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7/27/2019 129084963 Estudios Quiropraxia
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7/27/2019 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:
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
publication. However, the published material isbeing distributed without warranty of any
kind,eitherexpressorimplied. Theresponsibilityfortheinterpretationanduseofthematerial
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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Guidelines on basic training and safety in chiropractic
4
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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Guidelines on basic training and safety in chiropractic
6
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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Basic training in chiropractic
7
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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Guidelines on basic training and safety in chiropractic
8
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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Basic training in chiropractic
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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Guidelines on basic training and safety in chiropractic
10
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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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List of participants
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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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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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)
Neuromusculoskeletal
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)
Principles & Philosophy of
Chiropractic (20)Static & Dynamic Spinal
Palpation (60)
Chiropractic Skills (120)
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)
Neuromusculoskeletal
Diagnosis (30)
Diagnostic Imaging (45)
Neurology (45)Physical Diagnosis (30)
Neuromusculoskeletal
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 (90)
Principles & Philosophy of
Chiropractic (20)Static & Dynamic Spinal
Palpation (60)
Chiropractic Skills (90)
Principles & Philosophyof Chiropractic (20)
Chiropractic Skills (60)
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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References
41
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