Introduction: scope of practice

Dry needling is a treatment technique practiced around the globe by numerous healthcare disciplines, including allopathic, osteopathic, naturopathic, podiatric, veterinary, and also chiropractic medicine, acupuncture, physical therapy, dentistry and massage therapy, among others, dependent upon the country and local jurisdictional regulations (Dommerholt et al. 2006). Dry needling, like many other treatment techniques, is not in the exclusive scope of any discipline (Dommerholt 2011, APTA Practice Department and APTA State Government Affairs 2011). A chiropractor or physical therapist who employs dry needling is practicing chiropractic or physical therapy, respectively. Uneducated patients may occasionally refer to dry needling by a physical therapist as a form of acupuncture, but they should be informed that only acupuncturists are practicing acupuncture. Similarly, some patients may assume that all spinal manipulations are chiropractic interventions, not realizing that manual physical therapists and osteopathic physicians also employ spinal manipulative interventions (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).

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 recognized 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 authorized 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 recognizes 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 emphasized that near-exclusive scopes of practice lead to unreasonable barriers to high-quality and affordable care (Finocchio et al. 1995). Even US state statutes recognize the importance of overlap in scope, for example, the South Dakota Codified Laws acknowledge that ‘a nurse practitioner may perform [an] overlapping scope of advanced practice nursing and medical functions’ (South Dakota Legislature 2011). The Attorney General of Maryland confirmed that ‘state law recognizes 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).

Acupuncture opposition to dry needling by non-acupuncturists

In the United States, acupuncture organizations have expressed growing opposition to dry needling performed by physical therapists, chiropractors, and other non-acupuncturists (Hobbs 2007, Hobbs 2011). Although initially, reputable acupuncturists supported dry needling by physical therapists (Seem et al. 1991), more recently, it has been suggested that dry needling would constitute the exclusive practice of acupuncture, which by definition can only be practiced by acupuncturists (Hobbs 2007, 2011). Although such exclusive interpretations of scope of practice do not necessarily benefit patients and may negatively impact the overall quality of healthcare (Finocchio et al. 1995), acupuncture organizations such as the American Association of Acupuncture and Oriental Medicine (AAAOM), the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM), and the Illinois Acupuncture Federation (IAF), among others, have taken a firm stand and published position papers against dry needling by physical therapists (AAAOM 2011a, 2011b, Hobbs 2011). Twenty years after the Maryland Board of Physical Therapy Examiners approved dry needling by physical therapists in 1989, the Maryland Board of Acupuncture formally questioned the physical therapy board before filing an inquiry with the state’s Attorney General.

A few medical state boards, which in some states regulate acupuncture practice, have also argued against dry needling by physical therapists and chiropractors, although their own professional Federation of State Medical Boards co-published a statement in support of overlap of scope of practice (Association of Social Work Boards et al. 2009). In a letter to the Oregon Board of Physical Therapy, the Oregon Medical Board claimed that ‘dry needling’ is a derivative of acupuncture and is defined by the World Health Organization (WHO) as ‘acupuncture’, although the WHO has never released any report on dry needling (Finklestein & Haley 2009). The WHO did confirm that ‘making use of acupuncture in modern medical care means taking it out of its traditional context and applying it as a therapeutic technique for a limited number of conditions for which it has been shown to be effective, without having to reconcile the underlying theories of modern and traditional medicine’ and ‘some physicians or dental surgeons might wish to acquire proficiency in certain specific applications of acupuncture (for example, pain relief, or dental or obstetric analgesia) and for them flexibility would be needed in designing special courses adapted to their particular areas of interest’ (1999).

In fairness, it appears that physical therapists may have contributed to the growing opposition. The inquiry with the Maryland Attorney General was triggered by a Maryland-licensed physical therapist, who filed a complaint with the Maryland Board of Acupuncture regarding an acupuncturist who allegedly practiced physical therapy without a license, because the practitioner used dry needling techniques. Many physical therapists have included statements in their marketing materials that ‘dry needling is not acupuncture’, which would be quite irritating to acupuncturists who are convinced that dry needling is in the exclusive scope of their practice. In a few older publications, I also stated erroneously that ‘dry needling is not equivalent to acupuncture and should not be considered a form of acupuncture’ (Dommerholt 2004, Dommerholt et al. 2006). Following Jane Goodall’s advice that ‘change happens by listening and then starting a dialogue with the people who are doing something you don’t believe is right’, I discussed these issues with several acupuncturists in various countries. Based on the feedback I received, I formally apologized and retracted those statements in an article published in the Qi Unity newsletter, a publication of the AAAOM (Dommerholt 2008). Sadly, in spite of my apology and correction, the CCAOM did not hesitate to reference my erroneous statements in their 2011 position statement (Hobbs 2011). In more recent publications, I have indicated that it is counterproductive and inaccurate to state that dry needling would not be in the scope of acupuncture, and that within the context of acupuncture, dry needling is a technique of acupuncture (Dommerholt 2011, Dommerholt & Gerwin 2010). But, as stated previously, dry needling is not in the exclusive scope of any discipline. It is physical therapy when performed by a physical therapist, chiropractic when performed by a chiropractor, and dentistry when performed by a dentist.

Non-acupuncturists, who use dry needling techniques, often contrast dry needling with Traditional Chinese Medicine (TCM), its meridians, flow of energy, and metaphysical theoretical concepts. From a Western medical perspective, dry needling has little if anything in common with TCM (Gunn 1998, Baldry 2005). Physical therapists who write on their websites that ‘dry needling is not acupuncture’ most likely have no knowledge of acupuncture and in many cases have not considered the issue. Yet, according to Janz and Adams, ‘the relationship between the biomedical foundation of trigger point (TrP) dry needling and clinical practice describes a variation of classical acupuncture rather than the invention of a new therapy’ (Janz & Adams, 2011).

The CCAOM believes that physical therapists have recognized the benefits of acupuncture ‘and its various representations such as dry needling 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 ‘re-titling’ and ‘re-packaging’ a subset of acupuncture techniques with the terms ‘dry needling’ and ‘intramuscular manual therapy’ (AAAOM 2011a). The IAF suggested that ‘simply renaming and rebranding “Acupuncture” as “Trigger Point Dry Needling” does not make it a unique technique’ (AAAOM 2011b). Janz and Adams (2011) also postulated that dry needling is a pseudonym for the practice of musculoskeletal acupuncture. While these arguments may make some sense from a narrow acupuncture point of view, they lack a more global perspective.

In the TCM treatment of pain TrPs are commonly referred to as Ashi points first described by Sun Si Miao in 652 CE (Janz & Adams 2011, 2011a). Although according to the AAAOM (2011a), TrP phenomena are well known to acupuncturists as Cummings mentions in Chapter 13 of this book, the theoretical backgrounds are quite different. Whether TrPs and Ashi points represent the same phenomenon continues to be an area of debate. From a dry needling perspective, acupuncturists may well be treating TrPs when needling Ashi points (Audette & Blinder 2003, Hong 2000); however, Seem argued that American acupuncturists usually do not ‘treat tender or tight spots and, hence, never really achieve myofascial release in their recurrent and chronic pain patients’ (Seem 2007).

Melzack and colleagues suggested a 71% overlap between acupuncture points and TrPs based on anatomical location (Melzack 1981, Melzack et al. 1977), but acupuncturist Birch concluded that Melzack et al. erroneously had assumed that local pain indications of acupuncture points would be sufficient to establish a correlation. Instead, Birch concluded that at best there is only an 18–19% overlap between acupuncture points and TrPs (Birch 2003). Dorsher (2006) disagreed with Birch and concluded that most acupuncture points do have pain indications and can be directly compared to TrPs. He concluded that out of a total of 255 TrPs, 92% had anatomically corresponding acupuncture points and 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. Several acupuncturists described similarities in between the pathways of acupuncture meridians and common referred pain patterns of TrPs (Cardinal 2004, Cardinal 2007, Dorsher & Fleckenstein 2009).

One major flaw in comparing acupuncture and TrP locations is that the TrP locations reflect only the most common locations as observed by Travell (1952). TrPs occur near motor endplates distributed widely throughout muscles, which means that there many other potential TrP locations as any clinician familiar with TrP will readily confirm (Simons 2004, Simons & Dommerholt 2007). Because TrPs do not have 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, it is nearly impossible not to find topographical correspondences.

Hobbs (2011) clarified that acupuncture is not necessarily ‘limited to its historical roots and centuries’ old theory, but is also a dynamic, evolving modern medical practice, which incorporates the use of neuro-anatomical terminology’. In other words, acupuncture is not necessarily always based on or limited to Oriental medicine concepts, although the majority of US acupuncture state statutes define acupuncture in the context of ‘Oriental medicine’ or ‘Oriental health concepts’. Since there are so many different schools of acupuncture around the world, it is not surprising that different interpretations and orientations have been developed (Ma et al. 2005, Seem 2007). In China alone are over 80 different acupuncture schools (Ma et al. 2005). The US National Commission for the Certification of Acupuncture and Oriental Medicine (NCCAOM) reported that 80% of diplomats in acupuncture practiced Traditional Chinese Medicine and less than 40% of practitioners practiced other approaches, such as ‘auricular, laser, electroacupuncture, color puncture, and TrP therapy’, among others (Ward-Cook & Hahn 2010). In 2003, only 3.7% of acupuncturists used TrP therapy as their primary practice tradition (Fabrey et al. 2003).

Considering the perspective of acupuncturists that TrPs are the same as Ashi points, and that dry needling is just a new name for an old technique, it is understandable that very few schools of acupuncture specifically include the assessment, identification, and dry needling techniques of TrPs (Seem 2007). The 2002 NCCAOM acupuncture examination included only one question related to TrPs and motor points (Fabrey et al. 2003). An online review of the curricula of US acupuncture school revealed only one US acupuncture school that mentioned TrP dry needling (Dommerholt, unpublished data).

Counter-arguments

In contrast to the acupuncture perspective, it is a fact that when Janet Travell developed the concepts of myofascial pain in the 1940s, she never considered the practice and concepts of acupuncture, nor was she aware of any previous medical descriptions of TrP phenomena (Travell 1949, Travell 1952). Chiropractor Nimmo was not aware of the acupuncture literature either, when he ‘rediscovered’ TrPs in the 1950s (Cohen & Gibbons 1998, Schneider et al. 2001). TrPs had been described in the medical literature by multiple physicians in the course of several centuries (Simons 1975, Baldry 2005) and a TrP manual had been published in 1931 in Germany (Lange 1931). As Baldry reported, already early in the 19th century, British physicians Churchill and Elliotson published books and articles about acupuncture without considering the concepts of traditional acupuncture (Churchill 1821, 1828, Elliotson 1827). Instead, they inserted needles in points of maximum tenderness, which does resemble the current practice of TrP dry needling and the ancient practice of needling Ashi points. In 1912 prominent physician Sir William Osler recommended inserting ladies’ hat pins at tender points in the treatment of low back pain (Osler 1912).

During the 1980s and 1990s, Travell did interact with acupuncturists (Seem 2007), but by then her notions of TrPs and TrP injections were already well established (Travell & Simons 1983). Even if Travell had studied acupuncture techniques, since when are different disciplines not allowed learning from each other? Acupuncturist Amaro (2007) recommended that practitioners of acupuncture ‘absorb the philosophy and procedure of dry needling as an adjunct for musculoskeletal pain control’. With the advancement of knowledge of myofascial therapies, it is noteworthy that in 1988, acupuncturists Matsumoto and Birch suggested to consider acupuncture as a myofascial therapy (Matsumoto & Birch 1988). Along those lines, acupuncturist Seem studied osteopathic paradigms when he developed his ‘new American acupuncture’ (Seem 2007) and combined insights from osteopathy and physical therapy with acupuncture (Seem 2004). In his own words, ‘the next stage in my own development of a myofascial style of meridian-based acupuncture was my encounter with the work of Dr Janet Travell’ (Seem 2007).

Given that Travell was not aware of Ashi points, the statement by the AAAOM that ‘a reasonable English translation of Ashi points is “TrPs”, a term used by Dr Janet Travell…’ (2011a), seems somewhat misleading as it insinuates that Travell used the term ‘TrP’ as a deliberate substitute for the term ‘Ashi points’. The term TrP was coined by Steindler (1940). From a Western medical perspective, TrP dry needling interventions were not developed until the late 1970s with nearly simultaneous publications in Canada and Czechoslovakia (the current Czech Republic; Lewit 1979, Gunn et al. 1980).

Dry needling from a medical perspective developed out of TrP injection therapy (Lewit 1979) and does not require any knowledge of the theoretical foundations of traditional or modern acupuncture practice (Baldry 2005). Already in 1944, Steinbrocker suggested that the effect of TrP injections was mostly due to mechanical stimulation of TrPs irrespective of the particular type of injectate (Steinbrocker 1944). Acupuncturists who have attended dry needling workshops offered by Myopain Seminars in Bethesda, Maryland (USA) agree unanimously that they have never before been exposed to the concepts of dry needling, which is consistent with the AAAOM Task Force of Inter-Professional Standards statement that ‘it is well established that Acupuncture and Oriental Medicine consists of physiological paradigms, diagnostic methods, and treatment applications that are distinctly independent and different from western medicine’ (Dommerholt 2012). It is somewhat ironic that the AAAOM cited Yun-Tao Ma as proof that ‘there is a literary tradition in the Field of Acupuncture that uses the term “dry needling” as a synonym for a specific, previously established Acupuncture technique’ (2011a), since Dr Ma strongly emphasized that ‘the modern modality known as dry-needling or biomedical acupuncture does not share any common foundation with traditional Chinese acupuncture’ (Ma et al. 2005).

The perspective of acupuncturists that other healthcare providers are attempting to redefine acupuncture seems to deny the notion of original thought in the Western world. As Cummings indicates in Chapter 13, acupuncture-like therapies have been developed independently in different civilizations around the world. The concepts of TrPs and dry needling were developed independently of already existing acupuncture concepts (Cardinal 2004, 2007). Similarly, electro-acupuncture was developed in China in 1934 (Dharmananda 2002), but Duchenne developed electro-therapy as early as 1855 (Licht 1987). Would that mean that acupuncturists in China were practicing Western physical therapy or medicine when they only changed the kind of electrodes? Or, which is much more likely, perhaps they developed the same treatment strategies independent of developments earlier in Europe.