List of current events effecting the practice of acupuncture in the state of Tennessee.
Dry Needling Ruled Outside of Scope for Physical Therapists in Tennessee
On June 19, 2014 the Attorney General of the State of Tennessee rendered the opinion that dry needling is outside the scope of practice for physical therapists in Tennessee. In response to the question
"Is Intramuscular Manual Therapy ("IMT"), also known as Trigger-Point Dry Needling, within the scope of the practice of physical therapy under the Occupational and Physical Therapy Practice Act, Tenn. Code Ann. 63-13-101 to -318?"
The Attorney General rendered the opinion "No".
Functionally this means that acupuncture should only be practiced by fully licensed and trained acupuncturists no matter what else someone attempts to call the techniques of acupuncture. This is a responsible answer to this issue and protects the health and safety of those seeking acupuncture treatment.
If you would like to read the entire opinion statement, it is attached to this posting. Thanks for all of those who performed the hard work of getting our side of the argument into the discussion.
Chad J. Dupuis, L.Ac.
TAC May 31st, 2014 Meeting Minutes - Nashville
On Saturday, 31 May 2014, at 5:30pmCT the Tennessee Acupuncture Council (TAC) met at Scarritt-Bennett Center, Nashville, TN. There were 20 LAc and ADS in attendance. Judi Harrick and Jill Kelly facilitated the meeting. Current TAC president, Bret Moldenhauer, LAc, was regretfully unable to attend.
Dry needling was discussed. There is a request by the Physical Therapy Board that is waiting on the Tennessee Attorney General’s opinion regarding “dry needling”. As we have been advised by multiple state attorneys serving our license board, we must just wait for that opinion to present before any further action there.
Mention was made of Nurse Practitioner license act changing in 2013 to include the term “integrative medicine”. Note was made of some NP’s “practicing acupuncture” under that act.
Please note, our acupuncture license defines the practice. Anyone practicing acupuncture must have an acupuncture license through our Acupuncture Advisory Committee under the Board of Medical Examiners to legally practice. “Dry needling is the practice of acupuncture”. Anyone practicing outside their scope may be filed as a complaint to their governing board, i.e. NP to their board, PT to their board.
Request was made for volunteers to watchdog/oversee any legislation pertinent to acupuncture practice in Tennessee. Mention was made that patients/clients who are state senators, representatives, or lobbyists may be happy to be a vehicle of communication regarding bills or other topics of interest to TAC. Practitioners were encouraged to ask any acquaintances with active legislative participation to let them know as soon as possible of any bills or action relative to acupuncture practice. Also, please actively make and maintain connections with your own senators and representatives. Wayne Stephens, LAc, LMT, Christine Wooland, LAc, ND, and Christina Pisanello, LAc, DC, ADS volunteered to watchdog legislation. They were also willing to attend PT Board meetings in Nashville for “dry needling” or other pertinent updates since Board minutes are typically not posted publicly for months following any such meeting.
Current contact info was collected for all in attendance.
It was agreed to arrange regional heads to coordinate meetings in order to facilitate the reformation and progress of TAC. Judi Harrick, LAc, PhD will head the Western region. Christina Pisanello, LAc, DC, ADS will head the Middle region. Terry Jeanne, LAc will head the Eastern region. As long as there is no conflict with her state board service, Jill Kelly, LAc will head the South region. The goal is quarterly meetings with focus on establishing communication within our profession locally, nominations for officers (president, vice-president, and secretary/treasurer). Everyone is invited to attend any regional meeting. Thus, meetings are to be announced on the TAC website and emails from the TAC list serve. The next meetings should be scheduled in September, then December. Our goal is to have officers elected by the end of 2014. Any LAc or ADS may be nominated (or nominate themselves) including those previously or currently serving. A brief biography and supportive reasons should be submitted to your regional head. Regional heads will distribute their findings to Mary Helen Robert at acucenterinfo [at] gmail.com in a timely fashion. After all nominations are received, nominees information is to be submitted via the TAC list serve to all Tennessee LAc and ADS for voting with plans to have all positions filled by 1 January 2015.
David Eisen, LAc, OMD, founder and board member of NADA, expressed concern at the notion of regional meetings as he has seen in other states this method segregates and isolates, thus hindering overall progress. Please keep his comments in mind as one purpose in TAC efforts is to uphold a unified mutually beneficial organization for all LAc and ADS in Tennessee. Perhaps we will determine after all officer positions are filled that only statewide meetings serve us best. In the mean time, thank you to all those who took their time and effort to attend, to those behind the scenes who have helped make this happen, and to those who stepped up to help continue progress. Let’s move some qi.
Jill Kelly, LAc
TN Acupuncture Council Statement Against "Dry Needling" by Physical Therapists in Tennessee
Currently in TN there are a number of licensed Physical Therapists openly advertising and offering the service of “Dry Needling”. In the American Physical Therapy Association’s 2012 Educational Resource Paper, “Physical Therapists & the Performance of Dry Needling” defines Dry Needling as follows:
“Dry Needling sometimes referred to as trigger point dry needling or intramuscular manual therapy is an invasive technique used by physical therapists to treat myofascial pain that uses a dry needle, without medication or injection, which is inserted into areas of the muscle known as trigger points.
The term Dry Needling was first used by Dr Janet Travell, MD in her landmark publication: Myofascial Pain and Dysfunction, the Trigger Point Manual, 1983. Dr Travell, a cardiologist, was particularly interested in whether there was a pathological relationship between myofascial trigger points in the pectoralis muscles and non-specific chest pain. Dr Travell defined these Trigger Points as: “hyperirritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers”
The earlier stages of her research involved the injection of substances, saline, procaine, etc. into these points to determine their effect on relieving muscle contraction and its associated pain. Although her work with injectable solutions supported her hypothesis, over time she determined that the needle itself was providing most of the remedial effect, not the injected substrate. Consequently, experiments using a hypodermic needle without injection required the development of the term Dry Needling to distinguish it from the Wet Needle injection technique.
In her book she discusses the relationship between Trigger Points and Acupuncture points, stating: “The distinction between Trigger Points and Acupuncture points for the relief of pain is blurred for a number of good reasons… There is a high degree of correspondence between published locations of Trigger Points and classical acupuncture points for the relief of pain” According to her studies at that time there was an approximate 71% correlation between Acupuncture points and myofascial trigger points.
A 2008 study by the Mayo Clinic’s Department of Physical Medicine and Rehabilitation, entitled “Trigger Points and Classical Acupuncture Points”, (P.T. Dorsher, J. Fleckenstein) further explores the relationship of Acupuncture points to myofascial trigger points. It concludes that myofascial trigger point regions were demonstrated to have 93.3% anatomic correspondences with classical acupuncture points. Further, that trigger points most likely represent the same physiological phenomenon as Acupuncture points in the treatment of pain disorders.
In essence, both sources are saying that, with respect to myofascial pain management, trigger points and acupuncture points are substantially the same points. Trigger points, being fewer in number, are then a subset of the catalog of acupuncture points as published by the World Health Organization (WHO). By logical inference, using a needle to puncture a trigger point is substantially the practice of Acupuncture.
By extension, Dry Needling of Trigger Points is a form of Acupuncture. Although Dry Needling proponents claim it is more scientific than acupuncture and is therefore a different technique, choosing to describe classical Acupuncture in Western biomedical terms does not make it a different science, just a more elucidated one.
Acupuncture, once the target of skeptics, has now been demonstrated in contemporary western studies to have significant impacts on pain management. Consequently, the interest in its use has increased in recent years. Several classes of healthcare practitioners would now like to include needling techniques in their scope of their practice. Amongst these is the membership of the American Physical Therapy Association.
The APTA seeks to include Dry Needling into the scope of practice of Physical Therapists on a national basis. In its 2010 Resource Paper the APTA adopts the position held by the American Academy of Orthopedic Manual Physical Therapists (AAOMPT) that “dry needling is within the scope of physical therapy practice”. In Appendix B of this paper, the Federation of State Boards of Physical Therapy (FSBPT) states that “Although the FSBPT Model Practice Act does not specifically mention intramuscular manual therapy there is nothing to specifically exclude the technique.”
The APTA Resource Paper is designed as a resource for state Physical Therapy boards to consult as they make a determination whether to approve Dry Needling/Intramuscular Manual Therapy for inclusion in the scope of practice for Physical Therapists. It is concerning that there is a movement to persuade state boards that Dry Needling is already in the scope of practice for Physical therapists, yet there is no substantial, uniform regulatory requirement for education of Dry Needling proposed. In the Resource Paper it is stated: “Currently dry needling is not specifically included in entry‐level education for physical therapist”. They further state that the therapist must be competent to perform this intervention but fail to state what level of education is necessary to gain this competency.
At present, two main sources of outside training have sprung up to offer certification classes in Dry Needling. Kineticore, a Physical Therapist education company in Colorado offers a Level 1 and Level 2 course, which when combined total 55 hours of instruction. Another company, Myopain Seminars, offers weekend certification classes across the country. Completion of all the modules of this program total 104 hours of training. These courses are designed for practitioners who have never had any previous training in the insertion of a surgical needle into a human body.
These seminars purport to adequately train individuals to perform this technique. However, it is not clear from the AAMA statements whether all or only part of this instruction constitutes adequate training to be competent; this is apparently left to the state board to decide. Moreover, the inadequate number of hours does not meet the level of competency or safety which is deemed necessary by regulations governing the practice of Acupuncture in the state of Tennessee. The APTA claims that the basic PT curriculum already includes gross anatomy and physiology, which they claim is a sufficient pre-requisite for the Dry Needling certification offered by these outside vendors. However, it is noteworthy that in most states even MDs are required to have 200-300 hours of approved training in this invasive needle technique.
Acupuncture is considered safe when performed by a well-trained practitioner. Serious risks and adverse events are avoided when practitioners have been prepared to a high level of competency. Licensure to practice Acupuncture in Tennessee requires that candidates meet the standards set forth by the National Certification Commission on Acupuncture and Oriental Medicine (NCCAOM ). These standards currently include 1490 hours of training in Acupuncture, of which 660 hours must be clinical hours supervised by a licensed acupuncturist. Successful completion of board examinations for Foundations, Diagnostics, Point Location, and Western Biomedicine award the practitioner advanced standing in our field. Successful completion of the Clean Needle examination through the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) meet eligibility requirements to practice Acupuncture in the United States.
Competency and safety should be the standard when decisions of the public interest are being interpreted. Training has to meet the standard set forth by the Tennessee Code Annotated, Title 63, Chapter 6, Part 10; 63-6-1001, and, the Acupuncture Certification Process; Rule 0880-12-.02 in the General Rules and Regulations Governing The Practice Of Acupuncturists.
The Acupuncture Act of Tennessee, TCA:63-6-1001, part 10, et seq., sets active certification in acupuncture by the National Commission for the Certification of Acupuncturists and Oriental Medicine as the presumptive standard of education and training for safe practice in this field.
On the websites of both the aforementioned companies offering Dry Needling certification are statements that the State of Tennessee Physical Therapy Board has approved Dry Needling for Physical Therapists. (http://www.kinetacore.com/physical-therapy/-/page63.html). The physical therapy practice act for the State of Tennessee does not specify that the insertion of any needle lies within the scope of practice for physical therapists. In August, 2011, the Tennessee Physical Therapy Board convened to propose, by administrative rule, that the practice of ‘Dry Needling’ by a licensed physical therapist be upheld by the board and signed into rule by the Attorney General. An email to the Board of Physical therapy requesting information on the adoption of any rule allowing Dry Needling received the following response:
The Practice Act has not changed in any way. The Board’s understanding is that ‘Dry Needling’ is and has always been in the Scope of Practice for physical therapists in the state of Tennessee.
In its 2012 position paper on Dry Needling, the APTA stated that Dry Needling is now within the Scope of Practice for PT’s in Tennessee. However, it is important to note this change from its 2001 annual executive update which reported that Dry Needling fell beyond the PT’s scope of practice in the state of Tennessee and that any practice of an invasive technique was deemed illegal.
The foregoing appears to echo the AAMA language, and presumes that the practice of Dry Needling is already in the scope of practice for Physical Therapists in Tennessee. Given that a significant number of physical therapists are openly advertising and practicing Dry Needling in Tennessee, one must conclude that they are either in flagrant violation of the law, or that they are basing their right to practice the insertion of Acupuncture needles on the approval of their board, which is probably more reasonable.
(Note: Dry Needling, as practiced by Physical Therapists, utilizes a solid, filiform needle, not a hypodermic needle as the technique was first developed. The filiform type of needle is presently classified and regulated by the FDA as an Acupuncture needle.)
Following is a sample list of Physical Therapy websites offering Dry Needling services in the State of Tennessee:
In conclusion, there are several states across the nation that are in the middle of legal battles over whether the Board of Physical therapy has the authority to presume Dry Needling already in the scope of practice. North Carolina, Maryland, and Oregon courts have issued temporary injunctions. Mississippi, Louisiana, Illinois, and South Carolina are in the beginning stages of legal action on this issue. Currently, South Carolina requires the any discipline practicing Acupuncture must meet all of the academic and clinic requirements set forth by the NCCAOM. At this time, no Physical Therapist has within its scope of practice the ability to insert a needle into the skin for therapeutic purposes.
It is the opinion of the Tennessee Acupuncture Advisory Committee to the Medical Board that a further investigation should be conducted as to the jurisdiction under which the regulation of Dry Needling should fall.
Dr. Zhu Position Statement on Dry Needling by Physical Therapists in Tennessee
Chongbin Zhu, Ph.D., M.D. L.Ac
Vanderbilt Center for Integrative Health
I am writing this letter to discuss the issue regarding the practice of acupuncture and so-called “dry needling” .
Let’s look at the definition of “acupuncture” and “dry needling” .
Officially, in the website of National Institute of Health, it is stated that “ The term "acupuncture" describes a family of procedures involving the stimulation of anatomical points on the body using a variety of techniques. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. (http://nccam.nih.gov/health/acupuncture).
“Dry Needling is a general term for a therapeutic treatment procedure that involves multiple advances of a filament needle into the muscle in the area of the body which produces pain and typically contains a 'Trigger Point’. “
“Depending on the brand, we highly recommend using Seirin brand filament needles,…” (www.kinetacore.com/physical-therapy).
By the definitions, is there any significant difference between the two? The answer is obviously no. The tools used are the same (the Seirin brand filament needles were actually labeled as “acupuncture needles”. When using a needle to penetrate the skin, regardless in the “trigger points” or traditional acupoints, it already falls into the scope of acupuncture.
In traditional acupuncture theories, meridians are the basic systems to guide the acupuncture treatment. There are 14 regular meridian systems, but there are countless branches of those systems covering all aspects of human body. There are classical acupoints distributed along the meridian systems, there are acupoints that do not go along the meridians called “extra acupoints outside the meridians”, and there are also countless acupoints called “A’Shi” points representing the places or area where the pain and discomfort are produced. These “extra acupoints” and “A’shi” points are literally “Trigger Points”, not to mention that most of the classical acupoints are also “Trigger points” . Therefore, no matter it is called “dry needling” or other names, or whether using or not using traditional meridian theory, there’s no difference of the two practice—they are all the techniques from acupuncture. In fact, the originators and proponents of dry needling acknowledged the origin and inspiration of this technique to be acupuncture.
Recent studies also demonstrated that the trigger points are not distinct from acupoints. In 1983, Janet Travell et al. described trigger point locations as 92% in correspondence with known acupuncture points. In 2006, Peter T. Dorsher, acupuncturist at the Mayo Clinic, concludes that the two point systems are in over 90% agreement. In 2009, Dorsher and Fleckenstein conclude that the strong (up to 91%) consistency of the distributions of trigger point regions’ referred pain patterns to acupuncture meridians provides evidence that trigger points most likely represent the same physiological phenomenon as acupuncture points in the treatment of pain disorders. An article in Acupuncture Today (May 2011, p. 3, “Scope and Standards for Acupuncture: Dry Needling?”) further corroborates the 92% correspondence of trigger points to acupuncture points. The North Carolina Acupuncture Licensing Board has published a position statement asserting that dry needling is acupuncture and thus is covered by the North Carolina Acupuncture Licensing law, and is not within the present scope of practice of Physical Therapists, and Physical Therapists are not among the professions exempt from the law.
In acupuncture field, it requires3-8 years post-graduate training before one can goes to practice. It specifically required the technique of the needling to be enhanced to the level that does not generate any harm or any unwanted effect. There are a variety of techniques in acupuncture needling, each of which may result in different effect. Doing it without such knowledge, it most likely will do harm than benefit. One can not simply insert a needle to treat a condition without sufficient training.
Please let me know should you have any further questions.
Chongbin Zhu, Ph.D., M.D., L.Ac