State Examining Boards
Referring patients for Magnetic Resonance Imaging is not within the scope of practice of chiropractors in the State of Georgia.
The question has arisen as to whether referring patients for Magnetic Resonance Imaging (MRI) is within the scope of practice of chiropractors in the State of Georgia. The scope of practice of chiropractic is defined in O.C.G.A. §§ 43-9-16 and 43-9-1(2).
As was noted in an opinion rendered by the Attorney General in 1984, 1984 Op. Att'y Gen. 84-53, the definition of the practice of medicine in the State of Georgia contained in O.C.G.A. § 43-34-20 has been broadly construed by the courts to include every branch of the healing arts. See Georgia Ass'n of Osteopathic Physicians and Surgeons v. Allen, 31 F. Supp. 206 (M.D. Ga. 1940); Mabry v. State Bd. of Examiners in Optometry, 190 Ga. 751 (1940). The opinion went on to conclude, however, that "[s]ince the licensed practice of chiropractic is an exception to the Medical Practice Act, a practitioner of chiropractic [*2] may perform those limited functions specified in O.C.G.A. Ch. 43-9 which would otherwise be construed as the practice of medicine." 1984 Op. Att'y Gen. 84-53, p. 114.
The 1984 opinion addressed several questions relating to whether certain equipment and procedures were authorized by the Chiropractic Practice Act for use by licensees. The test set forth for making this determination was whether:
1. [T]he equipment and procedures are utilized to make an adjustment, and
2. if so, whether their use conforms with specific chiropractic methods.
1984 Op. Att'y Gen. 84-53, p. 117.
Since the 1984 opinion was issued, the scope of chiropractic has been expanded by the Legislature to include certain equipment and procedures previously not authorized. For example, O.C.G.A. § 43-9-16(b) now provides that chiropractors who have complied with O.C.G.A. T. 43, Ch. 9 may use certain electrical therapeutic modalities in conjunction with adjustments of spinal structures. It appears that the test for whether a procedure or the use of equipment is now authorized is whether it meets the test of the 1984 opinion or whether it is specifically authorized by some other statutory provision contained [*3] in O.C.G.A. T. 43, Ch. 9. Based on this analysis, it appears that a referral of a patient by a chiropractor for an MRI is not within the scope of chiropractic practice.
MRI is a diagnostic tool which can provide images of internal structures without the use of radiation. Instead:
The head or body is placed in a strong magnetic field to align the hydrogen protons in the direction of the field. An additional, specific radiofrequency pulse then 'flips' the aligned intra- and extracellular protons into a higher energy state. When the radiopulse is turned off, the protons 'relax' back into their original alignment, and the energy emitted gives information on the chemical makeup of the tissue.
The Merck Manual 1323 (15th ed. 1987).
As noted above, MRI is a diagnostic tool rather than a therapeutic one, and, therefore, is not utilized to make an adjustment. Thus, it does not meet the 1984 test. The next question which must be asked is whether the referral of a patient for an MRI is specifically authorized by some other statutory provision. After a review of O.C.G.A. §§ 43-9-16 and 43-9-1(2), it appears that there is no such authorization. Official Code of Georgia Annotated [*4] § 43-9-16(b) and (c), which authorize the use of electric therapeutic modalities such as therapeutic ultrasound, do not authorize the use of MRI since the procedure is not a therapeutic modality.
Official Code of Georgia Annotated § 43-9-1(2) specifically defines "Chiropractic" as "the adjustment of the articulation of the human body, including ilium, sacrum, and coccyx, and the use of electric X-ray photography, provided that the X-ray shall not be used for therapeutical purposes." X-rays, or roentgen rays, are defined as:
[E]lectromagnetic vibrations of short wavelengths (from 5 A.U. down) or corresponding quanta (wave mechanics) that are produced when electrons moving at high velocity impinge on various substances, especially the heavy metals. . . . They are able to penetrate most substances to some extent, some much more readily than others, and to affect a photographic plate. These qualities make it possible to use them in taking roentgenograms of various parts of the body.
The Sloan-Dorland Annotated Medical-Legal Dictionary 604 (1987).
The technologies of X-rays and MRI are quite different. An X-ray utilizes ionizing radiation whereas an MRI utilizes a magnetic [*5] field. The authority to use X-ray photography for diagnostic purposes, therefore, is not broad enough to include the use of MRI. When a statute expressly provides for certain matters, items which are not included are excluded by implication. Bailey v. Lumpkin, 1 Ga. 392, 395 (1846).
For the reasons stated above, it is my official opinion that referring patients for Magnetic Resonance Imaging is not within the scope of practice of chiropractors in the State of Georgia.
THOMAS K. BOND,