What Does a Chiropractor Need to Be Allowed to Do?

Editor’s note: This is the second of a three-part essay series examining what happens when chiropractic is understood primarily as a technique rather than as a health care system.

For years in North Carolina, physical therapists could not perform spinal manipulation on their own authority. They could do it when it had been prescribed by a physician, but the law drew a line there. Physical therapists wanted that changed, and chiropractors had reasons to pay attention. As the NCCA’s legislative chair, I was involved in this issue over the years, meeting with legislators and talking through it repeatedly with our lobbyists as the proposal moved around the General Assembly. One concern came up again and again in those conversations: if physical therapists could manipulate without a physician’s prescription, they could start taking patients from chiropractors. A patient who wanted an adjustment would no longer necessarily need to come to us.

Not everyone was worried. There were plenty of hallway jokes from chiropractors who had spent years adjusting thousands of patients and were confident in their ability to do it. Their point was that giving someone legal authority to manipulate did not give them the experience of a chiropractor who had been doing it every day for twenty years. There is some truth in that, but both reactions were still focused on the same thing: who could perform the procedure, and who could perform it better.

In 2019, the General Assembly changed the law. Appropriately trained physical therapists could perform spinal manipulation without first getting a physician’s prescription, while the law still separated that authority from the broader practice of chiropractic. The feared shift did not follow. Chiropractic patients did not suddenly start leaving their chiropractors because physical therapists could now manipulate. I cannot say there was no competitive effect anywhere in the state, and I do not have data that would support that claim, but nearly seven years later the concern that PTs would gain access to manipulation and begin taking large numbers of chiropractic patients has not played out the way many people expected.

This was a North Carolina fight, but the concern was not unique to North Carolina. Chiropractors in other states have had versions of the same argument whenever another profession has sought authority over a procedure closely associated with chiropractic. If they can do what we do, what happens to us? North Carolina gave us one answer. Physical therapists gained access to something chiropractors do. They did not become chiropractors, and patients did not suddenly treat the two professions as interchangeable simply because both could manipulate a spine. Whatever patients thought they were choosing when they chose a chiropractor, it was not based only on which profession had legal access to manipulation.

If chiropractic is larger than the adjustment when another profession gains the right to manipulate, then that has to remain true when we talk about our own scope. Consider what happens when chiropractors go to a legislature asking for some new authority. It may involve imaging, ordering a test, evaluating an area of the body, or using a procedure that is not already clearly inside the chiropractic statute. The first question is often whether chiropractors have enough training to do it. We pull curricula, compare classroom hours, show what is taught in chiropractic colleges and explain that doctors of chiropractic are educated well beyond the adjustment. Those arguments may be true, and they may be necessary to get a bill passed, but they still run into a basic problem if the people hearing them have spent years thinking of chiropractic mainly as spinal adjustment: why does someone who adjusts spines need this?

That is not always hostility. Sometimes it is simply the question that follows from the definition the person already has. Take a patient who walks into a chiropractic office with neck pain. Before I ever put my hands on that patient, I have decisions to make. The history may change what I thought was happening. The examination may point somewhere else. I may need an X-ray or other imaging before deciding whether care is appropriate. I may find something that should not be treated in my office. If I do begin care and the patient is not improving, I have to decide whether my original thinking was wrong, whether I need more information, whether the plan should change or whether the patient should be somewhere else. That is part of the job before and around the adjustment. If the law lets me adjust the patient but prevents me from doing something I reasonably need in order to make one of those decisions, then the issue is not that I want another procedure. It is that I cannot fully do the job the patient expects me to do.

This is where a narrow definition of chiropractic can create its own problem. Even a chiropractor whose practice is centered almost entirely on detecting and correcting subluxation still has to decide whether the person in front of them should be adjusted, whether something in the history or examination changes that decision, whether imaging is needed, whether the patient is responding as expected, and when the patient belongs somewhere else. Defining what we intend to treat narrowly does not remove those responsibilities. In some states, chiropractic practice acts and board rules have historically drawn very specific lines around what chiropractors may examine or how they may evaluate patients. We should be careful about assuming those limits preserve chiropractic simply because they keep the profession narrow. At some point a definition can become so narrow that the doctor is denied authority needed to make responsible decisions about the patient already sitting in the office.

That is different from saying chiropractors should have broader scope because we are trained to do more things. There are things chiropractors could be trained to do that do not necessarily belong in chiropractic. Adding something to our scope because another profession has it is not much better than trying to keep manipulation away from another profession because we have long associated it with ours. But the opposite mistake is just as real: keeping chiropractic so tightly confined to a procedure that the doctor cannot fully evaluate the person before deciding whether that procedure is appropriate.

The problem is that we can run straight into the definition we have helped reinforce. Chiropractors adjust spines. If that is what chiropractic is, why do chiropractors need authority beyond what is necessary to adjust spines? We cannot argue that chiropractic is much larger than manipulation when another profession gains the ability to manipulate, then expect everyone else to understand that larger role when we have not made it visible.

A scope statute can help. It can recognize diagnostic authority, allow access to imaging or testing, establish portal-of-entry status and give chiropractors legal room to do work that already belongs in chiropractic practice. Those victories matter. I have spent years working on them. But changing the statute does not necessarily change what people think a chiropractor is. We can add authority that makes sense for the patients chiropractors care for without assuming the change itself will make anyone outside the profession see us differently.

A judge is not reading the practice act when a chiropractor takes the witness stand. A regulator is not starting with our statutory definition when a chiropractor walks into a meeting. A bank deciding whether to lend money to a chiropractic business is not studying our college curriculum first. Neither is the patient deciding whether a new problem is something they should bring to their chiropractor. They have already seen chiropractors. They have heard us talk about what we do. They have seen our offices, our records, our advertising, our testimony and our professional organizations. Some have worked with very capable chiropractors. Some have not.

What they expect from us was being formed long before anyone opened the statute.

Dr. Glenn Jaffe is a practicing chiropractor with more than twenty years in the profession. He served as president of the North Carolina Chiropractic Association and has worked at the national and legislative level on the profession's governance priorities. He is the founder of BoldAzure, a leadership platform for chiropractors. He writes about where the profession is, how it got there, and what maturation actually requires.

Learn more at boldazure.com