Utah’s Chiropractors, Determining Their Own Destiny, Via a Unique and Interesting Advanced Scope of Practice

Utah’s Chiropractors, Determining Their Own Destiny, Via a Unique and Interesting Advanced Scope of Practice

ADVANCED PRACTICE

Laurence V. Hicks, Sr1

Geoffrey N. Hicks²

Laurence V. (Ben) Hicks, Jr.3

As mentioned in a prior article, it is a firm belief of the authors that a profession needs to have latitude in determining the course of its own destiny. For many years, chiropractors were limited under various restrictions. The interest in and the inclusion of clinical acupuncture into chiropractic statutes, as a therapeutic modality, became a forerunner, spurring the desire to expand the scopes of chiropractic in various ways from one jurisdiction to the next.

In recent years, several states, including Oklahoma, have expanded their scope of practice to add acupuncture, homeopathy, naturopathy, parenteral nutrition, and animal chiropractic and oxygen. New Mexico even promulgated an advanced practice, which includes the limited use of pharmaceuticals.1 It is the natural preference of practitioners and professionals to define the intellectual and clinical framework of their practice.

This paper is important because it details how Utah in particular has developed a unique approach to an advanced scope of chiropractic practice that allows for Chest Physical Therapy and debridement of wounds, together with cleansing and changing dressings, the use of topically applied medicinal agents, well-defined orthopedic services, Homeopathic injection therapy or Bio puncture and Prolozone, animal chiropractic and clinical Acupuncture, all of which have been woven into the framework of legal practice rights.

Utah’s Unique Approach to an Advanced Chiropractic Scope of Practice

Chang, in a 2014 report, projected that the states with the broadest chiropractic practice laws, based on the total number of allowed services, A were Missouri (n = 92), New Mexico (n = 91), Kansas (n = 89), Utah (n = 89), Oklahoma (n = 88), Illinois (n = 87) and Alabama (n = 86). Her projection was based on the statutory allowances of the states’ scope of practice.2

A review of the current chiropractic law in Utah illustrates within section 58-73-601 that chiropractic physicians, licensed under this chapter, may engage in the practice of chiropractic as defined in section 58-73102 in accordance with specific standards. We are informed that a chiropractic physician may:

• Examine, diagnose, and treat only within the scope of chiropractic as described in this Subsection;

• use x-ray for diagnostic purposes only;

• administer physical agents, including light, heat, cold, water, air, sound, compression, electricity, and electromagnetic radiation except gamma radiation; and physical activities and devices, including:

• exercise with and without devices;

• joint mobilization;

• mechanical stimulation;

• postural drainage (PD);

• traction;

• positioning;

• wound debridement, cleansing and dressing changes;

• splinting;

• training in locomotion and other functional activities with and without assistance devices and

• correction of posture, body mechanics, and gait.

PD and wound debridement, cleansing and changing dressings, aka wound care (WC), represent two distinctive practice arenas that are not usually reserved to the chiropractic clinician and appear to be characteristic of advanced practice privileges. They are important procedures specifically allocated to Utah’s chiropractic physicians and not usually found in the chiropractic-related statutes of other states. Further, a skilled clinician could build a busy practice around either or both PD and wound debridement, cleansing, and dressing changes. Further discussion of each of these advanced healthcare procedures deserves individual attention.

Postural Drainage

PD is a technique that is likely more familiar to nurses, respiratory and physical therapists than chiropractors, whereby a patient is placed in one or more positions designed to facilitate the drainage of secretions from the bronchial airways. The procedure takes advantage of gravity to encourage secretions to move toward the trachea, where they can more easily be coughed out. Because PD is effective in draining fluid out of the lungs, it may help to treat or prevent infection, allow easier breathing, and prevent various other pulmonary problems.3

PD has been shown to be beneficial in bronchiectasis, Cystic Fibrosis and lung abscess. A patient’s body is positioned so that the trachea is directed inferiorly and below the affected chest area into a position in which the lobe(s) can be drained.4 5

Postural Drainage and Percussion

PD is aka chest physical therapy (CPT) or postural drainage and percussion (PDP). In addition to using the benefit of gravity, PDP adds percussion over the chest and/or back, together with vibration and deep breathing and coughing to loosen the thick, viscous mucus in the lungs to enhance removal with coughing. Pulmonary lobes are subdivided into segments. During CPT, the segments are the initial location from which mucus is drained.

Appropriate attention must be taken to avoid percussions over the spine, breastbone, stomach, and lower ribs to reduce the risk of injury to the spleen, the liver, and the kidneys. Various physiotherapy modalities may be used in place of a traditionally cupped palm method for percussion, e.g., vibration gently shakes mucus loose and moves it into the larger airways.

Normally, a CPT treatment session will last for 20 to 40 minutes and should be codable for reimbursement in 15-minute increments. The length of PDP and the frequency needed may be increased when a patient is more congested or during acute illness.

The clinician should avoid excessively leaning forward while providing percussion and attempt to remain in an upright position to protect his or her own back. The table on which the patient lies should be at a comfortable height for the caregiver.6

Debridement, Cleansing, and Changing Dressings

Normally, wound care is the province of surgeons and specialized nurses, as well as physical therapists, so finding that Utah’s chiropractic law permits wound care in the scope of practice is most interesting. Wound care is a commonly needed and important clinical procedure.

Ulcers and wounds commonly occur in professional athletes and bed-ridden patients. Statistics show that approximately 3.5 million sports injuries are reported annually. Further, between 5% and 10% of the global population suffer from ulcers at some point in time. Thus, proper treatment and healing of wounds is essential. Debridement and dressing are the two most popular techniques shown to result in a speedy recovery.

Wound debridement embraces all of the scientific methods needed to remove damaged, infected, or necrotic tissues from a site of injury so as to encourage speedy recovery and healing of the remaining healthy tissues in addition to the affected tissues. The relative effectiveness of the debridement technique determines the healing potential of the damaged tissues.

Various methods such as chemical, mechanical, surgical, autolytic, and maggot therapy are made use of for wound debridement purposes. Surgical debridement will be outside of the chiropractic scope of practice and maggot therapy as a prescribed modality; thus, a chiropractor could make use of this treatment only when strictly under the supervision of an M.D. or D.O.

Autolytic Debridement

A review of the sundry types of debridement include autolytic debridement, which involves destruction of cells (aka self-digestion). This is the process of complete dissolution of a cell with the help of its very own enzymes. Here, advantage is taken of the body’s own enzymes and moisture to re-hydrate, soften, and melt the sloughing material or eschar. This method of debridement is most effective in dealing with Stage III or Stage IV wounds, in which mild to moderate exudates are released. The most-often recommended approach to autolytic debridement is to use occlusive or semi-occlusive dressings to ensure that the wound fluid remains in contact with the necrotic tissues. Hydrogels, hydrocolloids, and transparent films are frequently used materials.

Enzymatic Debridement

This method involves the use of enzymes to eat away or breakdown necrotic tissues. These enzymes may be derived from microbes like histolyticum and Clostridium; however, plants produce Papain, Bromelain, Streptokinase, and Collagenase, which are useful and potent enzymes. Streptokinase is available only with a prescription, so Sub-section (3), which states that a D.C. must be required by law as provided in Sub-section (2)(d).7 This approach is best implemented for wounds, especially burns, with a large amount of necrotic debris or eschar formation.

Mechanical Debridement

Hydrotherapy is commonly used in this case to provide selective mechanical debridement, wherein a tissue is removed as a part of wound management. The preferred means of mechanical debridement are:

• directed wound irrigation and

• mechanical irrigation.

Whirlpool water baths, though

commonly and effectively used by physical therapists, should not be a primary consideration for hydrotherapy because a selective tissue cannot be targeted, and the healthy tissues may be damaged in the process. Non-selective mechanical debridement involves drying up of a moist dressing, followed by removal of the dressing. Mechanical debridement turns out to be most effective method for wounds with dead tissue present.

Wound Cleansing

Wound cleansing is making use of fluids to gently remove loosely adherent contaminants and devitalized material from a wound surface (Krasner, Rodeheaver, and Sibbald, 2007). Gentleness is the prime consideration during cleansing to minimize trauma to the wound bed. Most wounds should be cleansed initially and again during each dressing change.8 9

Wound Dressing

Wound dressing is the application of a sterile pad or a compress to a wound to enhance the healing process, as well as to reduce the risk of a wound from becoming infected. Therefore, it is important to appreciate the differences between a dressing and a bandage. A dressing is the product that is placed directly in contact with the wound, whereas a bandage is a protective strip of material serving to support the dressing so as to attach the dressing firmly to the wound. To simplify the need for bandages during dressing changes, dressings now most often incorporate adhesives.

The various purposes of wound dressing are to:

• Control bleeding by sealing the wound and encouraging coagulation.

• Provide wound protection from pathogens and mechanical trauma.

• Assist fluid absorption of the exudates (blood and plasma released from the wounds) and to prevent skin maceration.

• Aid pain reduction via an analgesic effect, which lessens discomfort to some extent.

• Encourage debridement by removing sloughed and infectious tissues from the wound site, hastening healing.

Wound dressings are classified into the following categories:

• Gauze Dressings

• Biologies

• Skin substitutes

• Scaffolds

• Bio-membranes

• Hydrocolloid dressing

• Foam dressing

• Film/composite dressing and

• Stretch gauze/stretch net products.10

Topically Applied Medicinal Agents

A further provision of the Utah chiropractic statutes, which appears to represent an advanced practice provision, allows for the administration of topically applied medicinal agents, including steroids, anesthetics, coolants, and analgesics for wound care and for musculoskeletal treatment, including their use by iontophoresis or phonophoresis.

Orthopedic Services

Another advanced practice provision under Utah statutes is the language that provides an opportunity for chiropractic physicians to undertake a broad range of orthopedic services including the rights to utilize immobilizing appliances, casts, and supports for support purposes. Although chiropractors may not set displaced bone fractures, they are, nonetheless, permitted to cast non-displaced fractures. The D.C. is also permitted to treat a human being to assess, prevent, correct, alleviate and limit physical disability, movement dysfunction, bodily malfunction, and pain resulting from disorders, congenital and aging conditions, injury and disease; and administer, interpret, and evaluate tests.

Homeopathic Injection Therapy or Bio puncture and Prolozone

A review of the websites of several licensed Utah chiropractic physicians reveals that Homeopathic Injection Therapy (HIT), aka Bio puncture, covered under the rules related to chiropractic practice in Utah,11 appears to garner broad professional support. This injection therapy clearly supports an advanced chiropractic practice model. HIT consists of injecting biological homeopathic natural products into specific anatomical areas or into acupuncture points.12 It is reported that these injections are to be given subcutaneously or intramuscularly, including trigger points.

It appears that HIT is not as painful as a typical medical injection, because the needle used is very fine and the quantity injected is very small. Most injections are given into or just under the skin, others are given into specific muscle points and/or around joints.

Here, we are informed that the low-dose homeopathic content from within the injection ampules ensures that the side effects are negligible. The homeopathic agents are described as completely natural, pyrogen-free, pharmaceutical-grade substances derived from mineral, vitamin, and plant sources.

There are many different conditions that have been treated with homeopathic agents over the years. Some common uses include myofascial trigger points, pain management, recovery from injuries and promotion of healing, fat reduction, arthritis, carpal tunnel syndrome, wrinkles, headaches, and fibromyalgia.

A variant of HIT is Prolozone. Prolozone is a combination of a given homeopathic remedy, such as Traumeel or Zeel coupled with ozone gas. The cocktail is injected into the connective tissues and muscles around joints to promote healing where other treatment methods may have failed. It is suggested that Prolozone works by reducing inflammation and pain, directing nutrients to the damaged tissues, and promoting cellular repair and regeneration.1314

This therapy is applied to chronic conditions, sports injuries, and musculoskeletal pain in the neck, back, shoulder area, arms, legs, and feet.

In the interest of public safety, Utah’s statutes proclaim that unprofessional conduct, under section (12), includes administering injections through the skin, limited to subcutaneous or intramuscular administration, of any substances other than non-prescription drugs as defined in Subsections 58-17b-102(39) or non-controlled substances as defined in Subsection 58-37-2(1 )(f)(ii); and under section (13) administering injections of non-prescription drugs or non-controlled substances would result without sufficient competency and training as demonstrated by the following:

• Completion of a recognized course on injectables and their administration, under the sponsorship of or approval by an institution, organization, or association meeting the continuing education standards as defined in Section R156-73-303b; and

• Receiving a passing score on a certifying examination.

• Also, under section (14), it would also be unprofessional conduct to (14) delegate the administration of injections to a chiropractic assistant.

In a late August memo, sent via email to chiropractic physicians licensed in Utah, James Knight, D.C, offered an important opinion “as a former licensing board member, Chairman of said board for 2 years and as a current Chairman of the R156-73-602 Advisory Peer Committee. You cannot inject anything not in the Homeopathic Pharmacopeia, and then only in the soft tissue, not into a joint, this includes placental tissues despite what some salesmen may tell you.” 15

Animal Chiropractic

Animal chiropractic is another interesting aspect of Utah’s advanced chiropractic practice. R156-73-603 provides the essential Standards for Practice of Animal Chiropractic. It reads that in accordance with Subsection 58-28-307(12)(a), a chiropractic physician, practicing animal chiropractic, shall have completed an animal chiropractic course approved by the American Chiropractic Veterinary Association (ACVA) or another course that is substantially equivalent to the ACVA course.

Clinical Acupuncture

If you happen to be a D.O. or M.D. physician, the scope of practice provisions permits you to practice acupuncture in 38 U.S. states, without further training. The following states are exceptions, and require specific training: Georgia, Hawaii, Maryland, Montana, New Jersey, New York, Rhode Island, Pennsylvania, South Carolina, South Dakota, Virginia, and Washington, D.C.16

Interestingly, about the same number states—16— prohibit Chiropractic Acupuncture as part of the scope of practice. The practice-limited states include California, Georgia, Hawaii, Kentucky, Michigan, Mississippi, Montana, New Jersey, Nevada, New York, Oregon, Pennsylvania, Rhode Island, South Carolina, Washington, and Wisconsin.17

In jurisdictions where acupuncture is a legal chiropractic practice right, the authors believe it may be thought of as permitting an advanced chiropractic scope of practice modality.

Under section (1) of the Utah chiropractic practice act, “C linical acupuncture” means the application of mechanical, thermal, manual, and/or electrical stimulation of acupuncture points and meridians, including the insertion of needles, by a chiropractic physician who has demonstrated competency and training by completing a recognized course that is sponsored by an institution or organization approved to sponsor continuing education, as defined in Section R156-73-303b.

“Competency Requirements to Perform Acupuncture” are provided under Utah code R156-73-601,where we find that the requirements to demonstrate competency and training to perform clinical acupuncture will vary depending on whether the D.C. began providing acupuncture services as a part of their practice prior to January 1, 2002, on or between January 1,2002 and January 1,2005 or after January 1, 2005. Licensees who begin providing clinical acupuncture as a part of their practice on or after January 1, 2005, are meeting current requirements and shall:

• Meet the requirements to take and receive a passing score on the NBCE Acupuncture Examination; or

• Meet the requirements to take and receive a passing score on the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) Examination.

Conclusion

At the beginning of this paper, we stated our steadfast belief that it is important for a profession to experience latitude in determining its own direction on the scope of practice issues. Several chiropractic jurisdictions have broadened their practice privileges over recent years. Here, we are reporting on Utah’s unique provisions for an advanced scope of chiropractic practice, which permits Utah chiropractors to offer to their clients Chest Physical Therapy, debridement of wounds, together with cleansing and changing dressings, the use of topically applied medicinal agents, well-defined orthopedic services, Homeopathic injection therapy or Bio puncture, and Prolozone, as well as animal chiropractic and clinical acupuncture, all of which have been woven into the framework of their legal practice rights.

In reviewing the statutes covering the chiropractic scope of practice, we concede, there is the possibility of misinterpretation; if so, we defer to the Utah Board of Chiropractic Examiners.

Dr. Laurence Hicks is a Board certified Osteopathic Family Physician and a Chiropractic physician nutrition specialist. He practices full time, and has, for over 35 years. As an avid teacher in medicine, Dr. Hicks has trained many medical, chiropractic PA and NP students and practitioners. He is currently the instructor of the Clinical Nutrition Certification modules which lead to an Advanced practice licensure for qualified Idaho chiropractic physicians. Tel: 208-733-444.

Geoffrey N. Hicks is a Family Nurse Practitioner (FNP) and a co-owner of the Falls Centre for Functional Medicine, PLLC. He is certified in family practice and working on certification in pain management. Geoffrey is interested in both conventional and complementary approaches to health care. He holds a MSN as a FNP from Samford University and a HMD form KCNH.

Laurence V. (Ben) Hicks, Jr. is a recent Physician's Assistant graduate of the Idaho State University with a Master of Physician Assistant studies. He is interested in CAM as well as conventional medicine and has a particular interest in Psychiatry. He holds an ND from Central States College and completed the Clinical Nutritional specialty course through Boise State University, which is part of a pathway to become a diplomate of the American Clinical Board of Nutrition.

References

1. Chiropractors Can Still Prescribe Drugs in New Mexico • http://chiropractic.prosepoint. net/146047 • February 8, 2017

2. Chang, Mabel. The Chiropractic Scope of Practice in the United States: A Cross-sectional Survey • J Manipulative Physiol Ther. 2014 (Jul); 37 (6): 363-376[3]

3. Postural Drainage: Uses, Benefits, and Risks—healthline.com

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5. www. healthline, com health postural-drainage

6. Basics of Postural Drainage and Percussion \ CF Foundation, www.cff.org/LifeWith-CF/Treatments-and...

7. Streptokinase (Intravenous Route, Intracoronary Route ...

• https: www.mayoclinic.org > description > drg-20070834

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9. Overview of wound debridement and dressing • https: //factdr. com health-conditions wound-debridement-dressing • June 3rd, 2019

10. 7 Types of Wound Dressings and When to Use Each • https:// www. clhgroup. co. uk news-article/201 7. 09 12 7-types-ofwound-dressings-when-to-use-each/258

11. http: kempchiropracticutah.com treatments homeopathic-therapy

12. http:/ healthologyexperts.com services homeopathic-injections

13. https://www. bodyw’orkschiro. com chiropractor-services injections-homeopathics-trigger-point-injections.html

14. http://www. drkingchiropractic. com ozone-injection-therapy

15. Knight, James, D.C. • 1564 S 500 W, Ste 101 • Bountiful, UT 84010 • Phone: 801-292-9857 • Telephone interview with Laurence Hicks • https: '/www.drjamesknight.com meet-dr-jamesknight • September 5, 2019

16. https: acupracticeseminars. com/resources/us-state-acupunc1 lire-laws

17. http://councilbfchiropracticacupuncture. org/state-requirements.html