J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 648654 ~ 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
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
We used the following search string to obtain articles that may
[((spinal manipulation) OR
(spinal manipulation therapy) OR
(spinal manipulative therapy) OR
(spinal mobilization) 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
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.
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 612% (Lawrence and
Meeker, 2007); estimates of chiropractic or osteopathic manipulation
use have not increased between 2002 and 2007 (Barnes et al.,
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; 3245% of visits for lowback
pain with spinal manipulation accounting for 6192% of all
reimbursed services and an average of 518 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).
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 19741982 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 19851991 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; C๔t้ 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.,
Across all geographic regions studied, patients receiving spinal
manipulation most commonly report musculoskeletal symptoms
of the low-back or neck. For example, in the 19741982 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),
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),
in Washington State (Lafferty et al., 2004),
organization members in Wisconsin (Hansen and Futch, 1997),
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 (23 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
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
(Sibbritt and Adams, 2010);
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 (C๔t้ 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 (C๔t้ 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
and to have difficulty accessing medical doctors (Cleary, 1982)
or to have adequate health insurance (Carey et al., 1995) (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 patients
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 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
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 bachelors 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.
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. Hurwitzs 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 Healths 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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