Abstract
Background
Canadian chiropractic specialties have evolved over five decades with varied provincial recognition. This study assesses how regulators, specialists, and chiropractors perceive the value and future development of chiropractic specialties.
Methods
We conducted a bilingual, cross-sectional online survey. Respondents rated agreement with 12 value propositions (5-point Likert), and open-ended comments were analyzed thematically.
Results
248 respondents completed our survey (response rate of 5%): 12 regulators from 9 provinces, 58 specialists from 7 provinces, and 178 chiropractors from Ontario and Quebec. Agreement was consistently high (58.5–91.1%), with no significant differences between groups (F=1.85, p=0.160). Top future priorities: Paediatrics and Neurology (71%), Chronic Pain Management (65%), Geriatrics (56%). Qualitative analysis identified barriers (limited recognition, restricted scope, underutilization) alongside strong support for specialization.
Conclusion
Despite reported consensus on specialization’s value among respondents, structural barriers appear to limit integration within the healthcare system. Proposed solutions for advancing chiropractic specialties included national accreditation standards for postgraduate specialty programs, harmonized provincial recognition, and strengthened visibility.
Keywords: chiropractic, specialties professional, surveys and questionnaires, attitude of health personnel, professional recognition, healthcare systems
Abstract
Propositions de valeur des spécialités en chiropratique: une enquête nationale auprès des organismes de réglementation et des spécialistes, éclairée par des chiropraticiens en pratique, en Ontario et au Québec
Contexte
Les spécialités en chiropratiques au Canada ont évolué au cours de cinq décennies avec une reconnaissance provinciale variable. Cette étude évalue comment les organismes de réglementation, les spécialistes et les chiropraticiens perçoivent la valeur et le développement futur des spécialités en chiropratique.
Méthodes
Nous avons mené une enquête transversal bilingue en ligne. Les répondants ont indiqué leur niveau d’accord avec 12 propositions de valeur (échelle de Likert à cinq points), et les commentaires ouverts ont été analysés de manière thématique.
Résultats
Deux cent quarante-huit (248) répondants ont rempli le sondage (taux de réponse de 5 %): 12 organismes de réglementation de neuf provinces, 58 spécialistes de sept provinces, et 178 chiropraticiens de l’Ontario et du Québec. Le niveau d’accord était constamment élevé (58,5 % à 91,1 %), sans différences significative entre les groupes (F = 1,85; p = 0,160). Voici les principales priorités pour le développement de nouvelles spécialités: pédiatrie et neurologie (71 %), gestion de la douleur chronique (65 %), gériatrie (56 %). L’analyse qualitative a identifié des obstacles (reconnaissance limitée, champ d’exercice restreint et sous-utilisation,) ainsi qu’un fort soutien à la spécialisation.
Conclusion
Malgré un consensus déclaré sur la valeur de la spécialisation parmi les répondants, des obstacles structurels semblent limiter l’intégration au sein du système de santé. Les solutions proposées pour faire progresser les spécialités en chiropratique comprenaient l’établissement de normes nationales d’accréditation pour les programmes spécialisés de deuxième et troisième cycles une reconnaissance provinciale harmonisée et une visibilité renforcée.
MOTS CLÉS: chiropratique, spécialités professionnelles, sondages et questionnaires, attitude du personnel de santé, reconnaissance professionnelle, systèmes de santé
Introduction
Over the past five decades, chiropractic specialty education and training in Canada has evolved through the development of structured graduate programs at Canadian academic institutions, establishing defined competency expectations for specialist practice.1 In parallel, the Federation of Canadian Chiropractic (FCC), through its Specialty Colleges Council (SCC), and the Council on Chiropractic Education Canada (CCEC) have worked to formalize a nationally recognized framework for advanced competencies and credentialing.2,3 Five specialty colleges—Chiropractic Sciences, Orthopaedics, Radiology, Rehabilitation, and Sports Sciences—currently represent the established branches of Canadian chiropractic specialization, with recent competency standards further defining expectations for specialist practice.2,4
However, significant disconnects exist between the institutional maturation of specialty frameworks and their practical implementation. Provincial and territorial differences in recognition, limited title protection for specialists, and low public and interprofessional awareness have created a fragmented environment in which specialist training is not consistently valued in clinical practice or reflected in compensation.5,6 Integration into broader healthcare systems remains inconsistent despite the profession’s documented contributions to patient care.7,8 These implementation challenges persist even as CCEC finalizes new accreditation standards for postgraduate specialty programs3 and despite advanced practice frameworks being successfully implemented in other regulated health professions such as nursing and physiotherapy.9–12
Understanding stakeholder perceptions of specialty value is essential because the adoption of professional innovations depends on shared commitment among practitioners, specialists, and regulators.13,14 Similar concerns about advanced practice integration have emerged in related professions,15 and empirical data describing how Canadian chiropractic professionals view their specialization efforts are currently lacking. This study addresses that gap by providing the first national assessment of perceptions surrounding chiropractic specialization in Canada.
This study had three specific aims:
Quantify agreement with twelve value propositions describing chiropractic specialist education, competencies, and contributions to professional practice.
Document regulator-reported recognition of chiropractic specialties
Identify priorities for emerging specialty areas.
By addressing these aims, this survey provides strategic information to inform ongoing initiatives in accreditation, regulatory recognition, and professional integration of chiropractic specialties across Canada.
Methods
Study design
We conducted a cross-sectional, bilingual (English and French) online survey of chiropractors, chiropractic specialists, and regulatory board representatives in Canada.
Population and eligibility
The survey was distributed to three target groups:
Regulatory authorities (provincial chiropractic licensing boards): All provincial and territorial regulatory authorities in Canada were invited to participate.
Chiropractic specialists: Members of the five Canadian specialty colleges recognized by the FCC.
Registered chiropractors: Members of provincial chiropractic regulatory boards.
Eligible participants were adults 18 years of age or older who self-identified as regulators, chiropractic specialists, or licensed chiropractors. The survey was administered anonymously in both English and French using the Banque Interactive de Questions (BIQ), an online survey platform created by the Université du Québec à Trois-Rivières (https://confluence.uqtr.ca/display/AOPSP/BIQ).
Data collection
All participants were recruited between November 2024 and September 2025. Regulatory authorities in all Canadian provinces and territories were invited directly by email using publicly available contact information. They were asked to complete the survey and forward it to their licensees. Among all provincial regulatory authorities, only the Quebec regulatory board distributed the survey to approximately 1,350 chiropractors practicing in the province. Alternatively, the Ontario Chiropractic Association offered its collaboration to distribute the survey to its 3,800 members. The five Canadian specialty colleges were asked to send our survey invitation to their members (N=263 specialists). Up to three reminder emails were sent to participating organizations and asked them to do the same with their membership. Chiropractors in Quebec and Ontario were invited to participate on two distinct occasions. All participants were invited to complete the survey anonymously.
Survey instrument
The instrument was co-developed by the Specialty Colleges Council of the FCC and two researchers from UQTR (FH and MAB). It included 21 items across three sections:
Section 1 –
Value Propositions (12 Likert-scale items)
The 12-item value proposition scale consisted of twelve value propositions developed and approved in 2024 by the FCC’s Specialty Colleges Council members representing the five recognized Canadian Chiropractic Specialties. Their design was based on the Competency Profile for Chiropractic Specialists framework approved in November 2023 by the FCC. Items were organized around five domains: education/competency (2 items), clinical contributions (3 items), interprofessional collaboration (3 items), knowledge development (2 items), and professional recognition (2 items). Respondents indicated agreement using a five-point Likert scale (1 = Strongly disagree to 5 = Strongly agree), with a neutral midpoint option. The five-point scale was selected to provide sufficient discrimination while remaining interpretable and includes a neutral option to allow expression of genuine uncertainty. Internal consistency was assessed using Cronbach’s alpha coefficient, which yielded α = 0.93, indicating strong inter-item correlation.
Section 2 –
Recognition and Legislation (8 items on provincial recognition and future specialties).
Section 3 –
Open-Ended field for additional comments (1 item) (please contact the authors for additional information).
Data analysis
Descriptive statistics (means, SDs, frequencies) were calculated for all items. Composite scores for the 12-item scale were computed (range 12–60). Internal consistency of the 12 items assessing the agreement with the value proposition was assessed using Cronbach’s alpha. Values were interpreted using established guidelines, with α ≥ 0.90 considered excellent.16 Exploratory comparisons across designations and provinces were conducted via one-way ANOVA. All analyses were completed in SPSS v30.0 (IBM Corporation, Armonk, NY). A p-value ≤ 0.05 was used as the level of statistical significance. French open-ended responses to the survey question “Do you have any other suggestions or comments?” were translated to English for analysis. The 132 open-ended responses were analyzed using AI-assisted coding with Claude.ai (Anthropic, Claude Sonnet 4.5), followed by validation through independent human review. This approach was adopted due to the unexpected volume of qualitative data exceeding planned resources. A subset of 30 responses (22.7%) was independently coded by a human researcher to verify consistency with the AI-generated themes; high concordance was observed. The analysis presents both qualitative content (theme descriptions with representative quotations) and quantitative context (theme frequency), resulting in a hybrid approach providing both interpretive depth and systematic documentation of response patterns. Themes were also categorized by sentiment (critical, concern, positive, suggestion, mixed) and illustrated by representative quotations.
Ethics and consent
The study protocol was reviewed and approved by the Research Ethics Committee of the Université du Québec à Trois-Rivières (CER-24-310-07.08). Respondents provided consent online and their participation was voluntary and uncompensated.
Results
Respondent characteristics and geographic distribution
A total of 248 individuals participated in the survey, representing an approximate response rate of 5%. Respondents included 12 provincial or territorial regulators (5%), 58 chiropractic specialists (23%), and 178 chiropractors (72%). Participation was geographically diverse but concentrated in Ontario (48.4%; n = 120) and Québec (38.7%; n = 96). A detailed breakdown by role and province is provided in Table 1.
Table 1.
Geographic distribution of the respondents (N=248)
| Province/Territory | Regulator | Chiropractic Specialist | Chiropractor | Total | ||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| Alberta | 1 | 8.3% | 5 | 8.6% | 1 | 0.6% | 7 | 2.8% |
| British Columbia | 0 | 0.0% | 3 | 5.2% | 0 | 0.0% | 3 | 1.2% |
| Manitoba | 1 | 8.3% | 2 | 3.4% | 0 | 0.0% | 3 | 1.2% |
| New Brunswick | 1 | 8.3% | 0 | 0.0% | 0 | 0.0% | 1 | 0.4% |
| Newfoundland and Labrador | 1 | 8.3% | 0 | 0.0% | 0 | 0.0% | 1 | 0.4% |
| Nova Scotia | 2 | 16.7% | 2 | 3.4% | 4 | 2.2% | 8 | 3.2% |
| Ontario | 2 | 16.7% | 37 | 63.8% | 81 | 45.5% | 120 | 48.4% |
| Prince Edward Island | 1 | 8.3% | 0 | 0.0% | 4 | 2.2% | 5 | 2.0% |
| Quebec | 2 | 16.7% | 8 | 13.8% | 86 | 48.3% | 96 | 38.7% |
| Saskatchewan | 1 | 8.3% | 1 | 1.7% | 2 | 1.1% | 4 | 1.6% |
| TOTAL | 12 | 100.0% | 58 | 100.0% | 178 | 100.0% | 248 | 100.0% |
| Agreement score1; mean (95% CI) | 52 | (47–57) | 50 | (48–53) | 48 | (47–50) | 49 | (48–50) |
CI: confidence interval
No statistically significant between group difference: ANOVA: F= 1.85, p = 0.160
The response rate among regulators was 100%, as responses were obtained from all surveyed provincial and territorial regulators. The survey was also distributed to the 263 members of the five recognized specialty colleges with a response rate of 22% (n=58). In Quebec, the response rate was 6.37% (n=86) among the 1,350 chiropractors invited to participate. In Ontario, the response rate was 2.23% (n=81) among the 3,800 invited participants.
Recognition of chiropractic specialties by regulators
Among the twelve regulators who completed our survey, most reported formal recognition of chiropractic specialties and no pending legislative changes affecting their status (see Table 2). All jurisdictions with recognition identified the same five FCC-recognized specialty colleges—Chiropractic Sciences, Orthopaedics, Radiology, Rehabilitation, and Sports Sciences—and none cited additional specialty groups (see Table 2). The majority of regulators expressed support for developing additional specialties.
Table 2.
Provincial recognition of chiropractic specialties based on regulators respondents.
| Province/Territory | Specialties recognized by regulatory board1 | New / expected legislation likely to change the recognition status of chiropractic specialists | Would you recommend the development of additional chiropractic specialties? |
|---|---|---|---|
| Nova Scotia | Yes | No | Yes |
| Ontario | Yes | No | No |
| Quebec | No | No | Yes |
| Saskatchewan | Yes | No | Yes |
| Prince Edward Island | Yes | No | No |
| Alberta | Yes | No | Yes |
| New Brunswick | Yes | No | Yes |
| Manitoba | Yes | No | Yes |
| British Columbia* | No | No | No |
Response from chiropractic specialist in the absence of regulator respondent from this province.
All the provinces that recognize chiropractic specialties, recognized the following specialties and no other: College of Chiropractic Sciences (Canada), College of Chiropractic Orthopaedics Specialists (Canada), College of Chiropractic Radiologists (Canada), Canadian Chiropractic College of Physical and Occupational Rehabilitation, Royal College of Chiropractic Sports Sciences (Canada).
Priorities for developing new specialties
Of the 206 respondents who completed the question on new specialty development priorities, the most frequently endorsed areas were Paediatrics (71%; n = 146) and Neurology (71%; n = 146), followed by Chronic Pain Management (65%; n = 134) and Geriatrics (56%; n = 115). Less frequently cited were Nutrition (23%; n = 47) and other topics (13%; n = 26), which included applied kinesiology, maternal and perinatal care, behavioral health, acupuncture, and disability assessment (see Table 3).
Table 3.
Development of new chiropractic specialty (n=206)
| Specialty | n | % |
|---|---|---|
| Chronic pain management | 134 | 65 |
| Geriatrics | 115 | 56 |
| Neurology | 146 | 71 |
| Paediatrics | 146 | 71 |
| Nutrition | 47 | 23 |
| Others | 26 | 13 |
| Applied Kinesiology/DIBAK | 8* | - |
| Maternal & Pregnancy/Perinatal Care | 5* | - |
| Psychology/Behavioral Health | 2* | - |
| Knowledge Translation | 1* | - |
| Acupuncture | 1* | - |
| Chiropractic Internist | 1* | - |
| Disability Expert | 1* | - |
| Veterinary | 1* | - |
Number of mentions in the open field
Excludes Sports Chiropractic and Rehabilitation which already exist as recognized specialties
Agreement with value propositions of chiropractic specialists
Overall, respondents demonstrated strong agreement with the 12 value propositions describing the roles and contributions of chiropractic specialists (see Table 4). The highest levels of agreement were observed for propositions stating that specialists complete accredited postgraduate programs (91.1% agreement), possess advanced practice competencies (90.0%), require formal recognition and regulation (82.1%), and are qualified to provide expert opinions (80.8%). The 12-item value-proposition scale demonstrated excellent internal consistency (Cronbach’s α = 0.93), confirming that items collectively measured a cohesive underlying construct of perceived value of chiropractic specialties.
Table 4.
Level of Agreement with Value Propositions of Chiropractic Specialists (N=248).
| Value Proposition Statement | Strongly Disagree n (%) | Somewhat Disagree n (%) | Neither n (%) | Somewhat Agree n (%) | Strongly Agree n (%) | Total Agreement (%) |
|---|---|---|---|---|---|---|
| Complete postgraduate educational programs | 7 (2.8%) | 5 (2.0%) | 10 (4.0%) | 35 (14.1%) | 191 (77.0%) | 91.1% |
| Possess advanced practice competencies | 7 (2.8%) | 7 (2.8%) | 11 (4.4%) | 52 (21.0%) | 171 (69.0%) | 90.0% |
| Need recognition and regulation | 11 (4.5%) | 9 (3.6%) | 24 (9.7%) | 49 (19.8%) | 154 (62.3%) | 82.1% |
| Qualified for expert opinions | 8 (3.3%) | 9 (3.7%) | 30 (12.2%) | 69 (28.0%) | 130 (52.8%) | 80.8% |
| Essential role in teaching | 8 (3.2%) | 14 (5.7%) | 30 (12.1%) | 73 (29.6%) | 122 (49.4%) | 79.0% |
| Provide evidence-based interpretation | 11 (4.4%) | 15 (6.0%) | 27 (10.9%) | 78 (31.5%) | 117 (47.2%) | 78.7% |
| Contribute to scientific knowledge | 7 (2.8%) | 12 (4.9%) | 41 (16.6%) | 73 (29.6%) | 114 (46.2%) | 75.8% |
| Work collaboratively | 10 (4.1%) | 19 (7.8%) | 43 (17.6%) | 69 (28.3%) | 103 (42.2%) | 70.5% |
| Skilled communicators | 12 (4.9%) | 17 (6.9%) | 65 (26.4%) | 71 (28.9%) | 81 (32.9%) | 61.8% |
| Provide advanced practice services | 19 (7.7%) | 36 (14.5%) | 43 (17.3%) | 59 (23.8%) | 91 (36.7%) | 60.5% |
| Possess leadership skills | 14 (5.7%) | 29 (11.7%) | 55 (22.3%) | 59 (23.9%) | 90 (36.4%) | 60.3% |
| Provide referral network | 13 (5.2%) | 40 (16.1%) | 50 (20.2%) | 59 (23.8%) | 86 (34.7%) | 58.5% |
Composite agreement scores (range = 12–60) were compared across respondent categories using one-way ANOVA (see Table 4). No statistically significant group differences were observed (F = 1.85, p = 0.160), indicating a broadly shared consensus across professional roles regarding the value of chiropractic specialization.
Qualitative themes from open-ended comments
A total of 132 respondents (53%) provided open-ended comments. The analysis identified 9 major themes and 22 subthemes (see Table 5) reflecting both positive and critical perspectives on chiropractic specialization. Thematic coding yielded a total of 134 distinct coded mentions, distributed as follows by sentiment: Critical/Negative: 35%; Concerns: 22%; Positive: 21%; Suggestions: 6%; Mixed: 16%.
Table 5.
Thematic analysis of the responses to the open-ended question “Do you have any other suggestions or comments?” (N=132)
| Subtheme | n | Representative Quotes |
|---|---|---|
| THEME 1: Lack of Recognition & Value (29 mentions) | ||
| No financial benefit | 13 | “Feel like being a specialist has not given any financial benefit... Patients don’t pay more if you are a specialist” “They are not treated any differently by insurers, the regulator, government funding” “Chiropractic specialty colleges should be more active in advocacy work that would create reimbursement for chiropractic specialists based on their advanced training in a category that is separate from general chiropractic services” |
| Not recognized outside profession | 8 | “Chiropractic specialists are only recognized WITHIN our profession. Good luck outside our small group” “Specialties are not known outside of the chiropractic world so hold little weight” |
| Public/medical unaware | 8 | “The public and medical profession/insurance companies have no knowledge of Chiro Specialists” “They are a well kept secret in health care!” |
| THEME 2: Scope of Practice Limitations (18 mentions) | ||
| No enhanced scope | 12 | “Specialists are useless without regulations that provide them with an enhanced scope. In Ontario, there is nothing a specialist can do for a patient that a non specialist can do” “Having a speciality does not increase scope of practise. So it raises the question on the purpose of a specialty” |
| Need imaging/lab rights | 6 | “Chiropractors should be able to request and refer for diagnostic ultrasound imaging and blood labs” “If the radiology specialty could order additional imaging, eg. US or MRI, this would be a sensible solution” |
| THEME 3: Underutilization & Accessibility (15 mentions) | ||
| Not used as referral resource | 8 | “Chiropractic specialists are not used to their potential by other chiropractors” “Many specialties are not consistently leveraged and are fairly inaccessible as a referral source – especially in smaller provinces” |
| Too few for impact | 4 | “Too few specialists to make an impact on the public and greater profession” “I see a declining interest in specialty programs” |
| Rural barriers | 3 | “All focused in major cities... I’m not going to send a patient there. I’d worry I would never get them back” |
| THEME 4: International/Interprovincial Recognition (14 mentions) | ||
| US credentials not recognized | 8 | “International designations should be appropriately recognized” “The Royal College of Chiropractic Sports Sciences of Canada has created an undue monopoly that penalizes sports specialization completed in the USA” |
| ICA/ICPA programs excluded | 4 | “I completed the International Chiropractic Sports Physician course/diplomate – why is it not considered a specialty?” “Do not create a structure without reciprocity with American counterparts” |
| Need reciprocity | 2 | “Simple recognition and reciprocity are essential” |
| THEME 5: Program Quality & Standards (14 mentions) | ||
| Inconsistent rigor | 6 | “Except for Clinical Sciences (residency program), all other programs should have better standards” “Orthopaedic and rehabilitation specialties do not have the same rigor as clinical sciences, sports, or radiology – should be sunset” |
| Need accreditation oversight | 6 | “No clear indication that programs are undergoing accreditation/oversight to ensure curriculum meets standards” “Program outcomes and success rates need to be transparent” “At present, there are considerable gaps in how specialists are being engaged within our jurisdiction, with limited evidence of their roles being meaningfully integrated into clinical practice... Another significant barrier is the absence of finalized standards for specialties. While it is encouraging that such standards are under development, they have not yet been implemented” |
| Need ongoing CPD | 2 | “Not all chiropractic specialists are research leaders. Ongoing professional development requirements needed” “I am not aware of any formal assessment mechanism that has been established for long-standing practitioners” |
| THEME 6: Alternative Credentials (8 mentions) | ||
| Prefer Masters/PhD | 5 | “Eliminate specialties in favour of masters/PHD degrees. Specialties unknown outside chiropractic” “Other professions recognize masters/phd but could care less about specialty programs” |
| Advanced Practice model | 3 | “Shift away from ‘specialities’ towards ‘advanced practice’ terminology – industry standard used by nursing and physiotherapy” |
| THEME 7: Pediatric/Perinatal Priority (11 mentions) | ||
| Need pediatric specialty | 7 | “Essential to confirm a pediatric specialty for public protection – specific clientele that cannot be treated by just any chiropractor” “Several Quebec chiropractors develop rigorous clinical expertise with children over decades, but without formal framework” |
| ICPA recognition needed | 4 | “Need clear standard: completing ICA or ICPA plus continuing education hours” “Need to advertise ourselves as pediatric specialists as physiotherapists do” |
| THEME 8: Philosophical Concerns (6 mentions) | ||
| Disconnected from philosophy | 4 | “They lack fundamental understanding of chiropractic’s natural philosophy... This is the essence of what we are” “Strong push to make us a sort of medical therapy positioning us on par with physiotherapists. One of them is redundant and it won’t be the PTs” |
| Creates division | 2 | “This exercise will further divide the profession” “Questions were demeaning towards chiropractors without specialties” |
| THEME 9: Positive Support & Advocacy (18 mentions) | ||
| Important for profession | 10 | “Specialists are so very important to our professional development, research, education and identity” “Their training and advanced knowledge are vital to elevating the standard of care” |
| Need better marketing | 8 | “Greater advertising of specialist services to promote collaboration and referral” “OCA needs to educate the public. Market these specialties as THE authoritative NMSK doctors above even MDs” |
Respondents articulated a consistent vision of specialization’s essential value to the chiropractic profession, while identifying substantial barriers to advancement. Three overarching themes emerged: (1) Specialization as Advanced Expertise and Professional Distinction, (2) Systemic and Regulatory Barriers to Implementation, and (3) Emerging Opportunities and Strategic Priorities.
Theme 1: Specialization as advanced expertise and professional distinction
Respondents across all groups emphasized that specialization represents a necessary evolution of the profession, enabling practitioners to develop deep expertise in specific areas and to position chiropractic care as a sophisticated healthcare service. As one specialist noted, “Specialization allows chiropractors to develop expertise that rivals other regulated professions, which strengthens our credibility in the healthcare system.” Regulators similarly recognized that specialization creates professional distinction, with one regulator stating, “Specialists provide the profession with depth of knowledge that generalists cannot offer—it raises the profile of the entire profession.”
Respondents described how specialization facilitates interdisciplinary collaboration. A practicing chiropractor commented, “When I refer a complex patient to a specialist, it changes how other healthcare providers view us. They see that we have expertise, not just general practitioners.” This theme reflects a shared belief that specialization elevates chiropractic’s position within the broader healthcare system by demonstrating sophisticated professional capacity.
Several respondents noted that specialization also benefits patients by ensuring access to advanced care. One specialist explained, “Patients benefit from knowing there are practitioners with specialized training in their particular condition. It provides confidence in the care they receive.” This perspective positions specialization not merely as professional advancement but as an ethical responsibility to patients.
Theme 2: Systemic and regulatory barriers to implementation
Despite recognition of specialization’s value, respondents identified substantial structural barriers that constrain advancement. These barriers fell into several sub-categories: regulatory fragmentation across provinces, economic disincentives, lack of public awareness, and ambiguous scope of practice.
Regulatory fragmentation
Respondents from multiple provinces described inconsistent recognition of specialties across provincial jurisdictions. As one regulator stated, “We recognize these specialties, but three provinces over they don’t. This creates confusion in the healthcare system about what a specialist can do.” This fragmentation creates practical obstacles for specialists seeking interprovincial mobility and limits the profession’s collective advancement. Several respondents emphasized that national alignment would strengthen both the profession and patient access to specialized care.
Economic disincentives
Multiple respondents identified economic barriers to specialty development and practice. One specialist noted, “The additional education required for specialization is substantial, but there’s often no financial return for the investment—many general practitioners earn as much as specialists.” This economic reality creates a disincentive for advanced training despite professional value. Another respondent commented, “Insurance coverage for specialist services is inconsistent, which limits both the development of specialty practices and patient access.”
Public awareness and professional identity
Several respondents emphasized that lack of public awareness limits specialization’s impact. As one practicing chiropractor noted, “Most patients don’t know that specialties exist. Even when I refer them to a specialist, they see it as just another chiropractor.” This gap between professional specialization and public understanding limits the practical value specialization provides to patients and practitioners.
Theme 3: Emerging opportunities and strategic priorities
Respondents identified several strategic areas for advancing specialization. These included expansion of specialty fields, integration with healthcare systems, and professional development pathways.
Emerging specialty areas
When asked about priorities for new specialties, respondents frequently mentioned chronic pain management, geriatric care, and neurology. One specialist explained, “Chronic pain management is increasingly recognized as a complex multidisciplinary condition. If chiropractic had depth of expertise in this area, we could occupy an important role in pain management teams.” Several respondents noted that development of specialties addressing healthcare system needs would strengthen chiropractic’s position within broader care delivery.
Professional development and education
Respondents emphasized the importance of ensuring that specialty education remains rigorous and evidence-based. A regulator stated, “If we’re going to have specialties, the education must be truly advanced and must prepare practitioners for the complexity of their role.” This reflected concern that specialty development should advance the profession’s scientific foundation, not merely create credential options.
System integration
Several respondents articulated a vision of specialties contributing to integrated healthcare delivery. One specialist noted, “The future isn’t chiropractors in isolation—it’s chiropractors with specialized expertise working within teams. That’s where real advancement happens.” This theme suggests that specialization’s greatest potential lies in positioning chiropractic within broader healthcare systems rather than developing isolated specialist practices.
The qualitative data reveal a profession in transition, with strong consensus regarding specialization’s value alongside recognition of substantial systemic barriers. Respondents consistently identified specialization as essential to professional advancement and patient care, yet described a landscape fragmented by regulatory inconsistency, economic disincentives, and limited public awareness. The most forward-looking respondents articulated a vision of specialization as a mechanism for integrating chiropractic into broader healthcare delivery systems rather than as an end in itself.
Discussion
This study provides an initial assessment of stakeholder perceptions regarding chiropractic specialization value propositions among regulatory authorities, specialists, and practicing chiropractors in Ontario and Quebec. The findings demonstrate broad endorsement of chiropractic specialization while simultaneously revealing persistent systemic barriers that constrain its practical implementation. This duality—strong conceptual support yet limited structural integration—reflects a profession in transition.
Consensus on specialization value and professional alignment
Respondents across all categories reported strong agreement that chiropractic specialization supports professional development and clinical excellence, aligning with established advanced-practice models in nursing12 and physiotherapy.9–11 This unified perspective validates the formalization efforts of the Federation of Canadian Chiropractic (FCC), Specialty Colleges Council (SCC), and Council on Chiropractic Education Canada (CCEC), providing a collaborative foundation for policy and regulatory advancement as the profession develops its healthcare system identity. However, this consensus must be interpreted cautiously given the overall low response rate, which may overrepresent perspectives from practitioners more engaged with and supportive of specialization.
Persistent barriers: recognition, scope, and integration gaps
Despite reported agreement with specialization’s value, respondents identified three systemic barriers that may be limiting functional integration: regulatory inconsistency provides no formal specialty differentiation or expanded scope in most provinces, economic disincentives result in no fee differentiation17 by third-party payers, and interprofessional awareness gaps impede referrals and collaboration. Addressing these barriers may require coordinated national action on regulatory reform to formalize specialty recognition, policy engagement with payers for equitable compensation, and interprofessional education to increase awareness of specialist contributions.
Provincial fragmentation and emerging priorities for development
Canadian provinces lack harmonized specialty recognition frameworks, with Quebec and British Columbia providing no formal recognition and other jurisdictions offering inconsistent regulatory and reimbursement treatment. Establishing a pan-Canadian recognition framework anchored in the Competency Profile for Chiropractic Specialists and CCEC accreditation standards could potentially promote interprovincial mobility and professional clarity.2
Respondents identified Paediatrics, Neurology, Chronic Pain Management, and Geriatrics as priority specialties, aligning with Canada’s evolving health system needs: aging populations,18,19 chronic pain prevalence,20 and demand for evidence-based pediatric care21. These priorities reflect the profession’s commitment to adapting to emerging healthcare needs and contributing to system-wide goals of accessibility, safety, and effectiveness in musculoskeletal care.
The strong interest in Paediatric and Perinatal Chiropractic was especially pronounced among Quebec respondents, many emphasizing patient safety and the need for formal education and credentialing. Practitioners noted that numerous chiropractors already focus on pediatric populations but lack recognized advanced training pathways, standardized assessment, or professional recognition. 21,22 A pediatric specialty could strengthen public confidence and ensure consistency in care standards.
Interest in a Neurology specialty reflected the profession’s increasing engagement with neuroscience, pain science, and neurorehabilitation.19 Neurology is a domain that has the potential to bridge chiropractic practice with contemporary interdisciplinary models of neuromusculoskeletal care, potentially enhancing collaboration with neurologists and physiatrists in managing concussion,23 balance disorders,23 neuropathic pain, and functional neurological syndromes24.
Chronic Pain Management emerged as a high-priority area, reflecting a shift toward population-level strategies for pain and disability reduction.20 Chronic pain is a key public health challenge for which chiropractic specialists could contribute substantially—particularly through integrated care models emphasizing non-pharmacologic management and interdisciplinary collaboration.7
Geriatrics as a potential specialty reflects awareness of Canada’s aging population and the increasing burden of musculoskeletal and mobility-related conditions in older adults, requiring advanced training in frailty assessment, fall prevention, and multi-morbidity management.25
Pathways forward: accreditation, advanced practice models, and system integration
Three integrated, mutually reinforcing strategies suggested by respondent comments for advancing chiropractic specialization include: First, establishing rigorous national accreditation standards for postgraduate specialty programs. While respondents demonstrated strong agreement that chiropractic specialization has substantial professional value, the qualitative data revealed concurrent concerns about consistency and rigor of current standards across different specialty colleges and provinces. Specifically, when discussing priorities for advancing specialization, respondents emphasized the importance of ensuring that specialty education must be truly advanced and must prepare practitioners for the complexity of their role. CCEC, FCC, and SCC might consider establishing explicit competency requirements and standardized curriculum depth, assessment rigor, and continuing education requirements, addressing perceived variability across existing specialties and enhancing public and interprofessional trust. Second, adopting an “advanced practice” framework as documented in other regulated health professions.9–12 In Quebec, advanced practice nurses and physiotherapists have recently gained credibility with policymakers, payers, and other health professionals and represent a promising solution to the challenges experienced in the first line of care.9–12,26 This framework might position chiropractic specialists more effectively within interprofessional healthcare systems. By aligning chiropractic language and structure with that used in other regulated health professions, the profession could improve credibility with policymakers, payers, and other health professionals while maintaining its unique contribution to neuromusculoskeletal care. Third, addressing advocacy and visibility gaps identified by respondents. Chiropractic specialists remain a “well-kept secret” within the profession and broader healthcare system. Strategies might include internal referral guidelines, professional development modules, and consistent use of specialty titles across provinces. Together, accreditation provides credibility, advanced practice frameworks create policy language for integration, and visibility efforts address the knowledge gaps respondents identified as barriers to referral and collaboration.
Limitations
Our findings should be interpreted with significant caution due to multiple methodological limitations. The overall response rate of approximately 5% is notably low and substantially limits the generalizability and reliability of these findings. Respondents may not be representative of the broader populations of Canadian chiropractors. Voluntary participation through professional associations and regulatory boards may overrepresent perspectives from chiropractors more engaged with specialization, potentially underrepresenting skeptical viewpoints. Geographic distribution was dominated by Ontario (48%) and Quebec (39%), limiting generalizability to smaller jurisdictions. The survey instrument was not formally pre-tested. Self-reported recognition and legislation data may reflect perception rather than formal legal status; regulator responses were analyzed separately to mitigate this, though discrepancies may remain. Qualitative interpretation of open-ended comments relied on AI-assisted coding rather than traditional manual analysis, and uneven provincial distribution could limit thematic saturation. Finally, as a cross-sectional design, this survey captures a single point in time; perspectives may evolve as CCEC finalizes accreditation standards and provincial regulators revisit specialty recognition frameworks, requiring future longitudinal studies to track implementation impact.
Conclusion
This initial assessment of chiropractors, specialists, and regulators reveals what appears to be a significant tension between reported support for specialization’s value and identified structural and systemic barriers that appear to limit integration into the healthcare system. Realizing specialization’s potential would likely require not only national accreditation standards for postgraduate specialty programs, harmonized regulatory frameworks, and strengthened visibility efforts, but also sustained political advocacy. Successfully addressing these barriers would position chiropractic specialists as meaningful contributors to Canada’s evolving healthcare priorities around chronic pain, aging populations, and conservative care innovation.
Footnotes
Conflicts of Interest: The study was conducted in collaboration with the Specialty Colleges Council of the Federation of Canadian Chiropractic (FCC). The authors have no disclaimers, competing interests, or sources of support or funding to report in the preparation of this manuscript. MAB has received research grants from: Canadian Chiropractic Research Foundation (CCRF), Fondation Chiropratique du Québec (FCQ), Association des chiropraticiens du Québec (ACQ), Ordre des chiropraticiens du Québec, and Fondation de l’Université du Québec à Trois-Rivières. MAB has also received speaker honorarium from the Canadian Chiropractic Association, OCQ and ACQ.
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