When I started, I didn’t think I was going to go this long. If you’re still with me, thank you for reading. If you’re a licensed acupuncturist and you’re still reading, buckle up it’s about to get bumpy.
The first 3 parts of this have thrown some other practitioners under the bus – mainly physical therapists. Now it’s time to give my own profession some love.
Why is there even an issue around dry needling? Short answer: because, as a group, acupuncturists are complete idiots. There are many reasons why I think this is the case. Specific to this discussion there are 2 reasons that are germane.
First, the textual evidence for the practice of acupuncture and Chinese medicine dates to about 200 BCE (1). The ideas in these texts are already well developed, and many of these texts reference earlier texts which have been lost (1). It’s likely the practice of acupuncture or something like acupuncture dates back much further. It’s also entirely possible that, at one time, the practice of acupuncture or something like acupuncture was much more wide-spread and was only preserved in east Asia.
We are dealing with a system that is pre-western scientific. In some ways Chinese medicine was at its zenith right around the same time the scientific revolution was getting started in the west - mid-16th century or so. We are also dealing with a system that was preserved in a Sino-Tibetan context and in a Sino-Tibetan language. The last time the Sino-Tibetan language group (where Mandarin sits) had anything at all to do with the Indo-European language group (where English sits) was so far back in time that it’s not worth discussing because no one knows when that might have been.
While scholars argue about the relationship between language and thought, it's clear there is some relationship; some aspects of language are universal and other aspects of language are particular to the specific language and culture in question (3). We also have to keep in mind that the Chinese language and culture are fairly high context relative to the US which is fairly low context (4). The difference between high context and low context boils down to the degree of precision (4). In English, we expect ideas to be explicitly stated and the words we choose to utilize, for the most part, reflect this expectation (4). In China, though, there is a lot more focus on underlying context, content, and tone (4). This can mean the wording isn't nearly as precise as a language like English (4).
Translating becomes a bit of a chore because words don't necessarily map in a 1:1 way between Mandarin and English. Accurate translation is dependent on having some understanding of the unstated context, content, and tone. Many of the translations currently utilized in the practice of Chinese medicine in the west are the result of work done in the 18th, 19th, and early 20th centuries. In many cases translations were made by people who weren’t scholars of Chinese culture or the Chinese language, and most of them had zero medical knowledge of any type. This has led to a lot of misunderstandings - and by “a lot”, I mean A LOT.
In modern times there has been a great deal of scholarship done by sinologists and other experts to correct the record of previous mistranslations or misunderstandings. Acupuncturists as a group largely refuse to adopt the updated terminology. There are many reasons why. Some are unaware of translation/terminology updates, some refuse to change because the academics making the translations don't practice Chinese medicine, and some don't like the implications around updating terminology - they may be afraid of being "wrong" initially or they may not like the way the updated meanings affect the way they're thinking about their practice.
As I alluded in my last post, there have been a great deal of scientific studies of the practice of acupuncture. We have learned a great deal about what acupuncture does, how it compares to more conventional treatments, and there are some tiny glimmers about how a single solid needle is able to induce these effects.
It’s not easy, but it is possible to have a conversation regarding how acupuncture works without referring to ancient Chinese terminology. And yet, go online and look at almost any acupuncturists’ web page. You’re going to see references to ‘Qi’, ‘yin-yang’, ‘moving energy’, ‘5-elements’ (which is itself a mistranslation), ‘intuitive diagnoses’, or my personal favorite ‘TaiQi’ (I’m not sure where this one came from, the proper term is ‘TaiJi’. Every time I see the “q” my eyes bleed a little.) It’s patently absurd and it turns off many patients who might otherwise benefit from acupuncture services.
Either a person thinks ‘Crouching Tiger, Hidden Dragon’ was a documentary and these magical powers are actually possible, or one takes the position that eastern and western medicine are looking at the same problems, and they’ve either used a different language to describe the problem or taken a different perspective on the issue. It’s probably not as simple a dichotomy as this but, in my experience, it’s close. To be fair, there are acupuncturists in practice who come at things from a more scientific angle – they can explain what’s going on in terms of biomedicine, they tend to have a realistic view of where acupuncture sits in a modern medical delivery setting, and they understand the shortcomings of the more standard translations. In my experience, these folks are few and far between.
Second, we have an access problem. Nation-wide, there are fewer than 40,000 licensed acupuncturists (2). More than 50% of them practice in California, Florida, or New York (2). That leaves fewer than 20,000 for the remaining 47 states. I live and practice in a town with a population of around 74,000. Regionally, there’s probably 100k’ish. I’m the only licensed acupuncturist in at least 60 miles, in some directions you’d have to drive for hours to find another. That is insane.
Why is this a problem? Because acupuncture works. There is a tremendous amount of science supporting the practice. People go looking for it, and when they can’t find acupuncture locally, they go for the next best thing they can find locally. There is no reason for licensed acupuncturists, as a group, to expect the average person to understand or appreciate the differences between medical providers. If a PT nearby is offering dry needling, folks are going to assume it’s legal and the PT knows what he or she is doing. If a chiropractor claims to be an "acupuncturist" after 100 hours of training, most folks believe they are, in fact, an acupuncturist.
Imagine you’re a farmer in central Kansas with low back pain. You have internet access, and you search on the best potential treatment for your problem. You’re working in and around heavy equipment and machinery every day and you cannot afford the side effects that come with typical prescription pain meds. During your search, you discover that acupuncture has a pretty good track record with your type of pain. You’re skeptical, but you’ve been hurting a while and at this point you’re willing to try anything so long as you can still run your farm.
You Google local acupuncturists. Nothing. Maybe you come across NCCAOM’s website, they have a find a practitioner page. Perfect, you think. You go there, plug in your zip code, and set it for 5 miles. Nothing. 10 miles? Nothing. 25 miles? Nothing. 50 miles? Still nothing.
One day you’re talking to your neighbor who mentions there’s a new PT clinic in town. They’re offering something called dry needling and it has really helped his wife. So, you go. Maybe they help you, maybe they puncture your kidney, maybe they cause a pneumothorax, maybe it hurts a lot and does nothing at all. Are you ever going to consider or recommend acupuncture? Probably not. Either the dry needling worked, and you now think it’s just as good and locally available, or it didn’t and now any non-pharma/non-surgical therapy is suspect.
Let's extend this little story a bit. I moved to Missouri from Colorado (with a short stop in Kansas). In Colorado, acupuncturists have injection therapy in scope. There’s a list of substances that we can buy, possess, and inject for the treatment of a variety of health problems. In Missouri, injection is not in scope for a licensed acupuncturist (in reality, the practice act in MO is vague – it doesn’t say we can, but it doesn’t say we can’t). In theory, I could use my CO training and offer injection therapy anyway. I have not and do not, but I’ve been sorely tempted with a couple of cases.
Now turn it around.
The state of Missouri has several excellent PT schools. Suppose I attend one of these schools, graduate, pass boards and practice as a PT for a while in MO. The subject of dry needling in Missouri is unclear. Much like injection therapy for licensed acupuncturists, the PT practice act doesn’t explicitly say they can, but it doesn’t exactly say they can’t either. Since practice act rules are often unevenly applied (I would likely get in some level of trouble if I started offering injection therapy while PTs usually get a pass for offering dry needling - even though the legal status of both treatments relative to their respective practice acts is exactly the same), PTs usually do it anyway.
So, I’m a PT, practicing in Missouri, using dry needling, and I decide to move. I end up in California where, at the moment, dry needling is not legal for physical therapists. I’ve been practicing for a while, I think I’m pretty good at dry needling, I also think I’m safe at dry needling. I don’t understand why I can’t offer this service to my patients. I link up with like-minded providers and I start lobbying the state. Eventually, with enough time, numbers, and money we will probably get the law changed.
Now, how, exactly, did this happen? It happened because there weren’t enough acupuncturists in Missouri offering trigger point services/acupuncture and PTs picked up the slack. These PTs then move to other states and use their numbers to lobby for more PT friendly laws. And they usually get those laws passed because of the first point - the language most of us insist on wrapping around acupuncture makes us look like kooks. From a law-makers perspective, you have one group that is widely accepted in the conventional medical community and they’re talking in a language that you kinda-sorta understand and that your medical advisors absolutely understand. And you have a second group who you think might break into a rain-dance at any moment. How are you going to vote?
It happened because acupuncturists are morons. We don't spread ourselves out more evenly from a geographic standpoint, we do a terrible job educating the public, and our national organizations do little to nothing to encourage licensed acupuncturists to move where acupuncturists aren't. There is absolutely no reason why any given individual shouldn’t have a licensed acupuncturist within say a 90-minute drive. I have patients that come from as far away as Iowa and Nebraska. In a town, like mine, of 74k there should be at least as many licensed acupuncturists as there are chiropractors or physical therapists. Right now, there is one – me.
I’ve said many times, in many different places, acupuncturists as a group are never going to be successful until any one of us can pack up and move to west-bumble Iowa, open a practice and be self-sustaining in a year or two. Just about every other medical professional could pull this off. If every small town in America can support a Chinese restaurant, then every small town in America can support a licensed acupuncturist.
1. Willmont, D. (2009). The Five Phases of Acupuncture in the Classical Texts. Willmountain Press, Marshfield, MA.
2. Fan, Y., Stumpf, S., Alemi, S., Matecki, A. (December 2018). Distribution of licensed acupuncturists and educational institutions at the start of 2018. Complementary Therapies in Medicine. 41:295-301
3. Comrie, B. (2023). Language and Thought. Retrieved from https://www.linguisticsociety.org/resource/language-and-thought
4. United Language Group. (2023). Communicating in High Context vs. Low Context Cultures. Retrieved from https://www.unitedlanguagegroup.com/blog/communicating-high-context-vs-low-context-cultures#:~:text=High%2Dcontext%20cultures%20will%20use,Spain%2C%20Brazil%2C%20and%20more.