Authors
Arthur Yin Fan, Ling Zheng and Guanhu Yang
Keywords
Introduction
The acupuncture technique most often studied scientifically involves penetrating the skin with thin, solid, and metallic needles that are manually or electrically manipulated. Practiced in China and other Asian countries for thousands of years, acupuncture is a key component of Traditional Chinese Medicine.[1] Currently, acupuncture is being practiced in countries all around the globe and is rapidly attracting interest in Western countries.[1]
In this context of expanding public and professional interest in acupuncture in the United States, a practice called dry needling (DN) has become a hotly debated topic in both academic[2,3] and regulatory[4–6] circles. DN is an issue because some professionals, especially physical therapists (PTs) (and also some chiropractors, nurses, and others) are claiming the right to practice DN, which requires little training, as a practice distinct from acupuncture. DN is viewed by many, especially in the acupuncture community, as a strategic method to bypass laws that require rigorous training and oversight to engage in practice as an acupuncturist.
On November 6, 2015, the Journal of Acupuncture in Medicine published an article[2] titled ‘‘Dry Needling Versus Acupuncture: The Ongoing Debate.’’ An accompanying editorial[3] concluded that DN, as used in treating musculoskeletal disorders, is a style of Western acupuncture that, while distinct from traditional acupuncture, is a form of the practice. This commentary reviews the origins of DN and reinforces that conclusion. Whatever rights to practice DN may be asserted or achieved by these professions, the historic evidence shows that there is no denying that DN is a form of acupuncture.
Acupuncturists Have Led Development and Education in DN
PTs and other professionals use the term dry needling to describe a therapeutic intervention that typically uses solid filiform needles (i.e., acupuncture needles) to puncture myofascial trigger points (TrPs). The clinical intent is to resolve pathologic myofascial tension and treat the myofascial and other pain. The method is sometimes called myofascial trigger point dry needling or intramuscular manual therapy.[7]
An overlap between the PT profession and that of licensed acupuncturists may be the origin of the DN debate. In the United States since roughly 2000, DN was mainly developed and advertised by licensed acupuncturists.[8–13] Some acupuncturists developed continuing education businesses and recruited large numbers of PTs as students.[8] Other acupuncturists were hired by PT schools to introduce acupuncture to their students and faculty. Still others of these acupuncturist educators attended PT schools to gain doctoral degrees in that field. Dry-needlers were not teaching how to use these needles. Acupuncturists were.
The earliest person in this field is Mark Seem, PhD, LAc, the founder of Tri-State College of Acupuncture in New York. Dr. Seem developed a classical Chinese acupuncture approach to integrate the work of a Western medical doctor, Janet Travell, MD, with acupuncture needling of myofascial pain.[11,13] Like some other doctors of her tradition, Dr. Travell mentionedDNin books or articles. Most did so via knowledge they gained in the 1970s through 1990s from clinical observation; the therapy was not widely used in their own daily practices.[2,11,12,14] In fact, most of the needles used by these doctors were the classic, hollow injection needles with a sharp
point. Such needles are different from the acupuncture needles that are currently used in DN.[2,9,11,14] Dr. Seem shared this classical acupuncture technique with Dr. Travell by treating a chronic, complex whiplash syndrome to release such TrPs. Dr. Seem published A New American Acupuncture covering this topic of DN in 1993. He has taught this acupuncture method internationally for over 25 years.[11]
Such TrP needling has existed for over 2000 years since the Huang Di Nei Jing (Yellow Emperor Inner Classics). Acupuncturists call this Ashi (ah-yes) point acupuncture.[15,16] In the United States, such techniques have been used by both traditional and medical acupuncturists since the 1820s, including by Sir William Osler.[17] Such Ashi points, including TrPs, motor points, or tender points, are considered acupuncture points.[16–18]
The Influence of Acupuncturist Yun-Tao Ma on the Use of DN
In recent years, one of the featured scholars, developers, and teachers of DN to PTs, Yun-tao Ma, PhD, LAc,[10,19–21] published several books related to DN. Among these are Scientific Acupuncture for Health Professionals[22] and Biomedical Acupuncture for Sports and Trauma Rehabilitation: Dry Needling Techniques.[19,20] Dr. Ma, a member of the Acupuncture International Standard Working Committee in the World Federation of Acupuncture-Moxibustion Societies, [23] is a licensed acupuncturist.[19] He practiced DN under his acupuncture license. Dr. Ma indicates that DN is the practice of acupuncture, via biomedical ‘‘language’’ for pain management. Other important authors in the field, including Giles Gyer, Jimmy Michael, and Ben Tolson, also indicate that DN is acupuncture.[24]
There is confusion, however, created by Dr. Ma. He claims that the DN he teaches, about which he wrote later, is a modern Western medical modality that is not related to traditional Chinese acupuncture in any way. He argues that DN has its own theoretical concepts, terminology, needling technique, and clinical application[21] and that (1) DN is not practicing acupuncture, (2) it has no relationship with acupuncture, and (3) it was developed by PTs themselves. This challenges basic logic. Dr. Ma is a licensed acupuncturist. He himself uses acupuncture as a name or synonym for DN, although he technically calls it ‘‘biomedical acupuncture.’’ [10,19,20] Also, DN uses acupuncture needles.[2,7,10,19,20] Dr. Ma did say, ‘‘DN originated in Traditional Chinese methods, and has developed from the ancient empirical approach to become modern, evidence-based practice.’’[20] Clearly, he merely developed a modern interpretation of acupuncture and renamed it ‘‘DN’’.[8] The practice of DN is simply another translation of the original name for this type of therapy, 针刺Zhen Ci.[25]
Widespread Use of DN in the Practice of Licensed Acupuncturists
That DN is acupuncture is also evident from a look at acupuncture practice in the United States. Acupuncturists are well trained to use TrPs and motor point Zhen Ci or ‘‘DN’’ treatment. Thus, Zhen Ci (DN) represents a substantial daily practice among U.S. acupuncturists. The National Certification Commission for Acupuncture and Oriental Medicine, the certifying board for licensed acupuncturists, completed an analysis in 2003 that documented the prevalence of DN
techniques in the practices of licensed acupuncturists. Of acupuncturists responding, 82% used needling of TrPs in patients who presented with pain. Of patients receiving acupuncture treatment, an estimated 56% present with TrPs pain. The other 18% of acupuncturists used acupuncture needling techniques in non-TrP locations for other types of pain or for nonpain conditions.[13]
With growing professional and public interest, the U.S. National Institutes of Health officially defined acupuncture as an actual insertion of a solid needle into the body.[1,26] Acupuncture, so defined, describes a family of procedures involving the stimulation of points on the body using a variety of techniques. Notably, the Food and Drug Administration classified acupuncture needles as Class II medical devices subject to strict regulations under the Federal Food, Drug, and Cosmetic Act (FDCA). Thus, individuals purchasing or receiving acupuncture needles, who are not licensed by law to practice acupuncture, are directly violating both civil and criminal provisions of the FDCA that is intended to protect public safety (21 U.S.C. x 331(a)–(c), (g)).
With this historic use, education, practice and federal language in mind, DN is clearly acupuncture, an invasive procedure. It is not a distinct manual therapy as claimed by PTs.
Rapid Development of DN Among PTs is Based on Low Training and is Associated with Harm
Yet the PTs’ claim has led to the rapid development of DN in the United States within the past 10 years as the PTs have worked to expand their scope of practice and move toward doctoral level training. The American Physical Therapy Association states that ‘‘the physiological basis for DN treatment of excessive muscle tension, scar tissue, fascia, and connective tissues is not well-described in the literature.’’ [7] DN, as a style of Western medical acupuncture, naturally belongs to a substyle of acupuncture. There are actually no major differences from traditional acupuncture in DN needling technique or in clinical applications of pain management or sports and trauma rehabilitation.[2]
As previously noted, DN educators in both continuing education and in schools are frequently licensed acupuncturists. DN has mainly been taught in continuing education level courses of 20–30 hours, although the duration proposed to increase to 54 hours in the future.[7,10,27] This low level of training increases the risk for injury and can be a threat to public health and safety. Reports of serious injuries associated with DN or acupuncture by PTs are not uncommon.[28–31] If a PT is practicing DN, how will a patient know that he or she has such limited training? The patients are not likely to know the practitioners’ experience level when DN technique is applied;
nor will the patient know whether the PT chooses to use needles for purposes beyond typical DN practice. This strategy is in line with the advice received from TrP pioneer Dr. David Simmons. He stated: ‘‘Your problem is largely one of semantics so the simple answer is to change the playing field and the semantics that go with it. If you. use the different terminology you leave other side without an argument.’’[32]
Conclusions
Current DN in the United States is an interpretation of traditional acupuncture focusing on musculoskeletal disorders but using PT language. The question is, How can we practice acupuncture using the name of DN and not claim this therapy as acupuncture? How we can say that a white horse is not a horse? Both are still a horse; one is just a subset of the other. The public has come to expect certain hard-earned standards of accredited education and licensing for those
professionals who are using acupuncture needles on them therapeutically. The PTs do not meet these standards.
This denial is creating tension between the acupuncture profession and PTs and other professionals who are seeking to provide acupuncture by calling the horse by a different name. If lawmakers and regulators are to decide to allow PTs and others to provide acupuncture to citizens based on 20–30 or even 54 hours of training, they can certainly do that. The historic record shows, however, that these lawmakers should know that they are granting them the right to practice acupuncture.
Acknowledgments
The authors would like to thank Ms. Sarah Faggert for editing support. This paper reflects the authors’ view only.
References
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