Who gets to hold the needle when it’s not called acupuncture

Your physical therapist suggests something new for the knot under your shoulder blade: a thin needle, with nothing injected through it, slipped into the tight spot in the muscle. This is dry needling, the therapist explains, and it is not acupuncture.

Whether that is true depends on who is asking. Since May 2025, a physical therapist in Utah who wants to offer it must finish a course of at least 304 hours, 250 of them spent treating patients under supervision, and then register with the state. In Oregon, physical therapists can’t do it at all until July 2027. And Medicare’s coverage rule for acupuncture lists dry needling as one of acupuncture’s types.

Dry needling is one of three routes by which needles reach American patients under a name other than acupuncture. The second is a five-needle ear protocol the military calls battlefield acupuncture, which the Department of Veterans Affairs has given to tens of thousands of veterans. The third is electroacupuncture, which runs a small current through the needles. A fourth route uses no needle at all: acupressure that patients do on themselves.

Below: who may do each, what the trials show, and how long benefit lasts. The wider fight over real versus fake needles, and the guidelines naming classic acupuncture, are laid out in our article on the numbers behind the acupuncture argument.

Dry needling and the fight over who holds the needle

As physical therapists use it, dry needling means inserting thin needles into trigger points, tender knots in muscle, to treat pain.

The last state-by-state chart the American Physical Therapy Association posted openly is dated February 2022 on its face. It showed 38 states and the District of Columbia allowing physical therapists to dry needle, five prohibiting it (California, Hawaii, New York, Oregon and Washington) and seven with no clear rule. The association’s July 2026 map sits behind a member login, so no open, current national count exists, and the old chart is already out of date. Oregon’s 2025 law, HB 3824, adds dry needling to physical therapists’ scope on July 1, 2027. The state’s licensing board says therapists may not do it before then, and it expects a dry needling workgroup with the Oregon Medical Board to begin in February 2027.

Training rules vary as much as permission does. Utah’s 2025 law is specific: a state-approved course of at least 304 hours, including 54 hours of in-person instruction and 250 hours of supervised patient treatment, then registration as a dry needling practitioner. The seven states the chart listed as silent had, as of that chart, no law addressing dry needling by physical therapists, so no training hours were written into law for it.

Utah’s 2025 law already applies the same course and registration rules to occupational therapists, and Colorado has followed: a law signed there in April 2026 lets occupational therapists dry needle from September 1, 2027, after an approved course, with written consent that covers benefits and risks and states that the therapist is not an acupuncturist.

Physicians’ organizations see it differently. In June 2016, according to a meeting report from the American Academy of Physical Medicine and Rehabilitation, the American Medical Association’s House of Delegates adopted a resolution calling dry needling an invasive procedure, to be done only by practitioners with standard training and everyday familiarity with needles, such as licensed physicians and licensed acupuncturists. That is association policy, not law.

The other side cites a different kind of evidence. The Federation of State Boards of Physical Therapy, the umbrella group for state PT regulators, commissioned a 2015 analysis that found 86% of the knowledge and skills needed to dry needle competently are acquired in entry-level physical therapy education. A 2020 update put it at 103 of 119 critical knowledge requirements, or 87%. The rest is almost entirely needling technique and hands-on skill from added training. That is a regulator-commissioned map of what therapists already know, not evidence that dry needling is safe or works.

Medicare settles the naming question its own way. The program’s national coverage determination for acupuncture, in force since January 2020, states: “All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.” There, cLBP means chronic low back pain, so Medicare files dry needling under acupuncture and excludes it for every other condition. Even for chronic low back pain, payment runs through the rule’s list of eligible practitioners, which our main acupuncture piece walks through. Physical therapists are not named on that list, which suggests, though the rule does not say so in words, that Medicare would not pay for dry needling by a physical therapist who lacks the acupuncture degree and license the rule requires.

So the claim that dry needling isn’t acupuncture is about professional turf, not the needle. Medicare files the practice under acupuncture, while Colorado makes occupational therapists tell patients they are not acupuncturists.

What dry needling trials show, and what it costs in bruises

The evidence is mostly short-term. A 2017 meta-analysis in the Journal of Orthopaedic & Sports Physical Therapy pooled 13 randomized trials of dry needling by physical therapists. On very low to moderate quality evidence, needling beat no treatment, sham needling and other treatments for pain for up to 12 weeks. At six to 12 months, the pain advantage was no longer statistically significant. Function improved more than with sham or no treatment, but not more than with other physical therapy, and the authors concluded that a long-term benefit has not been shown.

A larger 2021 meta-analysis by Spanish researchers, in the journal Physical Therapy, pooled 42 trials and found pain reductions from within 72 hours out to 13 to 24 weeks, compared with no treatment, sham or other therapies. Most of that evidence was rated low quality because results varied so widely. The two reviews covered different time windows, so they do not conflict: benefit out to about six months has low-quality support, and benefit beyond that has not been shown.

Minor side effects are common. In a 2020 survey, 420 physical therapists logged adverse events across about 20,000 treatments over six weeks. A minor event followed 36.7% of treatments, led by bleeding (16%), bruising (7.7%) and pain during needling (5.9%). Twenty major events were reported, roughly one per 1,000 treatments. The therapists were reporting on their own work, so these figures are approximate.

The most feared complication is a collapsed lung, or pneumothorax. A 2025 case report in Physical Therapy describes a 24-year-old woman treated at an outpatient clinic for chronic neck and shoulder pain who felt an unusually sharp pain as a needle went into the muscles between her shoulder blades, placed with a technique called rib bracketing. Over the next two days she developed breathlessness, chest pain and a dry cough. An X-ray showed a moderate collapse of the left lung, treated with a chest tube and one night in hospital, and she had recovered fully within a month. The authors, who included a dry needling specialist, questioned whether that technique is safe in that part of the back. The Melbourne emergency department series we cover alongside acupuncture’s harm record included two more lung collapses after dry needling.

Battlefield acupuncture: adopted widely, proven thinly

Battlefield acupuncture was developed in 2001 by Richard C. Niemtzow, an Air Force physician, as a fast pain treatment suited to military settings. It places five small semi-permanent needles at set points in each ear, where a 2021 review says they stay for three to four days or longer. Training is a four-hour course on this one protocol, according to studies summarized in the VA’s Whole Health Library.

That brevity made it easy to spread. A VA fact sheet says that, depending on state scope of practice, nurses, physical therapists and pharmacists may become certified to deliver limited protocols like this one, even though they are not acupuncturists. A VA cohort study counted 41,234 veterans who received battlefield acupuncture at 130 VA facilities between October 2016 and March 2019. Training counts come from separate programs and can’t be added together: more than 1,300 VA clinicians in one account, 2,712 providers over 19 months in another, and, by its developer’s own account, thousands trained through a $5.4 million joint Defense and VA fund.

The largest look at routine care, covering 11,406 veterans at 57 VA medical centers, found that more than three-quarters reported less pain right after treatment, with an average drop of 2.5 points on a 0-10 scale at the first session. Those were immediate ratings from ordinary visits, with no comparison group, and veterans who had used opioids in the previous year improved less.

Controlled trials tell a cooler story. A 2021 meta-analysis led by Mayo Clinic researchers pooled five randomized trials with 344 participants and found no significant improvement in pain intensity compared with no treatment, usual care, sham or delayed treatment; side effects were mild and brief, and study quality was poor. A second 2021 review, by authors at VA Connecticut and Yale, counted five of seven randomized trials as positive but rated six of them at high risk of bias for lack of blinding, and said wider adoption needs better trials. In 2017, a VA Connecticut pair that included one of that review’s authors had concluded that “the amount and quality of published research presently do not justify wide adoption of this practice by those strictly adherent to evidence-based medicine.”

Individual trials split. In a single-center VA trial of 72 surgical patients, ear needling roughly halved opioid use in the first 24 hours compared with sham and lowered pain, with no difference in hospital stay. In a Navy hospital trial of 99 adults having their tonsils out, pain was lower only on the day of surgery, with no difference in opioid use. An Air Force trial in 70 new mothers and an Australian emergency department trial of 90 patients found no significant added benefit.

VA clinicians have named downsides too. Interviews with 43 battlefield acupuncture providers raised thin clinical guidelines, patients asking for repeated visits, discomfort, and a post-treatment euphoria that could undercut patients’ own self-care. On the library’s scale, the ear protocol is widely used but its evidence is insufficient and mixed.

Electroacupuncture against the ear protocol

The most useful battlefield acupuncture data came from a head-to-head trial. In PEACE, published in JAMA Oncology in 2021, researchers at Memorial Sloan Kettering Cancer Center and five suburban sites in New York and New Jersey randomly assigned 360 cancer survivors with at least three months of musculoskeletal pain to 10 weekly sessions of electroacupuncture, 10 of battlefield acupuncture, or usual care.

At 12 weeks, electroacupuncture lowered pain 1.9 points more than usual care on a 0-10 scale, and the ear protocol 1.6 points more. But the ear protocol failed to show that it was not meaningfully worse than electroacupuncture, and 10.5% of patients assigned to it stopped because of side effects, against 0.7% with electroacupuncture. PEACE had no sham arm, so it cannot say how much of either benefit came from the needles themselves. PEACE’s sleep findings are left to our article on sleep and chronic pain.

Adding current does not guarantee a win over sham. In a double-blind Stanford trial of 121 adults with chronic low back pain, 12 sessions of real electroacupuncture over six weeks did not beat sham on the main pain measure, though back-related disability improved more with real treatment. In a 2021 trial in China of 442 people with knee osteoarthritis, 60.3% responded to eight weeks of electroacupuncture, 58.6% to manual acupuncture and 47.3% to sham; electroacupuncture beat sham at eight weeks, manual acupuncture narrowly missed, and both beat sham by week 16.

Acupressure: the door with no needle

Acupressure means pressing on acupuncture points without breaking the skin. Two University of Michigan trials taught people to do it on themselves.

In a 2016 trial in JAMA Oncology, 288 breast cancer survivors with persistent fatigue, at least a year past treatment, were assigned to six weeks of daily relaxing acupressure, stimulating acupressure, or usual care. At six weeks, 66.2% of the relaxing group and 60.9% of the stimulating group had fatigue in the normal range, against 31.3% with usual care, and the gap held at 10 weeks. Only the relaxing version improved sleep and quality of life. One woman withdrew because of bruising at the points, and there was no sham arm. In a 2019 pilot of 67 adults with chronic low back pain, pain fell 35% to 36% in the acupressure groups, and the few side effects came from pressing too hard.

The 2024 fatigue guideline from the American Society of Clinical Oncology and the Society for Integrative Oncology says acupressure may be recommended for survivors with persistent fatigue after treatment. The panel noted that this rests on that single trial, in which 90% of participants were White women with early-stage breast cancer, and judged the benefit for people still in treatment not yet established. It added that the technique is quick to pick up and cheap, with uncommon, mild side effects, and can be learned from a free app or one session with a licensed acupuncturist. The separate evidence on acupressure for nausea, and the wristbands sold for it, is weighed in our acupressure article.

How long does the benefit last?

One belief says needling wears off the moment a course ends; another says it fixes pain for good. The best data reject both.

A 2017 analysis in Pain by the Acupuncture Trialists’ Collaboration drew on individual patient data from 29 high-quality trials of acupuncture for chronic pain, though only some measured pain repeatedly after treatment ended. In the eight trials, with 2,985 patients, that compared acupuncture with no acupuncture, the advantage shrank by roughly 9% by 12 months, so about 90% of it persisted; at the pessimistic end of the statistical range, about 70%. In the 16 trials, with 4,534 patients, that compared real with sham acupuncture, the smaller advantage shrank by about half over the same year. Leaving out three neck pain trials, where effects clearly faded and courses were short, the loss against sham was roughly 30%. Typical courses ran 8 to 15 treatments over 10 to 12 weeks, and the authors warned that finding no important loss at a year does not mean the effects last well beyond one. These figures sit comfortably with the roughly 15% one-year erosion from the collaboration’s 2018 update, which appears in our look at the sham debate.

For the side doors, durability data are thinner still. Dry needling’s pain edge had lost statistical significance by six to 12 months in the 2017 review. Battlefield acupuncture has mostly been measured over hours or days, not months. A large US trial called BackInAction has randomized 800 people aged 65 and older with chronic low back pain, at four health systems, to standard acupuncture, acupuncture plus maintenance sessions, or usual care. Its results had not appeared in the medical literature as of late October 2026.

Questions to ask before anyone needles you

1. Does this state allow your profession to do this? Utah, Colorado and Oregon have all changed their rules since 2025.
2. How much dry needling training did you complete, and how much of it was supervised treatment of real patients? Utah’s 250 supervised hours is one concrete benchmark.
3. Will any needle go over my chest wall or between my shoulder blades, and what keeps it out of the lung? That region produced the collapsed-lung reports.
4. What should improve, by how much and by when, and what is the plan if it doesn’t? Dry needling trials show benefit mainly within the first three months.
5. For ear needles: how long do they stay in, and what should I watch for in the meantime?
6. Who is paying? Medicare’s rule excludes dry needling for everything except chronic low back pain, and even then limits who can be paid. Private plans vary.

When to get help

• Breathlessness, chest pain or a dry cough in the hours or days after needling near the upper back, shoulders or chest: same-day medical care, and 911 if breathing is severely difficult. The 2025 case followed exactly that course.
• Spreading redness, warmth, pus or fever around a needle site, especially for someone getting chemotherapy or radiation. Because those treatments blunt the body’s defenses against infection, the National Center for Complementary and Integrative Health calls for strict clean-needle practice with cancer patients.
• Pain that is new, getting worse, or arrives with numbness, weakness, or changes in bladder or bowel control calls for medical assessment, and whether a needling course makes sense is a decision for the clinician who does it. Whether needling, ear acupuncture or acupressure fits alongside cancer care or any other treatment is for the clinician managing that care to decide.

The Takeaway

The label on the door, whether dry needling, battlefield acupuncture or acupressure, tells you who may practice and who pays, not how well the treatment works. For that, ask the two questions the evidence keeps coming back to: compared with what, and for how long?

Dry needling has low-quality support for a few months of relief. The ear protocol has wide adoption, mixed trials, and a head-to-head trial in which it failed to show it was nearly as good as electroacupuncture, with more people stopping because of side effects. Self-acupressure has one solid trial, for fatigue after breast cancer. And a course of classic acupuncture keeps most of its edge over no treatment for a year, while losing more of its smaller edge over sham.

Sources

1. Centers for Medicare & Medicaid Services. “National Coverage Determination 30.3.3, Acupuncture for Chronic Lower Back Pain (cLBP) (effective January 21, 2020; implemented June 24, 2020; latest revision entry 10/2024, coding only). Section C: "All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.".” cms.gov
2. Oregon Physical Therapist Licensing Board. “HB 3824 status page (updated August 25, 2026): takes effect July 1, 2027; physical therapists may not perform dry needling before then; Dry Needling Workgroup with the Oregon Medical Board expected to begin February 2027.” oregon.gov
3. Utah State Legislature. “H.B. 188 Dry Needling Amendments, 2025 General Session, enrolled copy (effective May 7, 2025): course of at least 304 hours including 54 hours in-person instruction and 250 supervised patient treatment hours; registration required.” le.utah.gov
4. Colorado General Assembly. “HB26-1042 Dry Needling by Occupational Therapists (signed April 2, 2026; authorization from September 1, 2027; written consent stating the therapist is not an acupuncturist).” leg.colorado.gov
5. American Physical Therapy Association. “APTA Dry Needling Laws by State (chart printed "Last updated 2/13/22"; file name dated 2023): 38 states plus DC permit, 5 prohibit, 7 silent.”
6. American Physical Therapy Association. “State Laws and Regulations Governing Dry Needling Performed by PTs (dated July 18, 2026; data current as of July 2026; map behind member login).” apta.org
7. American Academy of Physical Medicine and Rehabilitation. “AMA Annual June 11-15, 2016 Report: Resolution 223, Dry Needling is an Invasive Procedure, adopted.” aapmr.org
8. Federation of State Boards of Physical Therapy. “Dry Needling Competencies (2015 practice analysis by HumRRO; more than four-fifths of required knowledge acquired in entry-level education).” fsbpt.org
9. Federation of State Boards of Physical Therapy. “Caramagno J, Harris J. Dry Needling Practice Analysis 2020 memo (January 8, 2021): 86% in 2015; 87% (103 of 119) in 2020.” FSBPT.org
10. U.S. Department of Veterans Affairs, Integrative Health Coordinating Center. “Acupuncture in VA fact sheet: RNs, PTs and pharmacists may be eligible to become certified providers of limited protocols such as battlefield acupuncture, depending on state scope of practice.” va.gov
11. U.S. Department of Veterans Affairs, Whole Health Library. “Battlefield Acupuncture (BFA) (last updated January 18, 2024): five semi-permanent needles per ear; 4-hour training; 1,300+ VHA clinicians trained (Taylor et al.); 2,712 providers over 19 months (Niemtzow et al.).” va.gov
12. National Center for Complementary and Integrative Health, National Institutes of Health. “Cancer and Complementary Health Approaches: What You Need To Know (Last Updated October 2021): strict clean-needle procedures for people with cancer because treatment weakens the immune system.” nccih.nih.gov
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24. Journal of Integrative and Complementary Medicine. “Baldawi M, McKelvey G, Patel VR, et al. "Battlefield Acupuncture Use for Perioperative Anesthesia in Veterans Affairs Surgical Patients: A Single-Center Randomized Controlled Trial." J Integr Complement Med, 2022. PubMed. DOI: 10.1089/jicm.2021.0429.” pubmed.ncbi.nlm.nih.gov
25. The Laryngoscope. “Shah AN, Moore CB, Brigger MT. "Auricular acupuncture for adult tonsillectomy." Laryngoscope, 2020 (e-published 2019). PubMed. DOI: 10.1002/lary.28338.” pubmed.ncbi.nlm.nih.gov
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28. JAMA Oncology. “Mao JJ, Liou KT, Baser RE, et al. "Effectiveness of Electroacupuncture or Auricular Acupuncture vs Usual Care for Chronic Musculoskeletal Pain Among Cancer Survivors: The PEACE Randomized Clinical Trial." JAMA Oncol, 2021. PubMed. DOI: 10.1001/jamaoncol.2021.0310.” pubmed.ncbi.nlm.nih.gov
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31. JAMA Oncology. “Zick SM, Sen A, Wyatt GK, et al. "Investigation of 2 Types of Self-administered Acupressure for Persistent Cancer-Related Fatigue in Breast Cancer Survivors: A Randomized Clinical Trial." JAMA Oncol, 2016. PubMed. DOI: 10.1001/jamaoncol.2016.1867.” pubmed.ncbi.nlm.nih.gov
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34. Pain. “MacPherson H, Vertosick EA, Foster NE, et al., for the Acupuncture Trialists' Collaboration. "The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain." Pain, 2017. PubMed. DOI: 10.1097/j.pain.0000000000000747.” pubmed.ncbi.nlm.nih.gov
35. Contemporary Clinical Trials. “Justice M, Piccorelli A, Avins AL, et al. "Baseline sample characteristics for the BackInAction pragmatic trial of acupuncture for chronic low back pain in older adults." Contemp Clin Trials, 2025. PubMed. DOI: 10.1016/j.cct.2025.107981.” pubmed.ncbi.nlm.nih.gov