Dry Needling is Acupuncture

by | Sep 16, 2019 | Acupuncture | 0 comments

There is a common misconception that dry needling is fundamentally different from acupuncture, that while dry needling treats pain, acupuncture works on supposedly imaginary acupuncture points and meridians.1 The reality is that dry needling is acupuncture, but not all acupuncture is dry needling.

The term dry needling originally came from the use of empty (“dry”) syringes to stimulate trigger points for pain relief. This technique was developed by Janet Travell MD, who distinguished it from “wet” needling which used substances such as lidocaine injected into the trigger points.

Depending on state laws, dry needling can now be practiced by medical doctors, chiropractors, nurse practitioners, and physical therapists using the same filiform needles that acupuncturists use.

Dry needling essentially developed in parallel with the rise of acupuncture and Chinese medicine in the United States over the past 50 years or so, crossing over with the use of the filiform acupuncture needle.

Although dry needling is a new term, it overlaps exactly with the traditional acupuncture technique of treating ashi points.

The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) Dry Needling Position Statement states, “Dry needling is a recently coined name for an acupuncture technique that involves the insertion of acupuncture needles directly into muscles and trigger points for the relief of musculoskeletal pain. Licensed acupuncturists have practiced and documented this acupuncture technique, now referred to as ‘dry needling’, for decades in the US.” 2

Acupuncture Approaches

Acupuncture is part of a system of Chinese and Eastern medicine used for thousands of years. But it is not an untouched fossil, this medicine is always evolving, just as Western medicine continues to grow based on clinical evidence and new research.

As a modality of medicine, acupuncture treats all manner of disorder and disease of the body, including musculoskeletal pain and dysfunction. Acupuncture tools are very simple: the filiform needle, but the methodology and application are very diverse.

Acupuncture may be applied according to any number of treatment theories, including: distal points on an affected channel, empirical points for a particular affliction, microsystems on the ear, scalp, hand, or foot, mirroring on the opposite side of the body, or opposite-analogous on the opposite but related joint. Acupuncture may also be applied directly to an affected area, focusing on a point of tension or soreness, called an ashi point.

Needling ashi points is a part of every acupuncturist’s training and scope of practice. Some acupuncturists get additional post-graduate training to specialize in orthopedic or sports acupuncture.

Trigger Points

Ashi points are found through palpation and are indistinguishable in function from trigger points. There is evidence that trigger points, as mapped out by Janet Travell MD in her book Myofascial Pain and Dysfunction: The Trigger Point Manual, have a high correspondence rate with traditional acupuncture points.3

Acupuncturists are trained to find traditional acupuncture points by way of physical anatomical landmarks, and all experienced acupuncturists know that the active point is ultimately found though palpation of the body.

Stimulating a tender and active point, (aka ashi point, aka trigger point) with a filiform needle to provide pain relief is a part of acupuncture theory, training, and practice.

Translation of Terms, Scope of Practice

There are efforts being made in several states to include the term dry needling in the acupuncture scope of practice, to protect this aspect of our medicine that is being taken out of context.

When the state scope of practice for acupuncturists is written with terms such as “ashi points” or “stimulation of qi” it is very difficult from outside the acupuncture profession to really qualify what type of medicine we are practicing.

As acupuncture moves more mainstream and its benefits become more widely accepted, there is a need for translation of language and concepts from Chinese medicine to Western medicine. This translation of language and concepts also has to be very conscientious to not lose the essence of what makes Chinese medicine so uniquely effective.

Acupuncture Training and Safety

One way to think about dry needling is that there are two kinds of acupuncturists practicing: licensed acupuncturists in the US who have completed at least 2000 hours of acupuncture-specific training, didactic material and supervised clinical training, as well as biomedical training; and practitioners of dry needling, who may be physical therapists, chiropractors, or medical doctors, but only complete up to 300 hours of acupuncture training, and in some states much less. 4

“As ‘dry needling’ is acupuncture, it presents the same inherent risks including but not limited to perforation of the lungs and other internal organs, nerve damage, and infection. Recent reports of serious and potentially life-threatening injuries associated with ‘dry needling’ include pneumothoraces and spinal cord injury. These and other injuries support the statement that ‘dry needling’ presents a substantial threat to public safety when performed without adequate education, training, and independent competency examination. Adequate training and competency testing are essential to public safety.“4

Dry Needling Billing Code

Currently the acupuncture CPT (Current Procedural Terminology) codes are based in units of 15 minutes. Acupuncture CPT codes did not used to be time-based, and since sometimes needles are not retained, particularly in ashi point treatment or trigger point treatment, there was a recent proposal of a Trigger Point Acupuncture code to the CPT committee, which is run by the American Medical Association. The proposal coincided with the submission by the physical therapists and chiropractors of a code for “Dry Needling” and so has been in discussion by the CPT committee.

The American Society of Acupuncturists (ASA) Report from the American Medical Association CPT Code Committee meeting 5  is worth reading in full, but the “Outcomes” and “Points to Take Home” sections are important so I am posting them here:

Outcomes

After much deliberation, the AMA Committee concluded the following:
1. Codes describing the procedure of needling with no needle retention are to be created.
2. The placement for these codes will be under the code set for trigger point injections. (This resides in the medical-surgical section of the code set, and not under either acupuncture nor physical medicine and rehabilitation.)
3. Accepted addition of codes 205X1, 205X2 to describe needle insertion(s) without injection(s). Codes will become active January 1, 2020
With these codes, representative vignettes were agreed upon. These vignettes make it absolutely clear that the intent of these codes is to describe a procedure with no needle retention and no auxiliary electric stimulation. These will become available upon the publication of the full code set, presumably just prior to 2020.

Points to take home

  • There is no “dry needling code”. There is now a code for “needle insertion(s) withoutinjection(s)”. This procedure is deemed identical to both Trigger Point Acupuncture and Dry Needling. The two are equated.
  • If there is needle retention or e-stim used, only the acupuncture codes are appropriate.
  • Every code in the code set can be used by any practitioner with that code’s procedure inscope. If a profession does not have a procedure in scope, it cannot use a code because of scope issues. Licensed Acupuncturists all by definition may use the new codes. Thereis no expansion of practice act language needed to protect scope.
  • If a profession does not have invasive needling in scope, it cannot use this code.
  • This is a non-time-based code usable by practitioners with often cursory training. Its valuation is the next step in the process, but it should not be as highly valued as the acupuncture codes.

 

References