Quebec Naturopathic Physician Continuing Education

• Outline the limitations of a recent trial on preventive treatments including spinal manipulation for neck pain and how they contribute to our interpretation of the results of the study
• Interpret results of an important trial on spinal manipulation and exercise for neck pain
• Discuss recent evidence comparing spinal manipulation to mobilization for recent onset neck pain
• Use recent evidence to justify manipulating various spinal regions for patients with neck pain
• Critique the potential for chest and neck mobilizations to affect spirometric performance (breathing)

• Contrast Clinical Guideline-based care with usual medical care for acute low back pain
• Recognize the potential benefit of adding exercise prescription to spinal manipulation for low back pain
• Compare the effectiveness of spinal manipulation to McKenzie Method interventions for persistent low back pain
• Outline factors that may help predict improvement in patients seeking chiropractic care for low back pain
• Explain the benefits of evidence-based care for low back pain

• Compare the efficacy of standard medical care (SMC) alone versus chiropractic spinal manipulation + SMC for acute low back pain patients
• Discuss the value of a combined (pragmatic) chiropractic approach for treating low back pain
• Analyze the state of the research literature directly comparing spinal manipulation, exercise and acupuncture as treatments for low back pain
• Update your understanding of joint cavitation during side posture lumbar manipulation
• Critique the only study (to date) on maintenance care for low back pain including spinal manipulation

• Develop evidence-based chiropractic treatment recommendations for nonspecific (mechanical) neck pain in adults
• Discuss the clinical criteria justifying spinal manipulative therapy for neck pain
• Assess the relative effectiveness of spinal manipulative therapy and rehabilitative exercise for neck pain in seniors
• Describe the working mechanism of manual therapy in participants with chronic tension-type headache
• Examine the cerebrovascular hemodynamic response of cervical spine positions using MRI on the vertebral artery

• Critique the state of the evidence for manual therapy interventions in the treatment of cervical radiculopathy
• Compare two common interventions – spinal manipulation and nerve root injection – for patients with MRI-confirmed lumbar disc herniation
• Critique the state of the evidence for spinal manipulation (specifically) in the treatment of cervical radiculopathy
• Interpret the results of a cohort study of MRI-confirmed symptomatic cervical disc herniation patients treated with cervical manipulation
• Compare isolated cervical SMT versus a combination of cervical, cervico-thoracic and thoracic SMT in patients with chronic mechanical neck pain

• Examine the effects of thoracic manipulation and non-thrust mobilization on pain sensitivity and intensity in patients with chronic mechanical neck pain
• Summarize the state of the literature on the utility of spinal manipulation for managing hypertension
• Critique a recent study on the importance of cavitation in the autonomic nervous system (ANS) effects of thoracic spinal manipulation
• Evaluate the scientific literature on the validity and reliability of the common methods used by chiropractors to inform the choice regarding where spinal manipulation is to be applied once it is deemed an appropriate treatment
• Explore biomechanical and neurophysiologic mechanisms of thoracic manipulation that might result in clinical benefit for patients with rotator cuff tendinopathy

• Describe the science behind chiropractic care
• Translate the intent of manipulative therapy to patients and other healthcare providers
• Describe the potential results of not having recommended chiropractic care
• Outline the different theories of the subluxation complex
• Justify the care you recommend based on electrodiagnostic, imaging, and laboratory studies

• Compare chiropractic maintenance care to symptom-guided care for patients with persistent or recurrent low back pain
• Investigate whether adding chiropractic care to usual medical care improves outcomes for military personnel suffering from low back pain
• Evaluate the research on the effectiveness of mobilization and manipulation for chronic non-specific low back pain
• Determine the effects of spinal manipulation on biochemical markers in humans
• Appraise the associations between chiropractic and primary care physician care in relation to acute lumbar disc herniation with early surgery

• This contains all courses with the educational objectives listed from Manipulation 117 through Manipulation 122

• Identify a sub-group of recurrent low back pain patients that might respond most favorably to a maintenance care schedule
• Summarize existing research literature on chiropractic maintenance care
• Investigate short-term changes in pain-pressure threshold (PPT) and temporal summation (TS) after lumbar spinal manipulation (SMT) compared to a credible sham intervention
• Determine whether cervical spinal manipulation leads to meaningful changes in vertebral and cerebral hemodynamics, compared to neutral or end-range neck rotation postures in adults with chronic neck pain
• Summarize the current state of the literature regarding the neurophysiological effects of high-velocity, low-amplitude spinal manipulative therapy (HVLA-SMT) in asymptomatic and symptomatic humans
• Critique the existing, sham-controlled literature evaluating the acute changes in autonomic nervous system (ANS) markers and function in patients receiving manipulation to spinal or peripheral joints

Hour 1

• Identify important spinal anatomy with relation to joint pain, degeneration and stabilization.
• Explain the efficacy of spinal manipulation (SM) for various clinical presentations
• Discuss current literature reviews regarding safety concerns and controversies with SM.
• Perform joint manipulative procedures to the spine and pelvis

 Hour 2

• Discuss common clinical anatomy related to the trunk and torso, with practically to joint manipulation.
• Examine the thoracic and lumbar spine through important clinical landmarks and topical anatomical structures.
• Perform alternative manipulative procedures to the spine and pelvis

 Hour 3

• Discuss common clinical anatomy related to the head, and neck.
• Examine the cervical spine through important clinical landmarks and topical anatomical structures.
• Perform joint manipulative procedures for cervical spine.
• Perform manipulative and mobilization procedures to the temporomandibular joints.

• Examine the effect of chiropractic manipulation on reaction and response time in combat-ready special operations forces qualified personnel
• Assess the influence of chiropractic care on the strength, balance, and/or endurance in active-duty United States military personnel
• Evaluate the impact of upper- vs lower-extremity chiropractic manipulation on postural sway and dual task performance
• Provide an update regarding the mechanisms of action for manual therapy, the impact of manual therapy on pain management, health care conditions for which manual therapy may be beneficial and treatment plans

Hour 1

• Review common foot and ankle anatomy.
• Evaluate the foot and ankle.
• Perform physical and neurological examinations and tests related to the foot and ankle.
• Identify uncomplicated common conditions during the evaluation of the foot and ankle.

 Hour 2

• Discuss evidence-based literature suggesting the practically of manipulation of the foot and ankle.
• Perform adjustments of the foot.
• Perform adjustments of the ankle.
• Utilize a speeder/toggle board for the foot.

 Hour 3

• Describe the impact of disturbances on the determinant factors of health in the structures of the foot and ankle
• Apply corrective and preventative measures to conditions affecting the health of the foot and ankle
• Utilize evidence-based low technology rehabilitative methods to manage patient care of common foot and ankle conditions.
• User strategies to address challenges patients have with adhering to rehabilitative programs.

Hour 1

• Review common hand, wrist and shoulder anatomy.
• Evaluate the hand write and shoulder.
• Perform physical and neurological examinations and tests related to hand wrist and shoulder.
• Identify uncomplicated common conditions during the evaluation of the hand wrist and shoulder

Hour 2

• Discuss evidence-based literature suggesting the practically of manipulation of the hand, wrist and shoulder.
• Perform adjustments of the hand.
• Perform adjustments of the wrist.
• Perform adjustments of the shoulder

Hour 3

• Describe the impact of disturbances on the determinant factors of health in the structures of the hand, wrist and shoulder
• Apply corrective and preventative measures to conditions affecting the health of the hand, wrist and shoulder
• Utilize evidence-based low technology rehabilitative methods to manage patient care of common hand, wrist and shoulder
• User strategies to address challenges patients have with adhering to rehabilitative programs.

• Summarize existing literature regarding the neurophysiological mechanisms of spinal manipulation for spine pain 
• Identify the beliefs, perceptions and practices of chiropractors and patients regarding benign adverse events after spinal manipulation and potential strategies to mitigate them
• Explore recent research pertaining to the importance or segmental pain and stiffness when targeting the application of spinal manipulation
• Assess the literature on the effect of SMT on acute neck pain, including pain, disability and quality of life measures and reported adverse effects
• Examine the evidence pertaining to the efficacy and effectiveness of spinal manipulation for preventing infectious disease and improving disease-specific health outcomes among patients with infectious disease

• Define and classify adverse events associated with manipulation and mobilization
• Review symptoms patients perceive as adverse
• Describe the incidence of severe adverse events among chiropractic recipients
• Outline adverse events in the pregnant and postpartum periods

• Describe the vertebral architectural distortion that predicts spinal imbalances. 
• Explain the factors involved in the etiology related to the primary components of the proprioceptor-cerebellar network. 
• Cite the law that establishes a classic chiropractic patient via radiograph. 
• Compare the classic manual osseous adjustment to Sensor-Based-Technique in regards to risk and effectiveness for reversing the cause of most chronic subluxations: An aberrant proprioceptor-cerebellar network feedback loop, (usually initiated by injury,) sustained through time by wedged vertebral bodies via Wolff's law, involving neuromuscular fixation engrams compensating for unlevel vertebral architecture. 
• Palpate the tendinous insertions of the paraspinal musculature in the areas of the spinous process tips and identify those areas that show tension, and demonstrate proper cross-friction massage at those points.

• Discuss the definition and scope of medical error
• Summarize the types of medical error
• Identify and describe ongoing safety research within the chiropractic profession
• Review the literature on the adverse events following chiropractic care
• Illustrate strategies to prevent common errors

Hour One:

• Discuss common medical errors made in the process of choosing diagnostic imaging for patients with cervical spine injuries
• Discuss the role of Clinical Prediction Rules and their role in preventing common errors in overutilization of radiographic studies in patients with cervical spine injuries
• Describe the Canadian C-Spine Rule, Canadian Head CT Rule and NEXUS Low-Risk Criteria, as well as their limitations and exceptions
• Review the literature supporting the use of Clinical Prediction Rules in the prevention of medical errors

Hour Two:

• Discuss limitations of plain film radiography in the evaluation of injured patients, and strategies to avoid medical errors due to inappropriate selection of imaging modalities
• Discuss relevant clinical indications for ordering advanced imaging studies in the evaluation of patients with cervical spine injuries
• Review common advanced imaging studies and their role in preventing medical errors of commission or omission
• Discuss the clinical relevance of recognizing loss of cervical motion segment integrity in the evaluation and management of injured patients

• List the conditions commonly treated with medical marijuana.
• List the basic physiological mechanism that result from medical marijuana
• Explain the different cannabinol receptors known in human tissues
• Explain the benefits of cannabidiol vs. tetrahydrocannabinols
• List the specific physiological benefits for conditions commonly treated with medical marijuana
• Recognize the side effects and potential dangers of medical marijuana

• Define and distinguish between primary care, secondary care, tertiary care, direct access, medical screening, screening for referral and signed prescription.
• Recall 5 reasons to conduct a medical screening.
• Outline 5 components for effective communication during the patient interview to obtain accurate and comprehensive baseline information.
• Define and explain the relevance of yellow flags, red flags and flag clusters as part of the medical screening process
• Define and describe the five components of the patient-centered interview and state the impact this has on patient satisfaction and outcome
• Define and provide the clinical relevance of sensitivity, specificity, odds ratios, and likelihood ratios as they pertain to the value of diagnostic/clinical tests

Hour 1

• Recall 3 general symptoms signs/symptoms of inflammatory joint conditions.
• Recite 3 general symptoms signs/symptoms of osteoarthritis
• Cite 4 serious pathologies or disorders that should be screened for in a patient presenting with lower back pain.
• Explain the clinical prediction rule for a vertebral fracture and identify the specific red flags necessary for high specificity in ruling in a vertebral fracture.
• Enumerate 3 red flags associated with a spinal infection that can detected during the medical screening process which may warrant subsequent referral.
• List 3 red flags associated with a spinal tumor that can detected during the medical screening process which may warrant subsequent referral.

Hour 2

• Explain the purpose of the Wells scoring system/ clinical prediction rule for screening a patient with lower leg pain.
• Recall 5 red flags associated with pericarditis during medical screening of a patient with thoracic pain.
• Outline red flags associated with pyelonephritis during medical screening of a patient presenting with thoracic pain.
• Summarize the components of the clinical prediction rule for ruling in cervical myelopathy.
• Recite 3 common clinical findings associated with osteonecrosis of the femoral head during the medical screening examination.
• List 3 red flag findings for a patient suspected of having compartment syndrome of the lower leg
• Explain the Pittsburgh Knee Rules as they relate to the necessity for follow-up imaging tests to rule out a knee fracture.
• Paraphrase the Ottawa Ankle Rules for warranting imaging tests to rule out an ankle fracture.

Hour 1

• Paraphrase the central purpose for the review of systems (ROS) approach to medical screening.
• Recall 8 ROS health components (key signs or symptoms) that can serve as a preliminary tool to determine the need for additional screening.
• Cite the 3 most common causes for unexplained weight loss in the older patient which may justify the need for further screening.
• List 8 signs / symptoms (cardiopulmonary system checklist) that should be assessed during a cardiopulmonary system screen.
• Enumerate 5 red flags for a myocardial infarction or unstable angina during a cardiopulmonary screen that would warrant immediate referral
• Recall 8 associated red flags (signs / symptoms) that may warrant referral in a patient that presents with edema of the hands, feet or abdomen
• Recite 4 prodromal red flags associated with a transient ischemic attack, and subsequently would warrant an immediate referral.
• Recall 1 important finding that can aid in the differentiation between claudication and psuedoclaudication, and subsequently impact the need for immediate referral.

Hour 2

• Outline 6 red flags associated with lung cancer, and subsequently may warrant an immediate referral.
• Identify 8 signs / symptoms (gastrointestinal system checklist) that should be assessed during a gastrointestinal system screen.
• Provide 7 red flags clinical findings) of NSAID induced complications which may justify an outside referral.
• Recount 8 signs / symptoms (endocrine system checklist) that should be assessed during an endocrine system screen.
• List 3 regional/anatomical locations where pulmonary -related disorders can refer pain to
• List 3 regional/anatomical locations where gastrointestinal -related disorders can refer pain to
• Recall 3 signs and/or symptoms of colorectal cancer
• List 2 regional/anatomical locations where urogenital -related disorders can refer pain to

• List and define the components of the SINSS classification used for an upper quarter evaluation
• Recall two neurophysiological effects of upper quarter joint mobilizations
• Cite two indications for performing grade 1-2 joint mobilizations to the upper quarter
• Identify two conditions that would warrant performing grad 3-4 joint mobilizations to the upper quarter
• Enumerate 5 contraindications for performing joint mobilizations to the upper quarter State two specific diagnostic or impairment-based indications for performing a cervical distraction mobilization.
• Summarize the purpose for performing a posterior mobilization to the glenohumeral joint
• Paraphrase the clinical prediction rule used to determine the effectiveness of cervico-thoracic mobilizations for patient’s presenting with subacromial impingement.

• List and define the components of the SINSS classification used for a lower quarter evaluation
• Recall two neurophysiological effects of joint mobilizations as applied to the lower quarter
• Cite two indications for performing grade 1-2 joint mobilizations for the lower quarter
• Identify two conditions that would warrant performing grad 3-4 joint mobilizations for the lower quarter
• Enumerate 5 contraindications for performing joint mobilizations as applied to the lower quarter
• State two specific diagnostic or impairment-based indications for performing a lateral to caudal hip joint mobilization.
• Explain the purpose for performing a posterior to anterior proximal tibiofibular glide
• Provide two common indications for performing a medial patella mobilization technique

• Discuss the history behind the discovery of and development of releasing somatic dysfunction via positional release techniques via the work of Lawrence Jones, DO, George Goodheart, DC and others
• Discuss the basic concepts of how the body responds to stress and trauma  according to Irvin Korr and how slackening the dysfunctional muscle and joint tissues works to restore normal function.
• Apply anatomy and kinesiology as a means of finding and unwinding somatic dysfunction.
• Include the learned techniques into your practice.
• Compare and contrast the rapid thrust vs. positional release modes of releasing subluxations or somatic dysfunction. 

• Summarize the muscle spindle, specifically, the anatomy and physiology of the spindle subcomponents and how it regulates function of skeletal muscle.
• Breakdown the neural reflex mechanisms of the muscle spindle and appreciate how these mechanisms operate in both somatic function and dysfunction.
• Explain the hypothesis of the “facilitated segment” aka somatic dysfunction, explained both in terms of neurology and by analogies so as to be clear to both the doctor and the patient
• Identify somatic dysfunction via locating tender points and learn the mechanism of slackening in order to relieve the tender point reactivity and restore normal function to the muscle and joint.
• Identify and correct tender point locations and positional releases.

• Define the basic principles of MRI imaging as it relates to the musculoskeletal system.
• Summarize current criteria utilized to identify Lumbar pathology and the appropriate lexicon utilized in neuroradiology to assist the Doctor of Chiropractic in interpreting studies ordered.
• Identify normal anatomy of the lumbar spine on MRI images.
• Differentiate gross pathology associated with the most common MRI presentations associated with general Chiropractic practice.
• Assess the necessity of MRI imaging for lumbar pathology, with an understanding of the pathophysiology of the degenerative process associated with lumbar spine aging

Hour 1:

• Describe the tensegrity model as it relates to biomechanics from a cellular to organism level.
• Define fascia, including anatomical lines and physical properties.
• Describe the Dural Fascial Kinetic Chain and its relationship to Adverse Mechanical Tension (AMT) on the spine and CNS.
• Describe the clinical relevance of biotensegrity, and how to apply these updated architectural and biomechanical principles to the delivery of chiropractic adjustments.

Hour 2:

• Explain the impact of chronic stress
• Recognize common signs and symptoms of sympatheticotonia during initial patient presentation.
• Outline the diagnostic process for sympatheticotonia, including both testing and interpretation.
• Summarize clinical considerations for the patient with sympatheticotonia.

Hour 3:

• Recognize and describe the common signs and symptoms of imbalance during initial patient presentation.
• Outline and demonstrate testing procedures for imbalance.
• Describe clinical interpretation of test results for imbalance.
• Make referral for imbalance when appropriate.

Hour 4:

• Describe statistical incidence and association with head and neck trauma
• Be able to recognize in clinical practice the common signs and symptoms of head and neck trauma
• Outline the diagnostic process for head and neck trauma, including both testing and interpretation.
• Summarize clinical considerations for the patient with head and neck trauma

• This contains all courses with the educational objectives listed for NeuroFascial Integration 201 - 203

Hour 1:

• Describe layered components of restrictions including updated osseous, muscular, and fascial relational anatomy.
• Describe how to palpate muscle tension versus fascial adhesion versus fascial tension lines.
• Differentiate between osseous restriction, muscular tension, and fascial restriction as they relate to spinal motion restriction.
• Use palpatory findings to select technique application for adjustments that last longer by addressing mechanical root cause and encourage parasympathetic dominance at rest.

Hour 2:

• Describe the difference between static misalignments and dynamic spinal restrictions (joints incapable of full range of motion).
• Differentiate with palpation both static and dynamic spinal restrictions.
• Describe neurological information gathered from palpation, including dysesthesia, hyperesthesia, reactive erythema, temperature differentials, and other signs.
• Palpate the patient with chronic pain, trauma history, and/or sympatheticotonia without triggering sympathetic bracing.

Hour 3:

• Describe the Oxford Grading Scale for manual muscle testing.
• Describe interpretation of manual muscle testing findings, including differentials for clinical significance of findings other than normal.
• Demonstrate manual muscle testing of major postural muscles.
• Apply manual muscle testing as pre- and post-clinical intervention measures during adjustment visits and to track change during review examination.

Hour 4:

• Describe the relevance of clinical history as it relates to chronic stress and trauma.
• List specific questions to assess for sympatheticotonia.
• List specific questions to assess for indications of head and neck trauma
• Determine appropriate individualized examination procedures based on history answers.