129084963 Estudios Quiropraxia

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WHOguidelineson

basictrainingandsafety

inchiropractic

Geneva

2005


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WHOLibraryCataloguinginPublicationData

WorldHealthOrganization.

WHOguidelinesonbasictrainingandsafetyinchiropractic.

1.Chiropractic education 2.Chiropractic standards 3.Guidelines I.Title.

ISBN9241593717 (NLMclassification:WB905.7)

WorldHealthOrganization2005

Allrightsreserved.PublicationsoftheWorldHealthOrganizationcanbeobtainedfromWHO

Press,WorldHealthOrganization,20AvenueAppia,1211Geneva27,Switzerland(tel:+4122

791 2476; fax: +41 22 791 4857; email: [email protected]). Requests for permission toreproduceortranslateWHOpublicationswhetherforsaleorfornoncommercialdistribution

should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; email:

[email protected]).

The designations employed and the presentation of the material in this publication do not

implytheexpressionofanyopinionwhatsoeveronthepartoftheWorldHealthOrganization

concerning the legal status of any country, territory, city or area or of its authorities, or

concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent

approximateborderlinesforwhichtheremaynotyetbefullagreement.

Themention

of

specific

companies

or

of

certain

manufacturers

products

does

not

imply

that

theyareendorsedorrecommendedbytheWorldHealthOrganizationinpreferencetoothersof

a similar nature that are not mentioned. Errors and omissions excepted, the names of

proprietaryproductsaredistinguishedbyinitialcapitalletters.

AllreasonableprecautionshavebeentakenbyWHOtoverifytheinformationcontainedinthis

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lies with the reader. In no event shall the World Health Organizationbe liable for damages

arisingfromitsuse.

Printed

in

Switzerland


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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

Philosophyand

basic

theories

of

chiropractic .................... ...................... ..................... ..................... 5

1.3 Administrativeandacademicconsiderations .................................................................................... 6

1.4 Monitoringandevaluation ...................... ...................... ...................... ...................... ...................... ..... 6

1.5 Furthereducationandcareerpossibilities ...................... ...................... ....................... ...................... . 7

2. Acceptablelevelsofeducationandretraining......................................................................................... 7

2.1 CategoryI fullchiropracticeducation............................................................................................... 7

2.2 CategoryII limitedchiropracticeducation....................................................................................... 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. Assessmentandexamination ofstudentsinchiropractic................................................................... 16


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9. Primaryhealthcareworkers andchiropractic....................................................................................... 16

9.1 Primaryhealthcareworkers myotherapists .................................................................................. 16

9.2 Objective................................................................................................................................................ 16

9.3 Coursecomponents.............................................................................................................................. 17

9.4 Methodanddurationoftraining ....................................................................................................... 17

Part2:Guidelinesonsafety ofchiropractic .................................................................. 19

1. Introduction.................................................................................................................................................. 19

2. Contraindicationstospinalmanipulativetherapy ..................... ....................... ...................... ............. 20

2.1 Absolutecontraindicationstospinalmanipulativetherapy .......................................................... 21

3. Contraindicationstojointmanipulation bycategoryofdisorder..................................................... 22

3.1 Articularderangement ........................................................................................................................ 22

3.2 Boneweakeninganddestructivedisorders...................................................................................... 23

3.3 Circulatoryandhaematologicaldisorders........................................................................................ 23

3.4 Neurologicaldisorders .................... ...................... ...................... ....................... ...................... ........... 233.5 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

5.5

Preventionof

complications

from

manipulation ....................... ....................... ...................... ......... 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


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i

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 DrJohn 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 toparticipants of the WHOConsultationonChiropractic (see

Annex1),whoworked 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.


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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 theonlypossibility forhealthprotection,butalso indevelopedcountries.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

appropriateuseofmethodswhich, ifusedcorrectly,cancontribute to theprotectionand

enhancement of citizens health and wellbeing. 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 undertakenby 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 hasbeen developed accordingly thanks to a

series of administrative provisions. The fouryear cooperation planbetween 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

appropriateasresourcesnotonly for theLombardyRegion,butalso forvariouscountry

situationsworldwide.With this inmind, thisdocument is tobeconsideredan important

reference

point

for

those,

among

practitioners,

political

and

administrative

authorities,

that

wantchiropractictobeasafeandefficaciousaidforcitizenshealthandforanyregulatory

andlicensingact.

AlessandroC

RegionalMinisterofHealth

RegionalGovernmentofLombardy

GiancarloAbelli

RegionalMinisterofFamilyandSocialSolidarity

RegionalGovernmentofLombardy

ii


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Introduction

1

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,productsandpractices innationalhealth

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. Conversionprogrammes havebeen developed to enable persons with substantialbasic 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 educationalbackgrounds 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.


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Guidelines on basic training and safety in chiropractic

2

In some countries with educational limitations, lack of financial resources or

unsatisfactory integration of indigenous communities into mainstream society,

primaryhealthcareworkersspecifically trained in myotherapymayhelp to enhance

health care services. This may also form thebasis for introducing some chiropractic

principles of health care and therapeutic interventions into national health systems

which would otherwise be unavailable for the management of common

musculoskeletal conditions and the optimization of health. Such programmes are

identifiedinPart1,Section9below.

Objectives

Inordertofacilitatequalifiedandsafepracticeofchiropracticaswellastoprotectthe

publicandpatients,theobjectivesoftheseguidelinesare:

to

provide

minimum

requirements

for

chiropractic

education

to serve as a reference for national authorities in establishing an examinationandlicensingsystemforthequalifiedpracticeofchiropractic

to review contraindications in order to minimize the risk of accidents and toadviseonthemanagementofcomplicationsoccurringduringtreatmentandto

promotethesafepracticeofchiropractic.

Howtousethisdocument

PartI of the guidelines coversbasic 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.

Thispartprovidesa reference for the establishment ofvarious 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 chiropracticby unqualified persons. It is tobe hoped that this will deter

commercial exploitation of chiropractic education and practice, which is a significant

andgrowingprobleminsomecountries.

PartIIof theguidelinesdeals with thesafetyofspinalmanipulative therapyand the

contraindicationstoitsuse.

DrXiaoruiZhang

Coordinator,TraditionalMedicine

DepartmentofTechnicalCooperation

forEssential

Drugs

and

Traditional

Medicine

WorldHealthOrganization


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Glossary

3

Glossary

Thetermsusedintheseguidelinesaredefinedasfollows.

Adjustment

Anychiropractictherapeuticprocedurethatultimatelyusescontrolledforce,leverage,

direction, amplitude and velocity, which is applied to specificjoints 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 hasbecome fully or partially immobilized in acertainposition,restrictingphysiologicalmovement.

Jointmanipulation

A manual procedure involving directed thrust to move ajoint past thephysiological

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.


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Posture

(1) The attitude of thebody. (2) The relative arrangement of the parts of thebody.

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

Includesallprocedures where thehandsormechanicaldevicesareused tomobilize,

adjust,manipulate,applytraction,massage,stimulateorotherwiseinfluencethespine

andparaspinaltissueswiththeaimofinfluencingthepatientshealth.

Subluxation1

A lesion or dysfunction inajointormotion 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.

1 This definition is different from the current medical definition, in which subluxation is a significant

structuraldisplacement,andthereforevisibleonstaticimagingstudies.


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Basic training in chiropractic

5

Part 1: Basic training in chiropractic

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).


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The relationshipbetween 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 assubluxationandthevertebralsubluxationcomplex(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

The training of chiropractors involves certain administrative and academic

considerations,forexample:

whocouldbetrained? whatwouldbethepractitionersroleandresponsibilities? whateducationwouldberequired? wherewouldsucheducationbeprovided,andbywhom? would suitable programmes have to be developed from scratch, or could

existingsubstandardcoursesbestrengthenedorappropriatelymodified?

aresuitablyqualifiedchiropracticeducatorsavailable,orwouldtheyhavetobetrained?

what would be the mechanisms for official recognition of practitioners,programmes,educatorsandinstitutions?

1.4 Monitoringandevaluation

In order to introduce qualified practice and proper use of chiropractic, systems areneeded 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 hasbeen the case in a number of countries or regions in the past, prior to the

legislative recognition of chiropractic, a government may wish to evaluateboth the

positiveandnegativeconsequencesof including itwithin thehealthcareservice (12,

13,14,15,16,17).


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1.5 Furthereducationandcareerpossibilities

It is recognized that, as an interim measure prior to the establishment of a full

chiropractic programme, it maybe necessary to provide limited programmes to

supplementexistinghealthcareeducation,inordertobegintoregisterchiropractorsin

these countries and ensure qualified practice of chiropractic. How countries will

recognizechiropractorswithlimitedprogrammeswillvaryaccordingtoindividual

countrysituations.

Practitioners with limited or no formal chiropractic education, practising as

chiropractors,should upgrade theireducation to meet the requirements laid down

bytheirgovernmentwhenregulationsareput intoplace. Inthiswaysuchpersonnel

canbeeffectivelyincorporatedintothedomesticprofessionalworkforce.

2. Acceptable levels of education andretraining

Summarizing various training programmes in different countries, these guidelines

address two levels and four different settings for chiropractic education, eachpreparing health care practitioners to practise in the health care system as a

chiropractor.Theseoptionsareavailabletocountriestomeettheirindividualneeds.

2.1 CategoryI fullchiropracticeducation

forstudentswithnopriorhealthcareeducationorexperience as the supplementary education required for medical doctors or other

appropriatehealthcareprofessionalstoacquirearecognizedqualificationasa

chiropractor

2.2 CategoryII limitedchiropracticeducation

A limited trainingprogrammeformedicalpersonnel and other appropriatehealthcareprofessionalsincountriesorregionsintroducingchiropracticwhere

no current legislationgoverning thepractice exists; it does not lead tofull

qualification.

Such training should be conducted as a temporary measure to establish a

provisionofchiropracticand/oras the firststage in thedevelopmentofa full

chiropractic programme. Such a course is established as a minimum

registerable requirement and courses of this type should be replaced by

appropriatefulltimeprogrammesassoonasitispracticaltodoso.


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Thetrainingrequiredtoattainaminimallyacceptablelevelofcompetencyforstudents who represent existing providers of chiropractic in countries or

regionswithout regulations but intending to introduce legislationgoverning

thepracticeofchiropractic.

Thisprovisiondoesnotleadtoafullqualification,buttoaminimalregisterable

standard. Courses of this type are a temporary measure, and should be

replacedbyappropriatefulltimeprogrammesassoonasitispracticaltodoso.

3. Models of chiropractic education

3.1

CategoryI(A)

Therearemanyslightvariationson thefollowingmodels:however, ingeneral,there

arethreemajoreducationalpathsinvolvingfulltimeeducation:

A fouryear fulltime programme within specifically designated colleges oruniversities, following 14years of suitable prechiropractic training inbasic

sciencesatuniversitylevel;foranexample,seeAnnex2.

Afiveyearbachelorintegratedchiropracticdegreeprogrammeofferedwithinapublicorprivateuniversity,withstudententrancebasedupontheapplicants

matriculation status and the universitys admission requirements and quota

restrictions.

A two or threeyear preprofessional Masters programme following thesatisfactorycompletion of a specifically designedbachelor degree programme

inchiropracticorasuitablyadaptedhealthsciencedegree.

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

shouldbe conveniently structured, of a parttime nature, satisfying at least all the

minimumrequirementsthoughnotleadingtoafullqualification.Foranexample,see

Annex4.


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9

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, ifbasic, chiropractic care. Such courses do not

leadtoafullchiropracticqualification.Foranexample,seeAnnex5.

4. Full chiropractic education category I(A)

Thisrefers to the trainingprogramme forpersonswithoutpreviousmedicalorotherhealthcareprofessionaleducation.

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

health

care

centres

or

hospitals.

4.2 Entrancerequirements

An acceptable applicant would have completed secondary schooling, university

entranceoritsequivalentwithappropriatetraininginbasicsciences,asrequiredbythe

particularprogramme.

4.3 Basictraining

Irrespectiveofthemodelofeducationutilized,forthosewithoutrelevantpriorhealth

care education or experience, not less than 4200 student/teacher contact hours are

required,ortheequivalent,infouryearsoffulltimeeducation.Thisincludesnotless

than1000hoursofsupervisedclinicaltraining.


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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/sheshouldpossessacomprehensiveunderstandingandcommandoftheskills

andknowledgethatconstitutethebasisofchiropracticinitsroleasahealthcare

profession,asfollows:

achieve a fundamentalknowledgeof healthsciences, with a particularemphasis on those related to vertebral subluxation and the

neuromusculoskeletalsystems;

achieveacomprehensivetheoreticalunderstandingofthebiomechanicsofthehuman locomotorsysteminnormalandabnormalfunctionand,

inparticular,possesstheclinicalabilityneededforanexpertassessment

ofspinalbiomechanics;

appreciatechiropractichistoryandtheuniqueparadigmofchiropractichealthcare;

achieve a level of skill and expertise in the manual proceduresemphasizing spinal adjustment/manipulation regarded as imperative

withinthechiropracticfield;

possess

the

ability

to

decide

whether

the

patient

may

safely

and

suitably

be treated by chiropractic or should be referred to another health

professionalorfacilityforseparateorcomanagedcare.

He/she should perform at the clinical level expected of a primarycontact

healthcarepractitioner,asfollows:

competently perform a differential diagnosis of the complaintspresentedbypatients;

achieve particular expertise in diagnostic imaging, orthopaedics, painmanagement and rehabilitation of the neuromusculoskeletal system

and/ordiagnosis

and

management

of

vertebral

subluxation;

achievecompetenceininterpretingclinicallaboratoryfindings; acquiretheabilitytoappraisescientificandclinicalknowledgecritically: understandandapplyfundamentalscientific/medical information,and

be capable of consulting with and/or referring to other health care

providers;

generally possesses the necessary knowledge and skill to serve andcommunicate with members of the public in an effective and safe

manner.


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11

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

accurately interpretclinical laboratoryfindingsanddiagnosticimagingoftheneuromusculoskeletalsystem

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, criticallyappraise clinical studies and participate in multidisciplinary research

programmes

commit to the need for lifelong learning and ongoing professionaldevelopment.

4.4.2 Basicsciencecomponents

Recognized programmes either require essential basic science components as

prerequisites,orincludenecessaryunitsofchemistry,physicsandbiologywithinthe

firstyearcurriculum.

4.4.3

Preclinical

science

components

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


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12

throat, orthopaedics,basic paediatrics,basic geriatrics,basic gynaecology and

obstetrics,andbasicdermatology.

4.4.5 Chiropracticsciencesandadditionalsubjects

Thesegenerallyinclude:

appliedneurologyandappliedorthopaedics; clinical biomechanics, including, specific chiropractic/biomechanical patientassessmentbymethodssuchas:

gaitandposturalanalysis; staticandmotionpalpationofjointsandbonystructures; assessmentofsofttissuetoneandfunction; diagnosticimagingandanalysis;

history,principlesandhealthcarephilosophypertinenttochiropractic; ethicsandjurisprudencepertainingtothepracticeofchiropractic; background studies of traditional medicine and complementary/alternativehealthcare.

4.4.6 Patientmanagementinterventions

Including:

manualprocedures,particularlyspinaladjustment,spinalmanipulation,otherjointmanipulation,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 ofback supports and

orthotics;

recognition of contraindications and risk management procedures, thelimitationsofchiropracticcare,andoftheneedforprotocolsrelatingtoreferral

tootherhealthprofessionals.

4.4.7 Documentationandclinicalrecordkeeping

Including:

recording of the primary complaints, health history, physical examinationfindings,assessment,diagnosisandtreatmentplan;

accuratedocumentationofeverypatientencounter; reexaminationfindingsanddocumentationofanymodificationstocareplans; appreciationofconfidentialityandprivacyissues;


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13

consentobligations; insuranceandlegalreporting.

4.4.8 Research

Including:

basicresearchmethodologyandbiostatistics; interpretation of evidencebased procedures/protocols and bestpractice

principles;

an epidemiological approach to clinical recordkeeping, encouragement todocumentparticularcasestudiesandparticipateinfieldresearchprojects;

development of a criticalthinking approach in clinical decisionmaking, theconsiderationofpublishedpapersandrelevantclinicalguidelines;

development of the necessary skills to keep abreast of the relevant currentresearchandliterature.

5. Full chiropractic education category I(B)

Full chiropractic education, includingentrancerequirements, generallyrequires from

four to seven years fulltime tertiary study. The curriculum includes a study of the

basicandpreclinicalsciencessimilarindurationandqualitytothatfoundinamedical

education.

Medicaldoctorsandotherhealthcareprofessionalsmaycompletetherequirementsfor

afullchiropracticeducationoverashorterperiodbecauseofcreditsgrantedinviewof

theirprioreducation.

5.1 Objective

The objective of such an educational programme is to enable suitable health care

practitionerstoqualifyaschiropractors.

5.2 Specialcourses

Such programmes maybe fulltime or parttime, depending upon the educational

experienceandcircumstancesofthestudentcohort.Programmesaredesignedtocover

thosesubjectsnotaddressedinprevioushealthcareeducation.Thiswouldincludethe

specificchiropracticsubjectsandthosemedicalsciencesubjectswherethetraininghas

beeninadequatefortherequirementsofachiropractor.

5.3 Basictraining

The duration of the training depends upon the credits received from previous

educationandexperience,butshouldnotbelessthan2200hoursoveratwo orthree


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14

year fulltime or parttime programme, including not less than 1000 hours of

supervisedclinicalexperience.

6. Limited chiropractic education category II(A)

In some countries, it has not been practicable to adopt the models outlined in

CategoryI, particularly when chiropractic education is first introduced and where

significant numbers of students exist who have prior medical and other health care

education and experience. As hasbeen done already in certainjurisdictions, such

studentsmayobtainbasicclinicalskillsforthedeliveryofchiropracticserviceswitha

morelimitedsupplementarycourse,offulltimeorparttimeeducation,dependingon

theextentoftheirprevioustraining.

Thisapproachshouldbeemployedasaninterimmeasuretoestablishtheavailability

of chiropractic services. A full chiropractic educational programme for students

choosing chiropractic as their primary career shouldbe implemented as soon as it is

practicabletodoso.

6.1 Objective

Theobjective

of

such

an

educational

programme

is

to

qualify

suitable

and

available

healthcareprofessionalstopractiseaschiropractorsinthehealthcaresystem.

This type of programme couldbe developed to facilitate an early introduction of

chiropracticatasafeandacceptablyeffectivelevel.

Programmes of this type should strongly consider the value of having an accredited

chiropracticprogrammeasacollaborativepartnerprovidingeducationalguidance.

6.2 Specialcourses

The programme is designed to cover those subjects which are important for the

practice of chiropractic and which have notbeen covered appropriately in previous

healthcareeducation.

Parttime courses havebeen designed tobe convenient for practitioners maintaining

their current employment, extending appropriate credits to persons depending upon

theirlevelofhealthcaretraining.Foranexample,seeAnnex4.

6.3 Basictraining

Althoughdependent

upon

the

human

resources

available

for

health

care,

the

entrance

requirementwouldnormallybecompletionofuniversityleveltrainingasahealthcare

practitioner.


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15

Thedurationoftrainingwouldbenot lessthan1800hoursoveratwo orthreeyear

fulltime or parttime programme, including not less than 1000 hours of supervised

clinicalexperience.

7. Limited chiropractic education categoryII(B)

This refers to the programmes necessary for persons with limited training, who

identify themselves as chiropractors, to obtain minimum requirements for safe

practice. In many countries, no formal requirements exist for minimum chiropractic

education.This leads to theunqualifiedpracticeofchiropractic,which isundesirable

for patient safety. These programmes prepare graduates to attain the minimal

acceptablerequirementsforthesafepracticeofchiropractic.

7.1 Objective

To upgrade the knowledge andskills of existingpractitioners 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

qualifyinglocal

programme

and

an

adequate

period

of

clinical

experience,

typically

2

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, includingnot less than1000hoursofsupervisedclinicalexperience.For

anexample,seeAnnex5.


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16

8. Assessment and examinationof students in chiropractic

Inordertoensurepatientsafetyandthequalifiedpracticeofchiropractic,asystemof

independentexaminationandlicensingisnecessary.Oncompletionofthefullperiod

oftraining,thestudentstheoreticalknowledgeandclinicalcompetenceinchiropractic

shouldbeindependentlyevaluatedthroughofficialexaminations.

Continuing professional development should be encouraged for maintenance of

licensing.

9. Primary health care workersand chiropractic

9.1 Primaryhealthcareworkers myotherapists

Training has been developed by individual chiropractors within multidisciplinary

settings, with programmes that meet national requirements. These courses introduce

basicmusculoskeletalsofttissuetechniques,massageandothermanagementskillsfor

indigenousnursesandcommunityhealthworkerswhoapplychiropractichealthcareprinciplesandbasicinterventionswithoutemployingspinalmanipulativetechniques.

Such training shouldbe sensitive to existing cultural and ethnic issues and should

exploreandembrace,wherepractical,localtraditionalpractices.

Certaintechniquestoalleviatepainandaddressmusculoskeletaldysfunction,aswell

as the constructive management of musculoskeletal factors amenable to change, may

be taught to primary health care workers, particularly community health workers,

increasingthequalityoflifeforpeopleinruralorremoteareas(18).

Such

workers

may

have

a

valuable

role

in

community

health

education

in

various

ways. These may include counselling on healthy lifestyles, prevention of

musculoskeletaldisordersandotherpublichealthissues.

9.2 Objective

Theobjectiveofsuchcourses istocreateacategoryofprimaryhealthcareworkerto

provideafirstleveloftreatmentandeducationinacommunitysettingasanadjunctto

othercommunityhealthcaremeasures.


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17

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).

Joint adjustment/manipulation is excluded from these training programmes.

Indicationswarranting this typeofcare would require attentionby a chiropractor or

othersuitablyqualifiedpractitioner.

9.4 Methodanddurationoftraining

Training involves workshops, interactive demonstrations, clinical applications and

assignments.

The duration (supervised) of such a training programme would be not less than

300hours.


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18


26/51

Guidelines on safety of chiropractic

19

Part 2: Guidelines on safetyof chiropractic

1. Introduction

Whenemployedskilfullyandappropriately,chiropracticcareissafeandeffectivefor

thepreventionandmanagementofanumberofhealthproblems.Thereare,however,

known risks and contraindications to manual and other treatment protocols used inchiropracticpractice.

While it isbeyondthescopeoftheseguidelinestoreviewthevarious indications for

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

synonymouswith,

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,

aswellas observationaland tactile assessments.Patientmanagement involvesspinal

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.


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2. Contraindications to spinal manipulativetherapy

Spinal manipulative therapy is the primary therapeutic procedure used by

chiropractors, and because spinal manipulation involves the forceful passive

movementofthejointbeyonditsactivelimitofmotion,chiropractorsmustidentifythe

riskfactorsthatcontraindicatemanipulationormobilization(19,20,21).

Manipulationscanbeclassifiedaseithernonspecific,longlevertechniquesorspecific,

shortlever, highvelocity, lowamplitude techniques (the most common forms of

chiropracticadjustment) whichmove ajoint through itsactiveand passiverangesof

movementtotheparaphysiologicalspace(22).

Mobilization is where thejoint remains within a passive range of movement and no

suddenthrustorforceisapplied.

Contraindicationstospinalmanipulativetherapyrangefromanonindicationforsuch

an intervention, where manipulation or mobilization may do no good,but should

cause no harm, to an absolute contraindication, where manipulation or mobilization

could be lifethreatening. In many instances, manipulation or mobilization is

contraindicated in one area of the spine, yetbeneficial in another region (23). For

example,hypermobility

may

be

arelative

contraindication

to

manipulation

in

one

area

of the spine, although it maybe compensating for movement restriction in another

where manipulation is the treatment of choice (24, 25). Of course, the chiropractors

scopeinmanualtherapyextendsbeyondtheuseofmanipulationormobilizationand

includes manual traction, passive stretching, massage, ischaemic compression of

triggerpointsandreflextechniquesdesignedtoreducepainandmusclespasm.

Successfulspinalmobilizationand/ormanipulationinvolvestheapplicationofaforce

to the areas of the spine that are stiff or hypomobile, while avoiding areas of

hypermobilityorinstability(26).

There are a number of contraindications tojoint mobilization and/or manipulation,

especiallyspinaljointmanipulation,whichhavebeenreviewedinpracticeguidelines

developed by the chiropractic profession (27, 28) and in the general chiropractic

literature(29,30,31).Thesemaybeabsolute,whereanyuseofjointmanipulationor

mobilization is inappropriatebecause it places the patient at undue risk (23, 32:290

291), or relative, where the treatment may place the patient at undue risk unless the

presence of the relative contraindication is understood and treatment is modified so

that the patient is not at undue risk. However, spinal manipulative therapy,

particularly lowforceandsofttissuetechniques,maybeperformedonotherareasof

the spine, depending upon the injury or disease present. Clearly, in relative

contraindications,lowforceandsofttissuetechniquesarethetreatmentsofchoice,as


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21

both maybe performed safely in most situationswherea relative contraindication is

present.

Conditionsarelistedfirstbyabsolutecontraindicationstospinalmanipulativetherapy.

Absolute and relative contraindications to spinal manipulative therapy generally are

thenoutlinedastheyrelatetocategoriesofdisorders.

2.1 Absolutecontraindicationstospinalmanipulativetherapy

Itshouldbeunderstoodthatthepurposeofchiropracticspinalmanipulativetherapyis

to correct ajoint restriction ordysfunction, not necessarily to influence the disorders

identified,whichmaybecoincidentallypresentinapatientundergoingtreatmentfora

differentreason.Mostpatientswith theseconditionswillrequirereferral formedical

careand/orcomanagement(33).

1.

anomaliessuch

as

dens

hypoplasia,

unstable

os

odontoideum,

etc.

2. acutefracture3. spinalcordtumour4. acute infection such as osteomyelitis, septic discitis, and tuberculosis of

thespine

5. meningealtumour6. haematomas,whetherspinalcordorintracanalicular7. malignancyofthespine8. frank disc herniation with accompanying signs of progressive

neurologicaldeficit

9.

basilarinvagination

of

the

upper

cervical

spine

10.ArnoldChiarimalformationoftheuppercervicalspine11.dislocationofavertebra12.aggressive types ofbenign tumours, such as an aneurismalbone cyst,

giantcelltumour,osteoblastomaorosteoidosteoma

13. internalfixation/stabilizationdevices14.neoplasticdiseaseofmuscleorothersofttissue15.positiveKernigsorLhermittessigns16.congenital,generalizedhypermobility17.signsorpatternsofinstability18.

syringomyelia

19.hydrocephalusofunknownaetiology20.diastematomyelia21.caudaequinasyndrome

NOTE: In cases of internal fixation/stabilization devices, no osseous manipulation may beperformed, although soft-tissue manipulation can be safely used. Spinal manipulativetherapy may also only be absolutely contraindicated in the spinal region in which thepathology, abnormality or device is located, or the immediate vicinity.


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3. Contraindications to joint manipulationby category of disorder

3.1 Articularderangement

Inflammatory conditions, such as rheumatoid arthritis, seronegative

spondyloarthropies, demineralization or ligamentous laxity with anatomical

subluxationordislocation,representanabsolutecontraindicationtojointmanipulation

inanatomicalregionsofinvolvement.

Subacuteandchronicankylosingspondylitisandotherchronicarthropathiesinwhich

there are no signs of ligamentous laxity, anatomic subluxation or ankylosis are not

contraindicationstojointmanipulationappliedattheareaofpathology.

Withdegenerativejointdisease,osteoarthritis,degenerativespondyloarthropathyand

facetarthrosis, treatmentmodificationmaybewarrantedduringactive inflammatory

phases.

In patients with spondylitis and spondylolisthesis, caution is warranted whenjoint

manipulationisused.Theseconditionsarenotcontraindications,butwithprogressive

slippage,theymayrepresentarelativecontraindication.

Fractures and dislocations, or healed fractures with signs of ligamentous rupture or

instability,represent

an

absolute

contraindication

to

joint

manipulation

applied

at

the

anatomicalsiteorregion.

Atlantoaxialinstabilityrepresentsanabsolutecontraindicationtojointmanipulationat

theareaofpathology.

Articular hypermobility and circumstances where the stability of ajoint is uncertain

representarelativecontraindicationtojointmanipulationattheareaofpathology.

Postsurgical joints or segments with no evidence of instability are not a

contraindication tojoint manipulationbut may represent a relative contraindication,

dependingonclinicalsigns(e.g.response,pretesttoleranceordegreeofhealing).

Acuteinjuriesofjointandsofttissuesmayrequiremodificationoftreatment.Inmost

cases,jointmanipulationattheareaofpathologyisnotcontraindicated.

Although trauma is not an absolute contraindication to manipulation, patients who

have suffered traumatic events require careful examination for areas of excessive

motion,whichmayrangefrommildheightenedmobilitytosegmentalinstability.


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23

3.2 Boneweakeninganddestructivedisorders

Activejuvenile avascular necrosis,specifically of the weightbearingjoints,represents

anabsolutecontraindicationtojointmanipulationattheareaofpathology.

Manipulationofboneweakenedbymetabolicdisorders is arelativecontraindicationbecauseoftheriskofpathologicalfractures(34,35).Demineralizationofbonewarrants

caution. It represents a relative contraindication tojoint manipulation at the area of

pathology.Thespineandribsareparticularlyvulnerabletoosteoporoticfracture,and

those patients who have a history of longterm steroid therapy, those with

osteoporosis, and women who have passed menopause are most susceptible (19:229,

36).Benignbonetumoursmayresultinpathologicalfracturesandthereforerepresent

a relativetoabsolute contraindication tojoint manipulation at the area of pathology.

Tumourlike and dysphasicbone lesions may undergo malignant transformation or

weakenbonetothepointofpathologicalfracture,andthereforerepresentarelativeto

absolutecontraindicationtojointmanipulationattheareaofpathology.

Malignancies, including malignant bone tumours, are conditions for which joint

manipulationattheareaofpathologyisabsolutelycontraindicated.

Infection of bone and joint represents an absolute contraindication to joint

manipulationattheareaofpathology.

Severe or painful disc pathology, such as discitis or disc herniations, are relative

contraindications and nonforceful, nonhighvelocity and nonrecoil manipulative

techniquesmustbeemployed.

3.3 Circulatoryandhaematologicaldisorders

Clinical manifestations of vertebrobasilar insufficiency syndrome warrant particular

caution and represent a relativetoabsolute contraindication to cervical joint

manipulation at the area of pathology. This would include patients with a previous

historyofstroke(37).

When a diagnosis of an aneurysm involving a majorblood vessel hasbeen made, a

relativetoabsolutecontraindicationmayexistforjointmanipulationwithintheareaof

pathology.

Bleeding is a potential complication of anticoagulant therapy or certain blood

dyscrasias.Thesedisordersrepresentarelativecontraindicationtojointmanipulation.

3.4 Neurologicaldisorders

Signs and symptoms of acute myelopathy, intracranial hypertension, signs and

symptoms of meningitis or acute cauda equina syndrome represent absolute

contraindicationstojointmanipulation.


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24

3.5 Psychologicalfactors

It is important to consider psychological factors in the overall treatment of patients

who seek chiropractic care. Certain aberrant behaviour patterns represent relative

contraindicationstocontinuedorpersistenttreatment.Failuretodifferentiatepatients

with

psychogenic

complaints

from

those

with

organic

disorders

can

result

in

inappropriatetreatment.Moreover,itcandelayappropriatereferral.Patientswhomay

needreferralincludemalingerers,hysterics,hypochondriacsandthosewithdependent

personalities(25:162).

4. Contraindications to adjunctive andsupportive therapies

4.1 Electrotherapies

Adjunctive therapies in chiropractic practice may include electrotherapies such as

ultrasound, interferential current and transcutaneous electrical nerve stimulation

(TENS).Theequipmentforthesemodesoftreatmentneedstobeproperlymaintained

andusedinaccordancewithappropriatespecificationsandclinicalindications,butin

thesecircumstancessuchtherapeuticmethodsposeonlyaverylimitedriskofcausing

harm(38,39,40).

4.2 Exercisesandsupplementarysupportivemeasures

A wide range of rehabilitative exercises and supportive measures are used in

chiropractic practice. These shouldbe prescribed in accordance with each patients

individual requirements, and the dosage or level of exercise shouldbe specifically

designed to address the individuals limitations and needs, being generally

conservativeatfirstandthenincreasingovertime.Inthesecircumstances,thereareno

significantcontraindicationswhichcouldnotbeaddressedbycommonsenseandthe

practitionersprofessionalknowledge(41).


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26

5.3.3 Lumbarregion

anincreaseinneurologicalsymptomsthatoriginallyresultedfromadiscinjury(50)

caudaequinasyndrome(51,52) lumbardischerniation(52) ruptureofabdominalaorticaneurysm(53)

5.4 Vascularaccidents

Understandably, vascular accidents are responsible for the major criticism of spinal

manipulative therapy.However, ithasbeenpointedoutthatcriticsofmanipulative

therapyemphasizethepossibilityofseriousinjury,especiallyatthebrainstem,dueto

arterialtraumaaftercervicalmanipulation.Ithasrequiredonlytheveryrarereporting

oftheseaccidentstomalignatherapeuticprocedurethat,inexperiencedhands,gives

beneficialresults

with

few

adverse

side

effects

(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 orboth of the vertebral arteries or itsbranches. The signs and

symptomsofvertebralarterysyndromearisingfromthatcompressionincludevertigo,

dizziness, lightheadedness, giddiness, disequilibria, ataxia, walking difficulties,

nausea and/or vomiting, dysphasia, numbness to one side of the face and/orbody,

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 hadbeen given at National

CollegeofChiropracticclinicsovera15yearperiod,withoutasinglecaseofvertebral

arterysyndromeassociatedwithmanipulation(58).

While it is understood that the actual incidence of cerebral vascular injury couldbe

higherthanthenumberofreportedincidents,estimatesfromrecognizedauthoritiesin

researchinthisareahavevariedfromaslittleasonefatalityinseveraltensofmillions

ofmanipulations(59),onein10million(60)andoneinonemillion(61)totheslightly

moresignificantone importantcomplication in400000cervicalmanipulations(62).


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27

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 canbe preventedby

carefulappraisal of thepatients history and examination findings. Information must

be sought about coexisting diseases and the use of medication, including longterm

steroiduseandanticoagulanttherapy.Adetailedandmeticulousexaminationmustbe

carriedout.Theuseofappropriatetechniques isessential,and thechiropractormust

avoidtechniquesknowntobepotentiallyhazardous(19:234235).

6. First aid training

Allrecognizedprogrammesinchiropracticcontainstandardcoursesinfirstaid,either

taught within the institution or required tobe taken from such authorities as Red

Cross. This is the case in all training programmes, whether they are fulltime,

conversion or standardization programmes. Also, within risk management courses,

timeisspentonprocedurestominimizethepossibilityofinjuriesandtheappropriate

actiontofollowshouldanincidentoccur.


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28


36/51

List of participants

29

Annex 1: List of participants

WHOConsultationonChiropractic

2

4December

2004,

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

DrEdwardTintakLee,Chairman,ChiropractorsCouncil,HongKongSAR,Peoples

RepublicofChina(CoChairperson)

Professor JeanPierre Meersseman, Chiropractor, Italian Chiropractic Association,

Genova,Italy

1Unabletoattend.


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30

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)

Representatives

of

professional

organizations

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

DrAnthony

Metcalfe,

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


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31

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


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32


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A sample four-year, full-time accredited programme

33

Annex 2:A sample four-year, full-time accredited

programmeCategoryI(A)Subjectstaughtinatypicalsemesterbasedchiropracticprogramme,byyearand

numberofhours.

DIVISIONFIRST YEAR

(HOURS)SECOND YEAR

(HOURS)THIRD YEAR

(HOURS)FOURTH YEAR

(HOURS)

Biological

Sciences

Human Anatomy(180)

Microscopic

Anatomy (140)Neuroanatomy

(72)

Neuroscience I(32)

Biochemistry (112)

Physiology (36)

Pathology (174)

Lab Diagnosis (40)

Microbiology &Infectious Disease

(100)

Neuroscience II (85)Nutrition (60)

Immunology (15)

Lab Diagnosis (32)

Toxicology (12)

Clinical Nutrition (26)

Community Health

(40)

Clinical Sciences

Normal

Radiographic

Anatomy (16)Radiation

Biophysics and

Protection (44)

Intro. Diagnosis (85)

Intro Bone Pathology

(48)Normal Roentgen,

Variants &

Roentgenometrics

(40)

Orthopaedics &

Rheumatology (90)Neuro. Diagnosis (40)

Diagnosis &

Symptomatology (120)

Differential Diagnosis(30)

Radiological Technology

(40)Arthritis & Trauma (48)

Clinical Psychology(46)

Emergency Care (50)

Child Care (20)Female Care (30)

Geriatrics (20)Abdomen, Chest &

Special Radiographic

Procedures (40)

Chiropractic

Sciences

Chiropractic

Principles I (56)Basic Body

Mechanics (96)

Chiropractic Skills I(100)

Chiropractic PrinciplesII (60)

Chiropractic Skills II

(145)Spinal Mechanics (40)

Chiropractic Principles

III (42)Clinical Biomechanics

(100)Chiropractic Skills III

(145)

Auxiliary ChiropracticTherapy (60)

Introduction to

Jurisprudence & Practice

Development (16)

Integrated

Chiropractic Practice(90)

Jurisprudence &

PracticalDevelopment (50)

Clinical

PracticumObservation I (30) Observation II (70) Observation III (400)

Internship (750)

Clerkships: Auxiliary

Therapy (30); ClinicalLab (20)

Clinical X-ray:

Technology (70);Interpretation (70)

Observer IV (30)

ResearchApplied Research &Biometrics (32)

ResearchInvestigative Project

Totals 914 962 1207 1382

TOTAL HOURS

Full-time

study over

four years:

4465

plus researchproject


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34


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A sample full (conversion) programme

35

Annex 3:A sample full (conversion) programme

CategoryI(B) Essentially, conversion programmes are dependent upon assessment of the

medicaltrainingofthestudentcohort.Theyarethendesignedsoastocompletesatisfactorily

allrequirementsofafullchiropracticprogramme.

DIVISION FIRST YEAR (HOURS)SECOND YEAR

(HOURS)THIRD YEAR

(HOURS)

Biological Sciences

Spinal Anatomy (45)Laboratory Diagnosis (30)

Pathology (60)

Physiology (45)

Pathology (120)Clinical Nutrition

(45)

Clinical SciencesRadiology (90)Neuromusculoskeletal

Diagnosis (30)

Radiology (90)

Neurology (45)Physical Diagnosis (30)


Diagnosis (30)

Paediatrics (45)Geriatrics (30)

Chiropractic Sciences

Chiropractic History (30)

Principles & Philosophy of

Chiropractic (20)

Spinal Biomechanics (60)Static & Dynamic Spinal

Palpation (30)

Chiropractic Skills (180)


Chiropractic (20)Static & Dynamic Spinal

Palpation (60)


Principles &

Philosophy ofChiropractic (20)

Chiropractic Skills

(60)

Clinical PracticumSupervised Clinical

Practicum (120)

Supervised Clinical

Practicum (225)

Supervised Clinical

Practicum (500)

Research Research (25)

TOTALS 740 740 725

TOTAL HOURS Full-time

or part-time study over

three years

2205


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A sample limited (conversion) programme

37

Annex 4:A sample limited (conversion) programme

CategoryII(A) Suitable for persons with a solid medical education to attain minimal

registerablerequirementstopractisesafelyandrelativelyeffectivelyaschiropractors.

DIVISION FIRST YEAR (HOURS)SECOND YEAR

(HOURS)THIRD YEAR

(HOURS)

Biological Sciences

Spinal Anatomy (45)

Pathology (60)

Physiology (45)

Pathology (60) Clinical Nutrition (30)

Clinical Sciences

Diagnostic Imaging (45)Neurology (45)


Diagnosis (30)

Diagnostic Imaging (45)

Neurology (45)Physical Diagnosis (30)


Diagnosis (30)

Paediatrics (45)

Geriatrics (30)

Chiropractic Sciences

Chiropractic History (30)


Chiropractic (20)Spinal Biomechanics (60)

Static & Dynamic Spinal

Palpation (30)Chiropractic Skills (90)


Chiropractic (20)Static & Dynamic Spinal

Palpation (60)


Principles & Philosophyof Chiropractic (20)


Clinical PracticumSupervised Clinical Practicum(100)

Supervised ClinicalPracticum (220)

Supervised ClinicalPracticum (420)

TOTAL 600 600 605

TOTAL HOURS

Part-time study

over three years

1805


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A sample limited (standardization) programme

39

Annex 5:A sample limited (standardization) programme

CategoryII(B) Addresses deficiencies identified through assessment of a students existing

knowledgeandskillsandenablesgraduatestoattainsafeandminimalregisterablestandards

aschiropractors.

DIVISION FIRST YEAR DL IR CPSECOND

YEARDL IR CP THIRD YEAR DL IR CP

Anatomy 56 24

Biochemistry 56 4

Physiology 56 4

Pathology 70 12

Public Health 56 4B

iological

S

ciences

Clinical

Nutrition56 4

Laboratory

Diagnosis42 8

Physical

Diagnosis56 14

Head/Cervical

Spine Care70 20

Orthopaedics/

Neurology56 14

Thoracic/Lumbar

Spine & Pelvis

Care

70 20

Radiology 56 16Hip/Knee/Ankle/

Foot Care70 20

Clinical

Diagnosis56 9

Shoulder/Elbow/

Wrist/Hand Care70 20

ClinicalSciences

Special

Population Care56 24

Biomechanics 56 16

Chiropractic

Sciences

Principles of

Chiropractic42 3

Patient

ManagementProcedures

42 18

Record Keeping,

Documentation &

QualityAssurance

42 16

Clinical

Practicum

400 400 400

Research

Methodology 50

Research

ComputerSkills

Workshop

6 FirstAid/Emergency

Care

28 24

Totals

448 71 406 486 103 400 378 100 400

TOTAL

HOURSPart-time

study over

three years

2790DL = Distance Learning (Self Directed Learning); IR = In Residence ( Lectures &Workshops); CP = Clinical Practicum (Supervised)


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40


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References

41

References

Introduction

1. MeadeTWetal.Lowbackpainofmechanicalorigin:randomisedcomparisonof

chiropracticandhospitaloutpatienttreatment.BritishMedicalJournal,1990,

300(6737):143137.

2. MeadeTWetal.Randomisedcomparisonofchiropracticandhospitaloutpatient

managementforlowbackpain:resultsfromextendedfollowup.BritishMedicalJournal,

1995,311(7001):349351.

3. BaldwinMLetal.Costeffectivenessstudiesofmedicalandchiropracticcarefor

occupationallowbackpain:Acriticalreviewoftheliterature.Spine,2001,1(2):138147.

Part1

4. WithingtonBT.Hippocrates,withanEnglishtranslation.Cambridge,MA,Harvard

UniversityPress,1928.

5. PalmerDD.Thechiropractorsadjustor.Portland,OR,PortlandPrintingHouse,1910.

6. GibbonsRW.MedicalandsocialprotestaspartofhiddenAmericanhistory.In:

HaldemanS,ed.Principlesandpracticeofchiropractic.EastNorwalk,CT,AppletonLang,

1992:17.

7. PalmerDD.Threegenerations:ahistoryofchiropractic.Davenport,Iowa,PalmerCollege

ofChiropractic,1967:29.

8. EhrenreichB,EnglishE.Forherowngood.NewYork,Anchor/Doubleday,1978:16.

9. CoulterID.Whatischiropractic?In:McNameeKP.Thechiropracticcollegedirectory,

199798,5thed.LosAngeles,CA,KMEnterprises,1997.

10. WorldFederationofChiropractic.ConsensusstatementsandtheACCpositionpaperon

chiropractic:Thechiropracticparadigm(ProceedingsoftheconferenceonPhilosophyin

ChiropracticEducation).FortLauderdale,FL,WorldFederationofChiropractic

Toronto,2000.

11. GattermanMI,HansenDT.Developmentofchiropracticnomenclaturethrough

consensus.JournalofManipulativeandPhysiologicalTherapeutics,1974,17(5):308.

12. GuthrieHN.ReportoftheHonoraryRoyalCommissiontoInquireintoProvisionsofthe

NaturalTherapistsBillinWesternAustralia.Perth,WesternAustralianGovernment

Printer,1961.

13. LacroixG.ReportoftheRoyalCommissiononChiropraxyandOsteopathy.Quebec,

GovernmentofQuebec,1965.

14. TeeceJ.ReportoftheNewSouthWalesHealthCommissionInquiryintotheQuestionof

RegistrationofChiropractors.Sydney,NewSouthWalesGovernmentPrinter,1975.

15. WebbEC.ReportoftheCommitteeofInquiryintoChiropractic,Osteopathy,Homeopathyand

Naturopathy.Canberra,AustralianGovernmentPublishingService,1977.


49/51


42

16. InglisBD,FraserB,PenfoldBR.ChiropracticinNewZealandreport:CommissionofInquiry

intoChiropractic.Wellington,NewZealandPrinter,1979:105106.

17. BinghamT.ReportoftheKingsFundWorkingPartyonChiropractic.London,KingsFund,

1993.

18. VindigniD,PerkinsJ.Identifyingmusculoskeletalconditionsamongruralindigenous

peoples.AustralianJournalofRuralHealth,2003,11(4):187192.

Part2

19. GattermanM.Standardsforcontraindicationstospinalmanipulativetherapy.In:

VearHJ,ed.Chiropracticstandardsofpracticeandqualityofcare.Gaithersburg,MD,Aspen

PublishersInc,1992.

20. VearHJ.Standardsofchiropracticpractice.JournalofManipulativeandPhysiological

Therapeutics,1985,8(1):3343.

21. GattermanMI.Indicationsforspinalmanipulationinthetreatmentofbackpain.Journal

oftheAmericanChiropracticAssociation,1982,19(10):5166.

22. HaldemanS.Spinalmanipulativetherapyinthemanagementoflowbackpain.In:

FinnesonGE,ed.Lowbackpain,2nded.Philadelphia,PA,JBLippincott,1980:260280.

23. GattermanMI.Contraindicationsandcomplicationsofspinalmanipulationtherapy.

JournaloftheAmericanChiropracticAssociation,1981,15:575586.

24. PalmerDD.Thescience,artandphilosophyofchiropractic.Portland,OR,PortlandPrinting

House,1910:101.

25. GattermanMI.Chiropracticmanagementofspinerelateddisorders.Baltimore,MD,

Lippincott,Williams&Wilkins,1990.

26. CassidyJD,PotterGE.Motionexaminationofthelumbarspine.JournalofManipulative

andPhysiologicalTherapeutics,1979,2(3):151158.

27. HaldemanS,ChapmanSmithD,PetersenDM,eds.Guidelinesforchiroprac

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