Maryland
Finally, there is some good news for select Maryland occupational therapists! On September 16, 2024, the Maryland Board of Occupational Therapy Practice approved dry needling regulations for occupational therapists who are also certified hand therapists. According to Title 10, Maryland Department of Health, Subtitle 46 Board of Occupational Therapy Practice, 10.46.09 Dry Needling,
“Dry needling” means a physical agent modality as defined in COMAR 10.46.06.03, also known as intramuscular manual therapy, that:
(a) Involves the insertion of one or more solid needles, a mechanical device, into the muscle and related tissues to effect change in muscle and related tissues of the hand, wrist, elbow, and shoulder;
(b) Requires ongoing evaluation, assessment, and re-evaluation of the impairments;
(c) Is only utilized in parts of the body with neuromuscular or musculoskeletal links to the impairments; and
(d) Is not performed for: (i) The purposes of acupuncture and East Asian medicine as defined in Health Occupations Article, §1A-101, Annotated Code of Maryland; or (ii) Any purpose outside the scope of occupational therapy.
While the new regulations may sound encouraging, they likely create many obstacles. They include many of the same illogical stipulations of the physical therapy dry needling regulations in Maryland:
- Unfortunately, occupational therapists who are not certified hand therapists are excluded from the privilege to offer dry needling to their patients and clients, which is somewhat ironic as the American Occupational Therapy Association (AOTA) has expressed that “….dry needling, and other techniques may be used in preparation for, or concurrently with occupations and activities or interventions that ultimately enhance a client’s engagement in occupation,” while the American Society of Hand Therapists (ASHT) does not endorse dry needling by certified hand therapists at this time. According to the ASHT, “the current body of evidence neither supports nor refutes the use of dry needling in the practice management of the hand and upper extremity.”
As we listed in a recent blog, occupational therapists can use dry needling in about 15 states. To the best of our knowledge, none of the other states require that OTs be certified hand therapists. There is no reported increased incidence rate of dry needling adverse events among OTs who are not CHTs, which makes one wonder why Maryland added the certified hand therapy requirement.
- In Maryland, having a good understanding of dry needling theory is valued more than having practical skills, even though protecting the public is the primary purpose of any licensing board. Solid practical needling skills would seem more important, but not in Maryland. According to the Annotated Code of Maryland, only occupational therapists who are also certified hand therapists in good standing can perform dry needling after having completed at least 52 hours of further instruction. After completing at least 27 hours of instruction in dry-needling-specific course theory content and 25 hours of practical, hands-on instruction, the therapist must apply to the Board and be approved and registered. We do not suggest that theoretical education is unimportant, but clinical skills are critical to ensure patient safety.
- The Maryland Board of Occupational Therapy Practice has restricted dry needling to “muscle and related tissues of the hand, wrist, elbow, and shoulder,” which, in our opinion, will significantly limit OT dry needling practice. Many upper extremity impairments are best managed by taking a comprehensive “whole-body” approach, which would be consistent with the position of the AOTA, which is recognized as the primary source of nationally recognized standards of OT practice.
OT practitioners work with people on their occupations, their activities, and the things they do daily, most of which require your full body, including hands, arms, and legs, and even cognition.
The Maryland OT dry needling regulations appear to contradict the definitions of occupational therapy included in the same regulations (Title 10, Maryland Department of Health, Subtitle 46 Board of Occupational Therapy Practice, Chapter 01 General Regulations, 03 Standards of Practice) where Standards of Practice are defined as
“An occupational therapist shall exercise sound judgment and provide adequate care in the performance of duties as provided in nationally recognized standards of practice.”
Considering that the national AOTA includes the “full body, including hands, arms, and legs,” the Maryland dry needling regulations contradict the “nationally recognized standards of practice” clause. Add to this that the dry needling regulations state that “dry needling is only utilized in parts of the body with neuromuscular or musculoskeletal links to the impairments.” However, when the initial OT evaluation determines that the low back or neck are linked to the impairment, the OT is not allowed to use dry needling in those regions of the body.
How will occupational therapists in Maryland implement the dry needling regulations in clinical practice? For example, the regulations do not specify what constitutes “the shoulder. Are all muscles attached to the scapula and clavicula part of the shoulder? The rhomboid, serratus posterior superior, and pectoralis minor muscles feature referred sensations into the arm. However, based on the definition, occupational therapists in Maryland may not be allowed to treat these muscles. One could argue that because the rhomboids attach to the scapula, one could consider them as shoulder muscles, but that may be a bit of a stretch. What about the serratus anterior or the part of the latissimus dorsi on the trunk? Again, these muscles could be shoulder muscles, but it is unclear what the Board has in mind.
- Just like the PT Dry Needling Regulations in Maryland, new occupational therapy graduates are not allowed to use dry needling once they are licensed in Maryland, partly because they would not have been able to become certified hand therapists but also because the regulations specifically state that
“An occupational therapist shall have practiced occupational therapy for at least 2 years, in addition to having been certified as a hand therapist, before performing dry needling in the State.”
Irrespective of the certified hand therapy requirement, the Maryland OT and PT Boards appear concerned that new graduates have too much mastery of anatomy. Since dry needling is very much anatomy-driven, OTs and PTs in Maryland must dumb down their anatomy knowledge over two years before they can start dry needling their patients and clients. How is that in light of protecting the public?
Sorry new graduate, but you know too much anatomy. Why don’t you come back in about two years so you will not be as safe when you start your dry needling practice?
North Carolina
Two days after the Maryland OT Board approved dry needling by OTs who are also CHTs, the North Carolina Board of Occupational Therapists also approved dry needling by OTs. There are some significant differences between the two states. In North Carolina, dry needling is considered
“a physical agent modality within the scope of practice of occupational therapy in North Carolina, provided that the occupational therapy practitioner demonstrates and documents competency in the modality and is practicing within the occupational therapy scope of practice. If the dry needling modality will be administered by an occupational therapy assistant both the supervising occupational therapist and the assistant must demonstrate and document competency in the techniques and modality.”
In North Carolina, OTs do not have to be CHTs to use dry needling. There are no minimum hours required for theoretical and practical instruction. Instead, the NC OT Board considered dry needling like all other physical agent modalities and required that OT practitioners demonstrate “competency.” Another significant difference is that in North Carolina, occupational therapy assistants are allowed to use dry needling as long as the OTA and the supervising OT can demonstrate competency.
Although we are puzzled by the new Maryland Occupational Therapy Dry Needling Regulations, we welcome Maryland occupational therapists, who are also certified hand therapists, and North Carolina occupational therapists to join us for our OT/CHT Dry Needling courses. Maryland-based OTs who have not been licensed for two years can start their dry-needling education before the two-year mark to be ready to submit their application immediately at the two-year mark.
Related Dry Needling Course Series
The OT/CHT Dry Needling 1 course is an excellent starting point for learning the fundamentals of dry needling therapy. Focusing on the safe and effective application of dry needling techniques, it will give you a solid understanding of myofascial trigger points, needling techniques, precautions, and how to apply these techniques in your occupational therapy and hand therapy clinical practice.
The OT/CHT Dry Needling 2 course is the final course in the OT/CHT series and the last step before becoming a Certified Myofascial Trigger Point Therapist – Dry Needling (CMTPT/DN). This course offers an in-depth study of advanced dry needling techniques for hand, shoulder, and neck muscles.