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Chiropractic Journal of Australia : CJA December 2012
Chiropractic Journal of Australia Volume 42 Number 4 December 2012 137 Differences in chiropractic education exist both internationally and nationally, despite regional accreditation standards and the quality assurance role of the Councils on Chiropractic Education International (CCEI). This is not necessarily a major problem, as the role and responsibilities of the chiropractor may vary -- not only between countries, but also within them. However, the goal common to all chiropractic educational institutions is to train primary care practitioners that can - at a minimum - function effectively in the community in which they are trained. Aconcept which is common to most chiropractic registration and accreditation bodies is the concept of training students to be able to take on the role of a 'primary care practitioner'. This does not, however, suggest that the chiropractor has the same role as a general medical practitioner. What it does imply is that educational institutions have a responsibility to train practitioners who can recognise a diverse range of disorders and know when referral to a medical practitioner is required. This is of vital importance, as patients consulting a chiropractor for a musculoskeletal symptom such as low back pain or headache, need to be screened for any underlying disorder which is not able to be managed by the chiropractor. Chiropractors trained at institutions which embrace evidence –based medicine are cognizant that research into the effcacy of chiropractic treatment is still in its infancy. Strategies used by the chiropractor are based on varying degrees of evidence, including anecdotal, case study reports, epidemiological studies and clinical trials. The emphasis given to different subjects within chiropractic programs often vary significantly between institutions. Diagnostic science is one such area. Many techniques are taught within this discipline. One which has initiated much discussion regarding its inclusion in the curriculum is ophthalmoscopy. Why is it taught in chiropractic institutions? Is there evidence to support its position within the curriculum? A search through the accreditation documents of the regional chiropractic accrediting bodies reveals no reference to ophthalmoscopy or fundoscopy, although it is acknowledged that this omission does not infer that ophthalmology should not be included within chiropractic curricula. A search of the literature fails to reveal any discussion of this subject in relation to chiropractic education, although there is some controversy regarding the function of role of ophthalmoscopy in medical school curricula. Benbassat et al1 question the type of training medical students currently receive in direct ophthalmoscopy. They suggest that studies have shown that it has a limited value, and as such, training should be limited to a few areas only. Fan et al2 examined ophthalmology curricula at 19 Australasian and Asian Medical schools, and found distinct differences between them. Variation in the breadth of topics covered, time devoted Commentary: Teaching Ophthalmoscopy to Chiropractic Students: Where is the Evidence for Inclusion in the Curriculum? to the discipline and number of clinical placements existed. This was despite the existence of international guidelines in the teaching of ophthalmology. Why target ophthalmoscopy as an issue? Firstly, in order to view the retina fully, the pupil should be pharmacologically dilated (mydriasis). This is not possible in chiropractic practice, due to restrictions in the use of pharmacological agents. In order to get maximum beneft without mydriasis, the examination room must be darkened in order to restrict as much light as possible. Optometrists and ophthalmologists (and even some general practitioners) now use a slit lamp or a retinal camera to view the fundus, which provides a far superior method of examination. In the developed world direct ophthalmoscopy is used far less frequently today. The second issue relates to why the chiropractor would wish to view the fundus in the frst place. Patients most commonly consult a chiropractor for a musculoskeletal problem. However, a full medical history is still taken. Consider the following scenarios which may present to the chiropractor. 1. A patient complains of a visual symptom, such as blurred vision, double vision or diminished vision. The chiropractor clearly needs to refer the patient to a medical practitioner or an optometrist for a more in depth eye examination. Referral is required, even if a sign is not detected with fundoscopy. 2. When conducting a neurological examination, an abnormality of one or more cranial nerves may be detected. An abnormality in a patient’s visual felds, or in visual acuity would highlight the need for referral. 3. A patient is known to be diabetic or hypertensive, and is under the care of a medical practitioner. The degree of retinopathy thus needs to be regularly monitored. However, this is usually conducted on a regular basis by an optometrist or ophthalmologist. 4. The patient has a family history of glaucoma. Although ophthalmoscopy is appropriate for the detection of normal pressure glaucoma, tonometry (conducted by either the optometrist or ophthalmologist), is the most appropriate diagnostic tool for high pressure glaucoma. This also will require referral. 5. The chiropractor suspects an acute disorder such as a retinal detachment, acute angle closure glaucoma or vascular occlusion. Regardless of ophthalmological evidence, a suspicion of such a problem necessitates immediate medical referral. 6. If a patient presents with a neurological symptom and/or sign, ophthalmoscopic examination would be appropriate. However, the absence of any deviation
CJA September 2012
CJA March 2013