THE CHIROPR ACTIC REPORT www.chiropracticreport.com Editor: David Chapman-Smith LL.B. (Hons.) May 2005 Vol. 19 No. 3

WHO AND WHAT IS A CHIROPRACTOR? Global Challenges—and Educational Standards from the Profession and the WHO

A. INTRODUCTION inadequate and short-term courses given STEOPATHS EVERYWHERE by qualified doctors of in O are challenged by their lack of betrayal of their own profession. There- agreed educational standards—interna- fore for example: tionally they have no identifiable profes- a) During the past year a US-educated sion. chiropractor, Dr. Alain Dhers, originally In the US they are the equivalent of from France and now living in Spain, has medical doctors with almost identical commenced weekend courses in chiro- training and the same specialties—your practic technique for other health profes- cardiologist, anesthesiologist or surgeon sionals in Spain and Portugal, countries may be an osteopath. In the UK there where the practice of chiropractic is is a more traditional osteopathic educa- nearing but has not yet achieved legal tion, similar in duration to chiropractic recognition. Notwithstanding pressure education. Elsewhere in Europe and in from the Spanish and Portuguese chiro- many other countries it is open season. practic associations and others, including Osteopaths are medical doctors, physi- his alma mater Sherman College, Dr. cal therapists or lay persons who have Dhers continues to advertise and give his completed part-time weekend courses, courses. The opportunity for personal PROFESSIONAL NOTES typically of inadequate quality and given gain has triumphed over integrity. Cervical Adjustment—What Risk? by entrepreneurs. b) This month, under the headline Ameri- Attacks against chiropractors concerning Chiropractic has taken a different path. can DC Angers Profession in Germany: perceived risks of cervical manipulation It has developed one minimum standard Should DCs be Teaching Chiroprac- are currently based on “coincidence, of education worldwide that offers much tic to Non-DCs?, the US newspaper anecdotal reports and junk ” said greater protection to both the profession Dynamic Chiropractic reports how “the the leading Canadian neurologist Dr. and the public it serves. This standard chiropractic profession in Germany and Adrian Upton, delivering a lecture titled has been enforced by a network of throughout Europe is up in arms” over Chiropractic Therapy as Seen by a Neu- affiliated accrediting agencies in vari- the actions of a young American chiro- rologist in Bournemouth, England on ous world regions, and by licensing laws practor, Dr. Mark Styers, who has com- April 22. worldwide that require licensed chiro- menced a 432-hour, 26-weekend course practors to be graduates of accredited of chiropractic technique seminars for Case reports and expert opinions rep- lay manipulators. resent a “very low level of evidence” schools. Countries with laws recognizing and cannot establish a scientific or legal and regulating chiropractic practice are Dynamic Chiropractic explains that, link between chiropractic treatment and given in Table 1. In many other countries upon completion of courses at Dr. Sty- vertebral artery injury or stroke. For the practice of chiropractic is legal—but ers’ American Institute of Chiropractic causation to be proven there need to not regulated. (AIC) in Hamburg, graduates are encour- be large—and extremely complex and 2. Now that chiropractic has become aged to join a new association formed by expensive—controlled trials. established and well-known in all world him, the WCA-Germany, as chiroprac- tors. These developments are bitterly If there is any risk it is extremely small, regions, a strong new threat to the integrity of the profession is emerging opposed by the German Chiropractors’ said Upton. People have vertebral artery Association (GCA) representing most of injury and stroke after many activities or in those countries where there is still no regulation of the profession, no law Germany’s 70 duly qualified doctors of spontaneously—but very rarely. No one chiropractic, but they have limited pow- knows whether there is a higher inci- controlling who may use the titles ‘doc- tor of chiropractic’ and ‘chiropractor’, or ers to act because Germany is a country dence of injury and stroke after turning where the chiropractic profession and its the head to sleep, visiting a chiropractor, claim to offer chiropractic services. This threat is principally from medical doc- practice are not yet recognized and regu- or eating a hamburger—or whether the lated by law. More on this below. rate is the same as in the general popula- tors, physiotherapists and lay manipula- tion at large. tors claiming to provide chiropractic c) In Taiwan a Dr. Julian Wang, a continued on page 4 services—sometimes, regrettably, after medical doctor who re-qualified as a Main Article continued from page 1 chiropractor in the US at the Southern California University of Health The Chiropractic Report is an international review Table 1: Countries with Legislation of professional and issues published six to Recognize and Regulate the (formerly the Los Angeles College of times annually. You are welcome to use extracts Chiropractic Profession Chiropractic), is providing short-term from this Report. Kindly acknowledge the source. courses in chiropractic to medical doc- Subscribers may photocopy the Report or order tors and physical therapists and asserting additional copies (.80 cents each – minimum of 20 African Region copies plus shipping) for personal, non-commercial to government that legislation to recog- Botswana use in association with their practices. However, nize the chiropractic profession when neither the complete Report nor the majority or Lesotho enacted, should include those who have whole of the leading article may be reproduced in Namibia taken courses such as his. any other form without written permission. Nigeria Subscription: for rates and order form, see page 8. d) In Brazil there are two new univer- For information or orders visit South Africa sity-based chiropractic schools that have www.chiropracticreport.com Swaziland or telephone 416.484.9601, fax 416.484.9665 graduated their first classes this year, but Zimbabwe email: [email protected] there is still no legal regulation of chiro- Editorial Board practic practice. In response the COFFI- Daniele Bertamini DC, Italy Asian Region TO, the national organization represent- Alan Breen DC PhD, England Hong Kong – SAR China ing physiotherapists, is lobbying to have Peter Gale DC, United States Scott Haldeman DC MD PhD, United States chiropractic recognized as a specialty of Donald J. Henderson DC, Canada Eastern Mediterranean Region physiotherapy, and PTs are beginning to Reginald Hug DC, United States Cyprus take postgraduate short-term part-time William Kirkaldy-Willis MD, Canada Iran Dana Lawrence DC, United States courses from informally trained Brazil- Miriam A. Minty DC, Australia Saudi Arabia ian ‘quiropatas’ in Sao Paulo. Michael Pedigo DC, United States United Arab Emirates Lindsay Rowe MAppSc(Chiropractic) MD, DACBR, e) In Buenos Aires in Argentina a medi- FCCR, FACCR, FICC, DRACR, Australia cal group led by Dr. Alberto Baigros has Louis Sportelli DC, United States European Region now provided a certificate in chiropractic Aubrey Swartz MD, United States Belgium* to MDs who completed a 200-hour part- Changes of mailing instructions should be sent to Denmark time course during May to December The Chiropractic Report, 203–1246 Yonge Street, Finland Toronto, Ontario, Canada M4T 1W5, 2004. A second year of the course has telephone 416.484.9601, fax 416.484.9665. France* now commenced. Printed by Harmony Printing Limited, Iceland 3. What is the profession doing to pre- 416.232.1472. Liechtenstein Copyright © 2005 Chiropractic Report Inc. vent and respond to these problems? ISBN 0836-144 Norway There are four major courses of action Portugal* and the World Federation of Chiroprac- Sweden tic, whose members are national associa- Switzerland tions in the above countries and through- importantly the World Health Organiza- United Kingdom out the world, has a significant role in all tion. of them: c) Putting maximum pressure on chiro- Latin American Region a) Maintenance of one minimum inter- practors and chiropractic organizations Costa Rica* national standard for full qualification as that are dishonouring the profession and Mexico* a chiropractor, and ensuring that this is threatening its identity by offering their Panama the standard incorporated in legislation self-serving courses. in each country as licensing laws are 4. This issue of The Chiropractic Report North American Region/Caribbean passed. reviews the above situation. If the right Bahamas b) For countries where persons with lim- to practise chiropractic is regulated by Barbados ited informal training are practicing as law for you in your country, why should Canada chiropractors, and can be expected to be you be concerned? Because the contin- Leeward Islands grandfathered into the profession when ued existence of chiropractic everywhere Puerto Rico licensing laws are passed, or where the as a separate and distinct profession, United States first introduction of formal chiropractic rather than a set of techniques used by various professionals, depends upon the US Virgin Islands education cannot realistically be at the international standard given social and defence of established educational stan- legal conditions, establishment of clear dards. Educational and legal develop- Pacific Region ments in one state or country can quickly Australia guidelines for interim limited education in two ways: influence developments in others in our Guam small, interconnected modern world. New Caledonia* • Through the profession’s own agen- All chiropractors should know of these New Zealand cies—including the Councils on Chiro- wider international professional issues practic Education International (CCEI) and be vocal in influencing colleagues * = Legislation to recognize the profes- and the World Federation of Chiropractic not to embark on educational initiatives sion, but legal framework for regulation (WFC). in other countries whatever their motives not yet complete. • Through external agencies that have —unless the standards set by the profes- influence with governments – most sion and now WHO are honored.

PAGE 2 Table 2: A Sample Four-year, Full-time Accredited Chiropractic Curriculum

Subjects Taught in a Typical Semester-based Chiropractic Program, by Year and Number of Hours.

Division First Year (Hrs) Second Year (Hrs) Third Year (Hrs) Fourth Year (Hrs)

Biological Sciences Human Anatomy (180) Pathology (174) Lab Diagnosis (32) Clinical Nutrition (26) Microscopic Anatomy (140) Lab Diagnosis (40) Toxicology (12) Community Health (40) Neuroanatomy (72) Microbiology & Infectious Neuroscience I (32) Disease (100) Biochemistry (112) Neuroscience II (85) Physiology (36) Nutrition (60) Immunology (15)

Clinical Sciences Normal Radiographic Intro. Diagnosis (85) Orthopaedics & Rheumatology Clinical Psychology (46) Anatomy (16) Intro Bone Pathology (48) (90) Emergency Care (50) Radiation Biophysics and Normal Roentgen, Neuro diagnosis (40) Child Care (20) Protection (44) Variants & Diagnosis & Symptomatology Female Care (30) Roentgenometrics (40) (120) Geriatrics (20) Differential Diagnosis (30) Abdomen, Chest & Special Radiological Technology (40) Radiographic Procedures Arthritis & Trauma (48) (40)

Chiropractic Chiropractic Principles I (56) Chiropractic Principles Chiropractic Principles III (42) Integrated Chiropractic Sciences Basic Body Mechanics (96) II (60) Clinical Biomechanics 100) Practice (90) Chiropractic Skills I (100) Chiropractic Skills II (145) Chiropractic Skills III (145) Jurisprudence & Practical Spinal Mechanics (40) Auxiliary Chiropractic Therapy Development (50) (60) Introduction to Jurisprudence & Practice Development (16)

Clinical Practicum Observation I (30) Observation II (70) Observation III (400) Internship (750) Clerkships: Auxiliary Therapy (30) Clinical Lab (20) Clinical X-ray: Technology (70) Interpretation (70) Observer IV (30)

Research Applied Research & Biometrics Research Investigative (32) Project

TOTALS 914 962 1,207 1,382

TOTAL HOURS OVER FOUR YEARS: 4,465 plus research project

B. ACCREDITED FULL EDUCATION. degrees, found in Australia and South nomic and political power. As examples 5. This is familiar to all licensed chiro- Africa. of this: practors worldwide, except those grand- In Europe, under the European Union’s a) In Japan, where the practice of chiro- fathered when laws were first introduced Bologna Directive, all professions practic is not regulated by law, there is and does not therefore need detailed dis- including chiropractic are moving to the recognition and government funding for cussion here. A typical semester-based model of a 3-year bachelor’s degree fol- a number of alternative health profes- program (two terms per year) is given in lowed by a 2-year master’s degree and sions that have developed from tradi- Table 2. one year in supervised professional prac- tional Japanese healing methods, known This represents four years of fulltime tice. However, whatever the model, the as ‘ryoujytsu’. These include judo bone- study following entrance requirements, content of the curriculum is substantially setting, moxibustion therapy, Japanese which are typically a bachelor’s degree the same. massage (anma)/shiatsu and acupunc- or three years colleges/university credits ture. Education comprises three years of in North America. As chiropractic educa- C. INTERIM LIMITED EDUCATION fulltime or part-time education. Many of these professionals have completed post- tion has spread internationally there are 6. No profession can control its world in graduate local courses in chiropractic, various other models of full education, countries where it is not recognized by practise as chiropractors, and belong to including the 5-year double bachelor law, and where social and legal condi- large and influential associations. degrees, or bachelor’s plus master’s tions allow others to usurp its name and standards and develop their own eco- continued on page 6

PAGE 3 THE CHIROPRACTIC WORLD

Cervical Adjustment—What Risk? • Appropriate health care only addresses 50% of the prob- continued from page 1 lem—the other half is occupational management of return to work. Primary health care professionals must communicate with employers on this. Professor Upton, Head, Division of Neurology, McMaster Uni- versity School of Medicine, Hamilton, Ontario, was speaking at • A key shift in attitude must be from the ‘work is harmful’ to the 80th Annual Spring Convention of the British Chiropractic ‘work is healthy’—physically, mentally and emotionally. Association (BCA) held jointly with the 40th anniversary cel- 2. Nilsson—Why Trials are Disappointing. Professor Niels ebration of the Anglo-European College of Chiropractic. Other Grunnet-Nilsson, DC MD PhD from the University of Southern noteworthy contributions on the topic included: Denmark, with a background of 12 years in practice and then • Dr. Paul Carey, familiar with malpractice claims history in 18 years in education and research, asked why the excellent Canada as President of the Canadian Chiropractic Protec- results he experienced with patients in practice are so hard to tive Association (CCPA), which has data confirming a risk of duplicate in clinical trials/research. He is partway through a stroke following cervical adjustment (following—not caused major analysis of this, and suggested that the answer may lie in by) of less than 1 in 1 million treatments, spoke of the surpris- problems in research design of trials in these areas: ing level of medical bias in claims handled by the CCPA. If an • Choice of patient population. With respect to headache tri- individual suffered stroke within a week or two of chiropractic als, for example, it is known that 20% of those with headaches treatment, almost invariably causation was assumed by medi- are seen in primary care, only 0.1% in headache centres—yet cal specialists—without any contact with the chiropractor or it is in these centres that the trials are done. A further point proper investigation. The absurdity of this was demonstrated by relates to pain levels. With respect to a back pain trial in which a recent incident in which a patient suffered a stroke following chiropractic management is being compared with another treat- chiropractic treatment—and, since this treatment was suggested ment and/or a placebo, the powerful factor of regression to the as a probable cause, commenced a claim for damages. This was mean—which means that all subjects will be presenting for easily resisted since the patient had only received chiropractic care at a more serious stage in their pain cycle and will tend treatment of the ankle. to improve anyway whatever treatment or lack of treatment • Dr. Haymo Thiel, providing an interim report on a major UK they are getting—means that you have to have subjects with a prospective study of the safety of chiropractic neck manipula- significant average level of pain if the trial is going to be able tion, commenced in June 2004 and involving 420 BCA mem- to demonstrate treatment effects over and beyond regression to bers, explained that to date there were data on 50,214 consecu- the mean. Many trials do not—the chiropractic treatment has tive neck manipulations without a single serious incident of no chance of demonstrating significant benefit. harm. (NSAIDs and even aspirin cannot manage that level of • Choice of outcome variables to measure results. In practice safety). clinicians tend to use a retrospective global assessment by the BCA/AECC Conference—Other Items. patient (“how are you doing”?) as well as disability question- naires and other measures. New research is showing that such 1. Waddell – Principles of Rehabilitation. The prominent Scot- a global assessment is actually more sensitive to change than tish orthopaedic surgeon Professor Gordon Waddell, who has questionnaires—but it has not often been used in trials. been reviewing the whole field of rehabilitation for the UK Department for Work and Pensions during the past three years, • Choice of treatment protocols. When drug trials are done the reviewed concepts of rehabilitation for common health prob- best dosage has already been established—how much to take lems. Traditionally rehabilitation has been seen as a secondary and how often—before the trial of effectiveness is begun. That intervention after primary health care for the obviously dis- is not the case for chiropractic and other physical treatments. abled—such as those who are blind or confined to wheelchairs. This means there is danger in adopting standardized treatment protocols in chiropractic research at this point in time. That In fact in the UK 80% of persons requiring rehabilitation and should not be done until best frequency of treatment—or dos- on long-term incapacity benefits have the common health prob- age—has been established. lems (CHPs) of mental health concerns (44%), back and other musculoskeletal disability (26%) and cardiovascular problems Grunnet-Nilsson illustrated this with two chiropractic random- (10%). Their problems are biopsychosocial. Their long-term ized controlled trials in the field of infantile colic/irritable incapacity is not inevitable, and is often the result of poor reha- baby syndrome. A Norwegian trial (Olafsdottir et al. 2001) bilitation. provided a standardized treatment protocol—3 treatments over 2 weeks—and did not report benefit from chiropractic manage- Rehabilitation for CHP should address not only obstacles to ment. A Danish trial (Wiberg et al. 1999) adopted a pragmatic recovery (the focus of health care), but also barriers to return to design of as many treatments as were felt necessary over a work. Key new principles and attitudes in the world of rehabili- 2 week period. Under this design different infants received tation are: between 1 and 7 treatment visits, and 64% had 4 or more treat- • Principles of rehabilitation must be incorporated in primary ments—more than the other trial allowed. The Danish trial did care—not secondary care. report significant benefit from chiropractic management as • Care should be directed not only at symptomatic relief but compared with standard medical management. Different dos- also restoration of function. age may have been the deciding factor.

PAGE 4 NEWS AND VIEWS

Research Highlights more likely to see a medical doctor only than more skilled 1. Australia—Long-Term Benefit of Chiropractic Manipu- workers. lation for Chronic Mechanical Back and Neck Pain. An Overall, then, there is large potential for growth in chiropractic important randomized controlled trial from Muller and Giles at practice in the occupational back pain field. The evidence of Townsville Hospital published in Spine in 2003 [28(14):1490- cost-effectiveness and patient satisfaction is there – what is 1503] reported that chronic back and neck patients receiving now needed is the trust and support of employers. chiropractic manipulation (twice weekly for a maximum of 9 (Côté P, Baldwin ML, Johnson WG (2005). Early Patterns of weeks) had significantly better results than patients receiving Care for Occupational Back Pain. Spine 30 (5) 581-587). or medication (Celebrex, Vioxx and paracetemol). 3. Canada—Management of Paediatric Health Conditions. At 9 weeks the highest proportion of patients with complete It is noteworthy that Paediatric Child Health, the official jour- early recovery (asymptomatic status) was found for patients nal of the Canadian Paediatric Society, has just published a sys- receiving chiropractic manipulation (27.3%), in comparison tematic review by chiropractic researchers Gotlib and Rupert to with acupuncture (9.4%) and medication (5%). determine the evidence supporting the benefits of chiropractic An important follow-up paper has just published long-term management for paediatric health conditions. results—at 12 months after treatment. Those receiving spinal Results are bittersweet. On one hand claims for chiropractic manipulation “gained significant broad-based beneficial . . . management and manipulation are “for the most part sup- long-term outcomes” compared with those receiving acupunc- ported by low levels of scientific evidence” and more rigorous ture or medication. As Muller and Giles relate, these results are study is needed. On the other hand the chiropractic profession important—firstly because chronic spinal pain is such a huge is the only one using spinal manipulation with children that problem in terms of suffering and cost, and secondly because has conducted significant research and, although the evidence there are very few RCTs for chronic spinal problems with long- is patchy, there are randomized controlled trials suggesting term follow-up. effectiveness for paediatric patients (those 18 years of age or (Muller R, Giles LGH (2005) Long-term Follow-up of a Ran- younger) for asthma, enuresis, infantile colic and chronic otitis domized Clinical Trial Assessing the Efficacy of Medication, media. This paper also gives you a good set of references for Acupuncture, and Spinal Manipulation for Chronic Mechanical the research to date. Spinal Pain Syndromes, J Manipulative Physiol Ther 28:3-11. (Gotlib A, Rupert R (2005) Assessing the Evidence for the Use 2. US—Chiropractors See Little Occupational LBP. The of Chiropractic Manipulation in Paediatric Health Conditions: Arizona State University Healthy Back Study, funded by A Systematic Review. Paediatric Child Health 10(3):157-161). NCMIC and with principal investigators that include prominent 4. Denmark—LBP and Degenerative Changes in Children. economists Marjorie Baldwin and William Johnson and Pierre Paediatric low-back pain is common, is associated with spinal Côté, DC PhD from the Institute for Work and Health in Toronto, degenerative changes visible on MRI, and is a significant area has the goal of discovering who injured workers with back pain of health care practice. These are messages from a large study consult, why, and with what results—in terms of effectiveness of 13-year-old children from Kjaer, Leboeuf-Yde et al. at the and cost-effectiveness. It is the most comprehensive study ever University of Southern Denmark just published in Spine. in this field and includes 200,000 workers from 37 states and five major US employers—America West Airlines, American Very little is known about lumbar MRI findings in youngsters Medical Response, The Earthgrains Company, Maricopa Coun- and how they are associated with LBP, which was the subject ty and Marriott International Inc. of this study, the largest single-age study of children yet per- formed in this field. Findings were: Over a three year period from July 1999 to July 2002 all work- ers with back injuries entered the study and completed pain, • Almost 1 in 4 (22%) had experienced back pain within the disability and quality of life questionnaires at baseline then 1, past month—a one month prevalence rate supported by three 6 and 12 months. Major findings from the first paper from the other recent studies—and 8% sought care. study, reporting professionals workers consult and why, are: • This was in a population of students which had a 4% one • Workers with back injuries in the US are most commonly month prevalence rate at the age of 9. treated by an MD and PT (44.7%) or MD alone (29.7%), and • MRI signs of degenerative disc changes were present in relatively few are seen by an MD and DC (5.3%) or a DC alone approximately one-third of the subjects, and there was asso- (only 4.1%). ciation between LBP and degeneration—“strong statistically • The major reason for this pattern of care, which is markedly significant associations” for boys in the upper lumbar discs and different from that of the general public with back pain— for girls in the lower segments of the spine. approximately 33% of them seeking care consult a chiroprac- • Endplate changes, especially in relation to the L-3 disc, were tor—is that the choice of health professional is not primarily strongly associated with LBP. a matter of personal choice or dictated by level of pain or (Kjaer P, Leboeuf-Yde C, et al. (2005) An Epidemiologic Study dysfunction - it is chosen by the employer. Another factor in of MRI and Low Back Pain in 13-Year Old Children, Spine choice of provider is the type of job held—unskilled workers, 30(7):798-806). as for example in the transportation/moving sector, are much

PAGE 5 Main Article continued from page 3 What can the Japanese Association of Chiropractors (JAC), rep- to commence a five-year program at the international level at resenting the relatively small number of duly qualified doctors RMIT Japan in Tokyo. This is currently on the point of receiv- of chiropractic in Japan who have studied in North America and ing full accreditation from the Australasian Council of Chiro- Australia, do when faced with this situation? How can the JAC practic Education. start a five-year fulltime course in a society that gives greater As a second example, when chiropractic education was intro- recognition to ‘chiropractors’ who can qualify with much less duced in Brazil in the mid-1990s this involved a partnership time and cost through other recognized natural healing arts? between the Brazilian Chiropractors’ Association, Palmer Col- b) In Argentina and Chile, for example, where there are large lege in the US and FEEVALE University in Brazil. Initially groups of kinesiologists practising as ‘chiropractors’ in the there was a two-year part-time course for health professionals absence of any regulatory laws, what can a few local DCs and (medical doctors, physical therapists and nurses), followed by the international profession do to achieve full educational stan- a one-year internship at Palmer for leading students who would dards? fill some future faculty positions in Brazil. What followed was 7. The profession has addressed these issues principally through a five-year program for high-school graduates, which graduated the World Federation of Chiropractic (www.wfc.org), formed its first class last September. in 1988 and now representing national associations in 80 10. These planned and orderly developments may be compared countries, and in official relations with the World Health Orga- with what is happening at the American Institute of Chiropractic nization since 1997. In dealing with these matters the WFC (AIC) in Germany. Dr. Styers, a young American chiropractor works closely with the profession’s specialized organizations who is a 1999 graduate of Life University, acting alone and with for accreditation (the CCEI and its members), accredited col- no expertise in curriculum design and no teaching experience, leges (the Association of Chiropractic Colleges) and examining has commenced a private course. There are neither the appropri- authorities (the US National Board of Chiropractic Examiners ate partners nor the plan for development of a curriculum, fac- and the recently formed affiliate, the International Board of Chi- ulty and school at the international level. ropractic Examiners). This is the 432-hour, 26-weekend web-advertised course he There are two major initiatives to be aware of: started: a) The WFC’s International Charter for the Introduction of • Upper Cervical Specific Techniques I, II, III, and IV Chiropractic Education (the Tokyo Charter—see paragraph 8 • Pediatrics I, II, and III below). • Instrument Adjusting (Activator) I & II b) WHO’s Guidelines on Basic Training and Safety in Chiro- • Chiropractic Biophysics Technique I & II practic (the WHO Guidelines—see paragraph 11 below). • Thompson Drop Technique I & II 8. The WFC’s Tokyo Charter. The full text of the Charter, with explanatory notes, may be found at www.wfc.org under • SOT Basic and Advanced Policy Statements. It was agreed unanimously by WFC member • Extremities Techniques associations at their Tokyo Assembly in 1997 following wide • Sports Rehabilitation I & II consultation and debate over a four year period. The key prin- ciples of the Charter are: • Neurological Re-Balancing Technique I & II a) When chiropractic undergraduate education is first introduced • Nutrition in a country there should be a plan for reaching the recognized • Basic and Advanced Cranial Techniques international standard, but local conditions may require transi- • CMRT (Chiropractic Manipulative Reflex Technique) tional staged development. • Chiropractic Practice and Case Management b) Partners should include a university or similar institution in • Network Technique I & II the country where education is being introduced, and an accred- ited chiropractic college from another country. There are no basic sciences, no clinical sciences such as bio- mechanics, applied neurology and radiology, and nothing on c) There must be approval by and support from the national the history and philosophy of chiropractic. However, quite association representing chiropractors in the country where apart from its individual areas of deficiency, the course presents education is being introduced. Ideally the national association chiropractic as a set of techniques rather than a separate and should be leading the project. distinct profession. It can be expected that graduates from such d) Any part of chiropractic undergraduate education is subject a program, as in Asian countries such as Japan and Korea in the to the above principles. Therefore for example an accredited past, will turn around and develop their own weekend courses in US chiropractic college should not provide human dissection or chiropractic. The Japan problem has arrived in Europe. other anatomy courses offshore to students from, say, an Asian This entrepreneurial initiative is naturally opposed by each country unless this is part of a complete undergraduate program of the German Chiropractors’ Association (GCA), represent- in that country that satisfies the principles of the Charter. ing Germany’s duly qualified chiropractors, and the European 9. As an example of how these principles should work, when Chiropractors’ Union (ECU), neither of which was consulted the Japanese Association of Chiropractors proposed a first offi- in advance. Dr. Styers, when contacted, alleges his initiative is cial chiropractic course in Japan in the early 1990s it partnered justified because of the number of heilpraktikers and medical with RMIT University of Melbourne, Australia. Initially the doctors in Germany claiming to be chiropractors. He claims to JAC and RMIT established a three-year fulltime program. This be motivated by the need to upgrade their standards. The GCA was the most that students could be expected to attend in the completely disagrees with his actions and, understandably, sees first instance, for reasons already given. Three years later, hav- this as “selling out chiropractic” and quite possibly “the begin- ing established a reputation and financial base, they were able

PAGE 6 Table 3: Sample Limited Interim Program An example of the type of program contemplated under the impending WHO Guidelines for persons with limited educational background practising as chiropractors in countries where the profession is unregulated by law. Such a program is design to enable graduates to attain a minimal and safe standard of practice and be suitable for grandfathering and registration when law is passed. This program was provided by Murdoch University, Perth, Australia, which has a chiropractic program at the international level, for graduates of a three-year part-time program at the Kansai Chiropractic School in Kurashiki, Japan.

Division First Year DL IR CP Second Year DL IR CP Third Year DL IR CP

Biological Anatomy 56 24 Laboratory Diagnosis 42 8 Sciences Biochemistry 56 4 Physiology 56 4 Pathology 70 12 56 4 Clinical 56 4 Nutrition

Head/Cervical spine Physical Diagnosis 56 14 care 70 20 Orthopaedics/ Thoracic/Lumbar Spine Clinical Neurology 56 14 & Pelvis care 70 20 Sciences Radiology 56 16 Hip/Knee/Ankle/ Clinical Diagnosis 56 9 Foot care 70 20 Shoulder/Elbow/ Wrist/Hand care 70 20 Special Population Care 56 24

Chiropractic Biomechanics 56 16 Patient Management Record keeping, Sciences Principles of Procedures Documentation & Chiropractic 42 3 42 18 Quality Assurance 42 16

Clinical Practicum 400 400 400

Research Research Methodology 50

Computer Skills First Aid/ Workshop 6 Emergency Care 28 24

TOTALS 448 71 406 486 103 400 378 100 400

TOTAL HOURS of Part time study over three years: 2,790

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

ning of the end for our profession in Germany”, to quote GCA be found at http://www.who.int/medicines/library/trm/strat- member and Palmer graduate, Dr. Gordon Janssen. egytrm.shtml. This strategy promotes the rational use of chiro- Under the new WHO Guidelines, which we now turn to consid- practic and other forms of CAM in national health systems and er, the type of students being accepted by the AIC would require offers advice to governments on how to regulate education and a far more comprehensive course of study over a minimum of practice. The strategy document opens with these words: 2,500 hours. Under the WFC’s Tokyo Charter, this course should “Traditional, complementary and attract the full spectrum be sponsored by the GCA and an accredited chiropractic college. of reactions—from uncritical enthusiasm to uninformed skepticism. Yet use of (TM) remains widespread in developing countries, while 11. WHO Guidelines. As discussed at some length in the July use of complementary and alternative medicine (CAM) is increasing rapidly in 2004 issue of The Chiropractic Report, the World Health Orga- developed countries. In many parts of the world, policy-makers, health profes- sionals and the public are wrestling with questions about the safety, efficacy, nization (WHO) has been developing guidelines on chiropractic quality, availability, preservation and further development of this type of health education for its 192 member nations during the past three years. care. This is through its normal broad consultation process and in It is therefore timely for WHO to define its role in TM/CAM by developing a partnership with the WFC. WHO’s principal consultant for the strategy to address issues of policy, safety, efficacy, quality, access and rational project has been WFC Past-President Dr. John Sweaney of Aus- use of traditional, complementary and alternative medicine.” tralia. The final text of the WHO Guidelines was discussed and This project is part of WHO’s Traditional Medicine/Complemen- agreed at a consultation meeting in Milan, Italy on December tary and Alternative Medicine Strategy 2002-2005, which may

PAGE 7 2-4, 2004 and is currently undergoing editing and printing and fulltime or part-time education, including a minimum of 1,000 will be available shortly. These WHO Guidelines will confirm: hours supervised clinical training. • that chiropractic is a distinct profession ii) Unregulated persons already practicing as chiropractors but • that one must be a duly qualified chiropractor to offer chiro- with little or no formal training. Not less than 2,500 hours in a practic services, rather than for example a medical doctor or fulltime or part-time program designed to address the deficien- other type of professional who claims to use chiropractic meth- cies in their theoretical and clinical education. Table 3 provides ods as part of medical or other practice, and an example of this type of program as given in Japan to students already practicing as chiropractors after two-year and three-year • that a comprehensive course of study is essential. part-time programs. There is a significant focus on the biologi- There will be provision for two levels of education: cal and clinical sciences, areas in which these students have a) Full education. weak background. These students are similar to the heilpraktik- i) General students. After entrance requirements, not less than ers in Germany offered the 432-hour program at the American 4,200 hours in four years of fulltime education, including a Institute of Chiropractic. minimum of 1,000 hours of supervised clinical training. (This represents the current international standard within the profes- E. CONCLUSION sion already discussed, and shown in Table 1). Detailed course 12. Chiropractic, unlike osteopathy, has a distinct and identifi- requirements are given by WHO. able profession worldwide because of its insistence on agreed, ii) Students with prior medical/health sciences professional high, minimum standards of education. Very importantly, at a qualifications. Not less than 2,100 hours in two to three years of policy level those standards are now being reinforced not only fulltime or part-time education, including a minimum of 1,000 by the profession but also by the UN agency responsible for hours of supervised clinical training. policy on health and healthcare professions, the World Health b) Limited education. (Transitional time-limited programs in Organization. It is clearly important that individual chiroprac- circumstances contemplated by the WFC’s Tokyo Charter, and tors understand and support this position, bringing maximum in countries where the profession is not regulated by law and pressure to bear on those that would undermine the profession’s there is no history of chiropractic education. This transitional integrity. education would not apply in a world region such as Europe, This Report has focused on the situation in Germany. What will where countries belong to the European Union in which many happen there, you may ask, given that under 100 duly qualified nations have already established accredited education at the full doctors of chiropractic are faced with thousands of medical doc- international level.) tors and heilpraktikers who have graduated from short-term pro- i) Students with prior medical/health sciences professional grams and are claiming to offer chiropractic services? Germany qualification. Not less than 1,800 hours in two to three years may well follow the example of France, where chiropractors not only faced a similar position but were also being prosecuted for the illegal practice of medicine until five years ago. France and Germany are both leading nations in the European SUBSCRIPTION AND ORDER FORM Union (EU). In March 1997 the EU Parliament adopted the (6 bi-monthly issues) Year commences January Lannoye Report on The Status on Non-conventional Medicine, Check one a committee report which in essence called for the uniform US and Canada 1 year $95.00 recognition and regulation of major complementary health (your currency) 2 years $185.00 disciplines such as chiropractic throughout the EU. As a result Australia 1 year A$120.00 various countries which had indicated that they would never 2 years A$220.00 recognize an independent profession of chiropractic, including Elsewhere 1 year US$95.00 France and also Belgium and Portugal, reversed this decision. 2 years US$185.00 Legislation was passed to recognize the profession, and full regulatory frameworks are currently being put in place. Name Germany is likely to follow this path in the near future—but Address only if as in France and the other countries mentioned, duly City Province/State qualified chiropractors maintain their distinct educational stan- dards and professional identity. Country Postal Code/Zip If you are ever offered the opportunity of teaching seminars in Telephone ( ) chiropractic diagnostic and treatment methods to anyone but PLEASE CHECK ONE duly qualified chiropractors, please reflect on the matters dis- Visa Card number cussed in this Report, the oath of allegiance to the profession MasterCard Expiration date you took upon graduation, and then decline unless the context is Cheque/Check enclosed consistent with the principles and standards laid down by your Payable to: The Chiropractic Report profession and WHO. 203–1246 Yonge Street Persuade others to do the same—nothing less than the inter- Toronto, Ontario, Canada M4T 1W5 national identity of the profession is at issue. This is not about Tel: 416.484.9601 Fax: 416.484.9665 brands of chiropractic, though some may try to portray it as E-mail: [email protected] such. It is about maintaining educational standards that justify Website: www.chiropracticreport.com and support an independent chiropractic profession. TCR

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