SCOPE OF PRACTICE OF PHYSICAL THERAPY

AGO 2016 No. 3 – Apr 15 2016
Attorney General Bob Ferguson

PHYSICAL THERAPISTS—Scope Of Practice Of Physical Therapy

The practice of dry needling does not fall within the scope of practice of a licensed physical therapist.

April 15, 2016

The Honorable Eileen Cody
State Representative, District 34
PO Box 40600
Olympia, WA   98504-0600

 

Cite As:
AGO 2016 No. 3

Dear Representative Cody:

By letter previously acknowledged, you have requested our opinion on the following question:

Is the practice of dry needling within a licensed physical therapist’s scope of practice as defined in RCW 18.74?

BRIEF ANSWER

            No. The statute that defines the practice of physical therapy allows a variety of interventions, but we conclude that the best reading of the statute excludes dry needling from the practice of physical therapy. Our conclusion is based solely on the law as currently written; it is not our role to weigh the policy benefits and drawbacks of authorizing physical therapists to engage in dry needling. The legislature, of course, could also expand the scope of physical therapy by amending the relevant statutes.

ANALYSIS

            We start by describing dry needling. As your letter summarizes, dry needling is a practice in which a solid (as opposed to hollow) needle is inserted through the skin for therapeutic effect. It is also known as intramuscular stimulation, intramuscular manual therapy, trigger point dry needling, or intramuscular needling. The American Physical Therapy Association describes 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. Dry needling (DN) is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and, diminish persistent peripheral nociceptive

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input, and reduce or restore impairments of body structure and function leading to improved activity and participation.

American Physical Therapy Ass’n, Description of Dry Needling In Clinical Practice: An Educational Resource Paper (APTA Paper) 2 (Feb. 2013).[1]

Put more simply, the person providing dry needling inserts a slim needle into a trigger point in the muscle and connective tissue of a patient for the purpose of stimulating the trigger point. APTA Paper at 2, 4. The American Physical Therapy Association supports the use of dry needling to address pain and movement impairments. APTA Paper at 3. But the insertion of a needle to reach muscle and connective tissue is invasive and it pierces the skin. As a result, it presents risks attendant to any such invasive procedure.[2]

Your question involves state regulation of physical therapy. Washington regulates the practice of physical therapy under RCW 18.74. That chapter of state law creates the Washington State Board of Physical Therapy, a Board with six members appointed by the governor. RCW 18.74.020. The Board consists of four physical therapists, one physical therapist assistant, and one public member. RCW 18.74.020. The chapter provides for licensing and regulation in order to advance two overarching purposes: “[1] to protect the public health, safety, and welfare, and [2] to provide for state administrative control, supervision, licensure, and regulation of the practice of physical therapy.” RCW 18.74.005.

To answer whether dry needling comes within the scope of the practice of physical therapy, we start with the definition of physical therapy. “Physical therapy”

means the care and services provided by or under the direction and supervision of a physical therapist licensed by the state. . . . [T]he use of Roentgen rays and radium for diagnostic and therapeutic purposes, the use of electricity for surgical purposes, including cauterization, and the use of spinal manipulation, or manipulative mobilization of the spine and its immediate articulations, are not included under the term “physical therapy” as used in this chapter.

RCW 18.74.010(9). This statute is too general to help in answering your question. It defines physical therapy simply as care and services provided by licensed physical therapists, which begs the question of what care and services fall within the scope of practice. The statute excludes three categories of services (radiation, use of electricity for surgical purposes, and spinal manipulations), but these exclusions indicate nothing regarding the scope of practice otherwise.

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Next, we turn to the statutory definition of the “practice of physical therapy.” It provides that the practice “is based on movement science and means”:

(a) Examining, evaluating, and testing individuals . . . in order to determine a diagnosis, prognosis, plan of therapeutic intervention, and to assess and document the ongoing effects of intervention;

(b) Alleviating impairments and functional limitations in movement by designing, implementing, and modifying therapeutic interventions that include therapeutic exercise; functional training related to balance, posture, and movement to facilitate self-care and reintegration into home, community, or work; manual therapy including soft tissue and joint mobilization and manipulation; therapeutic massage; assistive, adaptive, protective, and devices related to postural control and mobility except as restricted by (c) of this subsection; airway clearance techniques; physical agents or modalities; mechanical and electrotherapeutic modalities; and patient-related instruction;

(c) Training for, and the evaluation of, the function of a patient wearing an orthosis or prosthesis as defined in RCW 18.200.010. . . . ;

(d) Performing wound care services that are limited to sharp debridement, debridement with other agents, dry dressings, wet dressings, topical agents including enzymes, hydrotherapy, electrical stimulation, ultrasound, and other similar treatments. . . . ;

(e) Reducing the risk of injury, impairment, functional limitation, and disability related to movement, including the promotion and maintenance of fitness, health, and quality of life in all age populations; and

(f) Engaging in administration, consultation, education, and research.

RCW 18.74.010(10) (emphasis added).

Dry needling obviously falls outside most of these subsections, but could arguably fit within subsection (b), so we focus our analysis there. Subsection (b) allows “[a]lleviating impairments and functional limitations in movement by designing, implementing, and modifying therapeutic interventions[.]” In a very general sense, dry needling is a “therapeutic intervention,” and the literature describing the practice indicates that it alleviates impairments or limitations in movement. But the remainder of subsection (b) narrows the expansive opening language by limiting the term “therapeutic interventions” with a list of interventions and practices. Under subsection (b), the scope of practice includes:

  • therapeutic exercise;

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  • functional training related to balance, posture, and movement to facilitate self-care and reintegration into home, community, or work;
  • manual therapy including soft tissue and joint mobilization and manipulation;
  • therapeutic massage;
  • assistive, adaptive, protective, and devices related to postural control and mobility except as restricted by (c) of this subsection;
  • airway clearance techniques;
  • physical agents or modalities;
  • mechanical and electrotherapeutic modalities; and
  • patient-related instruction.

The question, therefore is whether dry needling falls within any of these approved practices or is similar enough to them that it falls within the scope of practice.  See, e.g., AGO 2010 No. 2, at 5-6 (construing the scope of practice for occupational therapists in light of a statutory list of included practices); Simpson Inv. Co. v. Dep’t of Revenue, 141 Wn.2d 139, 151, 3 P.3d 741 (2000) (“general terms, when used in conjunction with specific terms in a statute, should be deemed only to incorporate those things similar in nature or ‘comparable to’ the specific terms”). We conclude that dry needling was not intended to be included in the scope of practice because it is not explicitly described in subsection (b) and it does not fit into a fair or natural reading of any of the interventions that comprise the practice of physical therapy.

Most of the listed subjects (e.g., therapeutic exercise or massage, functional training, actions for posture control and mobility, airway clearance, and patient-related instruction) require no discussion. Dry needling falls far outside these subjects.

We considered whether dry needling fit within “manual therapy,” a term used in connection with “soft tissue and joint mobilization and manipulation.” RCW 18.74.010(10)(b) (emphasis added). But dry needling is not “manual therapy” as we understand the term.[3]

Similarly, we considered whether dry needling is a “physical agent” or “mechanical modality.” Those terms are somewhat ambiguous and presumably have specialized meanings peculiar to the physical therapy profession. While a generous reading of those terms might cover dry needling, we think such a reading is inappropriate because it would cover a wide range of practices that clearly fall outside the practice of physical therapy. For example, the term

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“physical agents” could include medications, but physical therapists are not allowed to prescribe medications. Therefore, in context, we believe that the legislature intended a narrower meaning for “physical agents or modalities” and “mechanical and electrotherapeutic modalities.” Whatever ambiguity exists, it seems unlikely that the legislature selected these obtuse phrases as a way of granting physical therapists broad discretion to use any device. Cf. 95 Op. Att’y Gen. 138, 146 (Md. 2010) (discussing Maryland statute with the phrase “treatment with . . . mechanical devices”).

We received many comments urging that dry needling should be considered an unlicensed practice of acupuncture, and many other comments urging that dry needling is based on different principles and foundations than is acupuncture. It is undisputed that dry needling uses the same type of needles used in acupuncture, which is separately regulated under RCW 18.06. However, nothing in the statutes governing East Asian medicine show legislative intent to make it the only health care practice that uses inserted solid needles. Thus, we are unable to resolve the question asked based on distinctions, or similarities, between dry needling and acupuncture. However, we do believe that where the legislature has adopted a detailed regulatory scheme for acupuncturists, we should be wary of interpreting broad language regulating the physical therapist profession as including a technique that at the very least is quite similar to acupuncture. Put another way, while physical therapy includes “[a]lleviating impairments . . . in movement by designing, implementing, and modifying therapeutic interventions that include . . . mechanical . . . modalities” (RCW 18.74.010(9)(b)), it is risky to interpret that broad authority to include practices historically engaged in only by other regulated professions. For example, a root canal might “alleviate impairments” in jaw “movement” through use of a “mechanical modality,” but no one would argue that it is within the practice of physical therapy.

In short, we believe that the best reading of current law is that dry needling falls outside the lawful practice of physical therapy. Admittedly, this reading of the statutory language may be debated by reasonable minds. But we also found no legislative history to suggest that the legislature intended to either include dry needling or to leave the matter open for individual practitioners to expand the scope of the profession by adopting a new practice.

We recognize that the lack of a legislative statement specifically directed to dry needling may simply reflect that dry needling is a relatively new approach for physical therapy. Reflecting the emergent nature of dry needling, several other Attorneys General have been called upon to opine on whether it is within the scope of their state’s laws governing the practice of physical therapy. Some of these opinions have concluded that dry needling can be included in the practice of physical therapy, and one has not.[4] But each of these opinions is based upon the particular statutes of the various states, just as our analysis is guided by the text of Washington law.

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Finally, many of the comments we received raised policy arguments concerning the value of dry needling and the benefits and drawbacks of allowing physical therapists to administer it, including issues related to safety, pain management, and quality of patient care. Attorney General Opinions, however, are not meant to decide what state policy should be; rather, they provide the best answer we can as to the meaning of current statutes. The concerns of these commenters would be best addressed to the legislature as it considers any possible changes to the laws. See State v. Wilson, 11 Wn. App. 916, 919, 528 P.2d 279 (1974) (“the scope of practice of persons engaged in the various healing sciences is exclusively a matter of legislative concern”); see also AGO 2010 No. 2, at 6 (citing York v. Wahkiakum Sch. Dist. 200, 163 Wn.2d 297, 342, 178 P.3d 995 (2008) (J.M. Johnson, J., concurring) (noting the role of legislative fact-finding in policy development)).

CONCLUSION

            The definition of the practice of physical therapy indicates that the legislature did not intend to include dry needling within the scope of practice. We have been informed of many reasons for including dry needling in the practice of physical therapy and arguments to the contrary, but our role is not to resolve such public policy disputes. We conclude only that RCW 18.74, as currently written and implemented, does not encompass dry needling in the practice of physical therapy.[5]

We trust that the foregoing will be useful to you.

ROBERT W. FERGUSON
Attorney General

 

JAY D. GECK
Deputy Solicitor General          

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[1] This description is provided by the American Physical Therapy Association and a copy is accessible via http://www.apta.org/StateIssues/DryNeedling/ClinicalPracticeResourcePaper/ (last visited Apr. 12, 2016).

[2] We do not purport to evaluate the extent of risk, but note that we have cited to professional literature that discusses some risk of adverse results even from trained dry needling. Sarah Brady et al., Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists, 22 J. Manual & Manipulative Therapy 134 (Aug. 2014), http://www.maneyonline.com/doi/abs/10.1179/2042618613Y.0000000044.

[3] A medical dictionary defines “manual therapy” as “[a] collection of techniques in which hand movements are skillfully applied to mobilize joints and soft tissues.” Medical Dictionary, © 2009 Farlex and Partners.

[4] Finding statutory authority to regulate dry needling as physical therapy: 95 Op. Att’y Gen. 138 (Md. 2010); Op. Att’y Gen. 428 (Miss. 2012), 2012 WL 6065221; Op. Att’y Gen. 478 (Miss. 2012), 2012 WL 6086335; Op. Att’y Gen. 13-010 (Ky. 2013); Op. Att’y Gen. 14-0216 (La. 2015). Finding no authority: Op. Att’y Gen. 14-62 (Tenn. 2014).

[5] We are grateful for the dozens of comments we received on this matter. These comments helped us understand the practice of dry needling, the concerns of other professions, and the legal landscape across the country as other states have considered similar questions.