the injection therapy done by some LAcs acupuncture? What about use of a tuning fork or a laser at a point – is that acupuncture?

What about the use of an empty hypodermic needle to stimulate a sore spot?  At what point does the use of a syringe become acupuncture? Or, is the use of the filiform needle the thing that makes a procedure acupuncture?

I’ll see if you have any input before I share my thoughts.


The AAAOM Position Statement on TPDN, or, Mine!

Who is on the Blue Ribbon Panel?  I can’t find a list of participants anywhere.  Are they independent experts on the regulatory process or medical terminology?  Are a variety of professions represented? Who selected them?  Is there any reason regulatory agencies should care what this mysterious Blue Ribbon panel thinks?

Does the AAAOM believe that acupuncture regulatory boards should be able to expand determine the limits of our scope of practice and make decisions about necessary training?  Are we hypocrites with double standards, demanding a degree of control over the practices of others that we find intolerable?

The AAAOM refers to a malpractice company’s refusal to cover PT’s doing TPDN as proof of an “actual risk of endangerment.” Shall LAcs be prohibited from using acupuncture to induce labor or turn a breech baby because malpractice companies don’t cover those procedures?

Regardless of our shouts of Mine! Dry Needling has been determined to be within the scope of practice of PT’s in the majority of states.  I suppose we can keep beating this dying horse, chasing this ship that has sailed, but there are better uses of our limited resources.

Coming soon – a sad story of how a state acupuncture board is limiting opportunities for LAcs and increasing the likelihood that residents will receive acupuncture from non-LAcs.

AAAOM Call for Comments

Not sure who out there gets communications from the AAAOM, or who pays attention to the communications they do get.  Despite the low of level of support the organization has from acupuncturists (the last I heard was that the organization has about 500 professional members, which would be less than 3% of the profession), it has an outsized impact on the profession’s reputation, our relationship with other providers, and public policy itself.  Therefore, it would be foolish to ignore their call for comments.  First I’ll address the introductory email, which is concerning in and of itself.  Comments on the position statement itself will follow soon.  Here is the email, with my comments inserted.

“Dear AAAOM Members and Colleagues:
We would like to hear from you, our membership, via this “Call for Comments” surrounding the term “trigger point dry needling (TPDN).” Please take a few moments to review this AAAOM position paper, “AAAOM Position Statement on Trigger Point Dry Needling and Intramuscular Manual Therapy.”

As many of you may already know, physical therapy (PT) boards have begun using TPDN terms for the purpose of expanding the PT scope of practice. [How does the AAAOM know the purpose for the choice of the term?  Perhaps the purpose was to help patients distinguish between the release of a trigger point and the practice of a complete medicine? Does the AAAOM believe professions should not be able to expand their scope?] By doing so, this therefore precludes the necessary and adequate education and safety standards already set by state legislatures for the practice of acupuncture. [Education and safety standards are primarily set by regulators, not legislators, and the rules typically apply to classes of professionals, not techniques.  Do we use the term Tui Na to preclude ourselves from massage standards? PT Boards have set standards for the use of TPDN by their licensees.]

At present, 43 states and the District of Columbia have statutorily defined acupuncture along with the educational and certification standards that qualify an individual for licensure. In addition, the current medical literature remains consistent with regards to the definitions of acupuncture as a procedure and practice provided by state practice acts. [I don’t know why the first sentence is significant and I don’t know what the second sentence means.]

The comments you submit via our Membership Feedback Form will be presented to the AAAOM’s Inter-Professional Standards Committee for review, enabling us to take action on your behalf. [Is there a deadline?  Who is on the committee? Can you share what actions are being considered by the AAAOM?]

Additionally, if you have patients who have been hurt by acupuncture performed by someone who doesn’t have a license a license to practice acupuncture, please direct them to the Food and Drug Administration (FDA) Adverse Event Form. These submissions are very important for our work and request that our members advise those patients who submit the FDA form to alert the AAAOM of their actions by clicking here. [Please, AAAOM, explain your strategy.  The FDA does not regulate practitioners, it regulates devices. Reporting adverse events might put our access to acupuncture needles at risk but would not impact state determinations of scope of practice or educational requirements.  If public safety is our concern, why request reporting only when non-LAcs are involved? Isn’t it important to report all adverse events?]

The views and comments we have received thus far on the TPDN issue have proven very helpful, thereby allowing us to fulfill our mission and advocate on behalf of your profession. Thank you for your interest and for taking the time to submit your thoughts on this extremely important issue.”

I’ll share my thoughts on the Position Statement soon.   In the meantime, AAAOM, I request you be clear about the percentage of the profession you represent when speaking on “our” behalf.

More Cross-Pollination

Once again, here is some writing I did for one of my listserve groups. This is in response to a conversation about the proper translation of jingmai from the Huang Di Nei Jing.

I’ve been hesitant to participate in this dialogue. I am not a Sinologist or deeply familiar with the Chinese Classics. Furthermore, my past experience with these sorts of debates is that at the conclusion we are all likely to feel further justified that we are right and everyone else is an idiot.  It isn’t all that unusual for these debates to devolve into personal attacks. The early comment in this thread regarding “their emotional but ungrounded negative responses” put the brakes on my initial desire to participate.

However, Matt’s inquiry re. the thread subject “Use of the concept of Meridians has Crippled the promotion of Acupuncture in the West” touches on issues that are near and dear to me.  Combined with his hope that others would get involved, I am finally going to offer a contribution.

Regarding the thesis that the term jingmai in the HDNJ was the blood vessels, again, this is not an area in which I have the expertise to come to a conclusion. Personally, I’d want to find out what Elizabeth Rochat and Heiner Fruehauf had to say on the matter. They are my personal experts when it comes to the Classics, the Chinese of the Classics, and a deep knowledge of Chinese Medicine itself. In Heiner’s case he also works and studies with practitioners with long unbroken lineages going back many generations.

From my initial training as a cultural anthropologist, I’d caution against the belief that there could be any direct one-to-one translation from a Classical Chinese term to the current use of Western anatomical term. Not only are we dealing with different languages, but different language families and different cultures.  I think Matt Bauer’s posts and writings addressed this.

My rudimentary knowledge of the Classics, along with my somewhat more developed experience as a practitioner, along with a quick read of even the most recent articles and our own conversations about mechanism of action make it seem unlikely that any practitioner or scholar of the past or present would think that when we are talking about the effective pathways of acupuncture that we mean the blood and blood vessels.

I don’t know what the myth of the Meridians is, exactly.  Can one of you explain? It seems like we have something of a straw man (or red herring?) here. Much of this conversation centers on dismissing a myth that none of you have described. Certainly I don’t know of any LAcs who refuse to accept any sort of modern scientific theory. I do know many LAcs who are, I believe, appropriately skeptical that the latest study or current understanding of how the body works is the total and complete truth.  Within my years of practice probiotics have gone from something that the western establishment dismissed with an eye roll to something they prescribe, and the appendix has gone from a worse than useless evolutionary vestige to a structure that may have important roles in the immune system and maintaining gut flora, to give only two examples.

Given the ever-evolving understanding of physiology and appreciation for the limits of what we currently know, along with the knowledge that the effect of acupuncture cannot be fully explained by blood vessels, I can’t see how insisting that the jingmai are blood vessels would serve the profession at all. Wouldn’t it be far more helpful to explore our languaging of the Meridians, making sure that all practitioners could describe their complexity, rather than substituting a term that doesn’t address that complexity? I fear using the term blood vessels would only further confuse the establishment.

As for what is behind the crippled promotion of acupuncture in West, is it crippled? Just this week I received an email Can Acupuncture Relieve Your Pain from WebMD, various emails about PT’s, MD’s, and others who are trying to “steal” our medicine, a notice of a job opening from one of the three acupuncture schools (of questionable quality) that have opened within 10 miles of my office, numerous requests for referrals for LAcs around the country, links to three different studies looking at acupuncture efficacy and mechanism of action, and news that POCA clinics did over 600,000 treatments in 2012 .  I also began treating an MD, and had several new clients referred to me by their MD’s, DC’s, or other providers. Overall, I’d have to say that Acupuncture is doing pretty damn well for itself in the West.

The promotion of the “profession”, though, that is a different question entirely. The debate over terminology does point to what I believe is the crux of the dysfunction within the profession.  When it comes to the risk/benefit analysis of accommodating ourselves to the trappings of the western medical establishment, most of us have strong feelings, and are rarely consistent about them even on a personal level, never mind across professional communities. Combine that conflict with the lack of trust, connection, mutual respect, and the venue necessary for exploring these issues in a productive way and the profession itself is certainly limping.