To this point I have not spoken out about this issue because I didn’t want to get embroiled in an ugly fight, but it has come to the point that I cannot in good conscience remain quiet about a serious threat to public safety and the integrity of a profession that I love. What is that threat? It is so-called dry needling, which is another name for acupuncture performed by physical therapists, occupational therapists, massage therapists, athletic trainers, physician’s assistants, and other allied health professionals, typically after 20-30 hours of training.
I feel that I have something unique to contribute to this discussion, given that I invested the time and money required to complete a 30-hour certification in “Dry Needling for Pain Management”. This experience gave me an inside look at the training that practitioners of dry needling receive in contrast with my training as a licensed acupuncturist. The bottom line? I am gravely concerned and see dry needling as a serious threat to public safety.
This is not about defending territory
When I first learned about dry needling I was open-minded. I am not by nature territorial or competitive. My primary goal is to offer my patients the most effective treatment and I am willing to entertain the possibility that people outside of my profession could have something clinically useful to contribute to my knowledge base. In the aftermath of a major car accident in 2003 I worked closely with a physical therapist for about six months and was extraordinarily impressed his knowledge and skill. This experience caused me to have a generally positive attitude toward physical therapy as a profession.
In an effort to make a fair assessment of dry needling and out of a desire to learn, I traveled to Phoenix in 2012 to attend a three-day “Dry Needling for Pain Management Certification” course. The instructor is well-known in the field and is the author of two textbooks on the topic and I was eager to learn more about his “neurophysiological” approach to treatment.
There were approximately 60 other practitioners in attendance. Most of them were physical therapists, a few were chiropractors, two were physicians, and there was one other licensed acupuncturist. Friday and Saturday were devoted to lecture and the material was interesting and useful. I scribbled copious notes (we were prohibited from using laptop computers out of concern that we would surreptitiously record the class), was fascinated by the in-depth theoretical discussion surrounding how acupuncture works neurophysiologically, and was impressed by the knowledge and enthusiasm of the other students.
The practical portion of the course is where things got scary
Sunday was the practical portion of the course. We were given boxes of cheap acupuncture needles in lengths ranging from 30 to 50 millimeters. The entire group of 60 gathered around one massage table and stood on tip-toe to try to get a good view of the instructor as he needled a series of points on a volunteer subject. Then we broke off into groups of three or four to practice. Because there was only one instructor for the whole group, within a matter of moments I became the informal guide for my side of the room.
Like many things, acupuncture looks simple and easy when done by an expert yet is a lot more complicated than meets the untrained eye. Most of the other practitioners in attendance had never handled acupuncture needles before, so they were fumbling with basic skills such as how to open needle packages and handle guide tubes. This seems like a minor point but is not — clumsy handling of acupuncture needles and associated equipment can easily result in contamination of the needles and risk for infection.
As the day of needling practice proceeded, I became more and more concerned. In Chinese medicine school we spent over a year in the classroom learning about safety considerations surrounding acupuncture before we so much as touched needles. Like high school students in driver’s ed who are forced to view videos of high speed collisions and look at photographs of the mangled wreckage of a drunk driver’s cars, we spent weeks studying cases (rare as they are) of people who had been harmed by inappropriate needling. We examined dozens of CT scans which showed how very close the apex of the lungs are to the underside of the trapezius muscles. We palpated the bodies of our classmates, learning to locate critical structures by feel. We discussed the fact that movements associated with respiration and/or digestion can cause a needle placement that was initially safe to become unsafe as the patient rests with the needles in place. We were encouraged to plan our treatments to make use of lower risk points on the extremities whenever possible.
In Chinese medicine school, when we did start needling, it was under the very close supervision of an expert. I inserted hundreds of needles in my own hands, feet, and legs before I touched another person and I inserted thousands of needles in my classmates’ hands, feet, and legs before I started practicing on points on the torso, neck, and face. I had been working with needles for two years (and hundreds of hours) by the time I touched a patient.
Now I found myself in a room full of minimally supervised individuals who were being encouraged to needle “assertively” into high-risk points located over internal organs less than 20 minutes after they touched an acupuncture needle for the very first time. I scurried between groups, answering questions, clarifying point locations or correcting angle of insertion, and exclaiming “hold on a sec, don’t do it that way!!!” over and over again. Although the other students were all experts in anatomy and musculoskeletal pathology, what they lacked entirely was the very subtle “feel” that is required to needle skillfully, safely, and painlessly.
Needling is a subtle skill that takes years to master
In Chinese medicine school, my early needling training was at the hands of a man who is the tenth generation acupuncturist in his family who had begun his own training in needling at age nine. He taught me that the acupuncture needle is a delicate instrument similar to the proboscis of a mosquito. He explained that, in the hands of a master acupuncturist, a needle is a living thing, an extension of the fingertips. The skilled and mindful acupuncturist can feel very clearly what is going on at the tip of the needle at all times. With this very careful attention, it is possible to feel when one’s needle tip is approaching structures that ought not be penetrated, such as nerves, blood vessels, the periosteum (the membrane surrounding bones), or the membrane surrounding internal organs.
The nature of the dry needling course made instruction in these types of subtleties impossible. One of the advantages being so busy answering questions during the practical portion of the course is that I was not subject to much needling myself. The exclamations of those who were being needled made it clear, however, that “painless” is not a description that could be attached to the techniques that were being used. I saw several rapidly developing bruises resulting from blood vessels that had been nicked, as well as heard the howls of a couple of practice subjects whose delicate periosteum had been plowed into by an incorrectly angled or too-deep needle.
Ignorant people overestimate their knowledge and skill because they are so ignorant that they don’t know they are ignorant
By the end of the day most of the students had needled each point no more than a few times (and clumsily at that), yet in his closing comments the instructor encouraged all of us to leap into the practice of dry needling the next morning at our respective clinics. My heart sank at the thought of how many patients these new “practitioners” would come into contact with. At best they would provide a painful and ineffective experience with acupuncture and at worst they could cause serious injury.
There was no discussion of the fact that three days of training is a tiny drop in the bucket of what is required to become competent with needles. The other professionals in that weekend course left on Sunday evening believing that they were fully qualified at something that I am well aware that I have still not mastered after nearly four years of formal education and over twelve years of full time clinical practice.
The whole experience made me think of the Dunning-Kruger Effect. According to the Journal of Personality and Social Psychology:
The Dunning–Kruger effect is a cognitive bias wherein unskilled individuals suffer from illusory superiority, mistakenly assessing their ability to be much higher than is accurate. This bias is attributed to a metacognitive inability of the unskilled to recognize their ineptitude. Conversely, highly skilled individuals tend to underestimate their relative competence, erroneously assuming that tasks which are easy for them are also easy for others.
In plain English: Ignorant people overestimate their knowledge and skill because they are so ignorant that they don’t know they are ignorant.
Based on my experience attending a dry needling certification, this explains exactly what is going on with physical therapists and other professionals who are practicing (and teaching) dry needling — having made no effort to understand the rich history, subtle skill, and extensive training involved with real acupuncture, practitioners of dry needling assume that the training of Licensed Acupuncturists is limited to “superstitious” or “archaic” notions such as Qi, meridians, Yin, and Yang. Having made this assumption, they further assume that a physical therapist’s extensive knowledge of anatomy qualifies them to wield needles with nothing more than a weekend’s training.
It is dangerous when any medical professional overestimates their ability
This state of affairs is dangerous, a fact that has been borne out by several recent cases in which high-profile patients have been injured by practitioners of dry needling (although a couple of these articles refer to “acupuncture” as opposed to “dry needling” the training of the practitioners involved is similar to what I experienced in the dry needling course). You can read about these cases here:
A few key facts regarding dry needling
DRY NEEDLING IS ACUPUNCTURE, NO MATTER WHAT YOU CALL IT.
Practitioners of dry needling are quick to claim that dry needling is not acupuncture. They explain that they needle trigger points , not acupuncture points and that they use filiform needles, not acupuncture needles. This is nothing more than a semantic slight of hand, as you will see below, and is done very deliberately in order to circumvent acupuncture licensure laws. Other terms used by practitioners of dry needling include trigger point manual therapy, trigger point dry needling, and intramuscular manual therapy. The fact remains, however, that agencies including the World Health Organization (WHO), the National Institutes of Health (NIH), and Medicare/Medicaid all consider dry needling (and equivalent terms) and acupuncture to be one and the same. The U.S. Department of Health and Human Services states “Acupuncture refers to the insertion of dry needles at specially chosen sites for the treatment or prevention of symptoms and conditions”.
The term “dry needling” was coined by Janet Travell, M.D. in the 1940s when she discovered that in some cases trigger points (taut bands of skeletal muscle within larger muscles that are tender to the touch and radiate pain to distant parts of the body) can be diffused by stimulating them with an empty hypodermic needle (hence the term dry needling). The problem is that this procedure is very painful — hypodermic needles are relatively large (the 22 gauge needles favored by Dr. Travell for dry needling are approximately five times the thickness of standard acupuncture needles) and are designed to slice through tissue. As a result, dry needling as originally described by Travell is not widely performed.
Recently practitioners of dry needling have abandoned the use of hypodermic needles and started using acupuncture needles instead. An acupuncture needle is different from a hypodermic needle in that it is much thinner and is solid (as opposed to having a hollow shaft). Although puncture of the skin with an acupuncture needle is an invasive/incisive procedure akin to minor surgery, needling with acupuncture needles is significantly less painful and less likely to cause bleeding or bruising than skin puncture with a hypodermic needle. Most practitioners of dry needling will refer to the needles they use as “filiform needles”, but if you examine the packaging you will see that they are, in fact, acupuncture needles (and are therefore subject to FDA regulation of acupuncture needles as described below).
Despite claims by practitioners of dry needling that they have discovered something new, the fact is that acupuncturists have been needling trigger points (called “a shi” points by acupuncturists) for thousands of years. The term “a shi” translates loosely as “ouch! that’s it!”, which is the typical patient response when a trigger point is pressed. There is a very long and documented history of acupuncturists using needles (often with the same lifting and thrusting or “pecking” techniques recently co-oped by dry needling practitioners) to diffuse tightness and relieve pain associated with a shi/trigger points. This practice was described medical writings going back to the Tang Dynasty (618-907 AD) and was explored in detail in The Yellow Emperor’s Internal Classic, published in the first century BC.
PURCHASE, POSSESSION, AND USE OF ACUPUNCTURE NEEDLES BY NON-ACUPUNCTURISTS VIOLATES FDA REGULATIONS AND IS ILLEGAL.
The FDA regulates acupuncture needles as Class II prescription medical devices, making acupuncture needles subject to the FDA’s strict prescription sale requirements. The FDA explicitly states that acupuncture needles “must be clearly restricted to qualified practitioners of acupuncture as determined by the States”. The FDA also explicitly defines the term acupuncture needle, stating “an acupuncture needle is a device intended to pierce the skin in the practice of acupuncture”. This may seem like a minor point but it is not — physical therapists and other practitioners of dry needling are NOT “qualified practitioners of acupuncture as determined by the States” and are therefore purchasing and using acupuncture needles in violation of FDA rules. No state deems physical therapists to be “qualified practitioners of acupuncture”.
BILLING INSURANCE FOR DRY NEEDLING, NEEDLING DISGUISED UNDER PHYSICAL THERAPY, OR TRIGGER POINT INJECTION CODES CONSTITUTES FRAUD.
The American Medical Association oversees a system called Current Procedural Terminology (CPT) coding in an effort to standardize the reporting and billing of medical, surgical, and diagnostic procedures and services. CPT codes are made up of five digits and specify the exact nature of the service performed. Among other things, insurance companies use this information to determine whether they will pay for that service and how much they will pay. CPT codes are very specific and designate the nature of the service, the credentials of the provider who performs the service, and the time involved in providing the service.
One of the selling points commonly used by practitioners of dry needling is that the procedure is “covered by most insurances, including Medicare”. Here are some key things to keep in mind if you are told that dry needling will be covered by your insurance:
- There is no CPT code for dry needling.
- Although some insurance policies cover acupuncture (97810-97814), those policies will not pay for acupuncture performed by a physical therapist.
- Acupuncture and/or the use of acupuncture needles (whether by a licensed acupuncturist or any other provider) are not covered services under Medicare.
- It is fraud for a physical therapist or a chiropractor to bill insurance for dry needling using physical therapy procedure codes such as manual therapy (97140), therapeutic exercise (97110), or neuromuscular re-education (97112).
- It is fraud for a physician, physician assistant, or nurse practitioner to bill insurance for dry needling using any of the physical therapy codes above or for trigger point injection (20550-20553).
- The only code that can legally be used to bill insurance for dry needling is unlisted procedure, musculoskeletal system, general (20999). The problem is that many insurance companies refuse to pay for unlisted procedure codes and providers generally prefer to avoid using unlisted procedure codes (because insurance companies require more documentation to process the codes and generally do not reimburse as much for them).
- To report suspected fraud, you can call the Medicare Fraud Hotline at 1-800-447-8477.
PHYSICAL THERAPY SCOPE OF PRACTICE DOES NOT INCLUDE ANY MODALITY THAT INVOLVES PUNCTURING THE SKIN.
No aspect of acupuncture/dry needling is covered by the standard classroom or clinical curriculum completed by physical therapists and questions related to acupuncture/dry needling are not included on the licensure exams taken by physical therapists. Physical therapy malpractice insurance generally does not cover dry needling.
Some physical therapists claim that dry needling is a type of manual therapy, even going so far as to refer to dry needling as “intramuscular manual therapy”, but the term manual clearly indicates a technique that is done using hands, not a Class II prescription device such as an acupuncture needle.
How to find a qualified acupuncturist
Fortunately it is easy to find a qualified practitioner of acupuncture in most major cities. The National Certification Commission for Acupuncture and Oriental Medicine maintains a database of board certified acupuncturists that is searchable by zip code here. Other resources for locating a qualified acupuncturist include the Texas Association of Acupuncture and Oriental Medicine’s find a practitioner page, the AcuTake directory, AcuFinder, and the Try Acupuncture directory.
- The Illegal and Unsafe Practice of Medicine in General and Acupuncture in Particular Under the Term
- Dry Needling and Violations of the U.S. Food, Drug, and Cosmetic Act (FDCA) and Food and Drug Association Rules
- Asian Medicine and Acupuncture Society of Arizona Position on Physical Therapists and Non-Licensees Using Dry Needling
- CPT Assistant: Coding Clarification – Trigger Point Injections Using “Dry Needling” Technique
- National Chiropractic Council letter to Oregon Medical Board
- Doctor fined $35,000 for Medicare fraud related to dry needling
- American Physical Therapy Association: Physical Therapy & the Performance of Dry Needling
- Oregon Board Physical Therapist Licensing Board: Updated Statement Related to Physical Therapists Using the Intervention of Dry Needling