Florida State Authorizes Chiropractic Physicians Specific Advanced Practice
ADVANCED PRACTICE
FLORIDA
Laurence V. Hicks
DC, DO & Troy Crane, DC
With a desire of enhancing the therapeutic interests of chiropractic physicians in Florida, DCs have expanded the scope of practice of chiropractic medicine by adding acupuncture, nonprescription medication, and the administration of emergency oxygen and aerosol anesthetics to their core chiropractic statutes. Thus, Florida chiropractic professionals have defined the intellectual and clinical framework in a most interesting way.
An Overview of Florida’s Chiropractic Scope of Practice
Section (9)(a) informs us that the “practice of chiropractic medicine” means a “noncombative principle and practice consisting of the science, philosophy, and art of the adjustment, manipulation, and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that are interfering with the normal generation, transmission, and expression of nerve impulse between the brain, organs, and tissue cells of the body, thereby causing disease, are adjusted, manipulated, or treated, thus restoring the normal flow of nerve impulse, which produces normal function and consequent health by chiropractic physicians using specific chiropractic adjustment or manipulation techniques taught in chiropractic colleges accredited by the Council on Chiropractic Education, etc.” Under the statutes, this scope is apportioned into diagnostic and therapeutic components.
"Natural remedies help the body to heal itself"
Part (b) covers the diagnostic element, providing “any chiropractic physician who has complied with the provisions of this chapter may examine, analyze, and diagnose the human living body and its diseases by the use of any physical, chemical, electrical, or thermal method; use the X-ray for diagnosing; phlebotomize; and use any other general method of examination for diagnosis and analysis taught in any school of chiropractic.”
Phlebotomy
A chiropractor is permitted to phlebotomize patients, but only if he or she is competent to do so and has had the proper training and education. (64B2-17.0025 EA.C.) Phlebotomy is defined as the act of drawing or removing blood from the circulatory system through an incision or needle puncture in order to obtain a sample for analysis and diagnosis. Phlebotomy may also be done as part of the patient’s treatment for certain blood disorders. 1
Part (c) allows for therapeutic interventions covered in the scope of practice. Aside from the chiropractic adjustment, physiotherapy, nonlegend drugs, natural methods, emergency oxygen administration, inhalant aerosols, needle acupuncture, and massage therapy are included in the practice act.
Physiotherapy
Though not an advanced practice feature, a Florida chiropractic physician is permitted to perform physiotherapy on patients or treat the human body by manual, mechanical, electrical, or natural methods by the use of physical means or physiotherapy, including light, heat, water, or exercise, but only if he or she is competent to do so and has had the proper training and education. (64B2-17.0025 EA.C.)
Administration of Nonlegend Drugs
In the “sunshine state,” a chiropractor is allowed to administer medications and “items” for which a prescription is not required, but only if he or she is competent to do so and has had the proper training and education. (64B2-17.0025, EA.C.) “Items for which a prescription is not required” include “proprietary drugs,” such as patent or over-the-counter drugs in their unbroken, original package and which are not misbranded under the provisions of Chapter 499.001499.081 of the Florida statutes. (64B2-17.0025(2), EA.C.) “Administration” is defined as the administration of only one dose of any proprietary drug, and the recommendation and direction of dosage levels for the patient’s needs. This provision, under the law, which allows chiropractors to administer proprietary medications, is atypical within most other states and should be considered an advanced practice feature.
Natural Methods
A chiropractic physician is permitted to use natural methods. Natural remedies help the body to heal itself. Natural methods might embrace many therapies, including herbs, massage, acupuncture, exercise, and nutritional counseling.2 In Florida, natural remedies appear to include the administration of foods, food concentrates, food extracts, and items for which a prescription is not required. The importance of nutritional counseling cannot be overstated. “We need nutritional supplements. We can’t eat enough food to obtain the disease-preventing or disease-treating benefits of most supplements. For example, we would have to eat two quarts of corn oil, five pounds of wheat germ, eight cups of almonds, or 28 cups of peanuts in order to consume 400 international units of vitamin E.” 3
Natural methods also seem to include physiotherapy, first aid, and hygiene, but chiropractic physicians are expressly prohibited from prescribing or administering to any person any legend drug except as authorized under subparagraph 2. Here, a legend drug is defined as a drug required by federal or state law to be dispensed only by prescription. (Section 460.403, Florida Statutes)3
Order, Store, and Administer Oxygen for Emergency Purposes Only
Florida code, subparagraph 2 declares, “notwithstanding the prohibition against prescribing and administering legend drugs under subparagraph 1 or section 499.83(2)(c), pursuant to board rule chiropractic physicians may order, store, and administer, for emergency purposes only at the chiropractic physician’s office or place of business.” 4 However, this paragraph does not authorize a chiropractic physician to prescribe medical oxygen as defined in chapter 499. (Section 460A03(9) (c)(2)). Emergent, or otherwise, most states don’t allow chiropractic physicians to administer oxygen, thus it represents an advanced practice provision.
Order, Store, and Administer Anesthetics in Aerosol Form
In addition, subparagraph 2 provides that a Florida chiropractic physician may also order, store, and administer the following topical anesthetics in aerosol form:
• Any solution consisting of 25% ethyl chloride and 75% dichlorodifluoromethane.
• Any solution consisting of 15% dichlorodifluoromethane and 85% trichloromonofluoromethane.
Access to and administration of aerosol anesthetics constitutes a form of advanced practice.
Legal Laboratory Orders
Part (d) affirms chiropractic physicians shall have the privileges of services from the department’s laboratories.
They Call it Chiropractic Medicine in the “Everglade State”
Part (e) covers language associated with protecting titles. Here it states the terms “chiropractic medicine,” “chiropractic,” “doctor of chiropractic,” or “chiropractor” shall be synonymous with “chiropractic physician,” and each term shall be construed to mean a practitioner of chiropractic medicine as the same has been defined herein. Chiropractic physicians may analyze and diagnose the physical conditions of the human body to determine the abnormal functions of human organism and to determine such functions as are abnormally expressed and the cause of such abnormal expression.
Part (f) appears summative in nature. It reads, “any chiropractic physician who has complied with the provisions of this chapter is authorized to analyze and diagnose abnormal bodily functions and to adjust the physical representative of the primary cause of disease as is herein defined and provided. As an incident to the care of the sick, chiropractic physicians may advise and instruct patients in all matters pertaining to hygiene and sanitary measures as taught and approved by recognized chiropractic schools and colleges.”
Clinical Acupuncture
Acupuncture is defined as a modality of diagnosing and treating disease, pain, or physical conditions by stimulating various points on the body or interruption of the cutaneous (skin’s) integrity by insertion of a needle to secure a reflex relief of the symptoms by nerve stimulation.6 Acupuncture is recognized as a modality of treatment, which is an adjunct to chiropractic, presently taught as part of the curriculum in approved chiropractic colleges. The proper administration of acupuncture requires a thorough knowledge of physiology, anatomy, therapeutics, and diagnostic acumen.
Administrative Code Section 64B2-17.003 regulates the practice of acupuncture by chiropractors. Prior to engaging in the practice of acupuncture, a chiropractic physician must present the Board of Chiropractic Medicine with verification that he or she has taken an examination from an approved college or institution after having completed the approved minimum course of study. This education must include a minimum of 100 hours of study in the practice of acupuncture in courses approved by the board. (38-10) Note that this training and instruction requirement is far less than that required of a licensed acupuncture physician.
A chiropractic physician may administer acupuncture treatments only if the Board of Chiropractic Medicine permits the DC to do so. Certification is only granted to chiropractic physicians who have satisfactorily completed the required course work in acupuncture from a college or university that is recognized by an accrediting agency approved by the United States Department of Education (if it is not accredited by the Department of Education, it doesn’t count) and passed an examination administered by the Department of Health. The burden is on the chiropractor to ensure the course that he or she takes is from a school that has been properly accredited.
Chiropractors are prohibited from utilizing the modality of acupuncture in treating various diseases and conditions, including cancer, AIDS, and leukemia. The regulation also provides restrictions on the use and cleaning of needles in the practice of acupuncture.
Chiropractors performing acupuncture must adhere to the following procedures:
• When nondisposable needles are used for acupuncture, said needles shall be sterilized, only by generally accepted procedures for sterilization of needles.
• Needles shall be individually packaged for each patient.
• The individually packaged needles shall be either destroyed following patient dismissal or put in a permanent file for the future use of the described patient when nondisposable needles are used.
• Only noncorrosive needles shall be authorized and used.
• Generally, acceptable cleansing agents shall be used for cleansing the needle insertion area. (64B2-17.003, EA.C.)
Acupuncture is an example of an advanced practice modality.
Massage Therapy
Chapter 480 of the Florida statutes regulates the practice of massage therapy. Pursuant to this law, the facility where massage therapy is administered must be licensed separately as a massage establishment unless it is the residence or office of the client.
The question is often asked, “Do I need to have a massage establishment license if my massage therapist also treats his or her own patients?” Pursuant to the law in chapter 480, the facility where massage therapy is administered (even a chiropractor’s office) must be licensed separately as a massage establishment unless it is the residence or office of the client.
Under the Chiropractic Medicine Practice Act, a chiropractic physician prescribing massage therapy for his or her patient in the chiropractic physician’s office does not need to have a massage establishment license. However, the chiropractor’s office does need a massage establishment license if the massage therapist is permitted to bring his or her own clients into the office for massage therapy not prescribed or supervised by the chiropractor. It does not matter who applies for the massage establishment license—the chiropractic physician or the massage therapist—as long as there is one for the facility.
Prohibited Acts, Procedures, and Treatments
Florida statutes also set forth certain prohibitions including activities that chiropractic physicians are expressly prohibited from:
• Prescribing or administering to any person any legend (prescription) drug except as specifically authorized elsewhere in the law.
• Performing any surgery except as stated in the law.
• Practicing obstetrics. (Section 460A03(9)(c)(l)
• Using diagnostic instruments or instruments for treatment of patients, the use of which are not taught in the regular course of instruction in a college recognized by the Florida Board of Chiropractic Medicine.
• Administering any form of injectable substance. (64B2-17.002S (4), EA.C.)
• Florida DCs may not treat cancer, leukemia, tuberculosis, syphilis, gonorrhea, hepatitis, anthrax, diphtheria, Hansen’s disease, hookworm disease, malaria, rabies, typhoid fever, or AIDS. (64B2-17.003, EA.C.)
Summary
We have observed that, in Florida, the chiropractic profession has defined the intellectual and clinical framework of their practice in specific interesting ways. The title of the profession is “chiropractic medicine” in Florida. While specific prohibitions do exist, chiropractors have balanced those limitations against the acquisition of an advanced scope of practice, which includes performing acupuncture treatments, using nonprescription medications, the administration of emergency oxygen and aerosol anesthetics, natural methods, and medical massage to their core professional role.
In reporting on these interesting practice provisions, the authors will defer to the board if an inadvertent misinterpretation may have occurred.
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.
Dr. Troy Crane is graduate of the former Ricks College, currently Brigham Young Unif versity Idaho, 1984, with an A.A.S. He also attended Idaho State University from 1984 through1985, then New College Science Institute in the Fall of 1985. He obtained the Doctor of Chiropractic degree from Life Chiropractic College West in December of 1989. Dr. Crane has been continuously in chiropractic practice since April 2, 1990 and has been a field consultant for Standard Process NW for 20 years.
Reference
1. www.surgeryencyclopedia.com > Pa-St > Phlebotomy
2. www.webmd.com > balance > guide > what-is-naturopathic-medicine
2. Journal of National Cancer Institute, Vol. 84, July 1992, p. 997.
4. https://en.wikipedia.org > wiki > Prescription dru
5. www.emergencycare.hsi.com > emergency-care-oxygen
6. www.medical-dictionary.thefreedictionary.com > aerosol +spray+ topical+a...
7. www.webmd.com > Pain Management > Slideshows
