Non-physicians performing "dry needling"

[ampaphb]

In Louisiana, PTs and Chiropractors have recently expanded their scope of practice to include dry needling.
The Board of Medical Examiners issued an opinion that "In the Board’s view, dry needling constitutes the practice of medicine and should only be performed by a physician or an acupuncturist."

It went on to alert physicians that unless specifically excluded from a physical therapy referral, it is possible that dry needling may be performed on your patient. Therefore, if you do not intend to authorize dry needling on a patient for whom you prescribe physical therapy services, you will need to specifically exclude it from your referral.

It also sought an opinion from the Attorney General, so that Chiropractors might not be able to include it in their scope of practice

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[pastafan]

"It went on to alert physicians that unless specifically excluded from a physical therapy referral, it is possible that dry needling may be performed on your patient. Therefore, if you do not intend to authorize dry needling on a patient for whom you prescribe physical therapy services, you will need to specifically exclude it from your referral."

Great, I checked my state's regs and PT can do dry needling. I haven't had a patient report that anyone did this on them but I will probably need to template a prohibition in the order set.

 

[lobelsteve]

Happens here all over Georgia. Got a PT in Jasper that has dry needled my patient's face.
Kid you not.

 

[yankeeh8r]

Wait, you guys are just hearing about the "Dry Needling Wars"? Around these parts you've gotta be careful that you don't end up walking down the street between an Acupuncturist and a Physical Therapist cause they've gone total, batsh*t, "There can be only one", Highlander crazy about dry needling with the state boards and legislature around here.

 

[emd123]

One or two PTs do this in my area also. In a couple cases it's helped my patients so I haven't found a reason to get too bent out of shape about it. Should I be?

I suppose they're taking trigger point injections away from my practice and I could put the halt on that if I wanted. I haven't seen any crazy facial dry needling or other crazy body parts. Mostly muscles/trigger points. I guess I have bigger fish to fry than this one.

 

[PinchandBurn]

I wonder what the rate of PTX is with Dry Needling

 

[lobelsteve]

I wonder what the rate of PTX is with Dry Needling

0 %. 30g 1/2" needles for most. And they would never recognize a ptx if it happened.

 

[nvrsumr]

0 %. 30g 1/2" needles for most. And they would never recognize a ptx if it happened.

Are they really using a 30g 1/2? That's ******ed.

 

[Prof Moriarty]

Acupuncturists use anywhere from 30g to 44g. I think most stick to 32 and 36, but depends on their training/style. There are tons of acupuncture points all over the face, and it's pretty common to see these used by acupuncturists. PT... not so sure about.

Needle length varies quite a bit. 1/2", 1", 1.5" are common, but longer needles are used in some areas. For instance, 6" needle to hit glutes in obese patient or to thread superficially elsewhere. In my experience, American LAc's tend to be fairly conservative with their needling depth; Chinese and Korean immigrants more aggressive; whereas Japanese tend to do very superficial needling.

In IL acupuncturists have to have ~2500 hours of training, but any chiro, dentist, or PT can "dry needle" with zero training. Not that they are. But they could. MD/DO's too (or even nurses under their supervision). Versus say... NY or CA: physicians need a 300 hour course.

 

[clubdeac]

Peter they do it all the time here too. What should piss you off is the NPs down my street that are doing sham mbb's and caudal ESIs. Have seen two patients now that got a "series of 4" bilateral L2-5 mbbs spaced 1 month apart with no mentioned of response to injection in any of the notes. I'm assuming they did 4 because that is the max # of facet interventions medicare will allow in a year. Oh and they are doing US guided lumbar tpi's! Dry needling is nuthin

 

[pjuer]

We have a chirocrackter on every corner in Southern Illinois that does "acupuncture". Some with many letters behind their name.

 

[Ducttape]

because the number of letters correlates directly to their level of expertise.... not.

 

[bedrock]

Peter they do it all the time here too. What should piss you off is the NPs down my street that are doing sham mbb's and caudal ESIs. Have seen two patients now that got a "series of 4" bilateral L2-5 mbbs spaced 1 month apart with no mentioned of response to injection in any of the notes. I'm assuming they did 4 because that is the max # of facet interventions medicare will allow in a year. Oh and they are doing US guided lumbar tpi's! Dry needling is nuthin

That is so messed up. The biggest danger if mid level encroachment is crap that which is why all procedures are being cut.

 

[ampaphb]

Peter they do it all the time here too. What should piss you off is the NPs down my street that are doing sham mbb's and caudal ESIs. Have seen two patients now that got a "series of 4" bilateral L2-5 mbbs spaced 1 month apart with no mentioned of response to injection in any of the notes. I'm assuming they did 4 because that is the max # of facet interventions medicare will allow in a year. Oh and they are doing US guided lumbar tpi's! Dry needling is nuthin

In Louisiana, the state board issued a pronouncement that interventional pain is the practice of medicine. Nurses went to court, got shut down. Talk to your state medical society

 

[jesspt]

We have a chirocrackter on every corner in Southern Illinois that does "acupuncture". Some with many letters behind their name.

Well, PTs won't be doing it in IL, at least for now. This is the first time I have ever seen the Illinois Medical Society align itself with chiropractors and accupuncturists. These turf ware are going on all over the country. It's getting crazy (on all sides).

 

[jpb26]

Dry needling is rampant in my area. Just last week I saw a patient with CRPS who had a PT dry needle the affected leg. Funny thing is it didn't seem to help.....

 

[ziggyziggy]

On a similar note, I sent out Fibro patient for aquatics. Pt told PT that water hurts her body and patient ended up getting mirror therapy and guided motor imagery.

 

[SeniorWrangler]

I recently read an article that Travell did all her "dry needling" with a 22G hypodermic needle and thought anything thinner wouldn't adequately grip the muscle. I have never tried doing this, it sounds pretty painful but maybe it takes dry needling to a whole new level.

 

[Baritonebass]

I know a pain doc in NYC that gives that uses a 18g needle with conscious sedation not sure if the needling or the ketamine is the result of his success

 

[lobelsteve]

I know a pain doc in NYC that gives that uses a 18g needle with conscious sedation not sure if the needling or the ketamine is the result of his success

http://www.sptimes.com/2002/06/11/Hernando/Woman_claims_doctor_d.shtml

Nana nana booboo, I win. Interweb now closed for repairs. Booya.

 

[clubdeac]

On a similar note, I sent out Fibro patient for aquatics. Pt told PT that water hurts her body and patient ended up getting mirror therapy and guided motor imagery.

Mirror therapy and guided motor imagery is now standard of care for CRPS. Not sure if aquatic therapy has any evidence

 

[DanOTR/LNMT]

As a therapist in Maryland (where dry needling is also a thing that happens) who is also in pain management, I can reliably tell you that not one single case of dry needling I've seen from other therapists has gone any other way than "dear god I'm growing a second head from my upper trapezius” or ”welp now I have hideous chest pain and my scalenes still hurt".

 

[pmrmd]

Muscle biopsy in myofascial pain has non-specific findings and in Fibromyalgia they are normal. I have always felt that if someone wants to perhaps cause a specific histologic finding of a muscle, they should keep stabbing it with a needle and perhaps it may scar. Dumb.

 

[lobelsteve]

Muscle biopsy in myofascial pain has non-specific findings and in Fibromyalgia they are normal. I have always felt that if someone wants to perhaps cause a specific histologic finding of a muscle, they should keep stabbing it with a needle and perhaps it may scar. Dumb.

http://www.painresearchforum.org/ne...e-fibromyalgia-patients-show-peripheral-nerve

But Clauw disagrees: Chicken or egg? I agree with that. fiber drop-out due to central process.

 

[pmrmd]

I would bet this study references a separate population without the classical symptoms. Those biopsies were only from the legs and only 4/10 had those changes. FMS is as much a society-produced condition as anything.

 

[Ligament]

http://www.sptimes.com/2002/06/11/Hernando/Woman_claims_doctor_d.shtml

Nana nana booboo, I win. Interweb now closed for repairs. Booya.

OMFG

"treated her in her living room and in his car, the lawsuit says."

 

[emd123]

Here's what I'd like to know. What are the PTs charging for "dry needling," the same as trigger points or some other amount?

How much?

 

[Sheldon]

Here's what I'd like to know. What are the PTs charging for "dry needling," the same as trigger points or some other amount?

How much?

Interesting conversation. I'm a PT and think the trigger point construct is terrible. Fred Wolfe has some good work on this and if you read with a critical and un-biased (as much as possible) eye, the literature especially from Travell, is not convincing. Anyway, some PTs charge under 97140 while others may charge a separate fee. Side question: Why are medical doctors against PTs doing dry-needling?

 

[jesspt]

Here's what I'd like to know. What are the PTs charging for "dry needling," the same as trigger points or some other amount?

How much?

In the state of Illinois, the initial ruling by the Department of Professional Regulation was that IntraMuscular Manual Therapy with the use of an accupuncture needle was within the scope of practice of a physical therapist. Given that title, most PTs would bill for it using 97140 (manual therapy). Obviously, the amount billed would be dependent upon the contracted rate agreed upon between the PT and the third party payor.

I am not aware of any PT in a cash-based practice that also does dry needling, so can't say what they might charge for that service.

 

[emd123]

Side question: Why are medical doctors against PTs doing dry-needling?

I haven't found a reason to get too bent out of shape over it...FWIW

 

[emd123]

In the state of Illinois, the initial ruling by the Department of Professional Regulation was that IntraMuscular Manual Therapy with the use of an accupuncture needle was within the scope of practice of a physical therapist. Given that title, most PTs would bill for it using 97140 (manual therapy). Obviously, the amount billed would be dependent upon the contracted rate agreed upon between the PT and the third party payor.

I am not aware of any PT in a cash-based practice that also does dry needling, so can't say what they might charge for that service.

So what does Medicare pay for that (97140) ? $25-30?

 

[jesspt]

So what does Medicare pay for that (97140) ? $25-30?

I'm a fairly unique setting (employer-sponsered health center) so I haven't actualyl seen a Medicare patient in over two years. But our usual and customary rate for 15 minutes of manual therapy is $52 so I'd say that the $25-$20 range is probably about right.

 

[ampaphb]

I haven't found a reason to get too bent out of shape over it...FWIW

pneumothorax. infection. vascular injury. nerve injury. corticosteroid-induced dermal atrophy.

 

[emd123]

pneumothorax. infection. vascular injury. nerve injury. corticosteroid-induced dermal atrophy.

Dry needling doesn't include steroids. Pneumothorax is a concern but if they do it, they're liable. Infection, vascular, nerve injury: rarely clinically significant from TPI or dry needling.

 

[ampaphb]

rarely clinically significant WHEN DONE BY A PHYSICIAN

 

[emd123]

rarely clinically significant WHEN DONE BY A PHYSICIAN

Or CRNA


(Just kidding)

 

[Sheldon]

pneumothorax. infection. vascular injury. nerve injury. corticosteroid-induced dermal atrophy.

This quote is similar to the same arguments that chiropractors use to limit PT scope of practice in regards to spinal manipulation. The "argument" is one of safety and "improper" or "inadequate" instruction and training yet in reality, these events (though they do occur at the hands of acupunturists, chiros, PTs alike; also wasn't there a recent case of a DO causing pneumothorax in a young male recently?) are rare and infrequent. I'd argue that the training from Myopain Seminars and Kinetacore are more than adequate and the safety record of PTs performing dry-needling does not put the public at risk above and beyond chance occurence. Anyway, all that said, and I still don't dry needle personally. Lastly, I do think it's quite risky to do anything with a needle near the spine and especially in the thorax.

Ampaphb, I'm wondering if you've had a bad experience/s with PTs doing this or why, other than the risks listed above, you are against this? Do you dry needle or feel threatened by PTs doing this from an economic perspective?

 

[ampaphb]

I'm opposed to the expansion of scope of practice by any groups of para professionals like pts, or quasi professionals like chiros. I'm opposed to CRNA's performing interventional procedures, psychologist waiting for medication, and optometrists expanding into opthalmology.

I believe practice of medicine should be reserved for allopathic and osteopathic practitioners. For others with minimal training and insufficient appreciation of the risks to put their own economic interests ahead of patient safety is unconscionable

 

[pmrmd]

I'm opposed to the expansion of scope of practice by any groups of para professionals like pts, or quasi professionals like chiros. I'm opposed to CRNA's performing interventional procedures, psychologist waiting for medication, and optometrists expanding into opthalmology.

I believe practice of medicine should be reserved for allopathic and osteopathic practitioners. For others with minimal training and insufficient appreciation of the risks to put their own economic interests ahead of patient safety is unconscionable

Nice answer. Also, some of us find needling a muscle entirely irrational. To the PT: What do you really think you are doing with your needle? What are you changing? If you think there is something wrong with the contractile elements, how does inserting a needle into it make it better and how do you know you are at EXACTLY the right spot?

 

[jonnylingo]

Nice answer. Also, some of us find needling a muscle entirely irrational. To the PT: What do you really think you are doing with your needle? What are you changing? If you think there is something wrong with the contractile elements, how does inserting a needle into it make it better and how do you know you are at EXACTLY the right spot?

Likewise, how do you know you're in trap or rhomboid and not in pleura or fat? Margin of error is small, especially with 1-2+ inches of blubber in some patients.

 

[Sheldon]

I'm opposed to the expansion of scope of practice by any groups of para professionals like pts, or quasi professionals like chiros. I'm opposed to CRNA's performing interventional procedures, psychologist waiting for medication, and optometrists expanding into opthalmology.

I believe practice of medicine should be reserved for allopathic and osteopathic practitioners. For others with minimal training and insufficient appreciation of the risks to put their own economic interests ahead of patient safety is unconscionable

FWIW, I'm opposed to the unjudicious use of diagnostic imaging, lack of a proper MSK exam, over-reliance of pharmaceuticals for the treatment of persistent pain, disabling/nocebo language allopathic and osteopathic practioners use during their interactions with their patients, and the frankly wrong diagnostic labels put on patients that I see every day coming from those who "practice medicine". I'm tired of referring patients with multi-segmental neurological weakness back to the PCP or a specialist and seeing patients s/p fusion that never tried any PT for any amount of time whose pain remains. And I'm tired of "heirarchy" and double-standard some allopathic and osteopathic practitioners have for PTs, for what should be an inter-disciplinary approach. But, hey, PTs are just "para-professionals" with minmial training so what good are we.....what with the how many billion dollars a year persistent pain costs the US annually?

 

[SSdoc33]

FWIW, I'm opposed to the unjudicious use of diagnostic imaging, lack of a proper MSK exam, over-reliance of pharmaceuticals for the treatment of persistent pain, disabling/nocebo language allopathic and osteopathic practioners use during their interactions with their patients, and the frankly wrong diagnostic labels put on patients that I see every day coming from those who "practice medicine". I'm tired of referring patients with multi-segmental neurological weakness back to the PCP or a specialist and seeing patients s/p fusion that never tried any PT for any amount of time whose pain remains. And I'm tired of "heirarchy" and double-standard some allopathic and osteopathic practitioners have for PTs, for what should be an inter-disciplinary approach. But, hey, PTs are just "para-professionals" with minmial training so what good are we.....what with the how many billion dollars a year persistent pain costs the US annually?

We'll said. Not sure what 'multisegmental neurological weakness' is, but agree with most of what you've said. I good PT is invaluable. A mediocre PT, on the other hand, is quite common and essentially useless.

 

[pmrmd]

FWIW, I'm opposed to the unjudicious use of diagnostic imaging, lack of a proper MSK exam, over-reliance of pharmaceuticals for the treatment of persistent pain, disabling/nocebo language allopathic and osteopathic practioners use during their interactions with their patients, and the frankly wrong diagnostic labels put on patients that I see every day coming from those who "practice medicine". I'm tired of referring patients with multi-segmental neurological weakness back to the PCP or a specialist and seeing patients s/p fusion that never tried any PT for any amount of time whose pain remains. And I'm tired of "heirarchy" and double-standard some allopathic and osteopathic practitioners have for PTs, for what should be an inter-disciplinary approach. But, hey, PTs are just "para-professionals" with minmial training so what good are we.....what with the how many billion dollars a year persistent pain costs the US annually?

Interesting points. Your comment about "multi-segmental" weakness and your peeps persistent use of "neuromuscular retraining" and core stabilization programs for everyone that walks through the door only reinforces my opinion that every bit of autonomy was gained because of a lobby group in Washington and nothing more. An inter-disciplinary approach means the P.T. doesn't tell my patient the specific exercise I provide based on the imaging and a standing radiograph is wrong and and a generic exercise program downloaded from some website is correct. It also means they don't discontinue a heel wedge for leg length inequality diagnosed by radiology saying it is from a temporary posture abnormality. It also means if I write mechanical traction I mean it, not modalities they think are better. You see, those actions make me think P.T.s feel they know more than me, that they direct the treatment program of the patient, and that they have some kind of answer. None of which is true.

 

[jesspt]

Interesting points. Your comment about "multi-segmental" weakness and your peeps persistent use of "neuromuscular retraining" and core stabilization programs for everyone that walks through the door only reinforces my opinion that every bit of autonomy was gained because of a lobby group in Washington and nothing more. An inter-disciplinary approach means the P.T. doesn't tell my patient the specific exercise I provide based on the imaging and a standing radiograph is wrong and and a generic exercise program downloaded from some website is correct. It also means they don't discontinue a heel wedge for leg length inequality diagnosed by radiology saying it is from a temporary posture abnormality. It also means if I write mechanical traction I mean it, not modalities they think are better. You see, those actions make me think P.T.s feel they know more than me, that they direct the treatment program of the patient, and that they have some kind of answer. None of which is true.

It's also interesting that you're lumping all PTs in with the lowest common denominator. There are a great many of us who recognize the limitations of the rampant core stabilization craze as well as all of the other rehab fads out there. Dry needling is just one of the more recent ones, and unfortunately our political organizaiton has decided to throw its weight behind including it in our scope. I'd much rather see them take that energy (and $$$) and channel it into addressing Medicare/third party payor issues, etc.

Every health care profession has its average and below average practitioners. Should I assume that you're a needle jockey just because some pain physicians are? Or worse yet, that you run an opoid pill mill? I see enough of those sitatuions to make me think that they're not going away any time soon. But, it seems like many of the posters on this board are trying to help solve those problems which were, in part, created by physicians who were cavalier and careless. Likewise there are PTs who are trying tocorrect some of our past incorrect decisions, to get us away from planting our flag in all of these interventions which have been traditionally associated with CAM, i.e. dry needling, manipulation, etc.

 

[jesspt]

We'll said. Not sure what 'multisegmental neurological weakness' is, but agree with most of what you've said. I good PT is invaluable. A mediocre PT, on the other hand, is quite common and essentially useless.

I'd go so far to say that a mediocre PT is harmful, at least to our profession. They've helped us garner a reputation as unthinking clods, flitting about from one fad to the next. Last year it was Active Release Technique, last month it was dry needling. Next month it will be something else. Ugh.

 

[ampaphb]

FWIW, I'm opposed to the unjudicious use of diagnostic imaging, lack of a proper MSK exam, over-reliance of pharmaceuticals for the treatment of persistent pain, disabling/nocebo language allopathic and osteopathic practioners use during their interactions with their patients, and the frankly wrong diagnostic labels put on patients that I see every day coming from those who "practice medicine". I'm tired of referring patients with multi-segmental neurological weakness back to the PCP or a specialist and seeing patients s/p fusion that never tried any PT for any amount of time whose pain remains. And I'm tired of "heirarchy" and double-standard some allopathic and osteopathic practitioners have for PTs, for what should be an inter-disciplinary approach. But, hey, PTs are just "para-professionals" with minmial training so what good are we.....what with the how many billion dollars a year persistent pain costs the US annually?

I'm opposed to the injudicious use "unjudicious" . I'm opposed to PT's getting legislatures to allow them to have direct access. I'm opposed to PTs and chiros having the unmitigated gaul to insist their patients call them "doctor". And yes, I'm STILL opposed to Chiros and PTs performing interventional procedures (and that's what dry needling is) when they don't have a clue what structures are at risk beneath the skin. PTs have a very sophisticated knowledge of MSK anatomy. Unfortunately, the lung is not an MSK organ.

 

[Fiveoboy11]

Physician's have to be the most arrogant, elitist, and controlling group in the history of mankind. No training or expertese in physical therapy whatsoever, but it's ok. They can "order" it up with all kinds of nonsense and poor POC recs. Little to no evidence exists or cited to support claims that non physician's are dangerous, and strong evidence to the contrary exists with regard to PT's in the US and around the world. There goes any evidence based approach physician's claim to subscribe and adhere to with regard to anti direct access to PT's services (as it challenges there egocentric, arrogant, elitist, controlling and entitlement beliefs). I see no legitimate focus of these groups on patient care and outcomes, more so to protect their perceived turf and monopoly. Was the DO originally intended to practice exactly as a MD? Nope. Are PT's still techs? Nope. Because PT's traditionally have required referrals, this should be the case for eternity? Why? And what evidence is there to support this? And by what stretch of the imagination are physician's safe compared to say, PT's? And how is it that the PT/physician relationship should stagnate? Because PT's started as certificate holders and didn't begin with illegitimate doctorates like many other professions? So sorry we went from certificate-bs-ms-doctorate over 100 yrs versus DPT right off the bat.

Speaking of danger, opponents to non physician's should review the dangers of there own, i.e. Over prescription of opioids, imaging, overutilization of worthless surgery and interventions. Hell consider the danger of physician abuse and arrogance in and of itself and compare that to the lofty nonscientific posts above. It's not magical if a physician does it and because they came first and have laws that reflect as such. Prestigecare is far more dangerous that the profession of PT will ever be.

 

[Fiveoboy11]

After reading more thoroughly through these posts I must say too that I couldn't care less what a physician writes on a "script" or what they say not to do. The PT POC is set by the PT and nobody else. Take note of the physician above "prescribing" aquatics. At least one physician subsequently noted the PT actually knew what to do. Heel lift? For what? Exercises based on imaging alone? Yikes. Surely PMRMD doesn't really think he knows a better PT POC than the actual PT? PT's are experts in the muscular system but nothing else? Wrong, PT's are experts in rehabilitation, function and pain as it pertains to disease. PT's don't "work with the muscles" and "get people stronger." Yet more proof of physician ignorance and incompetence with regard to physical therapy and physical therapists. But keep thinking we're personal trainers.

Sorry guys but we're not your tech, get over it and do your own job.

 

[lobelsteve]

After reading more thoroughly through these posts I must say too that I couldn't care less what a physician writes on a "script" or what they say not to do. The PT POC is set by the PT and nobody else. Take note of the physician above "prescribing" aquatics. At least one physician subsequently noted the PT actually knew what to do. Heel lift? For what? Exercises based on imaging alone? Yikes. Surely PMRMD doesn't really think he knows a better PT POC than the actual PT? PT's are experts in the muscular system but nothing else? Wrong, PT's are experts in rehabilitation, function and pain as it pertains to disease. PT's don't "work with the muscles" and "get people stronger." Yet more proof of physician ignorance and incompetence with regard to physical therapy and physical therapists. But keep thinking we're personal trainers.

Sorry guys but we're not your tech, get over it and do your own job.

Not long are we back from being banned?

Any data to suggest benefit from PT? For axial low back pain.

 

[emd123]

Hell consider the danger of physician abuse and arrogance in and of itself...

As a physician myself, I'll say there's a lot of truth this statement. If I had a dollar for every arrogant physician who I've seen treat a fellow physician, patient, nurse, family member or support staff like sh¡t, I'd be a very rich man.