Research Request — Chiropractor Training & Scope of Practice | FOI document library

FOI 24/25-0145 DOCUMENT 3

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Research Request — Chiropractor Training & Scope of Practice

Chiropractor tertiary training outline — does this specifically include function activity performance assessment and assistive technology prescription units.
Chiropractic scope of practice information based on Australian registration or recognised professional body membership
Information available from the NDIS website regarding provider guidance on ‘suitably qualified professional’ definition in relation to NDIS Capital support categories e.g. Declaration of Suitability and Terms of Business.
Given Chiropractors have not been registered NDIS providers previously, the Quality and Safeguards Commission may now have an updated view on registration so their website would also be worth reviewing provider suitability or registration requirements to deliver specific support types.

Date September 4, 2019 Requester Karyn redacted: s47F - personal privacy (Assistant Director - TAT) Researchers Craig redacted: s47F - personal privacy (Tactical Research Advisor — TAT) Aanika redacted: s47F - personal privacy (Senior Research Officer — TAT)

Contents

Overview …………………………………………………………………………………………………………………………………………………. 2 Chiropractor Training & Education …………………………………………………………………………………………………………….. 2 Regulatory Bodies and Associations ……………………………………………………………………………………………………………. 3 Australian Health Practitioner Regulation Agency ………………………………………………………………………………………. 3 Chiropractic Board of Australia ………………………………………………………………………………………………………………….. 3 Australian Chiropractors Association………………………………………………………………………………………………………… 3 Chiropractic Scope of Practice ……………………………………………………………………………………………………………………. 3 Chiropractic Board of Australia Competencies ……………………………………………………………………………………………. 3 Prescribing …………………………………………………………………………………………………………………………………………….. 4 Functional Assessments ………………………………………………………………………………………………………………………….. 6 5 Training Analysis ……………………………………………………………………………………………………………………………………. 6 5 Chiropractic and the NDIS Quality and Safeguards Commission ………………………………………………………………………… 6 NDIS Provider - Qualification for AT assessments ……………………………………………………………………………………………. 7 Future of Chiropractic …………………………………………………………………………………………………………………………………. 8 7 Current NDIA guidance regarding AT complexity level classification ………………………………………………………………… 8 Conclusion ……………………………………………………………………………………………………………………………………………….. 9 8 Reference List ………………………………………………………………………………………………………………………………………….. 10

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Overview

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Chiropractors in Australia work in an allied health profession, focusing on manual therapies and active care techniques that treat musculoskeletal conditions. These practices include the use of spinal adjustments and soft-tissue or joint manipulation to provide relief from discomfort. 1
It appears that prescribing assistive technology (AT), medicines, or other supports, is not in the scope of practice of the chiropractor, and could not be determined in analysing training curriculums.
It appears that performing functional assessments and physical/medical assessments, are within the scope of practice for a chiropractor according to training curriculums.
There is no specific information regarding chiropractic on the NDIS Quality and Safeguarding website, which indicates that chiropractors must only provide services within their scope of practice as outlined by the Chiropractic Board of Australia under AHPRA.

Chiropractor Training & Education

There are four education institutions in Australia where you can undertake accredited Chiropractic training in Australia:

Degree	University and details link
Bachelor of Science (Chiropractic) - 3 years / Master of Clinical Chiropractic This course is the ideal pathway into the Master of Clinical Chiropractic. Upon completion of the master’s course you will be eligible to apply for registration to practice as a Chiropractor and describe yourself as a Chiropractor.	Central Queensland University
Bachelor of Chiropractic Science — 3 years / Master of Chiropractic — 2,3 years Once both degrees are completed then graduates can obtain a licence to practise as a chiropractic practitioner. The combined program has national and international recognition.	Macquarie University
Bachelor of Chiropractic / Bachelor of Science (Chiropractic) — 5 years After completion of this course you are eligible to become a registered Chiropractor.	Murdoch University

1 Macquarie University, “Department of Chiropractic”, [website], 2019, https://www.mq.edu.au/about/about-the-university/faculties-and-departments/faculty-of-science-and-engineering/departments-and-centres/department-of-chiropractic (accessed 4 September 2019).

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Degree	University and details link
Bachelor of Health Science/Bachelor of Applied Science (Chiropractic) — 5 years After completion of this double degree you are able to practice chiropractic.	RMIT University

Regulatory Bodies and Associations

Australian Health Practitioner Regulation Agency

Chiropractors are registered under the Australian Health Practitioner Regulation Agency (AHPRA), the organisation responsible for the implementation of the National Registration and Accreditation Scheme across Australia.

The Research Team telephoned APHRA (04/10/19) to discuss the Chiropractic scope of practice. AHPRA suggested that the way they define scope of practice is dependent on the individual health professionals training, qualifications and competencies. They do not set a strict scope of practice. They noted that Chiropractors do not have specialisations, but must meet continuous personal development training expectancies, similar to other allied health professions.

Chiropractic Board of Australia

The Chiropractic Board of Australia (CBA) was established under the Health Practitioner Regulation National Law as in force in each state and territory. The Board’s role is to regulate chiropractors in Australia under the National Registration and Accreditation Scheme.

Australian Chiropractors Association

The Australian Chiropractors Association (ACA) is a “peak body representing chiropractors in Australia. ACA is the custodian for the chiropractic profession in Australia and provides risk management services, public education and promotion, opportunities for career advancement, advocacy initiatives, support and encouragement for the development of chiropractic research, and offers a strong unified voice for the profession whenever called upon”.

Chiropractic Scope of Practice

AHPRA confirmed that there is no formal scope of practice for Chiropractic that outlines what a chiropractor is and is not qualified to do.

Chiropractic Board of Australia Competencies

Part of the CBA’s function is approving accreditation standards and accredited programs of study of chiropractic, and developing standards, codes and guidelines for the chiropractic profession. The standards of practice competency for chiropractors take in three broad areas:

Clinical Assessment

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Planning Care
Implementing, Monitoring and Evaluating Care. ²

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CBA Competency Standards
UNIVERSAL COMPETENCY 1 PRACTISING PROFESSIONALLY Practises professionally, ethically and legally with safety and efficacy with the application of evidence-based practice as the primary consideration in all aspects of chiropractic practice.	PRACTICE COMPETENCY 3 CLINICAL ASSESSMENT Understands patients’ health status and related circumstances, critically analysing these and forms a clinical impression.	PRACTICE COMPETENCY 5 IMPLEMENTING, MONITORING AND EVALUATING CARE Coordinates the safe and effective implementation, monitoring and evaluation of patients’ care and management plans.
UNIVERSAL COMPETENCY 2 COMMUNICATION, COLLABORATION AND LEADERSHIP Communicates and collaborates effectively at all times with patients and others.	PRACTICE COMPETENCY 4 PLANNING CARE Works in collaboration with patients, exploring the care options available and developing agreed, evidence based care and management plans.

Prescribing

In broad terms the CBA competencies equate to the chiropractor having scope of practice in the following areas:

Obtains and records a history
Performs a clinical examination
Obtains the results of clinical, laboratory and other diagnostic procedures necessary to inform care
Recognises determinants of health
Critically analyses information available to generate a clinical impression
Identifies possible care and management options
Discusses care and management options
Formulates a care and management plan
Obtains and records patient-informed consent regarding care
Implements interventions safely and effectively
Monitors and evaluates progress of care and health outcomes

² Chiropractic Board of Australia, “Accreditation Standards for Chiropractic Programs, Competency Standards for Graduating Chiropractors”, [website], 2019. https://www.chiropracticboard.gov.au/Accreditation.aspx (accessed 3 September 2019).

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Adapts plans based on monitoring and evaluation

When ‘Planning Care’, a chiropractor “Works in collaboration with patients, exploring the care options available and developing agreed, evidence-based care and management plans”.

The Accreditation Standards for Chiropractic Programs, Competency Standards for Graduating Chiropractors states that when planning care a chiropractor must identify, discuss ad formulate care and management plans using the following criteria:

Integrates knowledge of chiropractic and other health sciences to inform decisions about care and management options.
Obtains, interprets and applies current evidence and information to inform decisions about care and management options.
Identifies care and management options likely to be therapeutically effective and safe for patients.
Adapts practice according to varying patient needs across the human lifespan, including need for care and management options to be tailored for patients.
Considers opportunities to enhance patients’ care and management through the involvement of other health professionals.
Explains and discusses the outcomes and implications of the clinical assessment with the patients.
Discusses purpose, nature, benefits, risks and expected outcomes of care and management with patients and others.
Discusses and seeks agreement with patients and others on patients’ goals and priorities.
Describes areas of practice of other health professions and explains interprofessional approaches to patients and others.
Formulates care plan in collaboration with patients, recognising personal and professional limitations.
Reaches agreement on patient-centred, evidence-based care plan, including chiropractic care, co-management or referral.
Establishes plans for review of care and management.

There is no direct reference to chiropractors having the scope to prescribe assistive technology (AT), medicines, or other supports, could be found within any of the CBA competencies. However, it appears that the competencies allow scope for the chiropractor to ~~refer to and~~ collaborate with other health professionals after identifying “possible ~~diagnosis~~”, “identifying red flags” and establishing “plans for review of care and management” 4. This care and management includes referring the patient onto other allied health professionals as required to provide holistic care.

The ACA Code of Ethics also supports the CBA in reflecting the scope of referring and collaborating with other health professionals:

“ACA members communicate and co-operate with colleagues, other healthcare professionals and relevant third parties in the best interest of their patients and the wider community. Members shall: collaborate professionally with all relevant providers to achieve optimal patient outcomes, refer patients, when clinically indicated, to an appropriate health professional”. 5

3 Ibid, Accreditation Standards for Chiropractic Programs, Competency Standards for Graduating Chiropractors, p.13. 4 Ibid.

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Functional Assessments

No direct reference to chiropractors having the scope to carry out functional assessments could be found in the CBA competencies. However, the university subjects that are completed during a chiropractic course do list: Physical examination (Murdoch), physical and functional assessment (Macquarie) or medical examinations of musculoskeletal and nervous systems (RMIT) units.

It may be that for some chiropractors it is within the scope to conduct these functional assessments.

As with the scope in prescribing, it appears that the competencies allow scope for the chiropractor to refer to and collaborate with other health professionals after identifying “possible diagnosis”, “identifying red flags”, establishing “plans for review of care and management”.

Training Analysis

The research team analysed the Australian courses available in Chiropractic. All courses require the 5 years (typically bachelors and masters) to be completed to become an accredited practicing Chiropractor in Australia.

A comparison was done of the standard subjects / course outlines and all courses have the following similarities:

A comprehensive variety of clinical practice, human anatomy and physiology units, which parallel those attained by an Occupational Therapist or Physiotherapist at the bachelor level.
Physical examination (Murdoch), physical and functional assessment (Macquarie) or medical examinations of musculoskeletal and nervous systems (RMIT) units
- Generally, these units teach skills in performing physical examinations of different body systems in a clinical setting and to identify symptoms of disease. This includes diagnostic imagining training, including reading X-rays.
- Note: the available unit information from RMIT and Murdoch does not include any reference to prescribing assistive technology.
Diagnosis science units focusing on for example, neurological, biomechanics, pathophysiology, orthopaedic examination and assessment of common neuromuscular and skeletal disorders.
Units focusing on inter-professional care partnerships with other health professionals, which is aligned with the code of ethics.

Chiropractic and the NDIS Quality and Safeguards Commission

There is no specific information about chiropractic, or any other allied health profession, on the NDIS Quality and Safeguarding website. However, the level of information provided in the course guides is not comprehensive. It is just a brief summary.

5 Australian Chiropractors Association, “Code of Ethics”, [website], 2019. http://aca.messystaging.com/wp-content/uploads/2019/05/ACA-Code-of-Ethics-1.pdf (accessed 3 September 2019).

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To become registered under the Commission, the provider must demonstrate compliance with the NDIS Practice Standards and NDIS Code of Conduct, amongst other things.

Code of Conduct

The NDIS Code of Conduct will apply to all NDIS providers, including unregistered providers.

The Code of Conduct: Guidance for NDIS Planners (March 2019) 6 states that providers must:

Provide supports and services in a safe and competent manner, with care and skill
Ensure workers have the necessary training, competence and qualifications for the supports and services delivered
Provide services consistent with relevant professional codes.

For chiropractors, if funding is made available for a participant for chiropractic supports as assessed as reasonable and necessary, this means that they must only provide services within their scope of practice as outlined by the Chiropractic Board of Australia under AHPRA.

NDIS Practice Standards

The NDIS Practice Standards and Quality Indicators (July 2018) 7 are dependent on the registration group / type of organisation and includes a set of modules.

This information is participant centred and generalised. None of this applies specifically to any type therapy support provider.

NDIS Provider - Qualification for AT assessments

Provider guidance resources were reviewed on the NDIS website with regard to ‘suitably qualified professional’ definition, and in relation to NDIS Capital support categories. No relevant information could be found regarding the research brief.

Regarding suitably qualified allied health professionals who can prescribe wheelchairs, the following information on government websites were found:

The Queensland Health MASS program says that the following providers are eligible to prescribe mobility devices:

Occupational therapists, physiotherapists and rehabilitation engineers are eligible to prescribe. In rural and remote areas, a registered nurse can prescribe (with designated specialist endorsement) 8.

The NSW Health website published a ‘Guidelines for Wheelchair Prescription’ document which states that the document is for:

6 NDIS Quality and Safeguards Commission, “The NDIS Code of Conduct: Guidance for NDIS Providers, March 2019”, [website], 2019. https://www.ndiscommission.gov.au/sites/default/files/documents/2019-03/code-conduct-providers-march-2019-10.pdf (accessed 3 September 2019). 7 NDIS Quality and Safeguards Commission, “NDIS Practice Standards: NDIS Practice Standards and Quality Indicators July 2018”, [website], 2019. https://www.ndiscommission.gov.au/sites/default/files/documents/2018-07/ndis-practice-standards-july-2018.pdf (accessed 3 September 2019). 8 Queensland Health, MASS, https://www.health.qld.gov.au/mass/prescribe/mobility

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Occupational therapists and physiotherapists who prescribe wheelchairs for people with spinal cord injury or traumatic brain injury [and]
Professionals with specific expertise who are involved in the prescription of a wheelchair, for example, rehabilitation engineers 9.

Future of Chiropractic

The chiropractic field are actively attempting to legitimise the practice as an allied health profession. A 2016 publication by an academic from Murdoch University discusses the field of chiropractic and a “ten point plan for a new chiropractic that will achieve full acceptance for this troubled profession” 10. The publication acknowledges that:

“Physical manipulation and manual therapies are thousands of years old. The most popular western world iteration of these therapies is delivered by chiropractors. It can be argued that the collective public health benefit from chiropractic for spinal pain has been very substantial, however as chiropractic has transitioned from craft to profession it has encountered many internally and externally driven machinations that have retarded its progress to a fully accepted allied health profession” 11. [and]
“The ten point plan consists of the following: improving the pre-professional education of chiropractors, establishing a progressive identity, developing a special interest for the profession, marginalising the nonsensical elements of the profession, being pro-public health, supporting the legitimate organised elements of the profession, improving clinical practice, embracing evidence based practice, supporting research and showing personal leadership” 12

Current NDIA guidance regarding AT complexity level classification

The NDIA uses 4 levels to categorise Assistive Technology requests based on their complexity and the associated risk to participant.

Level 1 — Basic AT
Level 2 — Standard AT devices
Level 3 — Specialised AT solutions
- Some wheelchairs fall under Level 3 Mobility items:
  - Power/power-assist wheelchairs; specialised strollers; scooters; gait aids; vehicle modifications (access); specialised car seats, harnesses* and postural supports; positioning devices; assistance animal; mobility cane (first issue).
Level 4 — Complex AT solutions
- Some wheelchairs fall under Level 4 Mobility items:

9 EnableNSW and Lifetime Care & Support Authority, Guidelines for the prescription of a seated wheelchair or mobility scooter for people with a traumatic brain injury or spinal cord injury, https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/167286/Guidelines-on-Wheelchair-Prescription.pdf 10 B. Walker, “The new chiropractic”, Chiropr Man Therap., vol., 30, 2016, pp. 24–26. https://www.ncbi.nlm.nih.gov/pubmed/27366317 11 Ibid. 12 Ibid.

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Power wheelchairs with integrated controls; motor vehicle AT (operator); highly configurable manual wheelchairs; electronic mobility AT for person who is blind.

For each AT level there are set ‘advisor characteristics’ that are required to be an appropriate prescriber.

For Level 3 the required advisor characteristics are:

Experienced professional support needed to identify, source and integrate components of assistive solutions into the participant’s life for effective use.
Assessment at this level and above will consider the extent of activity modification or learning required, or extent of environmental modifications, human support and/or specialist training required.

For Level 4 the required advisor characteristics are:

Specialist and/or ongoing support (including specialised training) needed to identify, source and integrate components of assistive solutions into the participant’s life for effective use 13.

Conclusion

Based on this available information and NDIA guidelines for assistive technology, a chiropractor would likely not meet the advisor characteristic standards required to recommend or prescribe power wheelchairs or manual wheelchairs of any variety or complexity.

While performing functional assessments and physical/medical assessments are within the scope of practice for a chiropractor according to training curriculums, this does not equate to prescribing complex / high risk assistive technology.

Unless a chiropractor can provide information on the additional, specialised training they have received that makes prescribing wheelchairs within their scope of practice, NDIA delegates should not accept these AT prescriptions.

There remain unanswered quality and safeguarding risks to the participant and there are other alternative allied health professions that specialise in complex AT (occupational therapists and physiotherapists).

13 https://www.ndis.gov.au/participants/home-equipment-and-supports/assistive-technology-explained/choosing-assistive-technology

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Reference List

Australian Chiropractors Association, “Code of Ethics“, [website], 2019. http://aca.messystaging.com/wp-content/uploads/2019/05/ACA-Code-of-Ethics-1.pdf (accessed 3 September 2019).

B. Walker, “The new chiropractic”, Chiropr Man Therap., vol., 30, 2016, pp. 24–26. https://www.ncbi.nlm.nih.gov/pubmed/27366317

Chiropractic Board of Australia, “Accreditation Standards for Chiropractic Programs, Competency Standards for Graduating Chiropractors”, [website], 2019. https://www.chiropracticboard.gov.au/Accreditation.aspx (accessed 3 September 2019).

EnableNSW and Lifetime Care & Support Authority, Guidelines for the prescription of a seated wheelchair or mobility scooter for people with a traumatic brain injury or spinal cord injury, https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/167286/Guidelines-on-Wheelchair-Prescription.pdf

Macquarie University, “Department of Chiropractic“, [website], 2019, https://www.mq.edu.au/about/about-the-university/faculties-and-departments/faculty-of-science-and-engineering/departments-and-centres/department-of-chiropractic (accessed 4 September 2019).

NDIS Quality and Safeguards Commission, “NDIS Practice Standards: NDIS Practice Standards and Quality Indicators July 2018“, [website], 2019. https://www.ndiscommission.gov.au/sites/default/files/documents/2018-07/ndis-practice-standards-july-2018.pdf (accessed 3 September 2019).

NDIS Quality and Safeguards Commission, “The NDIS Code of Conduct: Guidance for NDIS Providers, March 2019”, [website], 2019. https://www.ndiscommission.gov.au/sites/default/files/documents/2019-03/code-conduct-providers-march-2019-10.pdf (accessed 3 September 2019).

Queensland Health, MASS, https://www.health.qld.gov.au/mass/prescribe/mobility

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