Dry needling

Dry needling, also known as myofascial trigger point dry needling,[1][2][3][4]) is the use of either solid filiform needles (also referred to as acupuncture needles) or hollow-core hypodermic needles for therapy of muscle pain, including pain related to myofascial pain syndrome. Dry needling is sometimes also known as intramuscular stimulation (IMS). Acupuncture is a broad category of needling practices with solid filiform needles. Modern acupuncture notably includes both traditional and Western medical acupuncture; dry needling is arguably one subcategory of western medical acupuncture.[1]

Chinese style tendinomuscular acupuncture relies on careful palpation of what are called "Ah Shi" points, which often correspond to both trigger points and/or motor points in the myofascial tissue. Chinese style tendinomuscular acupuncture tends to use lower gauge (thicker) needles necessary for puncturing contraction knots with a high degree of precision. On the other hand, lighter styles of acupuncture, such as Japanese style, and many American styles, may tend towards very shallow insertions of higher gauge (thinner) needles. Most acupuncture styles, especially those with lighter techniques, require a detailed knowledge, not only of anatomy but also of the channel networks and connections. Thus, while some forms of acupuncture are not at all the same as dry needling, the term dry needling can refer quite specifically to what is now called Myofascial Acupuncture, Tendinomuscular Acupuncture, or some version of Sports Acupuncture.

Origin

The origin of the term “dry needling” is attributed to Janet G. Travell, M.D. In her book, 'Myofascial Pain and Dysfunction: Trigger Point Manual', Dr. Travell uses the term "dry needling" to differentiate between two hypodermic needle techniques when performing trigger point therapy. However, Dr. Travell did not elaborate on the details on the techniques of dry needling; the current techniques of dry needling were based on the traditional and western medical acupuncture. The two techniques Dr. Travell described are the injection of a local anesthetic and the mechanical use of a hypodermic needle without injecting a solution (Travell, Simons, & Simons, 1999, pp. 154–155). Dr. Travell preferred a 22-gauge, 1.5-in hypodermic needle for trigger point therapy and used this needle for both injection therapy and dry needling. Dr. Travell never used an acupuncture needle. Dr. Travell had access to acupuncture needles but reasoned that they were far too thin for trigger point therapy. She preferred hypodermic needles because of their strength and tactile feedback: “A 22-gauge, 3.8-cm (1.5-in) needle is usually suitable for most superficial muscles. In hyperalgesic patients, a 25-gauge, 3.8-cm (1.5-in) needle may cause less discomfort, but will not provide the clear “feel” of the structures being penetrated by the needle and is more likely to be deflected by the dense contraction knots that are the target… A 27-gauge needle, 3.8-cm (1.5-in) needle is even more flexible; the tip is more likely to be deflected by the contraction knots and it provides less tactile feedback for precision injection” (Travell, Simons, & Simons, 1999, p. 156).

The use of a hypodermic needle for dry needling was described by Dr. Chang-Zern Hong in his research paper on "Lidocaine Injection Versus Dry Needling to Myofascial Trigger Point”. In his research, he describes the procedure for trigger point injection and dry needling by using a 27-gauge hypodermic needle 1 ¼-in long (Hong, 1994). Both Travell and Hong used hypodermic needles for dry needling. Dr. Hong, like Dr. Travell, did not use an acupuncture needle for dry needling.

Although dry needling originally utilized only hypodermic needles due to the concern that solid needles had neither the strength or tactile feedback that hypodermic needles provided and that the needle could be deflected by "dense contraction knots", those concerns have proven unfounded and many healthcare practitioners who perform dry needling have found that the acupuncture needles not only provides better tactile feedback but also penetrate the "dense muscle knots" better and are easier to manage and caused less discomfort to patients. For that reason, both the use of hypodermic needles and the use of acupuncture needles are now accepted in dry needling practice. Ofttimes practitioners who use hypodermic needles also provide trigger point injection treatment to patients and therefore find the use of hypodermic needles a better choice. As their use became more common, some dry needling practitioners without acupuncture in their scope of practice, started to refer to these needles by their technical design term as "solid filiform needles" as opposed to the FDA designation "acupuncture needle."

The "solid filiform needle" used in dry needling is regulated by the FDA as a Class II medical device described in the code titled "Sec. 880.5580 Acupuncture needle" as "a device intended to pierce the skin in the practice of acupuncture." [5] Per the Food and Drug Act of 1906 and the subsequent Amendments to said act, the FDA definition applies to how the needles can be marketed and does not mean that acupuncture is the only medical procedure where these needles can be used.[6][7][8][9][10] Dry needling using such a needle contrasts with the use of a hollow hypodermic needle to inject substances such as saline solution, botox or corticosteroids to the same point. Such use of a solid needle has been found to be as effective as injection of substances in such cases as relief of pain in muscles and connective tissue. Analgesia produced by needling a pain spot has been called the needle effect.[11]

The Founder of Integrative Systemic Dry Needling (ISDN), Dr. Yun-Tao Ma Ph.D., L.Ac., has been spearheading the "dry needling" movement in the United States. Dr. Ma states, "Although ISDN originated in traditional Chinese methods, it has developed from the ancient empirical approach to become modern medical art rooted in evidence-based thinking and practice." [12] Dr. Ma then contradicts himself stating, "Dry needling technique is a modern Western medical modality that is not related to Traditional Chinese acupuncture in any way. Dry needling has its own theoretical concepts, terminology, needling technique and clinical application." [13] Dr. Ma realizing both the self-contradictions and the legal ramifications of dry needling being rooted in acupuncture and Chinese medicine has since taken down all information in his bios regarding his education in Chinese Medicine and being a Licensed Acupuncturist in the United States.[14]

The founder of Dry Needling Academy, Dr. Piyush Jain[15] (PhD Scholar) states Dry Needling as methods which can help in providing the healthcare professionals a great tool to serve their patients with great result in conjunction with other therapeutic modalities. No treatment protocol can work without a proper assessment of the patients, the need for clinical reasoning with proper assessment tools are the basic necessity of the therapist. As Per American Academy of Orthopedic Manual Physical Therapists (AAOMPT)

Dry needling is a neurophysiological evidence-based treatment technique that requires effective manual assessment of the neuromuscular system. Physical therapists are well trained to utilize dry needling in conjunction with manual physical therapy interventions. Research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor end plates, and facilitates an accelerated return to active rehabilitation.

The statement above is self-explanatory on the functional, physiological and medical aspect of treatment. His book Manual of Dry Needling Techniques Color Edition (2) (Volume 1) is a basic reference text for the therapists who are trained in the method of dry needling procedures in accordance with the norm of the practice of their respective countries. The basic steps given in the book can make a practicing therapist use dry needling technique for the subjects in different clinical conditions. The text focus not only on the steps needed to be performed but also focus on what should not be done by a therapist while performing the procedure. At work, we have taken all the guidelines given by OSHA for blood borne diseases as well as WHO guideline on workplace and hand hygiene.

Dry needling for the treatment of myofascial (muscular) trigger points is based on theories similar, but not exclusive, to traditional acupuncture; both acupuncture and dry needling target the trigger points, which is a direct and palpable source of patient pain. However, dry needling theory is only beginning to describe the complex sensation referral patterns that have been documented as "channels" or “meridians” in Chinese Medicine. Dry needling, and its treatment techniques and desired effects, would be most directly comparable to the use of 'a-shi' points in acupuncture.[16] What further distinguishes dry needling from traditional acupuncture is that it does not use the full range of traditional theories of Chinese Medicine which is used to treat not only pain but other non-musculoskeletal issues which often are the cause of pain. The distinction between trigger points and acupuncture points for the relief of pain is blurred. As reported by Melzack, et al., there is a high degree of correspondence (71% based on their analysis) between published locations of trigger points and classical acupuncture points for the relief of pain.[17] The debated distinction between dry needling and acupuncture has become a controversy because it relates to an issue of scope of practice of various professions.

Technique

In the treatment of trigger points for persons with myofascial pain syndrome, dry needling is an invasive procedure in which a filiform needle is inserted into the skin and muscle directly at a myofascial trigger point. A myofascial trigger point consists of multiple contraction knots, which are related to the production and maintenance of the pain cycle. Deep dry needling for treating trigger points was first introduced by Czech physician Karel Lewit in 1979.[18] Lewit had noticed that the success of injections into trigger points in relieving pain was apparently unconnected to the analgesic used.[11]

Proper dry needling of a myofascial trigger point will elicit a local twitch response (LTR), which is an involuntary spinal cord reflex in which the muscle fibers in the taut band of muscle contract. The LTR indicates the proper placement of the needle in a trigger point. Dry needling that elicits LTRs improves treatment outcomes,[19] and may work by activating endogenous opioids.[18] The activation of the endogenous opioids is for an analgesic effect using the Gate Control Theory of Pain.[20] Inserting the needle can itself cause considerable pain,[18] although when done by well-trained practitioners that is not a common occurrence. No study to date has reported the reliability of trigger point diagnosis and physical diagnosis cannot be recommended as a reliable test for the diagnosis of trigger points.[21][22]

Efficacy

There is currently no standardized form of dry needling, no body of evidence that indicates its efficacy, and there is no medical action pathway that provides a theoretical basis for why dry needling should be efficacious. Many of the studies published about dry needling do not have strong evidence; either the studies were not randomized, contained small sample sizes, had high dropout rates, used active interventions in the control group, did not follow the minimally acceptable criteria to diagnose a myofascial trigger point, or did not clearly state that myofascial trigger points were the sole cause for the pain. For example, in a systematic review on needling therapies in the management of myofascial trigger points, only 8 of the 23 trials described the minimally acceptable criteria for diagnosing a trigger point. Locating the trigger point for dry needling is the basis for performing dry needling and should, therefore, be documented in each study performing this technique. In the same review, two studies tested the efficacy beyond placebo of dry needling in the treatment of myofascial trigger point pain, but, in one, the dropout rate was 48% and it was neither blinded nor randomized, and the other study used potentially active interventions in the control group. Another concluded that dry needling can reduce pain, thus improving mood, function, and disability. The study used the dry needling on trigger points to relieve pain in patients with chronic myofascial pain.[23]

Another systematic review concluded that dry needling for the treatment of myofascial pain syndrome in the lower back appeared to be a useful addition to standard therapies, but stated clear recommendations could not be made because the published studies are small and of low quality.[19] A 2007 meta-analysis examining dry needling of myofascial trigger points concluded that the effect of needling was not significantly different to that of placebo controls, though the trend in the results could be compatible with a treatment effect. One study (Lorenzo et al. 2004) did show a short-term reduction in shoulder pain in stroke patients who received needling with standard rehabilitation compared to those who received standard care alone, but the study was open-label and measurement timings differed, limiting the use of the study. Again the small sample size and poor quality of studies was highlighted.[24] A recent systematic review and meta-analysis released by JOSPT on "effectiveness of dry needling for upper-quarter myofascial pain" recommends the usage of dry needling, compared to sham or placebo, for decreasing pain immediately after treatment and at 4 weeks in patients with upper quarter myofascial pain syndrome./url=http://www.jospt.org/doi/pdf/10.2519/jospt.2013.4668 However, the authors caution that "the limited number of studies performed to date, combined with methodological flaws in many of the studies, prompts caution in interpreting the results of the meta-analysis performed"

Practice

Dry needling is taught to and practiced around the world by Doctors of Medicine, Doctors of Osteopathic Medicine, acupuncturists, chiropractors, naturopathic physicians, and physical therapists, as well as other medical practitioners.

In the United States of America, dry needling and acupuncture are included in the scope of practice of Doctors of Medicine, Doctors of Osteopathic Medicine, acupuncturists, and in some states chiropractors and naturopathic physicians. Most states allow chiropractors to practice dry needling if needle use (including but not limited to acupuncture) was already included their scope of practice in that state. Some of these states and others have a rule specifically in favor of Chiropractic using dry needling techniques. Other states have ruled that chiropractors cannot practice dry needling. Many states allow physical therapists to perform dry needling, but not acupuncture.

The largest growth in practitioners of dry needling, as a specific technique, in recent years has been among physical therapists. When the Physical Therapy Boards of many states declared that dry needling was already included in their scope of practice, many states had no regulation of dry needling as distinct from acupuncture or trigger point injections allowed by Physicians. Many states have reviewed this stance and allowed Physical Therapists to continue the practice, some have prohibited this technique, and some still have no regulation.

Physical therapists practice in many countries, including South Africa, India, Bangladesh, the Netherlands, Spain, Switzerland, Canada, Chile, Ireland, the United Kingdom, Australia and New Zealand.

In the United States of America, physical therapists in most states perform the technique.[25] Physical therapists are prohibited from penetrating the skin or specifically from practicing dry needling in California, Hawaii, New York, and Florida, though many states have no regulations on dry needling. The Oregon Board of Appeals ruled in January 2014 that the Oregon Board of Chiropractic Examiners did not have the statutory right to determine this in their scope of practice. But the Court made no ruling that chiropractors do not have the training needed to perform dry needling.[26] Additionally, chiropractors are legally allowed to practice dry needling in many US states, as well as in many countries. There are however no established guidelines for the frequency a patient can receive dry needling for a specific location. Therefore, more research is needed to develop a set of safety guidelines.

Controversy

Many physical therapists and chiropractors have asserted that they are not practicing acupuncture when dry needling.[27] They assert that much of the basic physiological and biomechanical knowledge that dry needling utilizes is taught as part of their core physical therapy and chiropractic education and that the specific dry needling skills are supplemental to that knowledge and not exclusive to acupuncture. However, the originators and proponents of dry needling acknowledged that certain aspects of this techniques were inspired by acupuncture although they also acknowledge that the medical basis for it is purely Western Medicine in nature and therefore is not validly a subset of acupuncture and is a separate medical process. Many acupuncturists have argued that dry needling appears to be an acupuncture technique requiring minimal training that has been re-branded under a new name ("dry needling"). Whether dry needling is considered to be acupuncture depends on the definition of acupuncture, and it is argued that trigger points do not correspond to acupuncture points or meridians.[28] They correspond by definition to the ad hoc category of 'a-shi' acupoints.[16] It is important to note that this category of points is not necessarily distinct from other formal categories of acupoints. In 1983, Janet Travell et al. described trigger point locations as 92% in correspondence with known acupuncture points. In 2006, Peter T. Dorsher, acupuncturist at the Mayo Clinic, concludes that the two point systems are in over 90% agreement.[29] In 2009, Dorsher and Fleckenstein conclude that the strong (up to 91%) consistency of the distributions of trigger point regions’ referred pain patterns to acupuncture meridians provides evidence that trigger points most likely represent the same physiological phenomenon as acupuncture points in the treatment of pain disorders.[30] An article in Acupuncture Today (May 2011, p. 3, “Scope and Standards for Acupuncture: Dry Needling?”) further corroborates the 92% correspondence of trigger points to acupuncture points. In 2011, The Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) published a position paper describing dry needling as an acupuncture technique.

The North Carolina Acupuncture Licensing Board has published a position statement asserting that dry needling is acupuncture and thus is covered by the North Carolina Acupuncture Licensing law, and is not within the present scope of practice of Physical Therapists, and Physical Therapists are not among the professions exempt from the law.[31] The Attorney General was asked for an opinion by the North Carolina Acupuncture Licensing Board which he gave dated Dec 1st, 2011 saying that "In our opinion, the Board of Physical Therapy Examiners may determine that dry needling is within the scope of practice of physical therapy if it conducts rulemaking under the Administrative Procedure Act and adopts rules that relate dry needling to the statutory definition of practice of physical therapy." [32] But that is a matter of opinion and not a matter of law. The North Carolina Rules Review Committee of the legislative branch found that the North Carolina Physical Therapy Board had no statutory authority for the proposed rule.[32] The Physical Therapy board subsequently decided that they had the right to declare dry needling within scope anyway "the Board believes physical therapists can continue to perform dry needling so long as they possess the requisite education and training required by N.C.G.S. § 90-270.24(4), but there are no regulations to set the specific requirements for engaging in dry needling.".[33]

In May 2011 the Oregon Board of Chiropractic Examiners ruled to allow "dry needling" into the chiropractic scope of practice with 24 hours of training. In July 2011 the Court of Appeals of the State of Oregon issued an injunction, preventing chiropractors from practicing dry needling until the case is heard in court. The document issued by the court states that "dry needling" is "substantially the same" as acupuncture and that the "respondent has not explained how 24 hours of training, with no clinical component, provides sufficient training to chiropractors to adequately protect patients."[34] In September 2011, the Oregon Board of Chiropractic Examiners And Oregon Attorney General appealed said order on the grounds that they feel the commissioner who issued the order was mistaken in his assertion.[35] On November 10, 2011, The Court of Appeals of the State of Oregon issued an Order Denying the Motion for Reconsideration.[36] The effect of said ruling is that the entire Appeals Court will now determine if the stay was appropriate. The stay is relevant only in the State of Oregon.

In January 2014, The Oregon Court of Appeals ruled that the Oregon Board of Chiropractic Examiners did not have the statutory authority to include dry needling in the scope of practice for chiropractors in that state. The ruling did not address whether chiropractors have the medical expertise to use dry needling or whether the training they were being given was adequate.[26] Pending further discussion of training requirements the Oregon Physical Therapist Licensing Board has advised all Oregon physical therapists against practicing dry needling. They have not changed their ruling that dry needling is within the scope of practice for Oregon Physical Therapists.[37]

The American Medical Association adopted a policy in 2016 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. AMA board member Russell W. H. Kridel, M.D. stated "Lax regulation and nonexistent standards surround this invasive practice. For patients' safety, practitioners should meet standards required for licensed acupuncturists and physicians." [38]

See also

References

  1. 1 2 Zhou K, Ma Y, Brogan MS (2015). "Dry needling versus acupuncture: the ongoing debate". Acupunct Med. 33: 485–90. doi:10.1136/acupmed-2015-010911. PMID 26546163.
  2. ↑ http://jmmtonline.com/past/vol14no4.php
  3. ↑ https://clinicaltrials.gov/ct2/show/NCT00804089
  4. ↑ http://www.archives-pmr.org/article/S0003-9993%2815%2900006-4/abstract?cc=y=
  5. ↑ "[Code of Federal Regulations]". FDA.
  6. ↑ http://www.gpo.gov/fdsys/pkg/USCODE-2010-title21/pdf/USCODE-2010-title21-chap9-subchapV-partA-sec360j.pdf
  7. ↑ http://www.gpo.gov/fdsys/pkg/USCODE-2010-title21/pdf/USCODE-2010-title21-chap9-subchapV-partA-sec360c.pdf
  8. ↑ http://www.gpo.gov/fdsys/pkg/USCODE-2010-title21/pdf/USCODE-2010-title21-chap9-subchapV-partA-sec353.pdf
  9. ↑ http://www.gpo.gov/fdsys/pkg/USCODE-2010-title21/pdf/USCODE-2010-title21-chap9-subchapV-partE-sec360bbb.pdf
  10. ↑ http://www.gpo.gov/fdsys/pkg/USCODE-2010-title21/pdf/USCODE-2010-title21-chap9-subchapV-partE-sec360bbb-2.pdf
  11. 1 2 K. Lewit (February 1979). "The needle effect in the relief of myofascial pain". Pain. 6 (1): 83–90. doi:10.1016/0304-3959(79)90142-8. PMID 424236.
  12. ↑ Ma, Yun-Tao. "Integrative Systemic Dry Needling/ A New Modality for Athletes." Biomedical Acupuncture for Sports and Trauma Rehabilitation: Dry Needling Techniques. St. Louis: Churchill Livingstone Elsevier, 2011. 4. Print.
  13. ↑ Ma, Yun-Tao. "What Is Dry Needling?" (n.d.): 1. Web. 02 Aug. 2010.
  14. ↑ Ma, Yun-Tao. "Meet Your Teacher." Dry Needling Course RSS. Dr. Yun-Tao Ma, Ph.D., LAc, n.d. Web.
  15. ↑ Jain, Piyush (2015). Manual of Dry Needling Techniques. INDIA: PREF Publications. p. 2. ISBN 978-8192426723.
  16. 1 2 Aung & Chen, 2007, p. 101.
  17. ↑ Travell; Simons. Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body, Second Edition. North Atlantic Books.
  18. 1 2 3 Baldry, Peter; Yunus, Muhammad B.; Inanici, Fatma (2001). Myofascial pain and fibromyalgia syndromes: a clinical guide to diagnosis and management. Elsevier Health Sciences. p. 36. ISBN 0-443-07003-2.
  19. 1 2 Furlan AD, van Tulder MW, Cherkin DC, et al. (2005). Furlan AD, ed. "Acupuncture and dry-needling for low back pain". Cochrane Database of Systematic Reviews (1): CD001351. doi:10.1002/14651858.CD001351.pub2. PMID 15674876.
  20. ↑ Travell, JG (1999). "Myofascial Pain and Dysfunction". Trigger Point Manual.
  21. ↑ Lucas, N.; Macaskill P.; Irwig L.; Moran R.; Bogduk N. (2009). "Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature". The Clinical Journal of Pain. Eastern Pain Association. 25 (1): 80–9. doi:10.1097/AJP.0b013e31817e13b6. ISSN 0749-8047. PMID 19158550.
  22. ↑ Tough, Elizabeth A.; White, Adrian R.; Richards, Suzanne; Campbell, John (2007). "Variability of Criteria Used to Diagnose Myofascial Trigger Point Pain Syndrome-Evidence From a Review of the Literature". The Clinical Journal of Pain. Eastern Pain Association. 23 (3): 278–286. doi:10.1097/AJP.0b013e31802fda7c. PMID 17314589.
  23. ↑ http://web.b.ebscohost.com/ehost/detail/detail?vid=5&sid=433ddf1c-3e1d-4228-b7a2-65b00b10f9c1%2540sessionmgr115&hid=124&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=109604111&db=rzh
  24. ↑ Tough, Elizabeth A.; Adrian R. White; T. Michael Cummings; Suzanne H. Richards; John L. Campbell (2009). "Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials". European Journal of Pain. 13 (1): 3–10. doi:10.1016/j.ejpain.2008.02.006. PMID 18395479.
  25. ↑ "Myopain Seminars, Resources, Dry Needling News". Myopainseminars.com. 2009-06-04. Retrieved 2013-09-17.
  26. 1 2 http://www.publications.ojd.state.or.us/docs/A148924.pdf
  27. ↑ Dommerholt, Jan (2008). "The "Dry Needling Issue"". Qi-Unity Report. Retrieved 16 June 2010.
  28. ↑ Fernández De las Peñas, César; Arendt-Nielsen, Lars; Gerwin, Robert D. (2009). Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Jones & Bartlett Learning. p. 250. ISBN 0-7637-5283-5.
  29. ↑ Peter T. Dorsher (May 2006). "Trigger Points and Acupuncture Points: Anatomic and Clinical Correlations". Medical Acupuncture. 17 (3).
  30. ↑ Peter T. Dorsher; J. Fleckenstein (2009). "Trigger Points and Acupuncture Points: Anatomic and Clinical Correlations". Deutsche Zeitschrift fur Akupunktur. 52 (1): 9–14. doi:10.1016/j.dza.2009.01.001.
  31. ↑ "North Carolina Acupuncture Licensing Board Position Statement: Dry Needling is Intramuscular Manual Therapy is Acupuncture" (PDF). Retrieved 2013-09-17.
  32. 1 2 2015/21 NCAC 48C .0104 %E2%80%93 Summary.pdf "Proposed Rules presented to the Rules Review Commission" Check |url= value (help) (PDF). Retrieved 2015-01-30.
  33. ↑ regarding results of RRC Meeting - 01-15-15.pdf "Note: RE: Proposed Rules presented to the Rules Review Commission" Check |url= value (help) (PDF). Retrieved 2015-01-30.
  34. ↑ James W Nass, Order Staying Administrative Rule Pending Judicial Review, Court of Appeals State of Oregon, No. A148924, July 29, 2011
  35. ↑ OBCE & Oregon State Attorney General Motion Requesting Reconsideration of Administrative Stay, September 22, 2011
  36. ↑ Order Denying Motion for Reconsideration, Court of Appeals, State of Oregon, No. A148924, November 10, 2011
  37. ↑ http://www.oregon.gov/PTBrd/docs/current.topics/board.statement.relevant.to.dry.needling.pdf
  38. ↑ http://www.ama-assn.org/ama/pub/news/news/2016/2016-06-15-new-policies-annual-meeting.page
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