MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.
In 2016, members of the World Federation of Chiropractic Disability and Rehabilitation Committee conducted an international, cross-sectional survey of all 193 United Nation member countries and seven dependencies to describe the global chiropractic workforce in terms of:
  • the availability (numbers and where they are practising),
  • quality (education and licensing),
  • accessibility (entry and reimbursement),
  • acceptability (scope of practice and legal rights).

An electronic survey was issued to contact persons of constituent member associations of the World Federation of Chiropractic (WFC). In addition, data were collected from government websites, personal communication and internet searches. Data were analysed using descriptive statistics.

Information was available from 90 countries in which at least one chiropractor was present. The total number of chiropractors worldwide was 103,469. The number of chiropractors per country ranged from 1 to 77,000. Chiropractic education was offered in 48 institutions in 19 countries. Direct access to chiropractic services was available in 81 (90%) countries, and services were partially or fully covered by government and/or private health schemes in 46 (51.1%) countries. The practice of chiropractic was legally recognized in 68 (75.6%) of the 90 countries. It was explicitly illegal in 12 (13.3%) countries. The scope of chiropractic practice was governed by legislation or regulation in 26 (28.9%) countries and the professional title protected by legislation in 39 (43.3%). In 43 (47.8%) countries, chiropractors were permitted to own, operate, or prescribe x-rays, in 22 (24.4%) countries they were lawfully permitted to prescribe advanced imaging (MRI or CT), and in 34 (38.8%) countries owning, operating or prescribing diagnostic ultrasound was permitted. Full or limited rights to the prescription of pharmaceutical medication were permitted in 9 (10%) countries, and authorization of sick leave was permitted in 20 (22.2%) countries. The care of children was subject to specific regulations and/or statutory restrictions in 57 (63.3%) countries.

The authors concluded as follows: We have provided information about the global chiropractic workforce. The profession is represented in 90 countries, but the distribution of chiropractors and chiropractic educational institutions, and governing legislations and regulations largely favour high-income countries. There is a large under-representation in low- and middle-income countries in terms of provision of services, education and legislative and regulatory frameworks, and the available data from these countries are limited.

The countries where chiropractic is explicitly illegal are the following:

  • Egypt
  • Argentina
  • Columbia
  • Austria,
  • Estonia,
  • Greece,
  • Hungary,
  • Lebanon,
  • Republic of Korea,
  • Taiwan,
  • Turkey.
  • Ukraine.

Forty-two countries (61.8%) have regulations and/or rules under the legislation to provide for registration or licensure of chiropractors. Chiropractors may be available in 90 countries, but 50% percent of these have 10 or fewer chiropractors. Importantly, the care of children is under regulation or restrictions in most countries.

In comparison to similar professions such as physiotherapy, the chiropractic total workforce is small (worldwide 103,469). The World Confederation of Physical Therapy reports an estimated number of 450,000 physical therapists worldwide with the number of physio therapists per capita per 100,000 ranging from 0.19 in Malawi to 282 in Finland.
This survey holds plenty of interesting information. Here is what I found most remarkable:
  • The World Federation of Chiropractic takes 3 years to publish data which, by then, are of course out-dated.
  • In most countries, the chiropractic care for children is restricted.
  • In many countries chiropractic is illegal.
  • In many countries, there are only very few or no chiropractors at all.
  • There are about 4 times more physiotherapists than chiropractors.
  • In 9 countries, chiropractors have the right to prescribe medicines.

Much of the data revealed in this survey suggests to me that the world can do without chiropractors.

29 Responses to The chiropractic workforce: a global review

  • Ee…Much of the data revealed in this survey suggests to me that the world can do without chiropractors.

    Maybe because you are ignoring other data. Maybe we need more good chiropractors?

    “In 2015, low back and neck pain were ranked the fourth leading cause of disability-adjusted life years (DALYs) globally just after ischemic heart disease, cerebrovascular disease, and lower respiratory infection {low back and neck pain DALYs [thousands]: 94 941.5 [95% uncertainty interval (UI) 67 745.5-128 118.6]}. In 2015, over half a billion people worldwide had low back pain and more than a third of a billion had neck pain of more than 3 months duration. Low back and neck pain are the leading causes of years lived with disability in most countries and age groups.” https://link.springer.com/article/10.1007%2Fs00586-017-5432-9

    • In the UK the workforce issue in musculoskeletal care is a problem and the chiropractic profession is responding by increasing training places for chiropractors as new University courses are starting . In addition with organisations like NICE recognising that chiropractors can provide care for LBP (exercise and SMT) and the NHS start to utilise chiropractors the future of the profession looks bright.

      • ” organisations like NICE recognising that chiropractors can provide care for LBP”
        really?
        evidence please!

        • Sorry EE I thought that you were familiar with NICE guideline NG59. As you know NICE recommend treatments not professions and when they considered manual therapy in NG59 they stated:

          1.2.7 Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.

          In the full guideline evidence review of non-invasive treatment, section 12.1 p352 (https://www.nice.org.uk/guidance/ng59/evidence/full-guideline-assessment-and-noninvasive-treatments-pdf-2726158003) NICE state:

          “Mobilisation and soft tissue techniques are performed by a wide variety of practitioners; whereas
          spinal manipulation is usually performed by chiropractors or osteopaths, and by doctors or
          physiotherapists who have undergone additional training in spinal manipulation. Manual therapists
          often combine a range of techniques in their approach and may also include exercise interventions
          and advice about self-management.”

          I think that it is pretty clear that NICE RECOGNISE that chiropractors (and osteopaths and physiotherapists) can provide treatments consistent with their recommendations.

          • Andy wrote: “Mobilisation and soft tissue techniques are performed by a wide variety of practitioners; whereas spinal manipulation is usually performed by chiropractors or osteopaths…” I think that it is pretty clear that NICE *RECOGNISE* that chiropractors (and osteopaths and physiotherapists) can provide treatments consistent with their recommendations…as I stated above NICE in their guidelines CG88 and NG59 recommend treatments not professions but they do *recognise* that chiropractors, osteopaths and physiotherapists can provide the manual therapy and exercise component of these treatments. To suggest that they no longer *recommend* chiropractic or osteopathy is a falsehood …”
            [My asterisks]

            @ Andy

            Aren’t you confusing ‘recognise’ with ‘recommend’ and ‘chiropractic’ with ‘chiropractors’?

            Prof. Ernst is, apparently, correct when he says that NICE guideline NG59 no longer *recommends* ‘chiropractic’. For example, he has previously responded to your criticism with: “No, I use these terms not to describe professions but sets of modalities [the respective professions would be chiropractors and osteopaths] – just as I used ‘acupuncture’ in the same sentence.”
            Ref: https://edzardernst.com/2016/03/nice-no-longer-recommends-acupuncture-chiropractic-or-osteopathy-for-low-back-pain/#comment-75955

            In other words, the full NG59 guideline evidence review of non-invasive treatment, section 12.1 p352 (https://www.nice.org.uk/guidance/ng59/evidence/full-guideline-assessment-and-noninvasive-treatments-pdf-2726158003) appears to *recognise* that: “Mobilisation and soft tissue techniques are performed by a wide variety of practitioners; whereas spinal manipulation is usually performed by chiropractors or osteopaths, and by doctors or physiotherapists who have undergone additional training in spinal manipulation”.

            That seems rather different from the previous guideline (CG88) which implied a *recommendation* for chiropractic/chiropractors…

            QUOTE
            “Consider offering a course of manual therapy, including spinal manipulation, spinal mobilisation and massage. *Treatment may be provided by* a range of health professionals including chiropractors, osteopaths, manipulative physiotherapists or doctors who have had specialist training.”
            Ref: https://www.nice.org.uk/guidance/cg88/documents/press-releases2

            Here is the definition of ‘recommend’: ‘Put forward (someone or something) with approval as being suitable for a particular purpose or role’
            Ref: http://www.oxforddictionaries.com/definition/english/recommend

            Returning to the current guideline (NG59), it’s worth highlighting that it isn’t exactly good news for chiropractors:

            QUOTE

            “…let’s look at what the NICE guidelines say about exercise:
            ‘Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica. Take people’s specific needs, preferences and capabilities into account when choosing the type of exercise.’
            One important point from this guidance is that NICE recommends a “group exercise programme”. This presents something of a problem for pure manual therapists such as osteopaths and chiropractors as they don’t normally have access to a group exercise programme for their patients. I have already highlighted the fact that osteopathy and chiropractic are no longer first line treatment choices for low back pain and sciatica. NICE have made it clear in their own press release that exercise is the “first step in managing the condition”. The right person to deliver an exercise programme is of course a physiotherapist.
            The new NICE guidelines are something of a problem for osteopaths and chiropractors as their treatments are no longer first line choices and they are not well placed to offer a suitable exercise programme. Some of them may opt to continue treating patients the way the always have and not take the NICE guidelines into account. However, that is a potentially risky strategy for two reasons:
            It doesn’t seem to be in the best interest of their patients.T hey risk being found in breach of their “Practice Standards” which could result in formal complaints to either the GOsC or GCC.”

            Ref: https://complementaryandalternative.wordpress.com/2016/12/06/nice-guidelines-for-low-back-pain-and-sciatica-a-clarification/

        • Hi EE as I stated above NICE in their guidelines CG88 and NG59 recommend treatments not professions but they do recognise that chiropractors, osteopaths and physiotherapists can provide the manual therapy and exercise component of these treatments. To suggest that they no longer recommend chiropractic or osteopathy is a falsehood as they have never recommended these professions no more than they have recommended physiotherapy.

          • In answer to BW and EE above it seems that we now all realise that NiCE recognise chiropractors can provide recommended treatment.

            Your attempt to suggest that NICE longer recommend chiropractic or osteopathy is somewhat tenuous and applying your logic it would be more newsworthy to state that NICE no longer recommend physiotherapists.

            You really are clutching at straws!

          • … and I thought it was you!

    • When there is any substantial evidence to unilaterally support the efficacy of chiro for anything, present it, otherwise you are a scammer fleecing the gullible just like any other fraudster.

  • IF chiros stayed within the evidence (lower back pain), then I wouldn’t have a problem with them. Instead, you have chiros who don’t practice within their evidence base and condone pseudo-science.

    Case in point…

    https://sciencebasedmedicine.org/anti-vaccination-ideology-in-chiropractic-continuing-education-and-conferences-again/

    • That page is hardly a unbiased and comprehensive report on the topics.

      • I know, only chiros can be unbiased about chiropractic!

      • @DC

        That page is hardly a unbiased and comprehensive report on the topics.

        What page? And what is your argumentation for this opinion?

        • Bjorn, The link to the SBM article by Jann Bellamy from August 1, 2019.

          • @DC
            That is what I suspected, but as your exclamation contradicts common consensus and facts about SBM, I asked for confirmation.
            Now please answer the question about what grounds you base your oeculiar opinion upon.

          • In that particular blog she did not directly reference one research paper on the topic. Mainly just a few stories. The links may contain references, I didn’t take the time to look.

            At no time did she give information on the prevalence of the issue with the profession, the measures that some boards are taking on the issue, the stance of the progressive chiropractors, etc.

            One sided view on the topic…hence a biased and not a comprehensive report on the topic…which is what I stated.

  • They certainly ain’t like locus! 125 years and they are woefully behind even Scientologists.
    My neighbor told me of their Chiroquackery misadventure recently. He (patient) suggested he was going to get into an exercise program and not continue with his “treatments”…to which the quack (chiropractor) said: “chiropractic adjustments aren’t replaceable with exercise or other treatments, they are unique and need to be an integral part of a persons healthcare. You need to have both exercise and chiropractic to maintain optimal health”. So I guess that proves it. A quack wouldn’t lie for $65 3xs a week…would they?

  • Chiropractic certainly “can be used in the management of back pain.”
    Anything “can be”.

    But chiropractic is a system for adjusting subluxations and releasing ‘innate intellegence’ in order to affect pathological processes of many kinds. If chiropractors do not do that, they are not practising chiropractic. Simple.

    Problem is, there is no plausible evidence that subluxations exist or that adjustment has any benefit.
    Sorry.

    And the sadest thing is that most knowledgable chiropractors know this perfectly well, but can’t, or won’t, move on.
    Sigh.

    • RR….But chiropractic is a system for adjusting subluxations and releasing ‘innate intellegence’ in order to affect pathological processes of many kinds. If chiropractors do not do that, they are not practising chiropractic. Simple.

      They are not practicing based upon historical concepts. And the concept of adjusting “subluxations” and the possible effect on other physical complaints was not anything new. Harrison wrote about in 1821 in the London Medical and Physical Journal, vol 45, pg 113.

      DD Palmer introduced the concept of correcting subluxation having an effect on Innate Intelligence many years after naming it chiropractic (and even then II wasn’t a new concept in the world). The main thing DD brought to the table was that correcting spinal displacements somehow re-established II with UI, and that didn’t come to bearing until he was pressured and threatened by the AMA.

      To claim that a profession cannot evolve beyond a historical concept is silly.

      Now, if one wishes to discuss the topic of Ernst blog and his conclusion, let me know.

  • I am from Estonia and I found no evidence that chiropractic is explicitly illegal here (if we understand the meaning of illegal similarly). Chiropractors are definitely working here legally as in taking patients and paying taxes. There is even some kind of association for Estonian chiropractors (http://emmks.ee/en/). Only thing is that it is not covered by the Estonian Health Insurance Fund and there is no official professional license available for chiropractors so there are no official requirements for chiropractors. Meaning that anyone can call themselves a chiropractor in Estonia. However, it also means that doctors should not (probably even forbidden) direct their patients to chiropractors. Still, some doctors are also so called chiropractors and they have their doctor licences and their services are covered by the health insurance (of course if they explicitly say that the service was chiropractic then it is not covered). As well, the above-mentioned association is probably moving towards to make some kind of official professional licence available for chiropractors in Estonia.

  • DC wrote: “The main thing DD brought to the table…”

    @ DC

    Was apparently nothing but nonsense. For example, DD Palmer’s version of the Harvey Lillard ‘restored hearing’ event (the catalyst for chiropractic) has always been disputed by Lillard’s daughter, Valdeenia Lillard Simons:

    QUOTE
    “She says that her father told her that he was telling jokes to a friend in the hall outside Palmer’s office and, Palmer, who had been reading, joined them. When Lillard reached the punch line, Palmer, laughing heartily, slapped Lillard on the back with the hand holding the heavy book he had been reading. A few days later, Lillard told Palmer that his hearing seemed better. Palmer then decided to explore manipulation as an expansion of his magnetic healing practice. Simons said “the compact was that if they can make [something of] it, then they both would share. But, it didn’t happen”. [2]
    Chiropractic’s true origin appears to have been of a more mystical nature than the Lillard tale denotes. Palmer was an active spiritualist and apparently believed that the idea of “replacing displaced vertebrae for the relief of human ills” came in a spiritualist séance through communication with the spirit of Dr. Jim Atkinson, a physician who had died 50 years earlier in Davenport [3]. As a young man, Palmer regularly walked the six or seven miles to the estate of his spiritualist mentor, William Drury [4]. It was one of Drury’s followers who told him of her vision of a door with a sign on it reading ‘Dr. Palmer’. She said that he one day would lecture in a large hall telling an audience about a new “revolutionary” method of healing the sick [5]. Predisposed to magnetic healing by his belief in spiritualism, Palmer was drawn to the practice by seeing the financial success of illiterate ‘Dr.’ Paul Caster of Ottumwa… Individual chiropractors sometimes deny that they believe in Palmer’s biotheological ‘Innate Intelligence’, but when pressed as to their basis for practice, they must face the physiological facts described in a scientific brief on chiropractic: If there is partial blockage of impulses in a nerve fibre . . . the impulse is transmitted more slowly in a zone of partial blockage, and resumes all its characteristics as soon as it reaches normal tissue. Thus, it is impossible for a partial blockage of nerve impulses in a particular zone to affect the flow, since the impulses would resume their normal flow [9].”
    Ref: https://www.ncahf.org/articles/c-d/chiro.html

    DD Palmer certainly seemed to be inconsistent about the restored healing event – e.g., in his 1910 textbook, ‘The Chiropractor’s Adjuster’, he wrote:

    QUOTE
    “Harvey Lillard, a janitor, in the Ryan Block, where I had my office, had been *so deaf* for 17 years that he could not hear the racket of a wagon on the street or the ticking of a watch… I made inquiry as to the cause of his deafness and was informed that when he was exerting himself in a cramped, stooping position, he felt something give way in his back and immediately became deaf. An examination {i.e. not a slap on the back with a book as claimed by his daughter, Valdeenia Lillard Simons] showed a vertebra racked form its normal position. I reasoned that if that vertebra was replaced, the man’s hearing should be restored. With the object in view, *a half-hour’s talk* persuaded Mr Lillard to allow me to replace it.”

    You have to wonder how Mr Lillard could have heard what DD Palmer said to him in that half-hour conversation when he was, apparently, at least 90% deaf. See: http://www.chirobase.org/05RB/BCC/07.html

    It’s also interesting to note that, six years after inventing chiropractic, DD Palmer discarded it https://www.facebook.com/204610332906631/photos/a.349152545119075/2047167945317518/?type=3&theater – only for it to be resurrected by his (ruthless) businessman son, BJ Palmer.

    DC wrote: “To claim that a profession cannot evolve beyond a historical concept is silly”

    Is it? The World Federation of Chiropractic admitted just over a year ago that chiropractic reform had failed and that “chiropractors now practice in a range of different settings, using a wide range of interventions and practicing from varying philosophical standpoints” See p.3 here https://www.wfc.org/website/images/wfc/qwr/2018/QWR_2018JUL.pdf

    What’s more, the current (Interim) President of the World Federation of Chiropractic, Vivian Kil DC (who dreams of uniting the profession and wrote in 2015 that: “If we miss the boat, the nightmare has set in, and our profession may no longer have a reason to exist” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4685193/ ) – said in May of this year that: “We need, at least to the outside, to act as one profession…”
    Ref: http://chiropractic.prosepoint.net/164440

    ChiroprACTORS anyone? Here are a few reasons as to why Kil seems to be so reluctant to advocate for transparency:

    The British Chiropractic Association admitted in 2016 that “unity need not mean uniformity”: http://www.mccoypress.net/i/bca_bennett_letter_december_2016.jpg

    That stance is wholly reconcilable with a recent comment made by Michael Copland-Griffiths [DC, FRCC, FBCA, FEAC – former Chair of the Chiropractic Registration Steering Group (1994-1997), former President of the British Chiropractic Association (1985-1987) and former Chair of the General Chiropractic Council (2002-2006)] on the Chiropractors’ Act 1994: “the diverse Chiropractic profession had to continue to speak with one voice…disunity would kill the commencement of the Act”
    https://www.gcc-uk.org/UserFiles/Docs/Newsletters/The%20Chiropractors%20Act%20and%20opening%20of%20the%20GCC%20register%20MCG.pdf

    Indeed, it fits in very neatly with his article in the European Journal of Oriental Medicine, Vol.2 No.6, 2004, in which he wrote: “In spite of strong mutual suspicion and distrust, the profession united under a group formed specifically to pursue regulation and secured the Chiropractors Act (1994)…..Regulation for a new profession will literally ‘legitimise it’, establishing its members within the community, making them feel more valued. In turn, this brings greater opportunity for more clients and a healthier bank balance.”
    Ref: https://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1437-statutory-regulation-the-chiropractic-experience.html

    Still in the UK, David Newell, Professor of Integrated Musculoskeletal Care, Director of Research, and Reader at the Angle European College of Chiropractic (AECC) University College, a member of the Senior Management Group and chair of the Staff Development and Research Committee, has commented that: “Global and European chiropractic reform unlikely”
    Ref: https://tinyurl.com/y4vl9ath

    Newell seems to be correct, not least because the European Chiropractors’ Union admitted two years ago that it had not yet covered serious areas such as “ the subluxation complex, vaccination, the use of drugs and patient management, where we know there is a significant difference in opinion between the two groups [mechanists/vitalists].”
    Ref: https://www.chiropractic-ecu.org/wp-content/uploads/2017/03/01-32-Backspace-Mar17-to-print.pdf

    Meanwhile, it’s worth noting that the subluxation-based UK McTimoney Chiropractic Association was preaching #ChiropracticTolerance
    https://www.facebook.com/mctimoneychiropracticassociation/photos/a.145823282157071.35903.145726228833443/1980951451977569/?type=3&theater
    as water bottles were thrown onto the stage at a recent, major chiropractic conference
    https://edzardernst.com/2019/05/chiros-at-war/

    Looks like the nightmare has set in already.

    _______________________________________________________________________

    “Chiropractic is the correct term for the collection of deceptions DD Palmer invented.”

    Björn Geir Leifsson, MD

    • BW…DC wrote: “The main thing DD brought to the table…”

      @ DC

      Was apparently nothing but nonsense.

      Regardless, the points I brought up are shown in the history books. Most of what he came up with was borrowed from others. The only thing truly unique was the tie in between II and UI and the role manipulation played in that connection.

      Silly, yes. What percentage still hold onto that belief, probably very few if they actually understood what DD was suggesting.

      • DC wrote: “What percentage still hold onto that belief, probably very few if they actually understood what DD was suggesting.”

        @ DC

        It looks like it’s the majority of chiropractors: https://edzardernst.com/2019/04/a-risk-benefit-assessment-of-chiropractic-neck-manipulation/#comment-112698

        Unless you have better data…

        • If i recall, that discussion was with regards to the correlation between spinal subluxations and visceral function. The above topic was regarding II and UI.

          I am not aware of any survey that specifically addressed that belief system.

          However, surveys do show us that when taking historical concepts as a whole, around 20% of chiropractors hold onto that thinking. Thus, one could deduce that the percentage that believe in the II and UI connection and the role spinal manipulation plays in that relationship would be less than 20% of chiropractors.

          • DC wrote: “…one could deduce that the percentage that believe in the II [Innate Intelligence] and UI [Universal Intelligence] connection and the role spinal manipulation plays in that relationship would be less than 20% of chiropractors.”

            @ DC

            Whilst that might be an interesting speculation, the most important point, IMO, is that the data show that a majority of chiropractors still adhere to pseudoscientific beliefs.

  • BW…the data show that a majority of chiropractors still adhere to pseudoscientific beliefs.

    Well, by definition, per the Oxford Dictionary, pseudoscience is “a collection of beliefs or practices mistakenly regarded as being based on scientific method.”

    So yes, if a chiropractor thinks and/or claims his certain beliefs are based upon the scientific method, when they are not, that chiropractor would be guilty of pseudoscience.

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