Chiropractic Scope Of Practice Sunrise 631 046 Washington Dot

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Information Summary and Recommendations

Chiropractic Scope of Practice
Sunrise Review
December 2013

Publication Number 631-046
For more information or additional
copies of this report contact:

Health Systems Quality Assurance
Office of the Assistant Secretary
PO Box 47850
Olympia, WA 98504-7850
360-236-4612
John Wiesman, DrPH, MPH
Secretary of Health

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Contents

1

The Sunrise Review Process

3

Executive Summary

7

Summary of Information

19

Review of Proposal Using Sunrise Criteria

21

Detailed Recommendations

23

Summary of Rebuttals to Draft Recommendations
Appendix A: Applicant Report
Appendix B: Proposed Bill
Appendix C: Applicant Follow-Up
Appendix D: Public Hearing Transcript and Participant List
Appendix E: Written Comments
Appendix F: Pre-participation Physical Evaluation Form Recommended by the
Washington Interscholastic Activities Association (WIAA)
Appendix G: Medical Examination Report for Commercial Driver Fitness
Determination
Appendix H: Rebuttals to Draft Recommendations

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THE SUNRISE REVIEW PROCESS
A sunrise review is an evaluation of a proposal to change the laws regulating health professions in
Washington. The Washington State Legislature’s intent, as stated in chapter 18.120 RCW, is to
permit all qualified people to provide health services unless there is an overwhelming need for the
state to protect the interests of the public by restricting entry into the profession. Changes to the
scope of practice should benefit the public.
The Sunrise Act (RCW 18.120.010) says a health care profession should be regulated or scope of
practice expanded only when:


Unregulated practice can clearly harm or endanger the health, safety or welfare of the public,
and the potential for the harm is easily recognizable and not remote or dependent upon
tenuous argument;



The public needs and can reasonably be expected to benefit from an assurance of initial and
continuing professional ability; and



The public cannot be effectively protected by other means in a more cost-beneficial manner.

If the legislature identifies a need and finds it necessary to regulate a health profession not
previously regulated, it should select the least restrictive alternative method of regulation, consistent
with the public interest. Five types of regulation may be considered as set forth in RCW
18.120.010(3):
1. Stricter civil actions and criminal prosecutions. To be used when existing common law,
statutory civil actions, and criminal prohibitions are not sufficient to eradicate existing harm.
2. Inspection requirements. A process enabling an appropriate state agency to enforce violations
by injunctive relief in court, including, but not limited to, regulation of the business activity
providing the service rather than the employees of the business, when a service being
performed for people involves a hazard to the public health, safety or welfare.
3. Registration. A process by which the state maintains an official roster of names and
addresses of the practitioners in a given profession. The roster contains the location, nature
and operation of the health care activity practices and, if required, a description of the service
provided. A registered person is subject to the Uniform Disciplinary Act (chapter 18.130
RCW).
4. Certification. A voluntary process by which the state grants recognition to a person who has
met certain qualifications. Non-certified people may perform the same tasks, but may not use
“certified” in the title.1 A certified person is subject to the Uniform Disciplinary Act.
5. Licensure. A method of regulation by which the state grants permission to engage in a health
care profession only to people who meet predetermined qualifications. Licensure protects the
scope of practice and the title. A licensed person is subject to the Uniform Disciplinary Act.

1

Although the law defines certification as voluntary, many health care professions have a mandatory certification
requirement such as nursing assistants-certified, home care aides, and pharmacy technicians.

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EXECUTIVE SUMMARY
Background
Chiropractors have been licensed in Washington since 1919 under chapter 18.25 RCW and chapter
246-808 WAC. Chiropractors are experts in providing spinal manipulation. In Washington, they’re
authorized to diagnose, analyze and treat “the vertebral subluxation complex and its effects, articular
dysfunction, and musculoskeletal disorders, all for the restoration and maintenance of health and
recognizing the recuperative powers of the body. As part of the chiropractic differential diagnosis, a
chiropractor shall perform a physical examination to determine the appropriateness of chiropractic
care or the need for referral to other health care providers.”2 Chiropractic care doesn’t include
prescriptive authority; procedures involving the application of sound, diathermy or electricity; or any
form of venipuncture.
There are currently 2,348 licensed chiropractors in Washington.3 Requirements for licensure under
RCW 18.25.020 include completion of “not less than one-half of the requirements for a
baccalaureate degree” and graduation from a Council on Chiropractic Education (CCE) accredited
chiropractic school or college consisting of a course of study of not less than 4,000 classroom hours
of instruction. In addition, applicants must pass the National Board of Chiropractic Examiners
(NBCE) examination.4

Proposal for Sunrise Review
On May 23, 2013, Representative Eileen Cody, Chair of the House Health Care and Wellness
Committee, asked the department to conduct a sunrise review of House Bill (HB) 1573 from the
2013 legislative session. This proposal would prohibit discrimination against chiropractors and
require that licensed chiropractors be allowed to perform physical examinations for sports
physicals and commercial drivers’ licenses.
The applicant for this proposal is the Washington State Chiropractic Association (WSCA). The
applicant describes this proposal as a clarification of the scope of practice, not an increase. The
applicant report assessing the criteria required in chapter 18.120 RCW included the intent to
propose amendments to HB 1573 as follows:


Remove reference to the Washington Interscholastic Activities Association (WIAA);



Apply the proposed legislation to all youth sports;



Add an additional 18-hour training and examination requirement (with an optional challenge
to the examination for chiropractors with current Diplomate American Chiropractic of Sports
Physicians certification);



Create an endorsement to licensure for those chiropractors with the additional qualifications
to be able to perform pre-participation examinations (PPEs) for student athletes (although
this was not clear in the proposal, the applicant made it clear during the public hearing that it
intends this to be an endorsement); and

2

RCW 18.25.005(3)
As of July 1, 2013
4
Some chiropractic programs, such as the University of Western States in Oregon and Palmer College in Iowa, provide
up to 4,600 classroom hours, exceeding the minimum requirements in statute.
3

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

Require federal motor carrier training for doctors of chiropractic performing the physical
examinations that meet the criteria of the Federal Motor Carrier Safety Administration.

In addition, at the public hearing, the applicant’s representative stated that there were additional
amendments intended to occur last session to HB 1573 that would have included changes to the
statutory definitions in the chiropractic scope of practice.
The department is required to evaluate the proposal requested by the legislature. We will attempt
to address both the proposal and the many changes later suggested by the applicant.

Recommendations
The department has determined that the sunrise criteria haven’t been met in the three versions of
the proposal submitted because:
1. The department doesn’t support adoption of HB 1573 as written. HB 1573 doesn’t
amend the definitions of chiropractic or chiropractic treatment or care in RCW 18.25.005.
Physical examinations for student athletes and commercial drivers are clearly not within the
existing statutory scope of practice for chiropractors in Washington.
2. The department does not support the proposal submitted with the applicant report
from the Washington State Chiropractic Association in July, which included a proposal
to add additional educational requirements for chiropractors to perform physical
examinations of student athletes and commercial drivers. The applicant report also does
not propose to amend the definitions of chiropractic or chiropractic treatment or care in RCW
18.25.005. The applicant’s proposal should not be enacted, even with the additional training
it intends to include in amendment language, because the proposal still fails to amend RCW
18.25.005 to add the elements of a comprehensive physical examination to the chiropractic
scope of practice.
3. The department does not support expanding the chiropractic scope of practice to
include PPEs for student athletes and commercial motor vehicle examinations (CMV
exams) for commercial drivers. Since the department interprets these physicals as outside
the chiropractic scope of practice, we reviewed whether changing the definitions in RCW
18.25.005 to expand the scope would meet the sunrise criteria. The department found
potential risk of patient harm if PPEs and CMV exams are added to the chiropractic scope of
practice. Specifically:


Addition of PPEs and CMV exams would expand the chiropractic scope of practice
well outside of the current scope of diagnosing and treating conditions relating to the
musculoskeletal system.



PPEs and CMV exams are intended to be comprehensive physical examinations, not
cursory screenings. These exams are sometimes the only examination a person
receives regularly. For students, this includes the opportunity to receive ageappropriate vaccinations, which chiropractors can’t perform.



Chiropractic educational programs do not include adequate focus on pharmacology,
which is necessary in both types of physical examinations.

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

Although chiropractic training includes basic understanding of body and organ
systems, including the cardiovascular system, the department is unable to find that it
prepares chiropractors to potentially be the sole evaluator of all or most medical
conditions.



The additional trainings proposed by the applicant do not appear to adequately bridge
the gap in training, especially considering the range of education obtained by current
licensees. The Diplomate American Chiropractic of Sports Physicians specialty
certification training’s primary focus also appears to be on spinal and extremity
manipulation, exercise physiology, and sports-specific biomechanics without a
corresponding focus on broader medical conditions and pharmacology.



Examining a patient to evaluate his or her overall health should be done by a primary
care provider who can use their broad spectrum of training, clinical residency, and
experience to conduct the evaluations, and whose daily practice includes functions of
primary care.

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SUMMARY OF INFORMATON
Background
Chiropractors have been licensed in Washington since 1919 to diagnose, analyze and treat “the
vertebral subluxation complex and its effects, articular dysfunction, and musculoskeletal disorders,
all for the restoration and maintenance of health and recognizing the recuperative powers of the
body.” Chiropractors are experts in providing spinal manipulation.
In Washington, chiropractors are regulated by the Chiropractic Quality Assurance Commission
(commission) under chapter 18.25 RCW and chapter 246-808 WAC. “As part of a chiropractic
differential diagnosis, a chiropractor shall perform a physical examination…to determine the
appropriateness of chiropractic care or the need for referral to other health care providers.”5
Chiropractic care does not include prescriptive authority; application of sound, diathermy or
electricity; or any form of venipuncture.
As of July 1, 2013, there were 2,348 licensed chiropractors in Washington. Requirements for
licensure under RCW 18.25.020 include completion of “not less than one-half of the requirements
for a baccalaureate degree” and graduation from a CCE-accredited chiropractic school or college
consisting of a course of study of not less than 4,000 classroom hours of instruction. In addition,
applicants must pass the National Board of Chiropractic Examiners (NBCE) examination.

Proposal for Sunrise Review
On May 23, 2013, Representative Eileen Cody, chair of the House Health Care and Wellness
Committee, asked the department to conduct a sunrise review on House Bill 1573 from the 2013
legislative session, which would prohibit discrimination against chiropractors and require that
licensed chiropractors be allowed to perform physical examinations for sports physicals and
commercial drivers’ licenses. House Bill 1573, “An act relating to clarifying the prohibitions
against discriminating against licensed chiropractors,” included the following language:
“The state and its political subdivisions, including school districts, and all officials,
agents, employees, or representatives thereof, are prohibited from in any way
discriminating against licensed chiropractors in performing and receiving
compensation for services covered by their licenses. Licensed chiropractors must be
allowed to perform sports physicals for school athletes and physical examinations
required for commercial driver’s licenses.
Notwithstanding any other provision of law, the state and its political subdivisions,
and all officials, agents, employees, or representatives thereof, are prohibited from
entering into any agreement or contract with any individual, group, association,
including the Washington interscholastic activities association, or corporation which
in any way, directly or indirectly, discriminates against licensed chiropractors in
performing and receiving compensation for services covered by their licenses.”
On June 25, 2013, the Washington State Chiropractic Association (WSCA) submitted its
applicant report assessing the criteria required in chapter 18.120 RCW. The applicant states this
5

RCW 18.25.005(3)

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proposal is a clarification of their scope of practice, not an increase. The applicant report
included the intent to propose amendments to HB 1573 as follows:


Remove reference to the WIAA;



Apply the proposed legislation to all youth sports;



Add an additional 18-hour training and examination requirement (with an optional challenge
to the examination for chiropractors with current Diplomate American Chiropractic of Sports
Physicians certification);



Create an endorsement to licensure for those with the additional qualifications to be able to
perform PPEs. (Although this was not clear in the proposal, the applicant made it clear
during the public hearing that it intends this to be an endorsement); and



Require Federal Motor Carrier training for doctors of chiropractic performing the physical
examinations that would meet the criteria of the Federal Motor Carrier Safety Improvement
Administration.

In addition, the applicant stated at the public hearing that there were additional amendments
intended to occur last session to HB 1573 that would have included changes to the definitions in
the chiropractic scope of practice.

Public Participation and Hearing
The department received the request from the legislature to conduct this sunrise review on May
23, 2013, and received the applicant report on June 25, 2013. Interested parties were notified of
the sunrise review on June 28, and given the opportunity to provide written comments on the
proposal through August 2. We posted the proposal and all applicant materials to the
department’s website. A public hearing was held August 6, 2013. Written comments were
accepted through August 2, and there was an additional comment period after the hearing
through August 16. (See Appendix D for public hearing transcript and Appendix E for written
comments).
We shared a draft report with the applicant and interested parties October 23 and invited rebuttal
comments. The rebuttals and department responses are summarized beginning on page 23 (full
rebuttal comments are attached as Appendix H).
Nine people testified at the hearing in support of the proposal and nine in opposition. In addition,
we received 15 letters in support of the proposal and 23 in opposition. The following is a
summary of the written and oral comments we received during our review.
Support
Themes in the oral and written comments in support of the proposal:
 This was just an oversight in the statute that physicals weren’t included.
 It’s discrimination against chiropractors that they cannot perform these physicals.
 Chiropractors are well trained and fully prepared to conduct these physicals. They have
access to all medical diagnostic tools that are available to other health care providers.

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








There‘s a misunderstanding about chiropractic education, diagnostic ability, and didactic
training. Many opposing comments are emotionally charged and hold no factual
evidence.
There’s an access issue with primary care providers. Chiropractors often help patients
find primary care physicians who are accepting new patients.
Many patients would prefer a certified sports trainer to do their physicals because they
trust them, and their chiropractors know their history.
Chiropractors conduct PPEs for professional sports teams, Olympic teams, colleges, and
high schools across America.
It was suggested that the sunrise reviewers might wish to visit one or more chiropractic
colleges to observe the curriculum and the hands-on doctor/patient relationships being
taught.
Opposing comments attempt to engender concern and fear about potential negative
outcomes associated with the proposal. Ironically, the negative outcomes cited are
associated with medical physicians’ provision of these exams.
Washington is one of the few remaining states that restrict chiropractors from performing
physicals. It’s a disservice to Washington residents.
These are screenings, not treatment.

The applicant offered a response to perceived inaccuracies heard during testimony and to
written testimony received by the department. (Appendix C).
Opposed
Themes in the oral and written comments in opposition to the proposal:
 Chiropractors are not qualified and may miss critical issues. Chiropractic teaching falls
short of teaching the necessary skill set, especially regarding the ability to diagnose
simple or complex patterns of disease and injury. The lack of clinical training in cardiac
pathologies and concussion evaluation could be devastating to a young athlete.
 PPEs should be completed by a medical doctor or medical clinician who has the training,
background and skills to perform them and recognize heart disease.
 All medical practitioners should stay within their legal scope of practice.
 These visits may be the only time a child or teen sees his or her doctor. The physical
addresses the whole patient, and the ideal examiner is the primary care physician who
knows a patient’s medical history.
 It’s a critical time to perform vaccinations, which chiropractors cannot do. In addition,
chiropractors do not have prescriptive authority.
 The proposal is antithetical to efforts in the medical community to improve athlete safety
on the playing field. Extensive work is being done preventing sudden cardiac death based
on trained evaluation of the history and physical examination, proper use of non-invasive
cardiovascular testing, and a solid understanding of the conditions associated with sudden
cardiac death in athletes.
 The proposal doesn’t contain appropriate oversight. It doesn’t support the team approach
to medical care and the physician-led model.
 The Washington State Medical Association, Washington Osteopathic Medical
Association, and Washington State Nurses Association wrote in opposition, citing
inadequate training to provide comprehensive physical examinations. They also stated
there isn’t data supporting the need to expand the scope of practice due to a claimed
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


shortage of primary care providers, nor is the claim supported that this expansion would
benefit the public.
Sports physicals ascertain medical health status, not chiropractic health status; they
should solely remain the professional responsibility of medical practitioners.
The Athletic Trainers Association asserts that chiropractic training doesn’t emphasize the
main issues that affect young athletes such as sudden cardiac arrest, heat-related illnesses,
concussions and other medical issues.

Education and Training
RCW 18.25.025 authorizes the commission to grant accreditation to chiropractic schools and
colleges. The statute requires chiropractic educational programs to include minimum hours of
chiropractic curriculum in the following areas:






Principles of chiropractic – 200 hours;
Adjustive technique – 400 hours;
Spinal roentgenology – 175 hours;
Symptomalogy and diagnosis – 425 hours; and
Clinic – 625 hours.

RCW 18.25.020 and WAC 246-808-040(3)(b) require chiropractic educational programs to be a
minimum of 4,000 class hours of instruction over a four-year academic term. Some chiropractic
programs, such as the University of Western States in Oregon and Palmer College in Iowa,
include additional class hours. According to the applicant, these programs include 500 hours of
anatomy, 400 hours of physiology, 1,500 hours of diagnosis, and 2,000 hours of clinic, where
students see student-patients and patients from the surrounding communities under supervision.
The University of Western States in Oregon and Palmer College of Chiropractic in Iowa
submitted comments stating its programs prepare graduates to provide comprehensive health
examinations. These colleges included the following information about their programs:



Palmer College states that of the 4,620 total contact hours of instruction, 570 are in
diagnosis, 300 are in radiology procedures and interpretation, and 945 are in practical
clinical experiences in the Palmer Chiropractic Clinic system.6
The University of Western States indicates nearly 1,000 of their 4,200 to 4,600 hours of
training covers all aspects of ambulatory care patient evaluation, and the analysis and
employment of best practices therein. This education includes didactic and practical skills
instruction in emergency procedures, physical examination of each body region and
system, laboratory diagnosis, differential diagnosis, imaging, triage, evidence based
practice, etc. In addition to didactic instruction and practical application, clinical practice
training rotations include extensive experience in the application of these competencies
on a very diverse array of patients in ambulatory care settings.7

Dr. Gary Schultz, representing the applicant at the hearing, stated that chiropractors are trained in
all the essential elements that are required in PPEs and CMV exams as a part of their core
training. This training includes basic sciences, clinical sciences, and clinical experiences, which
6 Letter from Palmer College in response to proposal, dated August 30, 2013
7 Letter from University of Western States submitted in response to proposal, dated July 26, 2013

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incorporate all areas of the body. It isn’t an education focused simply on the neuromuscular
skeletal system, but he admits there is a focus in that area because it is the primary area of
treatment for most chiropractors’ practice. Dr. Schultz further stated that the very broad
education prepares chiropractors to diagnose any condition that would likely walk through an
ambulatory care center’s doors. He said at the very least, chiropractors are responsible to be able
know what they can and can’t treat and to be able to refer appropriately for conditions they
encounter that are not within their scope.
We received many comments in response to this proposal stating that chiropractors have no
training outside the musculoskeletal system. Our review of the documentation submitted by the
applicant and others shows this to be an oversimplification. Current chiropractic programs
provide broad medical training, including supervised clinical training; however, it is minimal in
comparison to the substantial training they receive in aspects of chiropractic care. In addition,
chiropractic programs are not required to include training in pharmacology. Some programs offer
some training in this area, but the amount varies from program to program. Chiropractic schools
don’t require clinical rotations specific to areas such as family medicine, internal medicine, or
pediatrics.
There are voluntary specialty certifications for chiropractors that include:


American Chiropractic Board of Sports Physicians:
o Certified Chiropractic Sports Physician (CCSP) which includes 100 hours of class
time.
o The Diplomate American Chiropractic of Sports Physicians which requires a CCSP
and an additional 200 class hours, 100 hours of practical experience, plus an
examination.
These specialty certifications include a small portion of broad medical training, but the
primary focus appears to be on spinal and extremity manipulation, as well as exercise
physiology and sports-specific biomechanics or occupational treatment.



The Department of Labor and Industries offers the following certifications:8
o Chiropractic Consultant Program. Chiropractors with additional clinical and workers’
compensation-specific training may be certified to perform second opinion
consultations for attending doctors to assist evaluation and care recommendations
when a worker’s recovery isn’t meeting expectations. Training includes 180 postgraduate hours in subject areas such as diagnostic assessment, neurology,
occupational health practices, and orthopedics. Only 20 hours are allowed in
chiropractic technique.
o Independent Medical Examiner (IME) certification. Chiropractors with two years of
experience as a chiropractic consultant and who have taken an IME seminar may be
certified to provide an independent assessment of a patient’s status, including rating
for permanent impairment.

8 , accessed September 11,
2013

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Current Regulation and Practice of Chiropractors
RCW 18.25.005 defines the chiropractic scope of practice:
(1) Chiropractic is the practice of health care that deals with the diagnosis or analysis and
care or treatment of the vertebral subluxation complex and its effects, articular dysfunction,
and musculoskeletal disorders, all for the restoration and maintenance of health and
recognizing the recuperative powers of the body.
(2) Chiropractic treatment or care includes the use of procedures involving spinal
adjustments and extremity manipulation. Chiropractic treatment also includes the use of heat,
cold, water, exercise, massage, trigger point therapy, dietary advice and recommendation of
nutritional supplementation, the normal regimen and rehabilitation of the patient, first aid,
and counseling on hygiene, sanitation, and preventive measures. Chiropractic care also
includes such physiological therapeutic procedures as traction and light, but does not include
procedures involving the application of sound, diathermy, or electricity.
(3) As part of a chiropractic differential diagnosis, a chiropractor shall perform a physical
examination, which may include diagnostic x-rays, to determine the appropriateness of
chiropractic care or the need for referral to other health care providers. The chiropractic
quality assurance commission shall provide by rule for the type and use of diagnostic and
analytical devices and procedures consistent with this chapter.
(4) Chiropractic care shall not include the prescription or dispensing of any medicine or drug,
the practice of obstetrics or surgery, the use of x-rays or any other form of radiation for
therapeutic purposes, colonic irrigation, or any form of venipuncture.
Chiropractors are currently required to perform physical examinations, but the purpose of those
examinations is to determine the appropriateness of chiropractic care or the need for referral, not
to assess the overall health of an individual. Current Washington law limits the practice of
chiropractors to diagnosis, analysis, and care or treatment for restoration and maintenance of
health of conditions relating to the musculoskeletal system.

Regulation in Other States
Washington’s chiropractic licensing requirements are similar to those in other states, some with
much broader scopes of practice. However, public expectations, regulatory policy, and
legislatively created scope of practice are quite different. Three other states were mentioned
during testimony comparing scopes of practice: Oregon, Michigan and Colorado. This report
focuses on those states for comparison, which shows the diverse regulatory policies regarding the
practice of chiropractic these states have based on their authorizing environments.
Michigan
Of the three states, Michigan is most like Washington in its approach to the chiropractic scope of
practice. Michigan doesn’t allow chiropractors to perform pre-participation examinations or
commercial motor vehicle examinations exams.

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An opinion by Michigan Attorney General9 makes it clear that physical examinations aren’t
within the scope of chiropractic practice:
Public health code doesn’t include within chiropractic practice general physical examinations,
including: analysis of blood, hair, urine samples, physical observations of throat, mouth, eyes,
taking of pulse and blood pressures, and examination of lungs and abdomen, even if
information such as that which can be ascertained from urine specimens and blood pressure
test would be helpful, if not health preserving, in preparation for chiropractic treatment, since
statute limits scope of chiropractic in determining existing subluxations or misalignments of
the spine.
Michigan’s chiropractic scope of practice statute is a part of Michigan Public Health Code
(Excerpt) Act 368 of 1978, Section 333.16401:
(e)"Practice of chiropractic" means that discipline within the healing arts that deals with the
human nervous system and the musculoskeletal system and their interrelationship with other
body systems. Practice of chiropractic includes the following:
(i) The diagnosis of human conditions and disorders of the human musculoskeletal and
nervous systems as they relate to subluxations, misalignments, and joint dysfunctions. These
diagnoses shall be for the purpose of detecting and correcting those conditions and disorders
or offering advice to seek treatment from other health professionals in order to restore and
maintain health.
(ii) The evaluation of conditions or symptoms related to subluxations, misalignments, and
joint dysfunction through any of the following:
Oregon
Oregon has a required form and protocol for PPEs (ORS 336.479). PPEs are required for all
students participating in extracurricular sports in grades seven through 12. ORS 336-479 Section
1 (5) (e) allows a licensed chiropractor who “has clinical training and experience in detecting
cardiopulmonary diseases and defects” to perform PPEs. The clinical training and experience is
assumed, by the Oregon Board of Chiropractic Examiners, under the basic chiropractic licensing
requirements.
However, Oregon clearly has a different policy view of chiropractic than Washington. Oregon
defines a chiropractic physician as an attending physician and allows chiropractors to perform
minor surgery and to use antiseptics and local anesthetics in connection with surgery.10 With
additional certifications, they can perform proctology11 and natural childbirth.12 They are seen as
primary care physicians and may sign birth and death certificates and conduct school physicals.13
They also perform physicals required by the United States Department of Transportation
(USDOT). They may not “administer or write prescriptions for, or dispense drugs, practice
optometry or naturopathic medicine or do major surgery”(ORS 684.015 (3)).
9

Attorney General, on Behalf of People v. Beno (1985) 373 N.W.2d 544, 422 Mich. 293

11
OAR 811-015-0030 (2)
12
OAR 811-015-0030(4)
13
Oregon Board of Chiropractic Examiners
10

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Colorado
In Colorado, the rules regulating PPEs are left to individual schools or school districts or are
delegated to the Colorado High School Athletics Association (CHSAA). Colorado High School
Athletics Association requires PPEs to be conducted for student athletic participation in middle
school, junior high and high schools.14 For chiropractors to perform PPEs for junior high and
high school student athletes in Colorado, CHSAA requires initial certification and recertification
every two years. The initial certification class is seven continuing education hours and covers
topics of patient history and physical examination, guidelines for student sports participation in
Colorado, and legal precautions.15
Colorado chiropractors may not perform surgery, practice obstetrics, treat cancer or prescribe
legend drugs. Colorado chiropractors may perform an EKG/ECG if they have the required 120
hours of initial and related clinical with didactic training and demonstrated competency in
cardiac medicine.16

Background on PPEs
A PPE is a physical examination that is generally required of student athletes prior to
participation in school sports. The goal is to help maintain the health and safety of the athlete in
training and competition. PPEs require evaluation of a wide range of body parts, such as eyes/
ears/nose/throat, lymph nodes, heart, lungs, abdomen, skin and genitourinary system (for males).
They also require an assessment of conditions such as asthma, diabetes, hernia, and heart
conditions. The examiner is expected to determine whether a student athlete can safely
participate in sports or whether clinical contraindications to practice or participation exist. (See
Appendix F for the authorization form recommended by the WIAA).
These physical examinations have taken on more importance in recent years due to an increase in
adverse events such as sudden cardiac deaths occurring in young athletes. An underlying or
undetected heart condition that increases the risk of sudden cardiac arrest is one of the serious
concerns that often escape detection during a PPE. The American Academy of Pediatrics
estimates that approximately 2,000 people under the age of 25 die from sudden cardiac arrest in
the United States each year. Student athletes run a significantly greater chance of experiencing
sudden cardiac arrest than a non-athlete of the same age.17 Sudden cardiac arrest usually stems
from a structural/functional defect in the heart or an electrical disorder. About 40 percent are
caused by hypertrophic cardiomyopathy, an excessive thickening of the heart muscle.
Medical providers must be aware of the warning signs and symptoms of sudden cardiac death
and respond appropriately with comprehensive cardiovascular evaluation, referral, treatment, and
activity restrictions. Work is being done on preventing sudden cardiac death based on trained
evaluation of patient history and physical examination, proper use of non-invasive cardiovascular
testing, and a solid understanding of the conditions associated with sudden cardiac death in
athletes. The Nick of Time Foundation, a nonprofit organization dedicated to preventing sudden

14

Colorado High School Athletics Association, 
Colorado Chiropractic Association
16
Examiners 3 CCR 701-1 Colorado state Board of Chiropractic Examiners Rules and Regulations
17
Pediatrics, Volume 129, Number 4. April 2012. American Academy of Pediatrics Policy Statement
15

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cardiac arrest in athletes, is one organization that is working to restructure the PPE with stricter
regulations.
Many children being examined through PPEs have other diagnosed or undiagnosed medical
conditions in addition to those on the standard PPE clearance form that may impact their ability
to play sports safely. Many of these children are on medications for conditions such as asthma or
attention deficit hyperactivity disorder (ADHD), which may carry risk of drug interactions with
other prescription and over-the-counter medications. In 2009, it was reported that over a quarter
of children in the United States were taking at least one medication on a chronic basis.18 In
addition, according to CDC prevalence rates:
 The national child asthma rate is 9.5percent,19 many of whom use at least a rescue
inhaler;
 In 2007-2008, between 3.7 and 4.7 percent of children in Washington State were on
medication for ADHD.20
Individual school districts in Washington have been given authority by the legislature to make rules
regarding their interscholastic activities, including PPEs. RCW 28A.600.200 states:
“Each school district board of directors is hereby granted and shall exercise the authority to
control, supervise and regulate the conduct of interschool athletic activities and other interschool
extracurricular activities of an athletic, cultural, social or recreational nature for students of the
district. A board of directors may delegate control, supervision and regulation of any such
activity to the Washington interscholastic activities association or any other voluntary nonprofit
entity and compensate such entity for services provided; subject to the following conditions . . .”
A school district may contract with the WIAA for administration of its athletic activities. Although
the WIAA includes in its handbook a sample form for school districts to use for PPEs, there is a
wide variety in the forms actually used by the various school districts and the WIAA’s 800-member
high schools and middle/junior high schools.

Background on Commercial Driver’s License Physicals
Commercial motor vehicle data shows that more than 3,000 truck crashes per year result from the
driver having a heart attack or other physical impairment.21 A medical eligibility clearance (or
CMV) exam is required to help prevent medically unqualified drivers from operating commercial
vehicles on our highways.
The CMV exam for interstate drivers includes many of the same items/conditions that are included
in a PPE, such as cardiovascular conditions (Appendix G). These examinations also include
requirements to evaluate and discuss mental health conditions, alcoholism, the effects of
medications, and non-disqualifying medical conditions that require remedial care, including:
18

“So Young and So Many Pills.” The Wall Street Journal, December 28, 2010. Study conducted by Medco Health
Solutions Inc. 2009.
19
, accessed September 11, 2013
20
, accessed September 11, 2013
21
2007 Study by the Washington State Department of Licensing,


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


Possible side effects and interactions of prescription and over-the-counter medications that
could negatively affect driving.22
Diabetes exemptions that may require blood glucose monitoring.23

Due to safety concerns, the USDOT’s Federal Motor Carrier Safety Administration (FMCSA)
has set up a required registry for all health care providers who wish to conduct these
examinations for interstate drivers. It describes the registry as:
The National Registry of Certified Medical Examiners (National Registry) is a
new FMCSA program. It requires all medical examiners (MEs) who wish to
perform physical examinations for interstate commercial motor vehicle (CMV)
drivers to be trained and certified in FMCSA physical qualification standards.
Medical examiners who have completed the training and successfully passed the
test are included in an online directory on the National Registry website.24
The medical examiner training reviews FMCSA-specific knowledge about CMV drivers and the
physical and mental demands of the job. This training is required because specialized knowledge
of CMV drivers is not included in health care practitioner education and licensure requirements.
The training ensures that candidates have baseline instruction in FMCSA's CMV driver physical
qualification standards, medical guidelines, and medical examiner responsibilities. Medical
scope of practice is defined by each state and demonstrates the practitioner's clinical knowledge.
The medical examiner training builds on that clinical knowledge and applies it to the fitness for
duty determination for CMV drivers.
If a licensed chiropractor is authorized to perform general physical exams under state statute,
they are able to complete the federal training and take the certification test to become a CMV
examiner.25 Forty-eight states allow chiropractors to perform CMV exams. Because the
performance of physical examinations for reasons other than chiropractic care or referral to
another health care provider is outside of the scope of practice for chiropractors in Washington
as defined in RCW 18.25.005, chiropractors aren’t eligible for FMSCA registry.

Definition of the Problem and Why Regulation is Necessary
The applicant states that the problem it is trying to remedy with the proposal is the arbitrary
selection of which health care providers are allowed to perform PPEs and CMV exams in
Washington.
These physical examinations are clearly outside the existing chiropractic scope of practice. Allowing
performance of these physicals would be a substantial increase to the current scope. This would
require the examiner to take on the role of primary care provider, examining and diagnosing systems
and issues of the whole body, including assessing possible side effects and interactions of
medications. Chiropractors have limited training in pharmacology and no prescriptive authority in
22

Medical Examination Report for Commercial Driver Fitness Determination Form # 649F (6045),

23
Medical Advisory Criteria for Evaluation Under 49CFR Part 391.41, 
24

25
Federal Motor Carrier Safety Administration. 49 C.F.R. Section 390.5 Definitions,


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Washington. CMV exams may necessitate the examiner to make highly subjective decisions, such as
whether cardiovascular disease should disqualify an individual, or whether a diabetic whose
condition is adequately controlled by medication and diet should be allowed to drive.26
The applicant states that chiropractic education prepares chiropractors to perform PPE exams
competently. It states that many chiropractors perform cardiopulmonary exams in their offices on
a daily basis; however, it acknowledges that not all chiropractors have maintained the level of
competency to perform PPEs at the level they should be performed. This is the reason the
applicant has stated it is requesting the endorsement to only allow chiropractors with additional
training and testing to perform PPEs. This specialty training includes an 18-hour course for PPEs
or Diplomate American Chiropractic of Sports Physicians sports medicine certification. The
applicant states that chiropractors who don’t specialize in PPEs and CMV exams will simply
choose not to do them, just as medical doctors don’t perform every type of service within their
scope of practice.
In order to determine the adequacy of the endorsement proposed by the applicant, the department
examined the core chiropractic training of currently licensed chiropractors. These practitioners
may have been trained 30 years ago or last year, creating a wide diversity in training. In addition,
even current chiropractic programs necessarily have a primary focus on chiropractic treatment,
leaving much less time devoted to primary medical education. Some chiropractic programs like
the University of Western States exceed the minimum accreditation requirements and
incorporate a broader focus on medical training, but not all schools do the same. The department
isn’t convinced that the specialty certifications for sports medicine chiropractors include enough
focus on broad medical training to adequately address the gap.
Concerns have been identified about how PPEs are currently being performed by other medical
professions, including allegations that physicians miss underlying or undetected heart conditions
that increase the risk of sudden cardiac arrest. These are concerns beyond the scope of this
review. Expanding the chiropractic scope of practice won’t address these issues. They are
currently being debated in the broader health care system and the discussions are leaning toward
increased regulations for those providers already performing them.

26

Medical Advisory Criteria for Evaluation Under 49CFR Part 391.41, 

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REVIEW OF PROPOSAL USING SUNRISE CRITERIA
The Sunrise Act, chapter 18.120 RCW, does not specifically address a proposal to modify or
expand a profession’s scope of practice; but RCW 18.120.010(2) states that when considering
regulating health professions for the first time, the profession should be regulated only when:




Unregulated practice can clearly harm or endanger the health, safety, or welfare of the
public, and the potential for the harm is easily recognizable and not remote or dependent
upon tenuous argument;
The public needs and can reasonably be expected to benefit from an assurance of initial
and continuing professional ability; and
The public cannot be effectively protected by other means in a more cost-beneficial
manner.

The department has applied the criteria in RCW 18.120.010(2) to HB 1573.
First Criterion: Unregulated practice can harm or endanger health or safety.
This criterion has not been met.
Chiropractors are currently a thoroughly regulated profession. The public health and safety
benefit of adding PPEs and CMV exams to the chiropractic scope of practice hasn’t been proven,
and the potential for harm is present. There is evidence that highly trained providers currently
conducting PPEs sometimes miss the warning signs of heart conditions, or do not perform PPEs
properly. Allowing providers with less training to perform PPEs won’t alleviate this issue and
may inadvertently compound the problem.
Chiropractic schools include supervised clinical training in many areas, including recognition of
cardiac conditions. However, it’s minimal in comparison to the substantial training they receive
in aspects of chiropractic care; and not all currently licensed chiropractors receive this level of
education. In addition, chiropractic programs aren’t required to include training in
pharmacology, although some programs offer some training in this area. The Diplomate
American Chiropractic of Sports Physicians specialty certification has a strong focus on spinal
and extremity manipulation, exercise physiology and sports-specific biomechanics.
Second Criterion: The public needs and will benefit from assurance of professional ability.
This criterion has not been met.
There are adequate laws and rules in place to assure the public of chiropractors’ initial and
continued professional ability for their current scope of practice. Chiropractors are clearly
authorized to provide all aspects of care that deal with diagnosis or analysis and care of treatment
of musculoskeletal disorders, including spinal adjustments, extremity manipulation, and other
modalities. This includes physical examinations determining whether chiropractic treatment is
appropriate or whether a referral is necessary to another health care provider. All licensed
chiropractors have received training to provide these services.
The three versions of the proposal under review don’t contain this assurance because:

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




They do not change the chiropractic scope of practice in RCW 18.25.005 to include
comprehensive physical examinations.
Even if the department recommended language to clearly add these examinations in the
chiropractic scope of practice, the applicants have not shown adequate training and
supervised clinical experience to assure the public of the professional ability of currently
practicing chiropractors to perform PPEs or CMV exams.
Chiropractors have limited training in pharmacology, which can play a significant part in
both types of physical examinations.

Third Criterion: Public protection cannot be met by other means in a more cost beneficial
manner.
This criterion has not been met.
Public protection is already in place with the current scope of practice of chiropractors. Although
the applicant shared anecdotal stories of children who could not find a health care provider to
perform a PPE, and has concerns that there may not be sufficient providers to perform CMV
exams in the future, they haven’t submitted actual evidence that the public will be denied these
services if this proposal isn’t granted.
Issues have been identified with the PPE. These include studies showing that physicians don’t
always follow appropriate guidelines and that critical health conditions are often missed. This
seems to indicate a need for stricter regulations and guidelines for those already conducting the
physicals to follow. None of the versions of the proposal considered address these issues.

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DETAILED RECOMMENDATIONS TO LEGISLATURE
In the course of the sunrise review, the department considered three different versions of the
proposal and determined the sunrise criteria have not been met:
1. The department does not support adoption of HB 1573 as written.
Rationale:
HB 1573 does not amend the definitions of chiropractic or chiropractic treatment or care in
RCW 18.25.005. Physical examinations for student athletes and commercial drivers aren’t
within the current chiropractic scope of practice.
2. The department does not support the proposal submitted with the applicant report
from WSCA in July, which included a proposal to add additional educational
requirements for chiropractors to perform PPEs and CMV exams.
Rationale:
The applicant report also does not propose to amend the definitions of chiropractic or
chiropractic treatment or care in RCW 18.25.005. The applicant’s proposal shouldn’t be
enacted, even with the additional training it intends to include in amendment language
because the proposal still fails to amend RCW 18.25.005 to add the elements of a
comprehensive physical examination to the chiropractic scope of practice.
3. The department does not support expanding the chiropractic scope of practice to
include PPEs and CMV exams. The legislature requested that the department assess
whether the proposal meets the sunrise criteria for expanding the scope of practice for
chiropractors. The department interprets these physicals as outside the chiropractic scope of
practice and they would be an expansion of that scope, as indicated in the request from the
legislature. Therefore, we reviewed whether changing the definitions in RCW 18.25.005
expanding the scope to include these physicals would meet the sunrise criteria.
Rationale:
The department found potential risk of patient harm if PPEs and CMV exams are added to
the chiropractic scope of practice. Specifically:


Addition of PPEs and CMV exams would expand the chiropractic scope of practice
well outside of their current capacity of diagnosing and treating conditions relating
to the musculoskeletal system.



PPEs and CMV exams are intended to be comprehensive medical examinations, not
cursory screenings. These exams are sometimes the only examination the person
receives regularly. For students, this includes the opportunity to receive ageappropriate vaccinations, which chiropractors can’t perform.



Chiropractic educational programs don’t include adequate focus on pharmacology,
which is necessary in both types of physical examinations.



Although chiropractic training includes basic understanding of body and organ
systems, including the cardiovascular system, the department is unable to find that
it prepares chiropractors to potentially be the sole evaluator of all or most medical
conditions.

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

The additional trainings proposed by the applicant don’t appear to adequately
bridge the gap in training, especially considering the range of education obtained by
current licensees. The Diplomate American Chiropractic of Sports Physicians
specialty certification training’s primary focus also appears to be on spinal and
extremity manipulation, exercise physiology, and sports-specific biomechanics
without a corresponding focus on broader medical conditions and pharmacology.



Examining a patient to evaluate their overall health should be done by a primary
care provider who can use their broad spectrum of training, clinical residency, and
experience to conduct the evaluation.

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REBUTTALS TO DRAFT REPORT
The department shared a draft report and recommendations with interested parties and invited
comments before finalizing the report. We received three letters of rebuttal and one letter of
correction that are summarized below. In addition, we received four letters in support of the draft
recommendations. These letters aren’t addressed below but are included in Appendix H.

Applicants
We received two letters of rebuttal from members of the applicant group, Lori Grassi and Dr.
Lorri Nichols. We’ll summarize the rebuttals and corrections below, along with our response or
actions. The full rebuttals are included in Appendix H.

Lori Grassi
1. Correction: The applicant identified an error in the background sections of the report
reflecting the date when chiropractors were first licensed in Washington.
Department Response
The department made an inadvertent error in this date in both the Executive Summary
and Summary of Information sections of the report. The date was changed in both places
to indicate chiropractors have been licensed in our state since 1919.
2. Correction: The applicant identified an error in citations where the department used the
term “may” in relation to chiropractors performing physical examinations to determine
the appropriateness of chiropractic care or the need for referral to other health care
providers.
Department Response
This was also an inadvertent error. The department was aware that the statute (RCW
18.25.005(3)) uses the term “shall.” We have corrected the report to indicate that
chiropractors are required to perform these types of examinations to determine the
appropriateness of chiropractic care or the need for referral to other health care providers.
3. Information from Hearing: The applicant was concerned that the department didn’t
include information it provided at the public hearing about intended amendments that
didn’t make it into HB 1573 last session that would have included changes to the
definitions.
Department Response
The department has added the applicant’s stated intent into the report. However, one of
the three versions of the proposal we reviewed included expanding the scope of practice
under appropriately amended definitions. Our task in this sunrise review was to review
the proposal submitted. We cast a broad net in what we evaluated based on
Representative Cody’s direction that we provide “an assessment of whether the proposal
meets the sunrise criteria for expanding the scope of practice,” in her request for sunrise
review that we provide

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4. Correction: The applicant identified an inaccuracy regarding pharmacology training,
where the department had stated that chiropractors don’t have training in pharmacology.
The applicant stated that chiropractors do have pharmacology in their core curriculum
and that they review all prescription and over-the-counter medications as part of their
basic intake and examination. The applicant specifically referenced the 2013 CCE
Accreditation Standards, where it states that “toxicology” is required as part of the
clinical sciences requirements, which include, physical, clinical and laboratory diagnosis;
neurology; spinal adjustment/manipulation, and other topics, as well as a review of
course materials of chiropractic colleges where toxicology or pharmacology were
mentioned.
The applicant also took issue with the reference to chiropractors not having prescriptive
authority within the report, stating that these examinations don’t require prescribing, nor
medical interventions.
Department Response
Pharmacology training: The department acknowledges inconsistencies in where we
referenced chiropractic training in pharmacology. We have corrected any statement that
indicates chiropractors have no pharmacology training. We did not intend to infer there
is’t training in this area, only that there are varying levels of education in pharmacology,
based on when and where a chiropractor graduated. The applicant references in rebuttal
comments a CCE Accreditation Standard requirement for a toxicology component.
Toxicology and pharmacology are not the same, with toxicology dealing with poisons
and their effect; and pharmacology dealing with drug origins, composition, use, and
reactions.27
Prescriptive authority: We acknowledge that PPEs and CMV examinations don’t
specifically require prescribing medications. Our intent was to show that because
chiropractors don’t have prescribing rights, most schools provide only minimum training
in pharmacology.28 We have clarified this in the report. In addition, lack of prescriptive
authority becomes an issue if the PPE is a child’s only annual examination because
vaccinations are a safe and effective way to keep children from getting 14 serious and
sometimes deadly diseases.
5. Multiple Subjects: The applicant’s rebuttal number five had many different components
so we are addressing those in pieces.
A. Performing physicals is outside the chiropractic scope of practice: The applicant
indicated disagreement with the department’s assessment that performing physicals is
outside the chiropractic scope of practice for the reasons summarized below:


The department has alleged chiropractors aren’t qualified to perform physicals
that would identify both chiropractic and non-chiropractic-related medical
conditions. “An exam is an exam.”

27

Taken from Merriam-Webster definitions
A 2010 press release from National University of Health Sciences stated it has determined that chiropractic
physicians would need 90 hours of pharmacology to be able to prescribe safely from a limited formulary. It states
that it offers chiropractic students 90 hours. 
28

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

Because chiropractors are required to perform physical examinations within
the chiropractic differential diagnosis, PPEs and CMV exams are also within
their scope of practice. The applicant points to the CCE standards included
with the applicant report materials as evidence supporting this claim, which
the applicant feels the department has ignored.



The department’s assessment in the report that chiropractors cannot perform
physicals for purposes other than chiropractic care is also incorrect. It
provided the commission’s interpretive statement CH-12-13-12 to the
department as evidence of this.

Department Response
The department disagrees with these assertions. The current scope of practice in law
limits chiropractors to performing physical examinations to determine the
appropriateness of chiropractic care or the need for referral to other health care
providers, not to do an overall health assessment of an individual. Interpretive
statement CH-12-13-12 discusses independent chiropractic examinations at the
request of a third party and doesn’t support the applicant’s claim. It states that if a
chiropractor provides diagnosis or analysis but stops short of providing care or
treatment, the activities are still considered the practice of chiropractic. For instance,
if a chiropractor only reviews a patient’s file without a physical examination of the
patient, that patient review is still considered the practice of chiropractic.
B. Chiropractic Education: The applicant stated evidence has already been provided to
show that chiropractors are trained to perform these physical exams, including a letter
from the University of Western States on the curriculum, but the department ignored
this training and subjected chiropractors to a double standard.
Department Response
The department disagrees with this assessment. We reviewed all of the documents the
applicant provided and have responded to the educational questions.
C. Heart Conditions Undetected by Physicians: The applicant stated that the
department acknowledged the existence of heart attacks following USDOT physicals
and sudden cardiac death events in athletes who have undergone PPEs as a concern,
but didn’t attribute these events as occurring in “the medical community’s watch.”
Department Response
The department has acknowledged these events occur in PPEs already being
conducted (on page 14 under Background on PPEs and on page 17 under Definition
of the Problem and Why Regulation is Necessary). In response to the applicant’s
concern, we added more specific language on page 17 that discusses heart conditions
undetected by physicians.
D. Document Reference: The department had referenced a document on the WSCA’s
website in a statement about a chiropractor’s training being intended for recognizing
conditions outside the scope of chiropractic for referral to other health care providers.
The applicant stated information from the University of Western States was provided
that we should have reviewed, rather than choosing a state association document.
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Department Response
We reviewed all of the materials provided from the applicant on the University of
Western States curriculum. Our choice to reference the WSCA document wasn’t
intended to replace the school curriculum but an attempt to capture a middle ground
between the varying educational programs. After further review, we have removed
the statement entirely.
E. Diplomate American Chiropractic of Sports Physicians Training: The applicant
took issue with the statement that only four percent of the examination is focused on
the PPE.
Department Response
That wasn’t the exact context of the statement; however, the department has removed
this statement because we have attempted to clarify our position related to this sports
medicine certification that isn’t based solely on the examination components.
6. PPEs are not screening exams: The applicant argues that the department is incorrect in
stating that PPEs aren’t merely screenings, but are intended to be comprehensive physical
evaluations.
Department Response
The department firmly believes that PPE and CMV exams both require comprehensive
physical examinations to determine whether an individual can safely participate in sports
or drive commercial vehicles. In order to conduct thorough examinations, the providers
performing these physicals should be qualified to make subjective decisions on
conditions that may disqualify individuals with conditions like diabetes or asthma from
safely participating in sports or driving commercial vehicles. These providers must also
be able to assess and discuss side effects and interactions of prescription medications.
The instructions for performing CMV exams in CFR 391.43 state “The purpose of this
history and physical examination is to detect the presence of physical, mental, or organic
conditions of such a character and extent as to affect the driver’s ability to operate a
commercial motor vehicle safely. The examination should be conducted carefully…”
(emphasis added).
Review of the Proposal Using Sunrise Criteria
The applicant also had issues with how the department addressed the sunrise criteria in the
report. The main points included:


First Criterion - The applicant disagreed with the department’s statement “allowing
providers with less training to perform PPEs won’t alleviate the issue” of highlytrained providers currently conducting PPEs missing warning signs of heart
conditions. The applicant stated this is penalizing the chiropractic profession and
limiting patient access, and is not appropriate.
Department Response
We don’t feel this is penalizing the chiropractic profession. In reviewing scope of
practice expansions, the department must look at whether the proposal ensures
adequate training, which we feel the current proposals under review don’t contain.

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The fact that another profession does or doesn’t perform PPEs adequately isn’t
relevant to the review.
 Second Criterion – The applicant stated that this criterion requires the scope of
practice language to be changed in order to avoid lack of clarity, but “is clearly not a
reason to recommend chiropractors that should not perform these exams.” The
applicant also stated the department disregarded the information provided on
education and training that qualifies chiropractors to be authorized to perform CMV
physicals, as well as the decision of the federal government.
Department Response
We clearly stated that changes to the definitions in RCW 18.25.005 must occur in
order to accomplish an increase in the scope of practice for chiropractors. The
department disagrees that we disregarded the information provided on chiropractic
education and the decision of the federal government.


Third Criterion – The applicant stated this criterion has already been met because
chiropractors are already regulated.
Department Response
The department disagrees with this statement because public protection is in place
with the current scope of practice, but the sunrise proposals don’t contain similar
assurances.



References – The applicant referenced materials provided with the original sunrise
application as well as follow-up after the hearing about American Heart Association
guidelines for use in PPEs. The materials discussed lack of compliance with the
guidelines by providers doing PPEs.
Department Response
The department acknowledged this lack of compliance with appropriate guidelines in
the report, as well as other issues identified with the way PPEs are currently being
conducted. We saw these as issues to be addressed, but not with this proposal.

Dr. Lorri Nichols, DC, CCEP
1. Use of “may” regarding conducting physicals - Dr. Nichols addressed the incorrect use
of “may” in relation to conducting physical examinations and stated that the department
made a significant error that she feels represents a bias about chiropractic education,
training and daily practice. She further stated this demonstrates that the department is
under an unfortunate and incorrect opinion that HB 1573 would be an expansion rather
than what she states is really a clarification of the scope of practice. She also added that
the information the applicant presented shows chiropractors have adequate education and
training, including the Diplomate American Chiropractic of Sports Physician and CCSP
specialties.

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Department Response
We addressed this issue in our response to Ms. Grassi’s rebuttals above, acknowledging
the unintentional error and amending it in the report. We disagree that this is a
clarification for reasons stated in our responses to Ms. Grassi’s rebuttal statements.
2. Screenings or Physicals – Dr. Nichols also disagreed with the department’s assessment
that these examinations are intended to be comprehensive physical examinations. She
reiterated Ms. Grassi’s argument that doctors who perform these examinations don’t
prescribe medications.
Department Response
Please see responses to Ms. Grassi’s rebuttal comments above.

Dr. Ben McCay, DC
1. Physical Examination – “There is no RCW that says comprehensive physical exams are
not part of the chiropractic scope of practice. The ‘physical examination’ I was taught in
school is comprehensive.”
Department Response
The department reiterates our position that the physical examinations required for PPEs
and CMV exams aren’t currently included in the chiropractic scope of practice in statute.
We have addressed the education and training in our above responses.
2. Prescriptive Authority – Prescriptive authority isn’t necessary to perform the PPE, only
to treat a condition upon referral to an MD.
Department Response
The department addressed this issue in our responses above.
3. Diplomate American Chiropractic of Sports Physicians Certification – It is incorrect
to state the Diplomate American Chiropractic of Sports Physicians certification focuses
primarily on spine, extremities, etc. It is 25 percent emergency medicine, including
showing proficiency as an emergency medical technician. Other parts include extensive
training in the management of concussion and keys to a proper cardiac exam.
Department Response
In reviewing the Diplomate American Chiropractic of Sports Physicians certification
materials, the department is unconvinced that this training bridges the gap in education,
especially considering the divergent range of education obtained by current licensees.
4. MDs Currently Performing PPEs – Dr. McCay states that many MDs doesn’t have a
“daily practice that includes functions of primary care,” providing examples such as
orthopedists and many sports physicians who can perform PPEs.
Department Response
The department has acknowledged issues with the current performance of PPEs and
continues to assert that the proposal doesn’t address these problems.
5. No solid evidence the number of deaths in sports will increase if DCs were allowed
to perform PPEs – He states that “the number one killer in sports (hypertrophic
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cardiomyopathy) is not traditionally detected through a routine examination. Clues to
HCM are only found in the patient history. Therefore, there remains no solid evidence
that the number of deaths in sport will increase if DCs were allowed to perform PPEs.”
Department Response
The department doesn’t allege to have evidence to this effect, only that there is a problem
with the current process that this proposal doesn’t address.

Washington East Asian Medicine Association
The association requested a correction to a statement in the draft report that chiropractors are
allowed to perform dry needling in Oregon. They stated this is no longer correct due to a judicial
stay issued by the Oregon Court of Appeals of the enabling administrative rule.
Department Response
The association is correct that dry needling by chiropractors in Oregon is under judicial scrutiny.
We have removed the reference to the use of dry needling in Oregon on page 13.

Chiropractic Sunrise

Page 29

Chiropractic Sunrise

30



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