Lyndon Amorin-Woods

Evidence Supports Model of Chiropractic Professional Competence

Introduction & Aim: A scoping review of chiropractic education publications is needed to guide future policy development, research agendas, and educational initiatives within the chiropractic profession. This review mapped the number of studies, topics, and designs of chiropractic education publications worldwide.

Methods: The study was conducted by authors from 9 countries with 704 years of combined academic experience. JBI methodology was followed and the PRISMA extension for scoping reviews guided reporting. Several health and education databases were searched from their inception to November 2023 without language limits. Data were extracted for primary topics, study designs, and regions and entered in Covidence by paired independent reviewers.

Results: The search resulted in 7494 documents of which 598 (years 1970-2023) were selected for data extraction. Education topics included knowledge and cognitive competence (49), functional and clinical competence (93), personal/behavioral competence (34), values/ethical competence (3), and program-relevant research (419). Most designs were quantitative (391), followed by descriptive reports (91), qualitative (43), mixed methods (40), commentary (22), and literature reviews (11). Chiropractic education was studied in 15 countries; most were in the United States (359), Australia (116), and Canada (106). The number of publications and proportion of research designs increased over time.

Conclusion: This scoping review quantifies the body of chiropractic education research. Program-relevant research comprises the majority, and all domains of learner competence are represented. The data show that chiropractic scholars and programs are engaged in collecting, analyzing, and distributing data relevant to education and training and that education research is becoming more complex.

Background
Accreditation of healthcare provider training programs ensures graduate competency and provides a means for programs to improve. Accreditation consistency assures the public that healthcare providers have similar basic training across world regions. Currently, it is unknown if chiropractic accrediting agencies have congruent standards globally. Therefore, the purpose of this study was to investigate similarities and differences in student competencies and program standards among four chiropractic accreditation agencies worldwide.

Methods
A quantitative content analysis was performed on accreditation standards from regional international accreditation agencies responsible for accrediting the majority of the world’s chiropractic degree programs. Agencies included the Council on Chiropractic Education (United States), the European Council on Chiropractic Education (Europe, United Kingdom, South Africa), the Council on Chiropractic Education Australasia (Australia, New Zealand, Malaysia), and the Council on Chiropractic Education Canada (Canada). The contents of the accrediting standards were coded using a standardized coding list. A modified Delphi technique was used by 21 international experts from December 1, 2023, to April 18, 2024. After four rounds of consideration to achieve consensus, the contents were analyzed for frequency and congruence of coded items across the accrediting agencies’ standards. A two-way analysis of variance was conducted to identify if there were any differences among the accreditation agencies.

Results
Neither student competencies [F(3,8) = 0.007, p > .05] nor program standards [F(3,4) = 0.002, p > .05] differed significantly across the accrediting agencies. The statistical relationships between accreditation agencies and coding frequencies remained stable across all coded items, with no single code exhibiting differential performance depending on the accrediting body. The overall model showed R2 = 0.96 for student competencies and R2 = 0.87 for program standards; thus, the models’ predictions align with the observed data.

Conclusions
The study findings demonstrate congruence for student competencies and program standards among chiropractic accreditation agencies across multiple geographic regions. The patterns of content were stable and consistent across the four accrediting agencies, with no evidence of differential effects among the agencies. In addition, this study provides essential details and standardized codes for agencies’ documents, which may facilitate dialogue and comprehension among agencies, educators, regulators, governing officials, and other stakeholders in chiropractic education.

Aim:
To report the rate and severity of adverse events (AEs) among patients receiving services at university-based chiropractic clinical placements over a 15-year period in Western Australia.

Methods:
Patients reporting AEs were identified from an incident register between 2008 and 2023. Details of all incidents were authenticated through extracted data from patient follow-up, clinical records, clinician reports, legal, and insurer advice and were graded (1-5) based on severity.

Results and Discussion:
Chiropractic services were delivered by 921 chiropractic students and supervised by 44 registered chiropractors during the 15-year time span in metropolitan, rural, and remote locations. Among 410,957 clinical encounters (CE) comprising 349,075 treatment sessions for 61,882 unique patients, 20 mild (grade 1) clinical AEs were identified, yielding a crude incidence rate of 4.87 per 100,000 (95% CI: 2.79-7.52), or 1:20,548 clinical encounters. Signs and symptoms of AEs were acute or exacerbated low back pain, neck pain, and mid-back pain/shoulder pain. The most common presenting complaints among the patients reporting an AE were pain in 3 spinal regions.

Conclusions:
The incidence of AEs associated with chiropractic care in this population corroborates previous studies that report the rate and severity of AEs to be rare and mild.

Objective:
This scoping review aimed to map the volume (number of studies) and nature (topics and designs) of chiropractic education research and scholarly publications on chiropractic learners and programs worldwide.

Introduction:
Despite the expansion of the chiropractic profession and its recognition by entities such as the World Health Organization, a gap exists in comprehending the international landscape of chiropractic education. No prior studies have systematically mapped the volume and nature of chiropractic education research and scholarly publications. A scoping review of chiropractic education research and scholarly publications is needed to guide future policy development, research agendas, and educational initiatives within the chiropractic profession.

Inclusion criteria:
Publications in the indexed literature on chiropractic students, graduates, academics, and programs in any chiropractic education setting were included. Studies focused on chiropractic programs and education for chiropractic students or chiropractors worldwide. All research designs, literature reviews, descriptive studies, and commentaries were included.

Methods:
This scoping review was conducted according to JBI methodology for scoping reviews and was reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The databases PubMed (NLM), Scopus, CINAHL via EBSCOhost, Index to Chiropractic Literature, Biblioteca Virtual em Saúde, and Educational Resources Information Center were searched from their inception to November 5 and 6, 2023, with no language limits. Data were extracted for primary topics, study designs, and regions of the included documents and entered in Covidence by paired independent reviewers. The findings were organized into figures and tables with a narrative description.

Results:
The search identified 7494 documents. After deduplication, 5041 were screened for relevance, of which 667 were selected for full-text review. From these, 598 were selected for data extraction. The chiropractic education topics included values/ethical competence (n=3), personal/behavioral competence (n=34), knowledge and cognitive competence (n=49), functional and clinical competence (n=93), and program-relevant research (n=419). Most designs were quantitative (n=391), followed by descriptive reports (n=91), qualitative (n=43), mixed methods (n=40), commentaries (n=22), and literature reviews (n=11). Chiropractic education was most studied in the United States (n=359), Australia (n=116), and Canada (n=106).

Conclusions:
This scoping review reports the volume and nature of indexed publications relating to chiropractic learners and programs worldwide. This body of literature contains learner competencies in knowledge, skills, and attitudes, as well as studies about chiropractic programs. The increasing number of publications and proportion of study designs over time show that chiropractic scholars and programs are engaged in collecting, analyzing, and distributing data relevant to education and training. The map of professional competencies in the chiropractic education literature shows that the profession possesses the fundamental traits needed to contribute to the global health care workforce.

This chapter introduces equity, diversity, and inclusion (EDI) represented in the chiropractic profession. Included is a description of what is currently known about EDI in chiropractic. Current activities and research related to EDI are described. Our analysis of available data and literature points out areas requiring further consideration and action to improve EDI within the profession. A call for action provides a model to address EDI issues for chiropractic and proposes a list of activities that will improve the chiropractic workforce to better serve the world’s changing population needs.

In 2019, Safer Care Victoria (SCV) conducted a government-funded inquiry into the practice of spinal manipulation (SMT) of children under 12 years of age by chiropractors. SCV assembled an advisory panel, commissioned a Cochrane Collaboration Review, and invited submissions from consumers, health practitioners, insurers, education institutions, professional organizations, and interested stakeholders.

The report's principal findings were that while spinal manipulation of children results in very rare instances of harm, since evidence of the effectiveness of SMT is lacking, SMT cannot be recommended for children under 12 for a list of conditions or for general wellness.

Critique and Discussion: Five reviewers evaluated the Cochrane Review that formed a part of the inquiry using the Scottish Intercollegiate Guideline Network (SIGN) instrument. Two reviewers also evaluated the SCV report in its entirety. A strength of the report is the safety review and the information in the detailed responses from consumers. There were 29,599 on li ne submissions received from across Australia, making it the largest survey of this kind. There were no reports of physical, mental, or financial harm to a child derived from this robust process.

However, the report and the Cochrane Review contain weaknesses.

1) An internal contradiction erroneously reported a cerebrovascular incident (CVI ) rate of 1:20,000 with SMT among children in the main text.

2) There was a departure from the inclusion/exclusion criteria for effectiveness studies. 3) The final recommendations disregard the submissions from consumers, the public, and practitioners.

Conclusion: While it has strengths, the SCV report is also flawed, and its final recommendations should be viewed with caution. The Cochrane Review within the report adds little to the body of knowledge or clinical practice for chiropractors managing children under 12.

Objective: To develop evidence-based recommendations on best practices for delivery of clinical preventive services by chiropractors and to offer practical resources to empower provider applications in practice.

Results: Recommendations were made on primary, secondary, tertiary, and quaternary prevention of musculoskeletal pain.

Conclusions: Application of this guideline in chiropractic practice may facilitate consistent and appropriate use of screening and preventive services and foster interprofessional collaboration to promote clinical preventive services and contribute to improved public health.

Objective

This study aimed to (1) collect and analyze statements about how to celebrate chiropractic in the present and roles that chiropractors may fulfill in the future, (2) identify if there was congruence among the themes between present and future statements, and (3) offer a model about the chiropractic profession that captures its complex relationships that encompass its interactions within microsystem, mesosystem, exosystem, and macrosystem levels.

Methods

For this qualitative analysis, we used pattern and grounded theory approaches. A purposive sample of thought leaders in the chiropractic profession were invited to answer the following 2 open-ended questions: (1) envision the chiropractor of the future, and (2) recommendations on how to celebrate chiropractic. Information was collected during April 2023 using Survey Monkey. The information was entered into a spreadsheet and analyzed for topic clusters, which resulted in matching concepts with social-ecological themes. The themes between the responses to the 2 questions were analyzed for congruence. We used the Standards for Reporting Qualitative Research to report our findings.

Results

Of the 54 experts invited, 32 (59%) participated. Authors represented 7 countries and have a median of 32 years of chiropractic experience, with a range of 5 to 51 years. Nineteen major topics in the future statements and 23 major topics in statements about celebrating chiropractic were combined in a model. The topics were presented using the 4 levels of the social-ecological framework. Individual (microsystem): chiropractors are competent, well-educated experts in spine and musculoskeletal care who apply evidence-based practices, which is a combination of the best available evidence, clinical expertise, and patient values. Interpersonal relationships (mesosystem): chiropractors serve the best interests of their patients, provide person-centered care, embrace diversity, equity, and inclusion, consider specific health needs and the health of the whole person. Community (exosystem): chiropractors provide care within integrated health care environments and in private practices, serve the best interests of the public through participation in their communities, participate through multidisciplinary collaboration with and within the health care system, and work together as a profession with a strong professional identity. Societal (macrosystem): chiropractors contribute to the greater good of society and participate on a global level in policy, leadership, and research. There was concordance between both the future envisioning statements and the present celebration recommendations, which suggest logical validity based on the congruence of these concepts.

Conclusion

A sample of independent views, including the perceptions from a broad range of chiropractic thought leaders from various backgrounds, philosophies, diversity characteristics, and world regions, were assembled to create a comprehensive model of the chiropractic profession. The resulting model shows an array of intrinsic values and provides the roles that chiropractors may provide to serve patients and the public. This study offers insights into the roles that future chiropractors may fulfill and how these are congruent with present-day values. These core concepts and this novel model may have utility during dialogs about identity, applications regarding chiropractic in policy, practice, education, and research, and building positive relationships and collaborations.