|Action||Practice of dry needling|
|Comment Period||Ends 7/26/2019|
The Practice of Acupuncture
Acupuncture is based on traditional Chinese medicine (TCM). They insert needles to change “chi”/”qi”, which are basically what eastern medicine describes as “life force energies”. Qi is believed to flow from the body’s organs to the “superficial” body tissues of the skin and muscles through channels called meridians. There are 12 standard meridians and 8 extraordinary points that are related to organs and “storage vessels” respectively—not muscles. There is no scientific basis or proof for qi, meridian lines, or extraordinary points—it is based on ancient Chinese philosophy.
In TCM, there are 4 diagnostic methods: inspection (focuses on the face and tongue), auscultation (listening to breath sounds) and olfaction (observing body odor), questioning (focus on the “seven inquiries” related to fever, perspiration, appetite/thirst/taste, defecation/urination, pain, sleep, menses), and palpation (feeling for tender points and for pulse). None of these diagnostic methods include clinical testing of the musculoskeletal system as is done with dry needling.
Dry needling is based on scientific research methods of western medicine, for the treatment of the musculoskeletal system, and orthopedic based in diagnosis and treatment; it does not claim nor teach anything related to qi and meridians. Dry needling has shown to produce immediate physiological effects within a muscle, the PNS, and CNS. Particularly for the muscle itself, inserting a dry needle directly into a trigger point will increased acetylcholinesterase (Ache), which will in turn decrease acetylcholine (Ach) which are responsible for keeping bands of muscles contracted; this will also lead to a cascade of other reactions, including decreasing proinflammatory chemicals (e.g. bradykinin, CGRP, 5HT, prostaglandins), improving acidity levels, and increasing oxygen/blood flow within the muscle fibers.
In the state of Virginia, there is 1 accredited school (Virginia University of Integrative Medicine); 1 school that was waiting on accreditation by March 2019 (Arirang University) but has not updated their website on whether or not they have received accreditation; and 1 school website that turns out to be fake with a bunch of pop ups (I may or may not have downloaded a virus because of that website…).
Virginia University of Integrative Medicine (VUIM) is only accredited for masters of science in acupuncture, and not for any of the doctorate level studies it offers; whereas ALL the schools in Virginia with a Physical Therapy program are accredited doctorate programs—in fact, 100% of Physical Therapists graduating from PT school are doctors, whereas many acupuncturist appear to be misinformed that we are at a master’s level as most of them are. On their website, their school catalog outlines their courses for the masters in acupuncture program. Their ~3 year program only requires 40 hours of “treatment of orthopedic disorders” (class AC510), which is a course that “provides applications to the diagnostic skills learned in Orthopedic and Neurological Evaluations of WM 540 class, and provides acupuncture treatments to the various disorders covered. This course covers treatment from a muscular and physiological perspective as well as a channel treatment perspective. This class provides practice in oriental medical approaches to athletic and other injuries, and refines students‘ability to palpate anatomical structures.” Upon further investigation, the WM 540 class is described as a course that “provides an introduction to the skills of history taking, physical assessment, and documentation. The student will demonstrate the skills to conduct a comprehensive health assessment including the physical, psychological, social, functional and environmental aspects of health. Effective communication, assessment, and documentation will be practiced in the laboratory setting. The student will become familiar with the techniques of physical assessment consisting of inspection, palpation, percussion”. Physical assessment does not appear to incorporate any clinical musculoskeletal testing.
Acupuncture vs Dry Needling Related Adverse Events
There are causalities related in any profession, however it is expected that the causalities and adverse effects are minimal and that there are safety precautions set in place to minimize harm—Physical Therapists, being western medicine, have taken an oath “to do no harm”… if there were not enough precautions in place or not enough training, the numbers would show it and as a profession we have the responsibility to change policies to protect our patients.
One acupuncturist on the forum quoted that there have been 3 cases of pneumothorax in Richmond, Virginia some years ago—no sources were stated by this professional. However, even if this were true, 3 cases is a very small number compared to how many patients are being needled on a daily basis in Virginia. Acupuncturist are not without fault either when is comes to pneumothorax, other serious adverse events, and even deaths. Between 2000 and 2009, one study quotes 95 cases of serious adverse events, including 5 deaths, from acupuncture (http://www.dcscience.net/Ernst-2011-AcupunctAlleviatePainRiskReview.pdf). In another study, in 25 countries between 2000 and 2011, there were 294 adverse events from acupuncture reported—these included spinal cord injuries, brain injuries, peripheral nerve injuries, heart injuries, etc… potentially way more serious than just a simple pneumothorax (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3616356). Yet another study
found 26 cases resulting in 14 deaths from cardiac tamponade after acupuncture (Cardiac tamponade caused by acupuncture: a review of the literature". International Journal of Cardiology. 149 (3). Then in 2013 a systematic review that found 31 cases of vascular injuries resulting in 3 deaths post acupuncture (http://www.minervamedica.it/en/journals/internationalangiology/article.php?cod=R34Y2013N01A0001).
Reading the forum, many acupuncturists commenting appear to be misinformed—or uninformed rather—on many issues including: education level of PTs, what dry needling entails, how dry needling physiologically produces changes within the musculoskeletal system, etc. Many of their comments also appear to be related to the assumption that dry needling equates to acupuncture simply because we are using needles to penetrate the skin, therefore we should be held under the same acupuncture licensing standards. If I use a rolling pin to massage a muscle, am I baker that is baking? If an acupuncturist suggests a form of meditation or guided imagery while performing acupuncture, should have to go through the licensing standards of a cognitive behavior therapist? If a patient is advised to perform a kind of stretch or strengthening by a chiropractor, should they have to get their doctorate in Physical Therapy? No. All healthcare professions overlap at least a little bit and that should be okay—no one profession is able to treat the entire holistic person, which is why there are doctors of specialty.
I would encourage Acupuncturists to take dry needling courses in order to be more educated and familiar with what is actually taught and practiced instead of speculating and trying to limit adequate care for patients, especially in rural underserved areas and military bases.