Overview of PT Dry Needling in Washington State

//Overview of PT Dry Needling in Washington State

By Susanne Michaud, DPT, OCS

February 11, 2019

 

Sweat is on your brow and dripping down your back…  Your legs are depleted, your feet ache…  But wait!!!  you see the finish line as you enter the stadium…

This is the long road, the ultra-marathon that the Physical Therapy Association of Washington (PTWA) along with their legislative committee and their dry needling work group have tirelessly walked and run over the past 8 years and are now rounding the corner toward the stadium.  The reason they run this race is to legalize the ability of Washington physical therapists to practice dry needling (DN).  That stadium is the Washington State Legislature, and that finish line is the passage of a bill that puts into statute a dry needling endorsement for physical therapists.

How did we get on this road to begin with and what mileposts have we passed so far in this race?  This article will provide a historical perspective on dry needling in Washington State, an overview of the provisions in our current bill, in the house (HB 1260) and senate (SB 5642), and an action plan you can take to “move the needle” forward to successfully cross the finish line with the passage of these bills.[1]

Washington State started out “silent” on the question of whether or not physical therapists could practice this technique.  This silence made Washington a “gray” state, meaning there were no laws or legal opinions stating whether they could or could not perform DN.  As a result, many PTs in this state took courses and started utilizing the technique.  Precedence for practicing a technique prior to legalization is seen with needle EMG statute: PTs were practicing needle EMG for 20 years prior to it becoming part of the PT statute in 2005.

In 2011, dry needling was put on the agenda of the licensing board, the Washington State Board of Physical Therapy (WBPT).  PTWA presented a white paper on dry needling at that meeting.  East Asian medical practitioners (EAMP), formerly titled Acupuncturists, were also present and demanded that PTs obtain an EAMP license to perform dry needling.  The licensing board took no action and remained silent.  In 2012, WBPT looked at the issue again and agreed that PTs performing dry needling need to be properly trained; however, they still took no action.  On the federal level, in January that same year, the American Physical Therapy Association (APTA) came out with a resource paper on PTs practicing DN.  Because the state remained silent on the issue, many therapists continued to practice, deferring to the opinion of their professional organization, the APTA, who were in the process of amending their “Guidelines to Physical Therapy Practice” to include dry needling in the interventions section (published 4/2014).

The battle with this scope of practice issue escalated in 2013, when the first shots were fired against PTs by the Secretary of the Department of Health and by 2 acupuncture organizations.  After KinetaCore, a dry needling education group, announced a course they were intending to hold in Seattle in October, the newly appointed Secretary sent a letter stating that dry needling was “illegal” and that, if the course was held, then action may be taken.  At the start of the course, KinetaCore and the clinic hosting the course, Salmon Bay Physical Therapy, were served a cease and desist letter by the National Center for Acupuncture Safety and Integrity (NCASI).  The enrollees in the class were asked whether or not they wanted to continue the course and all in attendance voted unanimously to continue (talk about courage!).  A legal complaint was then filed by the South Sound Acupuncture Association (SSAA) against KinetaCore and Salmon Bay in the Superior Court of King County.

Given the urgency of this matter, in December 2013, PTWA returned to the licensing board to formally ask that dry needling be placed into the PT scope of practice.  Licensing boards have made opinions in 24 out of the 43 states that legally permit dry needling in the PT scope of practice, so this was not an unusual ask.  However, the board was short staffed so no decision was made at that meeting, nor at the following 2 meetings.

In 2014, the issue caught the attention of Representative Eileen Cody, the Chair of the House Health and Wellness Committee, who not only felt that dry needling should not be performed (by anybody) but that the board was acting outside of their authority, stating that this was a legislative issue.  Simultaneously, the Secretary of Health sent a letter to the WBPT warning them to NOT determine in favor of PTs doing dry needling.  Given all of this pressure, and despite each board member agreeing that they thought dry needling should be in the physical therapy scope of practice[2], at the October 20, 2014 WBPT meeting the board had a split vote on the scope of practice determination.  Instead a motion was made that passed the decision off to the legislature.  Sadly, this determination meant the case against KinetaCore and Salmon Bay was lost, the outcome of which banned the clinic from practicing dry needling.  Although, the ruling is binding only on the parties involved in the case, the case could be used as precedent in other court cases and was cited as a win by acupuncture groups.

In January 2015, Eileen Cody sponsored a bill that would prohibit PTs from performing dry needling.  Again, PTWA stepped up to the challenge and, under the leadership of the PTWA president at that time, Elaine Armantrout, and the Legislative Chair, Emilie Jones, rallied the troops to write and testify against this bill.  The bill was successfully defeated in March, never getting out of the Senate Health Care Committee.  Senator Randi Becker, chair of that committee, then asked PTWA to come up with a bill to add dry needling into our scope of practice, with the caveat that we not practice this technique until it becomes law.  In compliance in April 2015, PTWA published a notice to all of its’ members, urging them to refrain from performing dry needling.  Meanwhile, in May of 2015, Rep. Eileen Cody asked the attorney general to make a formal opinion on dry needling.

At the start of the legislative session in 2016, PTWA ran a bill that would permit the practice of dry needling by Washington PTs with a specialty endorsement.  Strong opposition from the EAMPs and acupuncture groups nationwide persisted.  PTWA’s Lobbyist, Melissa Johnson, had worked her magic and had verbally secured the necessary votes to get our bill out of committee.  But in the eleventh hour, after repeated false testimony by several EAMPs stating that PTs could cause “abortions” with this technique, our bill died in committee.  Subsequently, PTWA asked Senator Becker to request a sunrise review from the Department of Health (full circle).

For those new to the intricacies of the legislative process, a sunrise review is an in-depth analysis of a specific health profession’s proposal or mandate.  These are done only at the request of the chairs of legislative committees (chapter 18.120 RCW).  The process involves a non-partisan panel from the department of health charged with gathering evidence and hearing testimony before submitting a report that summarizes and makes recommendations on the questions posed.  In this case, Sen. Becker asked that the DOH consider whether the bill as written was sufficient to add dry needling to the PT scope of practice, as well as consider the evidence on the efficacy of dry needling.

In the spring of 2016, the PTWA dry needling work group, once again lead by Emilie Jones, jumped into action and produced a 98 page document in support of physical therapists education, skill, and safety.  On August 2nd, an all-star panel of experts, including Jan Dommerholt and JJ Thomas, flew in to testify on behalf of PTs competence to perform this.[3]  Once again, the EAMPs were in force to testify against our claim.

While the DOH reviewed all the documents and testimony, in September of 2016 the Attorney General (AG) came out with an opinion that, currently dry needling does not fall within the physical therapy scope of practice.  This blow was the first definitive legal statement that PTs could not practice dry needling, so no more “gray” area.  However, AG Bob Ferguson does write in his statement that “the legislature, of course, could also expand the scope of physical therapy by amending the relevant statutes”.

The final Physical Therapy Sunrise Review came out in December 2016, which laid a pathway for our new bill.  Although the findings were not in favor of the provisions around hours of education and supervised clinical experience that were specified in the previous bill, it did agree that, with adequate training, “dry needling may fit within the physical therapist’s scope of practice”.  It also found that the evidence demonstrated a “low rate of serious adverse events” from physical therapists performing dry needling in other states, the US military and Canada.

In 2017, members of the dry needling work group, Ben Boyle and myself, combed through the recommendations spelled out in the Sunrise Review to draft language for a new bill.  Based on the recommendations from our sage Lobbyist, Melissa Johnson, we chose not to run the bill in 2018 so that we could meet with the EAMPs and try to come to a mutual agreement via a mediation process.

Late in 2017 and into 2018, PTWA hired the “Center for Dialog & Resolution”, a very reputable legislative mediation group, to facilitate a conversation between PTWA and WEAMA (Washington East Asian Medical Association).  Our greatest challenge was finding the dates when everyone could meet.  The team we assembled to represent PTWA included: Ben Boyle, PTWAs current legislative chair; Shane Koppenfeld, Baylor University Director of Research and Clinical Associate Professor; myself, Susanne Michaud, private practice owner and current PTWA Secretary; and our PTWA Lobbyist, Melissa Johnson.  WEAMA brought in their Lobbyist, Leslie Emerick, along with WEAMA present and past presidents, Jianfeng Yang, Curt Eschels, and Ash Goodard.

PTWA and WEAMA met two times at the mediators table in 2018 – once in May and again in September. The opposition that EAMPs have against PTs practicing dry needling is deep and varied[4].  At its root is a belief that dry needling is acupuncture.  However, what became clear in this mediation is that neither group wants to describe dry needling as capital “A” Acupuncture.  Acupuncture, also known as East Asian Medicine, is a distinct practice of medicine encompassing multimodal evaluation and treatment modalities. Their work is not just about using a needle.  Conversely, Physical Therapy encompasses a distinct model of western medicine, one tool of which overlaps with that used by Acupuncturists.  How that tool is used, the clinical reasoning behind the use of that tool is what separates our professions.  Despite a productive conversation in our first mediated meeting, WEAMA’s members chose not to see the mediation through, agreeing to meet only one more time.  Although we met a second time, we did not arrive at any agreement.  PTWA did however, concede the term dry needling, and instead put the term “intramuscular needling” into our bill, since this was a particular “sticking point” for WEAMA.

It is now 2019 and the start of the legislative session.  The House version of the bill, HB 1260, is sponsored by the Vice Chair of the House Healthcare and Wellness Committee, Representative Nicole Macri.  The corollary bill in the Senate, SB 5642, is sponsored by the Chair of the Health and Long Term Care Committee, Senator Annette Cleveland.  A key point in our bill is that we will have the most rigorous continuing education requirement in the country at 300 hours (this includes 75 hours of direct needle instruction, 75 hours of related content instruction and 150 hours of supervision).  The majority of other states require only 27-54 hours.  Our supervision requirement of 150 sessions is also the most rigorous in the country and far exceeds the 25 sessions that is required in the US Military.  Lastly we will require a specific informed consent about the risks and benefits of intramuscular needling along with a statement that it is not Acupuncture.

Today, Washington is one of only 7 states that prohibit physical therapists from practicing dry needling based on the Attorney General opinion in 2016.  Currently the only people in this state who can legally perform DN are military PTs, MDs, RNPs, NDs. We have an opportunity in this legislative session to overturn that opinion and squarely place dry needling into the scope of practice of physical therapists.

But alas another obstacle has been thrown in our path.  Currently the Chair of the Health & Wellness committee, Sen. Eileen Cody, is refusing to put our bill on the committee hearing calendar, with the rationale that patients are not asking their legislators for this service. We have 10 days, until Feb 21 of this legislative session to get our bill out of committee and we need to exert some pressure on our district representatives to demand this bill be heard.  Please click on the following link to the bill and go to the comment on this bill button, which will take you to a page that will then link your comments to your district representative (see below for talking points).  If you or someone you know has benefited from dry needling or you have a specific story around being denied access to this technique, please let you representatives know this on or before Thursday, 2/14/2019.  Your voice really matters right now.

We’ve done our due diligence in showing that PTs have the skill, knowledge and safety to practice dry needling.  We’ve jumped through all the hoops to show our professionalism.  Now is the time that the legislature sees this and approves our bill.

As long as we all join forces to get over the finish line…  As long as we all rally our energy and resources and presence, yes, as long as we all pitch in with our phone calls, emails, social media posts and patient testimonials then we all can be the hero’s that see this through to the end and secure the right for PTs to practice dry needling in statute.

 

Here are some talking points you can have with your representatives:

  1. Intramuscular needling is a therapeutic, non-pharmacological intervention used to treat pain and movement dysfunction.
  2. 43 states as well as all branches of the military allow physical therapists to practice intramuscular Washington, although it’s often a progressive state, is one of only seven states where PTs are unable to perform this. As a constituent and healthcare consumer, it is very frustrating to not have access to the same level of care I could get in other states.
  3. Intramuscular needling is an evidence-based practice that has been proven to reduce pain and improve movement. In addition, research has shown that it lowers the cost of care to patients and the medical system by reducing the amount of therapy needed to get better.
  4. Given the number of people looking for alternatives to opioids to address their pain, this is a low cost, low risk technique that can help them achieve their goals.
  5. Currently, intramuscular needling can only be performed by physicians, nurse practitioners and naturopathic physicians, all of whom cost more and are not using the technique in the context of movement rehabilitation as PTs do.
  6. The bill in the house, HB 1260, would establish the most rigorous training standards in the country for PTs, at 300 hours of training and supervision compared to the average of 27 to 54 hours in other states.

 

[1] This article does not cover the definition or broader history of dry needling.  Resources to find that information can be found in white papers by:

  1. The Federation of States Boards of Physical Therapy. Dry Needling Resource Paper. 2013
  2. American Academy of Orthopaedic Manual Physical Therapists. Position Statement: Dry Needling. 2009
  3. American Physical Therapy Association. Physical Therapists & the Performance of Dry Needling: An Educational Resource Paper. 2012
  4. Dry Needling for Myofascial Trigger Point Pain: A Clinical Commentary. Unverzagt et.al., IJSPT, June, 2015

[2] I was present at this meeting to hear each board member testify in favor of PTs doing dry needling

[3] A key element in substantiating physical therapists competency to perform this technique was the 3rd party report commissioned by the Federation of States Boards of Physical Therapy (FSBPT) from HumRRo which showed that 86% of the competencies needed are acquired in accredited physical therapy programs, the remainder of which are needle insertion techniques.

[4] Passage out of IJSPT, 2015 paper. Dry Needling for Myofascial Trigger Point Pain: A Clinical Commentary. Unverzagt, C. Berglund, K. Thomas, JJ.

Is Trigger Point Dry Needling the Same as Acupuncture?

Within practitioners or disciplines a particular practitioner does not own, or have the rights to a particular technique.  Such restrictions, especially in medicine, would ultimately be disadvantageous to patients.  For example, chiropractors do not posses an exclusive domain over the skill of manipulation; physical therapists and osteopathic physicians commonly utilize the skill as well, since they too have the prerequisite training necessary to effectively use the skill.  Neither naturopathic physicians nor homeopathic physicians “own” herbal remedies, but they instead use them autonomously for the purpose of improving patient outcomes.  Both a carpenter and a surgeon utilize a hammer; should one own the tool to the exclusion of the other?  The vast difference between the two professionals relates to their underlying philosophy, thought processes, and decision making; the only thing they really have in common is the tool.  The same argument applies to acupuncture versus dry needling: Traditional Chinese Acupuncturists and physical therapist utilizing DN use the same needles.  However, just like the surgeon has a completely different though process compared to the carpenter, despite having the same tool, a physical therapist diagnoses and treats pan and dysfunction completely differently than an acupuncturist.  Therefor, to prevent confusion on the part of the patient, it is imperative that physical therapists clearly communicate they are not performing acupuncture.  This is often done through utilizing consent forms, as well as during discussions with the patient.”

By | 2019-02-12T14:59:10+00:00 February 11th, 2019|Conversation|