Health Professions Council
POST-HEARING UPDATE OF PRELIMINARY REPORT:
CHIROPRACTORS

The Council issued its Chiropractors Scope of Practice (Preliminary Report) in August 1998. The public hearing was held on 31 May 1999. The following are changes to the Preliminary Report which arose from the submissions made either at the public hearing or in subsequent written submissions.

I.     SCOPE OF PRACTICE

The Council’s Preliminary Report recommended that chiropractors be granted the following scope of practice:

Chiropractic is concerned with those aspects of the restoration and maintenance of human health which relate to assessment of the spine or other joints of the human body and the associated soft tissue or nervous system and the treatment of nervous, muscular and skeletal disorders through manipulation and adjustment by hand or devices directly related to the adjustment.

A.     Treatment of Organic Diseases

In June 1998, prior to the public hearing, the Council met with representatives of the British Columbia College of Chiropractors (College). The purpose of the meeting was to discuss concerns that had been raised by respondents to the consultation process with regard to treatment of organic diseases by chiropractors. The College provided the Council a copy of the Clinical Guidelines for Chiropractic Practice in Canada published by the Canadian Chiropractic Association. The guidelines confirm that the vast majority of chiropractic treatment is for "neuromusculoskeletal disorders" defined at page 105 as:

conditions which display symptoms and/or signs related to two or more of the nervous, muscular and skeletal body systems. Such conditions may be contrasted with those which produce advanced pathologic states (e.g. neurofibromatosis). Neuromusculoskeletal conditions are sometimes referred to as "type M disorders," and distinguished from "type O disorders," which refer to internal organ disorders.

These guidelines are voluntary as noted in the general disclaimer. However, College representatives assured the Council that the treatment of organic disorders is not accepted practice in British Columbia.

Subsequently, respondents to the Council's Preliminary Report reasserted that current chiropractic practice includes treating organic conditions, such as otitis media in children and sinusitis. At the public hearing, two speakers who presented material on behalf of the College indicated that chiropractors do not treat organic disorders but may treat neuromusculoskeletal symptoms resulting from an organic condition, such as cancer. The speakers indicated that this would be done in the course of "co-treatment" in which a medical practitioner treats the underlying organic disease, disorder or condition.

The contradictory written and oral submissions indicate that there is a division in practice which is not sanctioned by the profession's regulatory body and educators. In accordance with testimony of the College and a representative of the only chiropractic educational institution in Canada, it is clear that the treatment of organic diseases, disorders and conditions is not within the scope of practice of chiropractors. Although they may treat the symptoms of organic disease, they do not treat the etiology of the disease, and co-treatment is required if symptoms of organic conditions are treated by a chiropractor. The Council believes it is in the public interest to make this distinction explicit to the public by a limitation to the scope of practice of chiropractic.

The Council has given careful consideration to the submissions made by the College and to the Clinical Guidelines for Chiropractic Practice in Canada and accordingly recommends the following scope of practice statement:

II.     RESERVED ACTS

In its Preliminary Report, the Council recommended the following reserved acts for chiropractors:

1. Making a diagnosis identifying as the cause of signs or symptoms of the individual, a disease, disorder or condition of the spine or other joints of the human body and their effects on associated soft tissue or nervous system.

2. Performing the physically invasive or physically manipulative act of movement of the joints of the spine beyond the limits the body can voluntarily achieve but within the anatomical range of motion using a high velocity, low amplitude thrust.

3. Performing the physically invasive or physically manipulative act of putting an instrument, hand or finger(s) beyond the anal verge for purposes of performing Reserved Act 2(c).

4. Ordering or applying a hazardous form of energy: x-ray for diagnostic purposes.

The Council did not recommend reserved act 4—applying or ordering a hazardous form of energy, other than X-ray—for chiropractors. The Council's decision was based upon absence of submissions from the College about chiropractors' education and training to utilize the technologies requested.

The College subsequently clarified at the public hearing that although it had requested in its 4 February 1998 letter that it be granted reserved act 4, its members would not order or administer all hazardous forms of energy authorized by that Act. It specifically clarified that its members do not require the use of diagnostic ultrasound. The College also presented written and oral submissions about chiropractic training in utilization of CT and MRI for differential diagnosis. College representatives testified that chiropractors do not interpret CT and MRI but, rather, rely on expert radiologists who interpret the testing. Chiropractors are seeking the reserved act of "ordering" certain hazardous forms of energy, specifically MRI and CT.

As the College has presented evidence of education and training in the use of MRI and CT for differential diagnosis, the Council recommends the following reserved act, in addition to those already recommended:

III.     OTHER ISSUES

A.     Use of Laboratory Testing Procedures

The College requested that "a member may...use...laboratory testing procedures and for this purpose may refer patients to certified specialists, public or private health facilities or laboratories."

Laboratory testing refers to blood and other specimen or tissue analysis performed in a medical laboratory, usually by a medical laboratory technician.

In its original submission, the College requested the use of laboratory testing generally, i.e., without qualification. In support of its request, the College subsequently submitted a portion of the Final Report of the Ontario Laboratory Services Review Commission (the Ontario Report), which contains a list of laboratory tests being considered for use by chiropractors in Ontario. The College relied on the Ontario Report for documentation of its requested reserved act.

The Council has recommended for chiropractors reserved act 1, "making a diagnosis identifying as the cause of signs or symptoms of the individual, a disease, disorder or condition of the spine or other joints of the human body and their effects on associated soft tissue or nervous system." Therefore, it may be in the public interest for chiropractors to utilize certain laboratory testing if there is a relationship to their diagnostic process.

A preliminary review of the recommendations contained in the Ontario Report indicates that the laboratory tests considered by that committee may be appropriate for use by chiropractors in British Columbia.

The Council recommended in its Preliminary Report the use of laboratory tests by chiropractors, subject to certain criteria, finding that:

While the Council is prepared to consider the College's request for use of laboratory tests in the context of their reserved act of diagnosis, as previously described, the Council does not find that the College submissions have set out the relationship between the laboratory testing requested and diagnosis as performed by a chiropractor.…The College has not shown that its members are educated, trained or experienced in the use and interpretation of the specific laboratory tests being considered in Ontario and requested by the College. Based upon the information before it, the Council has concerns about whether members of the College are sufficiently trained and educated to interpret the laboratory testing requested.

The College made submissions at the public hearing, specifically those of Dr. S. Injeyan who instructs chiropractic students in the use of laboratory testing, which indicated that chiropractors use laboratory testing for differential diagnosis, often to rule out contraindications to chiropractic treatment or for purposes of referring patients who need active medical treatment before or in lieu of chiropractic treatment. Based upon Dr. Injeyan's testimony, the Council has reconsidered its previous position and has determined that it would be in the public interest for chiropractors to have access to a limited range of laboratory testing.

Because the College has now demonstrated the relationship between chiropractors’ education and training, laboratory testing requested and chiropractic diagnosis, the Council has revised the recommendation with regard to laboratory testing.