United States Chiropractic Practice Acts and Institute of Medicine defined primary care practice

FALL 2002 • Number 4 • Volume 1

United States Chiropractic Practice Acts and Institute of Medicine defined primary care practice Richard Duenas, DC, DABCNa a

Private Practice of Chiropractic, West Hartford, CT. Submit requests for reprints to: Dr. Richard Duenas, 557 Prospect Avenue, West Hartford, CT 06105. Paper submitted May 30, 2002.

ABSTRACT Objective: This review was conducted to analyze the law for the practice of chiropractic throughout the United States, including the District of Columbia, Puerto Rico and the U.S. Virgin Islands, to determine the legal ability of the Doctor of Chiropractic in each jurisdiction to provide primary care service as described by the 1996 Institute of Medicine Definition of Primary Care. Method: The practice acts for each State, the District of Columbia, Puerto Rico and the U.S. Virgin Islands were reviewed for language that would permit the chiropractic doctor to meet the 9 criteria of primary care practice described by the Institute of Medicine. Forty-four practice acts were cross referenced with the results of a scope of practice survey of State Boards of Chiropractic in 1999. Results: The review of the practice acts and the survey on chiropractic scope of practice revealed a varied degree of chiropractic scope of practice with 23 of 53 of the jurisdictions limiting the ability of the chiropractic doctor to fully provide IOM defined primary care. Conclusion: The varied practice act definitions for chiropractic practice throughout the United States the District of Columbia, Puerto Rico and the U.S. Virgin Islands reveal an inability of the chiropractic profession to respond to a call for a standard nationally-based primary-care policy that could be readily achieved by all chiropractic practitioners throughout the Union. This void of primary-care qualification in many State and Commonwealth practice acts will need to be addressed by the leaders of the profession if government entities and national third party organizations are to utilize chiropractic health care services to the standard of chiropractic education and clinical experience. The need for a broad range chiropractic scope of practice model practice act is suggested. (J Chiropr Med 2002;1:155–170) KEY WORDS: Chiropractic, Chiropractic Code of Law, Chiropractic Practice Act, Chiropractic Statute, Institute 0899-3467/02/1002-049$3.00/0 JOURNAL OF CHIROPRACTIC MEDICINE Copyright © 2002 by National University of Health Sciences

of Medicine, Primary Care, Primary Care Clinician, Primary Care Physician, Primary Care Provider.

INTRODUCTION Primary health care, a formal, relatively new and wellestablished title for the description of a long tradition of basic health-care services requires great responsibility on the part of the primary-care clinician. This responsibility includes: 1. The determination of a patient’s state of health with whole body examination and diagnosis. 2. The establishment of a trustworthy relationship with the patient to provide accurate information regarding the patient’s state of health. 3. Responsiveness to the patient’s needs within a reasonable period of time. 4. The provision of a wide range of basic health-care services throughout the patient’s lifetime. 5. The possession of a wide knowledge base of available health-care services required for the patient’s needs with a willingness to integrate those services into the patient’s treatment plan. 6. An interaction with the community served by the practitioner. 7. An interaction with the public health services available for the patient. The Institute of Medicine (IOM) established a Definition of Primary Care in 1996; “Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (1). This study may be considered the most up-to-date and comprehensive report on primary care. Formulated by the IOM as a second review of the topic, the report encompassed the creation of the Committee on the Future of Primary Care which consisted of 19 primary care experts from academia, private practice, the insurance industry, medical organizations and government. The committee conducted literature reviews, interviews, surveys, and

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workshops on primary care. Invited guests from academic allopathic medicine, medical organizations, insurance associations, philanthropic groups and government agencies provided testimony. In this study primary care is defined in a functional sense that emphasizes the importance of the patient-clinician relationship as it relates to the family and community, provided through a health-care team in an integrated delivery system. The use of an arbitrarily determined definition would not serve well the patient-clinician relationship. Although the chiropractic profession did not participate in the formation of this definition, a broad scope of chiropractic practice appears to meet the criteria for primary care. Some may argue, however, that the criteria could not be achieved with chiropractic practice (2). Terms considered unachievable in chiropractic practice include: comprehensive, health-care services and widest possible range of conditions. “Comprehensive care addresses any health problem at any given stage of a patient’s life cycle” (1). Nelson argues that chiropractic is not a comprehensive form of health care, having limitations with the provision of care for organic disorders (2). He is supported by other chiropractic clinicians in the field (3–6). However, chiropractic education clearly requires the student to be prepared in whole-body diagnosis for all ages and recognize the need for chiropractic and/or other healthcare utilization for the appropriate treatment of the patient’s condition (7). With respect to the connotation for comprehensive within a primary-care definition, Starfield indicates the provider need not render a broad range of services, but rather recognize problems presented by the patient, give explicit notification of the services provided in the facility and arrange for appropriate patient care (8). Furthermore, the effects of the chiropractic adjustment (manipulation) is not limited to the musculoskeletal or neuromusculoskeletal systems, but also includes visceral, constitutional and brainfunction effects (9–14). Chiropractic practice is also not solely comprised of adjustment or manipulative services, but can include the provision of nutrient, botanical, dietary, hygiene, psychosocial counsel, public health, ergonomic and exercise services (15–17). “Health care services refers to an array of services that are performed by health care professionals or under their direction, for the purpose of promoting, maintaining, or restoring health. The term refers to all settings of care (such as hospitals, nursing homes, clinicians’ offices, intermediate care facilities, schools, and homes)” (1). The array of services that may be provided by the doctor of chiropractic (DC) are vast and may be summa-

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rized as naturally based non-drug, non-surgical health care. The degree of services allowed by law is determined by each State practice act. During the first half of the 20th century, chiropractic doctors did provide for a wide range of hospital based health care. Unfortunately, due to anti-chiropractic forces, chiropractic doctors were largely excluded from providing hospital-based health care in the latter half of the century (11,18). Fortunately today, the profession is making inroads to provide hospital-based services (19). Other locations of care such as house calls, industry and athletic fields are certainly not out of reach for the chiropractic profession. The majority of personal health-care needs “refers to the essential characteristic of primary care clinicians: that they receive all problems that patients bring— unrestricted by problem or organ system—and have the appropriate training to diagnose and manage a large majority of those problems and to involve other health care practitioners for further evaluation or treatment when appropriate. Personal health-care needs include physical, mental, emotional, and social concerns that involve the functioning of an individual” (1). This suggests the clinician recognize disease and/or dysfunctional states and serve as the advocate for the patient. A full range of patient concerns are addressed and managed in the primary-care office, the scope of which includes acute care, chronic care, prevention and early detection of illness and coordination of referrals. To manage the patient implies the clinician “direct or control the use of” (20) health-care services—a quality along with patient advocacy not unusual for chiropractic practice. The delivery of primary care is dependent upon the practitioners training and privileges established by law. Clearly, family practitioners, internists, pediatricians and geriatricians of the allopathic and osteopathic professions meet the criteria with their training in diagnosis, treatment and/or integration of care for all physiological systems of the patient. This is done within the framework of their discipline. They have a long tradition of providing primary health care. Given the broad scope of practice for the allopathic and osteopathic professions throughout the states, these practitioners readily enjoy the privilege of providing primary-care service. The chiropractic profession also meets the criteria for educational preparation in diagnosis, treatment and integration of care with other health-care practitioners (7,21). Traditionally, the profession has provided services consistent with primary care (11,21,22). With respect to state law, some states with a broad chiropractic

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scope of practice language would pose no restrictions for practically providing primary care service (10,23). Others, with narrow definitions that limit examination and treatment services leave in question the practicality for a DC to provide primary care. The purpose of this study was to apply the criteria of primary care as defined by the IOM to the practice acts of all States, the District of Columbia, Puerto Rico and the U.S. Virgin Islands. A study on chiropractic scope of practice was utilized to help clarify the scope of chiropractic practice in 44 of the jurisdictions with regards to diagnostic and treatment rights (23). METHODS The chiropractic practice acts (statutes, codes of law) for each State, the District of Columbia, Puerto Rico and the

U.S. Virgin Islands were reviewed (24–99). The definitions and descriptions for chiropractic practice were reviewed for their breadth of chiropractic services allowed by law. This was done in consideration of Prescott’s review of practice rights along with his point that the “law defines and regulates all aspects” of chiropractic practice (100). Nine major categories and 3 subcategories of primary care practice, as described in the IOM Primary Care definition, were used to measure the degree to which the DC is permitted to provide primary care services in each jurisdiction. (See Table 1) The results of a 1999 survey to state boards of chiropractic addressing chiropractic scope of practice relating to diagnostic and treatment rights in 44 States and the District of Columbia were cross referenced with the respective practice act to help clarify the descriptions of

Table 1 Institute of Medicine Primary Care Definition and Criteria Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Integrated is intended in this report to encompass the provision of comprehensive, coordinated, and continuous services that provide a seamless process of care. Integration combines events and information about events occurring in disparate settings, levels of care and over time, preferably through the life span. Comprehensive. Comprehensive care addresses any health problem at any given stage of a patient’s life cycle. Coordinated. Coordination ensures the provision of a combination of health services and information that meets a patients needs. It also refers to the connection between, or the rational ordering of, those services, including the resources of the community. Continuous. Continuity is a characteristic that refers to care over time by single individual or team of health care professionals (‘clinician continuity’) and to effective and timely communication of health information (events, risks, advice, and patient preferences) (‘record continuity’). Accessible refers to the ease with which a patient can initiate an interaction for any health problem with a clinician (e.g., by phone or at a treatment location) and includes efforts to eliminate barriers such as those posed by geography, administrative hurdles, financing, culture, and language. Health care services refers to an array of services that are performed by health care professionals or under their direction, for the purpose of promoting, maintaining, or restoring health. The term refers to all settings of care (such as hospitals, nursing homes, clinicians’ offices, intermediate care facilities, schools, and homes). Clinician means an individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients. Accountable applies to primary care clinicians and the systems in which they operate. These clinicians and systems are responsible to their patients and communities for addressing a large majority of personal needs through a sustained partnership with a patient in the context of a family and community and for (1) quality of care, (2) patient satisfaction, (3) efficient use of resources, and (4) ethical behavior. Majority of personal health care needs refers to the essential characteristic of primary care clinicians: that they receive all problems that patients bring—unrestricted by problem or organ system—and have the appropriate training to diagnose and manage a large majority of those problems and to involve other health care practitioners for further evaluation or treatment when appropriate. Personal health care needs include physical, mental, emotional, and social concerns that involve the functioning of an individual. Sustained partnership refers to the relationship established between the patient and clinician with the mutual expectation of continuation over time. It is predicated on the development of a mutual trust, respect, and responsibility. Patient means an individual who interacts with a clinician either because of illness or for health promotion and disease prevention. Context of family and community refers to an understanding of the patient’s living conditions, family dynamics, and cultural background. Communities refers to the population served, whether they are patients or not. Community can refer to a geographical boundary (a city, county, or state), or to neighbors who share values, experiences, language, religion, culture, or ethnic heritage (1).

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chiropractic (23). For the purpose of this study, certain services in the Lamm study were considered to be essential for the provision of primary care and were weighted against the respective practice act. (See Table 2) The major categories and sub-categories criteria for providing primary care was applied to the language for each practice act and scored “Yes” where the language provides the right to perform the criteria. A “No” score was applied where the language explicitly limits the provision of the criteria or fails to fully support the service. For language that cites chiropractic as the diagnosis, assessment and/or treatment of subluxation without reference to whole body influence by the subluxation or with reference that is made to a specific system, such as the neuromusculoskeletal system; a “No” score was applied. The results were tallied and scored 1 point for each “Yes” result. A “No” in the sub-categories disqualified the respective major category. RESULTS The practice acts from all U.S. states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands contained different language to define chiropractic and describe the type of services permitted and/or not permitted by law. Of the practice acts reviewed, 30 met all the

criteria for providing IOM defined primary care, 3 met 8 of 9 criteria, 5 met 7 of 9 criteria and 15 met 6 of 9 criteria. (see Table 3) Services queried in the Lamm study that are considered essential and non-essential for primary care service in this study are listed in Table 2. The practice acts with language considered to limit the chiropractic doctor’s ability to meet IOM defined primary care service are listed in Table 4. The procedures listed in the Lamm study and considered to confirm these limitations follow each citation in Table 4. Practice acts with language considered to qualify the DC for primary care are listed in Table 5. Procedures listed in the Lamm study which may limit the provision of primary care services in those States considered to meet the IOM criteria are listed in Table 6. A list of States which did not participate in the Lamm study and thus could not confirm the observations of the practice acts in this study are listed in Table 7. DISCUSSION Historically, the chiropractic profession has provided primary care as evidenced by training (7,10), conditions treated (10,11), direct access of services (10), coordination of care with other practitioners(10), utilization of a wide range of diagnostic services (23) and care provided for all age groups (101–103). These services were pro-

Table 2 Lamm (23) Study Services Considered Essential (Minimally Required Service) and Non-essential for Primary Care in this Study A. Essential: 1. Technical Diagnostic Procedures: X-ray procedures (full spine, skull, soft tissue), Thermography, EMG &/or nerve conduction studies, vasculizor analysis (Dopplar, etc.), Independently order CT scan, Independently order MRI, Clinical lab analyses (venipuncture for blood analysis, urinalysis, sputum analysis, fecal analysis, semen analysis, throat swab, skin scrape), Hair analysis. 2. Physical Diagnostic Procedures: School physicals, Pre-employment physicals, Premarital physicals, Eyes/ear/nose/ throat examinations, Abdominal examinations, Extremity examinations, Stethoscopic examinations (heart & lungs), Sphygmomanometry, Electrocardiography, Applied Kinesiology, Impairment ratings. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Female breast examination, Rectal examination, Male genital examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: Physiotherapy (electrotherapy, ultrasound, hydrocolation, TENS therapy, ice therapy, massage), Extremity adjusting, Soft tissue manipulation of the abdominal viscera, Craniopathy, Nutrition evaluation &/or treatment (vitamin supplement, glandular supplementation, diet formulation, botanical therapy, homeopathic preparations), Orthotic supports, Spinal supports, Counseling, Rehabilitation. 5. Invasive treatment procedures: Intrarectal manipulation of the coccyx, Ear irrigation, Temporomandibular joint evaluation &/or treatment, Endonasal technique digital manipulation of the eustachian tube orifice, Recommendation of nonprescription items (OTC). 6. Special treatment procedures: None. B. Non-essential: 1. Technical Diagnostic Procedures: X-ray procedures (barium studies, tomography, cholesystography). 2. Physical Diagnostic Procedures: Sign birth certificates, Sign death certificates. 3. Special Diagnostic Procedures: None. 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: Intravaginal uterine manipulation, Nonadjustive treatment of female pelvic conditions, Colonic irrigation, Nasal specifics (balloon inflation into nasal passages), Chelation therapy (oral, intravenous), Vitamin injection, Limited prescription writing privileges. 6. Specialty Treatment Procedures: Minor surgery, Obstetrics, Extremity casting (sprains or uncomplicated fractures), Hypnosis, Acupuncture (needle, electrode), electrolysis.

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Table 3 Chiropractic Practice Acts and Qualification of IOM Defined Primary Care Primary Care Criteria—State Statute Qualifications IOM Criteria

AL

AK

AZ

AR

CA

CO

CT

DE

DC

FL

GA

HI

ID

IL

Accessible Health care services Clinician Accountable Majority of personal health care needs Sustained partnership with patients Patient Practice in context of family and community Total

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N Y Y Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y N Y Y Y 8

N N Y Y Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N Y Y Y Y Y Y N Y Y Y 7

N N Y Y Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

IOM Criteria

IN

IA

KS

KY

LA

ME

MD

MA

MI

MN

MS

MO

MT

NE

Accessible Health care services Clinician Accountable Majority of personal health care needs Sustained partnership with patients Patient Practice in context of family and community Total

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N Y Y Y Y Y Y N Y Y Y 7

N N Y Y Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N Y Y Y N Y Y N Y Y Y 6

N N Y Y Y N Y Y Y Y Y Y 7

N N Y Y Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N Y Y Y N Y Y N Y Y Y 6

N N Y Y Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

IOM Criteria

NV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PA

PR

RI

SC

Accessible Health care services Clinician Accountable Majority of personal health care needs Sustained partnership with patients Patient Practice in context of family and community Total

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N N Y Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y N Y Y Y 8

N N Y Y Y Y Y Y N Y Y Y 7

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N Y Y Y N Y Y N Y Y Y 6

N N N N Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N Y Y Y N Y Y N Y Y Y 6

IOM Criteria

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N Y Y Y N Y Y N Y Y Y 6

N N Y Y Y Y Y Y N Y Y Y 7

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

N N Y Y Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y N Y Y Y 8

N N Y Y Y N Y Y N Y Y Y 6

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

Y Y Y Y Y Y Y Y Y Y Y Y 9

Integrated Comprehensive Coordinated Continuous

Integrated Comprehensive Coordinated Continuous

Integrated Comprehensive Coordinated Continuous

Integrated Comprehensive Coordinated Continuous Accessible Health care services Clinician Accountable Majority of personal health care needs Sustained partnership with patients Patient Practice in context of family and community Total

Y = Yes for statute which explicitly authorizes service or does not restrict service. N = No for statute which explicitly restricts service.

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Table 4 Disqualifying Language of IOM Defined Primary Care in Chiropractic Practice Acts with Restricted Services in Lamm Study 1. Alaska: “Sec. 08.20.100 Practice of chiropractic (C) . . . a person licensed under this chapter is not authorized to . . . or to administer or interpret the results of infectious disease tests required by statute or regulation” (25). Lamm study restricted services: None. 2. Delaware: “701 Chiropractic defined; limitation of chiropractic license. (c) Except as otherwise provided in this chapter, the practice of chiropractic does not include . . . or gynecological examinations or treatment” (32). Lamm study restricted services: Survey not returned. 3. District of Columbia: “2-3301.2 Definitions of health occupations (3)(A) ‘Practice of Chiropractic’ means the detecting and correcting of subluxations that cause vertebral, neuromuscular, or skeletal disorder, by adjustment of the spine or manipulation of bodily articulations for the restoration and maintenance of health; the use of x-rays, physical examination, and examination by noninvasive instrumentation for the detection of subluxations; and the referral of a patient for diagnostic x-rays, tests, and clinical laboratory procedures in order to determine a regimen of chiropractic care or to form a basis or referral of patients to other licensed health care professionals. ‘Practice of Chiropractic’ does not include the use of drugs, surgery, or injections, but may include, upon certification by the Board, counseling about hygienic and other noninvasive ancillary procedures authorized by rules issued pursuant to this chapter” (34). Lamm study restricted services: 1. Technical Diagnostic Procedures: Clinical lab analyses (fecal analysis, semen analysis, throat swab, skin scrape). 2. Physical Diagnostic Procedures: School physicals, Pre-employment physicals, Premarital physicals, Abdominal examinations, Electrocardiography. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Female breast examination, Rectal examination, Male genital examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: Nutritional evaluation &/or treatment (glandular supplementation, diet formulation, botanical therapy, homeopathic preparations). 5. Invasive Treatment Procedures: Ear irrigation, Endonasal technique digital manipulation of the eustachian tube orifice. 4. Georgia: “Code 43-9-16 (f) Chiropractors shall not use venipuncture, capillary puncture, acupuncture, or any other technique which is invasive of the human body either by penetrating the skin or through any of the orifices of the body or through the use of colonics” (37). Lamm study restricted services: 1. Technical Diagnostic Procedures: Clinical lab analyses (semen analysis, throat swab, skin scrape). 2. Physical Diagnostic Procedures: Premarital physicals, Eyes/ear/nose/throat examinations. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Rectal examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: Nutrition evaluation &/or treatment (botanical therapy, homeopathic preparations). 5. Invasive Treatment Procedures: Intrarectal manipulation of the coccyx, Ear irrigation, Endonasal technique digital manipulation of the eustachian tube orifice, Recommendation of nonprescription items (OTC). 5. Hawaii: “S442-1 Chiropractic defined. Chiropractic is defined to be the science of palpating and adjusting the articulations of the human spinal column by hand; provided that the practice of chiropractic is contemplated and set forth in this chapter may include the use of necessary patient evaluation and management procedures of the human spinal column, hot or cold packs, whirlpool, therapeutic and rehabilitative exercise, traction, electrical and electrochemical stimulation, therapeutic ultrasound, myofascial release, diathermy, infrared, and chiropractic spinal manipulation treatment and extraspinal evaluations for the diagnosis and treatment of neuromusculoskeletal conditions related to the human spinal column, subject to the restrictions contained in this chapter; and provided further that the practice of chiropractic as contemplated and set forth in this chapter shall not include the practice of lomilomi or massage. For the purposes of this section, spinal refers to the five spinal regions: cervical region (includes atlanto-occipital joint); thoracic region (includes costovertebral and costotransverse joint); lumbar region, sacral region; and pelvic (sacro-iliac joint) region” (39). Lamm study restricted services: 1. Technical Diagnostic Procedures: Clinical lab analyses (sputum analysis, fecal analysis, semen analysis, throat swab, skin scrape). 2. Physical Diagnostic Procedures: School physicals, Premarital physicals. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Rectal examination, Male genital examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: None.

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Table 4 (continued) 6. Kentucky: “312.015 Definition for chapter. As used in this chapter, unless the context otherwise requires: (2) . . . ‘chiropractic’ means the science of diagnosing and adjusting or manipulating the subluxations of the articulations of the human spine and its adjacent tissues; (3) . . . ‘chiropractor’ means one qualified by experience and training and licensed by the board to diagnose his patients and to treat those of his patients diagnosed as having diseases or disorders relating to subluxations of the articulations of the human spine and its adjacent tissues by indicated adjustment or manipulation of those subluxations and by applying methods of treatment designed to augment those adjustments or manipulation. The terms ‘chiropractic,’ ‘doctor of chiropractic,’ and ‘chiropractor’ shall be synonymous, and shall be construed to mean a practitioner of chiropractic as defined in this section” (47). Lamm study restricted services: 1. Technical Diagnostic Procedures: None. 2. Physical Diagnostic Procedures: School physicals. 3. Special Diagnostic Procedures: None. 4. Noninvasive Treatment Procedures: Nutrition evaluation &/or treatment (botanical therapy). 5. Invasive Treatment Procedures: None. 7. Louisiana: “Chapter 36. Chiropractors Part I. General 2801. Definitions (3)(a) ‘Practice of chiropractic’ means . . . the diagnosing of conditions associated with the functional integrity of the spine and treating by adjustment, manipulation, and the use of the physical and other properties of heat, light, water, electricity, sound, massage, therapeutic exercise, mobilization, mechanical devices, and other physical rehabilitation measures for the purpose of correcting interference with normal nerve transmission and expression. A chiropractor may also make recommendations relative to personal hygiene and proper nutritional practices for the rehabilitation of the patient. A chiropractor may also order such diagnostic tests as are necessary for determining conditions associated with the functional integrity of the spine” (48). Lamm study restricted services: 1. Technical Diagnostic Procedures: X-ray procedures (soft tissue), Clinical lab analyses (sputum analysis, fecal analysis, semen analysis, throat swab, skin scrape). 2. Physical Diagnostic Procedures: Premarital physicals. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears). 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: Endonasal technique digital manipulation of the eustachian tube orifice. 8. Maryland: “S 3-101. Definitions (f) Practice of chiropractic (1) ‘Practice of chiropractic’ means to use a drugless system of health care based on the principle that interference with the transmission of nerve impulses may cause disease. (2) ‘Practice of chiropractic’ includes the diagnosing and locating of misaligned or displaced vertebrae and, through the manual manipulation and adjustment of the spine and other skeletal structures, treating disorders of the human body” (51). Lamm study restricted services: 1. Technical Diagnostic Procedures: None. 2. Physical Diagnostic Procedures: None. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears). 4. Noninvasive Treatment Procedures: Nutrition evaluation &/or treatment (homeopathic preparations). 5. Invasive Treatment Procedures: None. 9. Massachusetts: “Title XVI Public Health. Chapter 112: Section 89. Definitions. ‘Chiropractic, the science of locating, and removing interference . . . It shall exclude operative surgery, prescription or use . . . and internal examinations whether or not diagnostic instruments are used except that the X-ray and analytic instruments may be used solely for the purposes of chiropractic examinations” (53). Lamm study restricted services: 1. Technical Diagnostic Procedures: None. 2. Physical Diagnostic Procedures: Premarital physicals. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears). 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: Recommendation of nonprescription items (OTC).

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Table 4 (continued) 10. Michigan: “333.16401 Definitions; principles of construction. (M.S.A. 14.15(16401)) (b) ‘Practice of chiropractic’ means that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. Practice of chiropractic includes: (i) Diagnosis, including spinal analysis, to determine the existence of spinal subluxations or misalignments that produce nerve interference, indicating the necessity for chiropractic care. (ii) The adjustment of spinal subluxations or misalignments and related bones and tissues for the establishment of neural integrity utilizing the inherent recuperative powers of the body for restoration and maintenance of health. (iii) The use of analytical instruments, nutritional advice, rehabilitative exercise and adjustment apparatus regulated by the rules promulgated by the board pursuant to section 16423, and the use of x-ray machines in the examination of patients for the purpose of locating spinal subluxations or misaligned vertebrae of the human spine. The practice of chiropractic does not include the performance of incisive surgical procedures, the performance of an invasive procedure requiring instrumentation, or the dispensing or prescribing of drugs or medicine” (55). Lamm study restricted services: Survey not returned. 11. Mississippi: “73-6-1. Practice of chiropractic; definitions; qualifications; limitations on practice; standard of care. (5) Chiropractors shall not use venipuncture, capillary puncture, acupuncture or any other technique which is invasive of the human body either by penetrating the skin or through any of the orifices of the body or through the use of colonics” (58). Lamm study restricted services: 1. Technical Diagnostic Procedures: Vasculizor analysis (Doppler, etc.), Clinical lab analyses (venipuncture for blood analysis, sputum analysis, fecal analysis, semen analysis, throat swab, skin scrape, hair analysis). 2. Physical Diagnostic Procedures: Premarital physicals, Eyes/ears/nose/throat examinations, Electrocardiography. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Female breast examination, Rectal examination, Male genital examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: Ear irrigation, Endonasal technique digital manipulation of the eustachian tube orifice. 12. Missouri: “Chapter 331 Chiropractors Practice of chiropractic, definition. 331.010.1. The ‘practice of chiropractic’ is defined as the science and art of examination, diagnosis, adjustment, manipulation and treatment of malpositioned articulations and structures of the body, both in inpatient and outpatient settings. The adjustment, manipulation, or treatment shall be directed toward restoring and maintaining the normal neuromuscular and musculoskeletal function and health” (60). Lamm study restricted services: 1. Technical Diagnostic Procedures: Clinical lab analyses (fecal analysis, semen analysis, throat swab, skin scrape). 2. Physical Diagnostic Procedures: None. 3. Special Diagnostic Procedures: None. 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: Intrarectal manipulation of the coccyx, Recommendation of nonprescription items (OTC). 13. New Jersey: “Title 45, Chapter 9 45:9-14.5. ‘Practice of chiropractic’ defined; instruments which may be used, not to sign certificates, use of title doctor; unlicensed persons. Within the meaning of the provisions of sections . . . the practice of chiropractic is defined as follows: ‘a system of adjusting the articulations of the spinal column by manipulation thereof.’ A licensed chiropractor shall have the right in the examination of patients to use the neurocalometer, X-ray, and other necessary instruments solely for the purpose of diagnosis or analysis. No licensed chiropractor shall use endoscopic or cutting instruments, or prescribe, administer, or dispense drugs or medicines for any purpose whatsoever, or perform surgical operations excepting adjustment of the articulations of the spinal column. No person licensed to practice chiropractic shall sign any certificate required by law or the State Sanitary Code concerning reportable diseases, or birth, marriage or death certificates” (66). Lamm study restricted services: 1. Technical Diagnostic Procedures: Vasculizor analysis (Doppler, etc.), Clinical lab analyses (sputum analysis, fecal analysis, semen analysis, throat swab, skin scrape). 2. Physical Diagnostic Procedures: School physicals, Pre-employment physicals, Premarital physicals, Eyes/ears/ nose/throat examinations, Abdominal examinations, Extremity examinations, Sphygmomanometry, Electrocardiography. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Female breast examination, Rectal examination, Male genital examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: Soft tissue manipulation of the abdominal viscera, Craniopathy, Nutritional evaluation &/or treatment (vitamin supplementation, glandular supplementation, diet formulation, botanical therapy, homeopathic preparations). 5. Invasive Treatment Procedures: Ear irrigation, Temporomandibular joint evaluation &/or treatment, Endonasal technique digital manipulation of the eustachian tube orifice, Recommendation of nonprescription items (OTC).

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Table 4 (continued) 14. New York: “Title VIII The Professions Article 132 Chiropractic S6551 Definition of practice of chiropractic. 1. The practice of the profession of chiropractic is defined as detecting and correcting by manual or mechanical means structural imbalance, distortion, or subluxations in the human body for the purpose of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. 2. a. A license to practice as a chiropractor shall not permit the holder thereof to use radio-therapy, fluoroscopy, or any form of ionizing radiation except X-ray which shall be used for the detection of imbalance, distortion, or subluxations in the human body. 3. A license to practice chiropractic shall not permit the holder thereof to treat for any infectious diseases such as pneumonia, any communicable diseases listed in the statutory code of the state of New York, any cardio-vascular-renal or cardio-pulmonary diseases, . . . ” (68) Lamm study restricted services: 1. Technical Diagnostic Procedures: Hair analysis. 2. Physical Diagnostic Procedures: Premarital physicals. 3. Special Diagnostic Procedures: None. 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: Ear irrigation, Recommendation of nonprescription items (OTC). 15. North Carolina “Article 8—Chiropractic 90-143. (Effective July 1, 1993) Definitions of chiropractic; examinations; educational requirements. a. ‘Chiropractic’ is herein defined to be the science of adjusting the cause of disease by realigning the spine, releasing pressure on nerves radiation from the spine to all parts of the body, and allowing the nerves to carry their full quota of health current (nerve energy) from the brain to all parts of the body” (70). *With respect to the effects of practice act definition limits upon the recognition of the DC as an expert on health related matters: “90-142. Rules and regulations. Case Notes: Chiropractor not qualified to testify as to Muscle Injury.—In a personal injury action arising from an automobile accident, the chiropractor’s testimony as to the plaintiff’s strain or sprain of a muscle was properly excluded, because such injury and treatment is beyond the field of chiropractic medicine as defined by this section; on the other hand, the trial court erred in excluding the chiropractor’s testimony concerning the plaintiff’s nerve strain or sprain, because such an injury and treatment is with-in the field of chiropractic medicine. Ellis v. Rouse, 86 N.C. App. 367 S.E.2d 699 (1987). Testimony regarding ligaments of the spine is within the scope of chiropractic as defined in this section. Smith v. Buckhram, 91 N.C. App. 355, 372 S.E.2d 90 (1988), cert. Denied, 324 N.C. 113, 337 S.E.2d 236 (1989)” (70). Lamm study restricted services: 1. Technical Diagnostic Procedures: None. 2. Physical Diagnostic Procedures: None. 3. Special Diagnostic Procedures: None. 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: None. 16. Pennsylvania: “Chapter 1 Preliminary Provisions Section 102 Definitions. ‘Chiropractic.’ A branch of the healing arts dealing with the relationship between the articulations of the vertebral column, as well as other articulations, and the neuro-musculo-skeletal system and the role of these relationships in the restoration and maintenance of health. The term shall include systems of locating misaligned or displaced vertebrae of the human spine and other articulations; the examination preparatory to the adjustment or manipulation of such misaligned or displaced vertebrae and other articulations; the adjustment or manipulation of such misaligned or displaced vertebrae and other articulations; the furnishing of necessary patient care for the restoration and maintenance of health; and the use of board-approved scientific instruments of analysis, including x-ray. The term shall also include diagnosis, provided that such diagnosis is necessary to determine the nature and appropriateness of chiropractic treatment; the use of adjunctive procedures in treating misaligned or dislocated vertebrae or articulations and related conditions of the nervous system, provided that, after January 1, 1988, the licensee must be certified in accordance with this act to use adjunctive procedures; and nutritional counseling, provided that nothing herein shall be construed to require licensure as a chiropractor in order to engage in nutritional counseling. The term shall not include the practice of obstetrics or gynecology, the reduction of fractures or major dislocations, or the use of drugs or surgery” (76). Lamm study restricted services: 1. Technical Diagnostic Procedures: Clinical lab analyses (sputum analysis, fecal analysis, semen analysis, throat swab, skin scrape). 2. Physical Diagnostic Procedures: School physicals, Premarital physicals. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears). 4. Noninvasive Treatment Procedures: Nutritional evaluation &/or treatment (Homeopathic preparations). 5. Invasive Treatment Procedures: None.

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Table 4 (continued) 17. Puerto Rico: “(a) Chiropractic—Shall mean the science of the treatment of the human body by means of adjustments and manipulations for the purpose of correcting partial misalignment and subluxation of the spinal column, causing compression on the nerves, thus hindering the transmission of vital energy from the brain to the organs, tissues and cells of the human body” (78). Lamm study restricted services: Not surveyed. 18. South Carolina: “Title 40—Professions and Occupations Chapter 9. Chiropractors and Chiropractic. Section 40-9-10. Definitions. (a) ‘Chiropractic’ is defined as that science and art which utilizes the inherent recuperative powers of the body and deals with the relationship between the nervous system and the spinal column, including its immediate articulations and the role of this relationship in the restoration and maintenance of health. (b) ‘Chiropractic practice’ is defined as the spinal analysis of any interference with normal nerve transmission and expression, and by adjustment to the articulations of the vertebral column and its immediate articulations for the restoration and maintenance of health and the normal regimen and rehabilitation of the patient without the use of drugs or surgery. (c) ‘Analysis’ is defined as a physical examination, the use of x-ray and procedures generally used in the practice of chiropractic. (d) Any machine used in ‘chiropractic practice’ or ‘analysis’ must first be approved by the South Carolina Board of Chiropractic Examiners” (82). Lamm study restricted services: 1. Technical Diagnostic Procedures: None. 2. Physical Diagnostic Procedures: None. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Rectal examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: None. 19. Tennessee “63-4-101. ‘Chiropractic defined—Mandatory practices.’ (b) The practice and procedures used by the doctor of chiropractic shall include the procedure of palpation, examination of the spine and chiropractic clinical findings accepted by the board of chiropractic examiners as a basis for adjustment of the spinal column and adjacent tissues for the correction of nerve interference and articular dysfunction. (d) Nothing in this chapter shall be construed to authorize any of the following: (3) Penetrating the skin with a needle or any other instrument; (8) Invasive diagnostic tests or analysis of body fluids. ‘Invasive’ means any procedure involving penetration of the skin or any bodily orifice whether by hand or by any device” (86). Lamm study restricted services: 1. Technical Diagnostic Procedures: X-ray procedures (soft tissue), Clinical lab analyses (sputum analysis, fecal analysis, semen analysis, throat swab, skin scrape). 2. Physical Diagnostic Procedures: Premarital physicals. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Rectal examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: Ear irrigation, Endonasal technique digital manipulation of the eustachian tube orifice, Recommendation of nonprescription items (OTC). 20. Texas: “Chapter 201. Chiropractors Subchapter A. General Provisions 201.2. Practice of Chiropractic (b) A person practices chiropractic under this chapter 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” (87); Lamm study restricted services: 1. Technical Diagnostic Procedures: None. 2. Physical Diagnostic Procedures: None. 3. Special Diagnostic Procedures: None. 4. Noninvasive Treatment Procedures: Craniopathy. 5. Invasive Treatment Procedures: None. 21. Virgin Islands “Practice of chiropractic defined as used in this subchapter, “practice of chiropractic” means the detecting and correcting by manual means of the structural imbalance, distortion, or subluxations in the human body for the purpose of removing nerve interference and effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column.” A license to practice chiropractic shall not permit the holder thereof to treat for any infectious or communicable diseases, any of the cardiovascular-renal or cardio-pulmonary diseases, . . . or to diagnostic or therapeutic methods involving chemical or biological means; . . . Nothing in this section shall be construed as restricting a licensed chiropractor from utilizing standard laboratory procedures as a means to assist in arriving at a diagnosis of the patient’s condition for the purpose of chiropractic treatment” (92). Lamm study restricted services: Not surveyed.

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Table 4 (continued) 22. Virginia: “54.1-1900. Definitions ‘Practice of chiropractic’ means the adjustment of the twenty-four movable vertebrae of the spinal column, and assisting nature for the purpose of normalizing the transmission of nerve energy, but does not include the use of surgery, obstetrics, osteopathy or the administration or prescribing of any drugs, medicines, serums, or vaccines” (94). Lamm study restricted services: 1. Technical Diagnostic Procedures: None. 2. Physical Diagnostic Procedures: School physicals. 3. Special Diagnostic Procedures: None. 4. Noninvasive Treatment Procedures: None. 5. Invasive Treatment Procedures: None. 23. Washington “RCW 18.25.005 ‘Chiropractic’ defined. (1) Chiropractic is the practice of health care that deals with the diagnosis and care or treatment of the vertebral subluxation complex and its effects, articular dysfunction, and musculoskeletal disorders, all for the restoration and maintenance of health and recognizing the recuperative powers of the body. (4) Chiropractic care shall not include . . . or any form of venipuncture. RCW 18.25.006 Definitions (8) ‘Chiropractic differential diagnosis’ means a diagnosis to determine the existence of a vertebral subluxation complex, articular dysfunction, or musculoskeletal disorder, and the appropriateness of chiropractic care or the need for referral to other health care providers” (95). Lamm study restricted services: 1. Technical Diagnostic Procedures: Vascular analysis (Doppler, etc.), Clinical lab analyses (venipuncture for blood analysis, sputum analysis, fecal analysis, semen analysis, throat swab, skin scrape). 2. Physical Diagnostic Procedures: Eyes/ear/nose/throat examinations, Abdominal examinations. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Female breast examination, Rectal examination, Male genital examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: Physiotherapy (electrotherapy, ultrasound, hydrocolation, TENS therapy), Soft tissue manipulation of the abdominal viscera, Counseling, Rehabilitation. 5. Invasive Treatment Procedures: Ear irrigation, Endonasal technique digital manipulation of the eustachian tube orifice.

vided with no practice act, limited and broad scope of practice acts (104). When a chiropractic act was sought, significant opposition from the allopathic profession would surely ensue. Furthermore, based upon chiropractic leadership practice philosophy and/or politics in each jurisdiction, legislation offered would result in different descriptions and definitions for chiropractic throughout the nation. The primary purpose of regulation by law of the activities of any profession is to protect the public, enhance its welfare and the profession (100,104). The chiropractic profession’s practice acts would therefore reflect the understanding each legislature had with the profession at the time of inception—preparatory education, chiropractic educational standards, national standards and research; weighted against the concerns for the public health. Such standards would expectedly be compared with the standards of the established allopathic profession. Thus, with each state or commonwealth, opposition from the allopathic profession, a lack of chiropractic organization, chiropractic educational standards and a deficiency in professional unification resulted in a wide variance of chiropractic practice acts throughout the Union (104). Each State established it’s own chiropractic practice act de-

pendent upon the forces of health-care competition (internal and external) throughout the course of the profession’s development. Perhaps, in a practical way, this was necessary for the profession to survive or an inevitable phase for a developing profession. Perhaps a unified definition and scope of practice for the profession will ensue. The reasoning and future forecast is beyond the scope of this review. This study confirms chiropractic practice act variance with U.S. States, the District of Columbia, Puerto Rico and the U.S. Virgin Islands, recognizing a wide to narrow scope of practice with explicit to vague language for describing chiropractic practice. There is no uniform national understanding of chiropractic scope of practice throughout the United States, the District of Columbia, Puerto Rico and the U.S. Virgin Islands. Although the Lamm studies (23,105,106) reveal a broadening of the chiropractic scope of practice, often times the language of the statutes become lengthy, overly detailed and archaic (10) with many definitions of terms that may leave one to wonder what chiropractic practice really encompasses.

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Table 5 Qualifying Language for IOM Defined Primary Care in Chiropractic Practice Acts 1. Connecticut: “Sec. 20–24. Definitions. As used in this chapter: (1) The practice of chiropractic means the practice of that branch of the healing arts consisting of the science of adjustment, manipulation and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that may interfere with the normal generation, transmission and expression of nerve impulse between the brain, organs and tissue cells of the body, which may be a cause of disease, are adjusted, manipulated or treated. (2) The terms ‘chiropractic’, ‘doctor of chiropractic’, ‘chiropractor’ and ‘chiropractic physician’ are synonymous, and mean a practitioner of chiropractic as defined in subdivision (1) of this section. (3) The term ‘accredited chiropractic college or colleges’ means only those institutions which are at the time of the applicant’s graduation, either (A) accredited by the Council on Chiropractic Education or other specialized accrediting agency recognized by the United States Department of Education or (B) if located outside the United States, deemed by said council to meet its educational standards. (b) Any chiropractor who has complied with the provisions of this chapter may: (1) Practice chiropractic as defined in section 20–24, but shall not prescribe for or administer to any person any medicine or drug included in materia medica, except vitamins, or perform any surgery or practice obstetrics or osteopathy; (2) Examine, analyze and diagnose the human living body and its diseases, and use for diagnostic purposes the x-ray or any other general method of examination for diagnosis and analysis taught in any school or college of chiropractic which has been recognized and approved by the State Board of Chiropractic Examiners; (3) Treat the human body by manual, mechanical, electrical or natural methods, including acupuncture, or by use of physical means, including light, heat, water or exercise in preparation for chiropractic adjustment or manipulation, and by the oral administration of foods, food concentrates, food extracts or vitamins; (4) Administer first aid and, incidental to the care of the sick, advise and instruct patients in all matters pertaining to hygiene and sanitary measures as taught and approved by recognized chiropractic schools and colleges” (31). 2. Illinois: “Illinois Compiled Statutes Professions and Occupations Medical Practice Act of 1987 225 ILCS 60/ (225 ILCS 60/11 Sec. 11. (B) Treating human ailments without drugs and without surgery. For the practice of treating human ailments without the use of drugs and without operative surgery” (40): 3. Florida: “Title XXXII Chapter 460 Regulation of Professions and Occupations Chiropractic Medicine 460.403 Definitions used in this chapter, the term: (9) (a) ‘Practice of chiropractic medicine’ means a noncombative principle and practice consisting of the science, philosophy, and art of the adjustment, manipulation, and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that are interfering with the normal generation, transmission, and expression of nerve impulse between the brain, organs, and tissue cells of the body, thereby causing disease, are adjusted, manipulated, or treated, thus restoring the normal flow of nerve impulse which produces normal function and consequent health by chiropractic physicians using specific chiropractic adjustment or manipulation techniques taught in chiropractic colleges accredited by the Council on Chiropractic Education. No person other than a licensed chiropractic physician may render chiropractic services, chiropractic adjustments, or chiropractic manipulations. (b) Any chiropractic physician who has complied with the provisions of this chapter may examine, analyze, and diagnose the human living body and its diseases by the use of any physical, chemical, electrical, or thermal method; use the x-ray for diagnosing; phlebotomize; and use any other general method of examination for diagnosis and analysis taught in any school of chiropractic. (c) 1. Chiropractic physicians may adjust, manipulate, or treat the human body by manual, mechanical, electrical, or natural methods; by the use of physical means or physiotherapy, including light, heat, water, or exercise; by the use of acupuncture; or by the administration of foods, food concentrates, food extracts, and items for which a prescriptions not required and may apply first aid and hygiene, but chiropractic physicians are expressly prohibited from prescribing or administering to any person any legend drug except as authorized under subparagraph 2, from performing any surgery except as stated herein, or practicing obstetrics” (35). 4. Oklahoma: “161.2. Chiropractic Defined—Scope of Practice. a. Chiropractic is the science and art that teaches health in anatomic relation and disease or abnormality in anatomic disrelation, and includes hygienic, sanitary, and therapeutic measures incident thereto in humans. The scope of practice of chiropractic shall include those diagnostic and treatment services and procedures which have been taught by an accredited chiropractic college and have been approved by the Board of Chiropractic examiners” (73).

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Table 6 Lamm Study Procedures which may Restrict Primary Care in IOM Qualified Jurisdictions Arizona 1. Technical Diagostic Procedures: Clinical lab analyses (skin scrape). California 5. Invasive Treatment Procedures: Ear irrigation. Colorado 1. Technical Diagnostic Procedures: EMG &/or nerve conduction studies. 2. Physical Diagnostic Procedures: School physicals, Impairment ratings. Florida 5. Invasive treatment procedures: Intrarectal manipulation of the coccyx. Idaho 1. Technical Diagnostic Procedures: EMG and/or nerve conduction studies. 2. Physical Diagnostic Procedures: Electrocardiography. Iowa 5. Invasive Treatment Procedures: Recommendation of nonprescription items (OTC). Maine 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears). Minnesota 1. Technical Diagnostic Procedures: X-ray procedures (soft tissue). 5. Invasive Treatment Procedures: Recommendation of nonprescription items (OTC). Nebraska 1. Technical Diagnostic Procedures: X-ray procedures (soft tissue). 2. Special Diagnostic Procedures: Female pelvic examination (Pap smears). 5. Invasive Treatment Procedures: Recommendation of nonprescription items (OTC). Nevada 1. Technical Diagnostic Procedures: EMG &/or nerve conduction studies. 4. Noninvasive Treatment Procedures: Nutrition evaluation &/or treatment (homeopathic preparations), Rehabilitation. 5. Invasive Treatment Procedures: Recommendation of nonprescription items (OTC). New Hampshire 1. Technical Diagnostic Procedures: Thermography, Hair analysis. 2. Physical Diagnostic Procedures: School physicals, Pre-employment physicals, Premarital physicals. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Female breast examination, Rectal examination, Male genital examination, Prostatic digital examination. 5. Invasive Treatment Procedures: Intrarectal manipulation of the coccyx. North Dakota 5. Invasive Treatment Procedures: Recommendation of nonprescription items (OTC). Oregon 4. Noninvasive Treatment Procedures: Nutrition evaluation &/or treatment (homeopathic preparations). South Dakota 2. Physical Diagnostic Procedures: School physicals, Pre-employment physicals, Premarital physicals. 5. Invasive Treatment Procedures: Intrarectal manipulation of the coccyx. Wisconsin 2. Physical Diagnostic Procedures: School physicals. 3. Special Diagnostic Procedures: Female pelvic examination (Bi-manual examination, speculum examination, recto-vaginal examination, Pap smears), Female breast examination, Rectal examination, Male genital examination, Prostatic digital examination. 4. Noninvasive Treatment Procedures: Nutrition evaluation &/or treatment (botanical therapy). 5. Invasive Treatment Procedures: Recommendation of nonprescription items (OTC). Wyoming 2. Physical Diagnostic Procedures: School physicals.

Leading chiropractic organizations have established definitions for chiropractic (107–109). The American Chiropractic Association does not provide a model practice act but recognizes “State statutes and regulations

determine the scope of clinical procedures chiropractors may legally perform” (16). The ICA established an “International Model Legislation For The Practice of Chiropractic” (110). This model, however, falls short in pro-

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Table 7 Non-participating States in Lamm Study Connecticut Michigan

Delaware Puerto Rico

Illinois Vermont

Indiana Virgin Islands

viding IOM defined primary care given the emphasis on “recognizing a relationship between spinal structure and function of the nervous system,” the evaluation of the “relationship between the musculoskeletal system and body functions” and the citation of specific diagnostic procedures to “determine the relationship between musculoskeletal structures and the nervous system” (110). With a description of specific chiropractic services for a specific purpose, the profession becomes limited. The state of Illinois simply exempts the use of drugs or surgery in the chiropractic act, thus allowing for a broad scope of practice (40,41). With jurisdictions that have a narrow scope of practice with specific descriptions for subluxation, one may be left to question the legal ability of the DC to provide primary care. It is usually suggested the subluxation affects the nervous system which controls or influences all other physiological systems. Thus with the detection and correction of the subluxation, one is affecting the total health of the individual and therefore providing primary care. However, there must be measurement of the effects of subluxation upon human physiology as well as objective determination of the effectiveness of subluxation correction upon other systems. This would certainly be a reasonable expectation from the scientific and the patient’s (consumers) perspective. To do this, one would need to be able to examine and diagnose the whole patient. Objective measurement would need to be obtained through such services as whole-body physical examinations, electrocardiography, spirometry, clinical laboratory analysis, imaging and others. When these services are excluded or restricted from chiropractic practice, primary care is not achievable. In essence, as the practice of chiropractic becomes more defined and specified in the code of law, the provision of primary care services becomes increasingly difficult to achieve. If the chiropractic profession is to achieve primary care recognition throughout the nation, a uniform practice act would serve an essential function. The practice act must provide for a broad scope of practice model for each State and Commonwealth to strive toward. This model should meet the criteria for IOM defined primary care and recognize the unique characteristics of chiro-

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practic. A model act would help the profession prepare for unrestricted inclusion in Federal health care programs such as Medicare, Medicaid, CHAMPUS, Military Health Care system and the Indian Health Care system. Presently, there are no chiropractic primary-care models within these programs. These public supported programs are therefore skewed toward a homogenous and autocratic system of allopathic primary care. A model practice act should also provide an impetus toward primary-care research funding from Federal, State and private sources. The result should be a greater understanding of the mechanisms of human health restoration and maintenance mechanisms. A greater variety of health-care services available to the health-care consumer through the public and private health-care systems should follow. One would expect this to be welcome in a pluralistic society. This review was conducted by one practitioner without the assistance of a chiropractic scope of practice expert and legal or legislative scholar for each jurisdiction and thus may suffer with an inaccurate interpretation of the practice acts. Furthermore, this study reviewed the practice acts only and not the regulations established for each jurisdiction. The regulations or other statutes may specifically permit the DC to provide primary care. Also, each jurisdiction may define primary care on their own terms, thus providing the opportunity to include limited chiropractic practice acts or even exclude broad chiropractic practice acts in their primary care definition. This study should be repeated with chiropractic and legal experts from each jurisdiction. This will be helpful in determining the course of political action required in each jurisdiction to achieve IOM defined primary care qualifications. CONCLUSION This review of the U.S. statutes was conducted to determine the provisions that allow the DC to provide primary care as defined by the IOM. The variance of chiropractic practice acts prohibits the achievement of IOM criteria for primary-care practice throughout the United States. With this, federal health care initiatives such as Medicare, Medicaid, CHAMPUS, veteran’s health-care programs, military health-care programs, Indian healthcare programs and Federal patient’s rights legislation as well as national third-party payment systems may establish rules and regulations to integrate chiropractic practice consistent with the least common denominator of practice - musculoskeletal, neuromusculoskeletal or subluxation based care that is regarded as a specialty or

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sub-specialty practice. The opportunity for a naturallybased primary-care profession to contribute to the health of the public becomes diminished. A uniform, chiropractic model practice act with a broad range scope that would allow for the provision and responsibility of IOM defined primary care is needed for the profession. REFERENCES 1. Donaldson MS, Yordy KD, Lohr KN, Vanselow A. Primary care - America’s health in a new era. Washington, DC: Institute of Medicine; National Academy Press; 1996. p. 27–51. 2. Nelson CF. Chiropractic scope of practice. J Manipulative Physiol Ther 1993;16:488–97. 3. Ivey TL. Chiropractic scope of practice, Letters to the editor. J Manipulative Physiol Ther 1994;17:198. 4. Homola S. Chiropractic scope of practice, Letters to the editor. J Manipulative Physiol Ther 1994;17:198. 5. Murphy DR. Chiropractic scope of practice, Letters to the editor. J Manipulative Physiol Ther 1994;17:198–9. 6. Gentile JM. Chiropractic scope of practice, Letters to the editor. J Manipulative Physiol Ther 1994;17:200–1. 7. Standards for chiropractic programs and institutions. Scottsdale, AZ: Council on chiropractic education commission on accreditation; February 2001. Http//.www.cce.org. 8. Starfield B. Measuring the attainment of primary care. J Med Educ 1979; 54:361–9. 9. Fallon JM. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. J Clinical Chiropr Pediatrics 1997; 2:167–83. 10. Chapman-Smith D. The chiropractic profession. West Des Moines, IA: NCMIC Group Inc; 2000 p. 65–98. 11. Bakkum BW, Green BN. Chiropractic hospitals in America - a case study of the Bakkum hospital (1936–1950). J Manipulative and Physiol Ther 2001; 24:34–43. 12. Spano D, Darling P. Cardiovascular changes in degenerative cervicopathy. Chiropractic treatment. In: Mazzarelli JP, editor. Chiropractic Interprofessional Research - Based on the World Chiropractic Conference April 30May 2, 1982. Torino, Italy: Edizioni Minerva Medica or Washington, DC: International Chiropractors Association or Milano (Italy): Instituto Nazionale Static; 1985. p. 77–87. 13. Masarsky CS, Todres-Masarsky M, editors. Somatovisceral aspects of chiropractic, an evidenced-based approach. New York, Edinburgh London, Philadelphia: Churchill Livingstone; 2001. 14. Carrick FR. Changes in brain function after manipulation of the cervical spine. J Manipulative Physiol Ther 1997;20:529–45. 15. Goldhamer A, Lisle D, Parpia B, Anderson SV, Campbell TC. Medically supervised water-only fasting in the treatment of hypertension. J Manipulative Physiol Ther 2001;24:335–39. 16. Adams A, et al. Chiropractic state of the art. Arlington, VA: American Chiropractic Association; 1998. American Chiropractic Foundation. 17. Killinger L. Chiropractors and public health: it’s what we do! Dynamic Chiropractic 2002;21:26–52. 18. Blevins SA. The medical monopoly protecting consumers or limiting competition? Washington, DC: CATO Institute; 1995. Policy Analysis no. 246. 19. Baird R. Entering the front door: hospitals include chiropractic services. JACA 1999;36:32–40. 20. Guralnik DB. Webster’s new world dictionary of the American language. 2nd college ed. New York and Cleveland: The world publishing company; 1970. p. 882. 21. Inglis BD, Fraser B, Penfold BR. Chiropractic in New Zealand, report of the commission of inquiry 1979. Wellington, New Zealand: Government Printer; 1979. p. 235. 22. Peterson D, Wiese G. Chiropractic: an illustrated history. St. Louis, MO: Mosby Year Book Inc; 1995. p. 489–95. 23. Lamm L, Pfannenschmidt K. Chiropractic scope of practice: what the law allows - update 1999. J Neuromusculoskeletal System 1999;7:102–6.

24. Bassett JL, code commissioner. Code of Alabama 1975, volume 18. Rochester, NY: Lawyers Cooperative Publishing; 1997. p. 781–800. 25. Price M, Canfield TD, Seymour A, supervisors. Alaska statutes 1962, volume 2, title 6 to title 9. Charlottesville, VA: Lexis Publishing; 2000. p. 172–80. 26. Arizona revised statutes, annotated, volume 10, title 32, professions and occupations. St. Paul, MN: West Publishing; 2001. p. 424–50. 27. Arizona revised statutes, annotated, 2001, cumulative pocket part, volume 10, title 32, professions and occupations. St. Paul, MN: West Publishing; 2001. p. 125–32. 28. Napper S, et al., Arkansas code revision commission. Arkansas code of 1987, annotated, volume 17B 2002 replacement, title 17, professions, occupations, and businesses. Charlottesville, VA: Lexis Publishing; 2002. p. 15–37. 29. State of California Board of Chiropractic Examiners. Laws and regulations relating to the practice of chiropractic. Scaramento, CA: California Office of Sate Printing; 1994. p. 19–62. 30. Pike CW, revisor of statutes. Colorado revised statutes, 2001, volume 4, title 12, professions and occupations. Denver, CO: Bradford Publishing Co; 2001. p. 360–76. 31. The general statutes of Connecticut, revision of 1958, revised to January 1, 2001, volume 7, title 20. State of Connecticut; 2001. p. 33–9. 32. Wolcott DF, Rogers BA, Delaware code revisors. Delaware code annotated, revised 1974, volume 12 1997 replacement volume. Charlottesville, VA: Michie; 1997. p. 187–98. 33. Wolcott DF, Rogers BA, Delaware code revisors. Delaware code annotated, revised 1974, 2000 supplement, volume 12 1997 replacement. Charlottesville, VA: Michie; 2000. p. 30–38. 34. Lexis District of Columbia code annotated 2001 edition, volume 4, titles 3–6. Charlottesville, VA: LexisNexis; 2001. p. 83–4. 35. Division of statutory revision of the Florida legislature. Official Florida statutes 2001. Tallahassee, FL: State of Florida; 2001. p. 1811–9. 36. Code revision committee, Office of legislative counsel, Lexis editorial staff. Official code of Georgia annotated, volume 30, 1999 edition, title 43, Professions and businesses. Charlottesville, VA: Lexis Law Publishing; 1999. P. 186–205. 37. Code revision committee, Office of legislative counsel, Lexis editorial staff. Official code of Georgia annotated, 2001 supplement, volume 30, 1999 edition, title 43, Professions and businesses. Charlottesville, VA: Lexis Law Publishing; 2001. p. 91–9. 38. Hawaii revised statutes, volume 10, 1993 replacement, title 25, chapters 436–471. Hawaii: State of Hawaii; 1993. p. 105–12. 39. Hawaii revised statutes, 2001 cumulative supplement, volume 10, title 25, chapters 436–471. Hawaii: State of Hawaii; p. 39–41. 40. West’s Smith-Hurd Illinois compiled statutes annotated, chapter 225, 1/1 to 104/end, professions and occupations. West Group; 1998. p. 406–529. 41. West’s Smith-Hurd Illinois compiled statutes annotated, chapter 225, 1/1 to 104/end, professions and occupations, 2002 cumulative annual pocket part, West Group; 2002. p. 90–118. 42. McFeeley ND, Bowen RD, Green CL, commissioners. Idaho code, general laws of Idaho annotated, titles 54–55. Michie; 2000. p. 68–80. 43. Burns Indiana statutes annotated code edition, title 25, articles 8–39, 1999 replacement volume. Charlottesville, VA: Lexis Law Publishing; 1999. p. 63–76. 44. Bolender DE, director. Volume 1 code of Iowa. DesMoines, IA: Legislative Service Bureau General Assembly of Iowa; 2000. p. 1485–7. 45. Furse NJ, revisor of statutes. Volume 5 Kansas statutes annotated, chapters 65–70a. Topeka, KS: State of Kansas; 1992. p. 266–306. 46. Revisor of statutes of Kansas. 2001 cumulative supplement to the Kansas statutes annotated, volume 5, chapters 65–70a, volume 5A, chapters 71–74. Topeka, KS: State of Kansas. 2001. p. 186–202 47. Michie’s Kentucky revised statutes annotated certified version, volume 12, 2001 replacement. Charlottesville, VA: LexisNexis; 2001. p. 131–46. 48. West’s Louisiana statutes annotated, revised statutes, sections 37:2401 to 37: end, volume 21B, part 2. West Group; 2000. p. 118–40. 49. Maine revised statutes annotated 1964, volume 15, title 32, section 1 to 6000. St. Paul, MN: West Publishing co; 1988. p. 87–98. 50. Maine revised statutes annotated 1964, volume 15, title 32, section 1 to 6000, 1998 supplementary pamphlet. West Group; 1998. p. 58–73. 51. Michie’s annotated code of the public general laws of Maryland, health

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