State legislatures routinely incorporate pseudoscience into health care practitioner licensing laws, a process I call “Legislative Alchemy.” These laws allow health care practitioners to use bogus diagnostic methods, diagnose fabricated diseases and conditions, and sell useless remedies to their patients. Legislatures credulously adopt the self-regulated educational and testing requirements of these practitioners instead of objectively evaluating their credentials.
Armed with the undeserved imprimatur of legitimacy bestowed by the state, naturopaths, chiropractors and acupuncturists diagnose and treat millions of patients each year. Yet, they offer nothing beneficial that is not readily available from evidence-based practitioners. As for the rest, at best, patients lose only their money. At worst, they lose their lives.
Today, we look at chiropractic efforts to benefit from the magic of Legislative Alchemy in 2017, a subject I previewed earlier this year.
The DC as PCP
The American Chiropractic Association (ACA), the Council on Chiropractic Education, and chiropractic schools have declared, ipse dixit, that chiropractors are primary care physicians, a rebranding campaign we’ve covered extensively here on SBM. (List of posts here.) For example, according to the National University of Health Sciences (NUHS), its chiropractic school:
prepares students to become first-, primary care physicians fully qualified to diagnose, treat, and manage a wide range of conditions.
We’ll examine the veracity of that statement more closely in a moment, but first let’s look at two Tennessee laws passed in 2017 which gave a big boost to chiropractic’s rebranding efforts.
Chiropractic scope of practice under prior Tennessee law was basically limited to diagnosing and treating neuromuscular conditions via the detection and correction of the phantom chiropractic subluxation. House Bill 387 vastly expands that scope for chiropractic “physicians” in a way that might not be immediately obvious to those unfamiliar with the chiropractic “DC as PCP” campaign.
Essential to this rebranding is a redefined scope of practice, which the ACA calls “Six Elements of a Modern Chiropractic Act.” Key elements include:
- An unrestricted right to diagnose any patient of any age with any disease or condition, including expanded authority to order and perform diagnostic testing.
- Deference to chiropractic schools in determining chiropractic scope of practice – if they teach it, chiropractors can legally do it.
- While giving lip service to chiropractic treatment of “neuromusculoskeletal” conditions, the authority to diagnose and treat an undefined “other health conditions or issues,” as well as “general health matters, wellness and health optimization.”
In other words, the ACA wants to sell the public on the notion that chiropractors should be everyone’s first stop for general health advice as well as a diagnosis of what ails them, no matter what the disease or condition, trusting the chiropractor to refer the patient to a real doctor should the need arise. In Tennessee, that’s pretty much what they got.
The scope of a chiropractor’s authority to diagnose was totally redefined to include “differential diagnosis,” defined as, without limitation as to disease or condition:
the source, nature, and extent of a disease or other physical condition for the purpose of establishing an appropriate plan of care, which may include referral to another provider for care that is outside the scope of practice of a chiropractic physician.
To conduct this differential diagnosis, the chiropractor can perform a “thorough examination and evaluation” of the patient as well as use “diagnostic procedures necessary to clinically correlate a physical examination to a diagnostic impression.” What diagnostic procedures can they use? A whole lot of them. They can:
- Perform x-rays and non-invasive diagnostic procedures, not otherwise described.
- Order advanced diagnostic imaging and “other diagnostic procedures,” again, not otherwise described.
- Collect blood, urine, saliva, and hair for analysis.
- Perform “minimally invasive procedures” if they learned it in chiropractic school and the state chiropractic board says it’s ok. (They must consult with the medical board but there’s no requirement that the medical board approve what they decide.)
Let’s pause for a minute to note that the chiropractic lobby wanted to include hair analysis (“a cardinal sign of quackery”) and saliva testing (used by quacks to diagnose hormone “imbalances” and validated only for Cushing’s syndrome, which no chiropractor has any business touching) along with the right to order, say, PET scans and MRIs.
But what about treatment? Are Tennessee chiropractors allowed to treat any disease or condition they diagnose? Probably not, but they can go well beyond musculoskeletal conditions. Again, you need to know a bit of background to understand how this will work.
Subluxation-based chiropractors will still be able to locate and remove “interference with nerve transmission and nerve function,” which they regard as beneficial to a host of diseases and conditions. For the rest, it depends on how expansively you are willing to read the statute. Under the new law, “treatment” means:
The treatment of neuromuscular, musculoskeletal, and related conditions . . . [and] the provision of supportive care with due regard for nutrition, hygiene, sanitation and rehabilitation designed to assist in the restoration and maintenance of a patient’s health. [Emphasis added.]
Recall that the chiropractors drafted this bill to include hair and saliva analysis. That’s a smoking gun showing they plan to diagnose non-existent “toxicities” and “hormone imbalances,” presumably with the intent to treat these “conditions,” most likely with dietary supplements (“nutrition”) under the rubric of “assisting in the restoration and maintenance of a patient’s health.” Of course, that’s just a small sampling of the many bogus “other diagnostic procedures” that can be used to diagnose all manner of “nutritional deficiencies” and assorted fabricated conditions, like “heavy metal toxicity” based on provoked urine testing and treated with dietary supplements.
In other words, in addition to detecting and correcting non-existent subluxations, chiropractors will have a scope of practice similar to a naturopathic “doctor” practicing in a state that does not allow prescription privileges: an unlimited right to diagnose and broad authority to treat with, for example, non-prescription drugs, dietary supplements and (presumably) homeopathy, as long as the treatment can be shoehorned into a vague category like “related conditions,” “supportive care,” “nutrition” and so on.
To bring home the point that a DC can be your PCP, the Tennessee legislature also passed a bill allowing chiropractors to enter into “direct primary care agreements” with patients, that is, agree to “provide primary care services” to the patient for a fee over an agreed period of time. The agreement must describe “the scope of primary service that is covered” by the fee.
“Primary care services” is defined to include:
the screening, assessment, diagnosis, and treatment for the purpose of promotion of health or the detection and management of disease or injury within the competency and training of the direct primary care physician, or, if applicable, within the scope of practice of a chiropractic physician.
Note that an MD or DO physician is limited to diagnosis and treatment within his “competency and training” but chiropractors can provide care within their “scope of practice,” that is, anything the chiropractic lobbyists who wrote the new scope of practice law say they can do.
With that in mind, let’s return to the National University of Health Science’s claim that the school is training students to practice primary care “fully qualified to diagnose, treat, and manage a wide range of conditions.” A recent chiropractic journal article authored by three members of the NUHS Department of Clinical Practice faculty casts doubt on that claim. (Whole article is behind a paywall.)
The authors report their treatment of constipation in two 7-month-old twins who were born prematurely at 29 weeks, both of whom had undergone abdominal surgery. Treatment consisted of scar tissue mobilization, detection and correction of phantom subluxations, and acupressure to the feet. One of the infants also underwent Dynamic Neuromuscular Stabilization “to correct aberrant movement patterns.” This lasted for ten treatment sessions for one and eight for the other, both at two treatment sessions per week. Follow up visits after the supposed resolution of their supposed constipation were then reduced to one visit per week, then one per month.
It hardly bears mentioning that none of these is a proven treatment for constipation in infants, and two of them are based on fantastical concepts of human anatomy and physiology. As best I can tell, the principles behind Dynamic Neuromuscular Stabilization remain unproven (if not fantastical) particularly in infants, and not meant for constipation. Scar tissue mobilization, described as “gentle cross-frictional movement along the scar” was used to “loosen up tightness of the abdominal musculature” and “stimulate the mechanoreceptors and nerve endings in the skin,” along with a lot of hand waving about how this relieves constipation.
I ran the article by SBM’s own Clay Jones, MD, a pediatrician (have a read of his post on constipation in children ). He noted that the determination of constipation in infants is often very subjective and thought that these babies were probably not constipated in the first place. He noted that some of the supposed symptoms of constipation described in the article were actually normal behavior. If anything, he guessed that:
the chiropractor was taking credit for the natural course of the complaints, maternal placebo response, and possibly other interventions [not described in the article].
I point all of this out to demonstrate the folly of legislatures’ relying on self-regulated chiropractic education and training (especially scant in pediatrics) in granting licensure to chiropractors and giving them the authority to treat any patient with any disease or condition. It also gives lie to comments made in response to SBM posts on chiropractic that subluxation-based chiropractic is fading and no longer taught in chiropractic schools. And it is a perfect example of how, in the words of the new Tennessee law, conditions “related” to (at least in the chiropractic view of things) neuromuscular issues can be expanded to cover all sorts of medical problems chiropractors have no business treating.
Chiropractic “nutrition” and other imagined competencies
Idaho passed a practice expansion bill in 2017 allowing chiropractors “certified in clinical nutrition” to administer vitamins A, C and all B vitamins, minerals such as calcium, copper, magnesium, selenium and zinc, by means that include intravenous injections, as well as orally and topically. Apparently, the law was passed because chiropractors had been giving injections anyway and wanted to continue. This brings the ACA closer to another desired element of the Modern Chiropractic Practice Act: Prescription authority. (Vitamins and minerals are legally considered drugs if they are injected, despite chiropractors’ protestations otherwise.)
Becoming certified in clinical nutrition is a pretty easy prospect. All they will need is 77 classroom hours 24 clinical hours in administration, lab testing and blood chemistry interpretation, all of which they can get at a chiropractic school.
The new law will allow chiropractors to cash in on the health craze for vitamin and mineral infusions. Considering the plethora of bogus nutritional testing methods available, there should be no shortage of opportunities to upsell patients on the need. Except in cases of actual deficiency, which are rare, and use for a handful of diseases, vitamin and mineral infusions are not supported by adequate evidence of safety and efficacy. Fortunately for them, this is not considered a barrier to chiropractors.
There were two other minor legislative successes for chiropractors in 2017. In Texas, the legislature added “diagnose” to the chiropractic scope of practice, although the Senate made it clear this is not an expansion and chiropractors are limited to diagnosing a biomechanical condition of the spine or musculoskeletal system. Virginia will allow chiropractors to perform physicals commercial driver’s licenses and learner’s permits.
Otherwise, chiropractic bills failed or, in three states, remain pending. (Links are provided for pending bills; for failed bills, see The Society for Private-investigator-detective.)
Two of the practices chiropractors covet are performing school physicals for student athletes and the authority to return students athletes to play after a concussion. (The cynic in me sees these as practice-building efforts.) Harriet Hall, MD, and Mark Crislip, MD, have analyzed chiropractors’ ability to perform these functions and found them wanting, but lack of education and training (not to mention reality-based practice) never stopped a legislator from introducing a practice expansion bill.
Both Connecticut and Oregon said “no” to chiropractors returning concussed athletes to play. Bills allowing chiropractors to perform school physicals remain pending in California, North Carolina (although it may have missed a deadline for further consideration), and Wisconsin. Even though the Wisconsin bills are opposed by the state medical society, medical specialty associations, the state nurses, and athletic trainers associations, hospitals and insurance groups, the Assembly passed its version of the bill. (Senate version here.)
Colorado allows animal chiropractic, which is based on the notion that non-existent subluxations exist in animals as well as humans and, as in humans, can be detected by x-ray. A bill failed that would have relieved chiropractors of the requirement that a veterinarian clear the animal prior to chiropractic treatment.
A bill granting chiropractors a Tennessee-sized scope of practice expansion didn’t make it in Indiana, while a substantial practice expansion bill remains pending in New York. Nevada rejected a practice expansion that would have allowed the correction of subluxations to “improve health.” Florida did not follow Tennessee’s lead in allowing chiropractors to enter into direct primary care agreements with patients. A New Mexico bill allowing “advance practice” chiropractors expanded prescription privileges, including all drugs used in primary care practice except Schedule I controlled substances, didn’t pass. In Wyoming, chiropractors tried, once again, to call themselves “physicians.” That bill didn’t pass either.
And on it goes. A practice expansion bill has already been filed in Indiana for consideration in the 2018 legislative session. We’ll be watching.