I am writing this comment in opposition to allowing athletic trainers in Virginia to practice dry needling as proposed in 18 VAC 85 -120.  The basis of my argument lies in athletic trainers do not have the clinical experience and education to perform the procedure of dry needling, which is different from other manual therapies for which they have received training, and there is no current way to monitor the training and safety of the public who may receive this therapy. This technique can also be considered acupuncture. In Virginia, the definition of acupuncture is the insertion of a needle into the body to create physiologic change. The actual definition is the same for dry needling, which was largely debated a few years ago when the Virginia Physical Therapy Board allowed its members to perform dry needling in this state. At the time of this public commenting period, there has been no change to this definition. Athletic trainers are not trained in the proper use of the insertion of needles to create physiologic change.

Education: Many comments mention that the education of athletic trainers in areas such as anatomy, physiology, and manual therapies is adequate to perform dry needling.  I do not think the goal of this public commenting period is to address how many hours an athletic trainer receives in school, as if they did not complete these hours and requirements, they would not be licensed.  I wish to highlight that the training to perform this procedure is not part of their standardized training, and nothing has been determined as an adequate amount of training for this profession.  This is still debated, and without standardization, even with the physical therapy and chiropractic training programs for dry needling.   Many have mentioned the need for additional education or certification to be allowed to perform dry needling; however, as of now, the public has not been made aware of how that would be performed, what kind of training, in person or online, multiple hours or days, or if this training would be standardized. Without this information, the public is at risk of receiving even a minimally invasive treatment, such as the insertion of needles for therapeutic benefit, from someone who is inadequately trained to do so and could create potential harm.

One could make a case that if the only training needed to perform dry needling was experience with the insertion and use of a needle, then a trained phlebotomist should be able to dry needle as well, but that is not practical. However, phlebotomists have more hours of training in the use of handling needles than many professionals currently practicing dry needling. On the other hand, licensed acupuncturists have many more hours and clinical experience, under supervision, in their training in needling technique, no matter if the needle is used in methods described by traditional medicine or in an orthopedic manner. More than a few hours are needed to use needling in a therapeutic manner, which is not addressed in this proposal. The guidance of a medical practitioner may only serve to provide the diagnosis of what needs to be treated, but the same medical practitioners may or may not be present when the actual dry needling is being performed.  The performance of this technique still lies with the athletic trainer who does not have needling training.

Public safety and Certification with the Board of Medicine- Currently, other healthcare professions allowed to perform dry needling should also be properly notified of this proposal outside of the public comment period, as it affects their practice.  The Virginia Board of Medicine would have to create additional policies and methods to monitor who has been trained properly across multiple professions if a certification process were made available, making sure the public has access to know which professionals have completed their proper training. This adds additional, unnecessary stress to the general Board of Medicine and sub-Boards. The Board has already seen and addressed a similar proposal from the athletic trainers to allow dry needling, before the physical therapist added this practice to their scope. Other attempts to increase the scope of practice by athletic trainers through the regulatory process have also met with opposition, such as the recent proposal to include athletic trainers in emergency room settings. This proposal was addressed in a Board meeting, and it was determined that it would need to be a change in the legislative process. While every healthcare professional wishes to help as many people as possible and wants to enhance the scope of one’s profession, there are also times when the addition of a procedure, such as dry needling in this case, will not enhance the practice of medicine and may promote improper use of a technique already practiced by others with training.

Another comment mentioned that dry needling by athletic trainers is already practiced in other states.  Athletic trainers with licenses in those states and/or additional medical licenses believe their training is suitable to perform this procedure in Virginia, where they may already be practicing it. We saw this statement brought up previously when the physical therapists mentioned they were already practicing dry needling without its inclusion into their scope. There are reasons each state has its own Board of Medicine to determine what is appropriate for its healthcare professions. There are reasons people have gotten additional training to enhance their knowledge. I have another license to practice medicine in another state, but I am not legally allowed to practice in Virginia. Simply because another state allows a procedure does not mean it should be imposed into another state.  One also has to assume the training each state requires to be licensed within the profession is one in which the most basic standards are met and applies to someone just out of school, as well as veteran practitioners with more experience, knowledge, and clinical hours. So more seasoned practitioners may be able to perform dry needling without issue, perhaps may not have to report any issues either, but someone directly out of school may not be properly trained to perform that same procedure.

There are many reasons, including a lack of education in the use of needles in treating patients, a lack of standardization in such training, and the lack of need for another healthcare profession to perform dry needling, for this proposal to move forward.  Medicine that best serves the people often comes from groups of practitioners who specialize in their form of medicine and when needed, refer out to those with proper training in other treatments rather than trying to simply adapt other useful techniques as their own.

I hope the Board of Medicine takes the time to consider all the comments, both for and against this proposal, when deciding to make the next step.  Does the addition of dry needling by athletic trainers help patients or present potentially unknown harm? Does inclusion of this practice seem necessary when other practitioners are performing this technique per requirements set in place already by the Board? Does the public stand a chance of being misinformed, misled, or misguided by this decision that can affect their health? Over a thousand comments were submitted during the public comment period when physical therapists wanted to include dry needling in their scope of practice. If that many comments are submitted by the public and healthcare professionals about dry needling effects and potential harm, then you know it is a topic that should not be taken lightly. There is too much debate about the procedure itself to just allow it to happen without standardization and regulation. Thank you.