Trigger-Point Dry Needling
The Illegal and Unsafe Practice of Acupuncture Under the
Term “Trigger-Point Dry Needling”: 10 Key Facts
A serious threat to public health and safety exists from the illegal and unsafe practice of acupuncture under the term “trigger-point dry needling.”
A growing number of physical therapists and other allied health professionals are circumventing state licensure requirements and regulations for the practice of acupuncture by advertising and providing acupuncture services to an unsuspecting public under the term “trigger-point dry needling” (or derivations of the term such as “functional dry needling”).
Acupuncture is a form of minimally invasive surgery that involves inserting acupuncture needles (slender, sharp-pointed, stainless-steel medical devices ranging from approximately one-half inch to six inches in length) into specific anatomical sites (acupuncture points) in the body and manipulating (for example, rotating and/or pistoning) them manually for diagnostic and/or therapeutic purposes. Acupuncture points are found in muscle and connective tissue and are located through palpation.
Additionally, acupuncture is—and has been for over 2,000 years—a discipline based on an integrated understanding of anatomy, physiology, and pathology.
As with any form of minimally invasive surgery, acupuncture is not without risk, including injury to blood vessels, nerves, muscles, bones, and internal organs as well as infection and cross infection. These and other risks can only be avoided or minimized through appropriate education and training in the correct administration of acupuncture treatments.
In fact, Seirin, the world’s leading manufacturer of acupuncture needles, warns: “Use [of acupuncture needles] by individuals other than licensed physicians or acupuncturists may lead to serious injury.”
In the interests of public health and safety, it is imperative that the public be assured that individuals who perform this form of minimally invasive surgery are nationally certified or licensed acupuncturists or licensed physicians (defined as doctors of medicine or osteopathy) who meet appropriate professional standards of education and training in acupuncture.
The AAMA (American Academy of Medical Acupuncturists – a physician organization promoting the integration of acupuncture with western medicine training) 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 and other allied health professionals to include dry needling as part of their practice.
Here are 10 key facts concerning the illegal and unsafe practice of acupuncture under the term “trigger-point dry needling”:
1. Trigger-point dry needling is acupuncture.
Trigger-point dry needling is acupuncture that involves inserting acupuncture needles into specific anatomical sites in the body, specifically tender points, and manipulating them manually for the treatment of pain and dysfunction—particularly of the neuromusculoskeletal system.
Trigger-point dry needling is not some new twentieth-century discovery. It was, in fact, first described in detail over 2,000 years ago in the Chinese medical treatise Yellow Emperor’s Inner Classic (黃帝內經 Huáng Dì nèi jïng).
2. Tender points (also known as “trigger points” or “motor points”) are acupuncture points.
Tender points—like all other acupuncture points—are found in muscle and connective tissue and are located through palpation.
As their name suggests, tender points are located through pain or tenderness on palpation. This was, in fact, one of acupuncture’s earliest forms of point selection. The Yellow Emperor’s Inner Classic states: “It is [the point of] pain or tenderness that defines an [acupuncture] point [以痛為腧 yǐ tòng wéi shù].”
Sun Si Miao (孫思邈 Sün Sï Miâo, 581–682 C.E.), China’s pre-eminent physician, referred to tender points as “Ah yes! points” (阿是穴 ā shì xué). That is because when the tender point is pressed, the patient feels an unexpected local and/or referred “wince-pain” (with or without a local fasciculation—a brief, involuntary contraction or twitching of groups of muscle fibers around the tender point) and says “Ah yes! That is the right spot.”
Incidentally, in a 1977 study published in Pain (the official journal of the International Association for the Study of Pain), Dr. Ronald Melzack, Dr. Dorothy M. Stillwell, and Dr. Elisabeth J. Fox examined the correlation between trigger points and acupuncture points. The results of their analysis showed that “every trigger point [reported in the Western medical literature] has a corresponding acupuncture point.”*
*Source: Melzack R, Stillwell DM, Fox EJ. Trigger points and acupuncture points for pain: correlations and implications. Pain. 1977 Feb;3(1):3–23.
3. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture would have the public believe that trigger-point dry needling is not acupuncture but manual therapy.
This is absurd because trigger-point dry needling is invasive, whereas manual therapy is non-invasive.
As stated earlier, trigger-point dry needling is acupuncture that involves inserting acupuncture needles into specific anatomical sites in the body, specifically tender points, and manipulating them manually for the treatment of pain and dysfunction—particularly of the neuromusculoskeletal system. It must be emphasized that manual therapy certainly does not include the practice of surgery in any form.
4. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture would have the public believe that the act of inserting acupuncture needles into specific anatomical sites in the body and manipulating them manually for diagnostic and/or therapeutic purposes does not define the profession of acupuncture.
Nothing could be further from the truth. The act of inserting acupuncture needles into specific anatomical sites in the body and manipulating them manually for diagnostic and/or therapeutic purposes does define the profession of acupuncture. It is this act that makes the profession of acupuncture unique.
Indeed, acupuncture literally means “pricking or piercing with a needle,” from Latin acu “with a needle” and punctura “pricking or piercing.”
5. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture would have the public believe that they do not use acupuncture needles to perform trigger-point dry needling.
The fact is, they do use acupuncture needles to perform trigger-point dry needling. However, they deliberately call them “dry needles” rather than “acupuncture needles” as part of their strategy to confuse and mislead the public.
6. It is illegal for physical therapists and other allied health professionals who are not licensed by law to practice acupuncture to purchase or possess acupuncture needles.
Acupuncture needles are Class II (special controls) medical devices and must comply with all applicable provisions of the Federal Food, Drug, and Cosmetic Act (FDCA) and U.S. Food and Drug Administration (FDA) implementing regulations.
FDA implementing regulations require that the sale of acupuncture needles “must be clearly restricted to qualified practitioners of acupuncture as determined by the States.” See 61 Fed. Reg. 64616 (Dec. 6, 1996) (emphasis added); see also 21 U.S.C. § 360j(e); 21 CFR § 880.5580(b)(1); 21 CFR § 801.109. Accordingly, FDA implementing regulations require that the label of acupuncture needles must bear the following prescription medical device statement: “Caution: Federal law restricts this device to sale by or on the order of qualified practitioners of acupuncture as determined by the States.” (Emphasis added.) See 21 U.S.C. § 360j(e); 21 CFR § 801.109(b)(1).
Therefore, physical therapists and other allied health professionals who are not licensed by law to practice acupuncture are directly violating civil and criminal provisions of the FDCA intended to protect public health and safety when they purchase or possess acupuncture needles. See 21 U.S.C. § 331(a)–(c), (g).
7. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture are not qualified to perform trigger-point dry needling.
Trigger-point dry needling is far outside the scope of their education, training, experience, expertise, and license.
In order to become a licensed acupuncturist in most states, an applicant must have completed at least 1,245 hours of didactic education in subjects including anatomy, physiology, pathology, diagnosis, and treatment as well as infection control, palpation-based acupuncture point location, and acupuncture needle use—including indications, effects, routes, methods, and frequency and duration of administration as well as relevant hazards, contraindications, side effects, and precautions. The applicant must have also completed at least 660 hours of clinical training, under direct supervision, in acupuncture.
Yet a growing number of physical therapists and other allied health professionals who are not licensed by law to practice acupuncture are advertising and providing acupuncture services to an unsuspecting public under the term “trigger-point dry needling” (or derivations of the term such as “functional dry needling”) with as little as a weekend workshop in acupuncture.
8. There are very real risks associated with the use of acupuncture needles (with or without the passage of electrical current through these needles) by physical therapists and other allied health professionals who are not licensed by law to practice acupuncture.
These risks include, but are not limited to, the following:
- Injury to blood vessels, nerves, muscles, bones, and internal organs resulting from:
- incorrect direction, angle, and/or depth of insertion of acupuncture needles;
- inappropriate manipulation of acupuncture needles; and
- inappropriate passage of electrical current through acupuncture needles.
- Infection and cross infection—including acquired immunodeficiency syndrome (AIDS), Hepatitis B, Hepatitis C, and methicillin-resistant Staphylococcus aureus (MRSA).
9. There have been recent reports of serious injury resulting from the use of acupuncture needles by physical therapists and other allied health professionals who lacked the education and training of licensed physicians or acupuncturists.
On June 21, 2006, Kim Ribble-Orr, a former Olympic athlete from Hamilton, Ontario, Canada, suffered a punctured left lung resulting from incorrect direction, angle, and/or depth of insertion of an acupuncture needle by a massage therapist who lacked the education and training of licensed physicians or acupuncturists. Her punctured left lung resulted in left-sided pneumothorax (the presence of air in the cavity between the lungs and the chest wall, causing collapse of the lung) with subsequent life-threatening infection—requiring surgeries and 11 days in the hospital. According to court records, “[s]he now has only 55% function in her left lung.” See Spurrell v. College of Massage Therapists of Ontario, 2013 ONSC 4117 (CanLII), 2013 ONSC 4117 (CanLII), at paragraph 11.
On October 4, 2012, Emily Kuykendall, a high-school teacher from Ellicott City, Maryland, suffered a punctured left-leg nerve resulting from incorrect direction, angle, and/or depth of insertion of an acupuncture needle by a physical therapist who lacked the education and training of licensed physicians or acupuncturists. Her punctured left-leg nerve resulted in severe, debilitating pain, literally from head to toe—requiring prescription drugs.
On November 29, 2013, Torin Yater-Wallace, a high-school student from Basalt, Colorado, suffered a punctured right lung resulting from incorrect direction, angle, and/or depth of insertion of an acupuncture needle by a physical therapist who lacked the education and training of licensed physicians or acupuncturists. His punctured right lung resulted in right-sided pneumothorax—requiring surgery and three days in the hospital.
10. It is illegal for physical therapists or any other providers to submit claims for payment to Medicare for trigger-point dry needling (a non-covered service) disguised as physical therapy (a covered service).
Trigger-point dry needling is acupuncture which is not a covered service under the Medicare program. See 42 U.S.C. § 1395y(a)(1). Use of acupuncture needles (with or without the passage of electrical current through these needles) is not a covered service under the Medicare program, whether the service is rendered by a licensed acupuncturist or any other provider.
Billing Medicare for trigger-point dry needling under the physical therapy codes (for example, 97110, therapeutic procedure; 97112, neuromuscular re-education; or 97140, manual therapy) is a misrepresentation of the actual service rendered and is considered fraud by Medicare. See 31 U.S.C. §§ 3729–3733.
For additional key facts concerning the illegal and unsafe practice of acupuncture under the term “trigger-point dry needling,” visit www.acupuncturesafety.org and www.liveoakacupuncture.com.