Re: “Evidence That Dry Needling Is the Intent to Bypass Regulation to Practice Acupuncture in the United States” by Fan et al. (J Altern Complement Med 2016;22:591–593)

Monday morning quarterbacking says that accepting a commentary on the historic origins of dry needling from acupuncturists on a topic as contentious as this stretched JACM's interest in “research on policy” relative to alternative and complementary approaches. The article stimulated the letter below, from two physical therapists, to which we invited the original authors to respond. Each picks from history's smorgasbord to bulwark a favored perspective. While JACM remains interested in actual research related to substantive questions on safety or effectiveness such as are asserted by these parties, we will not publish further on this dispute over the origins of the dry needling field. — Editor

Dear Editor:

We appreciate the article “Evidence That Dry Needling Is the Intent to Bypass Regulation to Practice Acupuncture in the United States” by Fan et al., ¹ but the authors did not succeed in providing convincing evidence that dry needling (DN) is a purposeful attempt to bypass acupuncture regulation.

Furthermore, their paper includes many incorrect and misleading statements: The authors' claims, that (1) DN was developed mainly by acupuncturists, (2) a physical therapy school hired acupuncturists, and (3) “dry-needlers were not teaching how to use these needles,” are unsubstantiated and factually incorrect. The first postprofessional DN courses in the United States were taught in 1997 by a neurologist and physical therapist (PT). ²

Birch established that there is no more than an 18%–19% overlap between Ashi points and trigger points (TrPs). ^3,4 Travell and Simons did not consider the acupuncture literature when they developed the technique of TrP injections. ⁵

Dr. Seem wrote, “The next stage in my own development of a myofascial style of meridian-based acupuncture was my encounter with the work of Dr. Travell.” ⁶ Travell influenced Seem—not the other way around, as the authors suggested. Many years earlier, in 1984, the Maryland PT Board approved DN for PTs.

Dr. Ma is not the main representative of DN by PTs. Acupuncturists who have attended his courses may conclude that he is teaching acupuncture techniques, ⁷ but that remains anecdotal evidence and not a scientific assessment.

The authors are incorrect when they state that, “Individuals purchasing or receiving acupuncture needles, who are not licensed by law to practice acupuncture, are directly violating civil and criminal provisions of the FDCA [Federal Food, Drug, and Cosmetic Act].” In fact, the U.S. Food and Drug Administration (FDA) has approved the sale and marketing of specific “dry needling needles” or “physiotherapy needles” for DN. The FDA down-classified acupuncture needles and promulgated 21 C.F.R. § 880.5580; FDA regulations 21 C.F.R. §§ 880.5580 and 801.109 make clear that the determination of who is authorized to use acupuncture needles is a matter left to the states.

The authors incorrectly state, “DN educators in both continuing education and in schools are frequently licensed acupuncturists.” Most DN instructors are licensed PTs.

The authors also write that, “The low level of training increases the risk for injury and can be a threat to public health and safety.” Here are the facts:

1. Our study of adverse events (AEs) with DN by PTs showed that the risk for a significant AE is less than 0.04%. ⁸

2. Licensed acupuncturists completed a minimum of 1905 hours of education, ⁹ while the typical Doctor of Physical Therapy completed 2676 hours of postbaccalaureate education. An independent study showed that 86% of the skills and knowledge a PT needs to have to practice DN safely is learned in PT school. In other words, only 14% of the skills and knowledge required to use DN needs to be covered by DN-specific education. ¹⁰

3. The major PT liability insurer has issued annual statements that DN does not pose an increased risk.

4. To be a safe needler requires a thorough knowledge of three-dimensional anatomy. ¹¹ PTs have advanced knowledge of the musculoskeletal system compared with many medical disciplines. ^12,13

In conclusion, DN by PTs developed independently from acupuncture without any effort to bypass acupuncture regulations.