WHO Guidelines on basic training and safety in chiropractic

During the last decade, the use of traditional and complementary/alternative medicine
(TM/CAM) has increased considerably not only in developing countries, where it often
represents the only possibility for health protection, but also in developed countries. The
percentage of the population that uses TM/CAM is in the order of 50% in many of high
income countries, such as Canada, France, Germany, United Kingdom and United States of
America. 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 and
appropriate use of methods which, if used correctly, can contribute to the protection and
enhancement of citizens’ health and well being. The development of these practices can
only be obtained according to safety, efficacy and quality criteria. Such principles
characterize the modern medical practice and are the essential basis for consumers’
protection.
TM/CAM activities undertaken by the Regional Government of Lombardy have always
been guided by the abovementioned criteria. TM/CAM was included in the Regional
Community Healthcare Plan (2002‐2004), and a comprehensive framework for the
protection of consumers and practitioners has been developed accordingly ‐ thanks to a
series of administrative provisions. The four‐year cooperation plan between the World
Health Organization and the Regional Government of Lombardy on the use and evaluation
of TM/CAM is a keystone in such a process. The promotion of several clinical and
observational studies on the regional territory is also to be considered an important step for
the 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 the
requisites 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 the
world. One of the conclusions of the Consultation was that these guidelines were
appropriate as resources not only for the Lombardy Region, but also for various country
situations worldwide. With this in mind, this document is to be considered an important
reference point for those, among practitioners, political and administrative authorities, that
want chiropractic to be a safe and efficacious aid for citizens’ health and for any regulatory
and licensing act.
Alessandro Cè
Regional Minister of Health
Regional Government of Lombardy
Giancarlo Abelli
Regional Minister of Family and Social Solidarity
Regional Government of Lombardy

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 and
therefore 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 the
proper use of safe and effective medication, products and practices in national health
services. In the light of the situation described above, there is a need to develop
guidelines on chiropractic education and safe practice, including information on
contraindications 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 have
been established. In these countries, the profession is regulated and the prescribed
educational qualifications are generally consistent, satisfying the requirements of the
respective accrediting agencies.
However, many countries have not yet developed chiropractic education or established
laws 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 have
received chiropractic training in an accredited programme.
With the rapid growth in demand for chiropractic services, other health care
practitioners may wish to gain additional qualifications in chiropractic. Conversion
programmes have been developed to enable persons with substantial basic medical
training to acquire the additional necessary education and skills to become
chiropractors, and these could be further expanded. Such programmes should be
flexible in order to take account of different educational backgrounds and previous
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 register
and to protect patients are outlined in this document. The recognition and
implementation of these minimum requirements will depend on individual country
situations.

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 examination
and licensing system for the qualified practice of chiropractic
• to review contraindications in order to minimize the risk of accidents and to
advise on the management of complications occurring during treatment and to
promote 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 health
authorities 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 the
practice of chiropractic by unqualified persons. It is to be hoped that this will deter
commercial exploitation of chiropractic education and practice, which is a significant
and growing problem in some countries.
Part II of the guidelines deals with the safety of spinal manipulative therapy and the
contraindications to its use.
Dr Xiaorui Zhang
Coordinator, Traditional Medicine
Department of Technical Cooperation
for Essential Drugs and Traditional Medicine
World Health Organization