“I have a question for you. Do you sanitize your needles?”
I stopped what I was doing. Of the questions I get about acupuncture, this is not one of the most common. In fact, I’ve never been asked it because nobody sterilizes their needles in the US – it’s dangerous.
“No, the process of repeatedly sterilizing* needles is really expensive and makes needles more prone to breaking. Reusing needles is dangerous anyway. I use single-use, disposable needles in sterile blister packs because I follow Clean Needle Technique.”
*there is a huge difference between sanitizing and sterilizing. Sanitizing is washing. Sterilizing is removing microbes.
This continued into a lively discussion about CDC recommendations, licensing regulations and all sorts of other safety bits about acupuncture that made me think I should write up a blog post.
The fact is that his question was a very important question that triggers other questions:
- What is Clean Needle Technique (CNT)?
- What is the difference between dry needling and acupuncture?
- Who is allowed to do acupuncture?
- What kind of training do people get before they are allowed to needle?
- What are some signs that your practitioner may be unsafe?
These are all very important questions that should be answered for every patient who wants to be in the know.
Additionally, this post is written from the perspective of Minnesota needling guidelines. Requirements vary from state to state, with some states being stricter and some being quite lax. If you are not Minnesotan contact a local acupuncturist to set up a safety chat if you’re curious.
What is Clean Needle Technique (CNT)?
Clean Needle Technique (CNT) is a collection of best practices meant to keep both patient and practitioner safe. The Council of Colleges of Acupuncture and Oriental Medicine developed the CNT manual and it is currently on its 7th incarnation. CNT is continuously updated based on current research, microbiology discoveries, and Center for Disease Control (CDC) and Occupational Safety and Health Administration (OSHA) recommendations.
So to answer this gentleman’s question in more detail, CNT is why I don’t sterilize my needles.
Best practices require me to use single use, sterile and disposable needles. They are manufactured in a sterile facility according to CDC recommendations, sealed in a blister pack and kept in a temperature and humidity-controlled environment until use.
Before touching this packaging best practices have me clean my hands first with soap and water and then again with an alcohol-based hand sanitizer. Then I set up my clean field.
Before the insertion of needles each point is swabbed with 70% isopropyl alcohol. Higher percentages evaporate too quickly, but 70% is high enough to clean the skin and minimize risk of infection. All cotton swabs and needles are discarded after use. Nothing – and I mean nothing – on my clean field is reused between patients. Following these procedures lowers your risk for any infection to the same levels as a visit to the doctor’s office for a vaccination or a blood draw.
So why are people still getting sick or hurt?
Different practitioners, different needling modalities
Here’s the thing about acupuncture. A lot of people who needle aren’t acupuncturists. But the adverse events (injuries, infections, etc.) that happen under their care are considered “acupuncture adverse events” because they involve acupuncture needles.
In Minnesota there are 5 modalities allowed to needle:
- Medical doctors
- Physical therapists
- Athletic trainers
Without additional training, only acupuncturists can call themselves Licensed Acupuncturists (L.Ac.). Other practitioners are “board certified” or “certified”. This differentiation tells you the kind of education, testing and continuing education required to maintain the legal ability to needle.
Let’s start with hours of education:
It takes 1,365 hours of 3,500 hours of education to properly learn needling safety, point location and techniques. Acupuncturists with doctorates have even more training.
Acupuncturists, MDs (Medical Doctors) and DCs (Doctors of Chiropractic) undergo standardized training that finish with exams testing the safety and knowledge of the practitioner. Acupuncturists, for instance, need to pass the CCAOM CNT exam, graduate with their masters, take a minimum of three board exams for National Certification and do a hefty chunk of continuing ed.
For more information, check out the Minnesota Acupuncture Associations Resource Page
But practitioners who dry needle? That’s a different story.
What is dry-needling?
Most of my patients know that I started as a massage therapist. My focus in school was on a modality called “Trigger Point Therapy” developed by Janet Travell and Dr. David Simmons. They did some fascinating research that found when practitioners injected saline or lidocaine into hyper-irritable pockets of metabolic waste (trigger points) pain elsewhere in the body would diminish. This is “referred pain.”
The solution was injected via a hypodermic needle, a hollow needle like the ones used to give vaccines.
Dry needling was the stimulation of these same points with a hypodermic needle without the solution (hence “dry” needling.) This was preformed by a physician in a clinical environment. Today it’s preformed by physical therapists, athletic trainers and some chiropractors.
Dry needling practitioners today use filiform needles, not hypodermic needles – they are using acupuncture needles.
In fact, the American Physical Therapy Association defines 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.APTA paper on Dry Needling
This is a far cry from what dry needling used to involve.
And if you look at the definition the APTA gives and you look at the definition of acupuncture for Minnesota acupuncturists:
“Acupuncture practice” means a comprehensive system of health care using Oriental medical theory and its unique methods of diagnosis and treatment. Its treatment techniques include the insertion of acupuncture needles through the skin and the use of other biophysical methods of acupuncture point stimulation, including the use of heat, Oriental massage techniques, electrical stimulation, herbal supplemental therapies, dietary guidelines, breathing techniques, and exercise based on Oriental medical principles.Minnesota Statutes, 2019 – 147B.01 Definitions, Subd. 3
and then dig a little deeper to the definition of acupuncture needle:
“Acupuncture needle” means a needle designed exclusively for acupuncture purposes. It has a solid core, with a tapered point, and is 0.12 mm to 0.45 mm in thickness. It is constructed of stainless steel, gold, silver, or other board-approved materials as long as the materials can be sterilized according to recommendations of the National Centers for Disease Control and Prevention.Minnesota Statutes, 2018 – 147B.01 Definitions, Subd. 4
and then tack on the definition of Oriental Medicine:
“Oriental medicine” means a system of healing arts that perceives the circulation and balance of energy in the body as being fundamental to the well-being of the individual. It implements the theory through specialized methods of analyzing the energy status of the body and treating the body with acupuncture and other related modalities for the purpose of strengthening the body, improving energy balance, maintaining or restoring health, improving physiological function, and reducing pain.Minnesota Statutes, 2018 – 147B.01 Definitions
We can see that Certified Dry Needlers are using acupuncture needles and acupuncture techniques to stimulate acupuncture points with less than 2% of the training a licensed acupuncturist would have. And that is only accounting for hands on practice – no diagnostics, no channel theory, no intention of shifting “energy balance.”
Certified DNs are stimulating classical acupuncture points 93% percent of the time. The other 7%? They are stimulating what we call ashi or “painful points.”
So while you think you may be getting acupuncture, many of these practitioners have not been required to take CNT classes or have been tested in proper aseptic techniques. Always check the credentialing of your practitioner. Look for NCCAOM diplomates, no matter where you a located, to guarantee they have taken and passed the CCCAOM Clean Needle Technique class.
If you’re interested in learning more about acupuncture, check out this blog post on How Acupuncture Works
Signs your practitioner may be unsafe
While training is an important metric for acupuncture safety, there are some other practices that could put you at risk that should be mentioned.
Find another practitioner if:
1) Your practitioner needles you through clothing
It’s shocking, but it does still happen. This is not sanitary. Fibers, dirt and other contaminants are carried into your body along the needle shaft. If your practitioner is going to needle you through clothing, end the session.
2) The practitioner sterilizes needles
While proper sterilization techniques are probably safe, a practitioner who sterilizes needles risks needles that break or equipment that malfunctions and does not clean properly. Best practices require single use, disposable needles.
3) Your practitioner cleans your points with essential oils
Your practitioner should clean points with 70% isopropyl alcohol. The alcohol remains in contact with microbes on the surface of your skin long enough to kill them and then evaporates. Essential oils may have antimicrobial properties but 1) they should not be being applied to your skin in high enough concentrations to clean at the appropriate levels and 2) they do not evaporate. Because they remain on the surface of your skin, when the shaft of the needle passes through the film of oil, the oil is carried into your body. This is not safe and can lead to complications.
4) Your practitioner uses an open pack of needles left over from a previous patient
If your practitioner is using single use needles, but not opening a fresh pack for you there is a chance of infection from a contaminated guide tube. Ask for a new pack of needles.
5) The practitioner directly touches the shaft of the needle
Best practice is that for techniques which require a supporting hand on the shaft of the needle, your practitioner should use sterile gauze just in case that part of the needle crosses your skin barrier.
I hope that this post helped to clear up the confusing world of Minnesota Acupuncture. Stay safe! If you have any questions comment below or shoot me a message through the contact form on the home page.
Resources and Links
Minnesota Acupuncture Association resource page on Dry Needling
NCCAOM Find a Practitioner Database
Disclaimer: I am an acupuncturist in the state of Minnesota, and the information falls within my scope of practice in my state. However, unless I have directed you here as your homework I am probably not your acupuncturist. The information in this post is for general purposes only and does not constitute medical advice. As always, check with your own acupuncturist or primary care provider before making any lifestyle changes. This post does not create a patient-practitioner relationship and I am not liable for any losses or damages resulting or relating to the content in this post.
Jessica Gustafson is a licensed acupuncturist in St Paul, MN specializing in women’s health and fertility. She loves working with patients through the Health Foundations Birth Center on Grand Avenue in St Paul as well as doing home visits in the Twin Cities area. Check out the services page for more information!
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