Spine (Phila Pa 1976). 2017 (Dec 1); 42 (23): 1810–1816 ~ FULL TEXT
Jon Adams, PhD, Wenbo Peng, PhD, Holger Cramer, PhD, Tobias Sundberg, PhD, Craig Moore,
Masters of Clinical Trials Research, Lyndon Amorin-Woods, MPH, David Sibbritt, PhD, Romy Lauche, PhD
Australian Research Centre in Complementary and Integrative Medicine (ARCCIM),
Faculty of Health, University of Technology Sydney,
Sydney, New South Wales, Australia.
STUDY DESIGN: Secondary analysis of a national survey.
OBJECTIVE: The aim of this study was to investigate the prevalence, patterns, and predictors of chiropractic utilization in the US general population.
SUMMARY OF BACKGROUND DATA: Chiropractic is one of the largest manual therapy professions in the United States and internationally. Very few details have been reported about the use of chiropractic care in the United States in recent years.
METHODS: Cross-sectional data from the 2012 National Health Interview Survey (n = 34,525) were analyzed to examine the lifetime and 12–month prevalence and utilization patterns of chiropractic use, profile of chiropractic users, and health-related predictors of chiropractic consultations.
RESULTS: Lifetime and 12–month prevalence of chiropractic use were 24.0% and 8.4%, respectively. There is a growing trend of chiropractic use among US adults from 2002 to 2012. Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being. A substantial number of chiropractic users had received prescription (23.0%) and/or over-the-counter medications (35.0%) for the same health problem for which chiropractic was sought and 63.8% reported chiropractic care combined with medical treatment as helpful. Both adults older than 30 years (compared to younger adults), and those diagnosed with spinal pain (compared to those without spinal pain) were more likely to have consulted a chiropractor in the past 12 months.
CONCLUSION: A substantial proportion of US adults utilized chiropractic services during the past 12 months and reported associated positive outcomes for overall well-being and/or specific health problems for which concurrent conventional care was common. Studies on the current patient integration of chiropractic and conventional health services are warranted.
KEYWORDS: chiropractic; prevalence; patterns; predictors; health services research; pain; national survey;
adults; back pain; USA
From the FULL TEXT Article:
Chiropractic is one a commonly used complementary healthapproaches in the United States (US) and
internationally. [1, 2] It is characterized by manual therapy techniques usually delivered to treat musculoskeletal
and neurological disorders. [3, 4] Certain chiropractic servicessuch asspine manipulation are covered by
Medicare and Medicaid for all adults in the US.  Also, chiropractic care is one of the health benefits included
in the workers’ compensation systems in most US States.  It is worth noting that there is growing utilization
of chiropractic care in the US over near recent years  with more than 70,000 chiropractors practicing in the
US6 and the total expense of visits to chiropractors in the US estimated to be over 10 billion in 2013. 
Previous work in a number of countries has shown inconsistent findings regarding the characteristics of
chiropractic users and predictors of chiropractic utilization. For example, a large cohort study conducted
inone State of Australia in 2005 revealed that adults who experiencedback problems and/or had a pension as
the main source of income were more likely to visit a chiropractor, while those who were older than 55 years
and/or consumed medication for certain health problems such as hypertension and high cholesterolwere less
likely to use chiropractic services.  A large-scale US surveyfocusing upon the use of health care and health
insurance coverage in 2008 reported that participants who were female, white, with higher family income,
and/or with arthritis were more likely to use chiropractic.  Meanwhile, asurvey undertaken in Switzerland in
2009 found patients aged 31–50 years,those who experienced low back pain,and/or experienced pelvic
pain or injury without leg pain were more likely to seek help from chiropractors. 
The National Health Interview Survey (NHIS) is the principal and reliable source of comprehensive health
care informationin the US, utilizing a nationally representative sample of the civilian non-institutionalized
population of the US.  An overview of chiropractic practiceamong US adults has been previously undertaken
by analysing the data collected in the 2002 and 2007 NHIS surveys. The focus of this previous work has
been predominantly upon the broad use of a range of complementary health care approaches, [13, 14] while only a
few specific details have been revealed regarding chiropractic such as prevalence rates of chiropractic use
and examination of the chronic conditions treated by chiropractic. [15–17] The 2012 NHIS survey is the most
recent source providing data on the use of complementary health care approaches by adults in the US. The
objective of this present paper is to update the examination of the lifetime and 12–month prevalence of
chiropractic use among US adultsand advance our understanding of the patterns and predictors of
chiropractic care by drawing upon the 2012 NHISsurvey dataset.
MATERIALS AND METHODS
Design and setting
Secondary analysis based on the NHIS nationally representative survey monitoring the health of the US
population in 2012.
Data and measures
For this analysis, data from the Family Core, the Sample Adult Core, and the Adult Complementary and
Alternative Medicine questionnaire were used. The Family Core and the Sample Adult Core collected data
regardingparticipants’ socio-demographic characteristics including age, gender, ethnicity, region, marital
status, education, annual household income and self-perceived general health status. The Adult
Complementary and Alternative Medicine questionnaire collected data on the use of a number of modalities
including the use of chiropractic. Lifetime prevalence of chiropractic use was determined with the following
question:Have you ever seen a provider or practitioner for chiropractic or osteopathic manipulation for
yourself? Those who answered ‘Yes’ were presented with an additional question asking whether they also
had consulted a chiropractic or osteopathic manipulation practitioner during the past 12–months. They were
further queried which of the practitioners they had consulted most (with the options of chiropractor,
osteopathic physician, refused, and do not know), and which of those they had consulted most often.
Those participants who had consulted a chiropractor in the past 12 months were asked to provide more
details, such as the number of consultations, the costs per each consultation, insurance coverage and the
purchase of self-help books or other materials to learn about chiropractic. These respondents were questioned
about the reasons for their use of chiropractic (including general reasons and specific medical conditions – a
total of 88 possible conditions) as well as theirdisclosure/non-disclosure of chiropractic care to their personal
health care provider and reasons for non-disclosure (where relevant), their perceived benefits of chiropractic
use, and their use of information sources about chiropractic.
A total of 42,366 households were eligible and 34,525 adults provided data (response rate:
79.7%).  Population-based estimates were calculated using weights calibrated to the 2010 census-based
population estimates for age, gender, and ethnicity of the US civilian non-institutionalized population.
Lifetime and 12–month prevalence of chiropractic use were analyzed descriptively, as were details on
chiropractic care and reasons for use. Results were reported as means and standard deviations, medians and
ranges, weighted frequencies and distributions as reasonable.
Socio-demographic characteristics were compared between those who had consulteda chiropractorever in
their life or within the prior 12 months and those non-chiropractic users via chi square tests. Independent
predictors of chiropractic utilization (ever used, used in prior 12 months) were identified using multiple
logistic regression analysis. The following socio-demographic predictors were considered: age (18–29; 30–
39; 40–49; 50–64, 65 or older), gender (female; male), ethnicity (non-Hispanic White; Hispanic; African
American; Asian; Other), region (West; Northeast; Midwest; South), marital status (not in relationship; in
relationship), education (less than college; some college or more), and annual household income (less than
$20,000; $20,000 to $34,999; $35,000–$64,999; $65,000 or more). Additionally, health-related factors such
as general health status (excellent or very good; good; fair or poor), BMI (<18.5; 18.5–25; 25–30; 30 or
more), smoking (non-smoker, smoker), alcohol consumption (alcohol abstainer; light drinker; regular or
heavy drinker), exercise behavior (low level exerciser; moderate level exerciser; high level exerciser); and
medical conditions or diseases (chronic pain conditions; rheumatologic disorders; mental health disorders)
were also used as potential predictors.
A backward stepwise procedure with a likelihood-ratio-statistic p-value of ≤0.005 was chosen, and adjusted
odds ratios with 95% confidence intervals were calculated. Only those associated with chiropractic use at a
p-value of ≤0.10 (chi-square test) were included in the regression analyses. Statistical analysis was
performed using the Statistical Package for Social Sciences software (IBM SPSS Statistics for Windows,
release 22.0. Armonk, NY: IBM Corp.).
A total of 54.6 million adults in the US had ever consulteda chiropractor (lifetime prevalence 24.0%), and
19.1 million adults had consulted a chiropractor within the prior 12 months (12–month prevalence 8.4%).
Predictors for lifetime and 12–months prevalence of chiropractic utilization are presented in Table 1. For
lifetime prevalence of chiropractic utilization the following statistically significant factors were identified.
Adults above 30 years of age were more likely to have ever used chiropractic (30–39: OR = 1.53; 95%CI:1.33
to 1.77; 40–49: OR = 2.00; 95%CI:1.74 to 2.29; 50–64: OR = 2.06; 95%CI:1.79 to 2.36; 65 or above: OR = 2.23;
95%CI:1.80 to 2.78)compared to adults under 30 years of age, as were those with a college or more
education (OR = 1.31; 95%CI:1.17 to 1.45)compared to those being less than college-educated, those living in
a relationship (OR = 1.12; 95%CI:1.02 to 1.24) compared to those not in a relationship, those with light
(OR = 1.32; 95%CI:1.17 to 1.48) or moderate to heavy (OR = 1.17; 95%CI:1.02 to 1.33) alcohol consumption
compared to abstainers, and those who were diagnosed with spinal pain (OR = 2.18; 95%CI:2.00 to 2.43),
headache or migraine (OR = 1.21; 95%CI:1.08 to 1.37), or arthritis (OR = 1.26; 95%CI:1.11 to 1.43) compared
to those without those diagnoses. On the other hand, those of Hispanic (OR = 0.48; 95%CI:0.41 to 0.56),
Black (OR = 0.46; 95%CI:0.38 to 0.55) or Asian (OR = 0.27; 95%CI:0.21 to 0.34) ethnic origin were less
likely to have ever used chiropractic compared to Non-Hispanic Whites, as were those living in the
Northeast (OR = 0.79; 95%CI:0.69 to 0.91) or South (OR = 0.69; 95%CI:0.61 to 0.78) compared to those
living in the West, those who smoked (OR = 0.75; 95%CI:0.66 to 0.85) compared to non-smokers, and/or
those respondents who were diagnosed with phobia (OR = 0.74; 95%CI:0.61 to 0.90), depression (OR = 0.78;
95%CI:0.68 to 0.88), coronary heart disease (OR = 0.68; 95%CI:0.48 to 0.96) or asthma (OR = 0.74;
95%CI:0.65 to 0.84) compared to those without these diagnoses.
Table 1 shows that those aged older than 30 years were more likely to have used chiropractic in the past 12
months (30–39: OR = 1.44; 95%CI:1.22 to 1.71; 40–49: OR=1.63; 95%CI:1.38 to 1.92; 50–64: OR = 1.51;
95%CI:1.29 to 1.78; 65 or above: OR = 1.72; 95%CI:1.34 to 2.20) compared to younger adults, as were those
living in the Mid-West (OR = 1.28; 95%CI:1.11 to 1.48) compared to those living in the West, and those
diagnosed with spinal pain (OR = 2.64; 95%CI:2.36 to 2.94) compared to those without. On the other hand
those living in the South (OR = 0.84; 95%CI:0.73 to 0.98) were less likely to have used chiropractic in the past
12 months compared to those living in the West, as were those of Hispanic (OR = 0.59; 95%CI:0.49 to 0.72),
Black (OR = 0.37; 95%CI:0.28 to 0.48) or Asian (OR = 0.32; 95%CI:0.23 to 0.45) ethnic origin compared to
Non-Hispanic Whites, those who had a BMI lower than 18.5 (OR = 0.54; 95%CI:0.32 to 0.93) or above 30
(OR = 0.83; 95%CI:0.72 to 0.95) compared to adults with a normal BMI, those who smoked (OR = 0.63;
95%CI:0.54 to 0.73) compared to non-smokers, those who reported a good self-reported health status
(OR = 0.78; 95%CI:0.69 to 0.89)compared to those with excellent/very good health status, and/or those
diagnosed with phobia (OR = 0.65; 95%CI:0.51 to 0.84), depression (OR = 0.65; 95%CI:0.55 to 0.77),
coronary heart disease (OR = 0.50; 95%CI:0.31 to 0.81) or asthma (OR = 0.68; 95%CI:0.58 to 0.80) compared
to those without these diagnoses.
The majority of those who had consulted a chiropractor within the past 12 months (83.3%) were able to
recall the number of times they consulted a chiropractor; the average number of consultations being 9.8±11.3
times (median:6; 25th percentile:3; 75th percentile:12). Insurance covered some costs of consultations in
60.2% of respondents, and in 31.7% of those with coverage they were reimbursed 100% of the costs. The
average of cost per chiropractic consultation visit as reported by 60.9% of the participants was
US$42.2±51.8 (median:30; 25th percentile:20; 75thpercentile:46). The average total amount of expense for
those who only paid out-of-pocket costs for chiropractic per year (approximately 5.9 out of 19.1 million
users) is estimated at US$2.2 billion and the average total amount of expense for those who have partial
reimbursement from health insurance for chiropractic per year (5.7 out of 19.1 million users) is estimated at
US$1.4 billion. Only 1.3% of respondents reported purchasing a self-help book or other materials to learn
about chiropractic; spending a total of US$36.0±41.3 on average for such items (median:25;
25th percentile:15; 75th percentile:50).
Table 2 shows,in the past 12 months,that only a small percentage of chiropractic users reported the use of
information sources for the utilization of chiropractic, including the internet (8.1%), books, magazines or
newspapers (4.1%) and scientific articles (3.7%). Most respondents reported consulting a chiropractor for
general wellness or disease prevention (43.3%), to improve their energy (16.3%), or to improve athletic or
sports performance (15.4%). Many respondents reported positive outcomes of chiropractic utilization
agreeing that such care had helped them to improve overall health and make them feel better (66.9%), to
sleep better (41.9%) and to reduce stress or to relax (40.2%).
Back pain or back problems (63.2%) and neck pain or neck problems (30.2%) were by far the top specific
health problems for which people consulted a chiropractorin the past 12 months, followed by joint
pain/stiffness (13.6%) and other pain conditions. Around two in three users (64.5%) reported that
chiropractic had helped a great deal to address these health problems. Chiropractic was used mainly due to
respondents believing it would help when combined with their medical treatment (64.8%), due to a
perception that it treated the cause and not just the symptoms of their health problem (61.9%), and due to it
being considered natural (37.5%). A large proportion of chiropractic users also received over-the-counter
(OTC) medication (35.2%)and/or prescription medication (23.2%)for the same health problem for which
chiropractic was sought and 33.8% of respondents used chiropractic because they considered medical
treatments to not be working for their condition (Table 2).
Chiropractic was mainly recommended by family (32.2%), friends (25.9%) and medical doctors (17.7%) in
the past 12 months. The use of chiropractic was disclosed to their conventional health care provider by
59.8% of respondents, and the main reasons for not disclosing their use of chiropractic included that the
provider did not ask (56.3%), the respondent thought the provider did not need to know (44.2%) or
conventional health care was not used at the time (29.1%). Less than 5% of respondents were worried that
their conventional health care provider would discourage their chiropractic use (Table 2).
To the best of our knowledge this paper is the first to analyse the details of the prevalence, patterns and
predictors of chiropractic care in a large-scale nationally representative sample based on the complementary
healthcare approaches statistics in the 2012 NHIS survey. The 12–month prevalence rate of chiropractic care
among US adults (8.4%) shown in our study is higher than that reported from the 2002 NHIS survey
(7.5%).  Due to the lack of reporting of an exclusive prevalence rate for chiropractic use in the 2007 NHIS
survey (8.6% of US adults sought chiropractic or osteopathic care),  we are unable to directly compare the
rate of chiropractic use in 2007 to our relevant finding (8.4%). However, in light of the small difference
between the exclusive prevalence of chiropractic care in 2012 and that of chiropractic or osteopathic care in
2007, our analysis suggests the use of chiropractic practice in the US population has increased from the
period 2002 to 2012. The growing trend of chiropractic use in US adults over these years is consistent with
findings from the US Medical Expenditure Panel Survey  as well as the US Medicare Current Beneficiary Survey.  However, the motivations behind this growing trend in chiropractic use and the feedback of such individuals about their experience of chiropractic care remain unclear and is deserving of further research
Our analyses show that, among the US adult population, spinal pain and problems – specifically for back pain
and neck pain – have positive associations with the use of chiropractic. This finding is in agreement with that
identified in a number of previous studies conducted in the US and elsewhere showing that the most common
complaints encountered by a chiropractor are back pain and neck pain [11, 20–22] and is in line with systematic reviews identifying emerging evidence on the efficacy of chiropractic for back pain and neck pain. [23, 24] Our analysis also shows that having mental health problems, coronary heart disease, and asthma are negatively
associated with seeking chiropractic care. Indeed, no convincing rationale or evidence exists for the use of chiropractic for mental health disorders or cardiovascular conditions and systematic reviews have failed to identify sufficient evidence to support the efficacy of chiropractic treatment for asthma. [25–27]
Our analyses indicate that a substantial proportion of chiropractic users also consume prescription medications and/or OTC medications for the same health problem for which they seek chiropractic care. Notably, in our analyses more than 60% of those in the US who consulted a chiropractor did so due to a belief that chiropractic would be helpful in combination with their medical treatment. Such concurrent use of
chiropractic care and conventional medications and health provision is in line with previous studies. [28–30] Further, previous randomized controlled trials have suggested the co-management of chiropractic and medical care is likely to show more improvement in pain relief than medical care alone. [31–33]
Our study found that a recommendation for an adult to consult a chiropractor is rarely initiated by a
conventional health care provider, and many respondents reported that their conventional health care
provider failed to enquire about their possible chiropractic use. These results are similar to those identified in
some previous studies which have specifically investigated the referral patterns of chiropractors in the US. [34–36], a recent national workforce survey of Australian chiropractic showed approximately half of the
chiropractors initiate and/or receive referrals to/from general practitioners and one-third initiate and/or receive
referrals to/from physiotherapists.  As such, further research examining the interface between chiropractors and conventional health providers is warranted to help tease out possible opportunities and challenges to safe,
effective coordinated patient care.
The findings of our analyses need to be considered in light of a number of limitations. The NHIS survey relies
on self-reported responses and this may lead to potential recall bias and measurement error. Moreover, the
statistics of the 2012 NHIS regarding use of complementary health care including chiropractic were drawn
from a cross-sectional survey, and our results can only suggest associations in the data. Nevertheless, the
NHIS dataset drawn upon in our study provides a large-scale nationally representative sample regarding
chiropractic use and the results of our analyses provide important insights regarding the recent prevalence
rate, patterns, and predictors of chiropractic utilization among US adults.
Chiropractic services are an important component of the healthcare provision for patients affected by
musculoskeletal disorders (especially for back pain and neck pain) and/or for maintaining their overall wellbeing.
Despite the substantive findings concerning the prevalence, patterns, and predictors of chiropractic
use in the US general population as reported in this manuscript, there nevertheless remains a wide research
gap in chiropractic care. Further studies on the details in chiropractic care and the relationship between
chiropractic and conventional/allied health providers and services in patient management in the US are
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