Physical Therapists. The Department of Health (DOH) licenses physical therapists. The Board of Physical Therapy (Board) works alongside DOH to regulate the profession. A physical therapist must be licensed to practice in Washington State. To receive a physical therapist license, an applicant must be of good moral character and have obtained either:
Licensed physical therapists may perform a variety of care and services, including:
Dry Needling. Dry needling is defined as a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Dry needling does not include the stimulation or treatment of acupuncture points and meridians.
Attorney General Opinion. The Washington attorney general provides official opinions on questions of law at the request of designated public officials. In 2016, the attorney general issued an opinion on whether the practice of dry needling was within a licensed physical therapist's scope of practice. The attorney general concluded that dry needling was not within the practice of physical therapy, based on how the law is currently written and implemented. But the attorney general noted that the Legislature could expand the scope of physical therapy by amending the relevant statutes.
Sunrise Review. The Sunrise Act states that a healthcare profession should be regulated, or the scope of practice expanded only when:
In 2016, DOH conducted a sunrise review of a proposal to add dry needling to the physical therapist scope of practice. The proposal defines dry needling as a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments; not including the stimulation or treatment of acupuncture points and meridians. The expanded scope would offer an endorsement to physical therapists that have completed one year of full-time physical therapy practice and 54 hours of education and training in dry needling. DOH found the submitted proposal did not meet the sunrise criteria for increasing a profession's scope of practice, based on the following rationale and challenges:
However, DOH found that with adequate training including a clinical component, dry needling may fit within the physical therapist's scope of practice in treating neuromusculoskeletal pain and movement impairments. DOH offered suggestions for proposed legislation if the Legislature considers adding dry needling to the physical therapist scope of practice. DOH suggested specialized education and training requirements, written informed consent from patients, and clear authorizations and limitations for the practice of dry needling by physical therapists.
Acupuncture and Eastern Medicine. Acupuncture and Eastern medicine is a health care service using acupuncture or Eastern medicine diagnosis and treatment to promote health and treat organic or functional disorders, which includes a variety of traditional and modern acupuncture and Eastern medicine therapeutic treatments, such as the practice of acupuncture techniques and herbal medicine to maintain and promote wellness, prevent, manage, and reduce pain, and treat substance use disorder. Acupuncture and Eastern medicine includes services and modalities, including intramuscular needling and dry needling of trigger points and other nonspecific points throughout the body in accordance with acupuncture and Eastern medicine training.
Informed Consent. A health care provider must obtain informed consent from a patient or the patient's representative before performing medical treatment. Informed consent is the process by which the treating health care provider discloses information to a patient or the patient's representative so the patient may make a voluntary choice to accept or refuse treatment. Informed consent generally includes a discussion of the following elements:
Intramuscular needling, also known as dry needling, means a skilled intervention that uses a single use, sterile filiform needle to penetrate the skin and stimulate underlying connective and muscular tissues for the evaluation and management of neuromusculoskeletal pain and movement impairments. Intramuscular needling requires an examination and diagnosis. Intramuscular needling does not include stimulation of auricular points, or distal points.
A physical therapist may perform intramuscular needling only after being issued an intramuscular needling endorsement by the Secretary of Health (Secretary). The Secretary, upon approval by the Board, shall issue an endorsement to a physical therapist who:
The instruction and clinical experience must meet or exceed the following criteria:
A qualified provider for the clinical review requirement must be one of the following:
After receiving 100 hours of didactic instruction and 75 hours of in-person intramuscular needling instruction, a physical therapist seeking endorsement has up to 18 months to complete a minimum of 150 treatment sessions for review.
A physical therapist can apply for endorsement before they have completed one year of clinical practice experience if they can meet the requirement of 100 hours of didactic instruction and 75 hours of in-person intramuscular needling instruction through their prelicensure coursework and have completed all other requirements.
A physical therapist may not delegate intramuscular needling and must remain in constant attendance of the patient for the entirety of the procedure.
If a physical therapist is intending to perform intramuscular needling on a patient who the physical therapist knows is being treated by an acupuncturist or acupuncture and Eastern medicine practitioner for the same diagnosis, the physical therapist must make reasonable efforts to coordinate patient care to prevent conflict or duplication of services.
All patients receiving intramuscular needling from a physical therapist must sign an informed consent form that includes:
PRO: There is an epidemic of pain in our state and the use of opioids for pain. Allowing physical therapists to perform intramuscular needling would provide treatment without medications. This bill requires the highest education and training requirements in the nation for intramuscular needling endorsement. Offering an endorsement to physical therapists could substantially improve patient's pain, function and care. Intramuscular needling is not the same as acupuncture and there are no widespread reports of harm to patients. Washington cannot afford to lose physical therapists and physical therapy students because they are unable to practice intramuscular needling in this state.
CON: Amendments are necessary to align this bill with the Sunrise Review recommendations. The current education and training hours are misleading and do not adequately protect patient health and safety. The technique is also ambiguous and potentially infringes on the acupuncture scope of practice. The current bill language is not specific enough, detail is needed on procedure, technique and the difference between acupuncture and needling.