Can Tennessee physical therapists perform trigger-point dry needling under their existing license?

Subject

Opinion No. 14-62, Trigger-Point Dry Needling and the Practice of Physical Therapy, June 19, 2014

Plain-English summary

Tennessee Board of Physical Therapy Chair Brigina Wilkerson asked whether Intramuscular Manual Therapy (IMT), commonly known as trigger-point dry needling, fell within the scope of physical therapy under the Occupational and Physical Therapy Practice Act (§§ 63-13-101 to -318). The AG said no.

The physical-therapy definition in § 63-13-103(15) lists therapeutic interventions including manual therapy, therapeutic massage, physical agents or modalities, mechanical and electrotherapeutic modalities, and others. Dry needling (a fine filiform needle inserted into trigger points to restore movement and reduce pain) is a therapeutic intervention, but it is not on the list. While the list is not exclusive, the AG found nothing in the statute clearly showing legislative intent to include invasive needle use for therapeutic purposes (Tidwell v. Collins on statutory construction).

The decisive factor was the resemblance to acupuncture. Acupuncture is "the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body based on oriental medical diagnosis as a primary mode of therapy" (§ 63-6-1001(7)). Acupuncture is a branch of medicine; physical therapists cannot practice it (§ 63-6-1002(a), (b)). The AG cited Op. 05-20 (Mar. 8, 2005), where this Office had concluded that chiropractors could not practice a needle-insertion treatment modality bringing about the same result as acupuncture without legislative authorization. The General Assembly responded to that opinion in 2006 by amending § 63-6-1002(a) to except qualifying chiropractors (2006 Tenn. Pub. Acts ch. 775, § 2). § 63-4-101(a) confirms the legislative pattern: chiropractors generally cannot practice "any branch of medicine osteopathy, or surgery, acupuncture being the exception."

The AG concluded that similar legislation would be needed for physical therapists, pointing to Utah as an example: in 2014 Utah amended its physical-therapy practice statute to include trigger-point dry needling among the therapeutic interventions (2014 Utah Laws ch. 354).

The opinion noted what physical therapists in Tennessee may already do involving needles: kinesiologic electromyography and diagnostic electromyography. Both are diagnostic, not therapeutic. Tenn. Comp. R. & Regs. 1150-01-.02(1)(b)(2)(i), (iii) and 1150-01-.04(4) limit them to university settings or to referral from an allopathic physician, osteopathic physician, dentist, or podiatrist. The current rules already keep needle use outside the therapeutic scope.

Currency note

This opinion was issued in 2014. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here.

Common questions

What is dry needling?

A skilled intervention using a thin filiform needle to penetrate the skin and stimulate myofascial trigger points and surrounding tissues. The aim is to reduce pain, restore movement, and address musculoskeletal disorders. Practitioners distinguish it from acupuncture on the basis of underlying theory (myofascial vs. meridian), but both involve inserting needles into the body.

Why is it considered too close to acupuncture under Tennessee law?

Because both involve "the insertion of needles for therapeutic purposes" to "promote, maintain and restore health and prevent disease" (§ 63-6-1001(2)). The AG opinion focused on the substantive similarity, not on whether the underlying theory differs.

Can Tennessee physical therapists ever use needles?

Yes, but only for diagnostic purposes. Tenn. Comp. R. & Regs. 1150-01-.02(1)(b)(2)(i), (iii) and 1150-01-.04(4) allow kinesiologic and diagnostic electromyography in a university setting or on referral from a physician, dentist, or podiatrist.

What would change in Tennessee?

A legislative amendment to the Occupational and Physical Therapy Practice Act expressly adding dry needling to the list of therapeutic interventions, or an amendment to § 63-6-1002 excepting qualifying physical therapists from the acupuncture-licensing requirement. Utah used the first approach.

Has anyone challenged this in court?

This opinion does not address pending litigation. The AG's conclusion is a legal analysis of the statute; whether a particular physical therapist might prevail in challenging discipline for performing dry needling is a separate, fact-bound question.

Why is acupuncture treated as medicine?

§ 63-6-1001(7)'s definition makes it "primary mode of therapy" based on "oriental medical diagnosis." The Tennessee legislature has chosen to treat acupuncture as a branch of medicine, which means non-physicians need specific statutory authorization to practice it.

Background and statutory framework

Tennessee regulates physical therapy through a comprehensive practice act (Title 63, Chapter 13) and acupuncture through Title 63, Chapter 6. The acupuncture provisions describe acupuncture as a branch of medicine and restrict its practice to licensed acupuncturists, who themselves must qualify under specific certification standards.

The AG's analysis tracks a familiar pattern: when a treatment modality resembles a regulated practice, it falls within that regulated practice unless the legislature has explicitly carved it out. The 2006 chiropractor exception (added in response to Op. 05-20) shows how the legislature carries through. Without parallel legislation for physical therapists, dry needling remains outside their scope.

Citations

• Tenn. Code Ann. §§ 63-13-101 to -318 (Occupational and Physical Therapy Practice Act)
• Tenn. Code Ann. § 63-13-103(15) (definition of practice of physical therapy)
• Tenn. Code Ann. § 63-6-1001(2) (purpose of acupuncture: promotion, maintenance, restoration of health and prevention of disease)
• Tenn. Code Ann. § 63-6-1001(7) (definition of practice of acupuncture)
• Tenn. Code Ann. § 63-6-1002(a), (b) (acupuncture certification requirements)
• Tenn. Code Ann. § 63-4-101(a) (chiropractic acupuncture exception)
• Tenn. Comp. R. & Regs. 1150-01-.02(1)(b)(2)(i), (iii) (kinesiologic and diagnostic electromyography by physical therapists)
• Tenn. Comp. R. & Regs. 1150-01-.04(4) (university or referral setting requirement)
• Tidwell v. Collins, 522 S.W.2d 674 (Tenn. 1975) (Tennessee Supreme Court; statutory construction)
• Tenn. Att'y Gen. Op. 05-20 (Mar. 8, 2005) (chiropractor needle-insertion treatment as acupuncture)
• 2006 Tenn. Pub. Acts, ch. 775, § 2 (chiropractor acupuncture exception)
• 2014 Utah Laws ch. 354 (Utah's statutory inclusion of dry needling in physical-therapy scope)

Source

• Landing page: https://www.tn.gov/attorneygeneral/opinions.html
• Original PDF: https://www.tn.gov/content/dam/tn/attorneygeneral/documents/ops/2014/op14-062.pdf

Original opinion text

STATE OF TENNESSEE
OFFICE OF THE ATTORNEY GENERAL
June 19, 2014
Opinion No. 14-62
Trigger-Point Dry Needling and the Practice of Physical Therapy

QUESTION

Is Intramuscular Manual Therapy ("IMT"), also known as Trigger-Point Dry Needling, within the scope of the practice of physical therapy under the Occupational and Physical Therapy Practice Act, Tenn. Code Ann. §§ 63-13-101 to -318?

OPINION

No.

ANALYSIS

Under the Occupational and Physical Therapy Practice Act, "practice of physical therapy" means:

(A) Examining, evaluating and testing individuals with mechanical, physiological and developmental impairments, functional limitations and disability or other health and movement-related conditions in order to determine a physical therapy treatment diagnosis, prognosis, a plan of therapeutic intervention and to assess the ongoing effect of intervention;

(B) Alleviating impairments and functional limitations by designing, implementing, and modifying therapeutic interventions that include, but are not limited to, therapeutic exercise, functional training, manual therapy, therapeutic massage, assistive and adaptive orthotic, prosthetic, protective and supportive equipment, airway clearance techniques, debridement and wound care, physical agents or modalities, mechanical and electrotherapeutic modalities and patient-related instruction;

(C) Reducing the risk of injury, impairments, functional limitation and disability, including the promotion and maintenance of fitness, health and quality of life in all age populations; and

(D) Engaging in administration, consultation, education and research[.]

Tenn. Code Ann. § 63-13-103(15). IMT, or "dry needling," involves the application of a fine, filiform needle to the neuromusculoskeletal system to restore movement, reduce pain, and address other musculoskeletal disorders. Dry needling must therefore be regarded as a therapeutic intervention, but it is not listed among the therapeutic interventions identified in § 63-13-103(15)(B). Although that list is not exclusive, and includes "manual therapy," "physical agents and modalities," and "mechanical and electrotherapeutic modalities," nothing in subdivision -103(15)(B) clearly indicates a legislative intent to include within the practice of physical therapy the invasive use of needles for therapeutic purposes. See Tidwell v. Collins, 522 S.W.2d 674, 676 (Tenn. 1975) ("The premier rule of statutory construction is to ascertain and give effect to the legislative intent."). Furthermore, while there are no doubt distinctions to be drawn between the two, dry needling's obvious similarity to acupuncture cannot be ignored, and physical therapists may not perform acupuncture, which is a branch of medicine. See Tenn. Code Ann. § 63-6-1002(a), (b).

Under Tenn. Code Ann. § 63-6-1001(7), "'practice of acupuncture' means the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body based on oriental medical diagnosis as a primary mode of therapy." In 2005, this Office opined, precisely because acupuncture is regarded as a branch of medicine, that chiropractors may not practice a treatment modality that uses the insertion of needles to bring about the same result. See Tenn. Att'y Gen. Op. 05-20 (Mar. 8, 2005). That "same result" is "the promotion, maintenance and restoration of health and the prevention of disease." Tenn. Code Ann. § 63-6-1001(2). In 2006, the legislature amended the acupuncture certification statutes to expressly except chiropractors who have satisfied certain requirements. See 2006 Tenn. Pub. Acts, ch. 775, § 2 (amending Tenn. Code Ann. § 63-6-1002(a)); see also Tenn. Code Ann. § 63-4-101(a) ("Nothing in this chapter shall be construed to authorize the chiropractic physician to practice any branch of medicine osteopathy, . . . or surgery, acupuncture being the exception.") (emphasis added).

Similar legislation would be necessary in order to bring dry needling within the scope of the practice of physical therapy. See, e.g., 2014 Utah Laws ch. 354 (amending physical-therapy-practice statute to include trigger-point dry needling among therapeutic interventions). Like acupuncture, dry needling uses the insertion of needles for therapeutic purposes, to restore movement, reduce pain, and address other musculoskeletal disorders. Although current rules of the Tennessee Board of Physical Therapy allow physical therapists to perform kinesiologic electromyography (invasive needle study of the muscles to determine the degree and character of a muscle during certain movements) and diagnostic electromyography (invasive needle study of multiple muscles for diagnosis of muscle and nerve disease), the purposes of these procedures are solely academic or diagnostic, and they may be performed only in a university setting or upon referral from an allopathic or osteopathic physician, a dentist, or a podiatrist. See Tenn. Comp. R. & Regs. 1150-01-.02(1)(b)(2)(i), (iii); id. 1150-01-.04(4).

ROBERT E. COOPER, JR.
Attorney General and Reporter

JOSEPH F. WHALEN
Acting Solicitor General

SARA E. SEDGWICK
Senior Counsel

Requested by:
Brigina T. Wilkerson, PT
Chair, Tennessee Board of Physical Therapy
665 Mainstream Drive
Nashville, Tennessee 37243