Background
In the United States, dry needling performed by physical therapists has traditionally excluded intra-articular techniques. Recently, a published clinical study incorporated intra-articular and periosteal electrical dry needling as part of an intervention for knee osteoarthritis.(Dunning et al., 2025). Following the publication of this study, multiple state boards of physical therapy indicated that their statutes, rules, or regulations do not explicitly prohibit intra-articular dry needling. While this may be surprising, perhaps this paper led to the clarification that any form of dry needling may be permissible, as long as there are no specific rules against it. A rare exception would be North Carolina, where in 2024, the Board of Physical Therapy Examiners issued a position statement that perineural dry needling is not within the scope of physical therapy.
At the same time, several state physical therapy boards have reaffirmed longstanding positions that they do not issue declarative opinions regarding scope of practice unless prompted by a formal complaint or enforcement action. This regulatory posture raises a fundamental question for licensees and researchers alike: if a state board cannot or will not clarify whether a specific procedure is within the scope of physical therapy practice, who bears responsibility for determining legality and compliance?
Scope-of-Practice Ambiguity
Scope-of-practice determinations historically rely on statutory language, administrative rules, advisory opinions, and case law. In the absence of explicit authorization or prohibition, clinicians are left to interpret broad statutory definitions, often under conditions of professional uncertainty and potential legal exposure.
The lack of definitive guidance regarding intra-articular dry needling places physical therapists in a precarious position. While the absence of prohibitive statutory language may suggest permissibility, it does not necessarily equate to affirmative authorization. This ambiguity becomes particularly consequential when emerging or invasive techniques are introduced into clinical practice or research protocols.
Electrical Dry Needling and State-Specific Restrictions
The study in question examined periosteal and intra-articular electrical dry needling and reported that data were collected in multiple U.S. states, including Illinois. However, Illinois law and regulatory interpretation have historically placed limits on the use of electrical stimulation in conjunction with dry needling by physical therapists, raising questions about whether the procedures performed in the study were within the lawful scope of physical therapy practice in that jurisdiction. According to the Illinois Statutes Chapter 225. Professions, Occupations and Business Operations § 90/section 1.5. Dry needling:
Dry needling does not include the teaching or application of acupuncture described by the stimulation of auricular points, utilization of distal points or non-local points, needle retention, application of retained electric stimulation leads, or other acupuncture theory.
Does this mean that in Illinois, physical therapists would not be allowed to use electrical stimulation combined with dry needling? Or are “needle retention” and “the application of retained electric stimulation leads” permissible if physical therapists do not apply acupuncture? Do the statutes suggest that any “application of retained electric stimulation leads” automatically implies the practice of acupuncture? That would require more clarification of what is meant by the application of retained electric stimulation leads. The word “retained” does not necessarily imply the presence of indwelling needles. Would that apply to all electrical stimulation, including TENS, which, one could argue, involves the application of retained electric stimulation leads? The latter would be unimaginable, as electrical stimulation by physical therapists dates to the late 19th century, almost a century before acupuncturists began exploring electro-acupuncture.
This clause in the Illinois Statutes appears to be somewhat ambiguous. It highlights a potential discrepancy between what is commonly assumed (electrical dry needling is not within the scope of PT practice in Illinois) and what may actually be written in the Statutes (acupuncture described by the stimulation of auricular points, utilization of distal points or non-local points, needle retention, application of retained electric stimulation leads, or other acupuncture theory).
This potential discrepancy introduces concerns regarding:
- Compliance with state-specific scope-of-practice laws
- Consistency of study procedures with local regulatory requirements
- Potential exposure of clinicians and institutions to legal or disciplinary risk
Research Ethics and Institutional Review Board Oversight
An additional ethical concern arises from the study’s approval by a foreign institutional review board (IRB). While international IRBs may provide valid ethical oversight, they may not be fully aware of, or positioned to evaluate, the variability of state-by-state scope-of-practice laws within the United States. Many universities require that research protocols must be approved by the local equivalent of an Institutional Review Board (IRB) in addition to the university’s overall IRB approval. For example, Cornell University requires
“Research conducted by Cornell faculty, students, and staff in foreign countries must be reviewed and approved by the Cornell IRB. In addition to Cornell IRB approval, some international research must also be approved by the local equivalent of an IRB. Where there is no equivalent board or committee, researchers should work with local NGOs, researchers, or community leaders to ensure that the project is consistent with cultural and legal expectations, and to secure support for the conduct of the research.”
If research data are collected in a jurisdiction where a study intervention may fall outside the legal scope of practice for the participating clinicians, several ethical and regulatory questions emerge:
- Were investigators operating in compliance with local laws governing professional practice?
- Were participants adequately protected from procedures that may have been unlawfully delivered?
- Did the informed consent include information that stipulated that at least part of the study protocol may have been illegal in their state?
- Does IRB approval remain valid if it is based on an incomplete understanding of applicable local regulations?
- What responsibility do principal investigators and sponsoring institutions have to verify state-level legal compliance in multi-jurisdictional research?
According to the Belmont Report, “When a clinician departs in a significant way from standard or accepted practice, the innovation does not, in and of itself, constitute research” (“Protection of human subjects; Belmont Report: notice of report for public comment”, 1979).
I am not suggesting that the researchers violated state laws, as intra-articular dry needling is not necessarily outside the scope of practice in several states, and electrical dry needling may actually be within the scope of physical therapy practice, even in Illinois, as long as a therapist is not applying acupuncture.
Position and Recommendations
Given the issues outlined above, the following positions are advanced for consideration:
- Regulatory Clarification Is Necessary
State boards of physical therapy, professional associations, and regulatory bodies should collaborate to provide more explicit guidance regarding intra-articular and electrical dry needling to protect clinicians, patients, and researchers. - Scope-of-Practice Responsibility Must Be Defined
In the absence of formal board opinions, more precise mechanisms are needed to determine who is responsible for interpreting scope-of-practice limitations—particularly in research contexts. - Research Must Comply with State Law
All clinical research conducted within the United States must adhere not only to ethical standards but also to the specific laws and regulations governing professional practice in each state where data are collected. - IRB Review Should Include Legal Due Diligence
Institutional review boards—domestic or foreign—should require documentation demonstrating that proposed interventions comply with local scope-of-practice laws across all research sites. - Transparency and Disclosure Are Essential
Published studies should clearly disclose how regulatory compliance was assessed in each participating jurisdiction to maintain research integrity and public trust.
Conclusion
The introduction of intra-articular and electrical dry needling into physical therapy practice and research highlights longstanding gaps in regulatory clarity. These gaps become especially problematic in multi-state and international research settings. Addressing these issues proactively is essential to uphold patient safety, professional accountability, and the ethical conduct of research.
Jan Dommerholt, PT, DPT | President/CEO, Myopain Seminars
References
Dunning, J., Young, I., Taylor, N., Mourad, F., Bliton, P., Butts, R., Escaloni, J., Gorby, P., Varghese, R., Maselli, F., & Fernandez-de-Las-Penas, C. (2025). Effect of dose interval of periosteal and intraarticular electrical dry needling boosters on pain and disability in patients with knee osteoarthritis: a multi-center randomized clinical trial. Physiother Theory Pract, 1–14. https://doi.org/10.1080/09593985.2025.2575837
Protection of human subjects; Belmont Report: notice of report for public comment. (1979). Federal Register, 44(76), 23191–23197.