WHO guidelines onbasic training and safetyin chiropractic

Geneva2005

WHO Library Cataloguing‐in‐Publication Data
World Health Organization.
WHO guidelines on basic training and safety in chiropractic.
1.Chiropractic ‐ education 2.Chiropractic ‐ standards 3.Guidelines I.Title.
ISBN 92 4 159371 7(NLM classification: WB 905.7)© World Health Organization 2005

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Contents
Acknowledgements ............................................................................................................................................... i
Foreword.................................................................................................................................................................ii
Introduction ........................................................................................................................................................... 1
Objectives ........................................................................................................................................................ 2
How to use this document ............................................................................................................................ 2
Glossary .................................................................................................................................................................. 3

Part 1: Basic training in chiropractic .................................................................................. 5
1. General considerations .................................................................................................................................... 5
1.1. Historical information ........................................................................................................................... 5
1.2 Philosophy and basic theories of chiropractic .................................................................................... 5
1.3 Administrative and academic considerations .................................................................................... 6
1.4 Monitoring and evaluation ................................................................................................................... 6
1.5 Further education and career possibilities .......................................................................................... 7
2.

Acceptable levels of education and retraining......................................................................................... 7
2.1 Category I ‐ full chiropractic education............................................................................................... 7
2.2 Category II ‐ limited chiropractic education....................................................................................... 73.

Models of chiropractic education ............................................................................................................... 8
3.1
3.2
3.3
3.4

4.

Full chiropractic education – category I(A)............................................................................................... 9
4.1
4.2
4.3
4.4

5.

Category I(A) .......................................................................................................................................... 8
Category I(B) ........................................................................................................................................... 8
Category II(A) ......................................................................................................................................... 8
Category II(B).......................................................................................................................................... 9

Objective .................................................................................................................................................. 9
Entrance requirements........................................................................................................................... 9
Basic training........................................................................................................................................... 9Core syllabus......................................................................................................................................... 10

Full chiropractic education – category I(B) ............................................................................................. 13
5.1 Objective ................................................................................................................................................ 13
5.2 Special courses ...................................................................................................................................... 13
5.3 Basic training......................................................................................................................................... 13

6.

Limited chiropractic education – category II(A) .................................................................................... 14
6.1 Objective ................................................................................................................................................ 14
6.2 Special courses ...................................................................................................................................... 14
6.3 Basic training......................................................................................................................................... 14

7.

Limited chiropractic education – category II(B).................................................................................... 15
7.1 Objective ................................................................................................................................................ 15
7.2 Special courses ...................................................................................................................................... 15
7.3 Basic training......................................................................................................................................... 15

8.

Assessment and examination of students in chiropractic ................................................................... 16

9.

Primary health care workers and chiropractic....................................................................................... 16
9.1
9.2
9.3
9.4

Primary health care workers ‐ myotherapists .................................................................................. 16
Objective ................................................................................................................................................ 16
Course components.............................................................................................................................. 17
Method and duration of training ....................................................................................................... 17Part 2: Guidelines on safety of chiropractic .................................................................. 19
1.

Introduction.................................................................................................................................................. 19

2.

Contraindications to spinal manipulative therapy ............................................................................... 20
2.1 Absolute contraindications to spinal manipulative therapy .......................................................... 21

3.

Contraindications to joint manipulation by category of disorder..................................................... 22
3.1
3.2
3.3
3.4
3.5

4.

Articular derangement ........................................................................................................................ 22
Bone‐weakening and destructive disorders...................................................................................... 23
Circulatory and haematological disorders........................................................................................ 23
Neurological disorders ........................................................................................................................ 23
Psychological factors............................................................................................................................ 24

Contraindications to adjunctive and supportive therapies ................................................................. 24
4.1 Electrotherapies .................................................................................................................................... 24
4.2 Exercises and supplementary supportive measures........................................................................ 24

5.

Accidents and adverse reactions............................................................................................................... 25
5.1
5.2
5.3
5.4
5.5

6.

Causes of complications and adverse reactions ............................................................................... 25
Examples of inappropriate practices ................................................................................................. 25
Serious adverse consequences ............................................................................................................ 25
Vascular accidents ................................................................................................................................ 26
Prevention of complications from manipulation ............................................................................. 27

First aid training .......................................................................................................................................... 27

Annex 1: List of participants ............................................................................................................................. 29
Annex 2: A sample four‐year, full‐time accredited programme.................................................................. 33
Annex 3: A sample full (conversion) programme.......................................................................................... 35
Annex 4: A sample limited (conversion) programme ................................................................................... 37
Annex 5: A sample limited (standardization) programme........................................................................... 39
References ............................................................................................................................................................ 41

Acknowledgements
The World Health Organization (WHO) greatly appreciates the financial and technicalsupport provided by the Regional Government of Lombardy, Italy, for thedevelopment and publication of these guidelines, as part of the implementation ofcollaborative projects with WHO in the field of traditional medicine. The Region of
Lombardy kindly hosted and provided financial support for the WHO Consultation on
Chiropractic, held in Milan, Italy, in December 2004.
Thanks to Dr John A. Sweaney, New Lambton, Australia, who prepared the originaltext.
WHO acknowledges its indebtedness to over 160 reviewers, including experts andnational authorities and professional and nongovernmental organizations, in over
54 countries who provided comments and advice on the draft text.
Special thanks are due to participants of the WHO Consultation on Chiropractic (seeAnnex 1), who worked towards reviewing and finalizing the draft guidelines, and to
the WHO Collaborating Centre for Traditional Medicine at the State University of
Milan, Italy, in particular to Professor Umberto Solimene, the Director, and to Miss
Elisabetta Minelli, the International Liaison Officer, for their assistance to WHO inorganizing the Consultation.

iForeword
During the last decade, the use of traditional and complementary/alternative medicine(TM/CAM) has increased considerably not only in developing countries, where it often
represents the only possibility for health protection, but also in developed countries. The
percentage of the population that uses TM/CAM is in the order of 50% in many of highincome countries, such as Canada, France, Germany, United Kingdom and United States ofAmerica. This occurs also in Italy (not less than 15%) as well as for certain Italian regions,
including the Lombardy Region, where the percentage is around 20% and continues rising.
Facing this challenge, it is extremely important to create the conditions for the correct andappropriate use of methods which, if used correctly, can contribute to the protection andenhancement of citizens’ health and well being. The development of these practices canonly be obtained according to safety, efficacy and quality criteria. Such principles
characterize the modern medical practice and are the essential basis for consumers’
protection.
TM/CAM activities undertaken by the Regional Government of Lombardy have always
been guided by the abovementioned criteria. TM/CAM was included in the Regional
Community Healthcare Plan (2002‐2004), and a comprehensive framework for theprotection of consumers and practitioners has been developed accordingly ‐ thanks to aseries of administrative provisions. The four‐year cooperation plan between the World
Health Organization and the Regional Government of Lombardy on the use and evaluationof TM/CAM is a keystone in such a process. The promotion of several clinical andobservational studies on the regional territory is also to be considered an important step forthe evaluation of the efficacy of TM/CAM methods.
The quality of the practice depends mainly on the training performed by the practitioner.
For this reason, the Regional Government of Lombardy supported the development of the
WHO Guidelines on Basic Training and Safety in Chiropractic that aim at defining therequisites for chiropractic practitioners. The process of development of these Guidelines
included the WHO Consultation meeting held in Milan in December 2004, which brought
together experts, national authorities and professional organizations from all over theworld. One of the conclusions of the Consultation was that these guidelines wereappropriate as resources not only for the Lombardy Region, but also for various country
situations worldwide. With this in mind, this document is to be considered an importantreference point for those, among practitioners, political and administrative authorities, thatwant chiropractic to be a safe and efficacious aid for citizens’ health and for any regulatory
and licensing act.
Alessandro Cè
Regional Minister of HealthRegional Government of Lombardy
Giancarlo Abelli
Regional Minister of Family and Social Solidarity
Regional Government of LombardyiiIntroduction

Introduction
Chiropractic is one of the most popularly used forms of manual therapy. It is now
practised worldwide and regulated by law in some 40 national jurisdictions.
As a health care service, chiropractic offers a conservative management approach and,
although it requires skilled practitioners, it does not always need auxiliary staff andtherefore generates minimal add‐on costs. Therefore, one of the benefits of chiropractic
may be that it offers potential for cost‐effective management of neuromusculoskeletal
disorders (1, 2, 3).
The World Health Organization (WHO) encourages and supports countries in theproper use of safe and effective medication, products and practices in national healthservices. In the light of the situation described above, there is a need to develop
guidelines on chiropractic education and safe practice, including information oncontraindications for such care.
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, chiropractic has been legally recognized and formal university degrees havebeen established. In these countries, the profession is regulated and the prescribededucational qualifications are generally consistent, satisfying the requirements of therespective accrediting agencies.
However, many countries have not yet developed chiropractic education or establishedlaws to regulate the qualified practice of chiropractic. In addition, in some countries,
other qualified health professionals and lay practitioners may use techniques of spinal
manipulation and claim to provide chiropractic services, although they may not havereceived chiropractic training in an accredited programme.
With the rapid growth in demand for chiropractic services, other health carepractitioners may wish to gain additional qualifications in chiropractic. Conversion
programmes have been developed to enable persons with substantial basic medical
training to acquire the additional necessary education and skills to becomechiropractors, and these could be further expanded. Such programmes should beflexible in order to take account of different educational backgrounds and previous
medical training.
In countries where no regulatory legislation currently exists, there may be no
educational, professional or legal framework governing the practice of chiropractic.
The minimum educational requirements needed to encourage practitioners to registerand to protect patients are outlined in this document. The recognition andimplementation of these minimum requirements will depend on individual country
situations.
1Guidelines on basic training and safety in chiropractic

In some countries with educational limitations, lack of financial resources or
unsatisfactory integration of indigenous communities into mainstream society,primary health care workers specifically trained in myotherapy may help to enhance
health care services. This may also form the basis 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
identified in Part 1, Section 9 below.

Objectives
In order to facilitate qualified and safe practice of chiropractic as well as to protect the
public and patients, the objectives of these guidelines are:•••to provide minimum requirements for chiropractic education
to serve as a reference for national authorities in establishing an examinationand licensing system for the qualified practice of chiropractic
to review contraindications in order to minimize the risk of accidents and toadvise on the management of complications occurring during treatment and topromote the safe practice of chiropractic.

How to use this document
Part I of the guidelines covers basic requirements for different training programmes,
each one designed for trainees with various educational backgrounds, including
nonmedics, physicians wishing to use chiropractic and primary health care workers.
This part provides a reference for the establishment of various training programmes,
particularly where no formal education degree has been established. If national healthauthorities wish to evaluate the training programme, they may consult Councils on
Chiropractic Education International (CCEI – www.cceintl.org). This organization does
not function as an accrediting agency, but promotes an understanding of the variations
between recognized accrediting bodies through dialogue and communication.
A system of examination and licensing may be established or adapted on the basis of
this training programme to ensure the competence of the trainees and to avoid thepractice of chiropractic by unqualified persons. It is to be hoped that this will deter
commercial exploitation of chiropractic education and practice, which is a significant
and growing problem in some countries.
Part II of the guidelines deals with the safety of spinal manipulative therapy and thecontraindications to its use.
Dr Xiaorui Zhang
Coordinator, Traditional Medicine
Department of Technical Cooperation
for Essential Drugs and Traditional Medicine
World Health Organization
2

Glossary

Glossary
The terms used in these guidelines are defined as follows.
Adjustment
Any chiropractic therapeutic procedure that ultimately uses controlled force, leverage,
direction, amplitude and velocity, which is applied to specific joints and adjacenttissues. Chiropractors commonly use such procedures to influence joint andneurophysiological function.
Biomechanics
The study of structural, functional and mechanical aspects of human motion. It isconcerned mainly with external forces of either a static or dynamic nature, dealing
with human movement.
Chiropractic
A health care profession concerned with the diagnosis, treatment and prevention ofdisorders of the neuromusculoskeletal system and the effects of these disorders on
general health. There is an emphasis on manual techniques, including joint adjustment
and/or manipulation, with a particular focus on subluxations.
Fixation
The state whereby an articulation has become fully or partially immobilized in acertain position, restricting physiological movement.
Joint manipulation
A manual procedure involving directed thrust to move a joint past the physiologicalrange of motion, without exceeding the anatomical limit.
Joint mobilization
A manual procedure without thrust, during which a joint normally remains within its
physiological range of motion.
Neuromusculoskeletal
Pertaining to the musculoskeletal and nervous systems in relation to disorders thatmanifest themselves in both the musculoskeletal and nervous systems, including
disorders of a biomechanical or functional nature.
Palpation(1) The act of feeling with the hands. (2) The application of variable manual pressure
through the surface of the body for the purpose of determining the shape, size,
consistency, position, inherent motility and health of the tissues beneath.

3

Guidelines on basic training and safety in chiropractic

Posture(1) The attitude of the body. (2) The relative arrangement of the parts of the body.
Good posture is that state of muscular and skeletal balance that protects the supporting
structures of the body against injury or progressive deformity irrespective of theattitude (erect, lying, squatting, stooping) in which the structures are working or
resting.
Spinal manipulative therapy
Includes all procedures where the hands or mechanical devices are used to mobilize,
adjust, manipulate, apply traction, massage, stimulate or otherwise influence the spine
and paraspinal tissues with the aim of influencing the patient’s health.
Subluxation1
A lesion or dysfunction in a joint or motion segment in which alignment, movement
integrity and/or physiological function are altered, although contact between joint
surfaces remains intact. It is essentially a functional entity, which may influencebiomechanical and neural integrity.
Subluxation complex (vertebral)
A theoretical model and description of the motion segment dysfunction, which
incorporates the interaction of pathological changes in nerve, muscle, ligamentous,
vascular and connective tissue.
ThrustThe sudden manual application of a controlled directional force upon a suitable part ofthe patient, the delivery of which effects an adjustment.

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

structural displacement, and therefore visible on static imaging studies.

4Basic training in chiropractic

Part 1: Basic training in chiropractic

1. General considerations
1.1.

Historical information

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),with the first school for the training of chiropractors commencing in the United Statesof America in Davenport, Iowa in 1897 (6).
Palmer developed the chiropractic theory and method from a variety of sources,
including medical manipulation, bonesetting and osteopathy, as well as incorporating
unique aspects of his own design. The term “chiropractic”, derived from Greek roots tomean “done by hand”, originated with Palmer and was coined by a patient, theReverend Samuel H. Weed (7).
Chiropractic developed in the United States of America during a period of significant
reformation in medical training and practice. At the time, there was a great variety oftreatment options, both within conventional medicine and among innumerable otheralternative health care approaches (8).

1.2

Philosophy and basic theories of chiropractic

Chiropractic is a health care profession concerned with the diagnosis, treatment andprevention of disorders of the neuromusculoskeletal system and the effects of these
disorders on general health. There is an emphasis on manual techniques, including
joint adjustment and/or manipulation, with a particular focus on the subluxation.
The concepts and principles that distinguish and differentiate the philosophy ofchiropractic from other health care professions are of major significance to mostchiropractors and strongly influence their attitude and approach towards health care.
A majority of practitioners within the profession would maintain that the philosophyof chiropractic includes, but is not limited to, concepts of holism, vitalism, naturalism,
conservatism, critical rationalism, humanism and ethics (9).

5Guidelines on basic training and safety in chiropractic

The relationship between structure, especially the spine and musculoskeletal system,
and function, especially as coordinated by the nervous system, is central to chiropractic
and its approach to the restoration and preservation of health (9, 10:167).
It is hypothesized that significant neurophysiological consequences may occur as aresult of mechanical spinal functional disturbances, described by chiropractors as
subluxation and the vertebral subluxation complex (9, 10:169‐170, 11).
Chiropractic practice emphasizes the conservative management of theneuromusculoskeletal system, without the use of medicines and surgery (10:169‐170,
11). Biopsychosocial causes and consequences are also significant factors inmanagement of the patient.
As primary‐contact health care practitioners, chiropractors recognize the importance ofreferring to other health care providers when it is in the best interests of thepatient (10).

1.3

Administrative and academic considerations

The training of chiropractors involves certain administrative and academic
considerations, for example:
•
•
•
•
•
•
•

1.4

who could be trained?
what would be the practitioner’s role and responsibilities?
what education would be required?
where would such education be provided, and by whom?
would suitable programmes have to be developed from scratch, or could
existing substandard courses be strengthened or appropriately modified?
are suitably qualified chiropractic educators available, or would they have to be
trained?
what would be the mechanisms for official recognition of practitioners,
programmes, educators and institutions?

Monitoring and evaluation

In order to introduce qualified practice and proper use of chiropractic, systems areneeded to monitor the entire profession, the performance of practitioners and theeducation and training of practitioners.
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 ofindividuals.
As has been the case in a number of countries or regions in the past, prior to thelegislative recognition of chiropractic, a government may wish to evaluate both thepositive and negative consequences of including it within the health care service (12,13, 14, 15, 16, 17).
6

Basic training in chiropractic

1.5

Further education and career possibilities

It is recognized that, as an interim measure prior to the establishment of a fullchiropractic programme, it may be necessary to provide “limited” programmes tosupplement existing health care education, in order to begin to register chiropractors inthese countries and ensure qualified practice of chiropractic. How countries willrecognize chiropractors with “limited” programmes will vary according to individual
country situations.
Practitioners with limited or no formal chiropractic education, practising as“chiropractors”, should upgrade their education to meet the requirements laid downby their government when regulations are put into place. In this way such personnel
can be effectively incorporated into the domestic professional workforce.

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, each
preparing health care practitioners to practise in the health care system as achiropractor. These options are available to countries to meet their individual needs.

2.1

Category I ‐ full chiropractic education
•
•

2.2

for students with no prior health care education or experienceas the supplementary education required for medical doctors or otherappropriate health care professionals to acquire a recognized qualification as achiropractor

Category II ‐ limited chiropractic education•

A limited training programme for medical personnel and other appropriate
health care professionals in countries or regions introducing chiropractic where
no current legislation governing the practice exists; it does not lead to full
qualification.
Such training should be conducted as a temporary measure to establish aprovision of chiropractic and/or as the first stage in the development of a fullchiropractic programme. Such a course is established as a minimum
registerable requirement and courses of this type should be replaced byappropriate full‐time programmes as soon as it is practical to do so.
7

Guidelines on basic training and safety in chiropractic•

The training required to attain a minimally acceptable level of competency forstudents who represent existing providers of chiropractic in countries orregions without regulations but intending to introduce legislation governing
the practice of chiropractic.
This provision does not lead to a full qualification, but to a minimal registerable
standard. Courses of this type are a temporary measure, and should be
replaced by appropriate full‐time programmes as soon as it is practical to do so.

3. Models of chiropractic education
3.1

Category I(A)There are many slight variations on the following models: however, in general, there
are three major educational paths involving full‐time education:
•

•

•

3.2

A four‐year full‐time programme within specifically designated colleges oruniversities, following 1‐4 years of suitable pre‐chiropractic training in basic
sciences at university level; for an example, see Annex 2.
A five‐year bachelor integrated chiropractic degree programme offered within apublic or private university, with student entrance based upon the applicant’s
matriculation status and the university’s admission requirements and quota
restrictions.
A two or three‐year pre‐professional Masters programme following thesatisfactory completion of a specifically designed bachelor degree programmein chiropractic or a suitably adapted health science degree.

Category I(B)

Programmes for persons with prior medical or other health care professional
education. Such courses would vary in length and subject requirements, depending on
the applicant’s previous educational background. For an example, see Annex 3.

3.3

Category II(A)

Conversion programmes for persons with prior medical or other health care
professional education to obtain a “limited” chiropractic educational qualification
should be conveniently structured, of a part‐time nature, satisfying at least all theminimum requirements though not leading to a full qualification. For an example, see
Annex 4.

8

Basic training in chiropractic

3.4

Category II(B)In these programmes, the course content and length may also vary greatly depending
upon the applicant’s previous training and experience. On completion of the
programmes, students will have met the requirements of a first bachelor‐level
programme in chiropractic through part‐time study and acquired the necessary
knowledge and skills to provide safe, if basic, chiropractic care. Such courses do notlead to a full chiropractic qualification. For an example, see Annex 5.

4. Full chiropractic education – category I(A)This refers to the training programme for persons without previous medical or other
health care professional education.

4.1

Objective

The aim at this level is to provide an education consistent with the requirements
established in those countries where government regulations have been enacted. Basedupon this education, chiropractors practise as primary‐contact health care providers,either independently or as members of health care teams at the community level within
health care centres or hospitals.

4.2

Entrance requirements

An acceptable applicant would have completed secondary schooling, university
entrance or its equivalent with appropriate training in basic sciences, as required by theparticular programme.

4.3

Basic training

Irrespective of the model of education utilized, for those without relevant prior healthcare education or experience, not less than 4200 student/teacher contact hours are
required, or the equivalent, in four years of full‐time education. This includes not lessthan 1000 hours of supervised clinical training.

9

Guidelines on basic training and safety in chiropractic

4.4

Core syllabus

4.4.1

Educational objectives

Competence in the practice of chiropractic requires the acquisition of relevant
knowledge, understanding, attitudes, habits and psychomotor skills. The
curriculum and the student evaluation processes should be designed to ensure thatthe chiropractic graduate demonstrates the following skills.
He/she should possess a comprehensive understanding and command of the skills
and knowledge that constitute the basis of chiropractic in its role as a health care
profession, as follows:• achieve a fundamental knowledge of health sciences, with a particularemphasis on those related to vertebral subluxation and theneuromusculoskeletal systems;• achieve a comprehensive theoretical understanding of the biomechanicsof the human locomotor system in normal and abnormal function and,in particular, possess the clinical ability needed for an expert assessmentof spinal biomechanics;• appreciate chiropractic history and the unique paradigm of chiropractic
health care;• achieve a level of skill and expertise in the manual proceduresemphasizing spinal adjustment/manipulation regarded as imperative
within the chiropractic field;• possess the ability to decide whether the patient may safely and suitably
be treated by chiropractic or should be referred to another healthprofessional or facility for separate or comanaged care.
He/she should perform at the clinical level expected of a primary‐contact
health care practitioner, as follows:• competently perform a differential diagnosis of the complaints
presented by patients;• achieve particular expertise in diagnostic imaging, orthopaedics, pain
management and rehabilitation of the neuromusculoskeletal system
and/or diagnosis and management of vertebral subluxation;• achieve competence in interpreting clinical laboratory findings;• acquire the ability to appraise scientific and clinical knowledge critically:• understand and apply fundamental scientific/medical information, andbe capable of consulting with and/or referring to other health careproviders;• generally possesses the necessary knowledge and skill to serve andcommunicate with members of the public in an effective and safemanner.

10

Basic training in chiropractic

He/she should be able to:• apply fundamental scientific knowledge of the human body• understand the nature of normal and abnormal biomechanics andposture, as well as the pathophysiology of the neuromusculoskeletal
system and its relationship to other anatomical structures• establish a satisfactory rapport with patients• gather and record clinical information and communicate suchinformation• accurately interpret clinical laboratory findings and diagnostic imagingof the neuromusculoskeletal system• establish an accurate clinical diagnosis• accept responsibility for the patientʹs welfare• apply sound judgment in deciding on appropriate care
• provide competent treatment• provide competent continuing health care
• understand the application of contemporary methods and techniques inwellness care
• accept the responsibilities of a chiropractor• appreciate the expertise and scope of chiropractic and other health care
professions in order to facilitate intradisciplinary and interdisciplinary
cooperation and respect• select research subjects, design simple research projects, criticallyappraise clinical studies and participate in multi‐disciplinary research
programmes• commit to the need for lifelong learning and ongoing professional
development.
4.4.2

Basic science components

Recognized programmes either require essential basic science components asprerequisites, or include necessary units of chemistry, physics and biology within thefirst‐year curriculum.

4.4.3

Preclinical science components

The preclinical science components within chiropractic programmes generally include:anatomy, physiology, biochemistry, pathology, microbiology, pharmacology
and toxicology, psychology, dietetics and nutrition, and public health.
4.4.4

Clinical science components

Clinical science components would include or cover:history‐taking skills, general physical examination, laboratory diagnosis,
differential diagnosis, radiology, neurology, rheumatology, eyes, ears, nose and11

Guidelines on basic training and safety in chiropractic

throat, orthopaedics, basic paediatrics, basic geriatrics, basic gynaecology andobstetrics, and basic dermatology.
4.4.5

Chiropractic sciences and additional subjects

These generally include:•

applied neurology and applied orthopaedics;•

clinical biomechanics, including, specific chiropractic/biomechanical patient
assessment by methods such as:• gait and postural analysis;• static and motion palpation of joints and bony structures;• assessment of soft‐tissue tone and function;• diagnostic imaging and analysis;•

history, principles and health care philosophy pertinent to chiropractic;•

ethics and jurisprudence pertaining to the practice of chiropractic;•

background studies of traditional medicine and complementary/alternative
healthcare.

4.4.6

Patient management interventions

Including:
•
•
•
•
•
•
•

4.4.7

manual procedures, particularly spinal adjustment, spinal manipulation, otherjoint manipulation, joint mobilization, soft‐tissue and reflex techniques;
exercise, rehabilitative programmes and other forms of active care;
psychosocial aspects of patient management;
patient education on spinal health, posture, nutrition and other lifestylemodifications;emergency treatment and acute pain management procedures as indicated;other supportive measures, which may include the use of back supports andorthotics;
recognition of contraindications and risk management procedures, thelimitations of chiropractic care, and of the need for protocols relating to referral
to other health professionals.
Documentation and clinical record‐keeping

Including:
•
•
•
•
12

recording of the primary complaints, health history, physical examination
findings, assessment, diagnosis and treatment plan;
accurate documentation of every patient encounter;re‐examination findings and documentation of any modifications to care plans;appreciation of confidentiality and privacy issues;

Basic training in chiropractic

•
•
4.4.8

consent obligations;insurance and legal reporting.
Research

Including:
•
•
•
•
•

basic research methodology and biostatistics;
interpretation of evidence‐based procedures/protocols and best‐practiceprinciples;
an epidemiological approach to clinical record‐keeping, encouragement todocument particular case‐studies and participate in field research projects;
development of a critical‐thinking approach in clinical decision‐making, theconsideration of published papers and relevant clinical guidelines;
development of the necessary skills to keep abreast of the relevant current
research and literature.

5. Full chiropractic education – category I(B)
Full chiropractic education, including entrance requirements, generally requires fromfour to seven yearsʹ full‐time tertiary study. The curriculum includes a study of thebasic and preclinical sciences similar in duration and quality to that found in a medical
education.
Medical doctors and other health care professionals may complete the requirements fora full chiropractic education over a shorter period because of credits granted in view of
their prior education.

5.1

Objective

The objective of such an educational programme is to enable suitable health carepractitioners to qualify as chiropractors.

5.2

Special courses

Such programmes may be full‐time or part‐time, depending upon the educational
experience and circumstances of the student cohort. Programmes are designed to coverthose subjects not addressed in previous health care education. This would include thespecific chiropractic subjects and those medical science subjects where the training has
been inadequate for the requirements of a chiropractor.

5.3

Basic training

The duration of the training depends upon the credits received from previous
education and experience, but should not be less than 2200 hours over a two‐ or three‐13

Guidelines on basic training and safety in chiropractic

year full‐time or part‐time programme, including not less than 1000 hours ofsupervised clinical experience.

6. Limited chiropractic education –category II(A)In some countries, it has not been practicable to adopt the models outlined in
Category I, particularly when chiropractic education is first introduced and where
significant numbers of students exist who have prior medical and other health careeducation and experience. As has been done already in certain jurisdictions, such
students may obtain basic clinical skills for the delivery of chiropractic services with amore limited supplementary course, of full‐time or part‐time education, depending on
the extent of their previous training.
This approach should be employed as an interim measure to establish the availabilityof chiropractic services. A full chiropractic educational programme for students
choosing chiropractic as their primary career should be implemented as soon as it ispracticable to do so.

6.1

Objective

The objective of such an educational programme is to qualify suitable and available
health care professionals to practise as chiropractors in the health care system.
This type of programme could be developed to facilitate an early introduction ofchiropractic at a safe and acceptably effective level.
Programmes of this type should strongly consider the value of having an accredited
chiropractic programme as a collaborative partner providing educational guidance.

6.2

Special courses

The programme is designed to cover those subjects which are important for thepractice of chiropractic and which have not been covered appropriately in previous
health care education.
Part‐time courses have been designed to be convenient for practitioners maintaining
their current employment, extending appropriate credits to persons depending upon
their level of health care training. For an example, see Annex 4.

6.3

Basic training

Although dependent upon the human resources available for health care, the entrance
requirement would normally be completion of university‐level training as a health carepractitioner.
14

Basic training in chiropractic

The duration of training would be not less than 1800 hours over a two‐ or three‐year
full‐time or part‐time programme, including not less than 1000 hours of supervised
clinical experience.

7. Limited chiropractic education – category
II(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 the unqualified practice of chiropractic, which is undesirable
for patient safety. These programmes prepare graduates to attain the minimal
acceptable requirements for the safe practice of chiropractic.

7.1

Objective

To upgrade the knowledge and skills of existing practitioners utilizing some form ofchiropractic, for the purpose of ensuring public safety and provision of adequatechiropractic service. This approach should be employed as an interim measure only.

7.2

Special courses

As the existing training of practitioners varies greatly, the educational models adopted
to address these situations also vary. Past experience suggests that the development ofcourses may require specific needs‐assessment studies.
The example used in Annex 5 is a basic three‐year, part‐time programme designed tomeet or exceed the minimum requirements. The applicant practitioners are offered
credits or considerations based upon their previous training or existing qualifications.
Admission requirements for such programmes have been the completion of aqualifying local programme and an adequate period of clinical experience, typically 2‐
3 years.
Programmes of this type should strongly consider the value of having an accredited
chiropractic programme as a collaborative partner providing educational guidance.

7.3

Basic training

The duration of training is not less than 2500 hours in a full‐time or part‐timeprogramme, including not less than 1000 hours of supervised clinical experience. For
an example, see Annex 5.

15

Guidelines on basic training and safety in chiropractic

8. Assessment and examinationof students in chiropractic
In order to ensure patient safety and the qualified practice of chiropractic, a system of
independent examination and licensing is necessary. On completion of the full periodof training, the student’s theoretical knowledge and clinical competence in chiropractic
should be independently evaluated through official examinations.
Continuing professional development should be encouraged for maintenance of
licensing.

9. Primary health care workers
and chiropractic
9.1

Primary health care workers ‐ myotherapists

Training has been developed by individual chiropractors within multidisciplinary
settings, with programmes that meet national requirements. These courses introduce
basic musculoskeletal soft‐tissue techniques, massage and other management skills forindigenous nurses and community health workers who apply chiropractic health careprinciples and basic interventions without employing spinal manipulative techniques.
Such training should be sensitive to existing cultural and ethnic issues and should
explore and embrace, where practical, local traditional practices.
Certain techniques to alleviate pain and address musculoskeletal dysfunction, as wellas the constructive management of musculoskeletal factors amenable to change, may
be taught to primary health care workers, particularly community health workers,
increasing the quality of life for people in rural or remote areas (18).
Such workers may have a valuable role in community health education in various
ways. These may include counselling on healthy lifestyles, prevention of
musculoskeletal disorders and other public health issues.

9.2

Objective

The objective of such courses is to create a category of primary health care worker toprovide a first level of treatment and education in a community setting as an adjunct toother community health care measures.

16Basic training in chiropractic

9.3

Course components

Courses contain a combination of flexible, compulsory and elective units that address
various competencies to meet existing requirements on‐site. These may include:
•
•
•
•
•
•
•
•
•
•

remedial massage;
specific myotherapy techniques;culturally appropriate health and lifestyle advice;addressing modifiable musculoskeletal risk factors, such as maintaining ideal
weight and physical activity, smoking cessation and injury prevention;musculoskeletal assessment;
trigger‐point techniques;
myofascial tension technique;deep tissue stimulation technique;stretching techniques;sports injury first aid (including taping and bracing techniques).

Joint adjustment/manipulation is excluded from these training programmes.
Indications warranting this type of care would require attention by a chiropractor orother suitably qualified practitioner.

9.4

Method and duration of training

Training involves workshops, interactive demonstrations, clinical applications andassignments.
The duration (supervised) of such a training programme would be not less than
300 hours.

17

Guidelines on basic training and safety in chiropractic

18

Guidelines on safety of chiropractic

Part 2: Guidelines on safetyof chiropractic

1. Introduction
When employed skilfully and appropriately, chiropractic care is safe and effective forthe prevention and management of a number of health problems. There are, however,known risks and contraindications to manual and other treatment protocols used inchiropractic practice.
While it is beyond the scope of these guidelines to review the various indications forchiropractic 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
manipulative therapy.
Contrary to the understanding of many within health care, chiropractic is notsynonymous with, or limited to, the application of specific manipulative techniques.
The “adjustment” and various manual therapies are central components of achiropractor’s treatment options: however, the profession as an established primarycontact health service has the educational requirements and respects the
responsibilities associated with such a status.
Chiropractic practice involves a general and specific range of diagnostic methods,
including skeletal imaging, laboratory tests, orthopaedic and neurological evaluations,as well as observational and tactile assessments. Patient management involves spinaladjustment and other manual therapies, rehabilitative exercises, supportive andadjunctive measures, patient education and counselling. Chiropractic practiceemphasizes conservative management of the neuromusculoskeletal system, without
the use of medicines and surgery.

19

Guidelines on basic training and safety in chiropractic

2. Contraindications to spinal manipulative
therapy
Spinal manipulative therapy is the primary therapeutic procedure used bychiropractors, and because spinal manipulation involves the forceful passive
movement of the joint beyond its active limit of motion, chiropractors must identify therisk factors that contraindicate manipulation or mobilization (19, 20, 21).
Manipulations can be classified as either nonspecific, long‐lever techniques or specific,
short‐lever, high‐velocity, low‐amplitude techniques (the most common forms ofchiropractic adjustment) which move a joint through its active and passive ranges of
movement to the paraphysiological space (22).
Mobilization is where the joint remains within a passive range of movement and nosudden thrust or force is applied.
Contraindications to spinal manipulative therapy range from a nonindication for suchan intervention, where manipulation or mobilization may do no good, but shouldcause no harm, to an absolute contraindication, where manipulation or mobilization
could be life‐threatening. In many instances, manipulation or mobilization iscontraindicated in one area of the spine, yet beneficial in another region (23). For
example, hypermobility may be a relative contraindication to manipulation in one areaof the spine, although it may be compensating for movement restriction in anotherwhere manipulation is the treatment of choice (24, 25). Of course, the chiropractor’s
scope in manual therapy extends beyond the use of manipulation or mobilization andincludes manual traction, passive stretching, massage, ischaemic compression of
trigger points and reflex techniques designed to reduce pain and muscle spasm.
Successful spinal mobilization and/or manipulation involves the application of a force
to the areas of the spine that are stiff or hypomobile, while avoiding areas of
hypermobility or instability (26).
There are a number of contraindications to joint mobilization and/or manipulation,
especially spinal joint manipulation, which have been reviewed in practice guidelines
developed by the chiropractic profession (27, 28) and in the general chiropractic
literature (29, 30, 31). These may be absolute, where any use of joint manipulation ormobilization is inappropriate because it places the patient at undue risk (23, 32:290‐291), or relative, where the treatment may place the patient at undue risk unless thepresence of the relative contraindication is understood and treatment is modified sothat the patient is not at undue risk. However, spinal manipulative therapy,
particularly low‐force and soft‐tissue techniques, may be performed on other areas ofthe spine, depending upon the injury or disease present. Clearly, in relative
contraindications, low‐force and soft‐tissue techniques are the treatments of choice, as
20

Guidelines on safety of chiropractic

both may be performed safely in most situations where a relative contraindication ispresent.
Conditions are listed first by absolute contraindications to spinal manipulative therapy.
Absolute and relative contraindications to spinal manipulative therapy generally arethen outlined as they relate to categories of disorders.

2.1

Absolute contraindications to spinal manipulative therapy

It should be understood that the purpose of chiropractic spinal manipulative therapy is
to correct a joint restriction or dysfunction, not necessarily to influence the disorders
identified, which may be coincidentally present in a patient undergoing treatment for adifferent reason. Most patients with these conditions will require referral for medicalcare and/or comanagement (33).
1.
2.
3.
4.

anomalies such as dens hypoplasia, unstable os odontoideum, etc.
acute fracture
spinal cord tumour
acute infection such as osteomyelitis, septic discitis, and tuberculosis of
the spine
5. meningeal tumour
6. haematomas, whether spinal cord or intracanalicular
7. malignancy of the spine
8. frank disc herniation with accompanying signs of progressive
neurological deficit
9. basilar invagination of the upper cervical spine
10. Arnold‐Chiari malformation of the upper cervical spine
11. dislocation of a vertebra
12. aggressive types of benign tumours, such as an aneurismal bone cyst,
giant cell tumour, osteoblastoma or osteoid osteoma
13. internal fixation/stabilization devices
14. neoplastic disease of muscle or other soft tissue
15. positive Kernig’s or Lhermitte’s signs
16. congenital, generalized hypermobility
17. signs or patterns of instability
18. syringomyelia
19. hydrocephalus of unknown aetiology
20. diastematomyelia
21. cauda equina syndrome
NOTE: In cases of internal fixation/stabilization devices, no osseous manipulation may be
performed, although soft-tissue manipulation can be safely used. Spinal manipulative
therapy may also only be absolutely contraindicated in the spinal region in which thepathology, abnormality or device is located, or the immediate vicinity.

21

Guidelines on basic training and safety in chiropractic

3. Contraindications to joint manipulation
by category of disorder
3.1

Articular derangement

Inflammatory
conditions,suchasrheumatoid
arthritis,
seronegative
spondyloarthropies, demineralization or ligamentous laxity with anatomical
subluxation or dislocation, represent an absolute contraindication to joint manipulationin anatomical regions of involvement.
Subacute and chronic ankylosing spondylitis and other chronic arthropathies in which
there are no signs of ligamentous laxity, anatomic subluxation or ankylosis are notcontraindications to joint manipulation applied at the area of pathology.
With degenerative joint disease, osteoarthritis, degenerative spondyloarthropathy andfacet arthrosis, treatment modification may be warranted during active inflammatory
phases.
In patients with spondylitis and spondylolisthesis, caution is warranted when joint
manipulation is used. These conditions are not contraindications, but with progressive
slippage, they may represent a relative contraindication.
Fractures and dislocations, or healed fractures with signs of ligamentous rupture or
instability, represent an absolute contraindication to joint manipulation applied at theanatomical site or region.
Atlantoaxial instability represents an absolute contraindication to joint manipulation at
the area of pathology.
Articular hypermobility and circumstances where the stability of a joint is uncertain
represent a relative contraindication to joint manipulation at the area of pathology.
Postsurgical joints or segments with no evidence of instability are not acontraindication to joint manipulation but may represent a relative contraindication,
depending on clinical signs (e.g. response, pre‐test tolerance or degree of healing).
Acute injuries of joint and soft‐tissues may require modification of treatment. In mostcases, joint manipulation at the area of pathology is not contraindicated.
Although trauma is not an absolute contraindication to manipulation, patients who
have suffered traumatic events require careful examination for areas of excessive
motion, which may range from mild heightened mobility to segmental instability.

22

Guidelines on safety of chiropractic

3.2

Bone‐weakening and destructive disorders

Active juvenile avascular necrosis, specifically of the weightbearing joints, represents
an absolute contraindication to joint manipulation at the area of pathology.
Manipulation of bone weakened by metabolic disorders is a relative contraindication
because of the risk of pathological fractures (34, 35). Demineralization of bone warrants
caution. It represents a relative contraindication to joint manipulation at the area of
pathology. The spine and ribs are particularly vulnerable to osteoporotic fracture, andthose patients who have a history of long‐term steroid therapy, those withosteoporosis, and women who have passed menopause are most susceptible (19:229,
36). Benign bone tumours may result in pathological fractures and therefore represent
a relative‐to‐absolute contraindication to joint manipulation at the area of pathology.
Tumour‐like and dysphasic bone lesions may undergo malignant transformation or
weaken bone to the point of pathological fracture, and therefore represent a relative‐to‐absolute contraindication to joint manipulation at the area of pathology.
Malignancies, including malignant bone tumours, are conditions for which joint
manipulation at the area of pathology is absolutely contraindicated.
Infection of bone and joint represents an absolute contraindication to joint
manipulation at the area of pathology.
Severe or painful disc pathology, such as discitis or disc herniations, are relative
contraindications and nonforceful, non‐high‐velocity and nonrecoil manipulativetechniques must be employed.

3.3

Circulatory and haematological disorders

Clinical manifestations of vertebrobasilar insufficiency syndrome warrant particular
caution and represent a relative‐to‐absolute contraindication to cervical joint
manipulation at the area of pathology. This would include patients with a previous
history of stroke (37).
When a diagnosis of an aneurysm involving a major blood vessel has been made, arelative‐to‐absolute contraindication may exist for joint manipulation within the area of
pathology.
Bleeding is a potential complication of anticoagulant therapy or certain blood
dyscrasias. These disorders represent a relative contraindication to joint manipulation.

3.4

Neurological disorders

Signs and symptoms of acute myelopathy, intracranial hypertension, signs andsymptoms of meningitis or acute cauda equina syndrome represent absolutecontraindications to joint manipulation.

23

Guidelines on basic training and safety in chiropractic

3.5

Psychological factors

It is important to consider psychological factors in the overall treatment of patients
who seek chiropractic care. Certain aberrant behaviour patterns represent relative
contraindications to continued or persistent treatment. Failure to differentiate patientswith psychogenic complaints from those with organic disorders can result ininappropriate treatment. Moreover, it can delay appropriate referral. Patients who mayneed referral include malingerers, hysterics, hypochondriacs and those with dependent
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). The equipment for these modes of treatment needs to be properly maintained
and used in accordance with appropriate specifications and clinical indications, but inthese circumstances such therapeutic methods pose only a very limited risk of causing
harm (38, 39, 40).

4.2

Exercises and supplementary supportive measures

A wide range of rehabilitative exercises and supportive measures are used inchiropractic practice. These should be prescribed in accordance with each patient’s
individual requirements, and the dosage or level of exercise should be specificallydesigned to address the individual’s limitations and needs, being generally
conservative at first and then increasing over time. In these circumstances, there are no
significant contraindications which could not be addressed by common sense and thepractitioner’s professional knowledge (41).

24

Guidelines on safety of chiropractic

5. Accidents and adverse reactions
5.1

Causes of complications and adverse reactions

See Henderson (42):
•
•
•

5.2

lack of knowledge
lack of skill
lack of rational attitude and technique.

Examples of inappropriate practices

See Henderson (42):
•
•
•
•
•
•
•
•

5.3

inadequate diagnostic habits
inadequate diagnostic imaging evaluation
delay in referral
delay in re‐evaluationlack of interprofessional cooperation
failure to take into account patient tolerancespoor technique selection or implementation
excessive or unnecessary use of manipulation.

Serious adverse consequences

Manipulation is regarded as a relatively safe, effective and conservative means ofproviding pain relief and structural improvement of biomechanical problems of thespine. As with all therapeutic interventions, however, complications can arise. Serious
neurological complications and vascular accidents have been reported, although bothare rare (43).

5.3.1
•
•
•
•
•
•

5.3.2
•

Cervical region
vertebrobasilar accidents (see part 2, section 3.3 above)
Horner’s syndrome (44)diaphragmatic paralysis (45)myelopathy (46)cervical disc lesions (25:66)
pathological fractures (47, 48)
Thoracic region
rib fracture and costochondral separation (49)25

Guidelines on basic training and safety in chiropractic

5.3.3
•
•
•
•

5.4

Lumbar region
an increase in neurological symptoms that originally resulted from a disc injury(50)
cauda equina syndrome (51, 52)
lumbar disc herniation (52)rupture of abdominal aortic aneurysm (53)

Vascular accidents

Understandably, vascular accidents are responsible for the major criticism of spinal
manipulative therapy. However, it has been pointed out that “critics of manipulative
therapy emphasize the possibility of serious injury, especially at the brain stem, due toarterial trauma after cervical manipulation. It has required only the very rare reportingof these accidents to malign a therapeutic procedure that, in experienced hands, gives
beneficial results with few adverse side effects” (43).
In very rare instances, the manipulative adjustment to the cervical spine of avulnerable patient becomes the final intrusive act which, almost by chance, results in avery serious consequence (54, 55, 56, 57).

5.4.1 Mechanism
Vertebrobasilar artery insufficiency is the result of transient, partial or complete
obstruction of one or both of the vertebral arteries or its branches. The signs andsymptoms of vertebral artery syndrome arising from that compression include vertigo,
dizziness, light‐headedness, giddiness, disequilibria, ataxia, walking difficulties,
nausea and/or vomiting, dysphasia, numbness to one side of the face and/or body,sudden and severe neck/head pain after spinal manipulative therapy (43:579).
Most cases of arterial thrombosis and infarction generally occur in the elderly and arespontaneous and unrelated to trauma.

5.4.2 Incidence
Vertebral artery syndrome attributed to cervical manipulation occurs in younger
patients. The average age is under 40, and it occurs more often in women than men. In
1980, Jaskoviak estimated that five million treatments had been given at National
College of Chiropractic clinics over a 15‐year period, without a single case of vertebral
artery syndrome associated with manipulation (58).
While it is understood that the actual incidence of cerebral vascular injury could behigher than the number of reported incidents, estimates from recognized authorities in
research in this area have varied from as little as one fatality in several tens of millions
of manipulations (59), one in 10 million (60) and one in one million (61) to the slightly
more significant “one important complication in 400 000 cervical manipulations” (62).
26

Guidelines on safety of chiropractic

Serious complications are very rare, and it would seem unlikely that the adverse
occurrences have been solely attributable to the therapeutic intervention.

5.5

Prevention of complications from manipulation

Incidents and accidents that result from manipulative therapy can be prevented bycareful appraisal of the patient’s history and examination findings. Information must
be sought about coexisting diseases and the use of medication, including long‐termsteroid use and anticoagulant therapy. A detailed and meticulous examination must be
carried out. The use of appropriate techniques is essential, and the chiropractor must
avoid techniques known to be potentially hazardous (19:234‐235).

6. First aid training
All recognized programmes in chiropractic contain standard courses in first aid, either
taught within the institution or required to be taken from such authorities as Red
Cross. This is the case in all training programmes, whether they are full‐time,
conversion or standardization programmes. Also, within risk management courses,
time is spent on procedures to minimize the possibility of injuries and the appropriate
action to follow should an incident occur.

27

Guidelines on basic training and safety in chiropractic

28

List of participants

Annex 1: List of participants
WHO Consultation on Chiropractic
2 ‐ 4 December 2004, Milan, Italy

Participants
Dr Abdullah Al Bedah, Supervisor, Complementary and Alternative Medicine,
Ministry of Health, Riyadh, Saudi Arabia
Dr Maurizio Amigoni, Deputy Director‐General, Directorate‐General of Health,Lombardy Region, Milan, Italy
Dr Sassan Behjat, Coordinator, Office of Complementary and Alternative Medicine,
Ministry of Health, Abu Dhabi, United Arab Emirates
Ms Anna Caizzi, Director of Consumer Protection and Support to the Commercial
System Structure, Directorate‐General of Markets, Fairs and Congresses, Lombardy
Region, Milan, Italy
Dr Martin Camara, Board Member, Philippine Institute of Traditional and Alternative
Health Care (PITAHC), Makati City, Philippines (Co‐Rapporteur)
Dr Margaret Coats, Chief Executive & Registrar, General Chiropractic Council,
London, England
Dr Alessandro Discalzi, Directorate‐General of Family and Social Solidarity,
Lombardy Region, Milan, Italy
Mr Igwe Lawrence Eleke, Assistant Director, National Traditional Medicine
Development Programme, Federal Ministry of Health, Abuja, Nigeria1
Mr Michael Fox, Chief Executive, Prince of Walesʹs Foundation for Integrated Health,London, England
Dr Ricardo Fujikawa, Centro Universitario Feevale, Novo Hamburgo, Brazil
Dr Edward Tin‐tak Lee, Chairman, Chiropractors Council, Hong Kong SAR, Peopleʹs
Republic of China (Co‐Chairperson)
Professor Jean‐Pierre Meersseman, Chiropractor, Italian Chiropractic Association,
Genova, Italy

1

Unable to attend.
29

Guidelines on basic training and safety in chiropractic

Professor Emilio Minelli, WHO Collaborating Centre for Traditional Medicine, Centreof Research in Bioclimatology, Biotechnologies and Natural Medicine, State Universityof Milan, Milan, Italy
Dr Koichi Nakagaki, Kokusai Chiropractic School, Osaka, JapanDr Susanne Nordling, Chairman, Nordic Co‐operation Committee for Non‐conventional Medicine (NSK), Committee for Alternative Medicine, Sollentuna,
SwedenMs Lucia Scrabbi, Planning Unit, Directorate‐General of Health, Lombardy Region,
Milan, Italy
Professor Vladimir S. Shoukhov, Health Officer, International Federation of Red Cross
and Red Crescent Societies (IFRCRC), Moscow, Russian Federation
Professor Umberto Solimene, Director, WHO Collaborating Centre for Traditional
Medicine, Centre of Research in Bioclimatology, Biotechnologies and Natural
Medicine, State University of Milan, Milan, Italy
Dr John Sweaney, New Lambton, Australia (Co‐Rapporteur)
Dr U Sein Win, Director, Department of Traditional Medicine, Ministry of Health,
Yangon, Myanmar (Co‐Chairperson)

Representatives of professional organizations
World Chiropractic Alliance (WCA)Dr Asher Nadler, Member of the International Board, Israel Doctors of Chiropractic,
Jerusalem, Israel
Dr Yannick Pauli, WCA Liaison to WHO, Lausanne, Switzerland
World Federation of Chiropractic (WFC)
Dr David Chapman‐Smith, Secretary‐General, Toronto, Ontario, Canada
Dr Anthony Metcalfe, President, Teddington, Middlesex, England

Local secretariat
Ms Elisabetta Minelli, International Relations Office, WHO Collaborating Centre for
Traditional Medicine, State University of Milan, Liaison with Planning Unit,
Directorate‐General of Health, Lombardy Region, Milan, Italy30

List of participants

WHO Secretariat
Dr Samvel Azatyan, Technical Officer, Traditional Medicine, Department of TechnicalCooperation for Essential Drugs and Traditional Medicine, World HealthOrganization, Geneva, Switzerland
Dr Xiaorui Zhang, Coordinator, Traditional Medicine, Department of TechnicalCooperation for Essential Drugs and Traditional Medicine, World HealthOrganization, Geneva, Switzerland

31

Guidelines on basic training and safety in chiropractic32

A sample four-year, full-time accredited programme

Annex 2:A sample four-year, full-time accredited
programme
Category I(A) Subjects taught in a typical semester‐based chiropractic programme, by year andnumber of hours.
DIVISION

Biological
Sciences

FIRST YEAR
(HOURS)SECOND YEAR
(HOURS)

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)Clinical Sciences

NormalRadiographic
Anatomy (16)Radiation
Biophysics andProtection (44)Intro. Diagnosis (85)Intro Bone Pathology(48)
Normal Roentgen,
Variants &Roentgenometrics(40)

Chiropractic
Sciences

Chiropractic
Principles I (56)
Basic Body
Mechanics (96)
Chiropractic Skills I(100)

Chiropractic Principles
II (60)Chiropractic Skills II(145)
Spinal Mechanics (40)

Clinical
Practicum

Observation I (30)914

Lab Diagnosis (32)Toxicology (12)Orthopaedics &Rheumatology (90)Neuro. Diagnosis (40)
Diagnosis &Symptomatology (120)Differential Diagnosis(30)
Radiological Technology(40)
Arthritis & Trauma (48)
Chiropractic Principles
III (42)
Clinical Biomechanics(100)
Chiropractic Skills III(145)
Auxiliary Chiropractic
Therapy (60)Introduction toJurisprudence & PracticeDevelopment (16)Observation II (70)

Observation III (400)962

Applied Research &Biometrics (32)1207

Research
TotalsTOTAL HOURS
Full-time
study overfour years:

THIRD YEAR
(HOURS)FOURTH YEAR
(HOURS)

Clinical Nutrition (26)Community Health(40)

Clinical Psychology(46)
Emergency Care (50)Child Care (20)
Female Care (30)
Geriatrics (20)
Abdomen, Chest &Special Radiographic
Procedures (40)Integrated
Chiropractic Practice(90)
Jurisprudence &Practical
Development (50)Internship (750)
Clerkships: Auxiliary
Therapy (30); ClinicalLab (20)
Clinical X-ray:
Technology (70);Interpretation (70)
Observer IV (30)
Research
Investigative Project
1382

4465
plus research
project

33

Guidelines on basic training and safety in chiropractic34

A sample full (conversion) programme

Annex 3:A sample full (conversion) programme
Category I(B) Essentially, conversion programmes are dependent upon assessment of the
medical training of the student cohort. They are then designed so as to complete satisfactorily
all requirements of a full chiropractic programme.
DIVISIONSECOND YEAR
(HOURS)FIRST YEAR (HOURS)

Biological Sciences

Spinal Anatomy (45)
Laboratory Diagnosis (30)
Pathology (60)Physiology (45)Pathology (120)

Clinical Sciences

Radiology (90)Neuromusculoskeletal
Diagnosis (30)Radiology (90)Neurology (45)Physical Diagnosis (30)
Neuromusculoskeletal
Diagnosis (30)

Chiropractic Sciences

Clinical Practicum
Research
TOTALSTOTAL HOURS Full-timeor part-time study overthree years

Chiropractic History (30)
Principles & Philosophy of
Chiropractic (20)Spinal Biomechanics (60)
Static & Dynamic Spinal
Palpation (30)
Chiropractic Skills (180)Supervised Clinical
Practicum (120)740

THIRD YEAR
(HOURS)
Clinical Nutrition(45)

Paediatrics (45)Geriatrics (30)

Principles & Philosophy of
Chiropractic (20)
Static & Dynamic Spinal
Palpation (60)
Chiropractic Skills (120)

Principles &Philosophy of
Chiropractic (20)
Chiropractic Skills(60)

Supervised Clinical
Practicum (225)Supervised Clinical
Practicum (500)
Research (25)
725

740

2205

35

Guidelines on basic training and safety in chiropractic36

A sample limited (conversion) programme

Annex 4:
A sample limited (conversion) programme
Category II(A) Suitable for persons with a solid medical education to attain minimal
registerable requirements to practise safely and relatively effectively as chiropractors.

DIVISIONFIRST 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)

Principles & Philosophy of
Chiropractic (20)
Static & Dynamic Spinal
Palpation (60)
Chiropractic Skills (90)Principles & Philosophyof Chiropractic (20)
Chiropractic Skills (60)Supervised Clinical
Practicum (220)600Supervised Clinical
Practicum (420)605

Chiropractic Sciences

Clinical Practicum
TOTAL
TOTAL HOURS
Part-time study
over three years

Chiropractic History (30)
Principles & Philosophy of
Chiropractic (20)Spinal Biomechanics (60)
Static & Dynamic Spinal
Palpation (30)
Chiropractic Skills (90)Supervised Clinical Practicum
(100)
600
1805

37

Guidelines on basic training and safety in chiropractic38

A sample limited (standardization) programme

Annex 5:
A sample limited (standardization) programme
Category II(B) Addresses deficiencies identified through assessment of a student’s existingknowledge and skills and enables graduates to attain safe and minimal registerable standards
as chiropractors.
FIRST YEAR

DL

IR

CP

Anatomy56

24

Biochemistry

56

4

Physiology

56

4Pathology

70

12Public Health56

4ClinicalNutrition

56

4

Biomechanics

Principles of
Chiropractic

56

42

Research

DL

Laboratory
Diagnosis

428

PhysicalDiagnosis

56

14

Orthopaedics/
Neurology

56

14Radiology

56

16

ClinicalDiagnosis

56

9

IR

CP

Patient
Management
Procedures

342

Computer
SkillsWorkshop

6

448

2790

71

406

THIRD YEAR

DL

IR

70

20

70

20

70

20

70

20

SpecialPopulation Care

56

24

Record Keeping,
Documentation &Quality
Assurance

42

16

Head/Cervical
Spine CareThoracic/Lumbar
Spine & Pelvis
Care
Hip/Knee/Ankle/
Foot Care
Shoulder/Elbow/
Wrist/Hand Care

18

400

TotalsTOTAL
HOURS
Part-time
study overthree years

SECOND
YEAR

16

Clinical
Practicum

Chiropractic
Sciences

Clinical Sciences

Biological
Sciences

DIVISION

400

Research
Methodology

50

First
Aid/Emergency
Care

28

24

486

103

400

CP

400

378

100

400

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

39

Guidelines on basic training and safety in chiropractic

40References

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44