I am a Licensed Acupuncturist in the Commonwealth of Virginia and also a Naturopathic Doctor (ND-AZ). I am opposed to the current draft of the proposed regulation 18VAC112-20-121 put forth by the Virginia Board of Physical Therapy.

“Dry needling” and/or “intramuscular/trigger point dry needling” is a style of acupuncture and not within the scope of practice of physical therapists.  Acupuncture is a modality regulated under Virginia law and “dry needling” is an acupuncture treatment strategy that should require the same kind of training, certification, clinical supervision, continuing education, and licensure requirements mandated for licensed acupuncturists. Potential patients are not aware that this proposed regulation does not protect them from the same people who are there to help them. If someone learns to hold a scalpel does that make them a surgeon simply because they have independently decided that they know what they are doing?  Is the public protected by a Board that allows this to happen?

There has already been at least one a case presented to the Virginia Board of Physical Therapy, for which the Board took no action.  In 2014, a physical therapist in northern Virginia performed “dry needling” into a patient’s upper back muscles and punctured their lung, requiring medical attention.  The Virginia Board of Physical Therapy dismissed it after they ruled that the procedure was within the PT scope of practice.  No disciplinary action was taken against the practitioner for harming the patient.  The proposed regulation, as it is currently written, would not protect this patient or any other in the future if “dry needling” is allowed to be performed by unqualified practitioners.

The current proposed regulation put forth by the Virginia Board of Physical Therapy contains misleading information that does not protect the public.

·         After the 2015 NORIA public comment period on the initial draft regulation to replace the guidance document that allowed “dry needling” by physical therapists, 1266 comments were submitted in opposition of “dry needling,” while 230 were in support.  The Virginia Board of Physical Therapy did not respond to all these comments or seek additional opinions outside their own Board to address these concerns.  At the public hearing held on February 7th, 2017, only a few physical therapists spoke in support of “dry needling” regulations focusing on educational requirements for graduation from any physical therapy program.  Six patients spoke who had received dry needling by a member of the Board. Fourteen commenters spoke in opposition of this proposed “dry needling” regulation, stating many reasons including patient injury, improper training and adverse clinical experiences relayed by their patients.

·        At no point during this regulatory process was another Task Force created to hear clinical opinions other than from physical therapists, for instance from medical doctors that are supposed to be providing supervision for “invasive procedures” as mandated by Virginia code § 54.1-3482. Since the original guidance document was written 10 years ago, with no public comment and limited input from other health professionals, numerous legal actions have been taken against state Boards of Physical Therapy and for-profit companies teaching dry needling courses.

·        Additionally, The Virginia Board of Health and Human Resources failed to address a potential conflict of interest involving a member of the Virginia Board of Physical Therapy who is a senior teacher for Myopain Seminars, which offers “dry needling” courses internationally and would certainly stand to profit with the passage of this regulation, which is a clear conflict of interest.

·        The “Analysis” document from the Federation of State Boards of Physical Therapy, submitted to show the education received by physical therapists allowing them to perform “dry needling,” is inherently biased and does not reflect the opinions of any other medical professions reviewing this information. All authors of this paper are physical therapists and either served on a state Board of Physical Therapy or are directly involved with a number of training companies that teach dry needling to PTs, again standing to profit with the regulation of “dry needling.”

·        This draft of the proposed regulation has removed any specific hourly training guidelines for the practice of “dry needling.” This draft would allow physical therapists to determine if they have sufficient training, based on their subjective determination of their experience level.  There are many “dry needling” courses available; some for as little as 12 hours over a weekend. This leaves the practitioner to determine their own level of experience and need for training, not the Board.  How does one determine if they are qualified to perform this invasive procedure on patients? The Board does not currently track practitioners, or require them to submit qualitative evidence of their “advanced training” that the public could have access to.  In Virginia, even chiropractors who complete 200 hours of advanced training in acupuncture must submit information on their coursework in order to have a designation of “Qualified Acupuncturist” on their state license, which is available for the public to access.  No such information is made available for the public to confirm the person performing this invasive procedure is even qualified to do so.  The Board of Physical Therapy lists no course of action to protect the public.

·        The Virginia Board of Physical Therapy has included in its Agency Statement for support of this draft regulation the dismissal of the case of the North Carolina Board of Acupuncturists against the North Carolina Board of Physical Therapy. This is misleading; a judge dismissed the case after he determined that the NC Board of Acupuncture had not exhausted all their remedies during the administration process before proceeding with a lawsuit.  This was not a ruling about the practice of “dry needling.” Also included was the May, 2016 Attorney General of Texas writing that the courts would “likely” rule that the Board of Physical Therapy Examiners has the authority to determine if dry needling was within the scope of practice.” This is an opinion and not a ruling on dry needling and only says that the Board may determine if “dry needling” is within the scope, much like the Virginia Board of Physical Therapy did in 2007-2008.

·        There is not currently an FDA-approved needle for “dry needling” treatment that is not an acupuncture needle.  According to FDA, acupuncture needles are to be used only by qualified practitioners.  “Physiotherapy needles” sold as “dry needles” have been pulled from the market.

 ·  The proposal does not address injuries to patients after “dry needling,” stating “since there is no current action against a licensee, the agency can not respond to the adverse action report.”  Numerous injuries have been documented after unqualified practitioners have performed “dry needling” such as the puncturing of patients’ lungs, improper needling through clothing, etc., thus increasing risk of infection and other injuries to patients, including nerve damage. Patients are often reticent to report adverse effects, so there may be more cases that are unknown caused by “dry needling”.  Such injuries, like hematomas, bruising during treatment and post-treatment pain may be overlooked.  .A list of these examples of injury to patients by dry needling, not including the one mention above in Virginia in 2014 and others mentioned during the public hearing in 2017, can be seen in a separate comment and are also listed on www.acupuncturesafety.com.  There may also be a deeper pathology that can be overlooked if not examined properly, such as referred pain from internal disease, where “dry needling” as a treatment strategy would be even more harmful than beneficial.

• The APTA definition of “dry needling” is very similar to the definition of “acupuncture” according to Virginia law. The definition of acupuncture by the State of Virginia is: "Practice of acupuncture means the stimulation of certain points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or to normalize physiological functions.”  The APTA definition of “dry needling” is: "Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments.”  Acupuncture points have been found to be reactive points, and the same as trigger points located in the muscle and connective tissues, used in modern times and described in classic texts of Chinese medicine as well. 

While acupuncture is based in anatomy and physiology and there are many styles of acupuncture, one of which is “dry needling.” The Virginia definition of acupuncture is not what is used in the informed consent required by patients to sign before “dry needle” treatment as required by the proposed regulation.  The current description used according to the background document states that “patients should be told they are not receiving an acupuncture treatment which focuses on energy flow and meridians from a holistic approach to practice.” Clearly this is not the definition of acupuncture as stated in Virginia regulations as noted above, and patients will continue to question if “dry needling” is actually acupuncture or vice versa. This continues to perpetuate a level of confusion that is not beneficial to the patient or to the general public.

Respective to the education of physical therapists that includes training in anatomy and physiology, these hours would be the same for a practitioner who wishes to perform “dry needling” as those who do not wish to perform dry needling and / or choose to use other therapies they have been trained to do during that same education.  These hours are required to complete an education in physical therapy and become licensed, and do not address the insertion of needles for therapeutic purposes.

The practice of dry needling is an invasive surgical procedure not in the scope of practice of physical therapist unless they hold an acupuncture license. As in many other states, there is opposition to this practice for many different reasons, the most important of which is the protection of the public and safety of patients who are receiving care. The proposed regulation does not offer that protection to the public and continues to put them in the path of injury and harm.  Physical therapists offer great service in the manner of manual therapy in which they are trained. However, “dry needling” is not in their scope of practice and they should refer patients to qualified acupuncturists instead of trying to expand their scope of practice via regulation, without a demonstrable standard of training, clinical supervision, or certification in place. Thank you.

Stephanie Pina L.Ac, MSOM, ND, FABORM

Burke, Virginia 22015