The dry needling debate comes in many forms – Is it acupuncture? Is it within the scope of physical therapy practice? Is current training sufficient for clinicians who dry needle?
Answers – No. Yes. Not always.
I feel the first question/answer requires its own post, and 30 state legislatures have already answered the second (that it is within PT scope of practice), but the last comes with the completely honest admission that not all dry needling courses are created equal. This was highlighted with a recent well-written piece authored by an acupuncturist. Although the commentary was certainly biased, I found myself agreeing with many of her thoughts on how poorly the dry needling course was organized in terms of safety and practical training. Not cool.
Instead of debating the good, bad and ugly of this previous piece, I thought it may be more informative to detail my training as a physical therapist who utilizes dry needling. Hopefully to illustrate the standard of dry needling education is higher than the original piece suggested. So the purpose of this post will be to describe what some dry needling education organizations have already embraced in terms of clinical education safety standards, and maybe how the rest of them ought to. Whether you are a clinician considering training in dry needling or a patient seeking a proficient clinician, I feel there are some necessities to consider in terms of dry needling education.
First though, it’s difficult to qualify these standards without recognizing that the clinicians taking these courses all have post-graduate education and at least 1-2 years of clinical experience. My education includes a Bachelors in Biology/Pre-Physical Therapy, a Doctorate of Physical Therapy, and 2 years of clinical experience prior to my first dry needling course. Dry needling is not an entry level skill and most organizations realize that the clinical reasoning and practical skills fostered in this requisite period prior to dry needling coursework is crucial. The majority of clinicians taking dry needling courses have either their MD, DPT, or DC. Acupuncturists seem very quick to criticize a weekend dry needling curriculum, but deny this doctoral education of physical therapists, chiropractors and physicians.
Unfortunately, it has been my experience that many acupuncturists lack substantial background education in basic human anatomy, musculoskeletal differential diagnosis, soft tissue palpation (or “hands on anatomy”), and clinical reasoning. And this observation was made both during conversation with acupuncturists as well as observing them during the same weekend workshops they condemn. My intent is not to be harsh, but simply to illustrate the expertise these acupuncturists criticize under the guise of safety is specious, and paradoxically is typically much more than their own in terms of human anatomy. But this is truly an apples v. oranges comparison considering the focus of coursework for a Master’s in Eastern or Oriental Medicine versus the Doctorate of Physical Therapy. That’s soapbox #2 on why acupuncture and dry needling are very different.
However, if the safety of needle penetration into human tissue is the concern, I suggest a simple field test. If you are considering dry needling as a patient with knee pain, ask your dry needling physical therapist, chiropractor or physician what the path of the femoral nerve is as it traverses the upper medial thigh and where it branches into anterior and posterior components. Now ask an acupuncturist. Do the same for the cervical plexus, sciatic nerve and where it branches into tibal and peroneal divisions, the adductor hiatus, femoral triangle, dorsal root ganglia, tibial artery, ulnar nerve, median nerve, and lung field. Point being, if we are looking to arbitrate a clinician intending to penetrate dermal and subcutaneous layers of tissue, they ought to be fully cognizant of every layer and potential structure that needle could influence. Safety of any medical procedure is predicated primarily on this appreciation of anatomy, not necessarily more hours handling needles. In fairness, I’m not implying that every single physical therapist will readily know these answers, and if they don’t I would be wary of undergoing dry needling with them. Just as I would be wary of an acupuncturist with debatable anatomical knowledge inserting a needle deeper into tissue.
So with an emphasis on clinical application, here is a list of 6 things specific to my dry needling education which I feel were of utmost importance in regards to safely and effectively implementing the technique. Specifically I intend to compare my experience to the unfortunately poor experience referenced in the post. Supporting literature, history, clinical dosage, and didactic lecture on mechanism, physiology and pathology are all very important; but let’s talk in terms of dry needling safety and technique first.
#1 – Education on clean needle technique.
It is unrealistic to maintain a sterile field in a PT clinic or gym, but using gloves, sanitizer, alcohol swab on the skin, sterile needles and basic training in clean needle technique is a necessity. Yes, the risk of infection is nearly zero, but why would you even slightly increase the risk of this?
#2 – Education on bloodborne pathogens and transmittable disease.
Again, the risk of this is nearly zero when practicing clean needle technique, but appreciating the needle as a potential vehicle for such disease is a necessary component of dry needling education. Protect your patients, protect yourself.
#3 – Instructor ratio of at least 1 instructor : 6 students.
My opinion – If you do not have small group lab instruction and supervision for a dry needling course, you are not being sufficiently trained. I see this as the main contributor to safety, practitioner understanding, and clinical efficacy. All coursework I completed was within this ratio and to be completely frank, I’m not sure I would have felt comfortable needling if I hadn’t had such tutelage.
#4 – Regional anatomy education including lecture, lab, and multimedia resources.
Before you even think about needling a region, you must know the 3-dimensional, cross-sectional, and palpable anatomy of ALL structures that needle may encounter. Not just muscles and tendons, but complete neurovascular, visceral and musculoskeletal anatomical integration. This is where physical therapists should excel. We are no longer just looking at Netter’s textbook pages or even a static cadaver; we are positioning a muscular system, manipulating tissue in our grip and directly influencing layers we were previously unable to.
#5 – Written and practical testing.
More specifically, practical testing that will fail you if you are unsafe, ineffective, or simply uneducated on clinical application. My practical testing included both oral and technical portions and not everyone in our class passed. Dry needling shouldn’t be a continuing education course where you pay registration and automatically expect a certificate afterwards. It is an advanced technique and I feel advanced manipulative courses should embrace this philosophy as well.
#6 – 200 documented patient contact hours required prior to Level 2 coursework.
With completion of Level 1 coursework, a required 200 patient treatment hours documenting muscles treated, outcomes, and response was needed to enroll for Level 2. In hindsight, I found this to be incredibly helpful in more objective assessment of my skills and the obvious repetition required to refine basic skills prior to advanced training.
Fast forward over 3 years and I personally have now used dry needling in over 3500 treatments since taking my first dry needling course. Dry needling has become a cornerstone of my manual skill set as a physical therapist and many patients come to us having minimal relief from other treatments, procedures, and modalities. I’m happy to say that in that time, no significant adverse event has occurred and we have been able to help a lot of people. Not necessarily because I am an extraordinary clinician (although I hope to be some day), but because of my background education, training, and respect of dry needling as a powerful modality.
As the popularity of dry needling increases, we will see federal and state standardization of the requirements and coursework associated with it. This is a good thing. In 2015, the Federation of State Boards of Physical Therapy commissioned a task force of industry leaders to create such standards for both certification coursework and hours required on a state level. In the meantime, as a healthcare consumer or practitioner, do your homework on the training your health professional has undergone. First comes safety, then comes expertise.
My hope is that the tone of this article did not come off as combative, but moreseo an expression of my personal experience which I felt upheld the high standards of safety and excellence in dry needling education. Although there are obvious foundational discrepancies between clinicians who dry needle and acupuncturists, I hope there can be agreement on the common goal to improve our patient’s lives.
As always, I encourage commentary of any opinion if it can be done so professionally.
Paul Killoren PT, DPT
Thanks for reading, feel free to ask questions, comment or follow us on Instagram, Facebook and Twitter (@DoctorsofPT or @DPTwithneedles)!