As the practice of medicine becomes ever more complex and the breadth of medical practice ever more in-depth medicine has evolved into many sub-groups of specialization. This specialization has become necessary for example in the area of radiology: a regular x-ray tech does not know how to operate an MRI machine. If a patient requires IV contrast then it is not given by the regular x-ray tech but rather by a radiology nurse who understands the side effects and adverse reaction associated with the contrast material. This helps protect the patients well-being AND protects the hospital against law suits. 

A orthopaedic surgeon would never do a hysterectomy.

A Gynecologist (though trained in surgery) would never do a heart valve replacement and a Cardiothoracic surgeon would never think of delivering a baby.

Veterinarians are well trained in tooth care. They regularly give anaesthesia to animals (large and small) and provide all sorts of dental care (cleaning, filing teeth and extractions). Yet none of us would consider allowing our veterinarian to perform a root canal or a tooth extraction on a human. If such a case ever happened we would all be outraged as we would clearly feel the veterinarian exceeded his SCOPE OF PRACTICE.

Physical Therapists in the State of Virginia are  at this very moment expanding their scope of practice to include "Dry Needling" WITHOUT following the legislative process where dry needling would get a proper review by the people entrusted to protect public safety: the legislators. 

Does this mean that in effect any professional group can just expand their scope of practice to include an invasive procedure of their choice by simply writing a few lines of text and adapting it into their practice guidelines. 

Should hair dressers be able to expand their practice to include Scalp Hair Implants?

Should Beauticians expand their practice to include Skin Tag Removal?

Should Personal Trainers expand to include steroid injections?

Should Nurse Practitioners expand to perform C-sections?

Should Acupuncturists include setting bones? No. Definitely NOT. We are all bound by our scope of practice. As long as we practice within our training patient safety is protected. Not so in the case of the new Physical Therapy Regulation. 

I believe the regulation is weak on several points:

1.) The Commonwealth of Virginia defines the practice of acupuncture in Chapter 29 of Title 54.1 Section 2900 of the Code of Virginia as "stimulation of certain points on or near the surface of the body by insertion of needles to prevent or modify the perception of pain or to normalize physiological functions, including pain control, for the treatment of certain ailments or conditions of the body...." Dry Needling is insertion of needles to prevent or modify the perception of pain ….etc etc etc. DRY NEEDLING IS ACUPUNCTURE. Acupuncture, Myofascial Trigger Point Needling, Dry Needling is all the same thing. Anybody observing the two practices would readily have to admit that there is no difference between the two. Physical Therapists are wishing to perform Acupuncture by simply re-naming it. Secondly the legislation fails to define dry needling, therefore leaving the practice field WIDE OPEN to do whatever the Physical Therapist imagines he or she might include under dry needling. 

2.) The proposed legislation states that "dry needling is not an entry level skill" but fails to specify how many hours of training are required. When I ask physical therapists at my local gym it seems that most dry needling courses are ONE WEEKEND LONG. 16 hours. Medical doctors are required to have 300 hours of additional training to perform Acupuncture. Chiropractors are required to have 500 hours of additional training to perform Acupuncture. The AAMA believes 300 hours of training are minimum. No doubt both Physicians and Chiropractors have vast knowledge in anatomy and Pathophysiology. Physical Therapists apparently get it done in one weekend. How is this possible?

3.) The assertion that "dry needling is not an entry level skill but requires post graduate training is really mis-leading and vague. It is my understanding that currently graduating Physical Therapists are trained at the doctoral level and thus are thought to have competencies to learn invasive techniques such as dry needling. Truthfully only an estimated 32% of licensed physical therapists currently in practice are trained at the doctoral level and 68% do not have this level of education. Dry needling courses are not limited to only doctorally trained physical therapists. Thus the wording in the proposed rules is entirely too vague. It fails to specify exactly what kind of training is required to perform this highly invasive procedure. 

4.) PT's who wish to perform dry needling should be held to the same standard as acupuncturists when it comes to continuing education. At this moment in time Acupuncturists are required to attain 60 Acupuncture related CEU's per 4 year licensing period. Should we not hold Physical Therapists to the same standard?

5.) Patients should definitely DEFINITELY be clearly told that the Physical Therapist is not an acupuncturist and that the "dry needling" is limited only to the treatment of Trigger Points but does not and should never be mistaken for an acupuncture treatment.  If the argument of PT's is "it's not acupuncture" then this should be clearly stated at the patient encounter and should be spelled out in the informed consent.

As a Registered Nurse with 15 years experience working in Hospitals and Trauma Centers I am puzzled how a group of professionals can expand their scope of practice to include a highly invasive procedure without at the same time having to answer to the Virginia Board of Medicine. Massage Therapists are governed by the Board of Nursing as their work is so highly intimate.  How is it that Physical Therapists can so drastically alter their scope of practice without coming under greater scrutiny? I really believe the proposed rules are vastly inadequate. The training requirements are laughable and while I understand that an intuitive physical therapist may benefit a patient by needling a trigger point we should at least call it what it is: Acupuncture without a license. 

Sincerely 

Brigitte Fox, RN, Licensed Acupuncturist