Over the past decade, the use of dry needling by physical therapists has grown exponentially. Currently, 46 states (not including CA, OR, HI, and NY) permit the use of dry needling by physical therapists.
To date, several State Boards of Physical Therapy,1-3 continue to have limited definitions of DN. As a result, many physical therapists are unfairly constrained to targeting intramuscular trigger points with dry needling, as their respective State Boards do not authorize them to insert needles into connective tissues (e.g., ligaments, tendons, teno-osseus junctions, musculotendinous junctions, scar tissue) or to perform peri-neural or peri-neurovascular needling. North Carolina is one such state that recently issued a narrowly focused position statement on dry needling.
NORTH CAROLINA PHYSICAL THERAPY BOARD IMPROPERLY REDEFINES DRY NEEDLING
On March 9, 2022, the North Carolina Board of Physical Therapy opined that “perineural dry needling extends beyond the current definition of dry needling and is therefore not within the scope of physical therapy practice in North Carolina”.4 Interestingly, the North Carolina Board of Physical Therapy has gone from “dry needling is a form of acupuncture” (2002), to permitting only dry needling to myofascial trigger points (2012), to now prohibiting perineural dry needling (2022).
Notably, in its Summer 2002 Newsletter for its licensees, the North Carolina Physical Therapy Board confirmed that “dry needling” was outside the scope of practice of physical therapists. More specifically in a Q & A section on page 4 of the Newsletter the following was stated:
Question: “Is dry needling within the scope of practice of physical therapists in North Carolina?”
Answer: “No. Dry needling is a form of acupuncture. In North Carolina, a practitioner who performs acupuncture must have a license from the NC Board of Acupuncture.”5
Interestingly, the former President of the APTA (2000-2006) served as the Executive Director of the North Carolina Physical Therapy Board when it claimed that dry needling was outside the scope of practice of physical therapists. In addition, in 2012, the North Carolina Board of Physical Therapy Examiners revised its definition of dry needling to read, “Intramuscular Manual Therapy (IMT), which is generally referred to as dry needling, is defined as a technique to treat myofascial pain using a dry needle (without medication) that is inserted into a trigger point with the goal of releasing/inactivating the trigger points and relieving pain”.6,7
In truth, the North Carolina Physical Therapy Board has gone back and forth on their written definition of dry needling on a number of occasions over the past 20 years. Given the state of the current literature supporting the use of perineural dry needling for several musculoskeletal conditions,13-21 it appears that the North Carolina Physical Therapy Board is, and will be, on the wrong side of history with their 2022 attempt to redefine dry needling in such a restrictive fashion.
APTA IMPROPERLY DEFINES DRY NEEDLING
In 2009, the APTA recommended ‘IMT’ (intramuscular manual therapy) as the term to be used by physical therapists to describe the intervention of dry needling.8 In 2012, the APTA narrowly and improperly defined dry needling as ‘an invasive technique used by physical therapists (where allowed by state law) to treat myofascial pain that uses a dry needle, without medication or injection, which is inserted into areas of the muscle known as trigger points”.9
Just a few months later, in February of 2013, the APTA broadened their definition to read as follows: “dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin, and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments”.10 Notably, the APTA’s definition still does not mention the use of dry needling for the treatment of neural tissue.
ARIZONA STATE BOARD OF PHYSICAL THEARPY ACCURATELY DEFINES DRY NEEDLING
In 2013, the Arizona Physical Therapy Association set the standard by becoming the first US-based, physical therapy association to explicitly recognize “neural, muscular, and connective tissue” as target sites for dry needling.11 Furthermore, on July 24, 2014, following the provisions of SB 1154 becoming law, the Arizona State Board of Physical Therapy adopted the following definition of dry needling that was established by the Arizona legislature: “Dry needling is a skilled intervention performed by a physical therapist that uses a thin filiform needle to penetrate the skin and stimulate underlying neural, muscular and connective tissues for the evaluation and management of neuromusculoskeletal conditions, pain and movement impairments”.12
PERINEURAL DRY NEEDLING IS EVIDENCE-BASED
Perineural needling has been found to improve sensory and motor nerve conduction velocities while reducing pain and disability in several musculoskeletal conditions.13-18, 24-26
Perineural needling (without injectate) to the median nerve, between the tendons of the flexor carpi radialis and palmaris longus, has been found to be superior to low-dose oral steroids for mild to moderate carpal tunnel syndrome in the short-term (1-month outcome)24 and long-term (1-year outcome).25 At the 1-year outcome, patients in the perineural needling group had significantly better improvement in distal motor latency (DML), distal sensory latency (DSL), and nocturnal awakening compared with the oral steroids group.25 Furthermore, ‘treatment failure’ occurred in 15.8% of the needling group versus 51.3% of the low-dose steroids group.25 Moreover, at the 1-year follow-up, the perineural needling group had a recurrence rate of just 10.5% versus 41% for the oral steroids group.25
Deep perineural electrical needling (without injectate) has been found to improve the pathological changes and function of injured sciatic nerves.26 Following perineural stimulation (20-minute sessions once daily for 14 days), the conduction velocity and the amplitude of the evoked potentials of the sciatic nerve were significantly improved.26 Furthermore, after deep perineural electrical needling, NGF expression was up-regulated and FOS protein expression was down-regulated.26 According to the authors of this clinical trial, this may be one of the mechanisms by which perineural electrical dry needling relieves sciatica in clinical practice.26
A 2017 systematic review and meta-analysis published in JOSPT highlighted the effectiveness of targeting perineural tissue in reducing neuropathic pain, suggesting that precise nerve modulation is key to pain relief.19 The efficacy of perineural needling to treat myofascial pain, neuropathic pain and musculoskeletal disorders was also published in 2019.20
Notably, a 2021 multi-center randomized clinical trial, in which all interventions were delivered by physical therapists in an APTA-accredited Orthopaedic Manual Physical Therapy Fellowship program, found perineural electrical dry needling targeting the greater occipital nerve, lesser occipital nerve, third occipital nerve, and great auricular nerve was effective in significantly reducing medication intake, headache frequency, intensity, and duration in patients with cervicogenic headache.21 Perineural electrical dry needling is thought to enhance intra and extra neural microcirculation via local neovascularization and vasodilation through autonomic reflexes and nitric oxide release.22,23
CONCLUSIONS
It is concerning that the APTA continues to omit “perineural” dry needling from their formal definition of dry needling. Furthermore, given the number of clinical trials that support the use of perineural dry needling for the reduction of pain and disability in a variety of neuromusculoskeletal conditions, the North Carolina Physical Therapy Board should not have improperly claimed that perineural dry needling is not within the scope of physical therapy practice.
The definition of dry needling that was developed by the Arizona legislature and implemented by the Arizona State Board of Physical Therapy (i.e., the use of needles to stimulate neural, muscular, and connective tissues for the management of neuromusculoskeletal conditions) remains the flagship legal language and continues to serve as the most accurate and evidence-based definition of dry needling to date.
AUTHORS
James Dunning, PhD, DPT, MSc, FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Montgomery Osteopractic Physical Therapy & Acupuncture, Montgomery, AL
Casey Charlebois, PhD(c), DPT, MSc, FAAOMPT, Dip. Osteopractic
Director of Clinical Research, AAMT Fellowship in Orthopaedic Manual Physical Therapy
PhD Candidate, Nova Southeastern University, Fort Lauderdale, FL
Paul Bliton PT, DPT, OCS, SCS, FAAOMPT, Dip. Osteopractic
Associate Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
William S. Middleton Veterans Hospital, Madison, WI
Patrick Gorby, DPT, MPH, FAAOMPT, Dip. Osteopractic
Assistant Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Gorby Osteopractic Physiotherapy & Wellness, Colorado Springs, CO
REFERENCES
1. MSSBPT. Intramuscular manual therapy (dry needling) may be performed by a licensed physical therapist. Mississippi State Board of Physical Therapy, Part 3101 Rule 1.3c, September 10, 2012. 2012;
2. LAPTB. Louisiana Physical Therapy Practice Act: Treatment with Dry Needling. Louisiana Physical Therapy Board, Rule 311, Page 29, October 20, 2011. 2011;
3. SPTB. Requirements for physical therapists to perform dry needling. Colorado Department of Regulatory Agencies: State Physical Therapy Board, Rule 211, 2008: 10-11. 2008;
4. NCPTBE. North Carolina Physical Therapy Board of Examiners. October, 25, 2023. https://www2.ncptboard.org/app/LandingPages/ScopeOfPracticeHome.php
5. NCPTBE. North Carolina Board of Physical Therapy Examiners Newsletter. 2002. https://www2.ncptboard.org/documents/newsletters/Summer2002.pdf
6. NCPTBE. Position Statement: NC Board of Physical Therapy Examiner Intramuscular Manual Therapy (Dry Needling). September 23, 2010. https://studylib.net/doc/18221238/position-statement–nc-board-of-physical-therapy-examiners
7. NCBPTE. Position statement: intramuscular manual therapy (dry needling). North Carolina Board of Physical Therapy Examiners, June 14, 2012.
8. FSBPT. Federation of State Boards of Physical Therapy Resource Paper Regarding Dry Needling 5th edition. Novermber 15, 2023. https://cdn.ymaws.com/aptany.org/resource/resmgr/Committees/DryNeedlingResourcePaper_5th.pdf
9. Coronado RA, Gay CW, Bialosky JE, Carnaby GD, Bishop MD, George SZ. Changes in pain sensitivity following spinal manipulation: a systematic review and meta-analysis. J Electromyogr Kinesiol. Oct 2012;22(5):752-67. doi:10.1016/j.jelekin.2011.12.013
10. FSBPT. Federation of State Boards of Physical Therapy Resource Paper Regarding Dry Needling 8th edition. Novermber 15, 2023. https://www.leg.state.nv.us/App/NELIS/REL/80th2019/ExhibitDocument/OpenExhibitDocument?exhibitId=40224&fileDownloadName=SB355_Dry%20Needling%20Resource%20Paper_Sherise%20Smith_Nevada%20State%20Physical%20Therapy%20Board.pdf
11. AZPTA. Definition and position statement for dry needling by physical therapists in Arizona. Arizone Physical Therapy Association, 2013. 2013;
12. Arizona So. Senate Bill 1154. October 24, 2023. https://www.azleg.gov/legtext/51leg/2r/bills/sb1154s.htm
13. Dimitrova A, Murchison C, Oken B. Acupuncture for the Treatment of Peripheral Neuropathy: A Systematic Review and Meta-Analysis. J Altern Complement Med. Mar 2017;23(3):164-179. doi:10.1089/acm.2016.0155
14. Kumnerddee W, Kaewtong A. Efficacy of acupuncture versus night splinting for carpal tunnel syndrome: a randomized clinical trial. J Med Assoc Thai. Dec 2010;93(12):1463-9.
15. Yang CP, Hsieh CL, Wang NH, et al. Acupuncture in patients with carpal tunnel syndrome: A randomized controlled trial. Clin J Pain. May 2009;25(4):327-33. doi:10.1097/AJP.0b013e318190511c
16. Yang CP, Wang NH, Li TC, et al. A randomized clinical trial of acupuncture versus oral steroids for carpal tunnel syndrome: a long-term follow-up. J Pain. Feb 2011;12(2):272-9. doi:10.1016/j.jpain.2010.09.001
17. Sim H, Shin BC, Lee MS, Jung A, Lee H, Ernst E. Acupuncture for carpal tunnel syndrome: a systematic review of randomized controlled trials. J Pain. Mar 2011;12(3):307-14. doi:10.1016/j.jpain.2010.08.006
18. Dunning J, Butts R, Fernández-de-las-Peñas C, et al. Spinal Manipulation and Electrical Dry Needling in Patients With Subacromial Pain Syndrome: A Multicenter Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(2):72-81. doi:10.2519/jospt.2021.9785
19. Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. journal of orthopaedic & sports physical therapy. 2013;43(9):620-634.
20. Cotchett MP, Landorf KB, Munteanu SE. Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review. J Foot Ankle Res. Sep 1 2010;3:18. doi:10.1186/1757-1146-3-18
21. Dunning J, Butts R, Zacharko N, et al. Spinal manipulation and perineural electrical dry needling in patients with cervicogenic headache: a multicenter randomized clinical trial. Spine J. Feb 2021;21(2):284-295. doi:10.1016/j.spinee.2020.10.008
22. Loaiza LA, Yamaguchi S, Ito M, Ohshima N. Electro-acupuncture stimulation to muscle afferents in anesthetized rats modulates the blood flow to the knee joint through autonomic reflexes and nitric oxide. Autonomic Neuroscience. 2002;97(2):103-109.
23. Ma S-x. Nitric oxide signaling molecules in acupoints: Toward mechanisms of acupuncture. Chinese Journal of Integrative Medicine. 2017/11/01 2017;23(11):812-815. doi:10.1007/s11655-017-2789-x
24. Yang CP, Hsieh CL, Wang NH, Li TC, Hwang KL, Yu SC, Chang MH. Acupuncture in patients with carpal tunnel syndrome: a randomized controlled trial. The Clinical Journal of Pain. 2009 May 1;25(4):327-33.
25. Yang CP, Wang NH, Li TC, Hsieh CL, Chang HH, Hwang KL, Ko WS, Chang MH. A randomized clinical trial of acupuncture versus oral steroids for carpal tunnel syndrome: a long-term follow-up. The Journal of Pain. 2011 Feb 1;12(2):272-9.
26. Liu YL, Li Y, Ren L, Dai LL, Bai ZH, Bai R, Ma TM. Effect of deep electroacupuncture stimulation of” Huantiao”(GB 30) on changes of function and nerve growth factor expression of the injured sciatic nerve in rats. Zhen Acupuncture Research. 2014 Apr 1;39(2):93-9.
