Scope and Standards for Acupuncture: Dry Needling?

Legislative scope and standards of practice are major elements that define a profession. Clarifying these two areas for the field of acupuncture and Oriental medicine is important because of emerging legislative arguments that are mixing the logics of scope and standards – to the possible detriment of society. Let me explain.

In professional licensing laws, scope describes the procedures practitioners are allowed to use. Standards on the other hand, refer to the behaviors of the practitioners.

When scopes overlap, turf battles between professions may occur. These are matters of closure where one privileged class prevents another class of providers from providing specific services. The socio-economic implications of these turf battles may be important and necessary, they cannot, however, be the focus of this paper.

Scope of Practice and Acupuncture

Acupuncture is an incisive and invasive procedure involving the subcutaneous application of a needle. Further, the needle is applied to a variety of tissues for various therapeutic affects. There can be bleeding or bruising. Acupuncture may also refer to a professional discipline, which includes other practices of healing that involve diagnosis and the delivery of a treatment plan. The procedures of the discipline include but are not limited to manual therapies, scraping, and use of physical agents such as cupping (negative pressure) scraping, mechanical devices, heat, cold, air, light, water, electricity, and sound in the aid of diagnosis or treatment. Some states include herbal medicine and nutrition in the scope of practice for acupuncture. Licensing scope provides autonomy, but also liability and culpability. For some of these reasons and more, safe and effective practice requires comprehensive education.

The procedure of acupuncture may have a variety of descriptors including trigger point dry needling, manual trigger point therapy, intramuscular dry needling, intramuscular manual therapy and intramuscular stimulation. Contemporary practices also involve the injection of therapeutic substances into an acupuncture point. The application of electrical current to the needles may be called electro-acupuncture or percutaneous electrical nerve stimulation or PENS.

Medical acupuncture and biomedical acupuncture are also forms of acupuncture-based upon biomedical thought. There are licensed acupuncture practitioners throughout the range of health professions who think this way. What matters is the way of thinking about acupuncture is not a scope of practice; it is a standard of practice.

Dry needling is a description of acupuncture that relies on a category of points described in Chinese language as ashi points. A reasonable English translation of ashi points is “trigger points,” a term used by Dr. Janet Travell in her landmark 1983 book, “Myofascial Pain Dysfunction: The Trigger Point Manual”¹. Dorsher et al², determined that of the 255 trigger points, listed by Travell and Simons, 234 (92 percent) had anatomic correspondence with classical, miscellaneous, or new acupuncture points listed in Deadman et al³.

Other authorities describe dry needling as acupuncture. Mark Seem discussed dry needling in “A New American Acupuncture” in 1993⁴. Matt Callison describes dry needling in his Motor Points Index⁵ as does Whitfield Reaves in “The Acupuncture Handbook of Sports Injuries and Pain: A Four Step Approach to Treatment”⁶. Yun-tao Ma, author of “Biomedical Acupuncture for Sports and Trauma Rehabilitation Dry Needling Techniques” describes dry needling as acupuncture and provides a rich historical explanation⁷. Chan Gunn, sought to create language more readily accepted in the West in a 1980 article⁸. These examples make it clear that there is a literary tradition in the field of acupuncture that uses the term “dry needling” as a synonym for acupuncture.

In a position paper, Valerie Hobbs states, “It is the position of the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) that dry needling is an acupuncture technique. It is the position of the CCAOM that any “total body” intervention utilizing dry needling is the practice of acupuncture, regardless of the language utilized in describing the technique”⁹.

Standards of Practice and Acupuncture

Standards of practice are behavioral and include professional judgment, such as the selection of procedures, diagnostic tools and referrals. Similar is the decision whether to use a trigger point or some other method of point selection. For instance, the decision to use a neuro-anatomical approach to acupuncture in a condition such as sciatic neuropathy by treating at the nerve root as opposed to traditional Chinese medical point functions. That is, it is based upon how the practitioner builds knowledge in the clinic. The way of thinking is not scope and therefore is not subject to the weight of law.

The National Certification Commission of Acupuncture and Oriental Medicine (NCCAOM), uses job task analyses to validate the examination that authorizes acupuncturists to seek licensure in most states. The 2003 job task analysis found that 82 percent of acupuncturists used trigger point needling. This makes dry needling a standard of practice.

In the CCAOM position paper, Hobbs cited a complaint made by a physical therapist in Maryland to the Maryland Board of Acupuncture regarding the use of the term dry needling in chart notes by an acupuncturist⁹. The PT claimed that the acupuncturist was using language unique to physical therapy. This is a matter of standards of practice, not scope. Language and thought is not controlled by scope of practice codes. This is an attempt to conflate standards of practice (professional judgment or medical thought) with scope of practice: the privilege to perform a procedure. Ultimately, the complaint was dismissed because the procedure was deemed to be acupuncture performed by a licensed acupuncturist.

The Little Hoover Commission, in its 2004 report to the California legislature concluded that, “interactions with other health care providers, including collaboration and referrals, as well as with many members of the public, benefit from the use of common, Western-based diagnostic terminology”¹⁰. Acupuncturists who graduate from ACAOM accredited schools are required to complete 30 semester credits in biomedical clinical sciences for acupuncture only education and 34 semester credits for combined Chinese medicine and acupuncture programs¹¹. The objectives tie neatly with the 2004 Little Hoover recommendation.

This commentary should not be considered a recommendation to remove the professional technical languages of Chinese medicine and acupuncture. In my opinion, it is not possible to effectively practice Chinese medicine without the language of the discipline, especially in the context of herbal and nutritional management.

References

1. Travel J, Simons D. Myofascial Pain Dysfunction: The Trigger Point Manual. Philidelphia, PA: Lippincott Willimas & Wilkins; 1983.
2. Dorsher PT. Trigger Points And Acupuncture Points: Anatomic And Clinical Correlations. Medical Acupuncture. 2006;17(3).
3. Deadman P, Al-Khafaji M, Baker K. A Manual of Acupuncture. Kingham, Oxfordshire Journal of Chinese Medicine Publications.
4. Seem M. A New American Acupuncture: Acupuncture Osteopathy, the Myofascial Release of the Bodymind. Boulder, CO: Blue Poppy Press; 1993.
5. Callison M. Motor Point Index: An Acupuncturist’sGuide to Locating and Treating Motor Points San Diego, CA: AcuSport Seminar Series LLC 2007.
6. Reaves W, Bong C. The Acupuncture Handbook of Sports Injuries & Pain. Boulder, CO: Hidden Needle Press; 2009.
7. Ma Y-t. Biomedical Acupuncture for Sports and Trauma Rehabilitation Dry Needling Techniques. New York: Elsevier; 2010.
8. Gunn CC, Milbrandt WE, Little AS, Mason KE. Dry Needling of Muscle Motor Points for Chronic Low-Back Pain: A Randomized Clinical Trial With Long-Term Follow-Up. Spine. 1980;5(3):279-91.
9. Hobbs V. CCAOM Position Paper on Dry Needling 2010.
10. Acupuncture in California: Study of Scope of Practice Overview of Current Status and Issues to Consider Prepared for the Milton Marks “Little Hoover” Commission on California State Government Organization and Economy: UCSF Center for the Health Professions; May, 2004.
11. Accreditation Manual: Structure, Scope, Process, Eligibility Requirements and Standards. In: Medicine ACfAO, editor.: Maryland Trade Center Building #3, Suite 760 7501 Greenway Center Drive Greenbelt, Maryland 20770-3514; 2009.

May 2011