MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

In the US, the scope of practice of health care professionals is a matter for each state to decide. Only the one of doctors is regulated nationwide. Other health care professions’ scope of practice can vary considerably within the US. This means that a chiropractor in one state of the US might be allowed to do more (or less) than in the next state. But what exactly are US chiropractors legally allowed to do?

A recent paper was aimed at answering this very question. Its authors assessed the current status of chiropractic practice laws in the US.

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.

Partial or complete responses were received from 96% (n = 51) of the jurisdictions. 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).

The authors conclude that 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.

For me, the most surprising aspect of this article was to realise how many ‘non-chiropractic’ activities chiropractors are legally permitted in some US states. Here are some of the items that amazed me most:

  • birth certificates
  • death certificates
  • premarital certificates
  • recto-vaginal exam
  • venepuncture
  • i.v. injections
  • prostatic exam
  • genital exam
  • homeopathy
  • ear irrigation
  • colonic irrigation
  • oral and i.v. chelation therapy
  • obstetrics
  • hypnotherapy
  • acupuncture
  • hyperbaric chamber

I have to admit that I did not even know what a PREMARITAL CERTIFICATE’ is; so I looked it up. The first one I found on the internet was entitled “PURITY  COVENANT” and committed the couple “to abstain from fornication and remain sincere to the Lord Jesus Christ and to each other”

I have to further admit that many other of the items on this list leave me equally speechless. For example, how can chiropractors with their training focussed on the musculoskeletal system responsibly complete a death certificate? Why are they allowed in some states to examine the genitalia of their patients?

I suspect the perceived need of chiropractors to do all these things must be closely related to their long-standing ambition to become primary care physicians. Just to be clear: a primary care physician is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis.  I have always been more than just a bit perplexed how chiropractors, who state that they are musculoskeletal specialists, might even consider being competent primary care providers.

But regardless of common sense, they do! The US ‘Council of Chiropractic Education’ accreditation process, for instance, requires schools 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” and the chiro-literature is awash with statements such as this one: “The primary care chiropractic physician is a viable and important part of the primary health care delivery system, with many chiropractic physicians currently prepared to participate effectively and competently in primary care.” Moreover, the phenomenon is by no means limited to the US: “chiropractors in the UK view their role as one of a primary contact healthcare practitioner and that this view is held irrespective of the country in which they were educated or the length of time in practice.”

As far as I am concerned, chiropractors might view their role as whatever they want. The fact is that, even if they add many more items to the list of their ‘services’, they are very far from being competent primary care physicians. Being able to provide the first contact as well as continuous care of medical conditions, not limited by cause, organ system, or diagnosis is not a matter of wishful thinking.

17 Responses to Chiropractic = a profession of wishful thinking?

  • The state of affairs in the USA is ridiculous. Its as if each state registration board is there to protect their patch of turf, when their main job is to protect patients and enforce standards. A friend went to the US recently to sit a local state board examination proir to moving there and I was shocked at what he told me about the varying standards from poor to very good. We are very fortunate to have standardised national registration boards for all professions here with common law requirements on informed consent, continuind professional development, advertising standards and recently added social media and the internet.
    http://www.ahpra.gov.au/
    I have read that paper and I had to reach for my medical dictionary then scratch my head trying to figure out how something came within chiropractics scope of practice! Facepalm! The USA has chiropractors who I admire immensely and it also has the total nut jobs!

    • thank you; I agree.
      but what about the notion that chiropractors can function as primary care physicians? clearly, it is not confined to the US.

      • Professor Ernst wrote: “…what about the notion that chiropractors can function as primary care physicians? clearly, it is not confined to the US.”

        Indeed. Let’s not forget that the President of the European Chiropractors Union, Øystein Ogre (DC) – who is heavily involved in developing chiropractic education throughout Europe – claims that a successful chiropractor “is being that person, the spinal expert in your area, that parents will consult when they are worried about their sick child”. See from 2:30 in here:
        https://www.facebook.com/permalink.php?story_fbid=685575191468899&id=391254640900957

        That says to me that ‘Dr’ Ogre sees, and is lobbying for, chiropractors to be general primary healthcare practitioners in Europe.

      • I agree that the situation in the USA is not representative of the way that chiropractors work in the UK or indeed Europe. However, chiropractors are primary contact practitioners, as like physiotherapists, patients can have direct access without the need for medical referral. Although treatment should be restricted to MSK conditions, any primary contact practitioner must be able to assess the health status of their patients and where appropriate refer patients to GPs/specialists.

        This is the model that is taught in the UK and certainly in my experience this approach is recognised by patients and GPs with GPs often thanking our chiropractors and physiotherapists for identifying patients with medical issues and referring them appropriately.

        • “primary contact practitioners”?
          what are you talking about?
          primary contact is not the issue here!
          the post is about PRIMARY CARE PHYSICIANS! have you ever heard a physio describe herself as a primary care physician?

          • What I am talking about is how chiropractors work in the UK which as you know you have already stated in your blog I quote
            “chiropractors in the UK view their role as one of a primary contact healthcare practitioner and that this view is held irrespective of the country in which they were educated or the length of time in practice”

            and as I have already stated the situation in the US is not reflected in Europe.

  • Primary care or primary contact? Treating patients is easy, what is far more important is knowing when not to treat and refer on. A large proportion of the chiropractic curriculum here is all about this. So far this year I have picked up 2 spinal metatstases and had to call 2 ambulances with patients having heart attacks. The last one I had the hospital ring up to thank me as one more hour and he would have been dead!

    • Thinking_Chiro wrote: “Primary care or primary contact?”

      It seems to be a very confusing picture. For example, bearing in mind that the scope of chiropractic in the UK isn’t defined or limited, the following terminology could easily leave the door wide open for the strong quack element of UK chiropractors to offer chiropractic as a panacea:

      1. The British Chiropractic Association Information for Healthcare Professionals

      “Chiropractic is a primary health-care profession”
      http://www.chiropractic-uk.co.uk/gfx/uploads/textbox/Fact%20Sheets/healthcareprofsindtro07.pdf

      2. The Anglo European College of Chiropractic offers:

      “Innovative and highly vocational courses that leave our students fully equipped for a successful career in primary healthcare.”
      http://www.aecc.ac.uk/

      3. The General Chiropractic Council

      Search through this document for the word ‘primary’
      http://www.gcc-uk.org/UserFiles/Docs/Agreed%20visit%20report%20for%206%20and%207%20Dec%2007.pdf

      The above indicates a major public health issue when you consider that the most recent survey of the chiropractic profession in the UK revealed that:

      QUOTE
      “Non-musculoskeletal conditions in adults, including asthma (64%), gastro-intestinal complaints (61%) and pre-menstrual syndrome (PMS) (70%), were considered conditions that can benefit from chiropractic management. Opinions on the treatment of osteoporosis (43%), obesity (26%), hypertension (42%) and infertility (30%) were less conclusive. Childhood musculoskeletal and muscular conditions, infantile colic, otitis media and asthma were perceived to benefit from chiropractic intervention by more than 50% of the respondents. Statistically significant differences between chiropractors of different associations in the UK were present, particularly regarding the benefits of chiropractic treatment for non-musculoskeletal conditions…Traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of the respondents and 63% considered subluxation to be central to chiropractic intervention.”

      Link: http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1188-the-scope-of-chiropractic-practice-a-survey-of-chiropractors-in-the-uk.html

  • From all that can be found out about it, chiropractic is simply massage and physical therapy, nothing more. Dr. Ernst is quite right to be stunned that a chiropractor could ever be put at the same level as a medical doctor, i.e., a physician. Chiropractors are not trained anywhere near as well as medical doctors. We here in the US are seeing the same “creep” of naturopathy into our legislation, being treated, that is, as if it were somehow a real medical approach. It’s not, nor is chiropractic. Neither are science-based. All we can do is write letters and point this out and hope our legislators check these things out more thoroughly. Sadly, even some very bright legislators fall for this stuff.

  • When I see a patient for chronic back pain, ruling out any red flags or contraindications to chiropractic care is standardised and systematic. I work closely with my local doctors, specialists, physio’s, remedial masseurs, exercise physiologists, personal trainers etc. I have a reputation with my doctors as the go to guy for difficult backs that they find frustrating. My parctice is constantly evolving and chanding as best practice presents itself. I do not have all the answers and I am not a universal panacea! I also work closely with doctors in a medical centre and our regular round table discussions over cappuccino’s is extremely educational for all. Most chiropractors I know have a referral relationship with doctors and this promotes accountability and understanding!

    • What if its the plethora of specialists that actually give more credence to the patients pain? and allows more conditions to become chronic than if left alone?

      The cappuccino relationship sounds lovely, as well as promoting accountability and understanding it also perpetuates more business. Nice.

      You’re intentions are honorable, but the efficacy of manual therapy treatments are debatable as the evidence consistently tells us, and riddled with personal biases. Your open attitude and obvious willingness to learn does not make you any less open to bias.

  • In response to Neil:
    Of cousre I am biased towards what I do. Every professional is, that is one of the reasons patients get so many differing pieces of advice from different professions and professionals. I discuss this with chronic pain patients that have been through the mill when I initially see them and they agree with the frustration and confusion that it produces. I set treatment goals and time frames to achieve them and discuss this with the patient. I also candidly tell them that I am also biased towards what I do, so take all advice I give with a dose of salt. I also educate the patient about how they are in the drivers seat and all health professionals are just the navigators offering advice and directions. De-catastrophising and de-medicalising their pain is very important as you have alluded to above. An intersting recent article discusses this topic:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097773/?tool=pmcentrez&report=abstract
    The title says it all!

    • That does not sound like chiropractic to me. Evidence based and totally appropriate, but, Chiropractic?

      It is not just Chiropractors that have this problem, physiotherapists and osteopaths do too. It would seem its not what you do its how you do it. Maybe all of them need too think about re branding themselves.

      • Neil wrote: “It would seem its not what you do its how you do it.”

        Intrestingly, three academic chiropractors in the UK hinted at that over 10 years ago…

        QUOTE
        “…it has [also] been shown that patients are very pleased and satisfied with chiropractic care whether they get better or not….Furthermore, it has been said that chiropractic’s greatest contribution to health care has been the development of a solid doctor-patient relationship. So, let’s not kid ourselves. It may not be what we say…but simply the way in which we say it that stimulates some measurable change in patient’s general health care status. Some studies support this view.”

        Ref: http://web.archive.org/web/20041215180456/www.familychiropractic.co.uk/news/Articles/article3.htm

  • In reply to Neil:
    “It would seem its not what you do its how you do it”.
    You are bang on the mark there Neil. The physio’s did some recent research on which are the best exercises and it found that the actual exercise was less important than how you delivered the exercise and engage the patient. It is an ongoing debate in physiotherapy, Prof Chris Maher of the George institute discusses it here. I love his reference to different exercises and describes them as “which branch of religion”. They all agree that exercises help, thay just cannot agree on which ones.
    http://sydney.edu.au/medicine/21st-century/back-pain.php

  • It is quite clear that many patients present to DC’s before any other Healthcare provider.

    Thankfully, contrary to what many people may naïvely believe, the education* Chiropractic students receive is outstanding.

    Thus, all DC’s are expected to provide a PRIMARY HEALTH CARE service practising WHAT THEY ARE TRAINED TO PRACTITION.

    Now…it is all very well giggling and being shocked at the above list of what certain DC’s can, LEGALLY, practition, but ERNST has FAILED, to inform us of the respective education of the DC’s.!!!!

    How does Ernst know whether the DC’s are actually trained adequately to perform competent recto-vaginal examinations, or administer injections?

    He doesn’t.!

  • Let’s face it: the Medical a Profession (my profession) has not done a good job educating Americans about the astonishing prevalence of pelvic floor PROLAPSE in women (the number 1 reason for in-patient hospitalization in women older than 70, with a huge health care expenditure. Breast cancer is glitzy and trendy, prolapse is gross. So women keep running and doing valsala excercises like squats, even after they have had babies. Truly, as I informed a friend of mine recently, “your uterus is eventually going to fall on the floor.”

    I was initially blown away when I read that physical therapists can now do vaginal And bi-manual exams. But after a lot of Thought and reading I realized the following: prolapse is not newsworthy, and most women are completely unawRe of this major medical problem. So if Chiros and PTs are extensivey trained in this area, why not let them address this problem in their patients ? But please keep in mind: a male ER doc may not do a vaginal or pelvic exam without a woman nurse in the room.
    I cannot find the training requirements for PT and Chiro gyn practices. Please make this a focus of future discussions ! Thanks

Leave a Reply

Your email address will not be published. Required fields are marked *

Gravityscan Badge

Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories