The development of a global chiropractic rehabilitation competency framework by the World Federation of Chiropractic
Pierre Côté1,2,3,4,
Deborah Sutton ORCID: orcid.org/0000-0002-5263-03682,
Richard Nicol4,
Richard Brown4 &
Silvano Mior2,5
The World Health Organization (WHO), in its "Rehabilitation 2030 A Call for Action", identified the need to strengthen rehabilitation in health systems to meet the growing demands of current and future populations. Greater access to rehabilitation services is required to secure the achievement of the United Nation's third Sustainable Development Goal, "Ensure healthy lives and promote well-being for all at all ages". To support this mandate, WHO issued a call for non-governmental organizations, associations and institutions to share their rehabilitation-related competency frameworks which will be used to construct a global rehabilitation competency framework. In response to this call, the World Federation of Chiropractic (WFC) developed a chiropractic rehabilitation competency framework. In this article, we present the chiropractic rehabilitation competency framework that will contribute to the development of the global framework in support of WHO's strategic planning for rehabilitation. The goal of WHO's strategic planning is to improve the integration and support of multi-disciplinary rehabilitation and establishing opportunities for global networks and partnerships in rehabilitation.
An increasing unmet need for rehabilitation exists globally as a consequence of the rising prevalence of non-communicable diseases and injuries and the ageing population [1]. While health plays a role in all 17 of the United Nations' Sustainable Development Goals (SDG), the provision of rehabilitation services is necessary for the achievement of the third SDG "Ensure healthy lives and promote well-being for all at all ages" [1]. However, there are significant concerns about the ability to access adequate rehabilitation services in several regions of the world.
In February 2017, the World Health Organization (WHO) launched its "Rehabilitation 2030 A Call for Action" to: "1) draw attention to the increasing needs for rehabilitation; 2) highlight the role of rehabilitation in achieving the SDGs; 3) and call for coordinated and concerted global action towards strengthening rehabilitation in health systems" [1]. Later in August 2018, WHO issued a call for non-governmental organizations, associations and institutions to share their rehabilitation-related competency frameworks. These submissions will inform development of a global rehabilitation competency framework to improve the integration and support of multi-disciplinary rehabilitation and establish opportunities for global networks and partnerships in rehabilitation.
The objective of this article is to present a chiropractic rehabilitation competency framework developed by the World Federation of Chiropractic Disability and Rehabilitation Committee (WFC DRC). The framework includes a set of core competencies: communication, knowledge, technical skills, clinical reasoning, values, and reflection which taken together will ensure the rights, well-being and safety of patients are protected and that chiropractors will employ evidence-informed practices in the delivery of patient care [2, 3].
Development of the framework
The Secretary-General of the World Federation of Chiropractic (WFC) invited the Chair of the WFC DRC to respond to the WHO call for rehabilitation competency frameworks. The WFC DRC Chair formed a subcommittee of individuals representing expertise in rehabilitation and disability, and educational frameworks for a competency-based education for chiropractors, to collaboratively develop the rehabilitation competency framework.
The WFC DRC subcommittee reviewed WHO documents and other key resources from chiropractic councils and educational institutions to inform the development of the chiropractic rehabilitation competency framework (see Additional files 1 and 2). The subcommittee developed the competency framework guided by the internationally accepted frameworks produced by the World Health Organization [4, 5].
The competency framework includes three key domains that groups related competencies. The first domain encompasses an overall understanding of the concepts of rehabilitation and disability, which are necessary for chiropractors to understand a person's health and rehabilitation needs. The second domain focuses on protection of the public and provision of rehabilitation services within the boundaries of laws, policies and regulations, and ensures the highest quality and professional standard of care. The third domain describes the competencies that a chiropractor requires in the rehabilitation management of disability and other health conditions. The competencies within each domain were selected to represent the essential knowledge, skills, attitudes and behaviors to be demonstrated by chiropractors providing rehabilitation services [6].
The subcommittee met on six occasions to develop the chiropractic rehabilitation competency framework. Each of the three key domains and associated competencies were discussed and independently reviewed by each member of the subcommittee. A draft framework was approved by the subcommittee through consensus. The final draft framework was then submitted to the WFC-DRC for critical review in September 2018 and comments were integrated in the final framework. WFC-DRC members represent various world regions (Africa (n = 1), Australia (n = 1), Europe (n = 7), North American (n = 9), South American (n = 1)) and professions (physical therapy (n = 3), psychology (n = 1), medicine (n = 1), chiropractic (n = 13), occupational therapy (n = 1)). An external chiropractic representative from Asia also provided peer review of the draft document in September 2018, to ensure representation across all world regions. Finally, the Chair of the WFC-DRC submitted the final framework to the WFC Secretary-General who submitted it to the WFC council members. WFC council members reviewed the final framework and approved it through consensus. The final framework was submitted to WHO on September 30, 2018.
Domains and competencies
The framework is based upon a universal understanding of the concepts of rehabilitation, disability and person-centered care (Table 1).
Table 1 Definitions of rehabilitation, disability and person-centered care
The competency framework is presented as a tabular matrix stratified by the three domains and their related competencies (Table 2). Each competency was further defined as measurable standards related to knowledge and skills that establish the expected level of performance (Table 3). Due to the interrelated nature of standards of attitudes and behaviors that cross all three domains, they are summarized in a separate table (Table 4). Certain competencies may not apply to all settings or environments. Therefore, our recommendations need to be interpreted and applied while respecting the defined roles and responsibilities of chiropractors in the specific region.
Table 2 Domains and competencies for rehabilitation of disability in chiropractic
Table 3 Core competencies and associated knowledge and skills
Table 4 Attitudes and behaviors that are an essential component of competencies
Domain 1: basic concepts of rehabilitation and disability
Chiropractors require a foundational understanding of rehabilitation and disability (Tables 1, 2 and 3). Disability is universal, yet diverse. It is neither simply a biological, psychological or social phenomenon. It is an umbrella term for impairments, activity limitations and participation restrictions [7]. Chiropractors require specialized skills in interpersonal communication, communication methods, technology and rehabilitation. Chiropractic rehabilitation competencies are framed upon the basic premise that culturally appropriate people-centered care is at the core of all patient/provider interactions (Table 1).
Domain 2: legal, regulatory and ethical components
This domain addresses social determinants of health in the context of statutory, regulatory and ethical frameworks guiding the delivery of rehabilitation services (Tables 2 and 3). It recognizes the contribution of multiple stakeholders, including healthcare professionals, policy makers and community representatives to deliver concerted, coordinated services in a person-centered environment [10].
Chiropractors should be aware of the legal and ethical issues and principles relating to the delivery of rehabilitation services. Human rights, including privacy and confidentiality, ethical issues around governance and management of facilities and understanding of competing interests are all components that are key elements of this domain [11].
Domain 3: rehabilitation management of disability and other health conditions
The objective of rehabilitation is to optimize function, enabling individuals to be as independent as possible, to participate in education, to be economically productive and fulfill meaningful life roles [1]. (Tables 2 and 3) It is essential that rehabilitation be offered in both health care facilities (clinics and hospitals) and community settings to ensure timely access to services along the continuum of care and across the lifespan [12]. The chiropractor should engage the patient to ascertain their valued roles within the context of environmental and personal factors. Restoration of body functions and structure are not enough alone to address the effect of disability, which must be framed within a biopsychosocial model. Rehabilitation should have both a beginning and an end. A stage of equilibrium in which active interventions are no longer required may occur. However, this does not preclude the need for future rehabilitation services to further a person's participation in education, employment and the community [13].
Attitudes, knowledge and skills are required to demonstrate core competencies.
Embodied in the provision of rehabilitation services are respect for human rights, principles of equity, meaningful participation and inclusion. Accordingly, there are underlying attitudes and behaviors that are an essential component of competencies and interrelated to each of the identified domains (see Table 4).
The rising prevalence of non-communicable diseases and injuries, along with an ageing population has contributed to a growing demand for rehabilitation worldwide [1]. However, the capacity to provide rehabilitation is limited or non-existent in many areas of the world, thus failing to meet population needs. Rehabilitation serves to optimize function and support those with health conditions to remain as independent as possible, participate in education, be economically productive and fulfill meaningful roles. Consequently, rehabilitation plays a foundational role in achieving the third SDG, "Ensure healthy lives and promote well-being for all at all ages" [14]. The objective of this commentary was to describe the development of a chiropractic rehabilitation competency framework.
The WFC DRC developed a chiropractic rehabilitation competency framework as a reference document to inform the development of the WHO global rehabilitation competency framework. Our framework includes three domains, their related core competencies and associated attitudes, knowledge and skills. Each domain is comprised of core competencies with a synopsis of the attitudes, knowledge and skills required to demonstrate these core competencies. The chiropractic rehabilitation competency framework will contribute to the development of the WHO global rehabilitation competency framework to support workforce evaluation and strategic planning for rehabilitation globally.
We surveyed and used current WHO documents and key resources from chiropractic councils and educational institutions to develop and structure the framework (see Additional file 1). The selected resources were considered to be most salient to the identification of domains and core competencies which are essential to chiropractic practice. Nevertheless, it is possible that we missed material that would have further informed the framework. We conducted a qualitative synthesis of the knowledge presented in retrieved documents, but we did not critically appraise the content of these documents. However, the critical review of the draft framework by the subcommittee, the WFC DRC and the WFC council allowed for a broad range of individual opinions and knowledge to be considered throughout the iterative development process.
Overall, we have presented a chiropractic rehabilitation framework consisting of three domains: basic concepts of rehabilitation and disability; legal, regulatory and ethical components; and, rehabilitation management of disability and other health conditions. Each domain is comprised of core competencies with a synopsis of the attitudes, knowledge and skills required to demonstrate these core competencies. The chiropractic rehabilitation framework developed by the WFC DRC will help inform WHO about the contribution of chiropractic to the agenda outlined by "Rehabilitation 2030: A Call for Action". The framework also provides a guide for chiropractic educational institutions and national associations to develop rehabilitation policies within their jurisdictions.
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The authors would like to acknowledge the invaluable contributions to this framework from:
the World Federation of Chiropractic, Disability and Rehabilitation Committee: E Aartun, C Cedraschi, A Diahoua, J Flannery, I Kanga, M Nordin, M Rezai, H Shearer, M Stochkendahl, P Torres; and, the World Federation of Chiropractic Council.
This research was undertaken, in part, thanks to funding from the Canada Research Chairs program to Dr. Pierre Côté, Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology.
Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario, L1H 7L7, Canada
UOIT-CMCC Centre for Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada
, Deborah Sutton
& Silvano Mior
Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario, L1G 0C5, Canada
World Federation of Chiropractic, Disability and Rehabilitation Committee, 160 Eglinton Avenue East, Suite 601, Toronto, Ontario, M4P 3B5, Canada
, Richard Nicol
& Richard Brown
Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada
Silvano Mior
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Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; PC, RN, RB, SM, DS. Been involved in drafting the manuscript or revising it critically for important intellectual content PC, RN, RB, SM, DS. Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; and PC, RN, RB, SM, DS. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved PC, RN, RB, SM, DS. All authors read and approved the final manuscript.
Correspondence to Deborah Sutton.
This research did not involve human subjects, human material or human data. Ethics approval and consent are not applicable.
Not applicable. Manuscript does not include details, images or videos relating to an individual person.
Richard Brown: Secretary-General, World Federation of Chiropractic.
Pierre Côté: Grant to the University of Ontario Institute of Technology: Canada Research Chair Program-Canadian Institutes of Health Research Reimbursement for travel expense to the University of Ontario Institute of Technology: World Federation of Chiropractic, Eurospine, Institut Franco-European de Chiropraxie, International Spine and Pain Institute Medical-legal expert report fee paid to PC: Canadian Chiropractic Protective Association.
Key Resources. WHO documents and key resources from chiropractic councils and educational institutions. (DOCX 21 kb)
Glossary. Alphabetical list and meanings of key terms used in chiropractic rehabilitation framework. (DOCX 22 kb)
Côté, P., Sutton, D., Nicol, R. et al. The development of a global chiropractic rehabilitation competency framework by the World Federation of Chiropractic. Chiropr Man Therap 27, 29 (2019). https://doi.org/10.1186/s12998-019-0249-8
Competency-based education