A bitter turf war has broken out between acupuncturists and physical therapists over something called “dry needling.”

It’s a much-debated technique used by an increasing number of physical therapists to relieve pain or improve range of motion.

Dry needling is allowed in more than 30 U.S. states, but is still prohibited in others.

The technique employs a so-called “dry” needle, which physical therapists describe as one without medication, inserted through the skin into areas of the muscle known as trigger points.

Multiple acupuncturists interviewed by Healthline insist dry needling is simply acupuncture with a different name, and is not within physical therapists’ scope of practice.

“Physical therapists who use dry needling are sidestepping laws and bypassing rules and regulations created for consumer protection,” said Neal Miller, an acupuncturist from Los Angeles with almost 30 years of experience, who’s served on the board of the California Society of Oriental Medicine (CSOM) and the Acupuncture Integrated Medical Society (AIMS).

“Dry needling is acupuncture and physical therapists are practicing it without a license and putting patients at risk,” Miller said. “Dry needling uses trigger points, 90 percent of which are acupuncture points. In many states where dry needling is now allowed, little or no extra training is required for physical therapists to perform it on patients.”

But multiple physical therapists told Healthline dry needling is safe and effective.

They said it is part of modern Western medicine and has nothing to do with acupuncture’s traditional Chinese medical tradition that, among other things, alters the body’s energy into healthier patterns.

Jan Dommerholt, a physical therapist, educator, and one of the nation’s most vocal proponents of dry needling, said the procedure is not acupuncture and is just one of many tools in a physical therapist’s toolbox.

“Of course there are similarities between dry needling and acupuncture, but there are equally as many differences,” said Dommerholt, who teaches dry needling and has spoken before numerous state boards of health on the subject. “I know nothing about energy flow. That’s not what I do as a physical therapist. I come from a motion-of-movement and pain perspective.”

The battleground states

The dry needling debate has led to pernicious accusations from both camps as well as lawsuits and heated state legislative fights from coast to coast.

In several states, including California, Florida, Idaho, New York, and South Dakota, dry needling is prohibited by state health boards.

In several other states, there has not yet been a definitive declaration about the legality of dry needling, in part because it is so new. It only became widely popular in the past seven or eight years.

Acupuncturists bemoan the fact that physical therapists spend virtually no time during their doctorate training learning how to use a needle.

Physical therapists adamantly insist they nonetheless have the proper training to perform dry needling.

Health boards in many states agree and have allowed them to perform the technique on their patients with no extra training.

In July, Nebraska Attorney General Douglas Peterson ruled that dry needling is within the scope of practice for physical therapists.

Acknowledging that there are “differing views as to the definition of dry needling,” Peterson wrote that “if dry needling is defined using the descriptions provided to this office by the Board of Physical Therapy and the American Physical Therapy Association, it is our opinion that a reasonable legal argument can be made that dry needling is a ‘mechanical modality’ or a ‘physical agent or modality’ and, therefore, falls within the statutory definition of physical therapy.”

Miller disagrees with Peterson’s conclusion.

“In Nebraska, like so many states, we see that the political power and politics of medicine have influenced legislators,” he said. “There are a dozen licensed acupuncturists in Nebraska compared to the thousands of physical therapists. These political decisions by elected officials are to the detriment of consumers having properly educated, well-trained practitioners.”

In some states, health boards require that physical therapists get additional training, which often amounts to simply a continuing education course that can be completed in as little as a few days.

Read more: What is soft tissue mobilization therapy ? »

Some states just say “No”

Other states have looked at dry needling more skeptically.

In Hawaii, physical therapists are still forbidden to perform dry needling.

In Washington, attempts by physical therapists to get state authorities or the court to green-light dry needling have hit a roadblock.

The Washington East Asian Medicine Association (WEAMA) successfully lobbied against a bill (SB 6374) reportedly put forward by physical therapists to allow physical therapists to practice dry needling with 55 hours of training.

“We're deep in this battle here in Washington. A resolution is coming shortly,” Ashley Goddard, an acupuncturist in Washington and acting president of WEAMA, told Healthline. “This is an important stand for us. Imitation may be the sincerest form of flattery, but dry needling is acupuncture, albeit with a fraction of the training.”

In October 2014, in the case of South Sound Acupuncture Association v. Kinetacore, the Washington Court of Appeals upheld a Superior Court decision in favor of Washington acupuncturists.

The court found that physical therapists lack the legal authority to insert acupuncture needles while calling the practice dry needling.

In April of this year, Washington Attorney General Bob Ferguson wrote that dry needling “does not fall within the scope of practice of a licensed physical therapist.”

Physical therapists subsequently filed a formal “scope expansion application.”

The state’s Department of Health is expected to release a preliminary draft recommendation for how physical therapists should proceed, if at all. State health officials will then make their final recommendations to Governor Jay Inslee.

A David vs. Goliath story?

Clearly, both sides of this national debate are entrenched and determined.

To date, the lobbying edge seems to go to the physical therapists, who some have described as the Goliath to the acupuncturists’ David.

There are approximately 200,000 physical therapists in the United States and roughly 30,000 acupuncturists. The physical therapists have a demonstrably more centralized and organized national identity.

Over the years, acupuncturists in the United States have kept a relatively low profile for various reasons, including the fact that until the past few decades, some proponents of modern Western medicine were skeptical of acupuncture.

But acupuncture is now widely accepted as legitimate, with hundreds of clinical studies showing its effectiveness for a broad range of conditions. This has been a positive catalyst for acupuncturists to become more visible.

And the dry needling issue has further galvanized the industry. Acupuncturists almost unanimously agree that it is an example of one industry sticking its nose, and its needles, where they don’t belong and poaching a competing profession.

Read more: 5 exercises for rotator cuff pain »

Medical establishment weighs in

Acupuncturists may not have the lobbying clout of their physical therapist counterparts, but they do have perhaps the most credible and powerful ally in this debate.

In June, at its annual policy meeting, the American Medical Association (AMA) came out against dry needling by physical therapists, saying the therapists at present are simply not properly trained.

The AMA adopted a policy that said physical therapists and other non-physicians practicing dry needling should — at a minimum — have standards that are similar to the ones for training, certification, and continuing education that exist for acupuncture.

"Lax regulation and nonexistent standards surround this invasive practice. For patients' safety, practitioners should meet standards required for licensed acupuncturists and physicians," Dr. Russell W. H. Kridel, an AMA board member, said in the statement.

That the AMA, which encourages the use of dry needling by medical doctors and licensed acupuncturists only, would weigh in so heavily in favor of acupuncturists might seem ironic given the historical acrimony between medical doctors and acupuncturists.

But that animosity is evidently fading fast, on both sides, said Miller, who often works in tandem with medical doctors for the benefit of patient outcomes and quality of life.

Miller and others noted that the medical paradigm has shifted recently in the evolution of medicine.

“The focus is now moving toward integrating modern, traditional, and complementary medicine,” Miller said. “What was once called alternative medicine is now called integrative medicine or functional medicine. This team approach has been the norm in Asia for many years and is becoming the new standard in the U.S.”

Is dry needling safe?

Physical therapists and their lobbyists insist that dry needling done by physical therapists is safe.

Justin Elliott, head of government affairs at the American Physical Therapy Association, the largest and most politically active group representing physical therapists, insists that physical therapists’ knowledge of anatomy from their training is more than sufficient to assure patient safety.

“We agree that providers need to be safe and competent,” Elliott told Healthline. “Our position is that physical therapists have the education and training to perform dry needling safely. This debate should be about the patient and patient choice and access to a provider who can get them better, faster. We need to stop thinking of this as a turf war and start thinking of it from the patient perspective.”

There have been injuries from dry needling, including punctured lungs, but even most acupuncturists admit those incidents are rare.

Acupuncture in the United States has had a positive record of safety when done by licensed certified acupuncture Asian medicine practitioners and medical doctors that are properly trained.

But, said Miller, “In recent years with physical therapists doing acupuncture and calling it dry needling, we have seen a big increase in the number of unfortunate, medically negligent injuries, including pneumothorax cases. This is terrible for patients and the many years of solid safety and consumer confidence in acupuncture.”

Becky Jacobs, an acupuncturist who lives in Hawaii, said that more than 20 years ago, doctors used hypodermic needles on her to do some kind of trigger point therapy for myofascial release.

“It was painful, caused horrendous bruising, and exacerbated the pain for a couple of weeks,” said Jacobs.

She added that if a medical doctor wasn’t even trained sufficiently to perform dry needling, a physical therapist is certainly not qualified.

Acupuncturists insist that patient safety is their biggest issue with dry needling. But Dommerholt told Healthline that in a study of 8,000 physical therapists who learned dry needling, the percentage of adverse events (or injuries) among the patients was just .04 percent.

“The risk of significant events using dry needling the way I teach it is very low,” he said.

But he acknowledged that there are currently few safety studies of dry needling and that “hopefully there will be more.”

Dommerholt said the fact that physical therapists receive little if any training with needles is just not that important.

“The act of dry needling is simple as long as you know the human anatomy,” he said. “It is not a public health hazard.”

In the dry needling classes he teaches, Dommerholt said the students practice on inanimate objects first, “and by the second day of the course pretty much everyone knows how to do it. Using a needle does not require a lot of skill. There is nothing to it. Acupuncturists say it takes years of practice to learn acupuncture, but dry needling is different. It is extremely simple. You need knowledge and understanding, not a lot of skill.”

Read more: Does Olympic cupping therapy work? »

A unique perspective

Mona Lee-Yuan has a slightly different take on the dry needling controversy as a physical therapist and licensed acupuncturist.

“As someone who understands the training of both the physical therapist profession and the acupuncture profession, it is my personal opinion that if physical therapists want to perform dry needling over trigger points, which coincides with acupuncture points 90 percent of the time, they need further training, the equivalent of at least what is required for an M.D.,” she said. “And they need to obtain the same credentials as we did.”

Lee-Yuan, who teaches at New York College of Traditional Chinese Medicine, has several physical therapists in her acupuncture classes.

“When physical therapists contend that what they learned about the anatomy while in school is enough to be able to do dry needling, that is not a sound argument,” she said. “Once out of school, they forget 70 to 80 percent of the anatomy they did learn in school. How do I know this? Because many of the physical therapists who are in the acupuncture classes I teach get the point locations wrong. So much for being an expert in anatomy.”

Safety, money, or both?

There are millions of dollars at stake in this debate between two professions that are often vying for the same patients.

In April, a Superior Court judge in North Carolina dismissed a lawsuit filed by an acupuncture group against a physical therapy group.

The North Carolina Acupuncture Licensing Board (NCALB) sued the North Carolina Board of Physical Therapy Examiners and several individual physical therapists with the hope the court would declare that dry needling by physical therapists in the state is the unlawful practice of acupuncture.

A separate antitrust lawsuit filed in U.S. District Court contended that the NCALB violated antitrust law and due process rights in its attempts to prevent physical therapists from performing dry needling.

Meanwhile, in Washington state, where state health officials and legislators will soon decide the fate of dry needling, acupuncturist Goddard eagerly awaits that decision.

“While acupuncture has been practiced for thousands of years, it is a relatively young profession in this country,” she said. “We're small in number and we have lacked a single, strong, unifying national organization. But that’s changing. We've fought hard for our place in the modern medical model.”