needling should – at a minimum – have standards that are similar to the ones for training, certification, and continuing education that exist for acupuncture. ama board member russell w. h. kridel, md: "lax regulation and nonexistent standards surround this invasive practice. for patients' safety, practitioners should meet standards required for licensed acupuncturists and physicians." additional adverse effects for dry needling including pneumothorax, cardiac tamponade, hematoma, infection, central nervous system injury, and other complications. during a recent study, a self-reported survey of almost 230,000 people, 8.6% (19726 patients) reported experiencing at least one adverse effect. 2.2% (4,963 patients) reported an adverse effect that required further treatment. however, since this study was based on the patient's self-reporting rather than actual incidence, the collective findings cited above demonstrated are probably lower than the actual incidence. because dry needling sometimes involves blood and other bodily fluids, there are sometimes risk of transmission of multiple forms of hepatitis as well as hiv. relation to acupuncture the debated distinction between dry needling and acupuncture has become a controversy because it relates to an issue of scope of practice of various professions. acupuncturists claim that dry needling is a form of acupuncture that does not fall in the scope of physical therapists, chiropractors, or the majority of other healthcare professionals; whereas those healthcare professionals claim dry needling is not acupuncture, but rather a procedure that is rooted in biomedical modern sciences. to become a certified acupuncturist requires hundred of hours spent in educational programs, national level exams, and good professional standings. on the other hand, to be certified in dry needling requires continued education or a certification program that is not yet regulated with strict standards; in addition, there is a general lack of policymakers, evaluation systems, or healthcare standards governing the technique of dry needling. many physical therapists and chiropractors have asserted that they are not practicing acupuncture when dry needling; however, much of dry needling research has been done with reference to acupuncture. they assert that much of the basic physiological and biomechanical knowledge that dry needling utilizes is taught as part of their core physical therapy and chiropractic education and that the specific dry needling skills are supplemental to that knowledge and not exclusive to acupuncture. many acupuncturists have argued that dry needling appears to be an acupuncture technique requiring minimal training that has been re-branded under a new name (dry needling). whether dry needling is considered to be acupuncture depends on the definition of acupuncture, and it is argued that trigger points do not correspond to acupuncture points or meridians. they correspond by definition to the ad hoc category of 'a-shi' acupoints. it is important to note that this category of points is not necessarily distinct from other formal categories of acupoints. in 1983, janet travell described trigger point locations as 92% in correspondence with known acupuncture points. in 2006, a journal article concluded that the two point systems are in over 90% agreement. in 2009, dorsher and fleckenstein conclude that the strong (up to 91%) consistency of the distributions of trigger point regions’ referred pain patterns to acupuncture meridians provides evidence that trigger points most likely represent the same physiological phenomenon as acupuncture points in the treatment of pain disorders. an article in acupuncture today further corroborates the 92% correspondence of trigger points to acupuncture points. in 2011, the council of colleges of acupuncture and oriental medicine published a position paper describing dry needling as an acupuncture technique. according to the results of a qualitative review, it suggests that dry needling combined with acupuncture was more effective in alleviating pain and achieved a higher response rate than dry needling alone. however, there is no clear research on if dry needling is a better treatment choice over laser, physical therapy, or other combined treatments. regulation the north carolina acupuncture licensing board has published a position statement asserting that dry needling is acupuncture and thus is covered by the north carolina acupuncture licensing law, and is not within the present scope of practice of physical therapists. the attorney general was asked for an opinion by the north carolina acupuncture licensing board which he gave in 2011: "in our opinion, the board of physical therapy examiners may determine that dry needling is within the scope of practice of physical therapy if it conducts rulemaking under the administrative procedure act and adopts rules that relate dry needling to the statutory definition of practice of physical therapy." however, the north carolina rules review committee of the legislative branch found that the north carolina physical therapy board had no statutory authority for the proposed rule. the physical therapy board subsequently decided that they had the right to declare dry needling within scope anyway "the board believes physical therapists can continue to perform dry needling so long as they possess the requisite education and training required by n.c.g.s. § 90–270.24(4), but there are no regulations to set the specific requirements for engaging in dry needling." in january 2014, the oregon court of appeals ruled that the oregon board of chiropractic examiners did not have the statutory authority to include dry needling in the scope of practice for chiropractors in that state. the ruling did not address whether chiropractors have the medical expertise to use dry needling or whether the training they were being given was adequate. pending further discussion of training requirements the oregon physical therapist licensing board has advised all oregon physical therapists against practicing dry needling. they have not changed their ruling that dry needling is within the scope of practice for oregon physical therapists.