Use of Chiropractic in the United States

By Felise Milan, MD

With 60,000 practicing chiropractors, they comprise the third-largest group of health care providers in the United States after physicians and dentists. It is the largest and fastest-growing group of complementary and alternative medicine (CAM) providers in the United States, and its ranks are projected to nearly double by 2010. One in three persons with low back pain sees a chiropractor, amounting to 190 million patient visits per year. This figure has doubled in the past 15-20 years.1 Most patients self-refer with only 3% of patients being referred by MDs. Most insurance carriers, including Medicare, cover chiropractic. Some plans now require a referral from a MD for coverage of the service. Several studies have attempted to determine what makes some patients with back pain seek chiropractic instead of or in addition to conventional medical care. Results have been inconsistent2-4 except for the finding that chiropractic use is associated with having insurance that covers the service or having no health insurance at all.3,4

A national telephone survey conducted in 1997 (n = 2,055) showed that 29% of those interviewed used some type of CAM therapy to treat back and neck pain, 25% used CAM in additional to a conventional provider, and 34% used neither.5 Chiropractic was the most commonly reported CAM therapy used at 20%.6 Women were more likely than men to use CAM providers to treat neck or back pain. In this same sample, conventional practitioners were perceived by 27% to have been "very helpful" in treating their neck or back pain while chiropractors were rated as very helpful in 62% of cases.6

Several randomized controlled and observational trials have examined patient satisfaction with chiropractic vs. medical care for low back pain. They have consistently found that patients prefer chiropractic care to care by physicians.4,7-11 Satisfaction levels are better or similar to those reported by patients receiving care for low back pain from physical therapists.9,12

A large randomized controlled trial (UCLA Low Back Pain Study) examined what factors accounted for the difference in satisfaction between chiropractic and medical patients with low back pain.9 In their cohort of 672 patients, satisfaction was significantly greater in the patients randomized to receive chiropractic care (P < 0.001). The difference in satisfaction was accounted for almost entirely by the patients’ reports of having received an explanation of treatment and self-care advice. This finding is not surprising when you consider that 85% of patients with isolated low back pain are not given a precise pathoanatomical diagnosis within the conventional medical framework.13

Dr. Milan, Associate Professor of Clinical Medicine Albert Einstein College of Medicine Montefiore Medical Center Bronx, NY, is on the Editorial Advisory Board of Alternative Therapies in Women’s Health.

References

1. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136:216-227.

2. Shekelle PG, et al. Factors associated with choosing a chiropractor for episodes of back pain care. Med Care 1995;33: 842-850.

3. Sharma R, et al. Patient attitudes, insurance, and other determinants of self-referral to medical and chiropractic physicians. Am J Public Health 2003;93:2111-2117.

4. Carey TS, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. N Engl J Med 1995; 333:913-997.

5. Eisenberg DM, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA 1998;280:1569-1575.

6. Wolsko PM, et al. Patterns and perceptions of care for treatment of back and neck pain: Results of a national survey. Spine 2003;28:292-297.

7. Anderson GBJ, et al. A comparison of osteopathic spinal manipulation with standard care of patients with low back pain. N Engl J Med 1999;341:1426-1431.

8. Cherkin DC, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998;339:1021-1029.

9. Hertzman-Miller RP, et al. Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: Results from the UCLA low-back pain study. Am J Public Health 2002;92:1628-1633.

10. Kane RL, et al. Manipulating the patient. A comparison of the effectiveness of physician and chiropractor care. Lancet 1974;1: 1333-1336.

11. Hurwitz EL. The relative impact of chiropractic vs. medical management of low back pain on health status in a multispecialty group practice. J Manipulative Physiol Ther 1994;17:74-82.

12. Meade TW, et al. Low back pain of mechanical origin: Randomised comparison of chiropractic and hospital outpatient treatment. BMJ 1990;300:1431-1437.

13. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001;344:363-370.