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Texas Performance Review
Realigning Chiropractic Oversight


Scope of Practice Issues


Background

Chiropractors are commonly viewed as specialists in back and neck pain. According to a survey by the American Chiropractic Association, problems related to neck, back, and joint pain accounted for nearly nine-tenths of the average chiropractor's practice in 1993.[23]

Beyond a concentration on spinal manipulation, however, chiropractors can hold very different views on the proper scope of chiropractic practice. Some chiropractors still hold to the belief that virtually all health problems can be corrected by spinal adjustment. Among the chiropractic community, these practitioners are commonly referred to as "straights" and are viewed as those chiropractors who confine their treatment practices to spinal manipulation. An increasing number of chiropractors, often referred to as "mixers," acknowledge that other factors can play a role in health problems. In addition to spinal manipulation, mixers may use nutritional methods, herbal remedies, and various types of physiotherapy including heat- and cold-treatments, traction, exercise, massage, and ultrasound.

Straights tend to eschew other forms of medical treatment other than spinal adjustment, noting that this procedure is the traditional role of chiropractors. Mixers are more likely to diagnose medical conditions in addition to spinal abnormalities, and to refer patients to medical practitioners for treatment. The distinction between the two groups is not clear-cut, however. Some straights, for example, use physiotherapy techniques, while some mixers believe that misaligned vertebrae cause the majority of all health problems.[24]

Wide variation in scope of practice

In many states, the predominant views of certain groups of chiropractors have found their way into state regulatory practice. This, coupled with resistance from state medical associations, has resulted in a wide variety of allowable practices from state to state (Exhibit 3). For example, Oregon allows greater latitude to the profession, permitting chiropractors to perform minor surgery, use hypnosis, deliver babies, and prescribe nutritional supplements. In neighboring Washington, the state places strong limits on chiropractors; the licensing law permits none of these practices and procedures allowed in Oregon and does not even allow physiotherapy.[25]


EXHIBIT 3: Allowable Chiropractic Practices in Other States*

Practice by Chiropractor Number of States Allowed Number of States Not Allowed or Questionable

No Answer or Unknown

Texas

Venipuncture
34**
18
1
Yes
Sell/Dispense any Type of Supplement from Office
45
6
2
Yes
Homeopathy
19
31
3
No
Surrogate Testing
8
36
9
No
Recommend Ibuprofen, Tylenol or Other Over-the-Counter Medication
25
25
3
Yes
Report for Examination of School Children Accepted
36***
15
2
***
Authorized to Sign Death Certificates
23
30
0
Not Allowed

* Totals include the District of Columbia, Puerto Rico and US Virgin Islands
** 20 of the 34 states allow venipuncture for diagnostic purposes only.
*** 12 of 36 states including Texas report acceptance of school exam depends on individual school.

SOURCE: Federation of Chiropractic Licensing Boards.

Chiropractic colleges train students in a wide variety of procedures, from vitamin therapy to minor surgery and obstetrics, even though some of these procedures may be legal in only a handful of states. The colleges' perspective, however, is to prepare the student to fully practice in any state. The individual chiropractor then must ascertain, with assistance from the appropriate state licensing board, what is legally permitted in the state in which he or she intends to practice.

Article 4512(b) of the Texas Chiropractic Act defines what the practice of chiropractic may include in Texas:

A person shall be regarded as practicing chiropractic within the meaning of this Act if the person:

(1) uses objective or subjective means to analyze, examine, or evaluate the biomechanical condition of the spine and musculoskeletal system of the human body;

(2) performs nonsurgical, nonincisive procedures, including but not limited to adjustment and manipulation, in order to improve the subluxation complex or the biomechanics of the musculoskeletal system; or

(3) hold himself out to the public as a chiropractor of the human body or uses the term "chiropractor," "chiropractic," "doctor of chiropractic," "D.C.," or any derivative of these terms in connection with his name....

The practice of chiropractic shall not be construed to include:

(1) incisive or surgical procedures;

(2) the prescribing of controlled substances or dangerous drugs or any drug that requires a prescription; or

(3) the use of x-ray therapy or therapy that exposes the body to radioactive materials....

In this Act, "incisive or surgical procedure" includes but is not limited to making an incision into any tissue, cavity, or organ by any person or implement. It does not include the use of a needle for the purpose of drawing blood for diagnostic testing....

Notwithstanding any other provision in this Act, the Board shall not adopt a process to certify chiropractors to perform manipulation under anesthesia.[26]

In recent years, this language has been amended to further clarify what chiropractors can and cannot do, but debates over allowable practice continue. Clear guidelines on allowable procedures are critical to TBCE's duty to discipline practitioners operating outside of their scope of practice. Many questions center on practices that, if endorsed by the board, would be eligible for third-party reimbursement through insurance and worker's compensation claims.

TBCE's role in scope-of-practice issues

Most chiropractic procedures and practices are not specifically addressed in statute. The board refers questions of scope to its Technical Standards Committee but has not had a consistent approach for evaluating these issues. In the past, the committee would evaluate each case and respond to individual questions by letter, without public input or notification to other practitioners. More recently, the board has opted to ask for Attorney General opinions on certain issues. During the period the Attorney General's office is deliberating on the opinion, chiropractors are not prohibited from performing the procedure in question.

TBCE has no rules designed to clarify scope of practice. Previous rules pertaining to this area were overturned through the courts.[27] The board's position is that the statute is sufficiently clear and that individual licensees can decide for themselves what is allowable based on the law and their own background and training. Without clear rules, however, the board's ability to enforce the legal provisions is seriously abridged, simply because licensees can always argue that their practice is appropriate based on their own interpretation.

The current confusion regarding statutory provisions on the use of needles (See Recommendation 1) illustrates the limitations of TBCE's passive approach to scope-of-practice issues. TPR's review also noted several requests for clarification on particular procedures; in one case a practicing chiropractor asked the board to create a written document listing exactly what therapeutic techniques Texas chiropractors are allowed to use, noting that he had been denied insurance coverage on several occasions because the board has no such document.[28]

In another recent case, a graduating chiropractic student submitted a list of 53 procedures and asked the board to verify which are not part of the scope of practice in Texas.[29] The list included items from physiotherapy and x-rays to minor surgery and obstetrics. The board referred this request to its Technical Standards Committee; ultimately the student, now a practicing chiropractor, was told to use her best judgment based on what she felt she was appropriately trained to do.[30] According to TBCE, the chiropractor recently withdrew the request.[31] However, the question of allowable procedures still remains unaddressed by the board.


Recommendations

A. TBCE should develop and adopt formal rules establishing clear and detailed guidelines on the permissible scope of practice for Texas chiropractors. The rules should state that procedures not specifically addressed cannot be assumed to be authorized and should be submitted to the board for consideration. These rules should be adopted and published no later than September 1, 1998. This process should involve the multi-disciplinary commission unless it is abolished subsequent to this report.

Formal rulemaking on scope-of-practice issues would give chiropractors better information on allowable practices, allow for public input, and provide for more consistent enforcement.

B. TBCE should adopt rules establishing a process for evaluating scope-of-practice issues brought before the board. This process should involve the multi-disciplinary commission unless it is abolished subsequent to this report.

If new issues arise that go beyond the statutory framework, these should be brought to the Legislature for expansion of the statutory definition of scope of practice.


Fiscal Impact

TBCE could implement these recommendations in the normal course of business. Thus, these recommendations would have no fiscal impact.


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