THE CHIROPRACTIC SCOPE OF PRACTICE IN THE UNITED STATES: A CROSS-SECTIONAL SURVEY Mabel Chang, DC, MPH

ABSTRACT Objective: The purpose of this study was to assess the current status of chiropractic practice laws in the United States. This survey is an update and expansion of 3 original surveys conducted in 1987, 1992, and 1998. Methods: A cross-sectional survey of licensure officials from the Federation of Chiropractic Licensing Boards e-mail list was conducted in 2011 requesting information about chiropractic practice laws and 97 diagnostic, evaluation, and management procedures. To evaluate content validity, the survey was distributed in draft form at the fall 2010 Federation of Chiropractic Licensing Boards regional meeting to regulatory board members and feedback was requested. Comments were reviewed and incorporated into the final survey. A duplicate question was imbedded in the survey to test reliability. Results: Partial or complete responses were received from 96% (n = 51) of the jurisdictions in the United States. The states with the highest number of services that could be performed were Missouri (n = 92), New Mexico (n = 91), Kansas (n = 89), Utah (n = 89), Oklahoma (n = 88), Illinois (n = 87), and Alabama (n = 86). The states with the highest number of services that cannot be performed are New Hampshire (n = 49), Hawaii (n = 47), Michigan (n = 42), New Jersey (n = 39), Mississippi (n = 39), and Texas (n = 30). Conclusion: The scope of chiropractic practice in the United States has a high degree of variability. Scope of practice is dynamic, and gray areas are subject to interpretation by ever-changing board members. Although statutes may not address specific procedures, upon challenge, there may be a possibility of sanctions depending on interpretation. (J Manipulative Physiol Ther 2014;37:363-376) Key Indexing Terms: Health Resources; Health Services; Legislation; Licensure; Chiropractic

hiropractic is the third largest health profession in the United States and the largest and most recognized of the complementary and alternative professions. 1 Chiropractors in all 50 states, the District of Columbia, Puerto Rico, and the United States Virgin Islands provide direct access care to patients. 1 Scope of practice is the regulation of professionals in a specific jurisdiction and is used to legally create boundaries by restricting the allowed activities for a specified profession. 2 Its purpose is to protect the public by setting legal limits for what a provider can do, and it can be used as a means to define a profession in a particular locale. 3–5 Some scholars counter that practice laws have failed to protect the public but have been used as a tool to limit competition. 6–12

C

Assistant Professor, Clinical Sciences, National University of Health Sciences–Florida, Pinellas Park, FL. Submit requests for reprints to: Mabel Chang, DC, MPH, Assistant Professor, Clinical Sciences, National University of Health Sciences, SPC–Health Education Center, 7200 66th St N., Pinellas Park, FL 33781. (e-mail: [email protected]). Paper submitted November 5, 2013; in revised form May 9, 2014; accepted May 13, 2014. 0161-4754 Copyright © 2014 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2014.05.003

Practice laws are the responsibility of each state, and this has caused variations in scopes of practice for a wide variety of health professionals. 3,13–17 The United States does not have a unified scope of practice for most health care professionals. This has contributed to fragmentation of health care across jurisdictions. The only health care professionals that have a unified scope of practice across state lines are medical doctors and doctors of osteopathy. 2 The medical profession was the first to have licensure standards, and because they were the first to become licensed, their scope of practice is uniform and broad. 4,5,18 As each health care profession sought licensure, the American Medical Association aggressively defended their practice rights and ensured that limitations were put on other professions. 7,18–21 It should be noted that all health professional organizations have followed the same tactics in defending their practice rights. 22,23 In addition to the prior 3 surveys, there have been several surveys that were located in the gray literature performed by state associations, student research projects, and the World Federation of Chiropractic. The state surveys explore local attitudes of their members on issues of chiropractic unity, drugs, and scope expansion. 24,25 “The Legal Status of Chiropractic Practice Internationally” is a survey of association members from 85 countries. Data from 49 363

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countries were collected pertaining to legal status, direct access to patients, protection of titles, presence of regulations for licensure, imaging rights, prescription rights, laboratory tests, ability to authorize sick leave, and reimbursement climate. The report was completed in June 2011. 26 The student research project surveyed alumni practicing in the states of Alabama and Florida. 27 None of the respondents to these surveys were members of regulatory boards. Data from the Congressional Budget Office indicates that the Patient Protection and Affordable Care Act will expand health care coverage to 33 million nonelderly Americans. 28 Twenty-seven million people are expected to gain health insurance by 2017. 29 In addition to the increase in the number of insured, the senior population has been growing at an exponential rate. One of 5 in the US population will be older than 65 years by 2030. 30 The fastest growing segment of this group is the oldest of the old—those 85 years and older. 31 With society's longevity comes the associated increase in chronic diseases. Those with chronic disease require more health care resources. 32 Full-scope physicians have not been able to address the needs of our population's growing health care demands. They are working fewer hours, 33 restricting their practices by opting out of Medicare, 34 and setting up boutique practices to provide better quality care to fewer patients. 35–37 In addition, a substantial number of these providers will be retiring soon. 38,39 This has caused public officials to worry about stretching an already thin workforce. 40–43 States are looking for ways to accommodate the demands for health care, especially in states that are already experiencing health care workforce shortages. 41 Using all health care providers to the fullest extent of their training is one solution that will provide timely relief to these problems. In addition to the workforce shortage, the Patient Protection and Affordable Care Act is encouraging the formation of Accountable Care Organizations and the Patient Centered Medical Home in an effort to improve health outcomes through integration and cross-communication between providers. 44 Clarification of the chiropractic scope of practice will help to facilitate referrals and participation in these organizations. Legislation relating to the scope of practice of health professionals is increasing in the United States because of these factors. There were 1795 scope of practice-related bills proposed in 54 states, territories, and the District of Columbia between January 2011 and December 2012, but only 349 have been adopted or enacted into law. 40,45 The purpose of this study is to clarify regulations that guide chiropractic practice by updating and expanding the 3 original surveys conducted in 1987, 46 1992, 47 and 1998. 48 The original 3 studies surveyed 78 services, whereas this study surveys 97 services. 46–48 To the author's knowledge, this update offers the most comprehensive survey of regulatory officials on specific services allowed in their jurisdictions.

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METHODS The institutional review board at the National University of Health Sciences reviewed this study and exemption was granted. Following the procedures of the 3 previous surveys, spinal manipulation and regional spine plain film radiography were not included in the survey. 46–48 The current survey was updated in consultation with the original investigator, the American Chiropractic Association, and the Federation of Chiropractic Licensing Boards (FCLB) to include the following items: diagnostic ultrasound imaging, surface electromyography (EMG), National Department of Transportation Driver Physicals, orthopedic and neurologic examinations, hernia examinations, magnetic therapy, traction, oxygen therapy, dry needling of trigger points, hyperbaric chamber, manipulation under anesthesia, and veterinary chiropractic. Electrotherapy was broken down to specific therapies. Applied kinesiology and intervaginal uterine manipulation were removed from the survey. Ninety-seven services were evaluated compared with 78 services in the prior surveys. A comment section was added to the survey to allow for commentary after each set of questions. To evaluate content validity, the survey was distributed in draft form at the fall 2010 FCLB regional meeting to regulatory board members, and feedback was requested. Comments were reviewed and incorporated into the final survey. In addition to surveying Canada, the United States, and the District of Columbia, the survey was expanded to include Puerto Rico, and the Virgin Islands, Australia, and New Zealand. Results from Australia, Canada, and New Zealand will be reported in a separate article. The sample frame used included regulatory officials who were a part of the FCLB e-mail list. Officials were asked to respond with their name, contact information, and position on the board. If the official was no longer a member of the board, he/she was asked to contact the investigator and provide contact information for an alternate official. The officials were asked to choose a single response indicating the extent that a health care service was within the chiropractic scope of practice in their jurisdiction. Structured answers included the following: (1) can perform (includes can order), (2) can perform with additional training/certification, (3) can order (or refer), and (4) cannot order/perform. After each section of the survey, officials were given an opportunity to clarify their responses in an essay box. If a jurisdiction left an item blank, it was not counted in the percentage totals. Reminders were sent each month to those who had not completed the survey. Portable document format of the survey was made available to the board members as well. In late January 2011, the study began data collection using the Form Creation Module for the DotNetNuke Content Management System (v 1.6.4 Code 5 Systems; LLC, Aberdeen, SD). Because of the magnitude of the

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survey, the survey instrument was migrated to SurveyMonkey (SurveyMonkey Inc, Palo Alto, CA) in late March 2011, so that respondents could save their responses and return to the survey later. The survey was closed in January 2012, and the process of reconciling the data continued. If there were inconsistencies within the same jurisdiction, the respondents were contacted by telephone, e-mail, or both; advised of the inconsistencies; and asked to review their answers. If the inconsistencies were not able to be resolved by this method, it had been decided a priori that rank of the responding official would determine which response was deemed correct. This decision was based on the assumption that higher-ranking officials have more responsibility within the organization and therefore will be more familiar with practice law in their jurisdiction than lower-ranking officials. During the data analysis, it was discovered that some of the inconsistent responses were made by the same official. Upon further inquiry, it was revealed that administrators had filled out their surveys using the president's or chair's demographic information. It was decided that the certifying official's responses would be considered accurate. Because of the length of the study, if multiple replies from the same jurisdictions were received, the most recent data were considered correct if the responses were greater than 6 months apart. If neither of the above applied, the question was considered unanswered. A duplicate question was imbedded in the survey to test reliability. If validation failed, respondents were notified that they had failed the duplicate question test and they were asked to review the survey in its entirety. In June 2013, all respondents were given a copy of their answers and asked to review them and make changes accordingly. Percentage totals were made for each item. The percent within scope reflects the combined responses of “can perform,” “can perform with additional training/certification,” and “can order.” If an item was left unanswered, it was not included in the calculations.

RESULTS Partial or complete responses were received from 96% (n = 51) of the jurisdictions surveyed. Of these, Indiana provided demographic information only, Maryland opted out of SurveyMonkey, and Puerto Rico did not respond to our requests. Respondents held a range of titles including president, chairperson, executive director, director, general counsel, legal assistant, bureau manager, program manager, executive assistant, administrative specialist, and board administrator. The results are reported in Tables 1, 2, and 3. The states with the broadest chiropractic practice laws determined by the number of services that could be performed were Missouri (n = 92), New Mexico (n = 91), Kansas (n = 89), Utah (n = 89), Oklahoma (n = 88), Illinois (n = 87), and Alabama (n = 86). The most restrictive states

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by the number of services that cannot be performed are New Hampshire (n = 49), Hawaii (n = 47), Michigan (n = 42), New Jersey (n = 39), Mississippi (n = 39), and Texas (n = 30). Extremity examinations (n = 48), orthotic supports (n = 48), orthopedic examinations (n = 47), spinal supports (n = 47), lifestyle counseling (n = 47), and neurologic examinations (n = 46) may be performed by a chiropractor without additional education in every jurisdiction that responded. Vitamin supplementation (n = 46), temporomandibular joint evaluation and treatment (n = 45), full-spine radiographs (n = 48), traction (n = 45), diet formulation (n = 44), electrical stimulation (n = 43), ultrasound (n = 42), tens (n = 42), botanical therapy (n = 39), IFC (n = 41), and microcurrent therapy (n = 41) may be performed in all jurisdictions that responded, but may require additional education. Ninety percent or more of the jurisdictions report that limited prescription rights and minor surgery were not within the chiropractic scope of practice. There were a total of 97 services surveyed.

Diagnostic Imaging Full-spine radiographs (n = 46) can be performed in all jurisdictions without additional education, except in Delaware and Rhode Island, where they can only be ordered. It is legal for doctors of chiropractic (DCs) to order or perform the following services in all jurisdictions that responded: computed tomography (CT; n = 43) and magnetic resonance imaging (MRI; n = 45). Idaho responded that thermography was under discussion during the time of the survey and that it may be allowed with additional training because it falls under diagnostic x-rays. Michigan qualified their answers to this portion of the survey by stating that DCs can order MRI of the spine only. In Ohio, “chiropractic radiologists are permitted to perform computed tomography (CT) scans, MRI, and fluoroscopy at free standing or mobile diagnostic imaging centers. A chiropractic radiologist must have diplomate status by the American Chiropractic Board of Radiology (ACBR) and those who perform CT and MRI must be credentialed by the ACBR.” Oregon reports that they do have specific training and informed consent requirements for breast thermography but more information can be found on their Web site. In Texas, there are no clear rules or guidelines for CT scan, cholecystography, thermography, or diagnostic ultrasound. Needle EMG cannot be performed in Texas, but a nerve conduction study without needles is permitted. Iowa code/rules does not address needle EMG, but a policy statement from the board indicates that needle EMG and nerve conduction velocity studies are within the scope with additional training and certification. Vermont states that the board has no ruling on electrocardiography and has not contemplated this issue.

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Please see Appendix A for locale abbreviations and Appendix B for a glossary and abbreviations of selected services.

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Table 1 Diagnostic and Examination Certifications

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Please see Appendix A for locale abbreviations and Appendix B for a glossary and abbreviations of selected services.

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Table 2 Physical Examination, Gender-Specific Services, Physiotherapeutics, and Specialty Adjusting Techniques

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Please see Appendix A for locale abbreviations and Appendix B for a glossary and abbreviations of selected services.

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Table 3 Adjunctive and Specialty Services

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Diagnostic Procedures Doctors of chiropractic are able to order or perform surface EMG (n = 43) in all jurisdictions that responded.

Laboratory Procedures Blood analysis (n = 44) can be ordered or performed in all jurisdictions that responded. Arkansas reports that blood can be drawn for analysis; however, nothing can be injected into the body. In Oklahoma, venipuncture of the skin is limited to the injection of natural nutrients and vitamin compounds. In Texas, needles can be used only to draw blood for diagnostic purposes and for acupuncture.

Examination Procedures All of the jurisdictions that responded allowed DCs to perform extremity examinations (n = 43), orthopedic examinations (n = 42), and neurologic examinations (n = 41) without additional education. Doctors of chiropractic may order or perform impairment ratings (n = 42) in all jurisdictions that responded. California law does not specify if signing birth certificates and performing electrocardiography are within the scope of practice. Hawaiian statutes do not address school physicals. In the District of Columbia, the survey was answered presuming that school physicals included giving vaccinations if needed/wanted for that age group, and thus, the official marked it as “cannot perform.” In Kentucky, a chiropractor may perform these examinations if taught by an accredited chiropractic college; however, the board recommends that these examination procedures be referred to a more specifically trained medical doctor. Tennessee statute allows for the performance of services such as impairment ratings, school physicals, sports physicals, and others, but there may be rules in place within the system (ie, Department Of Education, Worker's Compensation, and hospital) that bar chiropractors from performing them within that system. New Mexico states that premarital examinations are not required in their jurisdiction.

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these procedures would require signed informed consent from the patient prior to performing the examinations. In rare cases in New York, a cursory breast examination may be done if there is referred spinal pain to the chest or a skin eruption, that is, shingles, but not as a routine/preventive screening. Tennessee reported that statute does not prohibit the performance of any of these tests, except if/when they constitute the practice of some other branch of the healing arts. If/when that is said to occur has not been tested.

Physiotherapy All jurisdictions that responded also allowed DCs to perform ultrasound (n = 43), transcutaneous electrical nerve stimulation (n = 43), interferential therapy (n = 42), micro– current therapy (n = 42), and electrical stimulation (n = 43), except for the state of Washington, where these services can be ordered. Massage (n = 55) can be performed in all locales, except Hawaii. Hawaii notes, however, that DCs may perform trigger point therapy and paraspinal soft tissue work. Traction (n = 44) can be performed without additional education in all jurisdictions, except the District of Columbia, Kentucky, and Wisconsin, where additional education is required. It is legal for DCs to order or perform the following services in all jurisdictions that responded: ultrasound iontophoresis without prescription medication (n = 39), Russian stimulation (n = 41), nonablative laser therapy without tissue destruction (n = 40), and cryotherapy (n = 41). Illinois states that laser therapy is allowed but does not include laser hair removal or other dermatological cosmetic procedures that cause tissue destruction. In Ohio, nonablative laser therapy can only be related to musculoskeletal conditions.

Adjustive/Manipulative Procedures Extremity adjusting (n = 56) can be performed in all locales, except Hawaii.

Nutrition Gender-Specific Services An area of frequent commentary pertained to femaleand male-sensitive examinations. Washington State qualified that the hernia examination is approved as external only. Several jurisdictions noted that the procedures themselves are within the chiropractic scope of practice, but the “appropriateness” of such examinations must be documented. Arizona, Kansas, Kentucky, Ohio, Oregon, and Vermont recommended referral to a more appropriate professional. They stressed that if performed, documentation of appropriate setting and clinical rationale for these examinations was important. Without them, a doctor would very likely be investigated, subject to a hearing, and potentially face sanctions. Nevada and Oregon noted that

Vitamin supplementation (n = 44), diet formulation (n = 43), and botanical therapy (n = 41) could be performed in all jurisdictions.

Treatment Procedures All jurisdictions that responded allowed DCs to perform orthotic supports (n = 44), spinal supports (n = 43), and lifestyle counseling (n = 43) without additional education. All jurisdictions that responded allowed DCs to perform temporomandibular joint evaluation and/or treatment (n = 43), except for the state of Washington, where these services can be ordered. All jurisdictions allow rehabilitation to be performed (n = 43), except Rhode Island.

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Specialty Procedures Electrolysis is a minor surgery procedure that requires specialty certification in minor surgery to perform in Oregon. Alabama, Arkansas, Idaho, Illinois, Massachusetts, Michigan, Missouri, Nebraska, New Jersey, Ohio, Oregon, Pennsylvania, Utah, and Wisconsin state that a veterinarian and a chiropractor must work in conjunction with each other to deliver care to animals and the chiropractor must have training in animal chiropractic.

Jurisdiction-Specific Information Several jurisdictions stated that although a chiropractor has been trained in a procedure, because of the language of the law, these procedures would only be legally performed if it related to a spinal condition. For example, in New York, soft casts may be used in sprains to an extremity only if due to a primary spinal condition. New York also states that overthe-counter vitamins/nutritional supports can be recommended, but not over-the-counter medication. Endonasal technique is allowed if secondary to a primary spinal complaint. In Utah, “the Chiropractic Physician Practice Act and Rule permit examination, diagnosis and treatment using x-ray, and administration of physical agents, including light, heat, cold, water, air, sound, compression, electricity, and electromagnetic radiation except gamma radiation, provided the licensee has the education and training to competently practice a procedure. Specific diagnostic imaging procedures are not identified. Should questions arise concerning quality and adequacy of care, the Quality and Standards Committee will serve as an advisory peer committee to the Chiropractic Physician Licensing Board. This Committee is made up of five chiropractic physicians licensed and in good standing that are qualified by education, training and experience to competently act in quality care review to determine adequacy and appropriateness of care. A chiropractic physician may not: (a) perform incisive surgery; (b) administer drugs or medicines for which an authorized prescription is required by law except as provided in Subsection (2)(d); (c) treat cancer; (d) practice obstetrics; (e) prescribe or administer x-ray therapy; or (f) set displaced fractures.”

“Virginia law only mentions the 24 moveable vertebrae. The chiropractor may perform procedures necessary to practice his profession.” Virginia law states that “the practice of chiropractic does not include the use of surgery, obstetrics, or osteopathy.” Kentucky and Montana affirm that DCs may perform procedures as long as they were taught them at an accredited chiropractic school. In Michigan, procedures noted in Tables 1, 2, and 3 are permitted if they relate to the subluxation complex. Washington State notes that “analysis is considered the interpretation of results of a test by a chiropractor and does not include the technical performance of taking, collecting, or testing of samples. Diagnostic procedures that are within the scope of practice are allowed for purposes of providing a chiropractic differential diagnosis. However, individuals should review Washington law to determine how the law may apply to their particular circumstance.”

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DISCUSSION The number of jurisdictions that responded to this survey is higher than the past surveys possibly due to the increased number of requests for those who did not respond. 46–48 Similar to prior surveys, there appears to be a trend of increasing scopes of practice. 47,48 Similar to prior surveys, 46–48 there were instances where one procedure was within the scope of practice, yet an associated diagnostically valuable procedure was not. 46–48 For example, 58% of the jurisdictions reported that DCs could perform bimanual examination of the female pelvis without additional training, but only 44% allowed Papanicolaou test to be performed. There were several comments that should be discussed further. Respondents indicated that although procedures may be within the scope of practice, there may be other organizations such as insurers, employers, schools, and so on, that may not accept or reimburse for services provided. Some jurisdictions reported that although procedures were within the scope of chiropractic practice, they questioned whether they were “usual and customary.” As Vermont elaborates, “presumably a person properly trained may be able to do this procedure, but should a complaint or charge be made against the doctor, there is nothing in the statute that expressly permits or prohibits this procedure.” Other jurisdictions commented that although DCs are qualified in the procedures, the procedures must be related to a spinal condition as stated in the statutes. Documentation of rationale, justification, and consent was cited by a number of jurisdictions. Tennessee cited specific language indicating that services were permitted as long as they did not infringe on the practice rights of another healing profession. Some jurisdictions were in the midst of challenges to the performance of some items on the survey and chose to leave those items unanswered. This highlights the ambiguity of the statutes. Effective interprofessional and integrated health care requires that all providers understand each other's scope of practice. 49,50 Most health care providers will not refer to another profession if they do not understand their scope of practice. Complementary and alternative medicine is often not well understood by other professions. This lack of information prevents referrals unless a patient requests one. One study found that this leads to feelings of self-consciousness and defensiveness by the complementary and alternative medicine practitioner and leads to further isolation. 49 A study of the inclusion of chiropractic in the Veterans Health Administration found that varying perceptions of chiropractic care by health care providers and administrators caused problems in effective use of chiropractic. 51 Organizations that are considering integrative care are also concerned that limited scope providers make appropriate referrals when the situation arises. It is important that DCs know what is legally permissible in their states as well as organizationally created limitations to their scope of practice. This will allow for appropriate referrals. 50

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Education and training of limited scope health care providers is broader than what state practice laws allow. 42,52–54 For instance, as part of The Council of Chiropractic Education accreditation process, chiropractic schools are to educate and train students to become a “competent doctor of chiropractic who will provide quality patient care and serve as a primary care physician,” yet the variances in practice regulation do not allow this to occur. 16,55,56 In addition, the language of state practice acts may be vague and may not be sufficient to answer whether a technique or procedure is within a particular scope of practice. 16 This can be very confusing for patients, health care providers, insurers, students, and policy makers. Scope of practice is an important issue for patients, health care providers, health care organizations, and policy makers. Although scope of practice is important, there are many other factors that dictate whether procedures are used in practice. Some of these factors include organizational climate, 57–59 reimbursement, 7,57,59–61 the philosophy of the doctor, doctor preference, patient demand, and societal perceptions as to appropriateness. A practice analysis of chiropractic radiologists showed that although trained to read advanced imaging, the majority read only or mostly plain films. 62 Even with practice laws that were favorable for nurse practitioners to practice primary care, there were many organizational factors that restricted this from happening. 57,58 Uniform practice models for health care professionals have been advocated for many health care providers. The National Highway Traffic Safety Administration has proposed a model of uniform scope of practice for emergency medical personnel to alleviate public confusion, improve professional mobility, decrease reciprocity challenges, and increase the efficiency of the health care workforce. 13 Duenas 16 has advocated for a uniform chiropractic practice act in the United States. Having a uniform model of practice would decrease confusion of the public, policy makers, and other providers and would facilitate the use of chiropractic services.

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health care professionals may not be familiar with the services that were surveyed. This may have caused services that were not understood to be skipped. This survey was administered electronically, and this may limit the number and type of respondent. Another limitation includes vague statutes and gray areas that licensing boards are charged with interpreting when challenges to scope of practice arise. The interpretation will depend on who sits on the board at the time. The boards regularly have membership changes, and this can affect the interpretation of the practice laws.

Future Studies Areas of suggested research using this information include performing well-conducted studies on the adoption of expansion in scope by DCs, studies to assess whether quality or safety of health care is jeopardized in states with broader scopes. It would also be useful to look at health care costs in states with expanded chiropractic services. Lastly, because of the evolving nature of scope of practice, this survey should be repeated after health care reform has been implemented.

CONCLUSION This study found that chiropractic practice in the United States can vary widely between jurisdictions. Although statutes may not address specific procedures, upon challenge there may be a possibility of sanctions depending on interpretation. Scope of practice is dynamic, and gray areas are subject to clarification by ever-changing board members. This study should be helpful for providers, educators, patients, and policy makers in determining the limitations to chiropractic practice by jurisdiction and when addressing any changes that need to be made to the current scope of practice regulations. For more information about the statutes and rules for the study jurisdictions, please go to FCLB's Chiropractic Regulatory page found at http://www. fclb.org/Boards.aspx.

Limitations Limitations to this study include the transitory nature of board membership; thus, these results may not reflect the views of future board members. Some administrative personnel completed the survey using the highest ranking official's demographic information. Although there were a handful of boards that choose to complete the survey together, most responses came from individuals with a wide range of rank leading to concerns about self-reporting and that answers may not be representative of the entire board. In addition, the length of the survey may have caused respondents to only complete part of the survey or to incorrectly answer the survey questions due to fatigue. Although a number of respondents were health care professionals, some were not. Several states had their attorneys interpret the statutes and fill out the survey. Non–

Practical Applications • Although chiropractic services are allowed, due to the language of the law in some jurisdictions, services must be related to the spine. • Although chiropractic services are allowed, there were questions to appropriateness that would expose the chiropractor to sanctions. • Although services are within the scope of chiropractic practice, there may be other organizations that restrict payment or would not accept services provided. • Similar to prior surveys, in some cases although one procedure was allowed, another associated, diagnostically valuable service was not allowed.

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FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST No funding sources or conflicts of interest were reported for this study.

CONTRIBUTORSHIP INFORMATION Concept development (provided idea for the research): M.C. Design (planned the methods to generate the results): M.C. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): M.C. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): M.C. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): M.C. Literature search (performed the literature search): M.C. Writing (responsible for writing a substantive part of the manuscript): M.C. Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): M.C.

ACKNOWLEDGMENTS The author thanks Dr Lester Lamm for the use of his prior survey and advised in the updating of the survey. The author thanks the FCLB, Kelly Webb, and Donna Leiwer for the use of their mailing list, assistance in pretesting the survey, and their help in gathering responses. The author thanks Dr Susan Bedair for her assistance in data collection and editing the manuscript.

REFERENCES 1. NBCE 2010 Practice Analysis. [cited 2013 Aug 27]. Available from: https://www.nbce.org/links/publications/ practiceanalysis/. 2. Cassidy A. Nurse practitioners and primary care (updated). Health Affairs; 2013 [Available from: http://www. healthaffairs.org/healthpolicybriefs/brief.php?brief_id=92]. 3. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century—Institute of Medicine. Washington, DC: National Academy Press; 2001 [[cited 2014 Mar 18]. Available from: http://www.iom.edu/Reports/2001/Crossingthe-Quality-Chasm-A-New-Health-System-for-the-21stCentury.aspx]. 4. Final report of the Commission on Medical Education. Calif West Med 1933;38:112-3. 5. The National Council of State Boards of Nursing. Changes in healthcare professions' scope of practice: legislative considerations. [cited 2013 Aug 23]. Available from: https://www. ncsbn.org/ScopeofPractice_09.pdf.

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6. Bourgeault IL, Grignon M. A comparison of the regulation of health professional boundaries across OECD countries. Eur J Comp Econ 2013;10:199-223. 7. Blevins SA. The medical monopoly: protecting consumers or limiting competition. Policy Anal 1995;246:1-36. Available from: http://forhealthfreedom.org/Publications/Monopoly/ CatoPA246MedMonopoly.pdf]. 8. Folland S, Goodman AC, Stano M. The economics of health and health care. . 7th ed. Upper Saddle River, N.J: Pearson; 2013. 9. Fuchs VR. Who shall live? Health, economics and social choice. . 2nd ed. Singapore: World Scientific; 2011. 10. Safriet B. Impediments to progress in health care workforce policy: license and practice laws. Inquiry 1993;31:310-7. 11. Feldstein PJ. The politics of health legislation: an economic perspective. Health Administration Press Perspectives; 1988 [276 p.]. 12. Havighurst CC. The changing locus of decision making in the health care sector. J Health Polit Policy Law 1986;11:697-735. 13. National Highway Traffic Safety Administration. National EMS Scope of Practice Model. National Highway Traffic Safety Administration; 2007 [cited 2014 Jan 30]. Available from: https://www.nremt.org/nremt/downloads/Scope%20of %20Practice.pdf. 14. Gardner D. Expanding scope of practice: inter-professional collaboration or conflict? Nurs Econ 2010;28:264-6. 15. Wesorick BR, Doebbeling B. Lessons from the field: the essential elements for point-of-care transformation. Miscellaneous ArticleMed Care 2011;49:S49-58. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y& NEWS=N&PAGE=fulltext&D=yrovftm&AN=00005650201112001-00010]. 16. Duenas R. United States Chiropractic Practice Acts and Institute of Medicine defined primary care practice. J Chiropr Med 2002;1:155-70. 17. Bellamy JJ. Legislative alchemy: the US state chiropractic practice acts. Focus Altern Complement Ther 2010;15: 214-22. 18. Ronald Hamowy. The early development of medical licensing laws in the United States 1875-1900. J Libert Stud. 3(1):17–119. 19. Ameringer Carl F. The health care revolution: from medical monopoly to market competition—chapter 1: the professional regime. The Health Care Revolution: From Medical Monopoly to Market Competition. University of California Press; 2008 [[cited 2013 Sep 30]. Available from: http://www. ucpress.edu/content/pages/10188/10188.ch01.pdf]. 20. Baerlocher MO, Detsky AS. Professional monopolies in medicine. JAMA 2009;301:858-60. 21. Baer HA. Divergence and convergence in two systems of manual medicine: osteopathy and chiropractic in the United States. Med Anthropol Q 1987;1:176-93. 22. Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff (Millwood) 2013;32:1881-6. 23. Huijbregts Peter A. Chiropractic legal challenges to the physical therapy scope of practice: anybody else taking the ethical high ground? J Manipulative Ther 2007;15:69-80. 24. Alabama State Chiropractic Association. Alabama State Chiropractic Association: 2010 Scope of Practice Survey. [cited 2013 Aug 27]. Available from: http://www.mccoypress. net/subluxation/docs/ASCAscope.pdf. 25. NYSCA & New York Chiropractic College Conduct Scope of Practice Survey [Internet]. The Chronicle of Chiropractic. [cited 2013 Jul 18]. Available from: http://chiropractic. prosepoint.net/64259. 26. World Federation of Chiropractic. The legal status of chiropractic practice internationally. Toronto ON Canada: World Federation of

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45. Scope of Practice Legislation Tracking Database. [cited 2013 Aug 26]. Available from: http://www.ncsl.org/issues-research/ health/scope-of-practice-legislation-tracking-database.aspx. 46. Lamm L, Wegner E. Scope of practice: what the law allows. AJCM 1989;2:155-9. 47. Lamm L, Wegner E, Collord D. Chiropractic scope of practice: what the law allows—update 1993. J Manipulative Physiol Ther 1995;18:16-20. 48. Lamm L, Pfannenschmidt K. Chiropractic scope of practice: what the law allows—update 1999. J Neuromusculoskel Syst 1999;7:102-6. 49. Soklaridis S, Kelner M, Love RL, Cassidy JD. Integrative health care in a hospital setting: communication patterns between CAM and biomedical practitioners. J Interprof Care 2009;23:655-67. 50. Gray B, Orrock P. Investigation into factors influencing roles, relationships, and referrals in integrative medicine. J Altern Complement Med 2014;17 [140117124141004]. 51. Khorsan R, Cohen AB, Lisi AJ, et al. Mixed-Methods Research in a Complex Multisite VA Health Services Study: variations in the implementation and characteristics of chiropractic services in VA. Evid Based Complement Alternat Med. [cited 2014 Feb 6];2013. Available from: http://www. hindawi.com/journals/ecam/2013/701280/abs/2013. 52. Fairman JA, Rowe JW, Hassmiller S, Shalala DE. Broadening the scope of nursing practice. N Engl J Med 2011;364:193-6. 53. Dower Catherine, Christian Sharon, O'Neil Edward. Promising scope of practice models for the health professions. San Francisco: Center for the Health Professions University of California; 2007 [[cited 2013 Oct 8]. Available from: http:// futurehealth.ucsf.edu/Content/29/2007-12_Promising_ Scope_of_Practice_Models_for_the_Health_Professions.pdf]. 54. Dill MJ, Pankow S, Erikson C, Shipman S. Survey shows consumers open to a greater role for physician assistants and nurse practitioners. Health Aff (Millwood) 2013;32:1135-42. 55. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status, January 2007. The Council on Chiropractic Education; 2007 [[cited 2014 Jan 27]. Available from: http://www. cce-usa.org/uploads/2007_January_STANDARDS.pdf]. 56. Duenas R, Carucci GM, Funk MF, Gurney MW. Chiropracticprimary care, neuromusculoskeletal care, or musculoskeletal care? Results of a survey of chiropractic college presidents, chiropractic organization leaders, and Connecticut-licensed doctors of chiropractic. J Manipulative Physiol Ther 2003;26:510-26. 57. Poghosyan L, Nannini A, Stone PW, Smaldone A. Nurse practitioner organizational climate in primary care settings: implications for professional practice. J Prof Nurs 2013;29:338-49. 58. Poghosyan L, Nannini A, Smaldone A, et al. Revisiting scope of practice facilitators and barriers for primary care nurse practitioners: a qualitative investigation. Policy Polit Nurs Pract 2013;14(1):6-15. [[cited 2013 Aug 23]; Available from: http://ppn.sagepub.com.proxy.cc.uic.edu/content/early/2013/ 03/21/1527154413480889]. 59. Gaumer GL. Regulating health professionals: a review of the empirical literature. Milbank Mem Fund Q Health Soc 1984;62: 380-416. 60. Cooper RA. Health care workforce for the twenty-first century: the impact of nonphysician clinicians. Annu Rev Med 2001;52:51-61. 61. American Medical Association. Digest of Official Actions. 1969-1978, Reimbursement in Federal Programs [Internet]; 1-419; 1980248. [Available from: http://ama.nmtvault.com/jsp/ viewer.jsp?doc_id=Digest of Official Actions%2Fama_arch% 2FAD100001%2F00000003]. 62. Smith SD, Beran TN. Practice analysis of chiropractic radiology: identifying items for part I of the clinical competency examination. J Manipulative Physiol Ther 2012;35:710-9.

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APPENDIX A. LOCALE ABBREVIATIONS

APPENDIX B. SELECT SERVICES GLOSSARY AND ABBREVIATIONS (IN ORDER OF APPEARANCE)

Country abbreviations Australia New Zealand United States United States, territories, and possessions

AU NZ US

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Canadian provinces and territories names and abbreviations

AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

British Columbia New Brunswick Prince Edward Island Saskatchewan

BC NB PE SK

Diagnostic Imaging Full spine: radiographs of the entire spine Skull: radiographs of the head Soft tissue: imaging of the muscles, ligaments, and tendons 1 Barium studies/barium swallow (Ba): a small amount of barium paste or liquid administered orally and observed radiographically or by fluoroscopy for examination of swallowing and esophageal function 2 Tomography: the recording of internal body images at a predetermined plane by means of the tomograph 3 Computed tomographic scan: digitized, detailed, spatially accurate, serial, 3-dimensional body images, created by a narrow beam of x-rays delivered along a spiral trajectory (2-mm “slices” for foot and ankle), in which compact bone appears white, and air black; CT scans are especially useful for examination of cortical bone. 4 Magnetic resonance imaging (MRI): the patient is placed in a magnetic field and radiofrequency signals are transmitted and received by surrounding coils. A computer processes the information and constructs crosssectional images which provide detailed information on soft tissues. 5 Cholecystography: visualization of the gallbladder by x-rays after the administration of a radiopaque substance 6 Thermography: a technique wherein an infrared camera photographically portrays the body's surface temperature, based on self-emanating infrared radiation; sometimes used as a means of diagnosing underlying pathologic conditions, such as breast tumors 7 Diagnostic ultrasound (US): the use of ultrasound to obtain images for medical diagnostic purposes, employing frequencies ranging from 1.6 to about 10 MHz Diagnostic Testing 8 Electrocardiography (ECG): a commonly used, noninvasive procedure for recording electrical changes in the heart 9 Surface scanning electromyography (sEMG): the recording of electrical activity generated in muscle for diagnostic purposes using surface recording electrodes 10 , 11 Needle electromyography and/or nerve conduction studies (EMG/NCS): the recording of electrical activity generated in muscle for diagnostic purposes using needle recording electrodes/a noninvasive method for assessing a nerve's ability to carry an impulse, which quantifies latency periods and conduction velocities; larger peripheral motor and sensory nerves are electrically stimulated at various intervals along a motor nerve 12 Doppler (Vascularizer): a diagnostic instrument that emits an ultrasonic beam into the body; the ultrasound reflected from moving structures changes its frequency (Doppler effect). Of diagnostic value in peripheral vascular and cardiac disease

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Blood analysis: analysis of the blood Urinalysis: analysis of the urine Sputum analysis: (analysis of) matter coughed up and usually expelled from the mouth, especially mucus or mucopurulent matter expectorated in diseases of the air passages Fecal analysis: analysis of feces Semen analysis: analysis of semen Throat swab Skin scrape Hair analysis Examinations School physicals National Department of Transportation Driver Physicals Preemployment physicals Premarital physicals Impairment ratings Sign birth certificates Sign death certificates Eyes/Ears/Nose/Throat (EENT) examinations Abdominal examinations Extremity examinations Orthopedic examinations Neurologic examinations Chest auscultations 13 Sphygmomanometry: determination of the blood pressure by means of a sphygmomanometer 14 Bi-manual (pelvic) examination: a pelvic examination is a routine procedure used to assess the well-being of the female patients' lower genito-urinary tract 15 Speculum examination: a speculum is an instrument that is used during the internal genitalia examination. It can be made of plastic or metal and is used to open up the vaginal cavity in order for the examiner to view the walls of the vagina and the cervix. Rectovaginal examination 16 Papanicolaou test: a screening test for precancerous and cancerous cells on the cervix. This simple test is done during a routine pelvic examination and involves scraping cells from the cervix. Female breast examination: Rectal examination Male genital examination Prostatic examination (digital) Hernia examination Physiotherapy 17 Ultrasound therapy (UST): the application of ultrasound waves to soft tissue to heat and relax injured tissue and disperse edema 18 Transcutaneous electrical nerve stimulation (TENS): a technique used for pain relief in which nerves are electronically stimulated to block transmission of pain information to the brain Interferential therapy (IFC): a form of electrostimulation therapy using 2 or 3 distinctly different currents that are passed from a tissue through surface electrodes

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Microcurrent therapy: an electrotherapeutic modality that uses low levels of electrical current (b 1 mAmp) to facilitate circulation and cellular healing or to reduce pain or edema 20 Magnetic therapy: an alternative medical therapy in which the placement of magnets or magnetic devices on the skin is thought to prevent or treat symptoms of disease, especially pain Electrical stimulation 21 Iontophoresis (not with prescription medication): therapy that uses a local electric current to introduce the ions of a medicine into the tissues Russian stimulation: uses medium frequencies to provide electrical stimulation to muscle groups and is used to reduce muscle spasms as well as for muscle strengthening Nonablative laser therapy: laser therapy without tissue destruction Short wave therapy: warmth is created in the tissue via electric and magnetic fields. Hydrocolation: hot, moist pack used to treat bruises, sprains, and muscle spasms 22 Cryotherapy: medical treatment in which all or part of the body is subjected to cold temperatures, as by means of ice packs 23 Massage: the act of kneading, rubbing, and so on, parts of the body to promote circulation, suppleness, or relaxation 24 Traction: the use of a pulling force to treat muscle and skeleton disorders Extremity adjusting: manipulation the extremities of the body including arms, legs, feet, hands Soft tissue manipulation of the abdominal viscera 25 Craniopathy (cranial adjusting): area of medicine concerned with the bones that encase the brain Vitamin supplementation Glandular supplementation: thyroid, adrenal, thymus derived from cow or pig glands. Glandular therapy helps provide the exact nutrients that the gland needs to perform adequately. Diet formulation Botanical therapy: the use of plants or plant extracts for medicinal purposes (especially plants that are not part of the normal diet) Homeopathic preparations: a system for treating disease based on the administration of minute doses of a drug that in massive amounts produces symptoms in healthy individuals similar to those of the disease itself Orthotic supports Spinal supports Lifestyle counseling Rehabilitation: a treatment or treatments designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible. Nonadjustive treatment of female pelvic conditions Intrarectal manipulation of the coccyx

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Ear irrigation: a routine procedure used to remove excess earwax, called cerumen, or foreign materials from the ear 26 Colonic irrigation: a water enema given to flush out the colon Temporomandibular joint evaluation and/or treatment Digital manipulation of the Eustacian tube orifice (“Endonasal Technique”) Nasal Specifics (balloon inflation into nasal passages) 27 Oral chelation therapy: the process of removing a heavy metal from the bloodstream by means of a chelate as in treating lead or mercury poisoning—via mouth 28 Intravenous chelation therapy: the process of removing a heavy metal from the bloodstream by means of a chelate as in treating lead or mercury poisoning administered into a vein Vitamin injection Limited prescription writing privileges includes prescription writing of medications pertaining to field of care Recommendation of nonprescription items (over counter) 29 Oxygen therapy: treatment in which an increased concentration of oxygen is made available for breathing, through a nasal catheter, tent, chamber, or mask Dry needling of trigger points the use of solid filiform needles for therapy of muscle pain, sometimes also known as intramuscular stimulation 30 Minor surgery: surgical procedure for minor problems or injuries that are not considered life-threatening or hazardous 31 Obstetrics: the branch of medicine that deals with the care of women during pregnancy, childbirth, and the recuperative period after delivery

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Extremity casting: sprains Extremity casting: uncomplicated fractures 32 Hypnosis: an altered state of consciousness characterized by focusing of attention, suspension of disbelief, increased amenability and responsiveness to suggestions and commands, and the subjective experience of responding involuntarily 33 Acupuncture (needle puncture): practice in Chinese medicine in which the skin, at various points along meridians, is punctured with needles to remove energetic blockages and stimulate the flow of qi 34 Electroacupuncture: the application of electrical stimulation to acupuncture points 35 Electrolysis: destruction by passage of a galvanic current, as in disintegration of a chemical compound in solution or removal of excessive hair from the body 36 Hyperbaric chamber: an airtight chamber containing an oxygen atmosphere under high pressure. A patient may be placed in the chamber for the treatment of certain infections, tumors, and cardiovascular diseases in which atmospheric oxygen pressures up to 3 times normal may have therapeutic value. 37 Manipulation under anesthesia (MUA): multidisciplinary manual therapy treatment system which is used to improve articular and soft tissue movement using specifically controlled release, myofascial manipulation, and mobilization techniques while the patient is under moderate to deep intravenous sedation using monitorized anesthesia care (MAC) Veterinary chiropractic: refers to animal chiropractic care

The chiropractic scope of practice in the United States: a cross-sectional survey.

The purpose of this study was to assess the current status of chiropractic practice laws in the United States. This survey is an update and expansion ...
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