Author Archives: Jason Tutt

When dry needling becomes acupuncture

Recently, I attempted to contact and discuss an interesting paper I came across authored by James Dunning DPT, Raymond Butts PhD DPT, Thomas Perreault DPT, Firas Mourad OMT and Ian Young PT titled Dry needling: a literature review with implications for clinical practice guidelines. Interestingly enough, five out of six of the authors of this paper work for the Spinal Manipulation Institute where they teach physiotherapists, osteopaths and medical doctors dry needling and spinal manipulation with James Dunning being the president of this institute. This conflict of interest was declared in the appropriate section of the paper.

Unfortunately, Mr.Dunning appeared to be suspicious of my intentions and asked which organization I represented, what was my background and my work situation. When I informed him that I authored a blog called Needle Chat, and I wanted to ask him about his paper, he explained he was not interested in giving sound bites to acupuncture organizations that believe physiotherapists should go to acupuncture school before doing dry needling.

I further informed Mr.Dunning that I wanted clarification on certain points made in his paper regarding the techniques described. This appeared to push Mr.Dunning over the edge and he replied that he wasn’t interested in discussing his paper further on a blog, and any further comment would be dedicated to peer reviewed journals. He informed me that I should write a letter to the editor if I wanted to engage him in an academic discussion. Finally he stated that his point of view was made quite clear in his paper.

Surprised and confused by this response, I decided my only option was to use my interpretation of the paper to analyse what I believe was proposed in this literature review.

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Who is recommending Acupuncture?

Acupuncture sure has it’s fair share of skeptics, despite gaining in popularity. But who exactly is recommending patients to acupuncture these days?

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The struggle between acupuncture and dry needling – an analysis of facts

As you have probably figured out by now, I am a registered Acupuncturist and I received my initial training in TCM Acupuncture. Since entering the real world, I have been bombarded with the never ending argument that we Acupuncturists must fight against dry needling. I am part of several Acupuncture Facebook groups, and the administrator of the largest group told me in a private message.

Supporting dry needling by PT’s or DC’s or even MD’s who have not gone through full acupuncture training is just foolish

This is an argument that gets repeated over and over again, that these practitioners should go through acupuncture school. But this is simply a straw man argument because acupuncturist are using acupuncture in an attempt to treat everything, not just pain like dry needling is.

Another argument I have come across time and time again.

A Licensed Acupuncturist (LAc), or Acupuncture Physician (A.P.) is required to have a minimum of 4 years (nearly 3,000 hours) of post graduate training in the art and techniques of Acupuncture and Oriental Medicine.

On the other hand, a medical professional who practices dry needling is not required to complete any training. In the US, most practitioners of dry needling have a working knowledge of the musculoskeletal system but have not been trained on needle insertion or technique.

From another source

PTs do “dry needling,” aka acupuncture, with less than 40 hours of training using acupuncture needles! Yeek!

A news story on Arizona Nightly News featured acupuncturists making the following statements in regards to physical therapists performing dry needling.

• There is a severe risk to public health
• Physical therapists do not realize that when they needle a particular area, they’re actually affecting a change throughout the whole body
• They’re going for a weekend or two weekends of training and they’re going out and doing this.
• Dry needling patients are exposed to health risks like extreme pain, nerve damage, even punctured organs.

Another news story on CBS in Arizona involving an acupuncturist from the previously story named Lloyd Wrist, a licensed Acupuncturist in Arizona brought forth another argument in which he claimed;

• Acupuncturist are trained for a minimum of 800 hours supervised time

Now let’s look at the facts. I can tell you right now that some of these above claims are false.

Acupuncture

First of all, let’s talk about TCM Acupuncture training in Canada and what it takes to become licensed in the five difference provinces that actually regulate TCM acupuncture.

1. British Columbia
   • 1,900 hrs including 450 hrs of practicum completed in a minimum of 3 academic years – Source: CTCMA
2. Alberta
   • To be eligible to write the Provincial Acupuncturist Registration Examination of Alberta, applicants must have satisfactorily completed an acupuncture program approved by the Alberta Health Disciplines Board. – Source: CAAA
     • Grant MacEwan – MacEwan’s Acupuncture program features more than 600 hours of clinical practice on campus at our acupuncture teaching clinic. – Source: Grant MacEwan
3. Ontario
   • Successfully completed a program of clinical experience in the profession that is structured, comprehensive, supervised and evaluated and which consists of at least 45 weeks of clinical experience involving 500 hours of direct patient contact. – Source: CTCMPAO
4. Newfoundland
   • 1,900 hrs including 450 hrs of practicum completed in a minimum of 3 academic years – Source: CTCMPANL
5. Quebec
   • Applicants who do not hold an acupuncture degree from Rosemont College, or is legally authorized to practice the profession issued acupuncturist in Alberta, British Columbia, Ontario and Newfoundland, must obtain a diploma equivalence or such training specified in the Regulations for equivalence of diplomas and training standards for the licensing of the Order of Acupuncturists of Quebec. – Source: OAQ
     • Students receive 480 hours of clinical training – Source: Rosemont College

So in Canada, you can practice Acupuncture after an average of just under 500 clinical hours, the other roughly 2000 hours are didactic training spent in the classroom, many of which are spent learning theories that don’t have anything to do with how you insert needles into the body like QiGong, TuiNa, TCM Diagnosis, Acupuncture Therapy, Case studies, Pin Yin, Herbology, Patient Counselling, Business and Ethics, Shi Lao (Chinese Diet), etc….

Western courses are taught as well.

• Anatomy – 80 hours
• Physiology – 40 hours
• Pathology – 40 hours
• Microbiology – 20 hours
• Pharmacology – 20 hours
• Western Diagnosis – 40 hours

So again, in Canada, it’s very misleading to say that we get 2,500 hours of Acupuncture training, when the majority of it is in the class room, and only around 500 hours of it is in the clinic. And I can tell you from my own personal experience, there were times in our school clinic where we just sat around talking because sometimes we didn’t have enough patients for everybody.

Anyway, let’s look at the United States. In the US, 43 states plus D.C. require certification by the National Certification Commission for Acupuncture and Oriental Medicine. So I’m going to use that as our standard for eligibility to practice Acupuncture in the United States.

• Acupuncture Program – Source: NCCAOM
  • Minimum 3 years – 1905 hours
  • Acupuncture clinic – 660 hours

Where does this number of 3,000 hours of Acupuncture training that I keep seeing getting thrown around come from? California

California is the gold standard in the United States, and the California Acupuncture Board has the strictest requirements to become an acupuncturist in the entire country.

• An educational and training program approved by the Board for students who enrolled in an approved acupuncture and Oriental medicine training program must complete a minimum of 3,000 hours of theoretical and clinical training. The clinical training required is 950 hours. – Source: California Acupuncture Board

I think California is doing it correctly, 950 clinic hours is absolutely appropriate for doing something like acupuncture which could be fatal if done incorrectly or by somebody who is under trained. But to argue that we acupuncturists are trained for 3,000 hours in Acupuncture is very misleading and certainly the number thrown out by Mr.Lloyd Wright about acupuncturists being trained in 800 hours of supervised time is a stretch unless you are referring to California.

Dry needling – What does it take to learn it and be allowed to practice it?

Let’s again start with Canada. The eligibility to practice dry needling is that you must complete 1 of 9 approved courses. So just to cut down on time and space, I’ll only outline the one that appears to be the weakest in terms of training and hours.

• Acupuncture Association of Chartered Physiotherapists – Accredited 80 Hour Foundation Course

In The United States, each state is different in their regulation of dry needling with some states completely ruling against it, and others only requiring 24 hours of training, to some requiring as much as 50 hours of training. You can find out more about each individual state on the KinetaCore’s scope of practice page. KinetaCore is one of the most popular dry needling training course providers in the United States and Canada.

KinetaCore does offer two levels of training. Level 1 is 27 hours on-site, and to qualify for level 2 you must complete and submit proof for 200 treatment sessions before being accepted. Level 1 includes the hip, lumbar spine, thigh, cervical spine, shoulder, upper and lower extremity. While Level 2, includes the all dangerous thoracic spine, the TMJ/face and advanced needling in previously mentioned areas.

ANALYSIS ON ACUPUNCTURE

Statements being made by acupuncturists are untrue in that we receive 3,000 hours of Acupuncture training. In fact, we are closer to around an average of 600 hours in North America, with some provinces in Canada requiring as little as 450 hours and California requiring as much as 950 hours of clinical practice. It is important to note, that we acupuncturists do not spend 100% of our clinical training treating musculoskeletal pain and releasing ashi/trigger points. During school we are instructed to treat everything from digestive issues, to cold feet, to back pain, to headaches, to dry eyes, and the list goes on.

We acupuncturists are not experts in treating pain by the time we get out of school, we graduate as general practitioners knowing a little bit of everything. In fact, in my school, pain was probably what we focused on the least.

Certainly there are continuing education courses on sports acupuncture that we can take post-graduate by people like Whitfield Reeves and Matt Callison, but these are anatomically based acupuncture courses and when I took them, I realized how poor our anatomy training really was, at least in Canada.

ANALYSIS ON DRY NEEDLING

There is an obvious difference of requirements in North America ranging from 24 hours to 80 hours training in dry needling that allows physiotherapists to insert needles into their patients. This, in my opinion is not enough training to be inserting needles into areas such as over the thoracic spine, around the cervical spine and other high risk areas. However this may be sufficient for low risk areas like the majority of the areas focused on in Level 1 of KinetaCore’s dry needling course, as long as physiotherapists only needle the areas they have been shown how to do.

DO ACUPUNCTURIST’S OWN NEEDLING?

A statement from the APTA (American Physical Therapy Association)

It is unreasonable to expect a profession to have exclusive domain over an intervention, tool, or modality. – Source: APTA

A publication titled Changes in Healthcare Professions Scope of Practice: Legislative Considerations which was a collaboration by the following associations; Association of Social Work Boards (ASWB), Federation of State Boards of Physical Therapy (FSBPT), Federation of State Medical Boards of the United States, Inc. (FSMB), National Association of Boards of Pharmacy (NABP®), National Board for Certification in Occupational Therapy, Inc. (NBCOT®), and National Council of State Boards of Nursing, Inc. (NCSBN®) included the following statements:

Overlap among professions is necessary. No one profession actually owns a skill or activity in and of itself. One activity does not define a profession, but it is the entire scope of activities within the practice that makes any particular profession unique. Simply because a skill or activity is within one profession’s skill set does not mean another profession cannot and should not include it in its own scope of practice.

Overlapping scopes of practice are a reality in a rapidly changing healthcare environment. The criteria related to who is qualified to perform functions safely without risk of harm to the public are the only justifiable conditions for defining scopes of practice.

MY THOUGHTS

Acupuncturists are not experts in pain management after they graduate from school and therefore saying we are receiving 3,000 hours in Acupuncture, or even our full average of 600 hours of training 100% in pain management is false and misleading. We are trained in balancing meridians and moving qi, which is a practice I have discussed has it’s own issues in a previous article.

I believe dry needling courses are likely inadequate at the current time, and should be re-evaluated and require more clinical training before physiotherapists are left on their own to perform on their patients, especially in high risk areas of the body. Failure to do this can, and has resulted in several high profile cases of pneumothorax, which I talked about in previous articles here, here and here.

Sean Flannigan a physiotherapist from the second news story above was quoted as saying in regards to dry needling;

I’m not against us having a certain amount of requirements to do it.

And I, an acupuncturist, am not against physiotherapists learning dry needling, and I disagree with acupuncturists like the Facebook group administrator above quoted saying they should go through full acupuncture training because they are not trying to accomplish the same thing. Acupuncture was developed and taught to students with the intention of balancing meridians and treating everything. Dry needling was developed and taught to students for treating pain, and pain only. Saying that a physiotherapist needs to learn about meridians and qi in order to qualify to do dry needling is one of the most ignorant statements I have ever heard.

I don’t think Acupuncturists own the rights to do needling, just like chiropractors don’t own the right to do spinal manipulation. As we move into the future, more professions will be expanding their scopes to include more skills, more treatment options and those professions that are unwilling to adapt and bring in new skills will be the ones who miss out, not the ones who have their skills “stolen” from them.

Since originally “coming out” about this, I have received numerous threats from Acupuncturists who are attempting to have my license suspended for being what they believe to be “against acupuncture”. I’m not against acupuncture, I’m against stupid arguments and bending the truth about our own profession in order to appear better trained than we actually are, and claiming that we “own needling” and no one else should be allowed to do it unless they play by our rules.

Robert Davis – Society for Acupuncture Research – #6

Robert Davis is one of two co-presidents of the Society For Acupuncture Research. Robert Davis received a Masters of Science in acupuncture and oriental medicine from Southwest Acupuncture College, Santa Fe in 1999. He is board certified in acupuncture and Chinese herbal medicine and maintains a clinical practice in South Burlington, Vermont. He served as the President of the Vermont Association of Acupuncture and Oriental Medicine from 2001 – 2006. He is currently the CEO of Stromatec, Inc., a medical device R&D company developing quantitative tools and “know how” to researchers and clinicians in the areas of acupuncture needling techniques and connective tissue physiology and pathology. He has served as the Principle Investigator for six National Institute of Health SBIR grants.

Why you should listen – In this episode of Needle Chat, Robert talks about the Society for Acupuncture Research, what it is, it’s goals, what it has accomplished so far and the future of Acupuncture and SAR. Also, Robert touches on the issues of quality in research coming out of Asia, and the final word on Acupuncture for chronic pain.

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Dealing with the problem of ‘Qi and Meridians’ in the 21st century – Part 1

THESE STATEMENTS MADE IN THIS ARTICLE ARE THE OPINION OF JASON TUTT AND DO NOT NECESSARILY REFLECT THE OPINIONS OF OTHER PAST, PRESENT OR FUTURE AUTHORS AND CONTRIBUTORS OF NEEDLECHAT.COM, NOR DO THEY ATTEMPT TO SPEAK ON BEHALF OF OTHER ACUPUNCTURISTS OR THE ACUPUNCTURE COMMUNITY AS A WHOLE.

The most controversial concept in all of Chinese medicine is the concept of qi (pronounced chee) flowing through invisible lines called meridians. Many wonder, how can those who practice Chinese medicine, specifically acupuncture ever expect to be taken seriously, if they believe an invisible substance known as qi that can’t be seen or measured is flowing along predefined, and also equally elusive lines called meridians?

What is qi?

Let’s look at a couple of popular Chinese medicine websites.

• YinYangHouse.com –  Qi, pronounced “chee”, means energy
• Arthur Rosenfeld (Taoist Monk) – What we can say for sure is that qi is nonmaterial, and therefore, as TCM suggests, falls under the umbrella of “energy.”
• AcuHealing.com – For example, if the above functions are weakened as a result of the deficiency of Qi (vital energy)….
• Yin Lo PhD
  • Qi is vibration.
  • Qi is oscillation of the meridians. More precisely, qi is quantum oscillations on the system of meridians.
  • Qi is what carries the effect of acupuncture from one acupoint to other parts of the body.
• SacredLotus – The concept of Qi representing a continuum between immaterial and material is not so far from the concepts of matter and energy in modern physics.

What about some of the modern Chinese medicine text books, what do they have to say about qi?

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Eric Schanke – Acupuncture is medical not mystical – #5

Eric Schanke is an acupuncturist that practices what he refers to as ashi acupuncture. And for those of you who aren’t acupuncturists, there are generally two types of acupuncture.

1. Meridian or Jing Luo style acupuncture that’s based on the theory of qi flowing along meridians in the body
2. Ashi acupuncture, in which you find the tender points, and you stick a needle in them to reduce pain. Ashi roughly translates to “ouch”, “that’s it”, “oh yes”

Why you should listen – In this episode, Eric talks about acupuncture being medical not mystical. He talks about studying Acupuncture in the US, Korea and China and why he was ready to quit Acupuncture until he found a mentor to learn from and find out about ashi acupuncture. By taking a western medical approach to acupuncture, Eric has elevated his practice and results to a whole new level. Eric talks about how the process of ashi acupuncture and how it differs from meridian acupuncture as well as dry needling. Eric’s website is http://ashi-acupuncture.com

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Placebo Series Part 1 – Understanding Placebo Acupuncture – #4

In this special episode, Jason Tutt breaks down what the different forms of placebo acupuncture are, explains how they work, and shows a demonstration for each type of placebo acupuncture. Forms of placebo acupuncture in this episode include (1) minimal acupuncture (2) sham acupuncture (3) placebo needle acupuncture.

Why you should listen – For anyone trying to understand Acupuncture research, or just trying to understand what placebo acupuncture is when it is being compared to real acupuncture, this episode lays a strong foundation for understanding how acupuncture is often tested for efficacy in research studies and clarify some of the language you might come across in these studies when you hear that Acupuncture was superior or was not superior to sham Acupuncture.

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Conventional Medicine or Double Standard Medicine?

If you practice pharmaceutical medicine, or physiotherapy (physical therapy), you are considered to practice “conventional” medicine. And anything and everything else is considered part of the umbrella term CAM (Complimentary and Alternative Medicine). According to the hardcore pseudoskeptics, if CAM actually worked, it wouldn’t be classified under CAM, it would just be called medicine.

Funny enough, the biggest criticism of CAM, is that it’s not evidence based. And by evidence based, their definition means it hasn’t passed the ultimate test, the gold standard, the randomized double blind placebo controlled trial. (RCT)

Any type of healthcare treatment that is offered that isn’t based on pharmaceuticals, surgery or physiotherapy and hasn’t undergone and passed the test of the RCT is considered pseudoscience and quackery.

Coming from Acupuncture training based on  Traditional Chinese Medicine theory, I primarily prefer to treat pain. In fact, the laws in the province that I live in state that Acupuncture can be used to alleviate pain. Knowing that pain was a huge area of interest for me, I began to wonder what physiotherapy was doing right, and what Acupuncture was doing wrong. After all, every single hospital within a 50km radius of me has a physiotherapy department, and any time in the past when I had hurt my back, the medical doctor I would go see told me to go to physiotherapy if my back didn’t heal on it’s own.

So physiotherapy is the gold standard, it’s the “go to” for medical doctors when patients come in with musculoskeletal pain. So I began to look through the research journals for the mountains of RCTs that show physiotherapy is efficacious over a placebo treatment. Strange….. where are they?

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Acupuncture is more effective than drugs & physio for chronic low back pain

With all the controversies about Acupuncture since the beginning of the 21st century, there has been much debate over whether or not Acupuncture is a mere placebo, or actually has some specific value to it. However, one result has become seemingly clear for Acupuncture and chronic low back pain, and that is; Acupuncture is at least as effective, if not more effective than drugs and physiotherapy for chronic low back pain.

Now, how is it, if Acupuncture is nothing more than a placebo, could it be outperforming drugs and physiotherapy in large research studies? Researchers at Harvard suggest that acupuncture is a more powerful placebo in their study on sham acupuncture compared to a placebo pill for headaches. Other suggest that when participants join a trial hoping to receive acupuncture, and get randomized into the usual care group (drugs and physiotherapy) instead, they are affected by the nocebo effect due to their disappointment in their group assignment. And finally, we have Acupuncturists who suggest that the reason Acupuncture is outperforming usual care (drugs and physiotherapy) is because Acupuncture actually does have some specific effects that are more powerful than conventional medicine.

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Matthew Bauer: Acupuncture Now Foundation, Minimum effective dosage – #3

Matthew Bauer is the president of the Acupuncture Now Foundation. Matthew began his full-time practice of acupuncture and Chinese Medicine in 1986 after several years of studying Taoist history and philosophy with a 74^th generation Taoist Master. Matthew has worked with several acupuncture organizations in the U.S. as well as serving as an Expert Witness in both California State and private cases. He also has long worked in the Managed Care industry helping to create the first managed care acupuncture-based Utilization guidelines. In that role Matthew took part in a Think-Tank with a dozen experienced Acupuncturists from the U.S., Mainland China, Taiwan, and Korea. That experience convinced Matthew of the need to find ways to gather experienced Acupuncturists together to share their knowledge to further our understanding of this ancient healing system. Matthew has authored dozens of articles and two books and he has a passion for educating people about acupuncture believing it to be a responsibility of those who understand how it works to share this knowledge with those who don’t.

Why you should listen – Matthew talks about why the Acupuncture Now Foundation was formed and what it’s goals are. Matthew also talks about the problem in research study designs in which a suboptimal dosage is used in the “true” acupuncture group resulting in below industry average success rates and false negatives for the true acupuncture groups compared to sham groups. Nonetheless both groups still outperform usual care (physiotherapy and drugs) by as much as twice the effectiveness. Matthew lays out what is needed to do to fix these these problems, as well as a need for acupuncturists to rally around some centralized movement to demand better standards and fairer treatment in future research studies.

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