Professional Documents
Culture Documents
basictrainingandsafety
inchiropractic
Geneva
2005
WHOLibraryCataloguinginPublicationData
WorldHealthOrganization.
WHOguidelinesonbasictrainingandsafetyinchiropractic.
1.Chiropracticeducation2.Chiropracticstandards3.GuidelinesI.Title.
ISBN9241593717
(NLMclassification:WB905.7)
WorldHealthOrganization2005
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Contents
Acknowledgements ............................................................................................................................................... i
Foreword.................................................................................................................................................................ii
Introduction ........................................................................................................................................................... 1
Objectives ........................................................................................................................................................ 2
Howtousethisdocument ............................................................................................................................ 2
Glossary .................................................................................................................................................................. 3
Part1:Basictraininginchiropractic .................................................................................. 5
1.Generalconsiderations .................................................................................................................................... 5
1.1.Historicalinformation ........................................................................................................................... 5
1.2 Philosophyandbasictheoriesofchiropractic .................................................................................... 5
1.3 Administrativeandacademicconsiderations .................................................................................... 6
1.4 Monitoringandevaluation ................................................................................................................... 6
1.5 Furthereducationandcareerpossibilities .......................................................................................... 7
2.
Acceptablelevelsofeducationandretraining......................................................................................... 7
2.1 CategoryIfullchiropracticeducation............................................................................................... 7
2.2 CategoryIIlimitedchiropracticeducation....................................................................................... 7
3.
Modelsofchiropracticeducation ............................................................................................................... 8
3.1 CategoryI(A) .......................................................................................................................................... 8
3.2 CategoryI(B) ........................................................................................................................................... 8
3.3 CategoryII(A) ......................................................................................................................................... 8
3.4 CategoryII(B).......................................................................................................................................... 9
4.
FullchiropracticeducationcategoryI(A)............................................................................................... 9
4.1 Objective .................................................................................................................................................. 9
4.2 Entrancerequirements........................................................................................................................... 9
4.3 Basictraining........................................................................................................................................... 9
4.4 Coresyllabus......................................................................................................................................... 10
5.
FullchiropracticeducationcategoryI(B) ............................................................................................. 13
5.1 Objective ................................................................................................................................................ 13
5.2 Specialcourses ...................................................................................................................................... 13
5.3 Basictraining......................................................................................................................................... 13
6.
LimitedchiropracticeducationcategoryII(A) .................................................................................... 14
6.1 Objective ................................................................................................................................................ 14
6.2 Specialcourses ...................................................................................................................................... 14
6.3 Basictraining......................................................................................................................................... 14
7.
LimitedchiropracticeducationcategoryII(B).................................................................................... 15
7.1 Objective ................................................................................................................................................ 15
7.2 Specialcourses ...................................................................................................................................... 15
7.3 Basictraining......................................................................................................................................... 15
8.
Assessmentandexaminationofstudentsinchiropractic ................................................................... 16
9.
Primaryhealthcareworkersandchiropractic....................................................................................... 16
9.1 Primaryhealthcareworkersmyotherapists .................................................................................. 16
9.2 Objective ................................................................................................................................................ 16
9.3 Coursecomponents.............................................................................................................................. 17
9.4 Methodanddurationoftraining ....................................................................................................... 17
Part2:Guidelinesonsafetyofchiropractic .................................................................. 19
1.
Introduction.................................................................................................................................................. 19
2.
Contraindicationstospinalmanipulativetherapy ............................................................................... 20
2.1 Absolutecontraindicationstospinalmanipulativetherapy .......................................................... 21
3.
Contraindicationstojointmanipulationbycategoryofdisorder..................................................... 22
3.1 Articularderangement ........................................................................................................................ 22
3.2 Boneweakeninganddestructivedisorders...................................................................................... 23
3.3 Circulatoryandhaematologicaldisorders........................................................................................ 23
3.4 Neurologicaldisorders ........................................................................................................................ 23
3.5 Psychologicalfactors............................................................................................................................ 24
4. Contraindicationstoadjunctiveandsupportivetherapies ................................................................. 24
4.1 Electrotherapies .................................................................................................................................... 24
4.2 Exercisesandsupplementarysupportivemeasures........................................................................ 24
5.
Accidentsandadversereactions............................................................................................................... 25
5.1 Causesofcomplicationsandadversereactions ............................................................................... 25
5.2 Examplesofinappropriatepractices ................................................................................................. 25
5.3 Seriousadverseconsequences ............................................................................................................ 25
5.4 Vascularaccidents ................................................................................................................................ 26
5.5Preventionofcomplicationsfrommanipulation ............................................................................. 27
6.
Firstaidtraining .......................................................................................................................................... 27
Annex1:Listofparticipants ............................................................................................................................. 29
Annex2:Asamplefouryear,fulltimeaccreditedprogramme.................................................................. 33
Annex3:Asamplefull(conversion)programme.......................................................................................... 35
Annex4:Asamplelimited(conversion)programme ................................................................................... 37
Annex5:Asamplelimited(standardization)programme........................................................................... 39
References ............................................................................................................................................................ 41
Acknowledgements
TheWorldHealthOrganization(WHO)greatlyappreciatesthefinancialandtechnical
support provided by the Regional Government of Lombardy, Italy, for the
development and publication of these guidelines, as part of the implementation of
collaborative projects with WHO in the field of traditional medicine. The Region of
LombardykindlyhostedandprovidedfinancialsupportfortheWHOConsultationon
Chiropractic,heldinMilan,Italy,inDecember2004.
Thanks to Dr John A. Sweaney, New Lambton, Australia, who prepared the original
text.
WHO acknowledges its indebtedness to over 160 reviewers, including experts and
national authorities and professional and nongovernmental organizations, in over
54countrieswhoprovidedcommentsandadviceonthedrafttext.
Special thanks are due to participants of the WHO Consultation on Chiropractic (see
Annex1), who worked towards reviewing and finalizing the draft guidelines, and to
the WHO Collaborating Centre for Traditional Medicine at the State University of
Milan, Italy, in particular to Professor Umberto Solimene, the Director, and to Miss
Elisabetta Minelli, the International Liaison Officer, for their assistance to WHO in
organizingtheConsultation.
Foreword
During the last decade, the use of traditional and complementary/alternative medicine
(TM/CAM) has increased considerably not only in developing countries, where it often
represents the only possibility for health protection, but also in developed countries. The
percentage of the population that uses TM/CAM is in the order of 50% in many of high
incomecountries,suchasCanada,France,Germany,UnitedKingdomandUnitedStatesof
America.ThisoccursalsoinItaly(notlessthan15%)aswellasforcertainItalianregions,
includingtheLombardyRegion,wherethepercentageisaround20%andcontinuesrising.
Facingthischallenge,itisextremelyimportanttocreatetheconditionsforthecorrectand
appropriateuse of methods which, if used correctly, can contribute to the protectionand
enhancement of citizens health and well being. The development of these practices can
only be obtained according to safety, efficacy and quality criteria. Such principles
characterize the modern medical practice and are the essential basis for consumers
protection.
TM/CAM activities undertaken by the Regional Government of Lombardy have always
been guided by the abovementioned criteria. TM/CAM was included in the Regional
Community Healthcare Plan (20022004), and a comprehensive framework for the
protection of consumers and practitioners has been developed accordingly thanks to a
series of administrative provisions. The fouryear cooperation plan between the World
HealthOrganizationandtheRegionalGovernmentofLombardyontheuseandevaluation
of TM/CAM is a keystone in such a process. The promotion of several clinical and
observationalstudiesontheregionalterritoryisalsotobeconsideredanimportantstepfor
theevaluationoftheefficacyofTM/CAMmethods.
Thequalityofthepracticedependsmainlyonthetrainingperformedbythepractitioner.
Forthisreason,theRegionalGovernmentofLombardysupportedthedevelopmentofthe
WHO Guidelines on Basic Training and Safety in Chiropractic that aim at defining the
requisites for chiropractic practitioners. The process of development of these Guidelines
includedtheWHOConsultationmeetingheldinMilaninDecember2004,whichbrought
together experts, national authorities and professional organizations from all over the
world. One of the conclusions of the Consultation was that these guidelines were
appropriate as resources not only for the Lombardy Region, but also for various country
situations worldwide. With this in mind, this document is to be considered an important
referencepointforthose,amongpractitioners,politicalandadministrativeauthorities,that
wantchiropractictobeasafeandefficaciousaidforcitizenshealthandforanyregulatory
andlicensingact.
AlessandroC
RegionalMinisterofHealth
RegionalGovernmentofLombardy
GiancarloAbelli
RegionalMinisterofFamilyandSocialSolidarity
RegionalGovernmentofLombardy
ii
Introduction
Introduction
Chiropractic is one of the most popularly used forms of manual therapy. It is now
practisedworldwideandregulatedbylawinsome40nationaljurisdictions.
Asahealthcareservice,chiropracticoffersaconservativemanagementapproachand,
although it requires skilled practitioners, it does not always need auxiliary staff and
thereforegeneratesminimaladdoncosts.Therefore,oneofthebenefitsofchiropractic
maybethatitofferspotentialforcosteffectivemanagementofneuromusculoskeletal
disorders(1,2,3).
The World Health Organization (WHO) encourages and supports countries in the
properuseofsafeandeffectivemedication,productsandpracticesinnationalhealth
services. In the light of the situation described above, there is a need to develop
guidelines on chiropractic education and safe practice, including information on
contraindicationsforsuchcare.
Regulations for chiropractic practice vary considerably from country to country. In
some countries, e.g. the United States of America, Canada and some European
countries,chiropractichasbeenlegallyrecognizedandformaluniversitydegreeshave
been established. In these countries, the profession is regulated and the prescribed
educational qualifications are generally consistent, satisfying the requirements of the
respectiveaccreditingagencies.
However,manycountrieshavenotyetdevelopedchiropracticeducationorestablished
laws to regulate the qualified practice of chiropractic. In addition, in some countries,
otherqualifiedhealthprofessionalsandlaypractitionersmayusetechniquesofspinal
manipulationandclaimtoprovidechiropracticservices,althoughtheymaynothave
receivedchiropractictraininginanaccreditedprogramme.
With the rapid growth in demand for chiropractic services, other health care
practitioners may wish to gain additional qualifications in chiropractic. Conversion
programmes have been developed to enable persons with substantial basic medical
training to acquire the additional necessary education and skills to become
chiropractors, and these could be further expanded. Such programmes should be
flexible in order to take account of different educational backgrounds and previous
medicaltraining.
In countries where no regulatory legislation currently exists, there may be no
educational, professional or legal framework governing the practice of chiropractic.
Theminimumeducationalrequirementsneededtoencouragepractitionerstoregister
and to protect patients are outlined in this document. The recognition and
implementation of these minimum requirements will depend on individual country
situations.
Objectives
Inordertofacilitatequalifiedandsafepracticeofchiropracticaswellastoprotectthe
publicandpatients,theobjectivesoftheseguidelinesare:
toprovideminimumrequirementsforchiropracticeducation
to serve as a reference for national authorities in establishing an examination
andlicensingsystemforthequalifiedpracticeofchiropractic
to review contraindications in order to minimize the risk of accidents and to
adviseonthemanagementofcomplicationsoccurringduringtreatmentandto
promotethesafepracticeofchiropractic.
Howtousethisdocument
PartI of the guidelines covers basic requirements for different training programmes,
each one designed for trainees with various educational backgrounds, including
nonmedics, physicians wishing to use chiropractic and primary health care workers.
This part provides a reference for the establishment of various training programmes,
particularlywherenoformaleducationdegreehasbeenestablished.Ifnationalhealth
authorities wish to evaluate the training programme, they may consult Councils on
ChiropracticEducationInternational(CCEIwww.cceintl.org).Thisorganizationdoes
notfunctionasanaccreditingagency,butpromotesanunderstandingofthevariations
betweenrecognizedaccreditingbodiesthroughdialogueandcommunication.
Asystemofexaminationandlicensingmaybeestablishedoradaptedonthebasisof
this training programme to ensure the competence of the trainees and to avoid the
practice of chiropractic by unqualified persons. It is to be hoped that this will deter
commercial exploitation of chiropractic education and practice, which is a significant
andgrowingprobleminsomecountries.
PartII of the guidelines deals with the safety of spinal manipulative therapy and the
contraindicationstoitsuse.
DrXiaoruiZhang
Coordinator,TraditionalMedicine
DepartmentofTechnicalCooperation
forEssentialDrugsandTraditionalMedicine
WorldHealthOrganization
2
Glossary
Glossary
Thetermsusedintheseguidelinesaredefinedasfollows.
Adjustment
Anychiropractictherapeuticprocedurethatultimatelyusescontrolledforce,leverage,
direction, amplitude and velocity, which is applied to specific joints and adjacent
tissues. Chiropractors commonly use such procedures to influence joint and
neurophysiologicalfunction.
Biomechanics
The study of structural, functional and mechanical aspects of human motion. It is
concerned mainly with external forces of either a static or dynamic nature, dealing
withhumanmovement.
Chiropractic
A health care profession concerned with the diagnosis, treatment and prevention of
disorders of the neuromusculoskeletal system and the effects of these disorders on
generalhealth.Thereisanemphasisonmanualtechniques,includingjointadjustment
and/ormanipulation,withaparticularfocusonsubluxations.
Fixation
The state whereby an articulation has become fully or partially immobilized in a
certainposition,restrictingphysiologicalmovement.
Jointmanipulation
A manual procedure involving directed thrust to move a joint past the physiological
rangeofmotion,withoutexceedingtheanatomicallimit.
Jointmobilization
Amanualprocedurewithoutthrust,duringwhichajointnormallyremainswithinits
physiologicalrangeofmotion.
Neuromusculoskeletal
Pertaining to the musculoskeletal and nervous systems in relation to disorders that
manifest themselves in both the musculoskeletal and nervous systems, including
disordersofabiomechanicalorfunctionalnature.
Palpation
(1)Theactoffeelingwiththehands.(2)Theapplicationofvariablemanualpressure
through the surface of the body for the purpose of determining the shape, size,
consistency,position,inherentmotilityandhealthofthetissuesbeneath.
Posture
(1) The attitude of the body. (2) The relative arrangement of the parts of the body.
Goodpostureisthatstateofmuscularandskeletalbalancethatprotectsthesupporting
structures of the body against injury or progressive deformity irrespective of the
attitude (erect, lying, squatting, stooping) in which the structures are working or
resting.
Spinalmanipulativetherapy
Includes all procedures where the hands or mechanical devices are used to mobilize,
adjust,manipulate,applytraction,massage,stimulateorotherwiseinfluencethespine
andparaspinaltissueswiththeaimofinfluencingthepatientshealth.
Subluxation1
A lesion or dysfunction in a joint or motion segment in which alignment, movement
integrity and/or physiological function are altered, although contact between joint
surfaces remains intact. It is essentially a functional entity, which may influence
biomechanicalandneuralintegrity.
Subluxationcomplex(vertebral)
A theoretical model and description of the motion segment dysfunction, which
incorporates the interaction of pathological changes in nerve, muscle, ligamentous,
vascularandconnectivetissue.
Thrust
Thesuddenmanualapplicationofacontrolleddirectionalforceuponasuitablepartof
thepatient,thedeliveryofwhicheffectsanadjustment.
This definition is different from the current medical definition, in which subluxation is a significant
structuraldisplacement,andthereforevisibleonstaticimagingstudies.
1
1. General considerations
1.1. Historicalinformation
Although spinal manipulation dates back to Hippocrates and the ancient Greek
physicians (4), the discovery of chiropractic is attributed to D.D.Palmer in 1895 (5),
withthefirstschoolforthetrainingofchiropractorscommencingintheUnitedStates
ofAmericainDavenport,Iowain1897(6).
Palmer developed the chiropractic theory and method from a variety of sources,
includingmedicalmanipulation,bonesettingandosteopathy,aswellasincorporating
uniqueaspectsofhisowndesign.Thetermchiropractic,derivedfromGreekrootsto
mean done by hand, originated with Palmer and was coined by a patient, the
ReverendSamuelH.Weed(7).
ChiropracticdevelopedintheUnitedStatesofAmericaduringaperiodofsignificant
reformationinmedicaltrainingandpractice.Atthetime,therewasagreatvarietyof
treatment options, both within conventional medicine and among innumerable other
alternativehealthcareapproaches(8).
1.2
Philosophyandbasictheoriesofchiropractic
Chiropractic is a health care profession concerned with the diagnosis, treatment and
prevention of disorders of the neuromusculoskeletal system and the effects of these
disorders on general health. There is an emphasis on manual techniques, including
jointadjustmentand/ormanipulation,withaparticularfocusonthesubluxation.
The concepts and principles that distinguish and differentiate the philosophy of
chiropractic from other health care professions are of major significance to most
chiropractorsandstronglyinfluencetheirattitudeandapproachtowardshealthcare.
Amajorityofpractitionerswithintheprofessionwouldmaintainthatthephilosophy
ofchiropracticincludes,butisnotlimitedto,conceptsofholism,vitalism,naturalism,
conservatism,criticalrationalism,humanismandethics(9).
The relationship between structure, especially the spine and musculoskeletal system,
andfunction,especiallyascoordinatedbythenervoussystem,iscentraltochiropractic
anditsapproachtotherestorationandpreservationofhealth(9,10:167).
It is hypothesized that significant neurophysiological consequences may occur as a
result of mechanical spinal functional disturbances, described by chiropractors as
subluxationandthevertebralsubluxationcomplex(9,10:169170,11).
Chiropractic practice emphasizes the conservative management of the
neuromusculoskeletal system, without the use of medicines and surgery (10:169170,
11). Biopsychosocial causes and consequences are also significant factors in
managementofthepatient.
Asprimarycontacthealthcarepractitioners,chiropractorsrecognizetheimportanceof
referring to other health care providers when it is in the best interests of the
patient(10).
1.3
Administrativeandacademicconsiderations
1.4
whocouldbetrained?
whatwouldbethepractitionersroleandresponsibilities?
whateducationwouldberequired?
wherewouldsucheducationbeprovided,andbywhom?
would suitable programmes have to be developed from scratch, or could
existingsubstandardcoursesbestrengthenedorappropriatelymodified?
aresuitablyqualifiedchiropracticeducatorsavailable,orwouldtheyhavetobe
trained?
what would be the mechanisms for official recognition of practitioners,
programmes,educatorsandinstitutions?
Monitoringandevaluation
In order to introduce qualified practice and proper use of chiropractic, systems are
needed to monitor the entire profession, the performance of practitioners and the
educationandtrainingofpractitioners.
Most countries that regulate the profession use national, regional, state or provincial
examinations. Alternatively, health authorities may delegate to professional
associations the right to regulate themselves and to ensure the competence of
individuals.
As has been the case in a number of countries or regions in the past, prior to the
legislative recognition of chiropractic, a government may wish to evaluate both the
positive and negative consequences of including it within the health care service (12,
13,14,15,16,17).
6
1.5
Furthereducationandcareerpossibilities
2.1
2.2
CategoryIfullchiropracticeducation
forstudentswithnopriorhealthcareeducationorexperience
as the supplementary education required for medical doctors or other
appropriatehealthcareprofessionalstoacquirearecognizedqualificationasa
chiropractor
CategoryIIlimitedchiropracticeducation
A limited training programme for medical personnel and other appropriate
healthcareprofessionalsincountriesorregionsintroducingchiropracticwhere
no current legislation governing the practice exists; it does not lead to full
qualification.
Such training should be conducted as a temporary measure to establish a
provision of chiropractic and/or as the first stage in the development of a full
chiropractic programme. Such a course is established as a minimum
registerable requirement and courses of this type should be replaced by
appropriatefulltimeprogrammesassoonasitispracticaltodoso.
7
Thetrainingrequiredtoattainaminimallyacceptablelevelofcompetencyfor
students who represent existing providers of chiropractic in countries or
regions without regulations but intending to introduce legislation governing
thepracticeofchiropractic.
Thisprovisiondoesnotleadtoafullqualification,buttoaminimalregisterable
standard. Courses of this type are a temporary measure, and should be
replacedbyappropriatefulltimeprogrammesassoonasitispracticaltodoso.
CategoryI(A)
There are many slight variations on the following models:however, in general, there
arethreemajoreducationalpathsinvolvingfulltimeeducation:
3.2
CategoryI(B)
Programmes for persons with prior medical or other health care professional
education.Suchcourseswouldvaryinlengthandsubjectrequirements,dependingon
theapplicantspreviouseducationalbackground.Foranexample,seeAnnex3.
3.3
CategoryII(A)
Conversion programmes for persons with prior medical or other health care
professional education to obtain a limited chiropractic educational qualification
should be conveniently structured, of a parttime nature, satisfying at least all the
minimumrequirementsthoughnotleadingtoafullqualification.Foranexample,see
Annex4.
3.4
CategoryII(B)
Intheseprogrammes,thecoursecontentandlengthmayalsovarygreatlydepending
upon the applicants previous training and experience. On completion of the
programmes, students will have met the requirements of a first bachelorlevel
programme in chiropractic through parttime study and acquired the necessary
knowledge and skills to provide safe, if basic, chiropractic care. Such courses do not
leadtoafullchiropracticqualification.Foranexample,seeAnnex5.
4.1
Objective
The aim at this level is to provide an education consistent with the requirements
establishedinthosecountrieswheregovernmentregulationshavebeenenacted.Based
upon this education, chiropractors practise as primarycontact health care providers,
eitherindependentlyorasmembersofhealthcareteamsatthecommunitylevelwithin
healthcarecentresorhospitals.
4.2
Entrancerequirements
4.3
Basictraining
Irrespectiveofthemodelofeducationutilized,forthosewithoutrelevantpriorhealth
care education or experience, not less than 4200 student/teacher contact hours are
required,ortheequivalent,infouryearsoffulltimeeducation.Thisincludesnotless
than1000hoursofsupervisedclinicaltraining.
4.4
Coresyllabus
4.4.1 Educationalobjectives
Competence in the practice of chiropractic requires the acquisition of relevant
knowledge, understanding, attitudes, habits and psychomotor skills. The
curriculumandthestudentevaluationprocessesshouldbedesignedtoensurethat
thechiropracticgraduatedemonstratesthefollowingskills.
He/sheshouldpossessacomprehensiveunderstandingandcommandof theskills
andknowledgethatconstitutethebasisofchiropracticinitsroleasahealthcare
profession,asfollows:
achieve a fundamental knowledge of health sciences, with a particular
emphasis on those related to vertebral subluxation and the
neuromusculoskeletalsystems;
achieveacomprehensivetheoreticalunderstandingofthebiomechanics
ofthehumanlocomotorsysteminnormalandabnormalfunctionand,
inparticular,possesstheclinicalabilityneededforanexpertassessment
ofspinalbiomechanics;
appreciatechiropractichistoryandtheuniqueparadigmofchiropractic
healthcare;
achieve a level of skill and expertise in the manual procedures
emphasizing spinal adjustment/manipulation regarded as imperative
withinthechiropracticfield;
possesstheabilitytodecidewhetherthepatientmaysafelyandsuitably
be treated by chiropractic or should be referred to another health
professionalorfacilityforseparateorcomanagedcare.
10
He/sheshouldbeableto:
applyfundamentalscientificknowledgeofthehumanbody
understand the nature of normal and abnormal biomechanics and
posture, as well as the pathophysiology of the neuromusculoskeletal
systemanditsrelationshiptootheranatomicalstructures
establishasatisfactoryrapportwithpatients
gather and record clinical information and communicate such
information
accuratelyinterpretclinicallaboratoryfindingsanddiagnosticimaging
oftheneuromusculoskeletalsystem
establishanaccurateclinicaldiagnosis
acceptresponsibilityforthepatientswelfare
applysoundjudgmentindecidingonappropriatecare
providecompetenttreatment
providecompetentcontinuinghealthcare
understandtheapplicationofcontemporarymethodsandtechniquesin
wellnesscare
accepttheresponsibilitiesofachiropractor
appreciatetheexpertiseandscopeofchiropracticandotherhealthcare
professions in order to facilitate intradisciplinary and interdisciplinary
cooperationandrespect
select research subjects, design simple research projects, critically
appraise clinical studies and participate in multidisciplinary research
programmes
commit to the need for lifelong learning and ongoing professional
development.
4.4.2 Basicsciencecomponents
Recognized programmes either require essential basic science components as
prerequisites,orincludenecessaryunitsofchemistry,physicsandbiologywithinthe
firstyearcurriculum.
4.4.3 Preclinicalsciencecomponents
Thepreclinicalsciencecomponentswithinchiropracticprogrammesgenerallyinclude:
anatomy, physiology, biochemistry, pathology, microbiology, pharmacology
andtoxicology,psychology,dieteticsandnutrition,andpublichealth.
4.4.4 Clinicalsciencecomponents
Clinicalsciencecomponentswouldincludeorcover:
historytaking skills, general physical examination, laboratory diagnosis,
differentialdiagnosis,radiology,neurology,rheumatology,eyes,ears,noseand
11
Chiropracticsciencesandadditionalsubjects
Thesegenerallyinclude:
appliedneurologyandappliedorthopaedics;
history,principlesandhealthcarephilosophypertinenttochiropractic;
ethicsandjurisprudencepertainingtothepracticeofchiropractic;
4.4.6
Including:
manualprocedures,particularlyspinaladjustment,spinalmanipulation,other
jointmanipulation,jointmobilization,softtissueandreflextechniques;
exercise,rehabilitativeprogrammesandotherformsofactivecare;
psychosocialaspectsofpatientmanagement;
patient education on spinal health, posture, nutrition and other lifestyle
modifications;
emergencytreatmentandacutepainmanagementproceduresasindicated;
other supportive measures, which may include the use of back supports and
orthotics;
recognition of contraindications and risk management procedures, the
limitationsofchiropracticcare,andoftheneedforprotocolsrelatingtoreferral
tootherhealthprofessionals.
4.4.7 Documentationandclinicalrecordkeeping
Including:
12
4.4.8
consentobligations;
insuranceandlegalreporting.
Research
Including:
basicresearchmethodologyandbiostatistics;
interpretation of evidencebased procedures/protocols and bestpractice
principles;
an epidemiological approach to clinical recordkeeping, encouragement to
documentparticularcasestudiesandparticipateinfieldresearchprojects;
development of a criticalthinking approach in clinical decisionmaking, the
considerationofpublishedpapersandrelevantclinicalguidelines;
development of the necessary skills to keep abreast of the relevant current
researchandliterature.
5.1
Objective
5.2
Specialcourses
5.3
Basictraining
The duration of the training depends upon the credits received from previous
educationandexperience,butshouldnotbelessthan2200hoursoveratwoorthree
13
year fulltime or parttime programme, including not less than 1000 hours of
supervisedclinicalexperience.
6.1
Objective
6.2
Specialcourses
The programme is designed to cover those subjects which are important for the
practice of chiropractic and which have not been covered appropriately in previous
healthcareeducation.
Parttime courses have been designed to be convenient for practitioners maintaining
their current employment, extending appropriate credits to persons depending upon
theirlevelofhealthcaretraining.Foranexample,seeAnnex4.
6.3
Basictraining
Althoughdependentuponthehumanresourcesavailableforhealthcare,theentrance
requirementwouldnormallybecompletionofuniversityleveltrainingasahealthcare
practitioner.
14
Thedurationoftrainingwouldbenotlessthan1800hoursoveratwoorthreeyear
fulltime or parttime programme, including not less than 1000 hours of supervised
clinicalexperience.
7.1
Objective
To upgrade the knowledge and skills of existing practitioners utilizing some form of
chiropractic, for the purpose of ensuring public safety and provision of adequate
chiropracticservice.Thisapproachshouldbeemployedasaninterimmeasureonly.
7.2
Specialcourses
Astheexistingtrainingofpractitionersvariesgreatly,theeducationalmodelsadopted
toaddressthesesituationsalsovary.Pastexperiencesuggeststhatthedevelopmentof
coursesmayrequirespecificneedsassessmentstudies.
TheexampleusedinAnnex5isabasicthreeyear,parttimeprogrammedesignedto
meet or exceed the minimum requirements. The applicant practitioners are offered
creditsorconsiderationsbasedupontheirprevioustrainingorexistingqualifications.
Admission requirements for such programmes have been the completion of a
qualifyinglocalprogrammeandanadequateperiodofclinicalexperience,typically2
3years.
Programmes of this type should strongly consider the value of having an accredited
chiropracticprogrammeasacollaborativepartnerprovidingeducationalguidance.
7.3
Basictraining
The duration of training is not less than 2500 hours in a fulltime or parttime
programme, including not less than 1000 hours of supervised clinical experience. For
anexample,seeAnnex5.
15
Primaryhealthcareworkersmyotherapists
9.2
Objective
Theobjectiveofsuchcoursesistocreateacategoryofprimaryhealthcareworkerto
provideafirstleveloftreatmentandeducationinacommunitysettingasanadjunctto
othercommunityhealthcaremeasures.
16
9.3
Coursecomponents
Coursescontainacombinationofflexible,compulsoryandelectiveunitsthataddress
variouscompetenciestomeetexistingrequirementsonsite.Thesemayinclude:
remedialmassage;
specificmyotherapytechniques;
culturallyappropriatehealthandlifestyleadvice;
addressing modifiable musculoskeletal risk factors, such as maintaining ideal
weightandphysicalactivity,smokingcessationandinjuryprevention;
musculoskeletalassessment;
triggerpointtechniques;
myofascialtensiontechnique;
deeptissuestimulationtechnique;
stretchingtechniques;
sportsinjuryfirstaid(includingtapingandbracingtechniques).
9.4
Methodanddurationoftraining
17
18
1. Introduction
Whenemployedskilfullyandappropriately,chiropracticcareissafeandeffectivefor
thepreventionandmanagementofanumberofhealthproblems.Thereare,however,
known risks and contraindications to manual and other treatment protocols used in
chiropracticpractice.
Whileit isbeyondthescopeoftheseguidelinestoreviewthevarious indicationsfor
chiropractic care and the supportive research evidence, this part will review
contraindications to the primary therapeutic procedures used by chiropractors
techniques of adjustment, manipulation and mobilization, generally known as spinal
manipulativetherapy.
Contrary to the understanding of many within health care, chiropractic is not
synonymous with, or limited to, the application of specific manipulative techniques.
The adjustment and various manual therapies are central components of a
chiropractors treatment options: however, the profession as an established primary
contact health service has the educational requirements and respects the
responsibilitiesassociatedwithsuchastatus.
Chiropractic practice involves a general and specific range of diagnostic methods,
includingskeletalimaging,laboratorytests,orthopaedicandneurologicalevaluations,
as well as observational and tactile assessments. Patient management involves spinal
adjustment and other manual therapies, rehabilitative exercises, supportive and
adjunctive measures, patient education and counselling. Chiropractic practice
emphasizes conservative management of the neuromusculoskeletal system, without
theuseofmedicinesandsurgery.
19
2.1
Absolutecontraindicationstospinalmanipulativetherapy
Itshouldbeunderstoodthatthepurposeofchiropracticspinalmanipulativetherapyis
to correct a joint restriction or dysfunction, not necessarily to influence the disorders
identified,whichmaybecoincidentallypresentinapatientundergoingtreatmentfora
different reason. Most patients with these conditions will require referral for medical
careand/orcomanagement(33).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
anomaliessuchasdenshypoplasia,unstableosodontoideum,etc.
acutefracture
spinalcordtumour
acute infection such as osteomyelitis, septic discitis, and tuberculosis of
thespine
meningealtumour
haematomas,whetherspinalcordorintracanalicular
malignancyofthespine
frank disc herniation with accompanying signs of progressive
neurologicaldeficit
basilarinvaginationoftheuppercervicalspine
ArnoldChiarimalformationoftheuppercervicalspine
dislocationofavertebra
aggressive types of benign tumours, such as an aneurismal bone cyst,
giantcelltumour,osteoblastomaorosteoidosteoma
internalfixation/stabilizationdevices
neoplasticdiseaseofmuscleorothersofttissue
positiveKernigsorLhermittessigns
congenital,generalizedhypermobility
signsorpatternsofinstability
syringomyelia
hydrocephalusofunknownaetiology
diastematomyelia
caudaequinasyndrome
21
Articularderangement
22
3.2
Boneweakeninganddestructivedisorders
3.3
Circulatoryandhaematologicaldisorders
3.4
Neurologicaldisorders
23
3.5
Psychologicalfactors
Electrotherapies
4.2
Exercisesandsupplementarysupportivemeasures
24
Causesofcomplicationsandadversereactions
SeeHenderson(42):
5.2
lackofknowledge
lackofskill
lackofrationalattitudeandtechnique.
Examplesofinappropriatepractices
SeeHenderson(42):
5.3
inadequatediagnostichabits
inadequatediagnosticimagingevaluation
delayinreferral
delayinreevaluation
lackofinterprofessionalcooperation
failuretotakeintoaccountpatienttolerances
poortechniqueselectionorimplementation
excessiveorunnecessaryuseofmanipulation.
Seriousadverseconsequences
5.3.1 Cervicalregion
vertebrobasilaraccidents(seepart2,section3.3above)
Hornerssyndrome(44)
diaphragmaticparalysis(45)
myelopathy(46)
cervicaldisclesions(25:66)
pathologicalfractures(47,48)
5.3.2 Thoracicregion
ribfractureandcostochondralseparation(49)
25
5.3.3 Lumbarregion
5.4
anincreaseinneurologicalsymptomsthatoriginallyresultedfromadiscinjury
(50)
caudaequinasyndrome(51,52)
lumbardischerniation(52)
ruptureofabdominalaorticaneurysm(53)
Vascularaccidents
Understandably, vascular accidents are responsible for the major criticism of spinal
manipulative therapy. However, it has been pointed out that critics of manipulative
therapyemphasizethepossibilityofseriousinjury,especiallyatthebrainstem,dueto
arterialtraumaaftercervicalmanipulation.Ithasrequiredonlytheveryrarereporting
oftheseaccidentstomalignatherapeuticprocedurethat,inexperiencedhands,gives
beneficialresultswithfewadversesideeffects(43).
In very rare instances, the manipulative adjustment to the cervical spine of a
vulnerablepatientbecomesthefinalintrusiveactwhich,almostbychance,resultsina
veryseriousconsequence(54,55,56,57).
5.4.1 Mechanism
Vertebrobasilar artery insufficiency is the result of transient, partial or complete
obstruction of one or both of the vertebral arteries or its branches. The signs and
symptomsofvertebralarterysyndromearisingfromthatcompressionincludevertigo,
dizziness, lightheadedness, giddiness, disequilibria, ataxia, walking difficulties,
nausea and/or vomiting, dysphasia, numbness to one side of the face and/or body,
suddenandsevereneck/headpainafterspinalmanipulativetherapy(43:579).
Mostcasesofarterialthrombosisandinfarctiongenerallyoccurintheelderlyandare
spontaneousandunrelatedtotrauma.
5.4.2 Incidence
Vertebral artery syndrome attributed to cervical manipulation occurs in younger
patients.Theaverageageisunder40,anditoccursmoreofteninwomenthanmen.In
1980, Jaskoviak estimated that five million treatments had been given at National
CollegeofChiropracticclinicsovera15yearperiod,withoutasinglecaseofvertebral
arterysyndromeassociatedwithmanipulation(58).
While it is understood that the actual incidence of cerebral vascular injury could be
higherthanthenumberofreportedincidents,estimatesfromrecognizedauthoritiesin
researchinthisareahavevariedfromaslittleasonefatalityinseveraltensofmillions
ofmanipulations(59),onein10million(60)andoneinonemillion(61)totheslightly
moresignificantoneimportantcomplicationin400000cervicalmanipulations(62).
26
Serious complications are very rare, and it would seem unlikely that the adverse
occurrenceshavebeensolelyattributabletothetherapeuticintervention.
5.5 Preventionofcomplicationsfrommanipulation
Incidents and accidents that result from manipulative therapy can be prevented by
careful appraisal of the patients history and examination findings. Information must
be sought about coexisting diseases and the use of medication, including longterm
steroiduseandanticoagulanttherapy.Adetailedandmeticulousexaminationmustbe
carriedout. Theuseof appropriatetechniques isessential,andthechiropractormust
avoidtechniquesknowntobepotentiallyhazardous(19:234235).
27
28
List of participants
WHOConsultationonChiropractic
24December2004,Milan,Italy
Participants
Dr Abdullah Al Bedah, Supervisor, Complementary and Alternative Medicine,
MinistryofHealth,Riyadh,SaudiArabia
Dr Maurizio Amigoni, Deputy DirectorGeneral, DirectorateGeneral of Health,
LombardyRegion,Milan,Italy
Dr Sassan Behjat, Coordinator, Office of Complementary and Alternative Medicine,
MinistryofHealth,AbuDhabi,UnitedArabEmirates
Ms Anna Caizzi, Director of Consumer Protection and Support to the Commercial
System Structure, DirectorateGeneral of Markets, Fairs and Congresses, Lombardy
Region,Milan,Italy
DrMartinCamara,BoardMember,PhilippineInstituteofTraditionalandAlternative
HealthCare(PITAHC),MakatiCity,Philippines(CoRapporteur)
Dr Margaret Coats, Chief Executive & Registrar, General Chiropractic Council,
London,England
Dr Alessandro Discalzi, DirectorateGeneral of Family and Social Solidarity,
LombardyRegion,Milan,Italy
Mr Igwe Lawrence Eleke, Assistant Director, National Traditional Medicine
DevelopmentProgramme,FederalMinistryofHealth,Abuja,Nigeria1
MrMichaelFox,ChiefExecutive,PrinceofWalessFoundationforIntegratedHealth,
London,England
DrRicardoFujikawa,CentroUniversitarioFeevale,NovoHamburgo,Brazil
Dr Edward Tintak Lee, Chairman,Chiropractors Council, Hong Kong SAR, Peoples
RepublicofChina(CoChairperson)
Professor JeanPierre Meersseman, Chiropractor, Italian Chiropractic Association,
Genova,Italy
Unabletoattend.
29
ProfessorEmilioMinelli,WHOCollaboratingCentreforTraditionalMedicine,Centre
ofResearchinBioclimatology,BiotechnologiesandNaturalMedicine,StateUniversity
ofMilan,Milan,Italy
DrKoichiNakagaki,KokusaiChiropracticSchool,Osaka,Japan
Dr Susanne Nordling, Chairman, Nordic Cooperation Committee for Non
conventional Medicine (NSK), Committee for Alternative Medicine, Sollentuna,
Sweden
Ms Lucia Scrabbi, Planning Unit, DirectorateGeneral of Health, Lombardy Region,
Milan,Italy
ProfessorVladimirS.Shoukhov,HealthOfficer,InternationalFederationofRedCross
andRedCrescentSocieties(IFRCRC),Moscow,RussianFederation
Professor Umberto Solimene, Director, WHO Collaborating Centre for Traditional
Medicine, Centre of Research in Bioclimatology, Biotechnologies and Natural
Medicine,StateUniversityofMilan,Milan,Italy
DrJohnSweaney,NewLambton,Australia(CoRapporteur)
Dr U Sein Win, Director, Department of Traditional Medicine, Ministry of Health,
Yangon,Myanmar(CoChairperson)
Representativesofprofessionalorganizations
WorldChiropracticAlliance(WCA)
Dr Asher Nadler, Member of the International Board, Israel Doctors of Chiropractic,
Jerusalem,Israel
DrYannickPauli,WCALiaisontoWHO,Lausanne,Switzerland
WorldFederationofChiropractic(WFC)
DrDavidChapmanSmith,SecretaryGeneral,Toronto,Ontario,Canada
DrAnthonyMetcalfe,President,Teddington,Middlesex,England
Localsecretariat
Ms Elisabetta Minelli, International Relations Office, WHO Collaborating Centre for
Traditional Medicine, State University of Milan, Liaison with Planning Unit,
DirectorateGeneralofHealth,LombardyRegion,Milan,Italy
30
List of participants
WHOSecretariat
DrSamvelAzatyan,TechnicalOfficer,TraditionalMedicine,DepartmentofTechnical
Cooperation for Essential Drugs and Traditional Medicine, World Health
Organization,Geneva,Switzerland
Dr Xiaorui Zhang, Coordinator, Traditional Medicine, Department of Technical
Cooperation for Essential Drugs and Traditional Medicine, World Health
Organization,Geneva,Switzerland
31
32
Annex 2:
A sample four-year, full-time accredited
programme
CategoryI(A)Subjectstaughtinatypicalsemesterbasedchiropracticprogramme,byyearand
numberofhours.
DIVISION
Biological
Sciences
FIRST YEAR
(HOURS)
Human Anatomy
(180)
Microscopic
Anatomy (140)
Neuroanatomy
(72)
Neuroscience I
(32)
Biochemistry (112)
Physiology (36)
SECOND YEAR
(HOURS)
Pathology (174)
Lab Diagnosis (40)
Microbiology &
Infectious Disease
(100)
Neuroscience II (85)
Nutrition (60)
Immunology (15)
Clinical Sciences
Normal
Radiographic
Anatomy (16)
Radiation
Biophysics and
Protection (44)
Chiropractic
Sciences
Chiropractic
Principles I (56)
Basic Body
Mechanics (96)
Chiropractic Skills I
(100)
Chiropractic Principles
II (60)
Chiropractic Skills II
(145)
Spinal Mechanics (40)
Clinical
Practicum
Observation I (30)
914
Orthopaedics &
Rheumatology (90)
Neuro. Diagnosis (40)
Diagnosis &
Symptomatology (120)
Differential Diagnosis
(30)
Radiological Technology
(40)
Arthritis & Trauma (48)
Chiropractic Principles
III (42)
Clinical Biomechanics
(100)
Chiropractic Skills III
(145)
Auxiliary Chiropractic
Therapy (60)
Introduction to
Jurisprudence & Practice
Development (16)
Observation II (70)
962
Research
Totals
TOTAL HOURS
Full-time
study over
four years:
THIRD YEAR
(HOURS)
FOURTH YEAR
(HOURS)
Clinical Psychology
(46)
Emergency Care (50)
Child Care (20)
Female Care (30)
Geriatrics (20)
Abdomen, Chest &
Special Radiographic
Procedures (40)
Integrated
Chiropractic Practice
(90)
Jurisprudence &
Practical
Development (50)
Internship (750)
Clerkships: Auxiliary
Therapy (30); Clinical
Lab (20)
Clinical X-ray:
Technology (70);
Interpretation (70)
Observer IV (30)
Research
Investigative Project
1382
4465
plus research
project
33
34
Annex 3:
A sample full (conversion) programme
CategoryI(B) Essentially, conversion programmes are dependent upon assessment of the
medicaltrainingofthestudentcohort.Theyarethendesignedsoastocompletesatisfactorily
allrequirementsofafullchiropracticprogramme.
DIVISION
SECOND YEAR
(HOURS)
Biological Sciences
Pathology (120)
Clinical Sciences
Radiology (90)
Neuromusculoskeletal
Diagnosis (30)
Radiology (90)
Neurology (45)
Physical Diagnosis (30)
Neuromusculoskeletal
Diagnosis (30)
Chiropractic Sciences
Clinical Practicum
Research
TOTALS
TOTAL HOURS Full-time
or part-time study over
three years
THIRD YEAR
(HOURS)
Clinical Nutrition
(45)
Paediatrics (45)
Geriatrics (30)
Principles &
Philosophy of
Chiropractic (20)
Chiropractic Skills
(60)
Supervised Clinical
Practicum (225)
Supervised Clinical
Practicum (500)
Research (25)
725
740
2205
35
36
Annex 4:
A sample limited (conversion) programme
CategoryII(A) Suitable for persons with a solid medical education to attain minimal
registerablerequirementstopractisesafelyandrelativelyeffectivelyaschiropractors.
DIVISION
SECOND YEAR
(HOURS)
THIRD YEAR
(HOURS)
Biological Sciences
Pathology (60)
Clinical Sciences
Paediatrics (45)
Geriatrics (30)
Supervised Clinical
Practicum (220)
600
Supervised Clinical
Practicum (420)
605
Chiropractic Sciences
Clinical Practicum
TOTAL
TOTAL HOURS
Part-time study
over three years
37
38
Annex 5:
A sample limited (standardization) programme
CategoryII(B) Addresses deficiencies identified through assessment of a students existing
knowledgeandskillsandenablesgraduatestoattainsafeandminimalregisterablestandards
aschiropractors.
FIRST YEAR
DL
IR
CP
Anatomy
56
24
Biochemistry
56
Physiology
56
Pathology
70
12
Public Health
56
Clinical
Nutrition
56
Clinical Sciences
Biological
Sciences
DIVISION
Chiropractic
Sciences
Biomechanics
42
DL
Laboratory
Diagnosis
42
Physical
Diagnosis
56
14
Orthopaedics/
Neurology
56
14
Radiology
56
16
Clinical
Diagnosis
56
IR
CP
Patient
Management
Procedures
42
18
Research
400
Totals
Computer
Skills
Workshop
448
TOTAL
HOURS
Part-time
study over
three years
2790
71
406
THIRD YEAR
DL
IR
70
20
70
20
70
20
70
20
Special
Population Care
56
24
Record Keeping,
Documentation &
Quality
Assurance
42
16
Head/Cervical
Spine Care
Thoracic/Lumbar
Spine & Pelvis
Care
Hip/Knee/Ankle/
Foot Care
Shoulder/Elbow/
Wrist/Hand Care
16
Clinical
Practicum
Principles of
Chiropractic
56
SECOND
YEAR
400
Research
Methodology
50
First
Aid/Emergency
Care
28
24
486
103
400
CP
400
378
100
400
39
40
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