Dry Needling: Is It Derived From Acupuncture? How did Non-Acupuncturists Start Using It?

ABSTRACT

Context: In the U.S. and other Western countries, dry needling (DN) has been a disputed topic in both the academic and legal fields.

Objective: The research team intended to examine whether DN is a technique independent from acupuncture and also how non-acupuncturists, like physical therapists (PTs), started practicing DN.

Design: The research team completed research, examined critical issues related to DN, and published a white paper in 2017 that discussed evidence and expert opinions from academic scholars, for healthcare professionals, administrators, policymakers, and the general public that demonstrate that DN is acupuncture. This article continues that endeavor.

Results: DN is not merely a technique but a medical therapy that is a simplified form of acupuncture practice. To promote DN theory and business, some commercial DN educators have recruited a large number of non-acupuncturists, including PTs, athletic trainers, and nurse practitioners, in recent years. PTs did not initiate the practice of DN and DN doesn’t fit into the practice scope for physical therapists (PTs) because it’s an invasive practice. The national organizations of the PT profession, such as the APTA and FSBPT, began to support the practice of DN by PTs around 2010. Currently, more PTs are involved in DN practice and teaching than any other specialty.

Conclusions: Acupuncturists and physicians must complete extensive acupuncture training in accredited programs and pass national examinations to become licensed or certified to practice acupuncture. However, a typical DN course runs only 20-30 hours, often over the course of one weekend, and the participants may receive a DN certificate without any national examination being required. For the safety of patients and professional integrity, the research team strongly suggests that all DN practitioners and educators should have to meet the same basic standards as those required for licensed acupuncturists or physicians.

In the USA and other Western countries, dry needling (DN) has been a disputed topic in both the academic and legal fields.^1-7 The American Physical Therapy Association (APTA) states: “Dry needling is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue and to diminish persistent peripheral nociceptive input and reduce or restore impairments of body structure and function leading to improved activity and participation.”¹

Yun-tao Ma, a licensed acupuncturist and DN educator, wrote: “DN was first developed…by Janet Travell, MD….DN, also known as biomedical acupuncture, is based on a modern understanding of human anatomy and pathophysiology and on modern scientific research, drawing heavily on leading-edge neurological research using modern imaging techniques, such as functional Magnetic Resonance Images (fMRIs) of the brain.” However, he also argues that DN has its own theoretical concepts, terminology, needling technique, and clinical application and that (1) DN is not a practice of acupuncture, (2) DN has no relationship to acupuncture, and (3) the PTs developed it themselves.²

To resolve these conflicting statements, the current research team completed research, examined critical issues related to DN, and published a white paper in 2017.^8-10 This paper discussed evidence and expert opinions from academic scholars, for healthcare professionals, administrators, policymakers, and the general public that demonstrate that DN is acupuncture.

This article continues that endeavor and examines whether DN is a technique independent from acupuncture and how non-acupuncturists, like physical therapists (PTs), started practicing DN.

RESULTS: A TREND OF INDEPENDENCE FROM ACUPUNCTURE

Evolution of DN

Simons, Travell, and others systematically summarized 255 trigger points (TrPs) in 144 muscles in their book, Myofascial Pain and Dysfunction: The Trigger Point Manual,¹¹ popularizing TrPs and DN. Travell admitted to the general public that DN is acupuncture when she stated in a newspaper that DN, “[in] the medical way of saying it is ‘acupuncture.’ (Current authors note: i.e. DN is a customary name of acupuncture while acupuncture is a formal, medical or academic term.) In our language, that means sticking a needle into somebody,”^9,12 Also, in her book, “many practitioners of acupuncture use several TrP criteria to locate pain acupuncture points, and in fact, are successfully performing DN of TrPs that they call acupuncture therapy.”¹¹

Dommerholt,³ a physical therapist, wrote: “DN is an invasive procedure in which a solid filament needle is inserted into the skin and muscle directly at a myofascial TrP. A myofascial TrP consists of multiple contraction knots, which are related to the production and maintenance of the pain cycle.…DN also falls within the scope of acupuncture practice.…In contrast to most schools of acupuncture, DN is strictly based on Western medicine’s principles and research.”

The Federation of State Boards of Physical Therapy (FSBPT)¹³ stated, “The theoretical genesis of DN is attributed to the pioneering work of Travell and Simons, who used 0.22-gauge hypodermic needles to treat myofascial pain with TrP therapy, the needling of taut bands of muscle fibers. Over the past several decades, practitioners have adopted variations on the original approach, including superficial and deep needling techniques. Modern DN has largely abandoned hypodermic needles in favor of round tip, solid filament needles, ranging from 0.22 to 0.30 millimeters in diameter, because the beveled tip of hypodermic needles causes greater tissue damage. In addition, modern DN is used to treat a variety of conditions and dysfunctions of neuromusculoskeletal structures.” The needle preferred today for use in DN by physical therapists is the same type of needle used by acupuncturists, unlike hypodermic needles, which were first used by physicians.

The above mentioned TrPs, aka reactive (painful) points for needling strategies, are clearly documented in the Yellow Emperor’s Inner Classic—the Huang Di Nei Jing—compiled 2000 years ago in China,¹⁴ which states that “the painful point is the site for acupuncture.”  Simiao Sun (581-682 CE), a famous Chinese physician, formally coined the term Ashi point for these reactive (painful) acupuncture points.¹⁵

In the West as early as 1821, James M. Churchill published A Treatise on Acupuncture, using the information gathered from Japan and China. John Elliottson published a paper on acupuncture in 1827. Baldry indicates, “Neither of them employed the complex procedures, techniques, meridians, and other theories of traditional Chinese acupuncture because they were trying to avoid the rejection of acupuncture by the medical doctors of the time.”¹⁶ Instead, they employed the simplest strategy in acupuncture for the treatment of disease or other conditions, including musculoskeletal pain, by needling reactive (painful) acupoints, now commonly known as TrPs. This oversimplified strategy in acupuncture is now commonly known as DN.

The pioneers of DN, Gunn et al¹⁷ in 1976 proposed introducing a new system of acupuncture locus nomenclature. In their publications, the researchers used the term motor points as a synonym for TrPs and DN as a substitute for the terms acupoints and acupuncture.¹⁸ Said more clearly, a new modality was not developed and used; instead, acupuncture was used but given a different name to gain popularity and acceptance in the mainstream healthcare systems of the West.

Comparison of DN and Acupuncture 

As thoroughly demonstrated and discussed previously in the current research team’s white paper,^8,9 Zhou et al,⁵ Peng et al,^19,20 and Zhu and Most²¹ reviewed DN history and a large amount of literature since 1941 and identified the features of DN. They used these features to compare DN and acupuncture. The features included: (1) needles used, (2) targeted stimulation points and their distribution patterns, (3) action mechanisms, and (4) therapeutic effects. 

Zhou et al⁵ concluded that DN is a kind of Western acupuncture for treating myofascial pain. Peng et al^19,20 concluded that DN is TrP acupuncture, belonging to the category of Ashi-point acupuncture, which is one of the major acupuncture schools in traditional acupuncture. Traditional acupuncture encompasses an abundance of methods and techniques in acupuncture practices and has been widely used and studied for the management of a variety of disorders. Zhu and Most²¹ selected the above-mentioned 4 technical and biological features for a comprehensive analysis and concluded that DN is but one type of acupuncture when solid filiform needles are used.

The researchers concluded that DN uses the same needles; the same stimulation points, although with different names; and many of the same needling techniques. They also concluded that DN involves the same biological mechanisms as acupuncture. Furthermore, they found that DN focuses on treating myofascial disorders, while acupuncture encompasses myofascial disorders as well as much broader treatment indications. However, because of a lack of adequate training and appropriate regulation, the safety of DN practice by PTs has been called into question.^5,8,9,19-21

As the American Medical Association (AMA) policy on DN states, “DN is indistinguishable from acupuncture.”²²

As demonstrated and discussed previously by the current research team’s white paper,^8-10 the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM)⁴ states: “DN has resulted in redefining acupuncture and reframing acupuncture techniques in Western biomedical language…these treatment techniques are the de facto practice of acupuncture, not just the adoption of a technique of treatment.”

DISCUSSION: INDEPENDENCE TREND FROM ACUPUNCTURE

DN is clearly not just a technique on how to insert a dry needle—filiform, hypodermic hollow-core needles, or other injection needles, without an injection—into the skin, muscle, and fascia. It’s a complex medical therapy and a form of acupuncture practice, including using a diagnostic procedure with patients, identifying therapeutic indications, choosing the proper types of needles, determining the specific stimulation points or areas, and applying various techniques that involve an invasive procedure as well as testing theories and exploring the possible mechanisms.^5,8,11,23

Statements from related authors and analyses from independent scholars, as discussed above, all indicate that DN, in the West, does use acupuncture points and the same therapeutic tools as acupuncture; it applies some of the same techniques as acupuncture; and it has the same therapeutic indications when treating neuromusculoskeletal pain. While DN promoters redefine it as myofascial pain, it is indistinguishable from acupuncture in the mechanism of action.

DN looks like a rediscovery of traditional acupuncture, considering that the phenomena of DN arose much later than did that of acupuncture. DN promoters are themselves either acupuncture professionals or researchers—such as Gunn et al,^{17, 24}  Baldry,^{16, 24} Hong, ²⁴ and Ma et al,^{2, 24, 34,35} and Travell is a clinical researcher involved with acupuncture work who participates in the planning of acupuncture conferences.^12,25 The sole difference comes from the fact that these individuals use the term DN to replace acupuncture, to brand their TrPs hypothesis,^7,8,17,18,26 to promote DN as a novel technique,^7,8,26 and to help reveal the reasons and factors for the start of DN.^7,8,26 In fact, Ma’s claim that “DN…(draws) heavily on leading-edge neurological research using modern imaging techniques such as fMRIs of the brain”² may discredit his own statements about the existence of a difference between acupuncture and DN, because this claim was taken from a study on the mechanisms of acupuncture.^8-10

In addition, Travell admitted to the general public that DN is acupuncture,^9,12,25 and that acupuncture professionals do practice DN as acupuncture therapy and use several criteria in the acupuncture profession to locate TrPs as acupoints.¹¹

DN is an oversimplified version of acupuncture derived from traditional Chinese acupuncture except that it emphasizes biomedical language when treating neuromuscularskeletal pain.^8,9 Related definitions and descriptions from the National Institutes of Health (NIH),²⁷ Centers for Medicare and Medicaid Services (CMS),²⁸ and the World Health Organization (WHO)²⁹ all indicate that DN is a form of acupuncture.

It’s clear that DN came from renaming acupuncture, simply by using biomedical terms based on the fascia hypothesis to replace the original acupuncture terminology. 

Results:  USE BY NON-ACUPUNCTURISTS

Practice Scopes

As demonstrated and discussed previously in the current research team’s white paper,^8-10 Ma has taught many PT and other non-acupuncturist students in his commercial DN seminars.^2,7,26 He has clearly stated that DN was first developed by Travell, and has identified DN as a form of acupuncture using biomedical language. He also has made contradictory statements, indicating that “DN is not practicing acupuncture”; “DN has no relationship with acupuncture”; and DN was “developed by PTs themselves.”²

FSBPT has been trying to include DN in the PT practice scope and has published a report, “Analysis of Competencies for Dry Needling by Physical Therapists.”¹³ It stated that “DN is a procedural intervention used by PTs to treat pain, functional impairments, and disabilities. The technique involves the insertion of solid filament needles into the skin and underlying tissue to disrupt pain sensory pathways and relax contracted fibers.”

Mark Seem,²⁴ a known acupuncturist and the founder of Tri-State College of Acupuncture in New York, stated in his “Comments to practice of dry needling in Virginia” submitted online to Virginia State Town-hall on Dec. 30, 2015 that “after (Dr. Robert) Gerwin (current authors note: Dr. Gerwin is a neurologist and DN promoter, once worked with Dr. Travell and Dr. Simons in DN seminars in 1990) heard Travell and her colleague report on the similarity in efficacy of my one acupuncture session (current authors note: Dr. Seem demonstrated DN to Dr. Travell and her colleagues with thin acupuncture needles instead with  injecting needles) to TrP injection, and he saw the thin short Japanese Serein needles that I used, he found an osteopathic resident trained in such acupuncture release of TrPs. (current authors note: Dr. Seem’s student, an osteopathic resident, demonstrate DN to Dr. Gerwin with thin acupuncture needles and Dr. Gerwin saw thin acupuncture needles do release TrPs.) Subsequently, he met and partnered eventually with a PT (current authors note: around 1998) who claimed to have learned such needling with acupuncture needles in the Netherlands. I taught that technique to PTs, who were the main licensed providers in the Netherlands (current authors note: in Netherlands the law only allows physicians to perform acupuncture. As that limitation, Dr. Seem taught classical acupuncture under the name of DN to PTs, who were major student population of Dr. Seem’s seminars at that time.), together with physicians in my classical acupuncture seminars for the Anglo-Dutch Institute’s comprehensive acupuncture and traditional Chinese medicine program. I also taught it to PTs and physicians in rehabilitative medicine in the UK. All of them concurred that no one should do acupuncture treatment of such myofascial conditions without proper acupuncture training. They also agreed that DN—the use of an empty syringe with no medication—was nonsensical, even though Hong, an acupuncturist, who like Gunn became a physical and rehabilitation medicine physician, dropped any reference to his earlier acupuncture training. This same thing was done by Baldry in the UK and Ma in Colorado, to cover up their original comprehensive acupuncture training.”

The curriculum of PT schools is quite different from that of acupuncture schools. The current graduate level of PT education is about 1888-2080 hours (118-130 credits).^30,31 Until 2015, none of the accredited PT schools offered DN courses,¹³ and many nonregulated DN courses, ranging from 20-30 hours, have targeted PTs at a continuing-education level.³² In contrast, most acupuncturists must obtain around 3000 hours—although the national examination agency, the National Commission for the Certification of Acupuncture and Oriental Medicine (NCCAOM), requires a minimum of 1905 hours—at a master’s degree level. ³² Doctorates in acupuncture are now available as well as legal requirements for acupuncturists to pursue additional education and training.

(Will be continued in part II)