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Chiropractic in the United States:
Training, Practice, and Research

Chapter V: Licensure and Legal Scope of Practice
Ruth Sandefur, DC, PhD; Ian D. Coulter, PhD

**Comments in red by Stephen Barrett, M.D.

A. Licensure in 50 States

The practice of chiropractic is licensed and regulated in all 50 of the United States and in over 30 countries worldwide (Christensen, 1993). Attainment of licensure was the culmination of years of struggle by the profession (Wardwell, 1992). The quest began in the State of Minnesota in 1905 and ended in 1974 when Louisiana became the final State to license chiropractic (Peterson, 1995). Licensure helped to make the practice of chiropractic legitimate as well as helping to define the scope of chiropractic practice. Because there are 50 different legislative bodies involved in the licensing process, there is a wide variation in scope of practice from State to State. For example, in a recent survey of chiropractic licensing boards in the United States and Canada, it was shown that a few States allow very little other than spinal manipulation to be performed while others permit a number of diverse procedures such as acupuncture, electromyography, and laboratory diagnostics (Lamm, 1995).

The legislation that led to licensure also authorized the formation of State Licensing Boards that regulate, among other factors, the education, experience, and moral character of candidates for licensure. One of the main purposes of the State Licensing Boards is to protect the public health, safety, and welfare (FCLB, 1997). To varying degrees, State boards construct and administer examinations to candidates for licensure or require examinations administered nationally by the National Board of Chiropractic Examiners (described later). Additionally, some State boards may stipulate which of the chiropractic colleges are eligible to have their graduates take the State's licensing examination. Currently, students who have graduated from any of the 16 chiropractic colleges accredited by the Council on Chiropractic Education may take the licensing examination in all 50 States (FCLB, 1996). In 1996, all chiropractic colleges in the United States were accredited.

Because each State has a different governing board and regulatory structure, there are a variety of testing and licensing procedures across States. For example, only five States, Kansas, Illinois, Missouri, New York, and Virginia, grant licenses to applicants based solely upon the successful completion of the National Board of Chiropractic Examiners' battery of tests.

The National Board of Chiropractic Examiners (NBCE), established in 1963, functions similarly to the National Board of Medical Examiners (NBME). Part I of the NBCE covers the basic sciences and may be taken after the first year of chiropractic college education. Part II covers clinical sciences and is administered when a student is in his/her senior year of chiropractic college. Part III is a written clinical competency examination that requires an examinee to have passed Part I and be within 8 months of graduation (if taken while still in school). The optional NBCE Physiotherapy Examination may be taken following the completion of 120 hours of physiotherapy coursework. This exam is independent of Parts I, II, and III. The Physiotherapy Examination was initiated in 1965 as a response to requests from representatives of several State boards. Since the subject was being taught in many of the chiropractic colleges and because the use of physiotherapy was widespread among practicing chiropractors, there was interest in evaluating competency in the subject. The Physiotherapy Examination is maintained as a separate test because a few chiropractic institutions have not incorporated physiotherapy into their curricula and some States' scope of practice laws restrict the use of physiotherapy modalities by chiropractors.

Recently, another national examination has been developed at the request of the Federation of Chiropractic Licensing Boards (FCLB). The Part IV practical examination (Objective Structured Clinical Examination) tests students' practical skills in three areas: x-ray interpretation and diagnosis, chiropractic technique, and case management. This examination may be taken following successful completion of Part I and Part II of the NBCE when a student is within 6 months of graduation (FCLB, 1996).

All States, except the five States mentioned previously that do not have a separate examination, require passing scores on all or part of the NBCE tests as well as on one State-administered test. The content and format of the State-administered examinations vary considerably. Approximately one in three States require one State-administered evaluation. This may involve written questions regarding State regulations and statutes, an interview, or a practical examination covering diagnostic and management procedures. The remaining States require from two to four additional examinations. These State-administered examinations may cover clinical sciences, diagnostic sciences, x-ray interpretation, and spinal manipulative techniques, as well as questions about State statutes. Table 12, based on information from the Federation of Chiropractic Licensing Board's annual publication, provides detailed information about these individual requirements (FCLB, 1996, 1997).

1. The National Board of Chiropractic Examiners

The National Board of Chiropractic Examiners (NBCE) was established in 1963 to foster consistency and reciprocity among State boards (Wardwell, 1992). Initially the NBCE was met with resistance from some State examining boards, but by 1970, it was recognized in 29 States and by 37 licensing boards (Peterson, 1995). At present, all 50 States recognize the national examination and 49 require Part I for licensure (FCLB, 1997). Part II of the examination is required by all States except Maryland and Michigan (Table 12), and Part III is required by 45 States (FCLB, 1997). Part IV, the Objective Structured Clinical Examination, is currently required in 21 States. Despite wide acceptance of the NBCE, all but 10 States continue to administer their own examinations. Some of these examinations consist of a personal interview, some consist of questions about the State statutes governing the practice of chiropractic, and others give written/practical examinations in various subjects, such as radiology, adjusting techniques, clinical science subjects, or other areas of particular interest to that State (FCLB, 1997).

Table 12. Licensing and Reciprocity Regulations by State

State Pre-Prof. Education State Admin. NBCE Required Cont. Ed. hrs/yr. Reciprocity
AL I A,B,C,D 1,2 18 NO
AK II A,B,C 1,2,3,PT 12 YES
AZ I B,C 1,2,3,4,PT 12 YES**
AR II A,B,C 1,2,3,PT 24 NO
CA III B 1,2,3,4,PT 12 YES
CO I B,C 1,2,3 15 YES
CT II, III B 1,2,3,PT 0 NO
DE I A 1,2,3,PT 12 YES
FL Other B,C 1,2,3,PT 20 YES**
GA II, III B,C 1,2,3 12 YES
HI III B,C 1,2,3,PT 10 NO
ID II A,B,C 1,2,3,PT 12 YES**
IL II 0 1,2,3 Required‡ YES
IN II, III A,B,C 1,2,3,PT 12 YES
IO II B 1,2,3,4,PT 30 YES*
KS III, IV D 1,2,3,4,PT 50 NO
KY III B 1,2,3,4 12 NO
LA III B,C 1,2,3,PT 12 YES
ME II B,C 1,2,3,PT 12 YES*
MD IV A,B,C 1 24 YES
MA II C 1,2,3,4,PT 12 YES
MI II A,B None 12 YES
MN II A,B,C 1,2,3,4,PT 20 NO
MS II B 1,2,3,4,PT 12 NO
MO III 0 1,2,3,4,PT 20 YES
MT IV A,B,C 1,2,3,4,PT 12 NO
NE Other B 1,2,3,4,PT 15 YES
NV III B,C 1,2,3,PT 12 NO
NH I C 1,2,3,4 10 YES
NJ II B 1,2,3 0 NO
NM II A,B,C 1,2,3 10 YES*
NY II, III 0 1,2,3,4 Required‡ YES
NC IV A,B,C 1,2,3,PT 24 YES
ND II B,C 1,2,3,4 12 YES
OH III B,C 1,2,3,PT 12 NO
OK III A,B,C 1,2,PT 12 YES**
OR II A,B,C 1,2,3,PT 15 YES
PA II B,C, 1,2,3,4 12 YES
RI IV B 1,2,3 12 YES*
SC II B,C 1,2,3 12 NO
SD II A,B 1,2,3,4,PT 20 YES**
TN II A,B,C 1,2,3,PT 12 YES*
TX II B,C 1,2,3,4,PT 16 NO
UT II C 1,2,3,4,PT 15 YES*
VT II A,B 1,2,3,4,PT 12 YES*
VA I 0 1,2,3,4 0 NO
WA II A,B 1,2 25 YES*
WV II, III A,B 1,2,3 12 YES*
WI II, III, IV A,B,C 1,2,3 20 NO
WY II C 1,2,3,4,PT 12 YES

KEY: I=No requirement; II=Two Years College; III=60 Credit hrs; IV=Bachelor's Degree. A=Written exam in specific subjects; B=Practical or oral exam in specific subjects; C=Written or oral exam on state laws; D=Interview. 1=NBCE Part I; 2=NBCE Part II; 3=NBCE Part III; 4=NBCE Part IV; PT=NBCE Physiotherapy.
*=State Exam; **=State Exam plus other requirements; ‡=CE required/# hours unknown.

Sources: Official Directory of FCLB, 1996-97 and 1997-98.

2. Establishment of the Federation of Chiropractic Licensing Boards

There was an obvious need for the 50 separate State agencies to establish a single body to facilitate coordination and communication. A board, originally known as the Council of State Chiropractic Examining Boards (CSCEB) was established in 1933, with the mandate to promote unified standards for chiropractic licensure. It was renamed the Federation of Chiropractic Licensing Boards (FCLB) in 1974 and has had the following mission:

The FCLB publishes a directory that provides information about licensing requirements for each State (FCLB, 1997).

3. Effect of Licensing upon Chiropractic Educational Institutions

The FCLB was instrumental in the efforts to establish an independent accreditation agency for chiropractic educational institutions (Peterson, 1995). Federal recognition of the Council on Chiropractic Education (CCE) as the accrediting body for chiropractic colleges in 1974 was a landmark event in the history of chiropractic education (Keating, 1992). The CCE regulates preprofessional requirements for admission to chiropractic colleges as well as educational requirements for graduation from chiropractic colleges (Peterson, 1995).

B. Reciprocity Agreements

The term reciprocity has traditionally been used when describing the policy of States agreeing to grant licensure to practitioners licensed to practice in another State. In reality, however, there are no States that automatically provide a license to a chiropractor based solely on possession of a license to practice in another State (FCLB, 1996). Every State has set a minimum standard that must be met in order to obtain a license. Requirements for reciprocity are generally less stringent than those imposed for initial licensure.

Each State has established its own reciprocity policy (Table 12). A few States indicate that they do not reciprocate, which means that a licensee from another State must approach the board in the same manner as a new candidate for licensure. Other States, despite claiming that they grant reciprocity, still require that the chiropractor seeking reciprocity fulfill all of the same requirements as a new candidate. Several other States have specific requirements and/or examinations that must be passed. Some States require that a practitioner coming from another State provide a current measure of clinical competency by taking and submitting a score transcript on the NBCE Special Purposes Examination for Chiropractic (SPEC). This examination is designed to measure the competency level of an individual who has been in practice for at least 2 years.

C. Legal Scope of Practice

Chiropractic is licensed and regulated in every State (Lamm, 1995). State statutes and regulations determine the scope of clinical procedures chiropractors may legally perform in their respective jurisdictions. Within these legal boundaries individual practitioners may practice as they wish. Providing care for musculoskeletal conditions using manipulation as a primary intervention is within the legal scope of chiropractic practice in all 50 States. The legal right to use other procedures including modalities, myofascial work, acupuncture, and nutritional therapy varies from State to State.

The United States and State constitutions empower States to grant licensure and to regulate scope of practice (Christensen, 1993). State regulatory agencies, established by the legislature of each State, manage the licensing process and disseminate information regarding scope of practice. In most States, the extent of the scope of practice will be influenced by laws enacted through legislation, policies, or guidelines issued by the regulatory agency responsible for licensing, and by court decisions.

All States currently exclude prescribing drugs and performing major surgery from chiropractic practice. Otherwise, differences in scope of practice vary considerably from State to State. These variations are categorized here as: (1) restrictive, (2) expansive, or (3) intermediate. States are considered restrictive in scope if they explicitly prohibit chiropractors from performing two or more of the following: venipuncture for diagnostic purposes, use of physiotherapy modalities, dispensing of vitamin supplements, or provision of nutritional advice to patients. Michigan is an example of a State with a restricted scope of practice (FCLB, 1996). In Michigan, the license limits chiropractors to the use of spinal analysis and x-ray to detect spinal subluxations and misalignments and the administration of spinal adjusting procedures to correct these subluxations. Michigan prohibits the use of any type of physiotherapy, a rather standard adjunct to chiropractic procedures in most jurisdictions. Chiropractors may give patients advice about nutrition but cannot dispense nutritional supplements. They are not allowed to perform venipuncture, even for diagnostic purposes. Five other States share similar restrictions with Michigan and can also be considered restrictive: Mississippi, New Jersey, South Carolina, Tennessee, and Washington.

**As far as I can tell, disciplinary action related to the "prohibited" dispensing of nutrition supplements is very rare. I suspect that chiropractors disregard such prohibitions.

A State classified as having an expansive scope of practice allows three or more of the following practices: specialty diagnostic procedures, pelvic and rectal examinations, venipuncture for laboratory diagnosis, signing of birth and death certificates, and acupuncture using needles. An example of a State with an expansive scope is Oregon (FCLB, 1996). In Oregon, chiropractors are allowed to perform minor surgery, proctology, and obstetrical procedures. They also employ "chiropractic diagnosis, treatment and prevention of body dysfunctions, correction, maintenance of the structural and functional integrity of the neuromusculoskeletal system and the effects thereof or interferences therewith by the utilization of all recognized and accepted chiropractic diagnostic procedures and the employment of all rational therapeutic measures as taught in approved chiropractic colleges" (FCLB, 1996). Chiropractors practicing in Oregon may utilize physiotherapy devices, perform venipuncture to collect blood specimens for laboratory diagnosis, give nutritional advice, and dispense nutritional supplements from their offices. Three other States share the characteristics of an expansive scope of practice: Idaho, Ohio, and Oklahoma.

The remaining 40 States have practice statutes that fall somewhere in between the extremes of expansive or restrictive. An example of a state with an intermediate scope of practice is Kansas, where chiropractors may use venipuncture for diagnostic purposes, employ acupuncture using needles if certified, and utilize physiotherapies, but may not perform pelvic examinations or sign birth or death certificates. Lamm (1995) published a report that provides detailed information regarding specific diagnostic and treatment procedures that are either allowed or prohibited in 46 States whose board representative responded to a questionnaire.

**It might be interesting to examine the number and types of disciplinary actions taken by state chiropractic boards. I wonder why the authors did not cover this topic. Statistics on medical board actions are published every year by the Federation of State Medical Boards of the United States. Data from the Federation of Chiropractic Licensing Boards are much skimpier but indicate that ten have reported no disciplinary actions during the past 2-3 years.

References

Christensen M, Morgan D (eds). Job Analysis of Chiropractic: A Project Report, Survey Analysis and Summary of the Practice of Chiropractic in the United States. Greeley, CO: National Board of Chiropractic Examiners, 1993:3-7.

Federation of Chiropractic Licensing Boards. Official Directory of the Federation of Chiropractic Licensing Boards: 1996-97. Colorado: Federation of Chiropractic Licensing Boards, 1996.

Federation of Chiropractic Licensing Boards. Official Directory of the Federation of Chiropractic Licensing Boards: 1997-98. Colorado: Federation of Chiropractic Licensing Boards, 1997.

Keating JC. Toward a Philosophy of the Science of Chiropractic: A Primer for Clinicians. Stockton, CA: Stockton Foundation for Chiropractic Research, 1992:51-80, 337-40.

Lamm LC, Wegner E, Collord D. Chiropractic scope of practice: what the law allows -- update 1993. J Manipulative Physiol Ther 1995;18:16-20.

Peterson D, Wiese G. Chiropractic: An Illustrated History. St. Louis, MO: Mosby Year Book, 1995:196-98, 203-5.

Wardwell WI. Chiropractic: History and Evolution of a New Profession. St. Louis, MO: Mosby Year Book, 1992:105-30.

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