Summary of Arkansas' SB 146 as amended as of

							March 5, 2007

«title» «first_mid» «last»«suffix»
Arkansas Senate
Public Health, Welfare and Labor Committee
207 State Capitol Building
Little Rock, AR 72201

RE:     SB 145 & SB 146 relating to chiropractic

Dear Senator «last»:

The American Osteopathic Association (AOA) is writing to express our serious concerns
with and opposition to SB 145 and SB 146 relating to chiropractic. The AOA is a national
member association representing more than 56,000 osteopathic physicians (Doctors of
Osteopathic Medicine, or DOs). The AOA serves as the primary certifying body for DOs,
and is the accrediting agency for all osteopathic medical colleges and health care facilities.
The AOA’s mission is to advance the philosophy and practice of osteopathic medicine by
promoting excellence in education, research, and the delivery of quality, cost-effective
healthcare within a distinct, unified profession.

All 50 states and the District of Columbia provide for the unrestricted licensing and scope of
practice for DOs and MDs in recognition of their education, clinical internship and
residency experience, and competency examinations in medicine and surgery in providing
comprehensive patient care. Given this fact, it is the AOA’s official position that duly-
licensed DOs and MDs should remain at the center of the ―team approach‖ to providing
health care to patients. With respect non-DOs and non-MDs, the AOA also holds the
position that any new scope of practice states authorize to these healthcare professionals
should be based on adequate education, clinical experience, and examination to protect the
public welfare and patient safety. The AOA believes SB 146, as amended, broadly expands
the practice authorities of chiropractors in Arkansas without adequate safeguards to protect
patients.

SB 146, as amended, broadly and vaguely authorizes chiropractors to diagnose and analyze
―any health condition.‖ Under current law, chiropractors’ scope is limited to diagnosing and
analyzing ―interference with normal nerve transmission and expression…‖ with respect to
patient health. With this change and maintaining the existing statutory definition of
―chiropractic,‖ it would seem SB 146 creates a new modality of primary care in Arkansas
with the philosophy of chiropractic medicine. Arkansas defines ―chiropractic‖ as ―that
science and art which utilizes the inherent recuperative powers of the body and deals with
the interrelationship between the nervous system and the spinal column, including
immediate articulations, and the role of its relationship in the restoration and maintenance of
health.‖ Chiropractors’ education and training is centered on treating patients’ conditions
primarily related to the spinal column. Chiropractors perform spinal adjustments to patients
to promote spinal health.

The AOA believes simply deferring to ―as taught in chiropractic schools or colleges,‖ as
indicated in the bill, as the criteria by which the practitioner may ―practice chiropractic‖ is
inadequate to protect the public. With this change, the statute would fail to recognize that
not all chiropractic colleges teach the same material and differ in how many hours or clinical
experience are afforded in any particular area. It also expands chiropractors’ scope of
practice without a concurrent examination requirement as proof of competency.

Before being licensed to practice chiropractic, an applicant must complete four years of
chiropractic school, which consists of three years of didactic training in the basic sciences,
clinical chiropractic, spinal anatomy, and clinical exam skills, then one year of clinical
externship experience. The curriculum is focused on spinal manipulation techniques and
basic clinical skills, and it does not emphasize comprehensive patient care as in osteopathic
medical school, internships, and residencies. After graduating, the chiropractic applicant is
eligible to take the National Board of Chiropractic Examiners (NBCE) exam. The newly
licensed chiropractor may then practice chiropractic without further clinical training.

SB 146 recognized the ―National Chiropractic Board‖ as a credential, requiring as of 2002,
passage of Parts I, II, III, and IV with score of 375+ and Physiotherapy. The AOA assumes
this reference in the bill is referring to the NBCE examinations. The NBCE administers a
four-part exam that is utilized by most states in licensing chiropractors. Part I measures
knowledge in six basic science areas – general anatomy, spinal anatomy, physiology,
chemistry, pathology, and microbiology – and public health. Part II evaluates six clinical
science areas – general diagnosis, neuromusculoskeletal diagnosis, diagnostic imaging,
principles of chiropractic, chiropractic practice, and associated clinical sciences. Part III
measures nine clinical competency areas - case history, physical examination,
neuromusculoskeletal examination, radiological examination, clinical laboratory and special
studies examination, diagnosis or clinical impression, chiropractic techniques, supportive
techniques, and case management. And Part IV is designed to be an objective structured
clinical examination which tests radiological diagnosis and interpretation, chiropractic
technique, and case management.

Chiropractic colleges may offer hospital rotations to externs in their fourth year and spend a
number of weeks working with DOs or MDs in specialty areas such as radiography,
orthopedics, sports medicine, family practice, rheumatology, and neurosurgery. However,
when compared to the clinical rotations of DOs, chiropractic externs experience far fewer
volume and variety of patient encounters.1 Today, chiropractic externs are currently required
to complete 250 joint manipulations, 20 complete history and physical exams, 20 radiology
studies, and 15 complete patient workups during their final year of chiropractic schools. This
hardly seems sufficient to practice as proposed in the legislation.


1The necessary future of chiropractic education: a North American perspective. Chiropractic and Osteopathy.
2005; 13:10. Published at www.pubmedcentral.nih.gov on July 7, 2005.
Chiropractic graduates are eligible to participate in part-time post-graduate education
programs or full-time residencies in certain fields, although this training is far less rigorous
and far fewer chiropractors complete them than formal internship/residency programs
required of DOs. According to NBCE, 63.3% of licensed chiropractors in 2003 had no
formal clinical training after graduating from chiropractic colleges before obtaining their
licenses; only 30% completed a one-year clinical internship; and less than 1% of licensed
chiropractors completed a post-graduate clinical training program in 2003 prior to licensure.2

The NBCE exam is widely used by state licensing boards to evaluate the knowledge and skill
of a candidate for a chiropractic license. However, none of the NBCE examination parts
measure the knowledge or skills necessary to safety practice in areas authorized under this
legislation. This NCBE exam is a primary gateway to chiropractic practice, yet it does not
assess abilities to practice in medicine and surgery as is the case for the Comprehensive
Osteopathic Medical Licensure Examination (COMLEX) or the U.S. Medical Licensure
Examination (USMLE) used to assess the competency of DO and/or MD licensure
applicants.

DOs sit for COMLEX or USMLE after completing four years of osteopathic medical school
that include didactic and clinical rotations followed by internship and three to six years of
clinical residencies. The DO must successfully pass a national licensing examination
sequence that measures knowledge and clinical skills to practice medicine and surgery—
emphasizing preventative medicine and comprehensive patient care. Education, training,
experience, and examination are central to ensuring that unrestricted licensed physicians are
competent to practice medicine and surgery.

In reference to use of drugs and surgery, the scope language is changed from ―without the
use of drugs or surgery‖ to ―without administering drugs or surgery.‖ The bill is unclear on
what it is authorizing for chiropractors with respect to drugs and surgery. In addition, SB
146, as amended, indicates that nothing restricts a chiropractor from ―supervising the use of
over-the-counter products.‖ The bill does not indicate what ―over-the-counter products‖
means, and cautions the Committee that health professions need training and examination in
the use and risks of recommending OTC drugs and vitamins. Similarly, the AOA is
concerned the bill adds by statute—rather than by examination for competency—to the
―practice of chiropractic‖ such areas as physical therapy, naturopathic therapy, nutritional
therapy, and acupuncture.

We recommend that the current statutory definition of ―spinal manipulation‖ be left
unchanged rather than replaced as ―manipulation,‖ as DOs employ osteopathic manipulative
treatment (OMT) in their practice and limiting the definition of ―manipulation‖ would only
confuse the differences in the practices of chiropractors and DOs. OMT involves over 20
treatment options and techniques and is used in treating a wide range of illness, including
bone and joint problems, soft tissues, and lymphatics. Any legal definition of
―manipulation‖ should not be limited to ―a passive dynamic thrust that causes cavitation or
grapping and attempts to restore the manipulated joint’s range of motion and
neurophysiological function.‖


2   National Board of Chiropractic Examiners, Job Analysis of Chiropractic 2005, p. 90
Additionally, chiropractors’ training and examination is focused on spinal manipulation and
chiropractic adjustments to the spine and not ―extraspinal orthopedic manipulation.‖ We
request that any references to ―extraspinal orthopedic manipulation‖ be deleted from SB 146
as well as from SB 145.

Due to all of the concerns expressed in this letter, the AOA respectfully request that the
Public Health, Welfare and Labor Committee permanently table SB 145 and SB 146.
Chiropractors have not reached the point as a profession to practice in the areas proposed in
SB 145 and SB 146. It is problematic that the practice authority proposed in SB 146 creates
a broad new authority to diagnose and analyze ―any health condition.‖ It is also inadequate
to reference as an authorized scope of practice what a licensed chiropractor learned in
school, rather than passed in a licensing examination. The NBCE exam does not test for
competency beyond chiropractors’ techniques in treating spinal injuries or disorder and their
abilities to doing chiropractic adjustments.

Thank you for your consideration of the AOA’s concerns. Should you have any questions
or comments, please contact Linda Mascheri, Director of the AOA’s Division of State
Government and International Affairs, at (800) 621-1773, ext. 8184 or
lmascheri@osteopathic.org.

Sincerely,



John A. Strosnider, DO
AOA President

cc:     Ray E. Stower, DO, AOA Board of Trustees
        James J. Dearing, DO, AOA Board of Trustees
        John Crosby, JD, AOA Executive Director
        Sydney Olson, AOA Associate Executive Director
        Mike Mallie, AOA Director of State, Specialty and Socioeconomic Affairs
        Linda Mascheri, AOA Director of State Government and International Affairs
        Ed Bullington, Arkansas Osteopathic Medical Association Executive Director