Great and Necessary Perspective
Let's Be Honest About Dry Needling
April 21, 2017 | Dr. Christina Fick, DAOM
Earlier this year, the Acupuncture Association of Colorado (AAC) filed a lawsuit against the Colorado branch of American Physical Therapy Association (APTA) for the "unsafe use of Dry Needling." Why? Because less than 200 acupuncturists in the state of Colorado who are members of the AAC have determined that dry needling done by physical therapists is unsafe due to the lesser amount of training in needling than a licensed acupuncturist (1). Before I give you my opinion, I will try to lay out the facts...
First, what is the difference between dry needling and acupuncture? Dry needling is the insertion of a needle into a tight muscle (and/or a trigger point). Nothing more; nothing less. Often, the needle is twisted and manipulated until a fasciculation (or a twitch occurs). This stimulates a release of endogenous natural opioids and endorphin's which help with pain but not with inflammation.
Acupuncture, on the other hand, is designed to be a whole system. Two people with elbow pain may come in and receive two different types of treatments with needles in different locations based upon a differential diagnosis, or what the practitioner determines is the cause of the elbow pain. Acupuncture uses distal points, or channel points, which are acupuncture points that have certain functions and tend to run along nerves and blood vessels (2). Because of these distal points, acupuncture has been shown to affect several different areas of the brain, including the prefrontal cortex, the cingulate gyrus, and the sensory cortex. It's common in acupuncture to insert needles into the areas where it hurts to perform classic dry needling in conjunction with traditional acupuncture. Dry needling is only used for pain, while acupuncture is used for pain, decreasing inflammation, balancing hormones, regulating organ functions, and much more.
Why do PT's want to do dry needling in the first place? They are experts at assessing the physical body for musculoskeletal dysfunction, and they often suggest or prescribe therapies like exercises to help with those problems and pains. Often, patients complain, though, that they aren't getting out of pain as quickly as they would like. So, PT's needed another therapy to add to their toolbox to help patients overcome pain faster. First let's talk about the facts.
There are actually not a whole lot of facts the two professions can agree on when it comes to safety. Acupuncturists on the board have claimed there were about 10 lawsuits against PT's in Colorado in the past seven years, while PT's claim there have been zero! Dry needling is significantly more aggressive than your typical acupuncture treatment, but the verdict is still out about what the real numbers are. I can tell you this: the incidences of needle injuries from licensed acupuncturists are significantly less nationwide than that of lawsuits against PT's and dry needling.
Now it's time for my opinion and soapbox. Hope you're ready! I feel, as a medical provider, we should first, "do no harm." I strongly feel that if you are untrained and under educated about a particular therapy, it is in the patient's best interest that you allow the patient to seek care from a professional. In the real world, this doesn't always work. For example, here in Evergreen, we are limited on the number of professionals, so people tend to seek help wherever they can find it. Continually I am in the business of care. I am not in the business of medicine. I do not put my business and financial needs above the patient's. This is not true for everyone. I strongly feel that I must do whatever I can to protect, heal, and help my patients however I can. I also feel that most PT's feel the same way. They want their patients to get better. I would never want to be a part of something that would take away the ability of PT's to help their patients. PT's help my patients more than any other medical profession out there. They have a doctoral level of education and in Colorado they have practiced dry needling since 2007.
I think if a patient is in need of pain relief, they must understand the risks of dry needling and the differences between that and acupuncture. Dry needling is significantly more painful than acupuncture, but sometimes can be more effective for pain. I would never disallow a patient help. I have also seen in my own profession of acupuncture, the lack of ability to perform basic musculoskeletal exams, some lack of basic anatomy knowledge, and I have yet to find a licensed acupuncturist outside of my doctoral cohorts who performs true dry needling for pain. I am beyond saddened by this. This is why I am not a part of this lawsuit, nor will I ever be. My specialty is needle techniques. I am one of the few acupuncturists in the state who do "free-hand needling," and I combine both traditional Chinese acupuncture, using distal points, with dry needling and medical acupuncture. My goal is to train other acupuncturists to offer this service. I feel, if you are going to sue a profession for needling, you must first practice your own profession at its best. With that said, I hope you all can make the best informed decision for your own unique condition.
Well Thought Out Response by T. V. Kitchener, DPT
Dr. Fick, I am beyond grateful to see this factual, rational post regarding Acupuncture and Physical Therapist (PT) use of trigger point dry needling (TDN). I am proud to have you as a member of our Colorado healthcare team! I have been using TDN in my practice as a PT for years for the treatment of specific musculoskeletal pain with fantastic results. I have successfully used it in addition to specific exercises to manage chronic pain in individuals enabling them to avoid serious, high risk spinal surgeries, and/or decrease use of pain medication. I have personally and professionally also seen astounding results from Acupuncture that decrease use of medications with high side effect profiles and improve quality of life. I commonly refer patients for Acupuncture treatment in addition to or instead of PT. What I do with filiform needles is NOT Acupuncture. Treating Trigger Points and Myofascial pain is well within my scope of practice and doing so with a filiform needle has proven (in my experience) to be one of the most efficient and effective ways of doing so. I understand the industry's concern in ensuring public safety with adequate education for all practicing healthcare providers. I disagree with the common misrepresentation of PTs not being adequately educated by leaving out that PT is now a Doctoral Degree, generally requiring a minimum of 7 years of higher education including extensive anatomy and physiology. This includes an extensive human cadaver dissection. Yes, the hours specifically dedicated to trigger point dry needling education pale in comparison to an acupuncturists overall education. However, this is not a reasonable comparison when the majority of our education is completely disregarded. When you have all of the Anatomy and Physiology (as well as differential diagnosis, palpation, etc.) knowledge present, the additional knowledge necessary to practice TDN safely is easily condensed. When 2 years of practicing as a PT is additionally required, it ensures that certain skills beyond that of an entry level practitioner are present prior to learning an advanced skill such as TDN. Also, as you stated, PTs are not performing Acupuncture, therefore we do not require the same education as an Acupuncturist, only how to safely and effectively use filiform needles to address musculoskeletal impairments. "Nothing more; nothing less" as you so adequately put it. Is there an increased risk with use of filiform needles? Yes, I believe that there is. It is a more invasive procedure than external palpation or manual trigger point release. This is why PTs also most abide by the "first, do no harm" guidance. If less invasive procedures can yield the same results as safely and EFFICIENTLY as TDN, then TDN should be deferred. This should be up to the clinician and client/patient to decide after informed consent is received. While I do admit that using needles for treatment increases the risk profile, I want to point out that in trained hands it is relatively low. It is certainly much lower than the risk of surgeries that may be required if patients are unable to achieve pain management in more conservative therapies. I believe that as long as informed consent is obtained from each and every patient/client, and we continue to hold PTs to the same high standard that we are now, the risk will remain low, and patients will be able to determine on their own accord the appropriate direction of their care. If we can all play nicely with each other and put our own personal fears, biases, and wants aside; we can fulfill our ultimate common goal, which is to help our community live with the best quality of life possible. I look forward to continuing to work with acupuncturists in a multidisciplinary approach with my clients and in my personal life. I hope that we can start to do this on a larger scale in the professional realm. If we put our resources to advancing the profession instead of fighting with each other, we could achieve so much more. Again, thank you for your very honest and factual post which I know goes against a very popular view in your profession. I hope that you will inspire others to reevaluate the true goals of those in our practice.