Nurses and Needles

The costs of college and graduate education have soared out of control. I’m a strong advocate for giving people less expensive ways to learn what they need to know in order to work.  Overly broad professional licensure requirements can contribute to unnecessarily high education costs and generally to higher costs for consumers.

We only let certain people hold themselves out as doctors, lawyers, electricians, plumbers hearing instrument specialists, etc.  There are over 40 distinct fields protected by boards of registration established by state law.

Rules like this are absolutely necessary to protect the public, but they also become weapons in the hands of professional associations seeking to protect commercial turf for their members —  always, of course, in the name of protecting the public.  The legislature considers dozens of bills in every session to expand or contract the various practice areas defined by law.

I tend to want to let people work and feel that the public is usually well served by having more competition among professionals.  There are two particular bills pending now which matter to constituents of mine.  In both instances, my first reaction — contrary to my general bias — was to favor turf protection because they involve scary procedures — the administration of anesthesia and the use of dry needles for muscular therapy.

In both cases, after strong presentations by the excluded professionals, I’ve come to lean the way I usually lean — in favor of permitting the expanded practice.

Senate 1079 would expand the scope of what Certified Registered Nurse Anesthetists CRNA’s can do.  (It also gives mores authority to nurse practitioners but I have always been comfortable with that.)

CRNA’s are highly trained professionals with several years of specialized post-graduate education and supervised clinical experience.  The available evidence suggests that CRNA’s have enough education to safely administer anesthesia and we should let them do that.  The Institute of Medicine of the National Academies so concluded in 2011, stating in their report on the Future of Nursing:

No studies suggest that APRNs are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs. In fact, evidence shows that nurses provide quality care to patients, including preventing medication errors, reducing or eliminating infections, and easing the transition patients make from hospital to home.

See the report summary on practice scope here. The Federal Trade Commission reached a similar conclusion:

Empirical research and on-the-ground experience demonstrate that APRNs provide safe and effective care within the scope of their training,
certification, and licensure. Moreover, effective and beneficial collaboration among health care providers can, and typically does, occur even without mandatory physician supervision of APRNs.

CRNA’s who are my constituents perceive the issue as one of streamlining bureaucracy — they don’t like chasing down physicians to get perfunctory approval to do things that they are well trained to do. They respect physicians and know that they don’t have the broad medical educations that physician anesthesiologists have and want to be able to consult them as needed. Anesthiologists have chosen to oppose expansion of care, and assert the necessity of their direct supervision, but effectively acknowledge the lack of reliable evidence showing the superiority of a care model in which they have legal control over practice.

Bottom line: I’m strongly leaning to supporting Senate 1079 if it comes before me for a vote. I believe that allowing CRNA’s to practice at the highest level they are trained for will help control both health care costs and higher education costs.

On a separate topic in the same category, I am leaning towards opposing legislation which would define the scope of acupuncture licensing so as to prohibit the use of dry needling techniques by trained physical therapists. Section 7 of Senate 1107 would add the following statement to the definition of acupuncture:

The use of needles on trigger points, motor points, Ashi points, and/or for intramuscular needling for the treatment of myofascial pain will be considered the practice of acupuncture.

My first supportive reaction to this limitation was based on representations by acupuncturists that physical therapists would start dry needling patients “after a weekend course.” That sounded unsafe to me. More recently, I met with a PT who explained the education that he had been through — a six year combined batchelor’s and doctoral program. After some additional investigation, I do believe that PT’s have adequate training to know how to safely use of needles in therapy.

The practice of acupuncture, by legal definition, is based on “Traditional Oriental Medical Theories”. Acupuncturists use needles to manage a broad range of conditions according to their training. Physical therapists, by contrast, base their practice on western scientific theories. They are not holding themselves out as knowledgeable in alternative medicine. If, based on their adequate Western training, they believe that the use dry needles for specific muscular conditions could be helpful to their patients, they should be able to administer dry needle treatment. They appear to be no more likely to endanger their patients than acupuncturists are. So, I’m back to my basic orientation on this issue as well.

Although important to my constituents, neither of these bills is immediately before me. I’m just articulating my leanings in response to the concerns raised by constituents. I’ll keep listening on both issues and would welcome discussion in this forum.

Published by Will Brownsberger

Will Brownsberger is State Senator from the Second Suffolk and Middlesex District.

10 replies on “Nurses and Needles”

  1. I received by email this comment from an anesthesiologist at a major teaching hospital who consented that it be posted provided his/her name was withheld:

    I was very dismayed to read your assessment of the situation, as posted on your website. While I’m not sure I am aware of anyone who disagrees that nurses (and any specialty, healthcare or not) should “practice to the extent and scope of their training”, the point of disagreement is on whether or not independent, solo practice without a supervising or even affiliated physician meets that definition. I would argue that it certainly does not. Further, one of the passages from the FTC that you reference on your website specifically makes note that part of the safety margin in an expanded scope of practice for nurse anesthetists is that collaboration between nurse anesthetists and physician anesthesiologists will still occur without a mandatory supervisory role, which is exactly what this expansion of scope of practice is attempting to eliminate. There IS reliable data (although, I agree, few studies on this subject have actually been done, without bias or other flaw) that shows the anesthesia-team model (which involves a physician) is superior, from a patient safety perspective, to an independent, solo nurse anesthetist model. Eliminating the need for teamwork in the perioperative environment is, in my opinion, not in the best interest of our patients. The accurate facts are that 1) supervision provides a greater margin of patient safety, 2) solo practice is not within the scope of practice of nurse anesthetists, 3) more extensive training and high-acuity case experience in physician anesthesthesiologists IS meaningful, and 4) there is no cost-savings to the patient or the healthcare system at large in expanding the existing scope of practice to allow for unsupervised surgeries with nurse anesthetists.

    I hope that you change your mind on this issue—I know areas of medical practice and healthcare can be a daunting topic to approach, and information (and MISinformation) abound. In any case, please know how critical your support on issues such as this are to physicians like myself are in the political arena—it would be a tragedy to see professional and political maneuvering overcome patient safety and best interests.

    The writer’s point about the value of team practice is well taken. But I’m willing to trust hospitals to make appropriate use of team resources and don’t feel that the legislature should micromanage approval protocols within surgical teams. If the writer feels that his/her hospital might not give appropriate authority to his profession, that’s something s/he should duke out with hospital management rather than seeking to preserve legislative protections.

    The writer sent an additional comment with a relevant literature citation which suggests that anesthetized patients are no more likely to have complications in the absence of direct physician supervision, but may be less likely to be rescued if they do have complications. The effect size fairly small though — only 10% higher likelihood of failure to rescue with complications. My instinct is further strengthened that the state should leave to those who manage surgical care the question of what sign-offs nurses need to obtain from physicians — it’s time to pass legislation backing the state out of the design of surgical teams.

  2. An update regarding the acupuncture/PT dispute: Senate 1107 has been reported out of committee favorably, but without the language that would limit practice by physical therapists.

    The bill now sits in the Committee on Health Care Financing, a Committee which is often a graveyard for bills that would increase costs for insurers. This bill, which would help to increase reimbursements for acupuncture services, may fall in that category.

    Would welcome any feedback on the new draft, which is numbered as House 3972.

  3. Will,

    It is a ridiculous exercise in semantics to say that dry needling is not acupuncture. If you look at the history of “dry needling”, it was conceived explicitly as a way to re-name existing acupuncture techniques using known Western medical terminology. Using different language does not make it a different treatment, any more than describing surgery with reference to acupuncture channels would make it not surgery.

    Dry needling is in fact a subset of what acupuncturists do all the time, and have been doing for thousands of years. “Trigger points” are called “ah shi” points, but they are the same thing, used exactly the same way, in Traditional Chinese medicine to treat pain and musculoskeletal dysfunction. Dry needling is even done with acupuncture needles. It’s the most straightforward, symptom-based, non-theoretical part of acupuncture. But it’s still acupuncture.

    Let’s be honest: the change in terminology is political, as is the fight against the change in terminology. What is at stake is whether physical therapists are allowed to do acupuncture without being subject to the standards set by the Massachusetts Board of Registration in Medicine for the practice of acupuncture.

    I fully understand why physical therapists want to use acupuncture. It’s extremely effective, and a good fit for the kinds of problems physical therapists commonly treat. Calling it what it is — acupuncture — doesn’t mean physical therapists can’t do it. It means they have to meet existing standards for practitioners, or propose their own licensing criteria that fit the scope of their acupuncture practice and the professional competencies they already have. I would welcome and probably support such a proposal.

    I realize the conversation at times sounds territorial; and it’s important to stay focused on the interests of the patients/public. In my opinion, patients will benefit from more people practicing acupuncture, and from having physical therapists who know how to integrate it with the rest of their care. And it’s of critical importance that, wherever patients are receiving acupuncture, they can trust that it’s both effectively applied, and safe.

    Acupuncturists are regulated by the Board of Registration in Medicine in part because it is a (minimally) invasive medical procedure, and it is entirely possible to injure someone with an acupuncture needle. By far the most common injury is a pneumothorax, or punctured lung. This injury is most likely when needling the upper back, where many of the most common musculoskeletal trigger points are located.

    Injuries are avoided by knowing the correct depth and angle of insertion for each acupuncture point. While physical therapists are extremely knowledgeable about anatomy and physiology, this does not automatically mean they will know how to avoid needling injuries without instruction and practice.

    Licensed acupuncturists receive hundreds of hours of instruction and supervised practice on the correct depth and angle of needle insertion at different sites in the body, as well as proper needle technique and sterile procedure. (This is in addition to even more extensive training in Western scientific and medical concepts and Chinese medicine theory and treatment.) Most “dry needling” courses I’ve seen are 2-3 days over one weekend. In my judgment as a professional acupuncturist and an instructor at the New England School of Acupuncture, this is not sufficient to ensure patient safety.

    My question is this: why can’t we admit that “dry needling” is another name for acupuncture treatment of “ah shi” (trigger) points, and have a sensible discussion of the best way for physical therapists to learn and use this modality if they want to?

  4. Marilyn, this is a very fair and thoughtful statement. Certainly, the level of training in needling is a very fair question to ask. I hope that some on the PT side will comment further on this issue.

  5. Marilyn,

    You raise some fair questions and thoughts concerning the practice of dry needling by physical therapists. I do not believe that it is “ridiculous exercise in semantics to say that dry needling is not acupuncture.” I believe a struggle between the connotation and denotation of the terms may be a more accurate description. In the simplest sense, the word acupuncture comes from the latin terms “acu” meaning needle and “puncture” meaning penetration. “Needle penetration” in that sense could refer to any practice of inserting needles into the skin, include injectables or “wet needling”.

    But as for “dry needling”, I think it is unfair to assert that dry needling performed by a physical therapist (or a nurse, physician, chiropractor, or osteopathic physician) is the practice of acupuncture. You reference a difference in terminology, and indeed dry needling does not involve giving the patient an Eastern medicine diagnoses, but operates within a framework of Western medicine diagnoses. As James Dunning et al. explain in the 2014 literature review on dry needling, a difference in terminology, philosophy, and theoretical constructs exists. Where controversy seems to exist is the similarities in use of small monofilament needles, between the use of a trigger point versus an “Ah shi” point, and between the history and development of dry needling.

    The term “dry needling” should not be used interchangeably with “trigger point dry needling”, as cautioned again by James Dunning et al, 2014. Dry needling incorporates needling not just of trigger points but also of ligaments, tendons, subcutaneous fascia, scar tissue, peripheral nerves, neurovascular bundles, bones, and teno-osseous insertions. In fact the existing body of literature including randomized controlled trials calls for both trigger point and non-trigger point locations to treat a variety of neuromusculoskeletal conditions.

    Furthermore, trigger points and “ah shi” points represent different philosophies but similar locations. Indeed there is a convergence of the location of both and many researchers believe they represent the same phenomenon. A trigger point is firmly rooted in western medical concepts, and again referencing Dunning, who himself references one of the earliest authorities on dry needling Melzack, he states: “Trigger points are firmly anchored in the anatomy of the neural and muscular systems… and the stimulation of particular nerves or tissues by needles could bring about an increased input to the central biasing mechanism, which would close the gates to [pain] inputs from selected body areas.” To contrast this, Dunning et al. explain that an “ah shi” point corresponds to the Chinese translation “auwh, that’s where it hurts” or “thats it”, indicating a tender point on a muscle, which can be used as a target in acupuncture. I do not think it is fair to say that this convergence of trigger points and “ah shi” points makes dry needling the practice of acupuncture.

    I also do not agree that dry needling was “conceived explicitly as a way to re-name existing acupuncture techniques using known Western medical terminology”, referencing the history of dry needling. The pioneers of dry needling who developed our modern concepts were physicians like Dr. Janet Travell and Dr. David Simons. Together they have published some of the most widely recognized texts concerning dry needling. In the 1970s these physicians and others like them found that a variety of substances injected into trigger points produced an analgesic effect, even if the substance injected was saline. It was not long before the effects of a dry needle, or a needle itself without an injectable substance, were discovered to produce this same pain relieving effect. Since the hypodermic needles themselves were painful, later practitioners began using smaller monofilament acupuncture-like needles as they produced less pain. At no point in early works or texts can I find a reference to explicitly attempting to re-name existing acupuncture techniques using modern western medicine terminology. Rather the early works of dry needling appear to have been conceived independent of acupuncture, and more of an extension of trigger point injections.

    You have not been the first to question the training and preparation of physical therapists in practicing dry needling. I agree with Senator Brownsberger that this is a fair question. Keep in mind also that dry needling is not performed exclusively by physical therapists, but also by nurses, physicians, chiropractors, and osteopathic physicians. You mention the most serious adverse effect of dry needling being a pneumothorax. Consider the research report by Brady et al. from 2013 which examined exclusively the adverse effects of dry needling performed by physical therapists. This report found that the risk of serious complications like pneumothorax is less than .04%. This does not represent a health hazard to the public. Dry needling performed by physical therapists is clearly a safe intervention. Consider also that both in the US and internationally physical therapists typically train in the same manner, through post graduate courses and seminars, which range from 40 to 100 or more direct contact hours, and often include competency examinations and assessments. I would express concern myself if anyone could sign up for these courses, but physical therapists are highly trained and highly skilled practitioners. The entry level criteria for the profession is to have a doctoral level degree. I understand your concern that knowledge of anatomy and physiology does not guarantee avoiding needle injuries, but with 30 years of dry needling in the United States we have proven over and over again that we are safe to perform the practice. In this 30 years, a total of six complaints have been issued with a state board on behalf of a patient being injured as a direct result of dry needling.

    I appreciate you voicing your concerns and having a sensible discussion. I think equating the terms dry needling and acupuncture may confuse the public, as their experience with one will not and should not dictate their experience with the other. Dry needling is permitted in 34 states and the District of Columbia. It is a safe intervention with proven benefits for a variety of neuromusculoskeletal conditions such as knee osteoarthritis, carpal tunnel syndrome, and tension type headache to name a few.

    Paul Berkeley PT, DPT


    1. Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T: Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews. 2014.

    2. Brady S, McEvoy J, Dommerholt J, Doody C: Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. J Manual Manipulative Ther, 2013

  6. I’m not sure I would want anything less than a physician anesthesiologist working at my side during an operation. Too many things can go wrong with respect to being out during an operation…. I won’t go into them but we can all imagine.

    That being said, I am all for nurse practitioner taking on an expanded role in filling the gap for PCP’s which is a shrinking field…

    In the vast majority of cases, the complaint is due to something which is not complex and a doctor is really overkill. But this can all be triaged within an established model. One doctor in a building of many NP’s for one.

    We have to face the fact that PCP’s will continue to be in shortage and we must delivery health care more cost effectively while remaining effective.

  7. Appreciate the very thoughtful exchange between Marilyn and Paul.

    To Alan, thank you also for the comment — to my mind, removing the legal barriers to nurse-anesthetist practice will allow hospitals to design care teams and procedures in the safest and most efficient way possible. That will turn out to mean continued involvement of physician anethesiologists.

  8. Dear Will,

    I wrote you earlier this year expressing support for the independent practice of nurse practitioners. I am very pleased to see that you’re in favor of that.

    As it happens, I practice as an NP in anesthesia, alongside CRNAs and anesthesiologists. In all areas of healthcare, clinicians, regardless of title and training, vary in terms of experience, clinical acumen, and interpersonal skills. Some are better than others, and that’s the case in any profession. That said, there is not a single anesthesiologist nor CRNA in my department whom I would not trust with my life or that of a loved one. CRNAs have been administering over half the anesthesia given in the US for a long time, and in many states, they practice independently. In hospitals where there is physician oversight, it is often a CRNA who remains in the OR, monitoring the patient closely during the entire case. My CRNA colleagues are quick to pick up subtle changes in their patients because of the sheer amount of time spend at their sides in the operating room. I support expanding the scope and independent practice of CRNAs as well as NPs. Thanks in advance for your consideration.

    Mei-Ling Smith, NP

  9. I am writing to voice my opposition to o bills H930 and H2006, both of which would prohibit anyone other than licensed acupuncturists and medical doctors from delivering the practice of needling. As a patient I received a service known as dry needling from my physical therapist. I have also received acupuncture from a licensed
    acupuncturist and the techniques were distinctly different. My physical therapist delivered the technique safely and it proved to be the effective and right choice for me. I have a right to choose my own health care providers and these legislative bills would remove me of that right.

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