Introduction: scope of practice

Scope of practice is generally defined as the activities that an individual healthcare provider performs in the delivery of patient care. Overlap in scope of practice is recognised by many healthcare disciplines, ranging from medical radiation technologists (QSE Consulting, 2005) and nursing (Committee on Health Professions Education Summit, 2003; Association of Social Work Boards et al., 2009) to physical therapy, social work, occupational therapy (Association of Social Work Boards et al., 2009; Adrian, 2010; APTA Practice Department and APTA State Government Affairs, 2011), and medicine (Federation of State Medical Boards of the United States, 2005; Association of Social Work Boards et al., 2009). The Federation of State Medical Boards of the United States defines scope of practice as ‘those health care services a physician or other health care practitioner is authorised to perform by virtue of professional license, registration, or certification’ (Federation of State Medical Boards of the United States, 2005). According to the Federation, ‘the concept of collaboration acknowledges that scopes of practice often overlap within the health care delivery system’, which ‘can be an effective means for providing safe and competent health care’ (Federation of State Medical Boards of the United States, 2005). The Federation recognises that different healthcare professionals’ scopes of practice may overlap and that different disciplines can collaborate based upon shared competencies.

The Pew Health Commission Taskforce on Health Care Workforce Regulation emphasised that a nearly exclusive scope of practice leads to unreasonable barriers to high quality and affordable care (Finocchio et al., 1995). In the United States, many state individual statutes also recognise the importance of overlap in scope. The Attorney General of Maryland confirmed that ‘state law recognises that the scope of practice of health care professions may overlap’ and confirmed that the Maryland General Assembly ‘has fostered consumer choice in the selection of treatment and practitioner’ by providing for overlapping scope of practice for different healthcare disciplines (Gansler & McDonald, 2010). To offer high quality, affordable, and accessible healthcare, it is crucial that all healthcare providers can practice within the full scope of their professional competencies (Safriet, 1994; Schmitt, 2001).

Dry needling by multiple disciplines

Dry needling (DN) is a treatment technique practiced around the globe by a wide variety of healthcare disciplines, including allopathic, osteopathic, naturopathic, dental, podiatric, veterinary, acupuncture, physical therapy, occupational therapy, chiropractic medicine, myotherapy, athletic training, and massage therapy, among others, dependent on the country and local jurisdictional regulations (Dommerholt et al., 2006a). Similar to many other treatment interventions, DN is not in the exclusive scope of any discipline (APTA Practice Department and APTA State Government Affairs, 2011; Dommerholt, 2011). A chiropractor or physical therapist employing DN is practicing chiropractic or physical therapy, respectively. Uneducated patients may occasionally refer to DN as the practice of acupuncture even when performed by a nonacupuncturist, but they should be informed that only acupuncturists are practicing acupuncture. Similarly, physical therapists, chiropractors, and osteopaths administer manipulations with different names without necessarily encroaching on each other’s disciplines. A physical therapist does not apply chiropractic adjustments and a chiropractor does not utilise orthopaedic manual therapy manipulations even though the techniques may appear similar. Massage therapists, physical therapists, and a variety of other professions use massage or soft tissue manipulation without claiming ownership of a technique. Irrespective of any political or philosophical disagreements, the clinical reasoning process to perform joint or soft tissue manipulations may be quite different between professions. For example, traditionally chiropractors used adjustments as a primary intervention to correct spinal subluxations for a wide range of ailments. However, more recently, the practice has evolved into targeting movement of joints rather than the position of joints, and chiropractors are increasingly adopting the term ‘manipulation’ (Paris, 2000). A technique does not define the scope of practice, and no profession actually owns a skill or activity in and of itself (Association of Social Work Boards et al., 2009).

Opposition to dry needling by nonacupuncturists

Initially, reputable US-based acupuncturists supported DN by physical therapists (Seem et al., 1991). However, when DN became more integrated into physical therapy practice, US acupuncture organisations increased their opposition and argued that DN would constitute the exclusive practice of acupuncture, which by definition can only be practiced by acupuncturists (Hobbs, 2007, 2011). Twenty-five years after the Maryland Board of Physical Therapy Examiners approved DN by physical therapists in 1984, the Maryland Board of Acupuncture formally opposed DN by physical therapists. Many US acupuncture organisations—such as the American Association of Acupuncture and Oriental Medicine (AAAOM), the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM), the American Alliance for Professional Acupuncture Safety (AAPAS), and the National Centre for Acupuncture Safety and Integrity (NCASI), among others—have taken a firm stand and issued position papers confirming that DN is acupuncture (AAAOM, 2011a, 2011b; Hobbs, 2011). These organisations oppose DN by other disciplines such as physical therapy and chiropractic. A few medical associations and medical state boards, which in some states also regulate acupuncture practice, have also argued against DN by physical therapists and chiropractors, although the Federation of State Medical Boards copublished a statement in support of overlap of scope of practice (Association of Social Work Boards et al., 2009).

The CCAOM believes that physical therapists have recognised the benefits of acupuncture ‘and its various representations such as DN due to the fact that they are attempting to use acupuncture and rename it as a physical therapy technique’ (Hobbs, 2011). The AAAOM agreed that physical therapists are ‘retitling’ and ‘repackaging’ a subset of acupuncture techniques with the terms ‘DN’ and ‘intramuscular manual therapy’ (AAAOM, 2011a). Several more recent opinion papers share these sentiments (Zhou et al., 2015; Fan et al., 2016a, 2016b, 2017; Hao et al., 2016; Liu et al., 2016; Peng et al., 2016). Fan and colleagues (2017) conclude that physicians who have promoted DN have simply rebranded: (1) acupuncture as dry needling; and (2) acupuncture points as TrPs or dry needling points. Although these arguments may make some sense from a narrow acupuncture point of view, they lack a more global perspective.

Some studies conducted by Melzack suggested a 71% overlap between acupuncture points and TrP based on anatomical location (Melzack et al., 1977; Melzack, 1981); however, acupuncturist Birch concluded that Melzack erroneously had assumed that local pain indications of acupuncture points would be sufficient to establish a correlation (Birch, 2003). Instead Birch (2003) concluded that, at best, there is only an 18% to 19% overlap between acupuncture points and TrPs. Dorsher (2006) disagreed with Birch (2003) and concluded that most acupuncture points do have pain indications and can be directly compared with TrPs. He concluded that out of a total of 255 TrPs, 92% had anatomically corresponding acupuncture points and that nearly 80% of these acupuncture points had local pain indications similar to their corresponding TrPs (Dorsher, 2006). In a reply, Birch (2008) insisted that the presumed correspondence between acupoints and TrPs is based on a misunderstanding of the nature of both kinds of points. Similarly, several other acupuncturists have described similarities in between the pathways of acupuncture meridians and common referred pain patterns of TrPs (Cardinal, 2004, 2007; Dorsher & Fleckenstein, 2009).

One major flaw in comparing acupuncture points and TrP locations is that the ‘TrP locations’ reflect only a theoretical location as observed by Travell and Rinzler (1952). TrPs occur near motor endplates distributed widely throughout muscle bellies, which means that there are many potential TrP locations and not predetermined location of TrPs (Dommerholt et al., 2006b). Because TrPs do not have particular fixed locations, any comparison between TrPs and acupuncture points based on anatomical location is inaccurate and subject to inherent error (Dommerholt & Gerwin, 2010). As different schools of acupuncture have defined over 2500 acupuncture points worldwide, it is nearly impossible not to find topographical correspondences.

Summary

Many of the controversies surrounding DN are based on a profound lack of understanding of the nature, depth of knowledge, and scope of other disciplines, turf behaviour, and perceived economic effect. Within the context of acupuncture, DN may well be similar to needling of Ashi points, but in the context of medicine, chiropractic, veterinary medicine, dentistry, and physical therapy, DN is nothing but a modification of TrP injections. Nonacupuncturists need to understand the depth of contemporary acupuncture practice; acupuncturists need to realise that DN by other disciplines does not pose any threat to acupuncture and to the public at large. Overlap in scope of practice will lead to high quality and affordable healthcare (Finocchio et al., 1995). From that perspective, DN is firmly established across many healthcare disciplines.