Chiropractic—primary care, neuromusculoskeletal care, or musculoskeletal care? Results of a survey of chiropractic college presidents, chiropractic organization leaders, and Connecticut-licensed doctors of chiropractic

doi:10.1016/S0161-4754(03)00108-8

Journal of Manipulative and Physiological Therapeutics

Volume 26, Issue 8, October 2003, Pages 510-526

https://doi.org/10.1016/S0161-4754(03)00108-8 Get rights and content

Abstract

Background

The Connecticut Chiropractic Association authorized an ad hoc committee to study Connecticut chiropractic scope of practice in January 1999. This committee was chaired by Richard Duenas, DC, and included 4 other Connecticut-licensed doctors of chiropractic who responded to an appeal to participate.

Objective

Committee members investigated the terms primary care, primary care provider (PCP) (clinician, physician), neuromusculoskeletal care, neuromusculoskeletal care provider (clinician, physician), musculoskeletal care, and musculoskeletal care provider (clinician, physician) to determine which, if any, apply to the practice of chiropractic.

Data sources

A literature review was performed with in-depth analysis of the definitions of these terms and an interpretation of Connecticut Statutes for chiropractic, comparing the legal description of chiropractic practice to the term definitions. The literature review produced several detailed definitions of primary care and/or primary care provider (clinician, physician); however, no accurate description of neuromusculoskeletal (NMS) care or musculoskeletal care was found.

Results

Two opinion surveys were conducted: 1 survey included presidents of accredited chiropractic colleges, as well as leaders of chiropractic organizations throughout the world. The other survey was sent to doctors of chiropractic (DC) licensed in the State of Connecticut. Survey topics addressed definitions of primary care and PCP, the formulation of these terms, neuromusculoskeletal care and neuromusculoskeletal care provider, individual rights in selecting a PCP, and the types of practitioners considered PCPs. The consensus among chiropractic college presidents, organization leaders, and Connecticut-licensed doctors of chiropractic was that the doctor of chiropractic is qualified to provide primary care. Most considered any definition of primary care invalid if the chiropractic profession was not involved in its formulation. The overwhelming majority felt the patient should retain the ultimate choice in determining who should be their PCP. Mission statements of accredited chiropractic colleges were reviewed, paying particular attention to educational goals and professional qualifications of graduates. The committee found these institutions strive to train students in all aspects of primary care.

Conclusions

Upon review of the literature and term definitions, interpretation of the statutes pertaining to chiropractic practice, results of both surveys, and review of the chiropractic college mission statements, the committee concluded that the Connecticut-licensed DC, by education, licensure, definition, and intraprofessional consensus, qualifies as a PCP.

Introduction

In recent years, it has largely been the impression of government, private industry policymakers, many health care professions, the general public, and some within the chiropractic profession itself that chiropractic practice is not primary care and should be utilized for the treatment of neuromusculoskeletal or musculoskeletal conditions only.1, 2 Consequently, this impression, especially within the third-party payment system, may deter the health care consumer from choosing chiropractic as a naturally based discipline of primary care. Others, however, do consider the training and clinical practice of the doctor of chiropractic (DC) to constitute primary care.3, 4, 5, 6

A review of mission statements of chiropractic colleges accredited by the Council on Chiropractic Education (CCE), European Council on Chiropractic Education, Council on Chiropractic Education-Canada, and Australian Council for Chiropractic and Osteopathy reveals, additionally, that these institutions are preparing students to render primary care (Table 1). 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 This is consistent with the CCE's stated purpose²⁷ and established standards of chiropractic education and practice.²⁸

According to the Bylaws of the Connecticut Chiropractic Association (CCA), its objectives include:

•
To maintain the science of chiropractic as a separate and distinct healing arts profession.
•
To protect in every way not contrary to the law, the philosophy, science and art of chiropractic, and the professional welfare of its members.
•
To serve as an official spokesman for and representative of the chiropractic profession in the state of Connecticut.²⁹

A plan for the future of chiropractic in the state of Connecticut, established by the CCA in 1998, includes 4 primary strategies of development. One strategy, “To increase access to the patient population”, includes the objective, “...achieving direct access to patients, equitable payment for services provided and protection of the scope of practice in Connecticut.”³⁰

To this end and on inquiry regarding the CCA position on the issues of the DC as a primary care or neuromusculoskeletal care provider, an Ad Hoc Committee on Chiropractic Scope of Practice was formed in January 1999.

The committee's objectives were to:

•
Study the terms primary care, primary care provider (clinician, physician) (PCP), neuromusculoskeletal care, neuromusculoskeletal care provider (clinician, physician), musculoskeletal care, and musculoskeletal care provider (clinician, physician).
•
Analyze the chiropractic scope of practice in Connecticut according to state statutes.
•
Determine how the clinical practice of chiropractic relates to the legal scope of practice and these terms.
•
Formulate a CCA position statement on the role of chiropractic practice in Connecticut as primary care and/or neuromusculoskeletal care and/or musculoskeletal care.

The committee felt an established CCA position statement on these issues would be essential for the CCA to fulfill its mission, objectives, and strategic plan, and to further the chiropractic profession in the eyes of government, private industry, and the public.

Section snippets

Methods

A Medline, Chiropractic MANTIS Database, and Congressional Information Services Code of Federal Regulations search were performed for the terms primary care, primary care provider (clinician, physician), neuromusculoskeletal care, neuromusculoskeletal care provider (clinician, physician), musculoskeletal care, and musculoskeletal care provider (clinician, physician). The literature obtained was distributed by the chairman for review by committee members. Articles were chosen which would offer

Literature review

The American health care system is presently undergoing a dramatic transformation. Whether the current trend in utilization of naturally based treatment alternatives is due to disenchantment with allopathic medicine or renewed interest in vitalistic health care,42, 43, 44, 45 increased accountability of all health care disciplines will inevitably ensue. Moreover, in the midst of the confusion, a current issue in chiropractic's own evolution involves taking itself to task to establish a unified

Discussion

Based on this study, including primary care definitions, the definition of chiropractic, education, licensure, intraprofessional consensus, and clinical practice, the CCA Ad Hoc Committee concluded the Connecticut-licensed DC is qualified to provide primary care.

Conclusion

The committee set out to apply the terms primary care, neuromusculoskeletal care, or musculoskeletal care to the practice of chiropractic, particularly in Connecticut. The evidence supports chiropractic as a primary care profession and the Connecticut-licensed DC as qualified to provide primary care. The study also revealed the DC's interest in providing neuromusculoskeletal or musculoskeletal specialty care. It was very clear that health care consumer/patient choice is very important, if not

Acknowledgements

We extend our gratitude to the 1998-1999 CCA Board of Directors for recognizing the necessity of this study and authorizing the formation of the Ad Hoc Committee. Malcolm Doyle and Marge LaCroix were instrumental in helping this project run smoothly; we appreciate their assistance. We thank Sheryl Horowitz, PhD, for her guidance in preparing and reviewing the surveys.

References (67)

An overview of credentialing guidelines. Sacramento (CA): Landmark Chiropractic Independent Practice Associations;...
C.F. Nelson
Chiropractic scope of practice
J Manipulative Physiol Ther
(1993)
L.L. Brick
The future of chiropractic medicinea primary role
Colorado Chiropr J
(1999)
Ciancuilli A. Chiropractic: a primary care gatekeeper. Des Moines: Foundation for Chiropractic Education and Research;...
Gonyea MA. The role of the doctor of chiropractic in the health care system in comparison with doctors of allopathic...
T.H. Sokoloff
Chiropractic scope of practiceanother perspective
J Manipulative Physiol Ther
(1994)
Los Angeles College of Chiropractic academic catalog 1997-1999. Whittier (CA): Los Angeles College of Chiropractic;...
Life Chiropractic College West catalog 1998-2000. San Lorenzo (CA): Life Chiropractic College West; 1998-2000. p....
Educating leaders in chiropractic health care catalog 1997-1998. Los Angeles: Cleveland Chiropractic College of Los...

Prospectus Anglo European College of Chiropractic

(1997)

Canadian Memorial Chiropractic College. 1998/1999 course calendar on the web. Available at:...

Universite' du Quebec a Trois-Rivieres 1993-1994 Chiropratique. Trois-Rivieres (Quebec, Canada): Université du Québec à...

Bylaws of the Connecticut chiropractic association. Rocky Hill (CT): Connecticut Chiropractic Association; May 5,...

Minutes of strategic planning meeting. Rocky Hill (CT): Connecticut Chiropractic Association; November 5,...

L. Simpson et al.

Primary carean idea in search of a paradigm?

Am Fam Physician

(1993)

Millis JS. The graduate education of physicians. Report of the citizens commission on graduate medical education....

Primary health care: a joint report by the director-general of the World Health Organization and the executive director...

Cited by (16)

Defining chiropractic professional identity: A concept analysis
2023, Journal of Bodywork and Movement Therapies
The concept of professional identity within chiropractic is often discussed and debated, however in the field to date, there is no formal definition of chiropractic professional identity (CPI). This article aims to create a coherent definition of CPI and to formalise the conceptual domains that may encompass it.
Using the Walker and Avant (2005) process, a concept analysis methodology was employed to clarify the diffuse concept of CPI. This method initially involved selecting the concept (CPI), determining the aims and purpose of the analysis, identifying concept uses, and defining attributes. This was achieved from a critical literature review of professional identity across health disciplines. Chiropractic-related model, borderline and contrary cases were used to exemplify characteristics of CPI. The antecedents required to inform CPI, consequences of having, and ways to measure the concept of CPI were evaluated.
From the concept analysis data, CPI was found to encompass six broad attributes or domains: knowledge and understanding of professional ethics and standards of practice, chiropractic history, practice philosophy and motivations, the roles and expertise of a chiropractor, professional pride and attitude, and professional engagement and interaction behaviours. These domains were not mutually exclusive and may overlap.
A conceptual definition of CPI may bring together members and groups within the profession and promote intra-professional understanding across other disciplines. The CPI definition derived from this concept analysis is: ‘A chiropractor's self-perception and ownership of their practice philosophies, roles and functions, and their pride, engagement, and knowledge of their profession’.
Moving towards a contemporary chiropractic professional identity
2020, Complementary Therapies in Clinical Practice
Citation Excerpt :
Some chiropractors consider themselves as Integrative Medicine or Complementary and Alternative Medicine providers [96]. Chiropractors have also demonstrated their preference as being Primary Contact Practitioners [67,94], Primary Care Providers [31], MSK specialists [52,61,110] and back pain specialists or primary care generalists [110]. The purpose of this review was to evaluate the body of knowledge on practising chiropractors’ perspectives on their professional identity.
Since the inception of the chiropractic profession, debate has continued on differing practice objectives and philosophical approaches to patient care. While the political and academic leaders of the profession continue to dominate the discourse, little is known on the perspectives of the everyday practising chiropractor on their professional identity. In this paper, professional identity within the profession of chiropractic was evaluated using a systematised search strategy of the literature from the year 2000 through to May 2019. Initially 562 articles were sourced, of which 24 met the criteria for review. The review confirmed three previously stated professional identity subgroups; two polarised approaches and a centrist or mixed view. The musculoskeletal biomedical approach is in contrast to the vertebral subluxation vitalistic practice approach. Whilst these three main chiropractic identity subtypes exist, within the literature the terminology used to describe them differs. Research aimed at categorising the chiropractic profession identity into exclusive subtypes found that at least 20% of chiropractors have an exclusive vertebral subluxation focus. However, deeper exploration of the literature shows that vertebral subluxation is an important practice consideration for up to 70% of chiropractors. Patient care with a musculoskeletal spine focus is dominant in clinical practice. This review found that practising chiropractors consider themselves to be primary care or primary contact practitioners with a broad scope of practice across a number of patient groups not limited to musculoskeletal management. Across the research, there is a marked difference in the categories of practice objectives evaluated, and future research could examine the relatedness of these. Additionally, future research could explore the professional identity construct over time and within different practice contexts to help facilitate the progression of the profession.
The chiropractic scope of practice in the United States: A cross-sectional survey
2014, Journal of Manipulative and Physiological Therapeutics
Citation Excerpt :
Education and training of limited scope health care providers is broader than what state practice laws allow.42,52–54 For instance, as part of The Council of Chiropractic Education accreditation process, chiropractic schools are to educate and train students to become a “competent doctor of chiropractic who will provide quality patient care and serve as a primary care physician,” yet the variances in practice regulation do not allow this to occur.16,55,56 In addition, the language of state practice acts may be vague and may not be sufficient to answer whether a technique or procedure is within a particular scope of practice.16
The purpose of this study was to assess the current status of chiropractic practice laws in the United States. This survey is an update and expansion of 3 original surveys conducted in 1987, 1992, and 1998.
A cross-sectional survey of licensure officials from the Federation of Chiropractic Licensing Boards e-mail list was conducted in 2011 requesting information about chiropractic practice laws and 97 diagnostic, evaluation, and management procedures. To evaluate content validity, the survey was distributed in draft form at the fall 2010 Federation of Chiropractic Licensing Boards regional meeting to regulatory board members and feedback was requested. Comments were reviewed and incorporated into the final survey. A duplicate question was imbedded in the survey to test reliability.
Partial or complete responses were received from 96% (n = 51) of the jurisdictions in the United States. The states with the highest number of services that could be performed were Missouri (n = 92), New Mexico (n = 91), Kansas (n = 89), Utah (n = 89), Oklahoma (n = 88), Illinois (n = 87), and Alabama (n = 86). The states with the highest number of services that cannot be performed are New Hampshire (n = 49), Hawaii (n = 47), Michigan (n = 42), New Jersey (n = 39), Mississippi (n = 39), and Texas (n = 30).
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.
Caught in the crosshairs: Identity and cultural authority within chiropractic
2011, Social Science and Medicine
Citation Excerpt :
Setting a narrow scope as neuromusculoskeletal spine experts or back/neck pain specialists has been advocated by several segments within the profession (Mootz, 2007; Murphy et al., 2008; Nelson et al., 2005; World Federation of Chiropractic (WFC), 2005). Others are vehemently opposed to this (Duenas, Carucci, Funk, & Gurney, 2003; Kent, 2009; Riggs, 2007; Rosner, 2005; Sportelli, 2006). Smith and Carber (2009) report that 73% of surveyed chiropractors considered themselves as “back pain/musculoskeletal specialists” (p. 23).
In this paper the discourse over identity and cultural authority within the profession of chiropractic in the United States has been analyzed using critical discourse analysis. As the profession struggles to construct one singular image, versions of self must be internally debated and also shaped in consideration of larger, external forces. The dilemma of remaining tied to a marginal professional status must be balanced against considerations of integration. Written texts from chiropractic journals and newspapers are analyzed in a multidimensional approach that considers the rhetorical devices and thematic issues of identity construction; the representation of various voices within the discourse (both heard and unheard); and the extent to which external pressures affect the projection of cultural authority for the profession. A heterogeneous discourse characterized by conflict was found, with discrepancies between everyday chiropractors in actual practice versus academic chiropractors and leaders particularly over the idea, practice and significance of science for the profession.
Patient perceptions in New Mexico about doctors of chiropractic functioning as primary care providers with limited prescriptive authority
2011, Journal of Chiropractic Medicine
Citation Excerpt :
Chiropractors have an interest in providing primary care and claim to be qualified to perform the functions of a primary care provider.5,6 The Connecticut Chiropractic Association concluded that the chiropractic physicians licensed in Connecticut qualify to provide primary care services based upon the results of a survey of chiropractic college presidents, chiropractic organization leaders, and Connecticut-licensed doctors of chiropractic.7 The purpose of this study was to survey chiropractic patients in New Mexico on their perceptions about chiropractors being physicians and primary care providers and if the patients perceived that chiropractors should be trained to treat patients with a limited prescriptive authority and hands-on treatment to control pain.
The purpose of this study was to determine chiropractic patients' perceptions of chiropractors serving as primary care providers and having a limited prescriptive authority.
Four doctors of chiropractic in Albuquerque and Santa Fe, NM, participated in surveying their patients during the summer of 2008. The chiropractors distributed the questionnaires consecutively to chiropractic patients. Patients answered questions regarding their perceptions of their chiropractors, use of chiropractic care, and medications for pain. The participating chiropractors collected the completed patient questionnaires and mailed them to the primary investigator.
The chiropractic providers collected 275 chiropractic patient questionnaires. The number of patient questionnaires collected by each of the 4 participating chiropractors ranged from 35 to 100. The patients primarily sought care for the management and treatment of pain (98.5%), and 57.5% considered that their chiropractors were “primary care providers.” Eighty-five percent preferred that their chiropractor be qualified to prescribe medications and provide hands-on treatment, whereas 97.5% perceived their chiropractors to be chiropractic physicians.
This small group of chiropractic patients from 4 offices in New Mexico perceived that their doctors of chiropractic were physicians and primary care providers, and 85% preferred that their chiropractor treat patients with limited prescriptive authority when appropriately trained.
Triage and case presentations in a chiropractic pediatric clinic
2007, Journal of Chiropractic Medicine
The use of triage in a chiropractic practice is to determine whether or not a patient who has presented to an office is in need of a referral to another health care provider. The objective of this article is to illustrate the use of triage skills in a primary care, chiropractic pediatric practice. This is examined both in the new patient setting and during visit-to-visit protocol.
An analysis of the number of chiropractic triage visits during a 1-year period was performed on 48 new children or pregnant women and 1634 existing pediatric and pregnancy visits.
The average level of chiropractic triage for a new patient, whether pediatric or pregnant, was a limited level of concern (P3, green flag), with more than 85% of new patients falling into that category. Fifteen percent were at a cautionary (P2, yellow flag) level, and none were at the emergency (P1, red flag) level. Between 12% and 15% of the total of existing pediatric or pregnancy visits were at a P1 or P2 level of triage, and 11% of the total of pediatric triage visits were at the P1 level.
New patients rarely come to a chiropractic pediatric office in a P1-level crisis, whereas existing patients have a much higher likelihood of presenting during a P1 challenge. P2 triage levels are somewhat common, whereas P3 triage levels are the most frequent. Triage methods are a way to help place a patient in a category that can ensure an optimum, safe, and effective level of care.

View all citing articles on Scopus

View full text

Review of literatureChiropractic—primary care, neuromusculoskeletal care, or musculoskeletal care? Results of a survey of chiropractic college presidents, chiropractic organization leaders, and Connecticut-licensed doctors of chiropractic