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“Chiropractic was the original holistic medicine in that it focused on treating the whole person, not just the body part that hurt”,according to Michael Schneider, DC, PhD,an associate professor of health sciences at the University of Pittsburgh. His research on chiropractic suggests that cervical and lumbar manipulation can be an effective treatment for low back pain. A study published in April 2017 in the Journal of the American Medical Association supported this, finding that based on the latest research, spinal manipulation,the back and neck adjustments most people associate with a visit to a chiropractor, can modestly reduce a person’s lower back pain [47] .
An in-depth summary of the chiropractic profession at present is far beyond the scope of this chapter. Even when looking primarily at its country of origin, the US, with its decentralized,some would say fractured, health care delivery system and laws governing the profession that vary from state to state, the task is challenging.The goal of this portion of the chapter is to provide a broad overview of the profession’s current status relative to training programs,general parameters regarding its practice,economic considerations, practice models,public perception and emerging trends.
Over the past two decades, as chiropractic has reached its current level of maturity in the United States, paradoxical forces have influenced the profession, some pushing it forward, others seemingly pushing it backwards or, at best, holding it in check.
Small colleges and universities in the US are facing economic difficulties due to a combination of factors: rising tuition to cover rising costs (and a corollary, graduates’ debt load), decreasing or flat net tuition revenue and shifting enrollment trends [48] . As chiropractic degree programs are mostly offered at narrowly focused, small colleges and universities, they are subject to these same forces. In addition,they face challenges associated with factors generally described as the US healthcare crisis.In spite of these dual challenges, the number of training programs and students enrolled has not changed appreciably.
Laws governing the practice have remained intact but not without occasional challenges.In Texas, a protracted attempt by the medical establishment to limit the right of a chiropractor to make a diagnosis is reportedly ongoing [49] .In 2009 the scope of practice in New Mexico expanded to permit limited drug prescription privileges [50] . Beyond these two extremes, chiropractors across the county enjoy a relatively broad scope of practice to examine, diagnosis and treat a range of health conditions but do not have prescribing rights nor do they perform most other invasive procedures such as surgery with one exception, Oregon, where minor surgery is permitted.
The long-dominant model of private practice, with one or perhaps a few chiropractors working together, separate from larger,mainstream healthcare systems and facilities,persists but is beginning to wane. New models of practice, such as integrative, multispecialty practices, where chiropractors work with other healthcare practitioners, and employment opportunities, have emerged over the past 20 years and continue to grow. In some areas,particularly private practice, reimbursement from various sources has stagnated or shrunk.The new models of care and emerging employment opportunities, which were not present in the relatively recent past, are creating the possibility of enhanced earning capacity.Accessibility has been constrained by the design of private health insurance, particularly so-called managed care and government regulated healthcare networks, many of which require physician-approved referral or insurance company authorization. At the same time,entirely novel practice venues and arrangements are emerging that promise patients greater and more affordable access to chiropractic care.
Public perception is favorable and, among actual patients, it is extremely high. Demand for access to chiropractic care is strong but several factors dampen the ability of many patients to access care directly or promptly.
Traditionally, chiropractic colleges in the US have been single degree focused institutions. The Palmer College of Chiropractic was founded in 1897 and, as noted earlier in this chapter, many others were founded in the early 1900s. Some of these legacy programs have added other professional degree programs such as acupuncture, naturopathic medicine or master’s degrees in nutrition or sport-related fields. Three currently accredited universitybased chiropractic institutions are notable exceptions; each already offered training leading to bachelor’s and master’s degrees in liberal and applied arts, sciences and healthrelated fields, such as physical therapy, nursing,occupational therapy and psychology. Rather than beginning as chiropractic programs, these three institutions recently added a chiropractic degree program to the existing curricula.
There are approximately 10,000 students in chiropractic programs in the United States.This has been a fairly consistent number for decades except for the mid-1990s when there was an exceptionally large pool of students in college. Attracting new students has been a challenge historically as the US programs are all private institutions and have minimal to no government assistance for campus infrastructure, operations or tuition.Demographic trends across the country have resulted in a shrinking number of students enrolled in undergraduate college today,lessening the number of potential chiropractic students. In addition, over the last decade there have been hundreds of new programs that have opened, particularly schools of physical therapy and those granting Physician Assistant degrees,as well as several medical and osteopathic colleges. This has led to a reduction in the number of potential candidates for chiropractic college admission. The fact that enrollment in chiropractic programs has remained steady is remarkable given this reality.
In the US there are accredited programs on 18 campuses and the programs are represented by a common organization, the Association of Chiropractic Colleges. The Association is aware of prospective academic organizations exploring the creation of new chiropractic degree programs [51] .
Programs leading to a chiropractic degree,designated as a DC in the US, are typically four academic years in length. Depending on the specific program, training is completed in approximately three and one-half years as extended summer breaks, common in traditional college programs, are not incorporated.Entering students are not generally required to first obtain an undergraduate degree.
Following is an example of what is considered for admission at one institution, the Los Angeles College of Chiropractic, a college within Southern California University of Health Sciences. A prospective student must have completed a minimum of 90 semester units or 135 quarter units at an institution(s) accredited by an agency recognized by the US Department of Education or an equivalent foreign agency.From the minimum 90-unit requirements: 24 of these units should be in the Life and Physical Sciences; half of the 24 science units must have a substantive lab component; Biology and Chemistry Course are mandatory course requirements and science coursework must have been completed within seven years of admission [52] .
As noted earlier in this chapter, since 1974 chiropractic degree programs in the US are accredited by the CCE which sets national standards for curricula. Additionally,students are required to pass a sequence of four tests, administered by the National Board of Chiropractic Examiners (NBCE) during the course of training. The NBCE tests include three written exams and one option written exam, and one final practical exam. NBCE Part I Exam includes six basic science subjects: Anatomy,Spinal Anatomy, Physiology, Chemistry,Pathology, and Microbiology. NBCE Part II Exam includes six clinical science subjects:General Diagnosis, Neuromusculoskeletal Diagnosis, Diagnostic Imaging, Principles of Chiropractic, Chiropractic Practice, and Associated Clinical Sciences. NBCE Part III Exam addresses nine clinical areas: Case history,Physical examination, Neuromusculoskeletal examination, Diagnostic Imaging, Clinical laboratory and special studies, Diagnosis or clinical impression, Chiropractic techniques,Supportive interventions, and Case management.NBCE also conducts a Physiotherapy Exam which is an elective. A final, practical exam,Part IV, consists of three major sections and each of the sections is divided into stations. The three sections are: Diagnostic Imaging (DI),Chiropractic Technique, and Case Management.DI consists of 20 stations which are allotted two minutes per station. During the DI portion,candidates view diagnostic images on a monitor and answer questions related to the images.During the Chiropractic Technique portion of the exam, candidates are assessed in five stations with five minutes allotted to complete each station. During the Chiropractic Technique portion, candidates read instructions and subsequently set up for spinal and extremity adjustments while graded by a live exam proctor. The Case Management portion consists of 20 stations with five minutes allotted to complete each station. Candidates are asked to perform a case history, physical examination,or orthopedic or neurological test on a socalled standardized patient, an actor or actress who responds to questions and cues consistent with expected clinical responses, while graded by a live exam proctor [53] . Most US states accept completion of these four NBCE exams as sufficient for applying for licensure although a separate exam covering state rules and regulations is common. States may have specific requirements for training in addition to what the CCE prescribes but these are often minor and focused on state laws regulating practice in respective jurisdictions. Relative to curriculum, CCE does not prescribe specific classes but instead has guidelines that require students to acquire competencies in a number of areas [54] . Each chiropractic degree program creates curricula to meet those competencies as well as any state-mandated requirements.
In light of CCE competencies and NBCE testing topics, curricula at the various chiropractic degree programs cover comparable material. As an example, an overview of the doctor of chiropractic curriculum from Northwestern Health Sciences University(NHSU) is offered. The NHSU program is comprised of 84 course offerings, organized by eight academic and clinical departments. Basic sciences: biochemistry, anatomy, embryology,histology, immunology and microbiology,neuroscience, pathology and physiology.Chiropractic studies: chiropractic principles and philosophy (history of the profession and the nature of the chiropractic healthcare model), with lectures and labs, physiological therapeutics, exercise and rehabilitation.Diagnostic and clinical sciences: six trimesters are devoted to diagnostic skills with courses in clinical skills (obtain a medical history and perform a physical exam), clinical pathology,diagnosis and management of a variety of health and chiropractic problems. Health promotion and wellness: courses regarding special populations (pregnant patients, infants and children, women and the elderly) plus the role chiropractors play in public health, health promotion and wellness. Diagnostic imaging:the role of imaging technology in diagnostic decision-making and specific courses in normal radiographic anatomy, interpretation of advanced imaging and the diagnosis of chiropractic and medical pathologies. Clinical education: training in the university’s public clinic system and with chiropractors working in community-based private practices. In addition to the training in on-campus and related clinics, opportunities exist for students to rotate through facilities run by the Department of Defense (DoD) in military hospitals and clinics, at Veterans Administration (VA) clinics and hospital-based facilities and in clinics for underserved patients, that is, those with limited financial means to pay for care and little or no health insurance coverage [55] .
In comparison, medical school curricula have a similar breakdown but, compared with medical students, chiropractic students spend more hours in anatomy and physiology but fewer in public health. Both programs have similar hours in biochemistry, microbiology,and pathology. Chiropractic curricula provide relatively little instruction in pharmacology,critical care, and surgery but emphasize biomechanics, musculoskeletal function, and manual treatment methods. Medical education has more than twice as many hours in actual clinical experience but 1,000 fewer hours in didactic and workshop-like clinical courses [56] .A major distinction of training, however, are the two to four years of specialty residency training physicians pursue following acquisition of a medical degree. Comparable postgraduate training is available to only a tiny fraction of chiropractors.
There is no central agency that tracks the number of chiropractic doctors licensed nationally. Each state and territory have laws regarding licensure. There is no nationwide license issued. According to the Federation of Chiropractic Licensing Boards (FCLB), as of 2018 there are over 90,000 licenses issued for chiropractors in the 50 states, plus the United States territories of Puerto Rico and Virgin Islands [57] . Some jurisdictions do not report to the FCLB yearly and there are chiropractic doctors with licenses in more than one state so the exact number is not known with certainty.
Chiropractic is licensed and regulated in all 50 US states. Each state’s statutes and regulations determine the scope of clinical procedures chiropractors may legally perform in their respective jurisdictions. Broadly speaking, chiropractors take a patient’s history,perform and examine and arrive at a diagnosis.Providing care for musculoskeletal conditions using manipulation is within the legal scope of chiropractic practice in all states. Application of other procedures and modalities varies.With one exception previously noted, all states except New Mexico exclude prescribing drugs.Chiropractors in Oregon may perform minor surgery but all states preclude performing major surgery. Performing other diagnostic or therapeutic procedures, such as obstetrics(delivering babies), venipuncture for diagnostic purposes, use of physiotherapy modalities,dispensing of vitamin supplements or provision of nutritional advice to patients, vary from state to state [58] . As part of the examination process, chiropractors may order or perform diagnostic X-rays. They may order other imaging, such as MRI, CT, electrodiagnostic or laboratory tests, such as blood tests. In some jurisdictions, chiropractors are restricted to a narrow range of diagnoses, either spinal or broadly musculoskeletal. In others, they may treat or manage a wide or even unlimited number of conditions provided they do not use prohibited modalities or procedures, such as pharmaceutical products or performing surgery.In short, they may not practice medicine.
Regardless of the scope of practice granted by a state or the clinical orientation of a particular chiropractor, that is whether seeking to treat patients for general health or pain, the vast majority of patients seek care for a few specific conditions. In the general population,musculoskeletal conditions, particularly low back pain or back conditions and neck conditions, are the predominant reasons for seeking chiropractic care. In the pediatric population, the most common reason for attending chiropractic care was musculoskeletal conditions. More telling, only 3.1% of the general population sought chiropractic care for visceral/non-musculoskeletal conditions [59] .
The US-based International Chiropractors Association, in its description to the public regarding the educational courses taken by chiropractic students, refers to instruction in adjusting techniques, describing them as unique among healthcare professional education [60] .The American Chiropractic Association (ACA) describes spinal manipulation therapy (SMT or chiropractic adjustments, as previously noted) as one of the most common and wellknown therapeutic procedures performed by chiropractors. The ACA adds that the purpose of spinal manipulation is to restore joint mobility by manually applying a controlled force into joints that have become hypomobile or restricted in their movement [61] . According to the World Health Organization, chiropractors are a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health.There is an emphasis on manual techniques,including joint adjustment and/or manipulation with a particular focus on subluxations [62] .Similarly, the definition offered by the World Federation of Chiropractic includes reference to spinal adjustment and other joint and soft-tissue manipulation [63] .
It is clear from these definitions and descriptions that the spinal adjustment is central to the profession’s therapeutic approach and,further, that the adjustment is a type of manual therapy, specifically a form of SMT.
As described in the section on the profession’s Past, the spinal adjustment is one of many interventions within the scope of practice of chiropractors but it is the procedure most identified with the chiropractic profession.Medical and osteopathic physicians in the US are legally able to incorporate SMT in patient care and, in some states, depending on legislation and regulation, so can physical therapists and acupuncturists. In the United States, however, 94% of SMT is performed by chiropractors [64–65] .
The integral association between chiropractic care and SMT has been a benefit to the profession as the public expects chiropractors to be the most proficient and experienced in this approach. Chiropractic advocates feel that this level of training is a benefit to patients as they can be assured a high degree of expertise in adjusting skills or SMT when consulting a chiropractor. Other professions that may be legally able to offer SMT do not have the same degree of training.The association between SMT and chiropractic has, however, also led some to assume that it is the only tool chiropractors use. This may include the assumption that SMT or adjusting is a non-specific procedure applied absent performing an examination or arriving at a diagnosis. SMT is a signature procedure used by chiropractors, in a sense it is a modality or therapeutic procedure, but does not define the totality of what training and licensure permit [66–67] .
As noted in the portion of this chapter that discussed the profession’s history, specialized practice in radiology, orthopedics, sports,nutrition, and pediatrics developed. Residency programs also exist in sports medicine, primary spine care and hospital-based integrated clinical practice. The latter residency is available for 10 trainees per year with the Veterans Administration. The others mentioned are offered by some chiropractic degree granting institutions. The current practice of two of these special areas of practice are illustrated below.
A longstanding specialty in the profession is that of radiology which now incorporates training in other advanced imaging methods,such as MRI and, in some instances, diagnostic ultrasound. Following a three-year residency and passing an examination, chiropractors may recommend, supervise, and interpret radiologic studies as well as advanced imaging procedures. Those so trained may advise referring chiropractic colleagues on the necessity and appropriateness of radiologic services and whether to select or to avoid certain diagnostic or clinical procedures. The American Chiropractic Board of Radiology is the certifying agency for chiropractic radiologists [68] .
Gone are the days in the 1970s when pioneering sports chiropractor, Leroy Perry, DC,would see athlete patients against the advice of coaches, in secret. Officially appointed to the Olympic medical team for Antigua in the 1976 Olympics, Dr. Perry saw patients from other countries, including those from the US [69–70] .
In the modern era, chiropractors are increasingly becoming involved at all levels of sport from the club level to elite athlete.Both general practicing chiropractors and those with certificates of additional qualifications in sports medicine are more commonly engaged in the care of individual athletes and sporting teams. The American Chiropractic Board of Sports Physicians (ACBSP) produces Position Statements on important topics in sports medicine including concussion in athletics and participation examinations [71–72] . These position papers regarding the management of sport related topics are offered to the sports medicine community to guide and better define the role of qualifying doctors of chiropractic to make return-to-play decisions and clarify common concepts pertaining to evaluating and managing athletes.
There are doctors of chiropractic involved at elite levels of sport including leadership level of the world’s largest Olympic National Organizing Committee, the United States Olympic Committee (USOC). At the USOC the sports medicine division and clinics have been led by doctors of chiropractic with specialty certifications in sports medicine [73] .
Even with a high-level of representation in elite sport, doctors of chiropractic may have limits placed on their scope of practice in the management, evaluation and return to play decision-making by athletic associations or governmental bodies. Common areas of special access or restriction include sports related concussion and the participation examination.Rule-making bodies are recognizing those doctors of chiropractic with ACBSP sports medicine certificates of additional qualifications as having the appropriate clinical skills for recognition to provide advanced practices in sports medicine [74–75] .
There is increased interest to include conservative healthcare providers, including doctors of chiropractic, as a recognized part of the sports medicine team. The recognition of the determinate effects of opioid use in the sporting environment has served as a catalyst for sporting bodies to seek alternative non-pharmacological interventions, such as chiropractic and physical therapy, to manage athletes with pain [76] .Interventions for the management of pain in the athletic population using manual techniques should be expected to increase in the future. In order to continue the expansion of doctors of chiropractic at all levels of sport the profession must continue to increase sports medicine acumen and identify their role within the framework of the sports medicine environment they have available to them [77] .
Utilization of chiropractic within the professional sports world has also grown steadily. In 2002, 31% of National Football League teams used a chiropractor in an official capacity on their medical staff, and in 2006,a study analyzing Division I NCAA college athletes found that chiropractic usage was reported by 39% of respondents. Twelve years later, as of the 2014–2015 N FL season, all 32 N FL teams had an official team chiropractor;27 of 30 Major League Baseball teams had an official team chiropractor, and almost every NBA team has an official team chiropractor as well [78] .
According to the US Bureau of Labor Statistics (BLS), the median annual wage for chiropractors was $68,640 in May 2017 for those working in chiropractic offices and $78,710 for those working in the offices of medical physicians. The lowest 10% of chiropractors earned less than $34,550, and the highest 10% earned more than $144,730.Earnings vary with the chiropractor’s number of years in practice, geographic region of practice and hours worked. Geographic variations figure significantly in the earning capacity as illustrated in the following table (Table 2–2) [79] .
Like most businesses, chiropractors tend to earn more as a patient base is built and become owners of, or partners in, a practice. BLS calculation of national median wages for chiropractors in 2012 was $79,550, considerably more than the most recent figure of $71,410.80.The experience of those in practice for many years, however, is that reimbursement for services, or ability to bill for services, has fallen for most types of payment models, particularly in what is referred to as fee-for-service.
Employment of chiropractors is projected to grow 12% from 2016 to 2026, faster than the average for all occupations. According to the BLS, people across all age groups are increasingly becoming interested in integrative or complementary healthcare as a way to treat pain and improve overall wellness. Chiropractic care is appealing to patients because chiropractors use nonsurgical methods of treatment and do not prescribe drugs [80] .
Before discussing how chiropractic doctors are reimbursed for their services, it is helpful to summarize the healthcare system in the United States. It is fractured into multiple reimbursement models, each of which differs as to whether chiropractic care is covered and,if it is, to what extent. Table 2–3 illustrates the most common payment models and Table 2–4 is a summary of whether chiropractic care is considered and/or reimbursed under each model.
There are 28 million US residents who do not fit any of the categories noted in Table 2–3. They tend to be male, 19 to 64 years old,have less than a high school education and/or have lower incomes [81–82] . Private insurance is available to these residents but, due to high cost of individual plans, many have no meaningful healthcare insurance whatsoever.
Healthcare practitioners, pharmaceutical companies, hospitals and related service providers are paid relatively well when new technologies, advanced procedures or novel medications are involved. Time spent to talk to patients or deliver low technology, hands on, direct care, is seldom well-reimbursed.Chiropractic care generally fits this latter category. Although chiropractic doctors earn an above average income, as previously noted,medical physicians and other healthcare practitioners typically earn more.
Table 2–2 Top Paying States for this Occupation
Table 2–3 Varieties of Healthcare System
Table 2–4 Chiropractic Coverage of Varieties of Healthcare System
Chiropractic care is reimbursed by most insurance schemes but at varying levels of payment, many of which are relatively poor when compared with comparable services provided by medical physicians or physical therapists.
As previously noted, chiropractic doctors in the US tend to practice solo or in small groups with other chiropractors. This is gradually changing, however, with a minority but growing trend of practices integrating with medical and other healthcare practitioners [83] . According to William Morgan, DC, current president of Parker University, the trend is for more integration of chiropractors into medical clinics and hospitals, and for more physicians to work within chiropractic offices. Morgan adds,“The Department of Defense and the Veterans Administration are both following directives to find safe alternatives to opiates and pain procedures. As a result, they are gradually expanding the chiropractic benefit [84] ”.
Indeed, hospital-based academic medical centers including, but not limited to, those at Dartmouth College, Duke University,University of Texas, Austin, and the Medical College of Wisconsin have chiropractors on staff at outpatient clinics. Other hospital based medical centers and healthcare systems,such as Wisconsin-based Aurora Healthcare,Beth Israel Deaconess Hospital, Plymouth,Massachusetts and the Lehigh Valley Health Network in Pennsylvania, have chiropractors on staff. Chiropractic in-patient care is much less common but in at least one instance, Mercy Hospital St. Louis, chiropractors are part of integrative health offerings for patients within a hospital environment.
In response to Public Law 107–135, the Veterans Health Administration established chiropractic clinics at 26 Veterans Administration(VA) facilities beginning late 2004 [85] . Since that time, the use of chiropractic care and the chiropractic workforce in VA have grown without further mandate; expansion or development seen from 2005 through 2015 represents the organic growth of this new service. This growth may be explained by multiple factors including patient demand, patient access and the successful clinical outcomes of VA chiropractors.
Because little is known about the introduction of chiropractic services to other US hospital systems, there are no obvious comparators against which to gauge the manner, rate, and extent of penetration, of these services in VA.The fact that these services have expanded consistently and substantially beyond the minimum mandated level may suggest that some VA decision-makers perceive value in providing chiropractic care. There are now approximately 200 chiropractors employed by the VA which is most probably the largest single employer of chiropractors in the US; a definitive statement on this matter is not possible due to a lack of centralized data on employment. The VA also offers a one-year chiropractic residency position at 10 of its hospital-based clinics.Five of these sites are the only CCE accredited residency programs in the US and the other five are expected to apply for such by the end of 2020.
Active military personnel in the US also have access to chiropractic care since 1995,although employment of chiropractors is not directly with the Department of Defense(DoD) or specific branch of the military. Rather, employment may be arranged through contracting agencies, not directly through the various branches of the military. As such, there is no central repository of information regarding employment or utilization although research has been conducted to assess various aspects of care with the DoD [86] .
US employers, particularly those with large numbers of employees, have long offered on site healthcare services. A full one-third (33%) of US employers with 5,000 or more employees offer general medical worksite clinics in 2017,up from 24% in 2012. Employers are starting to offer on-site wellness and healthcare services as well. As these clinics are established, employees are asking specifically for chiropractic care.Patients, healthcare administrators and medical physicians recognize the value of adding chiropractic into multidisciplinary clinics [87] .
On-site or near-site clinics, often referred to as health and wellness centers, typically offer numerous services to employees including first aid, occupational health, acute, primary,specialty, condition management, wellness and ancillary services, and increasingly, chiropractic care. Healthcare costs for employers were calculated to reach $15,000 per employee in 2019. Additionally, direct and indirect costs associated with low back pain, a malady often managed by chiropractors, are estimated between $85 billion and $238 billion, and expenditures for back pain are rising more quickly than overall health expenditures. To help stem that growth, as many as 65% of large corporations are expected to offer company healthcare clinics by 2020.
According to a recent study conducted by the National Association of Worksite Health Centers, the majority of employers surveyed said their employees have expressed interest in chiropractic services at their clinics. Many worksite clinics are now offering integrative primary care services, including chiropractic care, as part of their on-site corporate clinic [88] .
In the past 10 years, the trend of chiropractors at onsite clinics has grown. Starting with a few individuals working at Silicon Valley technology companies and Midwest manufacturing sites,there are now several hundred chiropractors working in the employer-driven model. One of the key drivers has been large medical group vendors hiring chiropractors as part of their teams such as Crossover Health, Premise,Stanford, and One Medical Group [89] . One such clinic, affiliated with California-based Crossover Health, found that an integrated physical medicine clinic, including chiropractors,physical therapists, acupuncturists and medical physicians, resulted in favorable clinical outcomes, received fewer opioid prescriptions and had high patient satisfaction, all at a reduced cost compared to what can be described as usual care, i.e., non-integrated care [90] .
Employer-sponsored on-site clinics are unique and based on the employers’ specific needs and resources. As an example, a large Silicon Valley employer has what is considered the first fully integrated on-site holistic medical home. A medical home is a model of primary care that is patient-centered, comprehensive,team-based, coordinated, accessible and focused on quality and safety [91] . In addition to multiple healthcare services the facility also has a gym.In this on-site facility, chiropractic care is a part of the integrated front-line healthcare team, not merely a complementary, alternative option.According to a chiropractor who has worked at a Kansas City on-site clinic since 2009,medical providers in these integrated clinics have learned how chiropractic care can benefit patients with neuro-musculoskeletal conditions and complaints and actively refer and involve chiropractic in treating the patients [92] . A 2013 study suggests that chiropractic services offered at on-site clinics may promote lower utilization of costly healthcare services, while improving musculoskeletal function [93] .
Crossover Health and similar organizations have organized clinics that include chiropractic care for relatively smaller companies that do not have the option of operating a comprehensive,on-site clinic. This model is the near-site or shared-site clinic. A company can share costs with other similarly sized companies and offer employees attractive healthcare benefit without the overhead cost or providing the space on their campus to build the clinic [92] .
In either scenario, whether on-site or shared-site models, employers are learning that corporate health and wellness clinics help with the retention of employees. Investing in the well-being of employees with workplace health and wellness benefits can help attract and retain employees — clinics are often viewed as the most popular benefit by workers [91] .
Among those who saw a health care professional for neck or back pain over a 12-month period, 62% saw a medical doctor and 53% saw a chiropractor. About one-third saw a physical therapist (34%) or massage therapist (34%) for care [94] . A 2014 market research study gauged consumer appetite for chiropractic care. In 1,000 consumers surveyed,1 in 10 with chronic pain reported having back and/or neck surgery, 42.3% said surgery did not solve their pain, 65.8% of chronic pain respondents said they felt hopeless and 71.8%said they would consult with a chiropractor [95] .
In the Gallup-Palmer College of Chiropractic Annual Report, Managing Neck and Back Pain in America, patients who saw a chiropractor for significant neck or back pain over a 12-month period say their chiropractor often listens (93%), provides convenient, quick access to care(93%), demonstrates care/compassion (91%) and explains things well (88%) — and 90% of chiropractic patients say that their chiropractor spends the right amount of time with them.These figures are higher than those reported by patients who consulted physical therapists,generally by 5% on the same parameters, and superior to the ratings of medical physicians,generally by a 20% margin [94] .
The Consumer Assessment of Healthcare Providers and Systems (CAHPS ® ) program is a multi-year initiative of the Agency for Healthcare Research and Quality to develop and promote the use of standardized surveys of consumers’ experiences with health care.Fulcrum Health Inc., a regional chiropractic healthcare network, uses Press Ganey Associates to administer the Clinician and Group (CG CAHPS) survey type on a regular basis to assess patients’ experiences with health care providers and staff throughout the offices within the network. Press Ganey Associates is a 2019 Merit-based Incentive Payment System(MIPS) approved survey vendor. Fulcrum’s provider network is a multi-year recipient of Press Ganey’s Guardian of Excellence Award.This award honors those who have reached the 95 th percentile for patient experience,engagement or clinical quality performance.Guardian of Excellence Awards are awarded annually to those who sustain performance in the top 5% for each reporting period for the award year. This distinction demonstrates the network’s ability to excel in measures of patient experience when comparted to health care providers and medical staff among other medical specialties. In a recent survey, the overall percentile ranking for chiropractic services is 96.9, a figure that fares exceptionally well compared to medical specialties [96] . Simply stated, patient perceptions of the chiropractic profession are quite favorable.
An overview the profession’s development of research capacity through the 1990s was covered earlier in this chapter. At present, there are a few additional chiropractic journals that have come into existence but perhaps a more fundamental change is that chiropractic doctors now publish work in a broad number of medical scientific journals. Chiropractic researchers now routinely participate in making presentations at a variety of medical and scientific conferences in addition to those that are chiropracticspecific. There are also clinical and research collaborations between chiropractic colleges and academic medical institutions as well as similar ventures between chiropractors and hospitals,government health plans agencies. Changes such as these are due, in part, to an increase in government and private research dollars awarded to chiropractors and chiropractic institutions compared to that which historically occurred.Unfortunately, overall US government funding has declined for all types of research, pitting smaller chiropractic training programs against larger, more well-established, research-oriented universities and institutions. The latter are more likely to receive the benefits of grant money,leaving the chiropractic institutional funding at relatively low levels.
Although the profession began in the US,there are more chiropractic training programs outside of the United States than inside the US today [97] . The World Federation of Chiropractic(WFC) is the global voice of the chiropractic profession and has national association members in over 90 countries globally. In terms of distribution, it remains the case that over 80%of the profession is located in North America,particularly the United States and Canada,where over 90,000 chiropractors hold licenses to practice. This inequity in the provision of chiropractic services sees many countries with very sparse numbers or without representation at all. However, projected numbers are set to rise with the founding of new educational programs in Europe, Asia, Latin America and the Eastern Mediterranean regions.
Scope of practice varies from country to country and within countries. Some jurisdictions permit a wide scope, including rights to prescribe medication and refer for advanced imaging.In others, such as Austria and the Republic of Korea, chiropractic remains technically illegal,with chiropractors vulnerable to prosecution.Chiropractic is recognized as a health profession by the World Health Organization (WHO);indeed, the WFC has been a non-state actor in official relations with WHO since 1997 and remains the only chiropractic non-governmental organization afforded this status [98] .