Continuing Education for the Chiropractic Profession: A Cross-Sectional Study Analyzing Potential Barriers to Future Chiropractic Academic and Research Development

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Smith, Christopher A. Malaya, Jeffrey A. King, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6866581/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Aug, 2025 Read the published version in Chiropractic & Manual Therapies → Version 1 posted 9 You are reading this latest preprint version Abstract Background Continuing education (CE) for chiropractors is mandated by state licensing boards to ensure ongoing learning and to maintain professional excellence. While incorporating research into CE programs is crucial for practitioners to remain dynamic and evidence-based, conducting research and academic pursuits is necessary for further development of the profession. We aimed to determine how many states permit chiropractors (DC’s) to earn CE credits for research and academic activities and compare this to the allowances for medical doctors (MD’s), osteopaths (DO’s), physical therapists (PT’s), and athletic trainers (AT’s). Methods Internet searches of publicly available state board websites for each profession was undertaken with a cross-sectional study design between 12/19/2024 and 03/01/2025. Data extraction focused on whether CE was granted for research (publication and/or peer review) as well as academic pursuits (higher education and/or CE instruction). Descriptive statistics determined the frequency of states allowing CE while Fisher’s Exact test and one-way ANOVA was performed to compare states granting CE credits for research and teaching as well as comparisons among the professions. Results Only 16 US states allow DC’s to claim research activities for CE credit while 50% allow teaching for CE credit. This is significantly lower (p < 0.001) than AT’s, DO’s, and MD’s where teaching and research activities are accepted for CE credit in all states. Conclusions Precluding research and higher-education teaching opportunities for CE presents a potential barrier to chiropractic academic and research development at present and in the future. continuing education chiropractic licensure research teaching post-graduate Figures Figure 1 Figure 2 Introduction In the United States (US), chiropractic licensure is overseen at the state level with 52 unique and individual sets of statutes and administrative rules (i.e., 50 states, District of Columbia, and territory of Puerto Rico; hereby all referred to as ‘state(s)’) [ 1 ]. Maintenance of licensure is dependent on licensed chiropractors (DC’s) taking approved continuing education (CE) courses and or completing approved activities to obtain the required CE hours or credits within the renewal period, typically over a 1–2 year period, depending on the state [ 1 ]. If the CE requirements are not successfully achieved within the allotted time frame, licensees may face suspension, revocation, penalties, or fines [ 1 ]. Approval of chiropractic CE hours or credits are dependent on a range of requirements which can and do vary by state. Typically, these requirements focus on 1) the host of the course being on a list of approved providers, 2) the speaker or instructor having the experience, credentials, and knowledge to teach the course, 3) the content being related to the practice of chiropractic, and 4) the attendees achieving specific learning objectives [ 2 ]. Depending on state rules and laws, CE hours or credits can be obtained, in person, with distance learning, or through teaching CE courses [ 3 ]. However, many states require chiropractic CE credits to be approved by the Council of Chiropractic Education (CCE) or Providers of Approved Chiropractic Education (PACE). Medical doctors (MD’s) and osteopathic doctors (DO’s) undergo rigorous residency training upon the completion of their degree programs wherein they are able to accumulate CE credit for all or part of their training hours [ 4 , 5 ]. Conversely, chiropractors have access to optional residency programs, but currently only four states accept residencies or fellowships for CE credit [ 6 ], a demonstration of how the chiropractic profession is trailing behind other medical professions. Stuber et al. [ 3 ] found that the majority of chiropractors have interest in completing further training, such as a Master’s degree, particularly if the academic program would count towards continuing education credits. This implies that chiropractors may perceive a barrier to further academic pursuits, including research, due in part to the lack of understanding and acceptance by their state licensing board for such professional development. While there has been a substantial growth in the number and quality of chiropractic research publications over the past 50 years [ 7 ], there is a shortage of chiropractic clinicians who have the experience and training to conduct clinical research [ 8 ]. Thus, with the current barriers to CE regarding academic and research pursuits, the profession’s growth capacity may be further impeded if an academic/research CE barrier is verified. It is unclear how CE credits for research and higher-education teaching activities in the chiropractic profession compare to other similar professions, including MD’s, DO’s, physical therapists (PT’s), and athletic trainers (AT’s). These professions, other than PT’s, have national standards for CE credits which include recognizing research and academic teaching as qualified CE [ 4 , 5 , 9 ]. This appears to be in line with the National Academy of Medicine’s purpose of continuing medical education, which is to both reinforce current practice as well as translate new knowledge into practice [ 10 ]. However, a lack of similar alignment of the chiropractic profession could significantly impede knowledge development and adoption of evidence-based guidelines. Therefore, the aim of this study was to describe which states allow chiropractors to claim CE credits/hours through higher education teaching, publication, or participation in the peer review process. The hypothesis was that within the chiropractic profession fewer states would recognize CE for research or higher-education teaching activities. Methods This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [ 11 ]. This study did not qualify as human subject research and, therefore, did not require Institutional Review Board (IRB) approval [ 12 ]. The cross-sectional design of this study was based on and modeled from prior research that examined chiropractic state board websites for similar information [ 6 , 13 – 15 ]. Data Recording, Organization, and Validation Data were recorded in an Excel spreadsheet (Microsoft Corp, Redmond, WA). Between December 19th, 2024 and March 1st, 2025, five investigators (SS, DLS, CAM, JAK, NDS) recorded CE and licensure-related data from chiropractic board and licensure websites for all 50 states, the District of Columbia, and the US territory of Puerto Rico. The official website for each chiropractic board and/or state legislative website was accessed and reviewed. From the homepage, links to CE, license renewal, and frequently asked question (FAQ) sections (if available) were searched manually for content related to research and academic credit in addition to other variables (see additional files). Administrative code where available was also queried for descriptions related to CE credit offered for research and academic hours. Variables entered into the spreadsheet included: official name of the Board; Board statute oversight; process for rule change; CE hours required per cycle; renewal term in years; per year equivalent number of CE hours; whether CE must be board approved or CCE/PACE approved; whether CE courses were chiropractic specific or only to be taught by chiropractors; PACE allowed; number of credits allowed for online CE; percentage of CE credits allowed to be taken online; whether research related activities (manuscript publication and/or scientific peer-review) count toward CE; whether academic related activities (university level teaching or CE instruction) count toward CE; allowed CE topics; whether academic or research related CE credit information was found in FAQ sections. For the comparator professions (MD’s, DO’s, AT’s, and PT’s) state board required credit hours were obtained from each state’s legislative website for each profession and documented within a spreadsheet. Accepted CE credit types are nationally standardized for MD’s, DO’s, and AT’s through the Accreditation Council for Continuing Medical Education and American Medical Association (ACCME and AMA; accme.org, ama.org), American Osteopathic Association (AOA; osteopathic.org) and Board of Certification for Athletic Trainers (BOC-ATC; BOCATC.org) respectively. These national standardized CE requirements include varying categories of CE such as Physician’s recognition awards (PRA) Category I/II (MD’s), Category Ia/Ib/IIa/IIb (DO’s), and Category A-D (AT’s). For PT’s, accepted CE credit types differ at the state level, similar to chiropractic. The official website for each physical therapy board and/or state legislative website was accessed and reviewed for allowance of research activities or teaching as accepted forms of CE credit was documented. The 5 investigators served as the initial data extractor for approximately 10 states each. Following initial data extraction, each investigator verified the data extraction of a fellow investigator. Any ambiguities or discrepancies in data extraction that could not be resolved between two investigators were adjudicated by a 3rd investigator. These ambiguities were uncommon and usually involved information that was not provided in the CE portion of the state chiropractic board’s website. For pragmatic reasons, when no explicit information regarding academic or research related CE could be found on the board’s website or through administrative code, that state was classified as offering no CE for those activities. Data extraction noted whether research-related activities (e.g., publishing in peer reviewed journals or performing peer review) and/or academic related activities (e.g., higher-education instructor/professor, verified participation as an instructor of CE) counted toward CE credit requirements. Data Analysis Data was exported into JMP 18 Pro for statistical analysis. Descriptive statistics were determined. Fisher’s Exact test was performed to compare the number of states granting CE credits for research and teaching and One-way ANOVA was performed to compare among professions with Tukey’s HSD post hoc comparison performed for each pair when appropriate. An a priori value of ɑ<0.05 was set for significance. Results Information regarding the specific profession’s acceptance of research and academic work for CE credit and state required CE hours are presented in Additional Files 1–3. A full representation of additional data obtained for DC’s (e.g., board rules, regulations, specific state legislative requirements) is presented in Additional File 4. Fisher’s Exact test by profession demonstrated that the number of states allowing CE credit for performance of research were different for DC’s compared to AT’s, DO’s, MD’s, and PT’s with 69.2% not allowing research CE ( p < 0.001; Fig. 1 ). The PT profession was similarly lower than AT’s, DO’s, and MD’s with 12% of states not allowing research CE ( p = 0.012). States that allow for CE credit for performance of university level teaching or instruction of CE courses showed the DC profession was lower from all of the other professions (AT’s, DO’s, MD’s, and PT’s) with only 50% allowing for CE for teaching ( p < 0.001; Fig. 1 ). CE credit can be obtained via scientific publication, scientific peer review, university level teaching, and seminar instruction for AT’s, MD’s, and DO’s [ 4 , 5 , 9 ]. For DC’s, only 2 states, Illinois and Kansas, awarded CE credit for all four of these categories, while 19 states did not award CE credits for any of these categories (Fig. 2 ). The PT profession was not separated into specific research or academic categories, and is therefore not included within the below figure. An ANOVA comparing the annual CE hours required by each profession demonstrated differences between the five professions observed ( p < 0.001). Specifically, the PT profession had the lowest annual CE requirement with an average of 14.5 credits. PT’s were lower than DC’s (p = 0.010) and the other 3 professions (AT, DO, MD; p < 0.001). DC’s were similarly lower than these three professions (AT, DO, MD; p < 0.001) with an average of 18.5 CEs required annually. There were no other differences of annual CE hours required by the remaining professions, with AT’s, MD’s, and DO’s requiring an average of 25, 26.7, and 27.7 CE hours, respectively (Table 1 ). Table 1 Continuing education credits by profession Profession Mean CE (95% CI) % States Allow Research CE % States Allow Teaching CE AT 25 (22.9, 27.1) 100 100 DC 18.5 (16.3, 20.6) 30.8 50.0 PT* 14.5 (12.3, 16.6) 88.0 92.0 DO* 27.7 (25.4, 29.9) 100 100 MD* 26.7 (24.4, 28.9) 100 100 Discussion The chiropractic profession was found to have the least incentives to engage in research and higher-education teaching activities for CE credit relative to the other health professions. All states allow AT’s, DO’s, and MD’s to use research and higher-education teaching towards their customary CE requirements. PT’s were found to require the least CE hours for re-licensure, followed by chiropractors, but 92% of states allow PT’s to perform research or academic-related CE hours. Previous survey research [ 3 ] found that DC’s have interest in pursuing further academic and research related interests, particularly if that higher education program would count towards CE. We have verified that an academic/research CE barrier does exist for DC’s, but not for the other professions. We infer that this barrier is likely hindering the research capacity of the profession which is further constrained by the existing shortage of DC’s who have the requisite experience and training to conduct clinical research [ 8 ]. While there has been substantial growth in the number and quality of chiropractic research publications over time [ 7 ], the fact that the majority of states do not allow research activities to count toward CE is an obstacle to the growth of future research. With the rapid proliferation of chiropractic and health literature, it is more important than ever for chiropractors to stay up-to-date with the latest research. With roughly 82% of chiropractors working within a chiropractic office [ 16 ], offering CE credit for the conduct of and participation in research studies would provide a facile means towards additional, clinician-focused projects, as well as further practice-based research and training opportunities. CE that is grounded in evidence-based data is a means to provide skill and knowledge promotion among practicing clinicians [ 17 ]. However, Lyu & Li [ 17 ] also suggested that the large, increasing volume of medical information may overload and confuse providers, particularly those that are not able to distinguish between reliable and poor-quality evidence. By engaging with CE that incorporates high-quality evidence, clinical practice guidelines, and systematic reviews, medical providers can update their care paradigms and improve patient outcomes [ 17 ]; indeed, in medical education, this has shown demonstrable improvements in both physician performance and patient health outcomes [ 18 ]. The above data suggests that allowing CE for activities that contribute to the research and academic pursuits of DC’s will have a three-fold positive impact - it will contribute to the breadth of CE opportunities, facilitate evidence-informed practices in clinicians, all while simultaneously bolstering chiropractic academic and research development. As such, we propose that all states allow research and higher-education teaching activities for chiropractic CE credit to be consistent with that of AT’s, DO’s, and MD’s CE requirements. Limitations While we had at least two reviewers examine regulatory websites for each state it is possible that we misclassified states in terms of allowing CE credit for research or academic activities. Many state board websites did not provide specific information on CE for these activities and unless explicitly mentioned, we classified them as not allowing CE. Additionally, there was inconsistency where such information was located on state board websites. Some states such as Ohio offer information regarding obtaining academic CE in a FAQ on their website. Other states provide such information within their regulatory language, while many states simply did not address research or academic CE. Conclusion Chiropractors have significantly less opportunity to claim CE credit for research and higher-academic pursuits compared to AT’s, PT’s, MD’s, and DO’s. Precluding research and higher-education teaching opportunities for CE presents a barrier to the conduct and development of chiropractic research at present and in the future. State boards of chiropractic that do not currently allow for such CE opportunities are urged to promptly reconsider how both research and higher-education pursuits can magnify and advance the profession with vital knowledge development and adoption of evidence-based guidelines. Declarations Ethics approval and consent to participate This study did not qualify as human subject research and, therefore, did not require Institutional Review Board (IRB) approval [12]. Consent for publication N/A. Availability of data and materials The datasets generated during and/or analysed during the current study are provided as supplementary files. Competing interests DLS : post-graduate online instructor for chirocredit.com, an online continuing education provider; JAK: occasional post-graduate instructor for CE programs. Funding No funding was obtained for this study. Authors’ contributions All authors made significant contributions to the study design and interpretation of data. SS and NDS provided the idea for the research, planned the methods, collected data, analyzed data and drafted and reviewed the manuscript; DLS, CAM and JAK planned the methods, collected data, and drafted and reviewed the manuscript. All authors have read and approved the final version of the manuscript and agree with the order of presentation of the authors. Acknowledgements None References FCLB. Chiropractic Regulatory Boards: Federation of Chiropractic Licensing Boards. 2025 [Available from: https://fclb.org/chiropractic-licensing-boards.php FCLB. Model Practice Act for Chiropractic Regulation 2021 [Available from: https://fclb.org/files/publications/1638890937_fclb-model-practice-act.pdf Stuber KJ, Grod JP, Smith DL, Powers P. An online survey of chiropractors' opinions of Continuing Education. Chiropr Osteopat. 2005;13:22. AMA. The AMA Physician’s Recognition Award and credit system: American Medical Association. 2017 [Available from: https://www.ama-assn.org/system/files/pra-booklet.pdf AOA. 2025–2027 Certification CME Cycle CME Category & Activity Descriptions: American Osteopathic Association. 2025 [Available from: https://osteopathic.org/index.php?aam-media=/wp-content/uploads/CME-Activity-Descriptions.pdf Schut SM, Cole Ii MR, Price MR, Bucki FM, McCann BH, Corcoran KL. Chiropractic residencies and fellowships as continuing education: a review of chiropractic state boards policies. BMC Med Educ. 2024;24(1):1338. Trager RJ, Bejarano G, Perfecto RT, Blackwood ER, Goertz CM. Chiropractic and Spinal Manipulation: A Review of Research Trends, Evidence Gaps, and Guideline Recommendations. J Clin Med. 2024;13:19. Sawyer C, Haas M, Nelson C, Elkington W. Clinical research within the chiropractic profession: status, needs and recommendations. J Manipulative Physiol Ther. 1997;20(3):169–78. BOC-ATC. Certification Maintenance Requirements For Certified Athletic Trainers Reporting Period Ending December 31, 2025: Board of Certification for the Athletic Trainer; 2024 [Available from: https://bocatc.org/athletic-trainer-life-cycle/ The National Academies. Redesigning Continuing Education in the Health Professions 2010 [Available from: https://nap.nationalacademies.org/catalog/12704/redesigning-continuing-education-in-the-health-professions von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806–8. HHS. Human Subject Regulations Decision Charts. 2018 Requirements 2018 [Available from: https://www.hhs.gov/ohrp/regulations-and-policy/decision-charts-2018/index.html Cole MR 2nd, Mattox R, Tobiczyk H, Napuli JG, Bucki F. Telehealth Content From United States Chiropractic State Board Websites Compared With Medical and Physical Therapy Websites During the Early Stages of the COVID-19 Pandemic. J Chiropr Med. 2022;21(3):168–76. Neff SM, Roecker CB, Okamoto CS, Holguin SL, Napuli JG, Mattox R, et al. Guidance concerning chiropractic practice in response to COVID-19 in the U.S.: a summary of state regulators' web-based information. Chiropr Man Th. 2020;28(1):44. Daniels CJ, Paris D, Mooring S, Anderson K, Crivellii L, Muth C. United States guidance on informed consent for chiropractors: a review of state regulator websites. J Contemp Chiropr. 2025;8(1):135–43. NBCE. Practice Analysis of Chiropractic. 2025: National Board of Chiropractic Examiners; 2025 [Available from: https://www.nbce.org/practice-analysis-of-chiropractic-2025-2/ Lyu X, Li S. Professional medical education approaches: mobilizing evidence for clinicians. Front Med (Lausanne). 2023;10:1071545. Cervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes: an updated synthesis of systematic reviews. J Contin Educ Health Prof. 2015;35(2):131–8. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1.xlsx AdditionalFile2.xlsx AdditionalFile3.xlsx AdditionalFile4.xlsx Cite Share Download PDF Status: Published Journal Publication published 21 Aug, 2025 Read the published version in Chiropractic & Manual Therapies → Version 1 posted Editorial decision: Revision requested 02 Jul, 2025 Reviews received at journal 27 Jun, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviews received at journal 17 Jun, 2025 Reviewers agreed at journal 17 Jun, 2025 Reviewers invited by journal 17 Jun, 2025 Editor assigned by journal 16 Jun, 2025 Submission checks completed at journal 13 Jun, 2025 First submitted to journal 10 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Smith","email":"","orcid":"","institution":"Miami University","correspondingAuthor":false,"prefix":"","firstName":"Dean","middleName":"L.","lastName":"Smith","suffix":""},{"id":472768324,"identity":"ea0a449f-214c-407d-909e-709e4e9ddc8f","order_by":2,"name":"Christopher A. Malaya","email":"","orcid":"","institution":"Parker University","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"A.","lastName":"Malaya","suffix":""},{"id":472768325,"identity":"db6a3e35-ff3e-4921-8857-ad7c9514e7fe","order_by":3,"name":"Jeffrey A. King","email":"","orcid":"","institution":"Medical College of Wisconsin","correspondingAuthor":false,"prefix":"","firstName":"Jeffrey","middleName":"A.","lastName":"King","suffix":""},{"id":472768326,"identity":"ae3e2bdf-e406-4a40-a855-fcc2a0713e6d","order_by":4,"name":"Nathan D. Schilaty","email":"","orcid":"","institution":"University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Nathan","middleName":"D.","lastName":"Schilaty","suffix":""}],"badges":[],"createdAt":"2025-06-10 23:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6866581/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6866581/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12998-025-00596-x","type":"published","date":"2025-08-21T16:29:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84977084,"identity":"237f3f94-3cf6-47ca-bb40-ead367250826","added_by":"auto","created_at":"2025-06-19 12:36:30","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":60819,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of states awarding CE credits for teaching and research by profession.\u003c/p\u003e\n\u003cp\u003e*excluded states that have no CE requirements (MD/DO: CO, IN, MT, SD, NY; PT: ME) or laws could not be found (PT: PR)\u003c/p\u003e\n\u003cp\u003e**Excluded states that have no CE requirements MD/DO: CO, IN, MT, SD, NY; PT: ME, PR (specified laws could not be found). AT = athletic training; DC = chiropractic; PT = physical therapy; DO = osteopathic; MD = medicine.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6866581/v1/188611464029ab396e3f618a.jpeg"},{"id":84977088,"identity":"660b77da-4b0b-4b4f-8279-c6da324b490d","added_by":"auto","created_at":"2025-06-19 12:36:30","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":157710,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of categories in research and teaching awarded CE by state and profession.\u003c/p\u003e\n\u003cp\u003e*excluded states that have no CE requirements (MD/DO: CO, IN, MT, SD, NY; PT: ME) or laws could not be found (PT: PR)\u003c/p\u003e\n\u003cp\u003eThe location of the current accredited colleges of chiropractic are designated with a star.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6866581/v1/3e0d655e8d6a2da726bb940f.jpeg"},{"id":89847722,"identity":"38228c9b-95c7-4cc7-9201-febc1ea2340f","added_by":"auto","created_at":"2025-08-25 16:44:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":741444,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6866581/v1/5f0ee632-2637-4221-9c4c-9afa3d585752.pdf"},{"id":84978005,"identity":"198e13dc-a64b-46b0-a368-6eee1aefcb40","added_by":"auto","created_at":"2025-06-19 12:44:30","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13730,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6866581/v1/a4af444d8f9344c562c05a11.xlsx"},{"id":84978003,"identity":"efff8cfe-f72c-4d19-92b1-da5789d6b799","added_by":"auto","created_at":"2025-06-19 12:44:30","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":12629,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile2.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6866581/v1/3b160c174811f70164dfccfa.xlsx"},{"id":84977091,"identity":"a85e9048-0cae-4ef5-872e-5b0e387b9d01","added_by":"auto","created_at":"2025-06-19 12:36:30","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":12009,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile3.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6866581/v1/dc5e5867a88357f70652d91f.xlsx"},{"id":84978007,"identity":"b7b54596-ea5a-40b7-be7f-869f5ca33fdb","added_by":"auto","created_at":"2025-06-19 12:44:31","extension":"xlsx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":86474,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile4.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6866581/v1/8602572c617876d0ac97296e.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Continuing Education for the Chiropractic Profession: A Cross-Sectional Study Analyzing Potential Barriers to Future Chiropractic Academic and Research Development","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the United States (US), chiropractic licensure is overseen at the state level with 52 unique and individual sets of statutes and administrative rules (i.e., 50 states, District of Columbia, and territory of Puerto Rico; hereby all referred to as \u0026lsquo;state(s)\u0026rsquo;) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Maintenance of licensure is dependent on licensed chiropractors (DC\u0026rsquo;s) taking approved continuing education (CE) courses and or completing approved activities to obtain the required CE hours or credits within the renewal period, typically over a 1\u0026ndash;2 year period, depending on the state [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. If the CE requirements are not successfully achieved within the allotted time frame, licensees may face suspension, revocation, penalties, or fines [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eApproval of chiropractic CE hours or credits are dependent on a range of requirements which can and do vary by state. Typically, these requirements focus on 1) the host of the course being on a list of approved providers, 2) the speaker or instructor having the experience, credentials, and knowledge to teach the course, 3) the content being related to the practice of chiropractic, and 4) the attendees achieving specific learning objectives [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Depending on state rules and laws, CE hours or credits can be obtained, in person, with distance learning, or through teaching CE courses [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, many states require chiropractic CE credits to be approved by the Council of Chiropractic Education (CCE) or Providers of Approved Chiropractic Education (PACE).\u003c/p\u003e \u003cp\u003eMedical doctors (MD\u0026rsquo;s) and osteopathic doctors (DO\u0026rsquo;s) undergo rigorous residency training upon the completion of their degree programs wherein they are able to accumulate CE credit for all or part of their training hours [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Conversely, chiropractors have access to optional residency programs, but currently only four states accept residencies or fellowships for CE credit [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], a demonstration of how the chiropractic profession is trailing behind other medical professions. Stuber et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] found that the majority of chiropractors have interest in completing further training, such as a Master\u0026rsquo;s degree, particularly if the academic program would count towards continuing education credits. This implies that chiropractors may perceive a barrier to further academic pursuits, including research, due in part to the lack of understanding and acceptance by their state licensing board for such professional development. While there has been a substantial growth in the number and quality of chiropractic research publications over the past 50 years [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], there is a shortage of chiropractic clinicians who have the experience and training to conduct clinical research [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Thus, with the current barriers to CE regarding academic and research pursuits, the profession\u0026rsquo;s growth capacity may be further impeded if an academic/research CE barrier is verified.\u003c/p\u003e \u003cp\u003eIt is unclear how CE credits for research and higher-education teaching activities in the chiropractic profession compare to other similar professions, including MD\u0026rsquo;s, DO\u0026rsquo;s, physical therapists (PT\u0026rsquo;s), and athletic trainers (AT\u0026rsquo;s). These professions, other than PT\u0026rsquo;s, have national standards for CE credits which include recognizing research and academic teaching as qualified CE [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This appears to be in line with the National Academy of Medicine\u0026rsquo;s purpose of continuing medical education, which is to both reinforce current practice as well as translate new knowledge into practice [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, a lack of similar alignment of the chiropractic profession could significantly impede knowledge development and adoption of evidence-based guidelines. Therefore, the aim of this study was to describe which states allow chiropractors to claim CE credits/hours through higher education teaching, publication, or participation in the peer review process. The hypothesis was that within the chiropractic profession fewer states would recognize CE for research or higher-education teaching activities.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study followed the \u003cem\u003eStrengthening the Reporting of Observational Studies in Epidemiology\u003c/em\u003e (STROBE) guidelines [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This study did not qualify as human subject research and, therefore, did not require Institutional Review Board (IRB) approval [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The cross-sectional design of this study was based on and modeled from prior research that examined chiropractic state board websites for similar information [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Recording, Organization, and Validation\u003c/h2\u003e \u003cp\u003eData were recorded in an Excel spreadsheet (Microsoft Corp, Redmond, WA). Between December 19th, 2024 and March 1st, 2025, five investigators (SS, DLS, CAM, JAK, NDS) recorded CE and licensure-related data from chiropractic board and licensure websites for all 50 states, the District of Columbia, and the US territory of Puerto Rico. The official website for each chiropractic board and/or state legislative website was accessed and reviewed. From the homepage, links to CE, license renewal, and frequently asked question (FAQ) sections (if available) were searched manually for content related to research and academic credit in addition to other variables (see additional files). Administrative code where available was also queried for descriptions related to CE credit offered for research and academic hours. Variables entered into the spreadsheet included: official name of the Board; Board statute oversight; process for rule change; CE hours required per cycle; renewal term in years; per year equivalent number of CE hours; whether CE must be board approved or CCE/PACE approved; whether CE courses were chiropractic specific or only to be taught by chiropractors; PACE allowed; number of credits allowed for online CE; percentage of CE credits allowed to be taken online; whether research related activities (manuscript publication and/or scientific peer-review) count toward CE; whether academic related activities (university level teaching or CE instruction) count toward CE; allowed CE topics; whether academic or research related CE credit information was found in FAQ sections.\u003c/p\u003e \u003cp\u003eFor the comparator professions (MD\u0026rsquo;s, DO\u0026rsquo;s, AT\u0026rsquo;s, and PT\u0026rsquo;s) state board required credit hours were obtained from each state\u0026rsquo;s legislative website for each profession and documented within a spreadsheet. Accepted CE credit types are nationally standardized for MD\u0026rsquo;s, DO\u0026rsquo;s, and AT\u0026rsquo;s through the Accreditation Council for Continuing Medical Education and American Medical Association (ACCME and AMA; accme.org, ama.org), American Osteopathic Association (AOA; osteopathic.org) and Board of Certification for Athletic Trainers (BOC-ATC; BOCATC.org) respectively. These national standardized CE requirements include varying categories of CE such as Physician\u0026rsquo;s recognition awards (PRA) Category I/II (MD\u0026rsquo;s), Category Ia/Ib/IIa/IIb (DO\u0026rsquo;s), and Category A-D (AT\u0026rsquo;s). For PT\u0026rsquo;s, accepted CE credit types differ at the state level, similar to chiropractic. The official website for each physical therapy board and/or state legislative website was accessed and reviewed for allowance of research activities or teaching as accepted forms of CE credit was documented.\u003c/p\u003e \u003cp\u003eThe 5 investigators served as the initial data extractor for approximately 10 states each. Following initial data extraction, each investigator verified the data extraction of a fellow investigator. Any ambiguities or discrepancies in data extraction that could not be resolved between two investigators were adjudicated by a 3rd investigator. These ambiguities were uncommon and usually involved information that was not provided in the CE portion of the state chiropractic board\u0026rsquo;s website. For pragmatic reasons, when no explicit information regarding academic or research related CE could be found on the board\u0026rsquo;s website or through administrative code, that state was classified as offering no CE for those activities. Data extraction noted whether research-related activities (e.g., publishing in peer reviewed journals or performing peer review) and/or academic related activities (e.g., higher-education instructor/professor, verified participation as an instructor of CE) counted toward CE credit requirements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData was exported into \u003cem\u003eJMP 18 Pro\u003c/em\u003e for statistical analysis. Descriptive statistics were determined. Fisher\u0026rsquo;s Exact test was performed to compare the number of states granting CE credits for research and teaching and One-way ANOVA was performed to compare among professions with Tukey\u0026rsquo;s HSD post hoc comparison performed for each pair when appropriate. An \u003cem\u003ea priori\u003c/em\u003e value of ɑ\u0026lt;0.05 was set for significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eInformation regarding the specific profession\u0026rsquo;s acceptance of research and academic work for CE credit and state required CE hours are presented in Additional Files 1\u0026ndash;3. A full representation of additional data obtained for DC\u0026rsquo;s (e.g., board rules, regulations, specific state legislative requirements) is presented in Additional File 4.\u003c/p\u003e\n\u003cp\u003eFisher\u0026rsquo;s Exact test by profession demonstrated that the number of states allowing CE credit for performance of research were different for DC\u0026rsquo;s compared to AT\u0026rsquo;s, DO\u0026rsquo;s, MD\u0026rsquo;s, and PT\u0026rsquo;s with 69.2% not allowing research CE (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The PT profession was similarly lower than AT\u0026rsquo;s, DO\u0026rsquo;s, and MD\u0026rsquo;s with 12% of states not allowing research CE (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012). States that allow for CE credit for performance of university level teaching or instruction of CE courses showed the DC profession was lower from all of the other professions (AT\u0026rsquo;s, DO\u0026rsquo;s, MD\u0026rsquo;s, and PT\u0026rsquo;s) with only 50% allowing for CE for teaching (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eCE credit can be obtained via scientific publication, scientific peer review, university level teaching, and seminar instruction for AT\u0026rsquo;s, MD\u0026rsquo;s, and DO\u0026rsquo;s [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. For DC\u0026rsquo;s, only 2 states, Illinois and Kansas, awarded CE credit for all four of these categories, while 19 states did not award CE credits for any of these categories (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The PT profession was not separated into specific research or academic categories, and is therefore not included within the below figure.\u003c/p\u003e\n\u003cp\u003eAn ANOVA comparing the annual CE hours required by each profession demonstrated differences between the five professions observed (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Specifically, the PT profession had the lowest annual CE requirement with an average of 14.5 credits. PT\u0026rsquo;s were lower than DC\u0026rsquo;s (p\u0026thinsp;=\u0026thinsp;0.010) and the other 3 professions (AT, DO, MD; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). DC\u0026rsquo;s were similarly lower than these three professions (AT, DO, MD; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with an average of 18.5 CEs required annually. There were no other differences of annual CE hours required by the remaining professions, with AT\u0026rsquo;s, MD\u0026rsquo;s, and DO\u0026rsquo;s requiring an average of 25, 26.7, and 27.7 CE hours, respectively (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eContinuing education credits by profession\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProfession\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean CE\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% States Allow\u003c/p\u003e\n \u003cp\u003eResearch CE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% States Allow\u003c/p\u003e\n \u003cp\u003eTeaching CE\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25 (22.9, 27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.5 (16.3, 20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePT*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.5 (12.3, 16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDO*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.7 (25.4, 29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMD*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.7 (24.4, 28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe chiropractic profession was found to have the least incentives to engage in research and higher-education teaching activities for CE credit relative to the other health professions. All states allow AT\u0026rsquo;s, DO\u0026rsquo;s, and MD\u0026rsquo;s to use research and higher-education teaching towards their customary CE requirements. PT\u0026rsquo;s were found to require the least CE hours for re-licensure, followed by chiropractors, but 92% of states allow PT\u0026rsquo;s to perform research or academic-related CE hours.\u003c/p\u003e \u003cp\u003ePrevious survey research [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] found that DC\u0026rsquo;s have interest in pursuing further academic and research related interests, particularly if that higher education program would count towards CE. We have verified that an academic/research CE barrier does exist for DC\u0026rsquo;s, but not for the other professions. We infer that this barrier is likely hindering the research capacity of the profession which is further constrained by the existing shortage of DC\u0026rsquo;s who have the requisite experience and training to conduct clinical research [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile there has been substantial growth in the number and quality of chiropractic research publications over time [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the fact that the majority of states do not allow research activities to count toward CE is an obstacle to the growth of future research. With the rapid proliferation of chiropractic and health literature, it is more important than ever for chiropractors to stay up-to-date with the latest research. With roughly 82% of chiropractors working within a chiropractic office [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], offering CE credit for the conduct of and participation in research studies would provide a facile means towards additional, clinician-focused projects, as well as further practice-based research and training opportunities.\u003c/p\u003e \u003cp\u003eCE that is grounded in evidence-based data is a means to provide skill and knowledge promotion among practicing clinicians [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, Lyu \u0026amp; Li [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] also suggested that the large, increasing volume of medical information may overload and confuse providers, particularly those that are not able to distinguish between reliable and poor-quality evidence. By engaging with CE that incorporates high-quality evidence, clinical practice guidelines, and systematic reviews, medical providers can update their care paradigms and improve patient outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]; indeed, in medical education, this has shown demonstrable improvements in both physician performance and patient health outcomes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe above data suggests that allowing CE for activities that contribute to the research and academic pursuits of DC\u0026rsquo;s will have a three-fold positive impact - it will contribute to the breadth of CE opportunities, facilitate evidence-informed practices in clinicians, all while simultaneously bolstering chiropractic academic and research development. As such, we propose that all states allow research and higher-education teaching activities for chiropractic CE credit to be consistent with that of AT\u0026rsquo;s, DO\u0026rsquo;s, and MD\u0026rsquo;s CE requirements.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eWhile we had at least two reviewers examine regulatory websites for each state it is possible that we misclassified states in terms of allowing CE credit for research or academic activities. Many state board websites did not provide specific information on CE for these activities and unless explicitly mentioned, we classified them as not allowing CE. Additionally, there was inconsistency where such information was located on state board websites. Some states such as Ohio offer information regarding obtaining academic CE in a FAQ on their website. Other states provide such information within their regulatory language, while many states simply did not address research or academic CE.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eChiropractors have significantly less opportunity to claim CE credit for research and higher-academic pursuits compared to AT\u0026rsquo;s, PT\u0026rsquo;s, MD\u0026rsquo;s, and DO\u0026rsquo;s. Precluding research and higher-education teaching opportunities for CE presents a barrier to the conduct and development of chiropractic research at present and in the future. State boards of chiropractic that do not currently allow for such CE opportunities are urged to promptly reconsider how both research and higher-education pursuits can magnify and advance the profession with vital knowledge development and adoption of evidence-based guidelines.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not qualify as human subject research and, therefore, did not require Institutional Review Board (IRB) approval [12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are provided as supplementary files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDLS\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003epost-graduate online instructor for chirocredit.com, an online continuing education provider; JAK: occasional post-graduate instructor for CE programs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made significant contributions to the study design and interpretation of data. SS and NDS provided the idea for the research, planned the methods, collected data, analyzed data and drafted and reviewed the manuscript; DLS, CAM and JAK planned the methods, collected data, and drafted and reviewed the manuscript. All authors have read and approved the final version of the manuscript and agree with the order of presentation of the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFCLB. Chiropractic Regulatory Boards: Federation of Chiropractic Licensing Boards. 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://fclb.org/chiropractic-licensing-boards.php\u003c/span\u003e\u003cspan address=\"https://fclb.org/chiropractic-licensing-boards.php\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFCLB. Model Practice Act for Chiropractic Regulation 2021 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://fclb.org/files/publications/1638890937_fclb-model-practice-act.pdf\u003c/span\u003e\u003cspan address=\"https://fclb.org/files/publications/1638890937_fclb-model-practice-act.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStuber KJ, Grod JP, Smith DL, Powers P. An online survey of chiropractors' opinions of Continuing Education. Chiropr Osteopat. 2005;13:22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAMA. The AMA Physician\u0026rsquo;s Recognition Award and credit system: American Medical Association. 2017 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ama-assn.org/system/files/pra-booklet.pdf\u003c/span\u003e\u003cspan address=\"https://www.ama-assn.org/system/files/pra-booklet.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAOA. 2025\u0026ndash;2027 Certification CME Cycle CME Category \u0026amp; Activity Descriptions: American Osteopathic Association. 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osteopathic.org/index.php?aam-media=/wp-content/uploads/CME-Activity-Descriptions.pdf\u003c/span\u003e\u003cspan address=\"https://osteopathic.org/index.php?aam-media=/wp-content/uploads/CME-Activity-Descriptions.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchut SM, Cole Ii MR, Price MR, Bucki FM, McCann BH, Corcoran KL. Chiropractic residencies and fellowships as continuing education: a review of chiropractic state boards policies. BMC Med Educ. 2024;24(1):1338.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrager RJ, Bejarano G, Perfecto RT, Blackwood ER, Goertz CM. Chiropractic and Spinal Manipulation: A Review of Research Trends, Evidence Gaps, and Guideline Recommendations. J Clin Med. 2024;13:19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSawyer C, Haas M, Nelson C, Elkington W. Clinical research within the chiropractic profession: status, needs and recommendations. J Manipulative Physiol Ther. 1997;20(3):169\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBOC-ATC. Certification Maintenance Requirements For Certified Athletic Trainers Reporting Period Ending December 31, 2025: Board of Certification for the Athletic Trainer; 2024 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://bocatc.org/athletic-trainer-life-cycle/\u003c/span\u003e\u003cspan address=\"https://bocatc.org/athletic-trainer-life-cycle/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe National Academies. 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Human Subject Regulations Decision Charts. 2018 Requirements 2018 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.hhs.gov/ohrp/regulations-and-policy/decision-charts-2018/index.html\u003c/span\u003e\u003cspan address=\"https://www.hhs.gov/ohrp/regulations-and-policy/decision-charts-2018/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCole MR 2nd, Mattox R, Tobiczyk H, Napuli JG, Bucki F. Telehealth Content From United States Chiropractic State Board Websites Compared With Medical and Physical Therapy Websites During the Early Stages of the COVID-19 Pandemic. J Chiropr Med. 2022;21(3):168\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeff SM, Roecker CB, Okamoto CS, Holguin SL, Napuli JG, Mattox R, et al. Guidance concerning chiropractic practice in response to COVID-19 in the U.S.: a summary of state regulators' web-based information. Chiropr Man Th. 2020;28(1):44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaniels CJ, Paris D, Mooring S, Anderson K, Crivellii L, Muth C. United States guidance on informed consent for chiropractors: a review of state regulator websites. J Contemp Chiropr. 2025;8(1):135\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNBCE. Practice Analysis of Chiropractic. 2025: National Board of Chiropractic Examiners; 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nbce.org/practice-analysis-of-chiropractic-2025-2/\u003c/span\u003e\u003cspan address=\"https://www.nbce.org/practice-analysis-of-chiropractic-2025-2/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyu X, Li S. Professional medical education approaches: mobilizing evidence for clinicians. Front Med (Lausanne). 2023;10:1071545.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes: an updated synthesis of systematic reviews. J Contin Educ Health Prof. 2015;35(2):131\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"chiropractic-and-manual-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chmt","sideBox":"Learn more about [Chiropractic \u0026 Manual Therapies](http://chiromt.biomedcentral.com/)","snPcode":"12998","submissionUrl":"https://submission.springernature.com/new-submission/12998/3","title":"Chiropractic \u0026 Manual Therapies","twitterHandle":"@ChiroManTher","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"continuing education, chiropractic, licensure, research, teaching, post-graduate","lastPublishedDoi":"10.21203/rs.3.rs-6866581/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6866581/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eContinuing education (CE) for chiropractors is mandated by state licensing boards to ensure ongoing learning and to maintain professional excellence. While incorporating research into CE programs is crucial for practitioners to remain dynamic and evidence-based, conducting research and academic pursuits is necessary for further development of the profession. We aimed to determine how many states permit chiropractors (DC\u0026rsquo;s) to earn CE credits for research and academic activities and compare this to the allowances for medical doctors (MD\u0026rsquo;s), osteopaths (DO\u0026rsquo;s), physical therapists (PT\u0026rsquo;s), and athletic trainers (AT\u0026rsquo;s).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eInternet searches of publicly available state board websites for each profession was undertaken with a cross-sectional study design between 12/19/2024 and 03/01/2025. Data extraction focused on whether CE was granted for research (publication and/or peer review) as well as academic pursuits (higher education and/or CE instruction). Descriptive statistics determined the frequency of states allowing CE while Fisher\u0026rsquo;s Exact test and one-way ANOVA was performed to compare states granting CE credits for research and teaching as well as comparisons among the professions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOnly 16 US states allow DC\u0026rsquo;s to claim research activities for CE credit while 50% allow teaching for CE credit. This is significantly lower (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than AT\u0026rsquo;s, DO\u0026rsquo;s, and MD\u0026rsquo;s where teaching and research activities are accepted for CE credit in all states.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePrecluding research and higher-education teaching opportunities for CE presents a potential barrier to chiropractic academic and research development at present and in the future.\u003c/p\u003e","manuscriptTitle":"Continuing Education for the Chiropractic Profession: A Cross-Sectional Study Analyzing Potential Barriers to Future Chiropractic Academic and Research Development","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-19 12:36:25","doi":"10.21203/rs.3.rs-6866581/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-02T15:35:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-28T03:01:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"189642122566005481300182165350736279182","date":"2025-06-28T01:35:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-17T18:50:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122069398460922991323258447554624126732","date":"2025-06-17T16:25:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-17T16:05:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T10:33:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-13T11:00:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Chiropractic \u0026 Manual Therapies","date":"2025-06-10T23:46:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"chiropractic-and-manual-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chmt","sideBox":"Learn more about [Chiropractic \u0026 Manual Therapies](http://chiromt.biomedcentral.com/)","snPcode":"12998","submissionUrl":"https://submission.springernature.com/new-submission/12998/3","title":"Chiropractic \u0026 Manual Therapies","twitterHandle":"@ChiroManTher","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2c33fce6-ceee-4988-92dd-e9d248844655","owner":[],"postedDate":"June 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T16:39:32+00:00","versionOfRecord":{"articleIdentity":"rs-6866581","link":"https://doi.org/10.1186/s12998-025-00596-x","journal":{"identity":"chiropractic-and-manual-therapies","isVorOnly":false,"title":"Chiropractic \u0026 Manual Therapies"},"publishedOn":"2025-08-21 16:29:06","publishedOnDateReadable":"August 21st, 2025"},"versionCreatedAt":"2025-06-19 12:36:25","video":"","vorDoi":"10.1186/s12998-025-00596-x","vorDoiUrl":"https://doi.org/10.1186/s12998-025-00596-x","workflowStages":[]},"version":"v1","identity":"rs-6866581","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6866581","identity":"rs-6866581","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}