News

Author: Arthur Yin Fan10/31/2017

【《针灸应对阿片类药物危机白皮书》2.0版在《整合医学杂志》与《经络杂志》同时发表】

Arthur Yin Fan

Full TXT(link is external) PDF(link is external)                                            

The title of White Paper is “Acupuncture’s Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and Management, White Paper 2017”白皮书的题目是“针灸在解决阿片类药物危机中的作用：针灸作为一线非药物疗法治疗和控制疼痛的证据、花费和医疗服务的可行性”。

There were 6 organizations as the co-publishers-参加发表该白皮书的有6个合作单位：The American Society of Acupuncturists, ASA美国针灸师联合会 、The American Alliance for Professional Acupuncture Safety, AAPAS美国执业针灸安全联盟 ,  The Acupuncture Now Foundation, ANF针灸立刻行动基金会,  The American TCM Association, ATCMA全美中医药学会 ,  The American TCM Society, ATCMS)美国中医针灸学会和全美华裔中医药总会 National Federation of TCM Organizations, NFTCMO 。

White paper  was drafted and edited based on a letter, which original authors were(白皮书起草是在一封信的基础上起步的，信的原文作者是): The Joint Acupuncture Opioid Task Force (Chair: Bonnie M. Abel Bolash, MAc, LAc. Member organizations: The Acupuncture Now Foundation (ANF) ,The American Society of Acupuncturists (ASA) ;组员: Matthew Bauer, LAc ;Bonnie Bolash, LAc ; Lindy Camardella, LAc; Mel Hopper Koppelman, MSc ;John McDonald, PhD, FAACMA ;Lindsay Meade, LAc ;David W Miller, MD, LAc .

The first (revising) author 白皮书修改稿第一作者: Arthur Yin Fan, CMD, PhD, LAc (ATCMA) ；Correspondent author通讯作者: David W Miller, MD, LAc 。Other authors参与白皮书的其他作者: Sarah Faggert, DAc, LAc; Hongjian He, CMD, LAc;Mel Hopper Koppelman, MSc; Yong Ming Li, MD, PhD, LAc ; Amy Matecki, MD, LAc*;David W Miller, MD, LAc; John Pang, MD** ;Jun Xu, MD, LAc . *Division Chief, Dept. of Medicine, Highland Hospital, Alameda Health System; **Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego School of Medicine.

Abstract

The United States is facing a national opioid epidemic, and medical systems are in need of non-pharmacologic strategies that can be employed to decrease the public’s opioid dependence. Acupuncture has emerged as a powerful, evidence based, safe, cost-effective, and available treatment modality suitable to meeting this need. Acupuncture has been shown to be effective for the management of numerous types of pain, and mechanisms of action for acupuncture have been described and are understandable from biomedical, physiologic perspectives. Further, acupuncture’s cost-effectiveness could dramatically decrease health care expenditures, both from the standpoint of treating acute pain and through avoiding the development of opioid addiction that requires costly care, destroys quality of life, and can lead to fatal overdose. Numerous federal regulatory agencies have advised or mandated that healthcare systems and providers offer non-pharmacologic treatment options, and acupuncture stands as the most evidence-based, immediately available choice to fulfil these calls. Acupuncture can safely, easily, and cost -effectively be incorporated into hospital settings as diverse as the emergency department, labor and delivery suites, and neonatal intensive care units to treat a variety of pain seen commonly in hospitals.

Acupuncture is already being successfully and meaningfully utilized by the Veterans Administration and various branches of the U.S. Military.

摘要

美国正处于整个国家的阿片类药物流行危机，医疗系统亟需非药物的疗法、用以治疗疼痛并减少公众对阿片类药物的依赖。针灸作为强有效的、循证的、安全的、具有成本效益的治疗方式，满足这一需求。众多针灸临床试验已经证明针灸对许多类型的疼痛治疗有效，针灸的作用机制已被阐明，并且可以从生物医学和生理学角度解释。同时，从治疗急性疼痛的角度来看，针灸的成本效益可能会大大降低医疗保健支出，并避免发生昂贵的阿片类药物成瘾、破坏生命质量、并导致致命的过量。许多联邦监管机构已经建议或强制医疗保健系统和提供者提供非药物治疗选项，而针灸是最具实证性的、并立即可以采用。针灸可以安全、便利、经济有效地纳入医院设置，如急诊部门、产房以及新生儿重症监护室等，用以治疗医院里普遍见到的各种疼痛。

退伍军人管理局和美国军方的各个部门已经成功地有针对性地采用针灸。

1.  Acupuncture is an effective, safe, and cost-effective treatment for numerous types of acute and chronic pain. Acupuncture should be recommended as a first line treatment for pain before opiates are prescribed, and may reduce opioid use.

针灸疗法安全有效、经济，治疗多种急慢性疼痛有效：理应作为疼痛的一线治疗，先于阿片类药物使用，针灸疗法可以显著减少阿片类药物用量（我们在以下各分项中归纳了众多证据）。

1.1 Effectiveness/Efficacy of acupuncture for different types of pain.

针灸疗法治疗多种疼痛有效。

1.2 Safety and feasibility of acupuncture for pain management.

针灸疗法治疗疼痛安全、易行。

1.3 Cost-effectiveness of acupuncture for pain management.

针灸疗法治疗疼痛可以减少支出。

1.4 Can adjunctive acupuncture treatment reduce the use of Opioid-like medications?

结合使用针灸疗法可以减少阿片的用量。

2. Acupuncture’s analgesic mechanisms have been extensively researched and acupuncture can increase the production and release of endogenous opioids in animals and humans.

针灸的镇痛机制已经有大量的研究，针灸增加动物和人类的内源性阿片肽并促其释放。

3. Acupuncture is effective for the treatment of chronic pain involving maladaptive neuroplasticity.

针灸治疗慢性疼痛涉及改善其病态的神经塑形。

4. Acupuncture is a useful adjunctive therapy in opiate dependency and rehabilitation.

针灸是有益的治疗阿片依赖并促其康复的辅助疗法。

5. Acupuncture has been recommended as a first line non-pharmacologic therapy by the

FDA, as well as the National Academies of Sciences, Engineering, and Medicine in coping with the opioid crisis. The Joint Commission has also mandated that hospitals provide non-pharmacologic pain treatment modalities.

针灸已被FDA、以及美国国家科学院、国家工程院和国家医科院三院应对阿片类药物危机联合委员会推荐为一线非药物疗法。医院考核联合委员会也已经把非药物治痛疗法列为医院必须包括的项目。

6. Among most non-pharmacologic al managements for pain relief now available, acupuncture therapy is the most effective and specific for opioid abuse and overuse.

迄今为止，可用的非药物治疗疼痛的疗法，针灸疗法最为有效并对于阿片类药物滥用和过用使用针对性最强。

7. Acupuncture is widely available from qualified practitioners nationally.

美国有足够的合格的针灸从业人员。

Sponsorship Opportunities for 3rd American TCM Congress：

1. Summit Meeting Sponsorship: naming right on the Summit, 30 minutes presentation in the plenary session of Saturday conference, two table exhibit space, company name acknowledgment during the announcements throughout the conference. Sponsorship Fee: $20,000. Sold

2. Tea breaks: two coffee/tea breaks each day, four breaks available for sponsorship, sponsoring company will be acknowledged during the announcements throughout the conference and a sign can be placed at the tea break. Sponsorship Fee: $800/break

3. Lunch sponsorship:

• Saturday Lunch: lunch will be provided in the conference room, the sponsoring company will be acknowledged during the announcements throughout the conferences and will have an opportunity to present during the lunch time for 50 minutes. Sponsorship fee: $4000.(pending)

• Sunday Lunch: lunch will be provided in the conference room, two vendors jointly sponsor the lunch, the sponsoring company will be acknowledged during the announcements throughout the conferences and each vendor will have an opportunity to present during the lunch time for 20 minutes. Sponsorship Fee: $1500 each. Sold

4. Lanyard and name badge: sponsor’s logo printed on lanyard and name badge. Sponsorship Fee: $1000( pending)

5. Conference program in USB drive: sponsor’s logo and company name printed on the USB drive. Sponsorship Fee: $500 sold

Author: Arthur Yin Fan

POSITION LETTER

ON FDA BLUPRINT FOR PRESCRIBER EDUCATION

FOR EXTENDED-RELEASE AND LONG-ACTING OPIOIDS ANALGESICS

July 5, 2017

Ref: Docket No. FDA–2017–D–2497

We welcome the FDA’s position with regard to extended-release and long-acting opioids analgesics.  Patients need medications without severe side effects and addictive effects, as well as acupuncture, which belongs to safe, non-pharmacological therapies.

Acupuncture is an effective, cost-effective therapy without adverse side-effects.

The facts:

1. Acupuncture is a cost effective therapy¹:  
Acupuncture is a proven modality that saves thousands of dollars from pain medications when used in conjunction with a treatment plan focused on acupuncture. If using acupuncture for pain management, the patients and insurers can save money and successfully manage their pain and other symptoms without the adverse risks associated with prescription medications. Here are some examples: For post-stroke treatment, acupuncture saves $26,000 per patient; For Migraine, acupuncture saves $35,480 per patient; For Angina Pectoris, acupuncture saves $32,000 per patient; For severe osteoarthritis, acupuncture saves $9,000 per patient; For Carpal Tunnel Syndrome, acupuncture saves $4,246 per patient.

2. Clinical Efficacy: 
There are many acupuncture studies in both basic science and clinical trials, supported by National Center for Complementary and Integrative health (NCCIH) and National Cancer Institute (NCI), of the National Institutes of Health (NIH).  For the studies regarding acupuncture for pain, there are more than 7,000 articles published and documented in PUBMED or Medline. Almost all of the acupuncture studies in the basic science studies have positive results; they show that acupuncture has positive effects on the decrease of pain in both human and animal studies. Acupuncture can increase endorphins, serotonin, dopamine, and other internal neurotransmitters, and heal the course of pain (such as caused by various inflammatory, and neurogenic issues), and also directly treat the pain. For acupuncture clinical trials, most of them show that acupuncture is both safe and effective if the studies have large-enough patient samples (i.e. P<0.05). However, we should be aware of the methodology flaws, as some trial designs have obvious mistakes. For example, some researchers adopted so-called “sham acupuncture” to mimic the trials for pharmaceutic medication; they did not consider the difference between acupuncture, as an external nervous system stimulation therapy, and internal medications which requires absorbing into the blood steam to have some pharmacological actions. Most “sham acupuncture”, without validating study, is actually just one style of real acupuncture used by acupuncturists around the world. It is not a placebo. So while some people try to disregard the effectiveness of acupuncture by stating that acupuncture is just a placebo, they actually made their judgement based on a wrong term used in acupuncture clinical trials. ²

NIH reports that the data in support of acupuncture is as strong as those for many accepted Western medical therapies. In 1997 the NIH approved acupuncture as an adjunctive treatment for several conditions including pain, nausea, asthma, carpal tunnel syndrome and paralysis from stroke.  Over 500 positive clinical trials measuring the efficacy of acupuncture have been conducted in the past three decades. There are 50 systematic reviews of acupuncture in the Cochrane databases. Overall, the trend has been favorable, advocating the use of acupuncture in a clinical setting as an adjunct treatment with conventional therapies, where suitable (Witt et al. 2006). Positive studies include acupuncture treatment for low back pain, neck pain, osteoarthritis of the knee and hip, fibromyalgia, rheumatoid arthritis, TMJ, headaches, infertility, pain and nausea in cancer patients. ^1,3

Acupuncture is also effective way to treat the opioids addition, there are 32 basic studies and clinical trials included in PUBMED.⁴

3. Acupuncture is not expensive:³

Insurance coverage shows that: Federal employees have had acupuncture coverage for more than ten years (with the coverage beginning around 2006). Many other commercial healthcare insurances also have acupuncture coverage plans. Such insurance plans are aware that acupuncture is effective in pain management, and that there is solid evidence to support acupuncture as an effective therapy. Insurance coverage for acupuncture only costs a typical member’s monthly health insurance premiums of between $0.38 (0.08%) and $0.76 (0.16%) per year, based on a recent Massachusetts study.³

4. Many people are consciously deciding to choose natural therapies, including acupuncture.
People are aware that chemicals (such as those in prescription medications, especially opioids) may cause potential problems and adversely affect people’s health. More and more people are turning to natural medical therapies, like acupuncture, to avoid the adverse risks and side effects associated with pharmacologic therapies. Furthermore, patient satisfaction is incredibly high from acupuncture use.  One of the largest surveys of 89,000 U.S. acupuncture patients treated by over 6,000 acupuncturists in the American Specialty Health network found that 99% reported good, very good, or excellent service quality from licensed acupuncturists in 2014.  An impressive 93% of the respondents said that their provider was successful in treating their primary condition in 2014 and 2015.⁵

5. There has been a recent, big trend of building up integrative medicine centers in conventional medicine facilities and medical schools in the USA and around the world.
In the USA, most of the prestigious medical schools and hospitals have already had integrative medicine centers for years, including Harvard University School of Medicine and its affiliate hospitals Johns Hopkins, Cleveland Clinic, and Beth Israel in New York City. Among integrative medicine, as an important non-pharmacological therapy, acupuncture is an extensively used one. In the USA, the biggest healthcare system is the Veteran Affairs healthcare system (VA); the VA has more than 1,700 facilities as of 2015, in which 93% have established integrative medicine centers or programs which provide veterans acupuncture. In the U.S. military, many hospitals and clinics provide acupuncture service; even more, the experience of applying acupuncture has been introduced to the European military system (NATO). There are tons of news on TVs, newspapers, magazines and academic journals about the effectiveness of acupuncture. 

6. There are close to 50,000 acupuncture providers in the USA (including 34,682 active licensed acupuncturists, more than 6,000 physician acupuncturists and more than 6,000 chiropractors who adopt acupuncture in their practice). Modern acupuncture education or training and the practice provide patients an excellent resource for non-pharmaceutic pain managements and for other diseases or disorders’ treatments as well. There are already licensed and well-educated practitioners ready to serve these important groups within our population.

7.In the USA, there were about 100 million acupuncture treatments, or 25 million patients per year (estimation based on there being about 500 million acupuncture treatments per year around the world in 2015 (a survey shows at least 5 billion acupuncture needles used in that year).

In summary, acupuncture is an effective therapy, with very minor side effects, and is also effective for the treatment of opioids addiction. ATCMA strongly supports the FDA’s position on including acupuncture as a non-pharmacological therapy in the Blueprint for prescriber education for extended-release and longacting opioids analgesics.

References:

1. Acupuncture and Oriental Medicine Society of Massachusetts .Why an “Act Relative to the Practice of Acupuncture” is important: fact sheet. http://www.aomsm.org/resources/Documents/Legislature/Legislation%20relat…(link is external) 02017-2018/Acupuncture%20Insurance%20Fact%20Sheet.pdf. Accessed July 5, 2017.

2.  Fan AY. Dialogue with Dr. Lixing Lao: from a factory electrician to an international scholar of Chinese medicine. J Integr Med. 2013; 11(4): 278-284.

3. CHIA center for health information and analysis. MANDATED BENEFIT REVIEW OF H.B. 3972: AN ACT RELATIVE TO THE PRACTICE OF ACUPUNCTURE. file:///C:/Users/Arthur%20Fan/Downloads/MBR-H3972-Acupuncture%20%20CHIA%20report.pdf  Accessed July 5, 2017.

4. US National Library of Medicine National Institutes of Health,Search database. https://www.ncbi.nlm.nih.gov/pubmed/?term=opioids+addiction+acupuncture(link is external) Accessed July 5, 2017.

5.  American Specialty Health White Paper:  http://files.clickdimensions.com/ashcompaniescoma7oce/files/acupuncturec…(link is external) Accessed July 5, 2017

POSITION LETTER ON DRY NEEDLING

In terminology, dry needling is a synonym to acupuncture, just a different English translation from the original Chinese term针刺 (Zhen Ci). In China, dry needling is a common name of acupuncture for over 200 years.^(1,2)  In West, dry needling has become popular since 1980s, especially since late 1990s, for replacing the term acupuncture by some traditional and medical acupuncturists, medical doctors, as a step “toward acceptance of acupuncture by the medical profession”. ^{(3,4, 5)}

Dry needling is the use of dry needles alone, either solid filiform acupuncture needles or hollow-core hypodermic needles, to insert into the body for the treatment of muscle pain and related “myofascial” pain syndrome; a.k.a. intramuscular stimulation, trigger points (TrP) acupuncture, TrP dry needling, myofascial TrP dry needling, or biomedical acupuncture. In West, dry needling is a form of over-simplified acupuncture using biomedical language in treating “myofascial” pain, a contemporary development of a portion of Ashi point acupuncture from traditional acupuncture, an invasive practice, and is not in the practice scope of physical therapists (PTs). It seeks to redefine acupuncture by reframing its theoretical principles in a Western manner. Current dry needling protocol using filiform acupuncture needles is exact same as the acupuncture used by medical doctors in West since 1821, and same as part of Ashi point acupuncture in traditional acupuncture used in East over 2,000 years. ^(4,5) It is a medical therapy and a form of acupuncture practice, not just a technique on inserting a dry needle.

For the business of the commercial seminars, many dry needling educators have covered up their acupuncture background, and have intentionally denied the fact that dry needling is acupuncture. However, in in other situations, they did tell the truth. The Mother of dry needling, Dr. Janet Travell admitted to the general public that dry needling is acupuncture when she stated in a newspaper that “the medical way of saying it is ‘acupuncture’. In our language that means sticking a needle into somebody”, ^(5,6) and acupuncture professionals practice dry needling as acupuncture therapy and there are several criteria in the acupuncture profession to locate TrPs as acupoints.⁽⁷⁾

Dry needling issue causes many problems. Firstly, dry needling promotors have caused great confusion to academic scholars, healthcare professionals, administrators, policymakers, and the general public. As acupuncture professionals and researchers, they clearly know dry needling is acupuncture-just in different name. However, some of them made stories to fool people dry needling is different from acupuncture, and “discovered” or “developed” by themselves, or at least a “rediscovery” by western medical doctors. For example, Dr. Travell, a clinical researcher involved with acupuncture work and used to participate in the planning of acupuncture conferences ^(6,8) described a complicated dry needling “discovery processes” in her books–from injecting therapy with local anesthesia medication to  inserting injecting needle without medication–performing injecting needle dry needling, to using acupuncture needling; and used TrPs to rebrand acupoints. In fact, before had done all of these, in a newspaper she admitted to the general public that dry needling is acupuncture. This actually causes a problem in their academic integrity, although these dry needling promoters and educators are known scholars.

Secondly, in order to promote their “own” academic theory, commercial education business, and other objectives, dry needling educators have developed commercial courses for continuing education taught “dry needling techniques” to a large number of students, including PTs and other customers without acupuncture credentials in non-regulated seminars. While PTs programs do not include in any content in needling therapy,^(9,10) the national organizations of PT profession, such as APTA⁽¹¹⁾ and FSBPT⁽¹²⁾ started to support dry needling around 2010, currently there are more PTs involving the DN teaching and practice than other professionals.^(13,14) Not recognized dry needling as a part of acupuncture, PT professionals, nevertheless, made a great effort to promote dry needling practice in the past ten years in the U.S. While elevating their education level to a doctoral degree, PTs as a profession probably want to expand their scope of practice and take over dry needling, even “the physiological basis for dry needling treatment of excessive muscle tension, scar tissue, fascia, and connective tissues is not well-described in the literature.”⁽¹¹⁾ As noted, dry needling educators in both continuing education and in schools are often licensed acupuncturists.

Thirdly, dry needling has mainly been taught in continuing education level courses of 20-30 hours (proposed to increase to 54 hours in future in some program).^{(11, 13-16)}  This lack of adequate professional training increases the risk of patient’s injury and can be a threat to public health and safety. Reports of serious injuries associated with dry needling or acupuncture by PTs are not uncommon. ^(17-20) Under current healthcare regulations and system, a patient has no way to know if his or her dry needling practitioner has sufficient training and what is the risk of being injured when treated by “dry needlers” who received minimal training. More often, patients are not likely to know the practitioners’ experience level when dry needling technique is applied; nor will the patient know if the PT chooses to use needles for purposes beyond typical dry needling practice. Dr. David Simmons, a pioneer of TrPs, stated: “Your problem is largely one of semantics so the simple answer is to change the playing field and the semantics that go with it. If you… use the different terminology you leave other side without an argument”.⁽²¹⁾

How can anyone practices acupuncture under the name of dry needling and say it is not acupuncture therapy? The public has a right to expect certain hard-earned standards of accredited education and licensing for those professionals who are using acupuncture needles on them therapeutically. In most of the states of the U.S., for becoming a certified MDs acupuncturist, physician or medical acupuncturists (after they get their MD license after their western medical education and at least three years of residency) are required to get a minimum of an additional 300 educational hours in a board -approved acupuncture training institution (American Board of Medical Acupuncture, ABMA) and have 500 cases of clinical acupuncture treatments; For licensed in  acupuncture, the candidates are required to attain an average of 3,000 educational or training hours via an accredited school or program (such as The Accreditation Commission for Acupuncture and Oriental Medicine, ACAOM). ^(15,22,23) So far, there is no comparable requirements and regulations for PTs to study needling therapy and perform dry needling in the U.S. ⁽²⁴⁾ As noted that, even Dr. Travell opposes PTs to perform dry needling. ⁽⁸⁾

In addition to public risk, PT dry needlers’ denial of acupuncture recognition has created a big tension between the acupuncture profession and PTs, as well as among other professionals who are seeking to provide acupuncture by calling acupuncture in a different name. If law-makers and regulators are to decide to allow PTs and others to provide acupuncture to citizens based on only 20-30 hours of training, they can certainly do that. The historic record shows however that these lawmakers should know that they are granting them the right to practice acupuncture. ⁽²⁴⁾

ATCMA position:

In short, the evidence shows clearly that currently, at least in the U.S., dry needling practitioners intent to bypass the legal regulations to practice acupuncture in the name of dry needling.^(24,25)  We agree with the position on DN from American Medical Association (AMA):

“Dry needling is indistinguishable from acupuncture”, 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.  It emphasizes that “for patients’ safety, practitioners should meet standards required for licensed acupuncturists and physicians“. ⁽²³⁾

Acknowledgements

This position letter reflects the official view of ATCMA, it was published as the 3^rd part of AAPAS White Paper 2016 (Fan AY, Xu J, Li YM. Evidence and Expert Opinions:  Drying Needling versus Acupuncture (III). Chin J Integr Med. 2017 Mar;23(3):163-165.).

REFERENCES

1. Zhu H, Most H. Dry needling is one type of acupuncture. Med Acupunct 2016;28(4):1-10. 

2. Fan AY, He H. Dry needling is acupuncture. Acupunct Med 2016;34:241.

3. Gunn CC, Ditchburn FG, King MH, Renwick GJ. Acupuncture loci: a proposal for their classification according to their relationship to known neural structures. Am J Chin Med 1976;4:183-195.

4.  Fan AY, Xu J, Li YM. Evidence and Expert Opinions:  Drying Needling versus Acupuncture (I). Chin J Integr Med. 2017; 23(1):3-9.

5. Fan AY, Xu J, Li YM. Evidence and expert opinions:  dry needling versus acupuncture (II). Chin J Integr Med 2017; 23:83-90.

6. Nichols HW. Ancient pain-killing method works, while US scientists don’t know why. Albany Democrat-Herald (Albany), March 21, 1947. www.newspapers.com(link is external).  Accessed October 3, 2016.

7. Simons DG, Travell JG, Simons LS, eds. Myofascial pain and dysfunction: the trigger point manual. 2nd ed. Baltimore: Williams &Wilkins; 1999:151-174.

8. DeLorme L. Letter to Washington State Department of Health Sunrise Reviews, Re: Sunrise Review Panel Draft Recommendations. October 10, 2016. In: Washington State Department of Health. Information Summary and Recommendations Physical Therapy Dry Needling Sunrise Review. Page 688-694. Available at: http://www.doh.wa.gov/Portals/1/Documents/2000/DryNeedlingFinal2016.pdf(link is external) Accessed Jan. 17, 2017.

9. University of Maryland Eastern Shore. Physical therapy, credit hours and approximate tuition. Available at: https://www.umes.edu/Physical-Therapy/Pages/Admissions/Estimated-Costs/(link is external) Accessed December 26, 2016.

10. University of Maryland School of Medicine. Doctor of Physical Therapy (DPT) tuition, fees and living expenses budget. file:///C:/Users/Arthur%20Fan/Downloads/2015-2016_DPT_Tuition_and_Educational_Expenses.pdf Accessed December 26, 2016.

11. American Physical Therapy Association. Description of Dry Needling In Clinical Practice: An Educational Resource Paper (2013).  http://www.apta.org/StateIssues/DryNeedling/. (link is external) Accessed July 28, 2016.

12. Federation of State Boards of Physical Therapy. FSBPT Dry Needling Resource Paper (Intramuscular Manual Therapy) 4th edition. http://www.fsbpt.org/download/dryneedlingresourcepaper_4thedition.pdf  (link is external) Accessed Dec. 10, 2016.

13. Kinetacare. Intramuscular Manual Therapy (AKA Trigger Point Needling). http://www.kinetacare.com/physical-therapy/Intramuscular-Manual-Therapy-AKA-Trigger-Point-Needling/page27.html(link is external)  Accessed Dec 10. 2016.

14.  Sportscare Physical Therapy. What is intramuscular manual therapy? http://www.sportscarephysicaltherapy.com/intramuscular-manual-therapy/(link is external)  Accessed Dec. 10, 2016

15. Fan AY, Jiang J, Faggert S, Xu J. Discussion about the training or education for “dry needling practice”. World J Acupunct Moxibust 2016;26:6-10.

16. Ma YT. Dr. Ma’s integrative dry needling. Available at: http://integrativedryneedling.com/(link is external) Accessed December 12, 2016.

17. Cummings M, Ross-Marrs R, Gerwin R. Pneumothorax complication of deep dry needling demonstration. Acupunct Med 2014;32:517-519. doi: 10.1136/acupmed-2014-010659. Epub Sep 19,2014.

18. Almloff L. Opposed two reported cases of pneumothorax by PT in Virginia have been dismissed by Board. Available at: http://www.townhall.virginia.gov/L/viewcomments.cfm?commentid=48669(link is external). Accessed December 12, 2016.

19. Knauer J. Pneumothorax from a physical therapist performing dry needling in virginia.

Available at: http://www.townhall.virginia.gov/L/viewcomments.cfm?commentid=48189(link is external). Accessed December 12, 2016.

20. Terrell W. Pneumothorax Caused by Dry Needling of Intercostal. Available at https://www.youtube.com/watch?v=EWb69O__NiE(link is external). Accessed December 12, 2016.

21. Simmons DG. Letter to the editor. J Man Manip Ther 2007t;15:246.

22. The American Academy of Physical Medicine and Rehabilitation. AAPM&R Position on Dry Needling. https://www.aapmr.org/docs/default-source/protected-advocacy/Position-Statements/aapmr-position-on-dry-needling.pdf?sfvrsn=2(link is external). Accessed Dec. 19, 2016.

23.American Medical Association. Physicians take on timely public health issues. AMA Wire. Jun 15,2016. http://www.ama-assn.org/ama/ama-wire/post/physicians-timely-public-healt…(link is external). Accessed Dec. 19, 2016.

24. Fan AY, Zheng L, Yang G. Evidence that dry needling is the intent to bypass regulation to practice acupuncture in the United States. J Altern Complement Med 2016;22:591-593.

25. Fan AY, Yang G, Zheng L. Response to Dommerholt and Stanborough re: ‘‘Evidence That Dry Needling Is the Intent to Bypass Regulation to Practice Acupuncture in the United States’’.  J Altern Complem Med.2017;23(2):150-151.

CBS News (2/13, LaPook) reports on its website that the American College of Physicians released new guidelines that says “the first line of therapy” for chronic low back pain “should be non-drug treatments.” The new guidelines recommend “heat wraps, massage, acupuncture and spinal manipulation” for pain lasting less than three months, and recommend treatments such as “stretching and strengthening exercises, tai chi, yoga, acupuncture, and mindfulness techniques” for pain lasting more than three months.

       Newsday (NY) (2/13, Ricks) reports, “The new guidelines emphasize that opioid” pain medications “should be considered only as a last resort.”
   
     The New York Times (2/13, A21, Kolata, Subscription Publication) reports that in its recommendations, the ACP “did not address surgery.” Instead, “its focus was on noninvasive treatment.” In addition, imaging “scans… for diagnosis are worse than useless for back pain patients, members of the group said in telephone interviews.” Scan “results can be misleading, showing what look like abnormalities that actually are not related to the pain.” The new guidelines (2/14) were published in the Annals of Internal Medicine.