The Chiropractic Scope of Practice in the United States: A Cross-Sectional Survey

  • Mabel Chang
    Submit requests for reprints to: Mabel Chang, DC, MPH, Assistant Professor, Clinical Sciences, National University of Health Sciences, SPC–Health Education Center, 7200 66th St N., Pinellas Park, FL 33781.
    Assistant Professor, Clinical Sciences, National University of Health Sciences–Florida, Pinellas Park, FL
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      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.

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      1. NBCE 2010 Practice Analysis.
        ([cited 2013 Aug 27]. Available from:)
        • Cassidy A
        Nurse practitioners and primary care (updated).
        Health Affairs, 2013 ([Available from:])
        • Committee on Quality of Health Care in America
        • Institute of Medicine
        Crossing the quality chasm: a new health system for the 21st century—Institute of Medicine.
        National Academy Press, Washington, DC2001 ([[cited 2014 Mar 18]. Available from:])
      2. Final report of the Commission on Medical Education.
        Calif West Med. 1933; 38: 112-113
        • The National Council of State Boards of Nursing
        Changes in healthcare professions' scope of practice: legislative considerations.
        ([cited 2013 Aug 23]. Available from:)
        • Bourgeault IL
        • Grignon M
        A comparison of the regulation of health professional boundaries across OECD countries.
        Eur J Comp Econ. 2013; 10: 199-223
        • Blevins SA
        The medical monopoly: protecting consumers or limiting competition.
        Policy Anal. 1995; 246 (Available from:]): 1-36
        • Folland S
        • Goodman AC
        • Stano M
        The economics of health and health care.
        7th ed. Pearson, Upper Saddle River, N.J2013
        • Fuchs VR
        Who shall live? Health, economics and social choice.
        2nd ed. World Scientific, Singapore2011
        • Safriet B
        Impediments to progress in health care workforce policy: license and practice laws.
        Inquiry. 1993; 31: 310-317
        • Feldstein PJ
        The politics of health legislation: an economic perspective.
        Health Administration Press Perspectives, 1988 ([276 p.])
        • Havighurst CC
        The changing locus of decision making in the health care sector.
        J Health Polit Policy Law. 1986; 11: 697-735
        • National Highway Traffic Safety Administration
        National EMS Scope of Practice Model.
        National Highway Traffic Safety Administration, 2007 ([cited 2014 Jan 30]. Available from:
        • Gardner D
        Expanding scope of practice: inter-professional collaboration or conflict?.
        Nurs Econ. 2010; 28: 264-266
        • Wesorick BR
        • Doebbeling B
        Lessons from the field: the essential elements for point-of-care transformation.
        Med Care. 2011; 49 (Miscellaneous Article) (Available from:]): S49-S58
        • Duenas R
        United States Chiropractic Practice Acts and Institute of Medicine defined primary care practice.
        J Chiropr Med. 2002; 1: 155-170
        • Bellamy JJ
        Legislative alchemy: the US state chiropractic practice acts.
        Focus Altern Complement Ther. 2010; 15: 214-222
      3. Ronald Hamowy. The early development of medical licensing laws in the United States 1875-1900. J Libert Stud. 3(1):17–119.

        • Ameringer Carl F
        The health care revolution: from medical monopoly to market competition—chapter 1: the professional regime.
        The Health Care Revolution: From Medical Monopoly to Market Competition. University of California Press, 2008 ([[cited 2013 Sep 30]. Available from:])
        • Baerlocher MO
        • Detsky AS
        Professional monopolies in medicine.
        JAMA. 2009; 301: 858-860
        • Baer HA
        Divergence and convergence in two systems of manual medicine: osteopathy and chiropractic in the United States.
        Med Anthropol Q. 1987; 1: 176-193
        • Bodenheimer TS
        • Smith MD
        Primary care: proposed solutions to the physician shortage without training more physicians.
        Health Aff (Millwood). 2013; 32: 1881-1886
        • Huijbregts Peter A
        Chiropractic legal challenges to the physical therapy scope of practice: anybody else taking the ethical high ground?.
        J Manipulative Ther. 2007; 15: 69-80
        • Alabama State Chiropractic Association
        Alabama State Chiropractic Association: 2010 Scope of Practice Survey.
        ([cited 2013 Aug 27]. Available from:)
      4. NYSCA & New York Chiropractic College Conduct Scope of Practice Survey [Internet]. The Chronicle of Chiropractic.
        ([cited 2013 Jul 18]. Available from:)
        • World Federation of Chiropractic
        The legal status of chiropractic practice internationally.
        World Federation of Chiropractic, Toronto ON Canada2011 ([Available from:])
        • Hamill Jeff
        • Lange Chuck
        • Schmaltz Kim
        A survey of practicing logan college of chiropractic doctors located in the southeastern states of Alabama and Florida on the utilization of procedures and treatments per the legislated scope of practice in these states.
        ([cited 2013 Aug 27]. Available from:)
        • Congressional Budget Office
        • Joint Committee on Taxation
        Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act - CBO.
        Congressional Budget Office and the Joint Committee on Taxation, 2012 ([Available from:])
        • Congressional Budget Office
        Effects of the Affordable Care Act on Health Insurance Coverage—February 2013 Baseline.
        ([cited 2013 Sep 1]. Available from:)
        • He W
        • Sengupta M
        • Velkoff VA
        • DeBarros KA
        65+ in the United States: 2005.
        U.S. Dept. of Commerce, Economics and Statistics Administration, Bureau of the Census, Washington, D.C2005
        • Colwill JM
        • Cultice JM
        • Kruse RL
        Will generalist physician supply meet demands of an increasing and aging population?.
        Health Aff (Millwood). 2008; 27: w232-w241
        • Bodenheimer T
        • Chen E
        • Bennett HD
        Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job?.
        Health Aff (Millwood). 2009; 28: 64-74
        • Staiger DO
        • Auerbach DI
        • Buerhaus PI
        Trends in the work hours of physicians in the United States.
        JAMA. 2010; 303: 747-753
        • Stodd RT
        The Weathervane.
        Hawaii J Med Public Health. 2013; 72: 450
        • French M
        • Homer J
        • Klevay S
        • Goldman E
        • Ullmann S
        • Kahn B
        Is the United States ready to embrace concierge medicine?.
        Popul Health Manag. 2010; 13: 177-182
        • Barr P
        On retainer.
        Mod Healthc. 2011; 41: 28-30
        • Page L
        The rise and further rise of concierge medicine.
        BMJ. 2013; 47 ([f6465-f6465])
        • Orkin FK
        • McGinnis SL
        • Forte GJ
        • et al.
        United States anesthesiologists over 50: retirement decision making and workforce implications.
        Anesthesiology. 2012; 117: 953-963
        • Nusbaum NJ
        Commentary: physician retirement and physician shortages.
        J Community Health. 2009; 34: 353-356
      5. Scope of Practice Overview.
        ([cited 2014 Jan 10]. Available from:)
        • Chadi N
        Breaking the scope-of-practice taboo: where multidisciplinary rhymes with cost-efficiency.
        MJM. 2011; 13: 44-52
        • Reagan PB
        • Salsberry PJ
        The effects of state-level scope-of-practice regulations on the number and growth of nurse practitioners. Nurs Outlook.
        ([cited 2013 Aug 23]; Available from:)
        • U.S. Department of Health and Human Services: Health Resources and Services Administration- Bureau of Health Professions
        The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand.
        U.S. Department of Health and Human Services: Health Resources and Services Administration- Bureau of Health Professions, 2008 ([Available from:])
      6. Patient Protection and Affordable Care Act. 42. Sect. 18001.
        2010: 111-148
      7. Scope of Practice Legislation Tracking Database.
        ([cited 2013 Aug 26]. Available from:)
        • Lamm L
        • Wegner E
        Scope of practice: what the law allows.
        AJCM. 1989; 2: 155-159
        • Lamm L
        • Wegner E
        • Collord D
        Chiropractic scope of practice: what the law allows—update 1993.
        J Manipulative Physiol Ther. 1995; 18: 16-20
        • Lamm L
        • Pfannenschmidt K
        Chiropractic scope of practice: what the law allows—update 1999.
        J Neuromusculoskel Syst. 1999; 7: 102-106
        • Soklaridis S
        • Kelner M
        • Love RL
        • Cassidy JD
        Integrative health care in a hospital setting: communication patterns between CAM and biomedical practitioners.
        J Interprof Care. 2009; 23: 655-667
        • Gray B
        • Orrock P
        Investigation into factors influencing roles, relationships, and referrals in integrative medicine.
        J Altern Complement Med. 2014; 17 ([140117124141004])
        • Khorsan R
        • Cohen AB
        • Lisi AJ
        • et al.
        Mixed-Methods Research in a Complex Multisite VA Health Services Study: variations in the implementation and characteristics of chiropractic services in VA. Evid Based Complement Alternat Med.
        ([cited 2014 Feb 6];2013. Available from:)
        • Fairman JA
        • Rowe JW
        • Hassmiller S
        • Shalala DE
        Broadening the scope of nursing practice.
        N Engl J Med. 2011; 364: 193-196
        • Dower Catherine
        • Christian Sharon
        • O'Neil Edward
        Promising scope of practice models for the health professions.
        Center for the Health Professions University of California, San Francisco2007 ([[cited 2013 Oct 8]. Available from:])
        • Dill MJ
        • Pankow S
        • Erikson C
        • Shipman S
        Survey shows consumers open to a greater role for physician assistants and nurse practitioners.
        Health Aff (Millwood). 2013; 32: 1135-1142
      8. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status, January 2007.
        The Council on Chiropractic Education, 2007 ([[cited 2014 Jan 27]. Available from:])
        • Duenas R
        • Carucci GM
        • Funk MF
        • Gurney MW
        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.
        J Manipulative Physiol Ther. 2003; 26: 510-526
        • Poghosyan L
        • Nannini A
        • Stone PW
        • Smaldone A
        Nurse practitioner organizational climate in primary care settings: implications for professional practice.
        J Prof Nurs. 2013; 29: 338-349
        • Poghosyan L
        • Nannini A
        • Smaldone A
        • et al.
        Revisiting scope of practice facilitators and barriers for primary care nurse practitioners: a qualitative investigation.
        Policy Polit Nurs Pract. 2013; 14 ([[cited 2013 Aug 23]; Available from:]): 6-15
        • Gaumer GL
        Regulating health professionals: a review of the empirical literature.
        Milbank Mem Fund Q Health Soc. 1984; 62: 380-416
        • Cooper RA
        Health care workforce for the twenty-first century: the impact of nonphysician clinicians.
        Annu Rev Med. 2001; 52: 51-61
        • American Medical Association
        Digest of Official Actions.
        1969-1978, Reimbursement in Federal Programs [Internet]. 1980: 248 ([Available from: of Official Actions%2Fama_arch%2FAD100001%2F00000003])
        • Smith SD
        • Beran TN
        Practice analysis of chiropractic radiology: identifying items for part I of the clinical competency examination.
        J Manipulative Physiol Ther. 2012; 35: 710-719