Epidemiology: Spinal Manipulation Utilization

This section is compiled by Frank M. Painter, D.C.
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FROM:   J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 648–654 ~ FULL TEXT

Eric L. Hurwitz

Department of Public Health Sciences,
John A. Burns School of Medicine,
University of Hawaii,
M?noa, Honolulu, HI 96822, USA.

The objectives of this article are to

(1)   describe spinal manipulation use by time, place, and person, and

(2)   identify predictors of the use of spinal manipulation.

We conducted a systematic review of the English-language literature published from January 1, 1980 through June 30, 2011. Of 822 citations identified, 213 were deemed potentially relevant; 75 were included after further consideration. Twenty-one additional articles were identified from reference lists. The literature is heavily weighted toward North America, Europe, and Australia and thus largely precludes inferences about spinal manipulation use in other parts of the world. In the regions covered by the literature, chiropractors, osteopaths, and physical therapists are most likely to deliver spinal manipulation, often in conjunction with other conservative therapies.

Back and neck pain are the most frequent indications for receiving spinal manipulation; non-musculoskeletal conditions comprise a very small percentage of indications. Although spinal manipulation is more commonly used in adults than children, evidence suggests that spinal manipulation may be more likely used for non-musculoskeletal ailments in children than in adults. Patient satisfaction with spinal manipulation is very high.

From the Full-Text Article:


Although spinal manipulation has been practiced for thousands of years in several cultures spanning the globe, it is most commonly associated with chiropractic and osteopathy, which originated in the late 1800s in the United States (Pettman, 2007). The purpose of this article is to review the literature on the use of spinal manipulation. Specifically, our objectives are twofold: (1) To describe spinal manipulation use by time (temporal trends), place (geographic distribution), and person (practitioner and patient), and (2) to identify predictors of the use of spinal manipulation.

For the purpose of this paper, spinal manipulation is defined operationally as manual therapy techniques referred to as ‘‘spinal manipulation’’ or ‘‘spinal manipulative therapy’’ in the literature. These techniques include high-velocity, low amplitude (HVLA) manipulation as well as low-force techniques such as spinal mobilization. Massage and other manual therapy techniques non-specific to the spine are excluded.


We conducted a systematic review of the English-language literature using the following steps: Formulation of the review question; definition of inclusion and exclusion criteria; locating studies and development of a search strategy; selection of studies; assessment of study quality using a best-evidence synthesis approach; extraction of data; and analysis and interpretation of results (Egger et al., 2002). We defined inclusion and exclusion criteria in terms of participants, interventions and comparisons, outcomes, study designs, and methodological quality (Carroll et al., 2008). Our search strategy included a Medline search from January 1, 1980 through June 30, 2011, checking of reference lists, and hand-searching of key journals. We kept a log of excluded studies with reasons for exclusions.

We used the following search string to obtain articles that may have relevance:

[((spinal manipulation) OR
(spinal manipulation therapy) OR
(spinal manipulative therapy) OR
(spinal mobilization) OR
(chiropractic) OR
(manual therapy) OR
(osteopathic manipulation) OR
(osteopathic manipulation therapy) OR
(osteopathic manual therapy) OR
(osteopathic manipulative therapy)) AND ((use) OR (utilization))].

Editorial Comment:   This (above) search used Boolean Logic/Operators

We limited the search to human studies published in English between January 1980 and June 2011. Reference lists from selected articles were searched for additional relevant articles.

Figure 1

Of 822 citations identified, 213 were deemed potentially relevant after an initial screen of the title and abstract. Of the articles retrieved, 138 were excluded after further review; 75 were included. We identified an additional 21 articles through reference lists of these articles (Figure 1). The vast majority of retrieved articles were deemed irrelevant primarily because the articles (a) focused on chiropractic or osteopathic care in general; (b) did not include data on the use of spinal manipulation in particular; or (c) were commentaries or article types without empirical data. No studies were specifically excluded because of poor methodological quality. Portions of the PRISMA statement for systematic reviews applicable to utilization studies were used as a guide for reporting our methods and results (Liberati et al., 2009). The PRISMA statement (Preferred Reporting Items for Systematic reviews and Meta-Analyses) consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review.


      Temporal trends

Spinal manipulation has increased in use over the past several decades and is one of the most frequently reported complementary and alternative medicine modalities in the US (Eisenberg et al., 1993; Ni et al., 2002; Barnes et al., 2008; Su and Li, 2011) and elsewhere (e.g., Menniti-Ippolito et al., 2002; Yamashita et al., 2002; Al-Windi, 2004). Under the assumption that the vast majority (greater than 80%) of chiropractic patients receive spinal manipulation (Nyiendo and Haldeman, 1987; Shekelle and Brook, 1991; Hurwitz et al., 1998; Nyiendo et al., 2001; Mootz et al., 2005), about 4% of persons in the US had spinal manipulation in 1980 (Mugge, 1984), whereas between 1974 and 1982, 7.5% (41 visits per 100 person-years) received chiropractic services (Shekelle and Brook, 1991). An estimated 10% of the US population sought chiropractic care in 1990 with an average 13 visits per patient (Eisenberg et al., 1993); however, estimates declined from 9.9% in 1997 to 7.6% in 1999 (Ni et al., 2002) and 7.4% in 2002 (Tindle et al., 2005; Barnes et al., 2004). Estimates of annual chiropractic use rates from several studies range from 6–12% (Lawrence and Meeker, 2007); estimates of chiropractic or osteopathic manipulation use have not increased between 2002 and 2007 (Barnes et al., 2008).

A comprehensive literature review of spinal manipulation for low-back pain using data mostly from the 1980s revealed the rate of chiropractic services at approximately 50 visits per 100 personyears (5% of the total population per year; 32–45% of visits for lowback pain with spinal manipulation accounting for 61–92% of all reimbursed services and an average of 5–18 visits per episode) (Shekelle et al., 1992). More recent data from North America suggest that visit rates more than doubled to 101.2 visits per 100 person- years in the US and 140.9 visits per 100 person-years in Ontario (Hurwitz et al., 1998). However, changes in legislation and/or health policy in the past few years in Canada and the US may have resulted in reductions in visit rates of practitioners of spinal manipulation (Votova et al., 2010; Davis et al., 2010).

      Geographic distribution

Although spinal manipulation is used all over the world, given that the two professions most identified with spinal manipulation originated in the United States and the vast majority of their members reside in North America, the literature base is weighted heavily toward the US and Canada (Meeker and Haldeman, 2002). Nevertheless, evidence indicates significant geographic variation within and between countries that cannot be explained by simple publication bias. For example, in the 1974–1982 RAND Health Insurance Experiment which was designed to represent (a) the four major census regions, (b) both rural and urban areas, and (c) differing levels of demand for health services, chiropractic visit rates between the six sites differed by more than sevenfold (Shekelle and Brook, 1991). Data from 1985–1991 from the US and Canada indicate more than twofold differences in the number of visits per episode of low-back-pain care across sites (Hurwitz et al., 1998).

Spinal manipulation has become much more common in Australia and Europe in recent years as the populations of spinal manipulation practitioners have increased markedly with the opening of chiropractic schools, integration into local health-care systems, and the renewed interest in manual therapies among current health-care providers. In general, findings in Australian and European studies are consistent with the North American patterns of use (Xue et al., 2008; Leboeuf-Yde et al., 1997; Hartvigsen et al., 2002), though differences exist. For example, chiropractic and osteopathy are the most common modes of spinal manipulation in Australia (Zhang et al., 2007; Xue et al., 2008), whereas chiropractic and naprapathy, which are among the four most frequently used complementary therapies, are the most common in Sweden (Al-Windi, 2004). Compared to North America, annual spinal manipulation use rates are generally lower in England (Thomas et al., 2001) and Great Britain (Thomas and Coleman, 2004) but fairly similar in Japan (Yamashita et al., 2002) and Italy (Menniti- Ippolito et al., 2002).


Chiropractors deliver the vast majority of spinal manipulative care in North America (Shekelle et al., 1992; Cτtι et al., 2001). Ninety-four percent (94%) of spinal manipulation for which reimbursement is sought in the US is delivered by chiropractors (Shekelle et al., 1992); osteopathic spinal manipulation accounts for about 4% but has declined in recent years in the US (Johnson et al., 1997; Licciardone and Herron, 2001; Johnson and Kurtz, 2002), possibly because of the increasingly allopathic nature of training programs that de-emphasize manual therapy (Johnson and Kurtz, 2002; Johnson and Kurtz, 2001). Osteopaths and physical therapists are the second and third leading providers of manipulative services (Pettman, 2007); however, spinal manipulation is not a common practice among North American and European physical therapists (Li and Bombardier, 2001; Flynn et al., 2006).

Data from other parts of the world are scant, though chiropractors are prevalent in Europe (Leboeuf-Yde et al., 1997; Hartvigsen et al., 2002) and Australia (Xue et al., 2008; Sibbritt and Adams, 2010) and likely deliver much of the spinal manipulation in these areas. The 12-month prevalence of chiropractic and osteopathy use in Australia is about 16.1% and 4.6%, respectively (Xue et al., 2008). In contrast to most countries, general practitioners and ambulatory orthopedic surgeons in Germany are often specially trained in spinal manipulation and offer it to their patients (Chenot et al., 2007). For example in a recent cohort study of low-back pain patients consulting GPs in Germany, the majority received some form of CAM and spinal manipulation was the third most common therapy after local heat and massage (Chenot et al., 2007).

Australian physiotherapists frequently employed manipulation in patients enrolled in a clinical trial of treatment for cervicogenic headache; however, manipulation was used in tandem with other therapies, such as exercise and passive mobilization (Jull, 2002), a common practice in chiropractic and osteopathy as well (Christensen et al., 2010; Johnson and Kurtz, 2002). Mobilization has been reported to be much more common than manipulation (59% vs. 9%) among physiotherapists treating back pain patients in the United Kingdom in general (Foster et al., 1999; Gracey et al., 2002) and within a clinical trial of treatments for low back pain (Hurley et al., 2005).


Across all geographic regions studied, patients receiving spinal manipulation most commonly report musculoskeletal symptoms of the low-back or neck. For example, in the 1974–1982 RAND Health Insurance Experiment in the US, two-thirds of all visits to chiropractors were for head, neck or back pain (Shekelle and Brook, 1991), a finding mirroring more recent data indicating that an even greater percentage of chiropractic patients (68%) may be seeking care for low-back complaints (Hurwitz et al., 1998), with non-musculoskeletal symptoms comprising a very small minority (Coulter et al., 2002; Coulter and Shekelle, 2005). Low back, neck and head pain accounted for about three-quarters of all visits to chiropractors in Massachusetts and Arizona, 85% of which included spinal manipulation (Mootz et al., 2005). Similar findings have been reported from surveys in California (Gordon and Lin, 2004) and in Arizona, Connecticut, Massachusetts, and Washington State (Cherkin et al., 2002). Data from osteopathic practices in the US suggest that osteopathic manipulative treatment may be used relatively more frequently than chiropractic spinal manipulation for nonmusculoskeletal conditions (Johnson and Kurtz, 2002).

Chiropractic is the most frequently reported complementary therapy for back or neck pain in Australia (Walker et al., 2004) and in the US, used by 20% of those with these symptoms in the past year (Wolsko et al., 2003). Sizable use rates have been observed in population subgroups, for example

39% among long-term lymphoma survivors (Habermann et al., 2009),

34.5% among primary care outpatients (Palinkas and Kabongo, 2000),

29% among intercollegiate athletes (Nichols and Harrigan, 2006) and rehabilitation outpatients (Wainapel et al., 1998),

25.5% in multiple sclerosis patients (Nayak et al., 2003), and

22% among chronic tension-type headache patients (Rossi et al., 2006),

and somewhat lower use rates in others, such as

older adults (Astin et al., 2000; Foster et al., 2000; Najm et al., 2003; Cheung et al., 2007),

cancer patients in Washington State (Lafferty et al., 2004),

health maintenance organization members in Wisconsin (Hansen and Futch, 1997), and

patients with chronic liver and gastrointestinal diseases in Taiwan (Yang et al., 2002).

Utilization patterns in Europe are generally similar to those of North America, where the most frequently used complementary and alternative modalities for back pain are chiropractic manipulation, massage, and acupuncture (Santaguida et al., 2009). Osteopaths or chiropractors were seen by 13.4% of respondents with back pain in the past 3 months vs. 9.8% who consulted physiotherapists in the United Kingdom (Ong et al., 2004). In Sweden, lowback pain is the most common reason for seeking chiropractic care and the vast majority receive a short (2–3 treatments) course of spinal manipulation (Leboeuf-Yde et al., 1997). Sixty-five percent of chiropractic patients in Denmark reported low back (50%) or neck (15%) pain (Hartvigsen et al., 2002). As in the US and Canada, musculoskeletal complaints make up all but a very small percentage (less than 10%) of patients receiving chiropractic care or spinal manipulation.

Patients have reported very good or excellent satisfaction or perceived helpfulness with care that has included spinal manipulation (Nyiendo and Haldeman, 1987; Hansen and Futch, 1997; Coulter et al., 2002; Coulter and Shekelle, 2005; Licciardone and Herron, 2001; Hertzman-Miller et al., 2002; Hurwitz et al., 2005; Wolsko et al., 2003; Gaumer, 2006; Boudreau et al., 2006). Ninety-four percent of participants treated with chiropractic spinal manipulation in a recent World Games reported immediate improvement (Nook and Nook, 2011).

      Predictors of use

Health services researchers have investigated socio-demographic and health-related factors that differentiate users from non-users of chiropractic services for the past 30 years or so; however, studies addressing predictors of spinal manipulation use vs. other treatment modalities are few and far between.

Compared to non-users, chiropractic patients have been shown to be

middle-aged (Shekelle and Brook, 1991; Ni et al., 2002)
or older (Cleary, 1982; Mugge, 1984),

high school (Shekelle and Brook, 1991; Shekelle et al., 1995; Hurwitz and Morgenstern, 1997)
or college educated (Ni et al., 2002), married (Shekelle and Brook, 1991),

single (Hurwitz and Morgenstern, 1997),

female (Mugge, 1984; Ni et al., 2002),

male (Shekelle et al., 1995; Hurwitz and Morgenstern, 1997),

white (Mugge, 1984; Deyo and Tsui-Wu, 1987; Shekelle and Brook, 1991; Pedersen et al., 1993; Shekelle et al., 1995; Hurwitz and Morgenstern, 1997; Hawk and Long, 1999; Ni et al., 2002; Mikuls et al., 2003; Graham et al., 2005; Quan et al., 2008),

non-Hispanic (Mugge, 1984; Ni et al., 2002; Najm et al., 2003; Graham et al., 2005),

living in a rural (Hawk and Long, 1999; Lafferty et al., 2006; Lind et al., 2009; Sibbritt et al., 2006)
vs. urban (Cτtι et al., 2001) area or in the West (Deyo and Tsui-Wu, 1987; Hurwitz and Morgenstern, 1997),

more acculturated (Lee et al., 2010),
and employed (Hurwitz and Morgenstern, 1997);

to have worse overall health status (Palinkas and Kabongo, 2000; Coulter et al., 2002)

including mental (Coulter et al., 2002)
and emotional (Palinkas and Kabongo, 2000) health,

better overall health status (Carey et al., 1995; Hurwitz and Morgenstern, 1999),

multiple chronic health conditions (Cleary, 1982) including

chronic fatigue syndrome (Jones et al., 2007),

better social and physical function (Cτtι et al., 2001),

more activity limitations (Mugge, 1984),

fewer disabling comorbidities and restricted-activity days (Hurwitz and Morgenstern, 1997)
and bed days (Hurwitz and Morgenstern, 1999),

longer term pain (Hurwitz, 1994; Hurwitz and Morgenstern, 1997; Smith and Stano, 1997; Sibbritt and Adams, 2010),

less severe pain (Carey et al., 1995),

recent personal injury (Sibbritt et al., 2006);

to be high users of conventional medical care (Cleary, 1982; Hurwitz and Morgenstern, 1997; Ni et al., 2002; Sibbritt et al., 2006; Sibbritt and Adams, 2010)
and complementary care
(Sibbritt and Adams, 2010);

and to have difficulty accessing medical doctors (Cleary, 1982)
or to have adequate health insurance (Carey et al., 1995) (Table 1).

Table 1

A comprehensive analysis of chiropractic and general practice patients in North America revealed that compared with GP only patients in the US and Canada, chiropractic patients tend to be under 65 and white, with arthritis and disabling back or neck pain. US chiropractic patients are more likely than GP only patients to be obese and to lack a regular doctor; Canadian chiropractic patients are more likely than GP only patients to be college educated, to have higher incomes, and dissatisfied with medical care. Compared with seekers of both GP and chiropractic care, chiropractic only patients in both countries have fewer chronic conditions, take fewer drugs, and have no regular doctor. US chiropractic only patients are more likely than patients using both types of providers to be uninsured and dissatisfied with health care; Canadian chiropractic only patients are more likely than patients of both provider types to be under 45, male, less educated, smokers, and not obese, without disabling back or neck pain, on fewer drugs, and lacking a regular doctor (Hurwitz and Chiang, 2006).

In one study evaluating the appropriateness of chiropractic spinal manipulation use in low-back pain patients, manipulation was judged to be appropriate in 46% of cases, uncertain in 25% of cases, and inappropriate in 29% of cases (Shekelle et al., 1998), findings generally consistent with other medical procedures.

      Spinal manipulation in children

Many studies document the prevalence of spinal manipulation use among children in the US and elsewhere. According to data from the 2007 National Health Interview Survey, an estimated 2.8% of children in the US received chiropractic or osteopathic manipulation in the past 12 months, second only to non-vitamin, non-mineral or natural products among CAM therapies (Barnes et al., 2007). Use rates among pediatric patients are estimated to be much higher, for example 18% according to one survey (Sawni- Sikand et al., 2002). Chiropractors are the most frequently seen alternative care provider by children in Canada (Soo et al., 2005), Australia (Smith and Eckert, 2006) and in the US, with approximately 20 million US visits in 1993 (Spigelblatt et al., 1994; Lee et al., 2000) and 30 million in 1997, an increase of 50% (Lee et al., 2000). Spinal adjustments in children were reportedly used by 89% of chiropractors in a Boston area survey (Lee et al., 2000), a finding consistent with data from the 2010 practice analysis of chiropractic (Christensen et al., 2010). Two percent of pediatric patients in Denmark consulted chiropractic in the preceding month (Madsen et al., 2003).

Compared to adult patients, non-musculoskeletal complaints comprise a larger proportion of pediatric chiropractic practice (Spigelblatt et al., 1994); however, chiropractic visits by children are still much more likely to yield musculoskeletal-related diagnoses (Bellas et al., 2005; Smith and Eckert, 2006). Children with cancer or other life-threatening conditions or in tertiary settings may be more likely than children in primary care to use chiropractic (Lim et al., 2005; Post-White et al., 2009). One study suggests a relatively higher proportion of non-musculoskeletal diagnoses among children treated with osteopathic manipulative treatment (43.5% of visits) than chiropractic (Lund and Carreiro, 2010).


This review shows that spinal manipulation is prevalent in many countries and that its use has increased overall in the past several decades at least in the US and Europe, largely in tandem with the rise in complementary and alternative medicine utilization. Evidence from the most recent studies indicates that utilization rates have stabilized, however. Chiropractors, osteopaths, and physical therapists are the three types of providers most likely to deliver spinal manipulation. Medical doctors and other practitioners use spinal manipulation less frequently, though the literature does not enable computation of specific estimates of use.

Musculoskeletal conditions are by far the most frequent indications for receiving spinal manipulation, with low back and neck pain being the most common. Non-musculoskeletal conditions comprise a very small percentage of indications. Episodes of care are quite variable ranging from one to hundreds of visits over several years. A typical pattern of care encompasses visits from 1 to 3 times weekly for several weeks and would depend on the patient’s specific condition, treatment outcomes, and reimbursement or insurance plan. Spinal manipulation is often used in conjunction with other modes of therapy. Several studies have shown high patient satisfaction for spinal manipulative care.

Factors associated with health care that includes spinal manipulation are wide-ranging, from certain socio-demographic variables to health-related indices, though the literature is not entirely consistent, possibly due to (a) temporal and geographic differences between studies, (b) variations in health and reimbursement systems that may affect provision of certain types of care (including spinal manipulation), and (c) use of different comparators (non-users vs. users of other types of health care) or inclusion of specific populations at risk (e.g., back pain vs. general populations). Spinal manipulation is more commonly used in adults than children; however, some evidence suggests spinal manipulation may be more likely used for non-musculoskeletal ailments in children than in adults.

Limitations of our review include the exclusion of non-Englishlanguage articles and thus an inherent bias toward European, North American, and Australian literature. Our search strategy largely precludes estimates of spinal manipulation use in Asia and other areas in which publications are likely to be in languages other than English. Many articles that may have information on the epidemiology of spinal manipulation embedded within them, such as general utilization studies of chiropractic, osteopathy or physical therapy, were for the most part excluded from our review unless we could make reasonable assumptions regarding the use of spinal manipulation.


Spinal manipulation is used around the world for mostly musculoskeletal conditions, primarily back and neck pain. Chiropractors, osteopaths, and physical therapists deliver the vast majority of spinal manipulation, which is often combined with other manual therapies, physical modalities, or exercise. Although children receive spinal manipulation less frequently than adults, they are more likely than adults to have non-musculoskeletal ailments. Patients are generally very satisfied with care that includes spinal manipulation.

Conflict of interest

The author has no conflict of interest to declare.


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Eric L. Hurwitz

Dr. Eric Hurwitz is Professor and Graduate Chair of Epidemiology in the Department of Public Health Sciences of John A. Burns School of Medicine at the University of Hawaii at Manoa. He graduated from the University of California, Berkeley, and the Los Angeles College of Chiropractic with bachelor’s and doctorate degrees in physiology and chiropractic, respectively. Dr. Hurwitz subsequently received M.S. and Ph.D. degrees in epidemiology from UCLA, where he conducted postdoctoral research and taught epidemiologic research methods in the School of Public Health and served as codirector for epidemiologic studies in the Southern California Injury Prevention Research Center.

Dr. Hurwitz’s research interests include the epidemiology and treatment of musculoskeletal disorders and chronic diseases; the safety and effectiveness of therapeutic and preventive interventions; and methods in observational and clinical epidemiology. He has served as principal or co-investigator on several pioneering epidemiologic and health services research projects, including randomized clinical trials and systematic reviews of conventional, complementary and alternative interventions for low-back and neck pain.

Dr. Hurwitz’s research has been formally recognized nationally and internationally through a number of prestigious awards, and he is an author or coauthor of six book chapters and more than 90 scientific articles appearing in leading journals.

Dr. Hurwitz recently served on the Scientific Secretariat of the World Health Organization (WHO)-endorsed The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders, and is currently a deputy editor of The Spine Journal and a member of the National Institutes of Health’s Behavioral Medicine, Interventions and Outcomes Study Section, Center for Scientific Review. He is president of the Gamma (University of Hawaii) Chapter of the Delta Omega Honorary Society for Public


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