Chapter  177:  Complementary and Alternative Medicine in Back Pain Utilization Report

Analytic Framework

When considering the use of health services, the traditional understanding of utilization is a visit to a CAM provider or service. However, CAM includes the use of products and practices that may not be directed by a CAM provider. As such we adopted the model by Foubadbakhsh and Stommel⁷ as our analytic framework. This model, adapted specifically for CAM from Andersen's behavioral model of healthcare utilization,⁸ goes beyond provider directed service provision and incorporates CAM resources such as nutritional supplements and self-directed CAM practices such as meditation.

Searching and Eligibility Criteria

Standard systematic review methodology was employed. Traditional bibliographic databases, CAM specific databases and grey literature sources were searched from 1990 to November 2007. The traditional medical and allied health databases searched included; Medline^®; CINAHL^®; PsychINFO; EMBASE^®, and Cochrane Central Register of Controlled Trials^®. Alternative therapy bibliographic databases included: AMED; Index to Chiropractic Literature (ILC); National Library of Health: Complementary and Alternative Medicine Specialist Library; Acubriefs; Bandoliers CAM database; Mantis; Micromedex; Agricola; and HOM-INFORM.

Eligible studies were limited to those published in English and from 1990 forward. National U.S. population based surveys that probed CAM utilization were searched from 1970 to November 2007. Although our focus was on U.S. utilization of CAM, studies undertaken in Canada, the United Kingdom, Europe, Australia, and New Zealand were also eligible and compared to American patterns of use.

Studies were included if they presented information on the utilization of CAM therapies, CAM practitioners, or costs associated with CAM service use in adults with back pain in the neck, thorax, or lumbar regions. Self-administered home remedies were also included. The use of medical injections, prescription drugs, and back surgery were excluded as were mechanical traction, a variety of exercise techniques, patient education, cognitive behavioral therapy, deep brain therapy and orthoses. There were no restrictions for primary study designs. Clinical practice guidelines (CPG) were eligible if they focused on back pain and CAM use within the U.S.. Similarly, studies evaluating costs for CAM use in the United States for back pain were included.

Relative Use of CAM Therapies in Persons With Back Pain

We identified those publications that presented the relative use of CAM therapies in order to rank them from the most to least frequently utilized by persons with back pain. We did not select studies where subjects were recruited from the practices of CAM providers, as this would not reflect relative utilization but would reflect practice patterns with respect to combining differing CAM therapies. Four U.S. studies⁹–¹² reported utilization data for a minimum of four different CAM therapies or practitioners. All but one⁹ measured lifetime use of CAM and all subjects had chronic or recurrent back pain. Chiropractor or “chiropractic” was the CAM therapy that was most frequently used by patients with chronic low back or combined neck and back pain in three publications.¹⁰–¹² In one publication⁹ massage was the most frequently used CAM therapy; massage also ranked as the second mostly frequently used therapy in the other publications. Acupuncture was the third most frequently used therapy. When reported, other frequently used modalities were prayer and spirituality and glucosamine.

Given the limited number of studies that evaluated relative CAM utilization, we explored patterns for those individual therapies shown to be frequently used by persons with back pain.

Chiropractic/Spinal Manipulation

Thirty-six publications⁹–⁴⁴ on chiropractic/spinal manipulation, were undertaken in the U.S. The majority (n = 24) reported on low back pain (LBP) and the fewest on neck (n = 3) and thoracic spine (n = 1). Our review suggests that chiropractic care/spinal manipulation is commonly sought by patients with back pain. In the 10 cross-sectional studies^{9, 12}–^{14, 18, 19, 26, 29, 31, 35} based predominately on random or systematic samples, rates of utilization varied from 16¹⁴ to 45 percent.¹⁸ Eligible U.S. trials on LBP populations found that rates of attending for chiropractic/spinal manipulative therapy range from 10 to 47 percent.^{9, 11, 18, 19, 28, 30, 32, 35, 41} The number of visits for chiropractic care or other providers of spinal manipulative therapy varied from a mean of 4.3 to 15.7.^{9, 19, 22}–^{24, 28, 33} Between 79 and 94 percent of treatment by chiropractors included spinal manipulative therapy.^{9, 11, 22, 23, 28, 33, 37} Three studies provided some evidence for a gradient of use based on anatomical regions; thoracic pain was treated least often,⁴⁰ followed by the neck, with the low back being the most commonly treated.^{25, 40, 44}

Chiropractors were the providers of spinal manipulative therapy in most publications (n = 34), and physiotherapists in two publications.^{30, 35} Details on the type of spinal manipulation was provided in three only publications.^{15, 24, 33} The available information suggests that roughly equal proportions of LBP patients use chiropractic as complementary to conventional care and as an alternate. Current literature provides little insight into the manner in which chiropractic/spinal manipulation is combined with other therapies for back pain. Despite the common use of chiropractic/spinal manipulation by patients with back pain the current literature provides limited data on utilization.

Massage

Twelve U.S. publications^{9, 11, 12, 15, 16, 18, 20, 22, 23, 30, 33, 44} evaluated the use of massage in persons with back pain. The majority of populations were from specialized clinical practices or from the practices of licensed CAM providers. Two publications^{16, 20} using data from large health claims databases showed low rates of massage utilization for LBP, varying from 4 to 5 percent of the total sample. One study recruiting from a population based sample¹² reported a massage utilization rate of 14.1 (95 percent CI, 10.8–17.4) for patients with combined neck and back pain. Publications that evaluated use of massage in smaller samples, showed rates of use varying from 17 to 52 percent. The timeframe of reported use was one year, with the exception of two studies evaluating lifetime use.^{11, 18} The majority of studies reported on LBP (n = 9) and mostly for chronic pain; one study⁴⁴ reported on utilization of massage for neck pain. Only one publication¹⁵ provided any detail as to the type of massage administered, the provider, and use with other CAM therapies, or with conventional care.

Acupuncture

Eight publications¹⁰–^{12, 15, 16, 18, 44, 45} evaluated the use of acupuncture in persons with back pain and all but one used self-report methods.¹⁶ Two of these studies^{12, 45} were based on randomly selected general population samples and, as expected, these showed markedly lower rates of utilization for both neck and unspecified back (1 to 4 percent) and combined neck and back pain (1 percent). Similar rates of utilization were observed (1 percent) in a study evaluating a large administrative database.¹⁶ All other studies based primarily on subjects from clinical practices or with back pain showed higher rates of utilization (7 to 36 percent). Rates of use also varied by the timeframe for recall (12 months to lifetime prevalence), interval of analysis for administrative databases, and recruitment of subjects from clinical practices.

The majority of publications evaluated LBP or unspecified pain, with utilization for neck or combined neck and back problems being less commonly assessed. No clear pattern emerges for utilization rates as a function of the anatomical back region. One publication⁴⁴ reported no difference in the relative frequency of CAM use for neck and back but another⁴⁵ showed lower rates of use for persons with neck (14 percent) relative to back pain (34 percent). In part this may be due to the limited number of studies, but it may also be related to the lower prevalence of neck pain relative to LBP. Only one publication,¹⁵ provided any detail as to the specific type of acupuncture, the provider, the overlap with other CAM therapies, or with conventional care.

What is CAM?

Given the preference of many persons with back pain to use CAM therapies or CAM practitioner services in the management of their problem, a better understanding of what constitutes CAM therapies is important. CAM is comprised of a group of therapies that are considered to be outside the scope of treatment of most conventional practitioners or therapies. The number of therapies and practitioners classified as CAM, can vary depending on the country, but a recent classification scheme has been established within the U.S.^{72, 73} These CAM therapies represent diverse health system approaches, health practices, and products that are not presently considered to be conventional.⁷³ Conventional medicine in the U.S. is practiced by medical doctors, osteopathic doctors, physical therapists, psychologists and registered nurses.⁷³ However, osteopathic physicians do practice osteopathic manipulative therapy which can also be considered CAM in nature. This raises the issue that an increasing number of conventional practitioners are including what have been traditionally categorized as CAM therapies in their current clinical practice. There is some confusion as to whether the practitioner or the therapy should be the basis upon which the treatment is classified as alternative or complementary or conventional. This confusion presents some challenges to understanding utilization of these therapies.

As some of these CAM therapies develop an evidence base and are adopted into the conventional healthcare system as treatment options, the distinction of being CAM may change.⁷³ This may present some ambiguity when considering comparisons between alternative and conventional care; consider the case where 100 percent of the population uses the “alternative” therapy, and as such the therapy then becomes conventional.⁷⁴ The World Health Organization has defined CAM as “a broad set of health practices that are not part of a country's own tradition, or not integrated into its dominant health care system”.⁷⁵ As such the definition of what is alternative or complementary may vary by country.

The National Center for Complementary and Alternative Medicine (NCCAM)⁷³ classifies most CAM therapies into five domains as follows: 1) manual or mobilization therapies including manipulation and body movement therapies; 2) mind body medicines that include behavioral, psychosocial, and spiritual approaches; 3) chemical or biological based therapies that include the use of natural and biologically based products; 4) energy therapies that use differing methods to alter energy fields around the body; 5) holistic approaches that have an underlying theoretical framework for evaluating and promoting health such as Traditional Chinese Medicine, Homeopathy, and Chiropractic; and finally 6) “home remedies” that can include variants of all the therapies listed previously. From a health services perspective, this latter category is often not clearly identified as CAM therapy.⁶² There is no consensus regarding the classification of these various CAM therapies within the larger domains. However, from a health services research perspective, there is a need to specify the therapies used rather than identify broadly the CAM domains.⁶² There may also be a need to distinguish the “therapist” from the “therapy”. Establishing that a “naturopath” provided a specific type of care such as acupuncture is important; the dose or subtype of therapy may differ between practitioners. Whether the public distinguishes between the therapist and the therapy is not always clear.

Who Uses CAM?

Historically CAM approaches to health care were marginalized by the medical profession in the U.S. A review of population surveys within industrialized countries suggested that CAM users were predominately female, with higher education and socio-economic status, and of white race.⁶² This is consistent with patterns of use within the U.S.^{71, 76} A bimodal distribution with regards to use of CAM related to low socio-economic status and ethnicity has also been shown; ethnic minorities, who are generally underrepresented in surveys, typically use CAM on a regular basis.⁷⁷

In the early 1990's survey data suggested that respondents did not use CAM for serious medical conditions (denoted as “principle medical conditions”); rather they used it primarily for health promotion and disease prevention.^{5, 78} Amongst the aging American baby boomers, there is increasing awareness that health is not only the “absence of disease”, but incorporates the concepts of wellness and lifestyle.⁷⁹ This is creating a trend towards the increased use of CAM which is anticipated to continue, as these therapies are used to promote health and prevent disease in those who are well. In those who are ill, CAM is used to manage and treat specific health problems.

American attitudes towards CAM therapies have changed in part due to greater media coverage and access to web-based information about specific therapies. Interestingly, chronic back pain patients from urban settings were shown to be willing to try CAM therapies, despite indicating that they knew little about the therapy (with the exception of chiropractic and massage); moreover, no relationship was shown between high expectations for a particular therapy and previous use or knowledge of the therapy.¹⁸ In the case of chronic back pain, where conventional or allopathic treatments have had limited success, patients are more open to trying CAM therapies. The appeal of many CAM therapies may be due to dissatisfaction with traditional conventional medical therapies that may be perceived as more invasive or less effective such as back surgery versus manipulation. For some, the appeal of some CAM therapies is that they are perceived as emphasizing personal autonomy over one's own health. All of these factors have generated greater interest in using CAM therapies, which in turn has resulted in greater CAM availability within conventional heath care facilities and places of employment, availability of CAM courses in conventional health professional training centers, and changes in reimbursement in health insurance coverage.

What is CAM use and What are the Behavioral Models Explaining This use?

Health service utilization is a broad term that generally refers to the use of a health provider or health service and is generally understood to indicate a visit to a provider or a health service.^{8, 80} This concept of use has been expanded to include the use of CAM therapies that may or may not be directed by a practitioner, such as the use of supplements or other CAM therapies within the home.⁷ A number of outcomes have been used, predominately from survey-based data, to explore the use of CAM including prevalence rates, costs, patterns of use, changes in use over time, reasons for CAM use, attitudes associated with CAM use, and comparisons of users with non-users.⁸¹ However, a distinction should be made between outcomes that indicate obtaining a CAM therapy or service and factors that explain why someone chooses to use a CAM therapy or to access a CAM practitioner.

The use of health care services has often been explained by the physical, psychological and social characteristics of the users, the healthcare system, and the providers within the system. The Andersen model of health service utilization (and adapted versions) describes patterns and identifies predictors of use.^{8, 82} This behavioral model for the use of health services, is a multi-disciplinary attempt to integrate economic, healthcare-related, socio-cultural, and psychological factors. The model assumes that there is a sequential relationship between three sets of determinants of use: 1) the predisposition to use services (predisposing); 2) the ability to obtain services (enabling); and, 3) perceived (patient) or evaluated (medical) need. The predisposing component relates to demographic, socio-structural, and attitudinal-belief variables, irrespective of the underlying condition. The enabling component includes both family and community resource variables that are required to seek and obtain care. The need component involves an individual's perception of illness and the limitations that it imposes on daily activity. Health beliefs are attitudes, values and knowledge that people have about health and health services that might influence subsequent perceptions of need and use. Health beliefs in particular can influence use of services in relation to preventative health behaviors. Perceived need by the user may explain care seeking behaviors and adherence to care. Evaluated need as determined by the provider can assist in understanding the type and amount of treatment used.

The Andersen model of healthcare utilization has been expanded to include environmental variables.⁸ This would include characteristics of the healthcare delivery system such as policies, resources, organization and financial arrangements influencing accessibility, availability, and acceptability of the health services. External environmental factors include the economic climate, relative wealth, politics, level of stress and violence, and prevailing norms of the society. Finally, the community level environmental variables can include attributes of the community where one lives that enable them to obtain service (availability of practitioners).

While the Andersen model of healthcare utilization assumes that use necessarily entails a visit to a healthcare provider or health service, Fouladbakhsh and Stommel⁷ have proposed an alternative categorization of CAM therapies and activities and in turn a new model for conceptualizing health service use. Their model not only includes the CAM provider, but also “use” with regards to “products and resources” (i.e., the use of herbs, supplements, self-help manuals, etc.) and CAM practices (individual or communal direction of therapy). The developers of this new model argue that these expanded categories can be integrated with the Andersen model and serve to enhance the framework to improve prediction of CAM use. The new model, adapted specifically for CAM still includes predisposing, enabling, and need factors to explain healthcare use. It also allows for evaluation of the concurrent use of conventional health services.

What complementary and alternative medicine (CAM) therapies are being used for treatment of persons with back pain in the United States? (overarching question)

• 1)

  What is the relative utilization for the different CAM therapies?

  • i

    Does the utilization differ by where the BP is anatomically located (i.e., neck, mid-back, low back)?

  • ii

    Which therapies are used as complementary to conventional care and which are used as alternative?

  • iii

    When more than one therapy is used for back pain, how are these combined?

• 2)

  What is the utilization that is recommended by different types of healthcare providers?

  • i

    How do these recommendations compare to the actual utilization reported in studies from question one?

  • ii

    How do the recommended and actual utilization reported differ by CAM practitioner type?

• 3)

  What are usual costs for these therapies per treatment and for the prescribed course of treatments?

  • i

    How much of this cost is covered by insurance or included in the insurance health plan?

Eligibility Criteria

Outcomes

Note that utilization is typically defined as a visit to a clinical provider or clinical entity. However, we are including CAM therapies such as “home remedies” or “self-administered’ CAM therapies such as prayer, or supplements (Figure 1).

Inclusion

Research Q1: Utilization of CAM therapies can encompass

• Prevalence rates of CAM therapy use or provider visit for a specified time interval (this includes reported proportion of the total number of patients seeking care from a CAM practitioner for back pain).

• Frequency of visits or use of CAM therapies or provider

• Timing of visits (if possible in relation to the pain inception)

• Duration of use of CAM therapy for period surveyed

• Duration of each visit

Research Q2: Recommended use of CAM therapies for back pain

• Recommendations regarding use of CAM focusing on the frequency or duration of treatment

Research Q3: Costs associated with CAM therapies specific to the United States

• Direct costs for patient including CAM practitioner fees, diagnostic costs, therapy costs (needles, remedies, etc.)

• Direct non-therapy related costs for patient (transportation costs, costs of accompanying patients, etc.)

• Direct costs for provider (space and equipment provisions, ancillary staff, office costs, etc.)

• Indirect costs for patient (time off work to attend therapy, etc.)

• Induced costs for patient (adverse reactions due to CAM therapy)

Exclusion

• Non-utilization or cost outcomes such as measures of clinical efficacy or effectiveness

Data Collection and Reliability of Study Selection

A team of study assistants trained in the eligibility criteria for title and abstract screening were assembled. Standardized forms (Appendix B) and a guide manual explaining the criteria were developed from previous templates used in reviews for the Agency for Health Research and Quality (AHRQ) reviews; these forms were constructed within Systematic Review Software (SRS 3.0 (TrialStat Corporation, Ottawa, Ontario Canada). Two reviewers were required to achieve consensus on the identification, selection, validity and abstraction of articles and information. Disagreements that could not be resolved by consensus were resolved by a member of the investigative team. The level of agreement on inclusion of reports (full text) between observers was measured using a kappa statistic.

Quality Criteria

We anticipated that most of the eligible studies would be observational designs without a true control or concurrent group. Moreover, we anticipated that much of the utilization data would be collected by patient and practitioner recall surveys, and chart review or analysis of administrative health claim databases. In general, these methods suffer from recall bias and limitations inherent in records or databases not designed for research purposes. Given the nature of the study designs, and the means used to collect utilization data, a standardized quality criteria checklist specific to observational designs with control groups could not be applied to this literature.

For studies evaluating utilization, we focused on the means used to collect utilization outcomes as the basis of determining the potential for bias. We identified studies that used self-report via questionnaire or interview and evaluated these with respect to the following: 1) the selection of participants, 2) response rate, 3) recall time-frame, 4) questionnaire design (pre-testing), and 5) mode of questionnaire data collection.

For studies using chart review or administrative databases we considered the following: 1) manner in which patients or visits were identified, and 2) description of data linkages between use and patient identifiers.

For clinical practice guidelines that provided utilization data, we selected the use of the AGREE instrument for quality assessment.⁸⁹ Studies that were true economic evaluations (only those classified as cost-utility analyses, cost-effectiveness analyses, cost-minimization analyses, cost-benefit analyses, and cost-consequences) were evaluated for quality. Standardized methodological criteria for economic analyses are available and the Quality of Health Economic Studies (QHES) was selected to evaluate quality.⁹⁰

Summarizing the Findings Descriptive and Analytic Approaches

Data were collected on the sample size, characteristics of the population(s) studied, type of back pain evaluated, the definition of an episode of care, type of CAM intervention and utilization outcomes assessed. Standard evidence tables were developed. We used a qualitative synthesis to evaluate the quality of the studies eligible for this review.

Subgroup synthesis. We divided the eligible citations into U.S. versus non-U.S. studies. Furthermore, we evaluated eligible studies divided into subgroups based on: a) anatomical location of the back pain and utilization, and b) the types of therapies used concurrently and which of these are used as complementary versus those used as alternative.

We ask the reader to note the distinction between publications and studies. Some of the eligible publications are related to each other and are often termed companion studies. These companion publications may be based entirely or in part on patient cohort data. In general, these companion studies present subgroup analyses, re-analyses, or secondary analyses (linking previous data with new utilization data). In some cases the citations were related because of subsequent follow-up collection. Consensus on a convention to show the relationships between such publications (differing analyses on the same patient cohort) does not exist; some consider these analyses in and of themselves to be “new studies”. For this reason, we have selected to use the term publications to specify the number of eligible studies. We attempt to alert the reader when publications are companion in nature and to specify the nature of the relationship.

Utilization of CAM, Data not Stratified by Back Pain or Therapy

Twenty-nine publications did not stratify CAM utilization data with respect to use by persons with back pain. Rather than exclude these publications, we chose to identify and detail some aspects of these studies; many of these publications are recognized as contributing significantly to our current understanding of CAM utilization. Our intention was to highlight that these studies were lacking in utilization results specific to persons with back pain, despite being the sources that originally identified back pain patients as a key population that utilize CAM services. Similarly, we wished to highlight that several of the non-stratified studies evaluated different subgroups of persons that experience significant back pain related to spinal cord injuries, cancer, or pregnancy. Nineteen publications^{6, 47, 71, 76, 91}–¹⁰⁵ were based on utilization data from the U.S. and 10 publications¹⁰⁶–¹¹⁵ were from other eligible countries.

Utilization not Stratified by Back Pain Within the United States

Several American studies are seminal works based on large national samples^{6, 71, 76, 98, 99, 102, 105} that surveyed CAM utilization and established that back and neck pain were important reasons for seeking CAM treatments. However, the utilization data presented did not link the specific type of CAM therapy to persons with back pain; rather the prevalence of back pain within the samples was reported. Four publications¹⁰¹–¹⁰⁴ were based on the same study cohort, representing survey results from a national sample.

Three publications focused on persons with spinal cord injuries. Two of the publications^{92, 93} on spinal cord injury patients showed that back and neck pain was frequently a major source of their chronic pain (varying from 46 to 75 percent), but did not present stratified CAM utilization information. One study⁹² reported utilization of CAM combined with medical injections to manage pain.

One study⁹¹ evaluated the use of CAM for cancer and other chronic pain in American Veterans. Other publications identified CAM use within patients presenting to the emergency department,⁹⁵ a specialized CAM clinic within a university hospital,¹⁰⁰ or concurrent use of CAM in patients attending outpatient physiotherapy departments.⁹⁶ Another study⁹⁷ indicated the use of mind body therapies among patients with musculoskeletal pain. One study⁴⁷ assessed the use of CAM by pregnant women; although rates of back pain are very high within this population, the publication did not specify the trimester or whether or not the whole sample was experiencing back pain at the time of the study.

Summary of U.S. publications on utilization not stratified by back pain. Nineteen publications were based on utilization data from the U.S. Although, these establish that back pain was an important symptom for which patients sought services, they do not present results on utilization of CAM therapies stratified for persons with back pain. Several studies evaluated subgroups of patients with non-musculoskeletal related back pain and would suggest that CAM therapies are commonly used by these populations.

Utilization not Stratified by Back Pain Within Other Countries

There were 10 publications from other eligible countries that did not present utilization data stratified for persons with back pain. One study¹⁰⁶ evaluated neck and shoulder pain in newspaper workers, another the general population in Canada.¹¹⁵ Three publications^{108, 110, 111} evaluated physiotherapy outpatients and another¹⁰⁷ patients at osteopathic clinics. One study¹⁰⁹ evaluated the use of a chiropractic activator and another, general population with back pain in the United Kingdom.¹¹⁴ Another study evaluated persons with spinal cord injuries in Sweden.¹¹² Finally, one study evaluated the general population in Spain.¹¹³

Summary of non-U.S. publications on utilization not stratified by back pain. Ten publications were based on utilization data outside the U.S. No clear pattern emerges from these studies; there are differences in populations, providers, and CAM therapies evaluated that contribute to this heterogeneity.

Relative use of CAM Therapies

We identified publications that presented the relative frequency of CAM utilization in order to rank the most to least frequently used therapies by persons with back pain. We identified four U.S.⁹–¹² and four non-U.S. publications¹¹⁶–¹¹⁹ that reported utilization data for a minimum of four different CAM therapies or practitioners. An additional study³⁰ reporting more than four CAM therapies provided solely by a physical therapist, was not included in this grouping. Electrotherapies provided by conventional providers (such as physical therapists) were defined as non-CAM therapy; however, this publication provided utilization data for spinal manipulation and is detailed in the specific CAM therapy section below.

We did not select publications where subjects were recruited from the practices of CAM providers. The utilization patterns described within these studies would reflect practice patterns of concurrent CAM therapies and not that of relative utilization of CAM services. For example, utilization of differing CAM therapies reported from subjects currently receiving care by a chiropractor would reflect the manner in which this particular CAM practitioner combines various CAM modalities rather than the frequency with which persons with back pain would choose to use one CAM therapy over another. The manner in which CAM therapies are concurrently combined for treatment is described within the specific CAM therapy sections that follow.

Table 1

Studies listing the use of 4 or greater different CAM (more...)

Table 1

Studies listing the use of 4 or greater different CAM therapies specific to back pain

Study	Type of Back Pain	Subjects with Back Pain/Total Study n	Total n Seeking Care or Reporting CAM Use	Chiropractic (%)	Manipulation (%)	Massage (%)	Acupuncture (%)	Naturopathy (%)	Homeopathy (%)	Herbals (%) / Food Supplements (%)	Prayer Spirituality (%)	Ultrasonography (%)	Electrothreapy (%)	Yoga (%)	Relaxation Techniques (%)	Other (%)
U.S. Studies
Bruce10 Intervention Group	CLBP	190/296	190	62e			20e			G:45.8				I:29e		M:15
Bruce10 Control Group	CLBP	236/284	231	C:64e			22e			G:25.5				C:24e		M:18
Carey9	CLBP	269/4437	186	24.6	22.0	42.0					27.0*	27.0*	18*
Long11	LBP	2374/4171	2374	46.7	41.3	43.2	9.3 P:10.2			V:8.2	41.6	41.6	31.8*		21.5	HC:67.9
Wolsko12	CLBP	644/2055	644	19.8 P:18		14.1 P:9	0.9 P:0.9	2.6	P:2.0	V:1.8				1.5 P:0.3	11.7 P:1.7
Non U.S. Studies
Ramsay116+	CBN	667/2,000	Varies	75		43	30	16		20	29			19	R:22	EH:11
Esmail117+	CBN	667/2,000	Varies	61		39	30	10		14	18			14	R:13	EH:20
Foltz118	UBP	3259/12,946	3259	74.4		55.5	20.6		H:17.8	6.2	0.3				0.6	SG:11.0
Walker119	LBP	1,228/1,913	547		12.6	17.9	2.2					3.7*	2.5*

= data for lifetime prevalence of use of CAM;

*

= provider not specified;

+

= Percent estimates for use of CAM therapy based on frequency for each specific CAM (i.e., sample size varied for each CAM therapy)

Abbreviations: C = Control group; CBN = combined back and neck pain; CLBP = chronic low back pain; e = estimated from bar graph; EH = Energy healing; EL = electrotherapy; G = Glucosamine; HC = hot and cold; I = intervention group; LBP = Low back pain; M = Magnets; P = Provider; R = Reflexology; SG = Support group; UBP = unspecified back pain; V = vitamins

Relative Utilization of CAM Therapies Within the United States

Three publications⁹–¹¹ specified that there was overlap in use of the various CAM therapies, but type of therapy overlap was not detailed. One study¹² indicated that more than one CAM practitioner may have provided the therapy in the estimates of utilization. Similarly, overlap with conventional providers was not stratified for specific CAM therapies; a single study specified overlap with chiropractors alone but not other CAM practitioners.⁹

Relative Utilization of CAM Therapies Outside the United States

Two related publications^{116, 117} did not specify complementary or combined CAM therapy use. Two publications^{118, 119} evaluated patients with back pain alone and presented the degree of overlap with other CAM therapies. One of these publications¹¹⁸ showed a degree of overlap with conventional providers that varied from 6 percent with any physician to 1 percent with specialists; similarly, overlap with other conventional providers varied from 2 percent with physiotherapists to 0.3 percent with psychologists.

Trends in Utilization Within the United States

For those with LBP only, study¹⁹ showed that in 1987, 41 percent used chiropractic medicine and in 1997, 31 percent. Another study found that in 1990, 36 percent of individuals with unspecified back pain used a CAM therapy while 20 percent saw a CAM practitioner; in 1997, 48 percent used CAM for back pain while 30 percent saw a CAM practitioner.⁵ This same study found that in 1997, 57 percent of individuals with neck pain used a CAM therapy and 37 percent saw a CAM practitioner.⁵

Summary of trends in CAM utilization within the U.S. The limited literature on trends over time would suggest that utilization of chiropractic/spinal manipulation for LBP in the U.S. has decreased, while the use of CAM generally has increased, although data on specific CAM therapies was not reported. More research is required to highlight trends in the utilization of CAM therapies for back pain in the U.S.

Trends in Utilization Outside the United States

One study of LBP patients in the United Kingdom found that osteopathy was used by 49 percent of patients over an 18 month period.¹²² Note that osteopathy practices outside of the U.S. may differ in the types of CAM therapies administered. Another study found that over a 4-year period acupuncture was used for LBP by 9 percent of patients from teaching hospitals and 32 percent of patients from general hospitals.¹²⁵ One study from the Netherlands found that between 1989 and 1992, physical therapists (PT) administering massage and passive mobilizations were used by 12 percent of those suffering from LBP. This increased to 15 percent in 2002 to 2003.¹²¹ A Canadian study found that between 1996 and 2002 glucosamine was used by 5 percent of men and 10 percent of women with back pain.¹²⁰ A study from Norway found that in 1992, 59 percent of non-referred and 62 percent of referred chiropractic patients had LBP.¹²⁴

For those suffering from neck and back pain, in Canada, “in the past 12 months” the following utilization rates of CAM therapies were reported: chiropractic care 61 percent; massage 39 percent; acupuncture 30 percent; energy healing 16 percent; yoga 14 percent; relaxation techniques 10 percent; and prayer/spiritual practice 5 percent.¹¹⁷ In Denmark, between 1962 and 1999 patients visiting chiropractors increased by over 7 percent for the primary complaint of LBP alone, decreased by almost 9 percent for LBP with sciatica; increased by over 3 percent for neck pain, and remained essentially the same for neck and arm pain.¹²³

Summary of trends in CAM utilization outside the U.S. The limited literature on trends in countries outside the U.S. would suggest that utilization rates differ between countries and between specific CAM interventions. More research is required to determine the extent of these differences. No data were reported on the usual costs for these therapies per treatment or for the prescribed course of treatments.

Specific CAM Therapy Utilization: Acupuncture

Eighteen publications provided data on utilization of acupuncture by back pain patients. Of these, eight were specific to the U.S.;¹⁰–^{12, 15, 16, 18, 44, 45} two of these publications were based on the same sample.^{15, 44} Ten publications provided utilization outcomes from other eligible countries;^{51, 116}–^{119, 125}–¹²⁹ one publication¹¹⁷ was a companion to a previous study¹¹⁶ as it incorporated the findings of the initial survey and utilization from a resampling of new subjects 6 years later. The variation in the samples recruited for these studies is noteworthy and includes subjects from large population-based surveys or administrative databases and subjects from small clinical practices, or populations limited only to patients with back pain. As expected, the estimates of utilization varied substantially based on the type of denominator used to estimate prevalence.

Acupuncture Utilization Within the United States

There were eight U.S. publications that provided data on acupuncture utilization in persons with back pain. Three of these were of cross-sectional design using interviews.^{12, 18, 45} Three publications from two study cohorts used a single group prospective cohort study design based on interviews^{15, 44} and self-administered questionnaires.¹¹ One study was a retrospective design using data from a health claims database¹⁶ and another was a randomized controlled trial¹⁰ that used a self-administered questionnaire to evaluate use of CAM.

Two publications^{12, 45} reported CAM utilization based on samples from the general population. Two publications recruited subjects from health claims databases in Washington state.^{16, 18} Two publications^{15, 44} randomly sampled licensed acupuncturists and patients in their practices from seven states, including Washington and Massachusetts. One study recruited subjects from large urban specialty clinics for orthopedic or neurosurgery consultation¹¹ and another recruited a small sample of back pain subjects who had access to the internet.¹⁰

Utilization was primarily defined as a visit to an acupuncturist or having received or “ever tried” acupuncture based on self-report with or without information from health records. Three publications queried use “within the last 12 months”,^{10, 12, 45} three^{11, 18, 45} reported “lifetime” use, and two^{15, 44} reviewed visits to practitioner over a 1-year interval.

Only one of the publications¹⁵ provided any detail as to the type of acupuncture administered. This same study was the sole publication to provide information about the mean duration of the visits (60 minutes) but it did not specify the frequency of visits over the course of treatment. The training or type of acupuncturist was specified as “licensed acupuncturist”^{15, 18, 44} in three publications; the remaining eligible publications provided no further details about the practitioner.

Table 4A

Utilization of acupuncture in persons with neck pain (more...)

Table 4A

Utilization of acupuncture in persons with neck pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Burke45 2006 U.S.	CS	FI	“Lifetime” use and use in the past 12 months	30,278	General population	Any condition	Any use of acupuncture	1,266/30,278 (4.1%) reported “lifetime use” of acupuncture 327/30,278 (1.1%) reported use of acupuncture in the “past 12 months” 37/270 (13.6%) used acupuncture for neck pain
Cherkin44 2002 U.S. Companion to Sherman15 2006 U.S.	SGPS	SAQ	Visits to practitioner in a 12 month period	133 AT/488 eligible practitioners	Practitioners were asked to collect patient information	Any condition	Visit to a licensed acupuncturist	% of neck symptoms being the primary reason for visit by practitioner type and state Reported for Washington only: 92/1,263 (7.3%)

Abbreviations: AT = acupuncture therapist; CS = Cross-sectional; FI = Face to face interview; SAQ = Self-administered questionnaire; SGPS = Single group prospective study

Table 7A

Utilization of acupuncture in persons with combined (more...)

Table 7A

Utilization of acupuncture in persons with combined neck and back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Wolsko12 2003 U.S.	CS	TI	Past 12 months	644/2,055 respondents reported back pain (60% response rate)	Individuals who have had neck or back pain in the past 12 months	46% had pain in more than 1 location 38% had LBP only 16% had neck or upper back pain only	Use of a CAM therapy or visit with CAM practitioner	Acupuncture: 0.9% Mean number of visits: 2.6 Estimated total visits: 1.6 million Relative frequency for CAM use did not differ by the location of the back pain
Studies outside the United States
Esmail117 2007 Canada Companion to Ramsay116 1999 Canada	CS	TI	Past 12 months	Second wave: 376/2,000 (18.8%) respondents First wave: 386/1,500 (25.7%)	General adult population	NSBP back or neck problems in the past 12 months	Use of a CAM therapy or visit with a practitioner who is not a medical doctor	Acupuncture use in persons with back pain 30% (1997) 30% (2006)

Abbreviations: AT = Acupuncture Therapist; CAM = Complementary and Alternative Medicine; CS = Cross-sectional; LBP = Low back pain; NSBP = Data not stratified by back pain; TI = Telephone interview

Table 5A

Utilization of acupuncture in persons with unspecified (more...)

Table 5A

Utilization of acupuncture in persons with unspecified back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Bruce10 2004 U.S.	RCT	SAQ	Past 12 months	Intervention: 190/296 (64.1%) Control: 231/284 (81.3%)	Participants with recurrent back pain but not receiving any disability insurance	CBP Mean duration back pain: 13.4 yrs (SD=10)	Baseline: “Ever tried CAM”. Could include ≥1 CAM therapy 1 year: “CAM in past 6 months”	Baseline: Intervention: 38/190 (20%) Control: 53/231 (23%) Outcomes: Intervention: 5/190 (2.6%) Control: 5/231 (2.2%)
Burke45 2006 U.S.	CS	FI	“Lifetime” use and use within the past 12 months	30,278	General population	Any condition	Ever used or recent use of acupuncture	1,266/30,278 (4.1%) reported “lifetime use” of acupuncture 327/30,278 (1.1%) reported use of acupuncture in the “past 12 months” 92/270 (34.0%) used acupuncture for back pain
Cherkin44 2002 U.S.	SGPS	SAQ	Visits to practitioner in a 12-month period	133 AT, 488 eligible practitioners	Practitioners were asked to collect patient information	Any condition	Visit to a practitioner	Back ‘symptoms’ Massachusetts: 147/1,298 (11.3%) Washington: 215/1,263 (17.0%)
Sherman15 2006 U.S. Companion to Cherkin44 2002 U.S.	SGPS	SAQ	Visits to practitioner in a 12-month period	219 visits to licensed AT	Patients with CBP	Any condition	Visit to AT	10% of visits to the AT were for any back pain 2/3 of visits were for CBP 1/3 of visits were for acute back pain Visit duration: Median 60 minutes
Studies from outside the United States
Foltz118 2005 Canada	CS	TI	Past 12 months	Complete sample 66,253 Non-specific CBP 11,736 (17.7%) CAM users 3,259 (39%)	Subset from a large national general sample collected from 1996 to 1998 1 of 4 groups identified was “CBP or musculo-skeletal disease”	CBP was diagnosed by a health professional	‘CAM users’ if: 1) received or discussed CAM with a non-mainstream practitioner 2) used a support group for health problem 3) received care from D.C.	CBP respondents, 39% (95% CI: 38.1–39.9) had used CAM during the past 12 months 20.6% (95% CI: 19.4 to 22.8) of this sample used acupuncture
Giles126 2003 Australia	SGPS	HRR SAQ	New cases followed for 12 months	861/1,775 (48.5%) patients referred to spine pain clinic received treatment with CAM	Sample from a specialized clinic (multi-disciplinary spinal pain unit) Majority chronic pain (92.7%)	100% with spinal pain; of the 941 patients who could recall when their symptom began 92.7% reported chronic pain (>3 months duration)	Treatment with acupuncture	507/1,775 (28.6%) treated with needle acupuncture. Of those receiving treatment (507/861), 58.9% received needle acupuncture 7,831 visits patients receiving acupuncture
Sibbritt127 2007 Australia	CS	SAQ	Past 12 months	11,143/11,202 responded to question about acupuncture use. 466/11,143 (4.2%) women reported use of acupuncture	Middle-aged Australian women, aged 50 to 55	Variety of conditions	Consultation with an AT	284/466 (61%) consulted an AT for back pain

Abbreviations: AT = acupuncture therapist; CAM = Complementary and Alternative Medicine; CBP = chronic back pain; CLBP = Chronic low back pain; CS = Cross-sectional; D.C. = Doctor of Chiropractic; FI = Face to face interview; HRR = Health record review; LBP = Low back pain; M.D. = Medical Doctor; MT = massage therapist; NP = Naturopathic Physician; SAQ = Self-administered questionnaire; SD = Standard Deviation; SGPS = Single group prospective study; TI = Telephone interview; yrs = years

Table 5B

Utilization of acupuncture in persons with unspecified (more...)

Table 5B

Utilization of acupuncture in persons with unspecified back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Bruce10 2004 U.S.	Not collected	Not reported but data presented indicated respondents had used 1 or more CAM therapy
Burke45 2006 U.S.	Not reported	Not reported
Cherkin44 2002 U.S.	NSBP	NSCAM
Sherman15 2006 U.S. Companion to Cherkin44 2002 U.S.	Not reported	Heat: 61 to 72% East Asian massage: 24 to 42% Herbs: 27to 29% Cupping: 14 to 26%
Studies conducted outside the United States
Foltz118 2005 Canada	For CAM users: Percent reporting visit: To any physician: 6.2% (95% CI 6.0–6.4) To GP: 5.1% (95% CI 5.0–5.3) To specialists: 1.1% (95% CI 1.0–1.2) To PT: 2.4% (95% CI 2.2–2.4) To psychologists: 0.3% (95% CI 0.3–0.3)	Concurrent use evident but data not stratified by type of CAM therapy
Giles126 2003 Australia	Not reported	Not specified
Sibbritt127 2007 Australia	Not collected	Not collected

Abbreviations: CAM = Complementary and Alternative Therapy; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy; PT = Physical Therapist

Table 6A

Utilization of acupuncture in persons with low back (more...)

Table 6A

Utilization of acupuncture in persons with low back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Lind16 2005 U.S.	Retro Rev	AD	Outpatient visits over course of 1 year	109,080/601,044 enrollees had back pain; 104,358 (96%) were eligible for review	Enrollees (ages 18–64) in large health insurance plans; enrollees had NOT been hospitalized or undergone surgery for back pain	Back pain	At least one visit for back pain to a CAM provider	Acupuncture used by 2,701 persons (2.6% of back pain population) had 15,500 visits (2.4% of total visits) median number of visits was 4 962/104,358 (0.9%) LBP sought acupuncture only
Long11 1996 U.S.	SGPS	SAQ	Past 12 months	2,374/4,171 subjects had complete data and followup	Adult patients presenting to centers for orthopedic surgery or neurosurgery consultation	100% of patients presented with persistent LBP (mean duration of current episode 2.52 years)	Treatments or visits to CAM practitioners	Acupuncture was previously used by 9.3% Specialists consulted for back pain before enrollment in the study: AT - 10.2%
Studies from the United States
Sherman18 2004 U.S.	CS	TI	Lifetime use	Pilot sample obtained from health claims database; 249/787 patients responded to interview	Members of a non-profit managed health care system and a large multi-specialty group practice	100% persistent non-specific LBP >3 months	Reported “Ever tried”	Acupuncture had been “ever tried” by 11% of back pain patients
Studies from outside the United States
Caswell128 2002 U.K.	CS	SAQ	Lifetime use	150 subjects had back pain divided into three groups: 1) CBP using CAM 2) CBP not using CAM 3) no back pain	Subjects attending private physiotherapy or NHS pain clinics	CLBP	Visit to CAM practitioner	10/50(20%) used acupuncture to treat back pain 36% conventional patients had used at least 1 CAM therapy in the management of their back pain (use with acupuncture not specified)
Chenot51 2006 Germany	SGPS	FI	Past 12 months	1,345/ 1,588 (84.6%) back pain patients 1,218/1,345 (90.6%) completed 12 month followup	Sample recruited within practices of general practitioners	Consecutive patients with LBP	Use of CAM therapy	179/1,218 (13%) received acupuncture during 12 month followup Acupuncture sessions Range = 1 to 47 mean 12 (SD ± 8.8)
Davies125 1996 U.K.	BA	HRR	Within 6 months, then following 7 months	Observation period 1: 761/ 1,236 (62%) LBP Observation period 2: 1,096/1,791 (61%) LBP	Patients from 10 specialized outpatient pain clinics Patients with either nerve damage or LBP were selected	Nerve damage, LBP	Receiving acupuncture	Observation period 1: 142/ 761 (18.7%) acupuncture treatment Observation period 2: Not specified
Scheurmier129 1998 U.K.	SGPS Retro Rev	HRR	Past 4 months	484/592 (84%)	Patients from GP practices in the U.K.	100% with acute LBP (duration <6 weeks)	Visit to CAM provider	49/259 (19%) received acupuncture referral
Walker119 2004 Australia	CS	SAQ	Past 6 months	1,913/2,748 (69.6%) responded; 1,228/1,913 (64.1%) indicated at least 1 episode of back pain	Individuals from the electoral roll in Australia	100% reported LBP in the last 6 months	Visit to CAM practitioner	Acupuncture was sought by 35 patients (2.2%) with back pain and seeking care

Abbreviations: AD = administrative database; AT = Acupuncture Therapist; BA = before after; CAM = Complementary and Alternative Medicine; CI = Confidence interval; CBP = Chronic back pain; CS = Cross-sectional; D.C. = Doctor of Chiropractic; FI = Face to face interview; GP = general practitioner; HRR = Health record review; LBP = Low back pain; M.D. = Medical Doctor; MT = massage therapist; NHS = National Health Service; NP = Naturopathic Physician; Retro Rev = Retrospective Review; SAQ = Self-administered questionnaire; SD = standard deviation; SGPS = Single group prospective study; TI = Telephone interview

Table 6B

Utilization of acupuncture in persons with low back (more...)

Table 6B

Utilization of acupuncture in persons with low back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Lind16 2005 U.S.	Concurrent use possible, but not specified	Concurrent use evident but data not stratified by type of CAM therapy. However, 89% of CAM users saw one type of CAM provider (but not stratified by therapy type)
Long11 1996 U.S.	NSBP: Not reported for period prior to enrollment	NSCAM: Concurrent use evident but data not stratified by type of CAM therapy
Sherman18 2004 U.S.	Not specified for acupuncture	Not collected
Studies conducted outside the United States
Caswell128 2002 U.K.	90% (9/10) acupuncture patients used at least 1 conventional therapy as a CLBP management method 62% CAM users sought conventional care	Not collected
Chenot51 2006 Germany	Patients using acupuncture saw specialists (84%), physiotherapy (63%), took medications (16% to 75%), and injection therapy (75%)	Also received chiropractic (46%), and massage (37%) Electrotherapy and TENS also received but provider type not specified
Davies125 1996 U.K.	Use of medications, TENS, and nerve blocks were frequently used but proportion overlap with acupuncture not specified	Not collected
Scheurmier129 1998 U.K.	Not specified for acupuncture	Not specified for acupuncture
Walker119 2004 Australia	Not stratified by therapy	NSCAM

Abbreviations: CLBP = Chronic low back pain; LBP = Low back pain; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy; TENS = Transcutaneous Electrical Nerve Stimulation

It is important to note whether the denominator used to estimate utilization was based on the entire sample enrolled or just a specific subset of patients with back pain. Two studies^{12, 45} were based on general population samples and, not surprisingly, showed markedly lower rates of acupuncture utilization for both neck and unspecified back (1 to 4 percent) and combined neck and back pain (1 percent) than studies that recruited smaller samples of persons all of whom had back pain.

Acupuncture use as complementary care or combined with other CAM. The majority of publications did not collect or report sufficient information to determine concurrent use of conventional with CAM therapies for back pain. Two publications provided information on use with conventional care but were not specific to those respondents with back pain⁴⁴ or specific to those receiving acupuncture¹² (Table A2 and A4). Although not stratified for persons with back pain, up to 53 percent of acupuncture patients saw a medical or osteopathic physician, but only 10 percent of persons with back pain reported speaking to their doctor about using acupuncture.⁴⁴ Another study¹² suggested that CAM alone had been used by 29 percent of persons with back and neck pain; however, this was not specific to those receiving acupuncture.

Table 4B

Utilization of acupuncture in persons with neck pain (more...)

Table 4B

Utilization of acupuncture in persons with neck pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Burke45 2006 U.S.	Not reported	Not reported
Cherkin44 2002 U.S. Companion to Sherman15 2006 U.S.	NSBP Acupuncture patients receiving care from M.D. or OD Massachusetts: 49.7% Washington: 56.2%	Not reported

Abbreviations: CAM = Complementary and Alternative Therapy; M.D. = Medical Doctor; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy; OD = Osteopathic Doctor

Table 7B

Utilization of acupuncture in persons with combined (more...)

Table 7B

Utilization of acupuncture in persons with combined neck and back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Wolsko12 2003 U.S.	NSCAM 25% had used both complementary medicine and a conventional provider	Used any CAM: from those with back and neck pain, 29% had used CAM alone Concurrent use not specified
Studies conducted outside the United States
Esmail117 2007 Canada Companion to Ramsay116 1999 Canada	NSBP 2006: 30% saw a medical doctor in the 12 months 1997: 14% utilized both a medical doctor and alternative provider within the past 12 months.	Not specified for acupuncture

Abbreviations: CAM = Complementary and Alternative Therapy; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy

Quality assessment of U.S. acupuncture publications. Only one¹⁰ of the eight U.S. publications on the utilization of acupuncture for back pain used a study design with a true comparator group; as such the focus of our quality assessment is on the potential for selection and reporting biases. All but a single publication¹⁶ are based on self-reported utilization and therefore subject to recall bias; heterogeneity with respect to survey versus interview and the types of CAM services queried are also important sources of reporting bias.

Two^{12, 45} of three cross-sectional publications were of high quality, reporting CAM utilization based on random sampling of the general population with adequate response rates (74 and 63 percent respectively). The third study¹⁸ recruited subjects from a health database and then subsequently interviewed them. This study had a low response rate (36 percent) and had the potential for selection bias as the eligible sample had to have back pain (44 percent were ineligible due to no longer having back pain). One study, based on a large health insurance claims database, would also be considered high quality as it used standardized coding for back pain classification, provider visits, and treatments.¹⁶

There is greater potential for selection bias in studies using samples obtained from provider clinics. Two publications^{15, 44} randomly sampled licensed acupuncturists using a recruitment strategy based on the National Ambulatory Medical Care Survey. This methodology collects service visit characteristics close to the time of each patient encounter thereby minimizing longterm provider recall, errors from chart extraction, and retrospective administrative data analysis. The two remaining studies recruited chronic back pain subjects who had been referred for orthopedic or neurosurgery consultation or from urban specialty clinics¹¹ and a small sample of back pain subjects who had access to the internet.¹⁰ As noted previously, the rates of use for patients already seeking treatment differ from those in the general population; additionally, those already seeking CAM therapy services may possess inherent differences in defining characteristics that are not easily determined in the absence of comparison groups.

Across all eight U.S. publications, the methodological quality is rated as fair, indicating that they are susceptible to some biases but these, being somewhat endemic to self-report, are not sufficient to negate the results.

Summary of utilization for back pain for U.S. acupuncture publications. Eight publications evaluated the use of acupuncture in persons with back pain and all but one used self-report methods.¹⁶ Two of these studies^{12, 45} were based on randomly selected general population samples and, as expected, these showed markedly lower rates of utilization for both neck and unspecified back (1 to 4 percent) and combined neck and back pain (1 percent). Similar rates of utilization were observed (1 percent) in a study evaluating a large administrative database. All other studies based primarily on subjects from clinical practices or with back pain showed higher rates of utilization (7 to 36 percent). Rates of use also varied by the timeframe for recall (12 months to lifetime prevalence), the interval of analysis for administrative databases, and recruitment of subjects from clinical practices.

The majority of publications evaluated LBP or unspecified pain, with utilization for neck or combined neck and back problems being less commonly assessed. No clear pattern emerges for acupuncture utilization rates as a function of region of the back; in part this is due to the limited number of studies, but it may also be related to the lower prevalence of neck pain relative to LBP.

Only one of the publications¹⁵ provided any detail as to the specific type of acupuncture provided. A single publication⁴⁴ presented information on concurrent conventional care with acupuncture. When reported, conventional care overlap was generally not stratified for acupuncture. Similarly, a single publication¹⁵ sufficiently detailed combining of other alternative therapies with acupuncture. Overall these studies were rated as having fair methodological quality, indicating that they are susceptible to some biases. These threats to validity are somewhat endemic to the use of self-report of utilization but are not sufficient to negate the results.

Acupuncture Utilization Outside the U.S

Of the 10 publications on utilization outside of the U.S., three¹¹⁶–¹¹⁸ were based in Canada, three^{125, 128, 129} in the United Kingdom, three^{119, 126, 127} in Australia, and one⁵¹ in Germany.

Half the studies recruited participants from the general population, including a national sample within Canada,¹¹⁶–¹¹⁸ one within Australia,¹¹⁹ and one of Australian women.¹²⁷ The remaining studies recruited subjects from specialized outpatient or pain clinics,^{125, 126, 128} and general medical practices.^{51, 129}

Utilization was primarily defined as a visit with an acupuncturist or having received or “ever tried” acupuncture. In addition to a visit to a CAM practitioner, one study¹¹⁸ included “discussed CAM with, a non-mainstream practitioner” and “looked for a support group when faced with a health problem” as utilization. Half the publications^{51, 116}–^{118, 127} queried use within the last 12 months, and two publications^{119, 125} reported use within 6 months or less. One study¹²⁸ did not report a timeframe and another¹²⁶ reviewed visits over a 6-year interval.

None of the publications provided details as to the type of acupuncture provided. Only two publications indicated that the provider was either a medical acupuncturist¹²⁹ or was likely a conventional practitioner.¹²⁵

The majority of publications did not provide detail regarding concurrent or additional use with other CAM therapies. Two publications^{51, 119} indicated use of acupuncture with other CAM therapies including chiropractic (46 percent) and massage (37 percent).⁵¹

Quality assessment for non-U.S. acupuncture publications. Seven^{51, 116}–^{119, 126, 127} of 10 non-U.S. publications used self-reported utilization data and were subject to some degree of recall bias. The remaining three publications^{125, 126, 129} used medical health record information. Six of the 10 publications were of cross-sectional design with utilization outcomes derived equally from interviews or self-administered questionnaires; of these, five publications¹¹⁶–^{119, 127} were derived from random population samples, with one¹²⁷ being limited to older Australian women. However, the response rate was low (19 to 26 percent)^{116, 117} or not reported^{118, 127} in four of these publications. Three publications using non-comparative study designs recruited patients from general practices¹²⁹ or specialized pain clinics.^{125, 126} For these 10 non-U.S. studies the overall methodological quality is fair, suggesting some susceptibility to bias, but not sufficient to negate all the results.

Summary of utilization for back pain for non-U.S. acupuncture publications. Ten publications undertaken in Canada,¹¹⁶–¹¹⁸ the United Kingdom,^{125, 128, 129} Australia,^{119, 126, 127} and Germany⁵¹ evaluated the use of acupuncture in persons with back pain. Three of these^{125, 126, 129} retrieved utilization data from health records rather than using self-report methods; the quality of utilization data retrieved was limited by lack of standardized extraction methods. Six of the publications^{51, 116}–^{119, 127} using interview or survey methods were cross-sectional studies. Five of these selected random population samples and found utilization rates varying from 2 percent¹¹⁹ to 30 percent.^{116, 117} Differences in timeframes queried may account for this variation.

Of the 10 non-U.S. publications, five^{51, 116}–^{118, 127} probed use within the last 12 months, and two^{119, 125} reported use within 6 months or less. One publication¹²⁸ did not report a timeframe and another¹²⁶ reviewed visits over a 6-year interval.

The majority of publications evaluated LBP (n = 5) or unspecified pain (n = 3) and none evaluated or reported specifically on neck pain. No clear trend for utilization rates as a function of region of the back was observed in the non-U.S. studies. None of the publications provided details as to the type of acupuncture provided and only two publications specified the type of practitioner.^{125, 129} Although seven publications did report some information regarding use of conventional care with acupuncture, four of these did not either stratify results by persons with back pain¹¹⁶–¹¹⁸ or specify the CAM practitioner;¹¹⁹ the remaining three publications^{51, 125, 128} showed overlap varying from 63 to 90 percent. The majority of publications did not provide sufficient detail regarding concurrent or additional use with other CAM therapies. Two publications^{51, 119} indicated use of acupuncture with other CAM therapies including chiropractic (46 percent) and massage (37 percent).⁵¹ For these 10 non-U.S. studies the overall methodological quality is fair, suggesting some susceptibility to bias, but not sufficient to negate all the results

Specific CAM Therapy Utilization: Massage

Nineteen publications provided information on the utilization of massage in persons with back pain. Of these, 12 were specific to the U.S.^{9, 11, 12, 15, 16, 18, 20, 22, 23, 30, 33, 44} Seven of these publications are based on three patient study cohorts from Oregon State medical and chiropractic practices,^{20, 22, 23} the practices of licensed CAM practitioners in Connecticut and Washington,^{15, 44} and North Carolina.^{9, 30} Eight publications provided utilization outcomes from eligible non-U.S. countries;^{51, 116}–^{119, 121, 130, 131} one publication¹¹⁷ was a companion to a previous study¹¹⁶ as it incorporated the findings of the initial survey and utilization from a resampling of new subjects 6 years later.

Massage Utilization Within the U.S

Three of the 12 eligible U.S. publications used cross-sectional study designs based on interviews.^{9, 12, 18} Two studies were based on retrospective health claims database review¹⁶ or chart review.³³ Another study⁹ was designed as a single group prospective study but presented only baseline data for the subgroup of chronic pain patients and as such the results are cross-sectional. The remaining seven publications established CAM utilization using a single group prospective design based on telephone interviews,^{15, 30, 44} self-administered questionnaires,¹¹ and health record audit with administrative billing records.^{20, 22, 23}

The majority of populations were from specialized clinical practices or from the practices of licensed CAM providers. Three publications reported CAM utilization based on subjects from either a national sample,¹² or regional samples from North Carolina.^{9, 30} Two publications recruited subjects from health claims databases in Washington state,^{16, 18} and three from family medical and chiropractic practices in Oregon state.^{20, 22, 23} Similarly, two publications^{15, 44} randomly sampled licensed massage therapists and patients within their practices from the states of Washington and Connecticut. One study³³ recruited patient charts from chiropractic practices within California and another study recruited subjects from large urban specialty clinics for orthopedic or neurosurgery consultation.¹¹

Utilization was primarily defined as a visit with a CAM practitioner, having received or “ever tried” massage, or use from a health claims database or health record from a CAM practitioner. Persons with back pain were asked about use of CAM within the last 12 months,^{9, 10, 12, 20, 22, 23} lifetime use,^{11, 18} or visits to practitioner over a 1-year interval.^{15, 16, 33, 44}

Two publications^{16, 20} using data from large health claims databases showed low rates of massage utilization for LBP, varying from 4 to 5 percent of the total sample. One study¹² reported massage use for patients with combined neck and back pain and showed a utilization rate of 14.1 (95 percent CI, 10.8–17.4), an estimated 32.8 million visits (mean of 5.4 visits). In contrast, publications that evaluated use of massage within smaller samples, showed rates of use varying from 16 to 52 percent.

Only one publication¹⁵ provided any detail as to the type of massage administered to back pain patients. This publication also reported the mean duration of the visits as 60 minutes. The training or type of massage therapist was specified as a “licensed massage therapist”,^{15, 18, 44} provided within a chiropractor practice and thus likely provide by a chiropractor,^{20, 22, 23, 33} or provided within a physical therapy practice thus possibly from a physical therapist.³⁰ The remaining four publications^{9, 11, 12, 16} provided no details regarding the massage practitioner.

Table 8A

Utilization of massage in persons with neck pain

Table 8A

Utilization of massage in persons with neck pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Cherkin44 2002 U.S. Companion to Sherman15 2006 U.S.	SGPS	SAQ	Past 12 months	MT: 126/488 (25.8%) eligible practitioners	Practitioners from several professions asked to collect patient information	Any condition	Visit to a licensed MT	% of neck symptoms being the primary reason for visit by practitioner type and state Connecticut: 125/965 (13.0%) Washington: 208/1,040 (20.0%)
Studies from outside the United States
Vos130 2007 Netherlands	SGPS	SAQ	Utilization reported prior to entry into the study	187/259 (72%) patients enrolled in the study	Patients recruited from general practice setting - all persons had neck pain	Acute neck pain	Visit to CAM practitioner at baseline	Patients at baseline use: 13/187 (7%)

Abbreviations: CAM = Complementary and Alternative Medicine; MT = massage therapist; SAQ = Self-administered questionnaire; SGPS = Single group prospective study

Table 8B

Utilization of massage in persons with neck pain

Table 8B

Utilization of massage in persons with neck pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Cherkin44 2002 U.S. Companion to Sherman15 2006 U.S.	NSBP	NSCAM
Studies conducted outside the United States
Vos130 2007 Netherlands	Not applicable as all enrolled patients saw conventional practitioner	Concurrent use at baseline apparent but overlap not specified. During followup 12% (23 patients) used CAM; most often this was Reiki/energy, healing therapy and acupuncture

Abbreviations: CAM = Complementary and Alternative Medicine; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy

Table 9A

Utilization of massage in persons with unspecified (more...)

Table 9A

Utilization of massage in persons with unspecified back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Cherkin44 2002 U.S. Companion to Sherman15 2006 U.S.	SGPS	SAQ	Past 12 months	MT: 126/488 (25.8%) eligible practitioners	Practitioners from several professions, were asked to collect patient information	Any condition	Visit to a licensed MT	% of back symptoms being the primary reason for visit by practitioner type and state: Connecticut: 197/965 (20.4%) Washington: 210/1,040 (20.2%)
Sherman15 2006 U.S. *Companion to Cherkin44 2002 U.S.	SGPS	SAQ	Past 12 months	236 visits to licensed MT	Patients with CBP	100% had CBP	Visit to provider	# visits for CBP: Connecticut: 121 Washington: 115 Deep tissue 82(4%), 84(2%) Swedish 85(5%), 76(5%) Trigger point 57(6%), 62(5%) 1/3 ABP and 2/3 for chronic pain CBP
Studies from outside the United States
Foltz118 2005 Canada	CS	TI	Past 12 months	Complete sample 66,253 Non-specific CBP 11,736 (17.7%) CAM users 3,259 (39%)	Subset from a large national general sample collected from 1996 to 1998 Four groups were identified and one group was “CBP or musculoskeletal disease”	CBP was diagnosed by a health professional	‘CAM users’ if: 1) received or discussed CAM with a non-mainstream practitioner 2) used a support group for health problem 3) received care from D.C.	Chronic back pain respondents, 39% (95% CI 38.1–39.9) had used CAM during the past 12 months 55.5 % (95% CI 54.1–57.0) used massage 21% (2,425) had attended a D.C. in the past 12 months

Abbreviations: CAM = Complementary and Alternative Medicine; CI = Confidence interval; CBP = Chronic back pain; CS = Cross-sectional; D.C. = Doctor of Chiropractic; MT = massage therapist; SAQ = Self-administered questionnaire; SGPS = Single group prospective study; TI = Telephone interview

Table 9B

Utilization of massage in persons with unspecified (more...)

Table 9B

Utilization of massage in persons with unspecified back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Cherkin44 2002 U.S. *Companion to Sherman15 2006 U.S.	NSBP	NSCAM
Sherman15 2006 U.S. Companion to Cherkin44 2002 U.S.	Not specified for massage	Movement re-education 23%/30% Energetic work 5%/4% Neuromuscular 3%/6% Reflexology 3%/4% Breathwork 4%/4%
Studies conducted outside the United States
Foltz118 2005 Canada	CAM users reporting visit to: Physician: 6.2% (95% CI 6.0–6.4) GP: 5.1% (95% CI 5.0–5.3) Specialists: 1.1% (95% CI 1.0–1.2) PT: 2.4% (95% CI 2.2–2.4) Psychologists: 0.3% (95% CI 0.3–0.3)	Concurrent use evident but data not stratified by type of CAM therapy

Abbreviations: CAM = Complementary and Alternative Medicine; CI = Confidence interval; GP = General Practitioner; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy; PT = Physical Therapist

Table 10A

Utilization of massage in persons with low back pain (more...)

Table 10A

Utilization of massage in persons with low back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Carey9 1995 U.S.	CS	TI	Past 12 months	269/4,437 (3.9%) interviewed had CLBP	North Carolina residents	100% with CLBP (functionally limited for >3 months or >25 episodes of LBP in past 12 months)	Visit with a health provider; lifetime prevalence	For those seeking care for LBP massage: 78/187 (42%)
Lind16 2005 U.S.	Retro Rev	AD	Outpatient visits over 1 year	Back pain: 109,080/601,044 (18.1%) Reviewed: 104,358 (17.4%) Use massage; 11,694 (11.2%)	Enrollees in health insurance plans that had NOT been hospitalized or had surgery for back pain	Back pain	Visit for back pain to a CAM provider	Massage: 4,317/104,358 (4.1%) LBP patients sought massage only
Long 11 1996 U.S.	SGPS	SAQ	Past 12 months	2,374/4,171 (56.9%) subjects had complete data and followup	Adult patients presenting for orthopedic surgery on neurosurgery consultation	100% of patients with persistent LBP Mean duration LBP: 2.52 years	Treatments for back pain prior to enrollment into the study	Massage previously used by 43.2%
Mielenz30 1997 U.S.	SGPS	TI	Past 12 months	1,540 ALBP 199/1540 (12.9%) seeking treatment from PT	Patients recruited from healthcare providers	100% with acute LBP (<10 week duration)	Visit with a health provider; lifetime prevalence	Sought physical therapy: 49% received massage
Nyiendo22 2001 U.S.	SGPS	SAQ HRR	Past 12 months	121/2,945 (4.1%) from medical practices 147/2,945 (4.9%) chiropractor practices	Persons with CLBP with sciatica	100% with CLBP and sciatica (>6 weeks duration)	Visit to practitioner	Chiropractic patients: 52.4% received massage
Nyiendo23 2001 U.S. Companion to Nyiendo22 2001 U.S.	SGPS	SAQ HRR	Past 12 months	2,945 patients enrolled; 309 from medical practices 526 from chiropractic practices	Persons with CBP with sciatica	100% with chronic LBP and sciatica (>6 weeks duration)	Visit to practitioner	D.C. use of massage was similar to that reported for electrotherapy (42.7%) received electrotherapy at least 1 visit >5 treatments (10%)
Stano20 2002 U.S. Companion to Nyiendo22,23 2001 U.S.	SGPS	SAQ HRR	Past 12 months	2,872 total 922 medical patients 1,950 chiropractic patients	Patients with ALBP and CLBP	Acute and chronic ambulatory LBP of mechanical origin	Frequency of therapy procedure codes used	Out of 28,061 visits: 1,449 (5.2%) received massage
Shekelle33 1995 U.S.	Retro Rev	HRR	Past 12 months	80 patient records were selected (10 from each of 8 chiropractic practices)	Patient record from random sample of chiropractic practices	100% with LBP (56%<3 weeks duration; 25% >13 weeks duration)	First visit between specified interval	Massage 25%
Sherman18 2004 U.S.	SGPS	SAQ HRR	Lifetime use	Health claims database; Participants: 249/787 (31.6%) 24/249 (9.6%) tried massage for back pain	Members of a non-profit managed health care system and a large multi-specialty group practice	Non-specific LBP that had persisted for more than 3 months	Any visit to MT	Massage had been “ever tried” by 24% of back pain patients
Studies from outside the United States
Chenot51 2006 Germany	SGPS	FI	Past 12 months	1,345/ 1,588 recruited back pain patients. 1,218 completed 12 month followup; from these 179 used acupuncture	Sample recruited within practices of general practitioners	Consecutive patients with LBP	Use of CAM therapy	67/175 (37%) received massage in addition to acupuncture 350/1,145 (30%) received massage only
Groenendijk121 2007 Netherlands	Retro Rev	AD	Study 1: 1989 to 1992 Study 2: 2002 to 2003	Study 1: LBP: 1,948/16,000 (11.9%) Study 2: LBP: 1,200/7,561 (15.4%)	Sample from AD of patients treated by PT for back pain	LBP without radiation, greater than 18 years of age	Visits to physical therapist	Study 1: 55.9% massage (most frequently used modality) Study 2: 38.5% massage (third most frequently used modality)
Walker119 2004 Australia	CS	SAQ	Past 6 months	Responders: 1,913/2,748 (69.6%) At least 1 episode of back pain: 1,228/1,913 (64.1%)	Individuals from the electoral roll in Australia	100% reported LBP in the last 6 months	Visit to CAM practitioner	Massage: 286/1,595 (17.9%) of those with back pain seeking care MT use: 161/1,076 (15.0%)

Abbreviations: AD = administrative database; ALBP = acute low back pain; CAM = Complementary and Alternative Medicine; CBP = Chronic back pain; CLBP = Chronic low back pain; CS = Cross-sectional; D.C. = Doctor of Chiropractic; FI = Face to face interview; HRR = health record review; LBP = Low back pain; M.D. = Medical Doctor; MT = massage therapist; ND = Naturopathic Doctor; O.D. = Osteopathic Doctor; PT = Physical Therapist; Retro Rev = Retrospective Review; Q = Self-administered questionnaire; SAQ = self-administered questionnaire; SGPS = Single group prospective study; TI = Telephone interview

Table 10B

Utilization of massage in persons with low back pain (more...)

Table 10B

Utilization of massage in persons with low back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Carey9 1995 U.S.	Concurrent use evident but not stratified by therapy	Concurrent use evident but not stratified by therapy
Lind16 2005 U.S.	Concurrent use possible, but not specified	Concurrent use evident but data not stratified by type of CAM therapy 89% of CAM users saw one type of CAM provider not stratified by therapy type
Long 11 1996 U.S.	Not reported for period prior to enrollment	Concurrent use evident but data not stratified by type of CAM therapy
Mielenz30 1997 U.S.	Concurrent use evident but not stratified by therapy	Massage may have been used with spinal manipulation; other modalities are not considered CAM if administered by a physical therapist
Nyiendo22 2001 U.S.	Not applicable	Concurrent use evident but not stratified by therapy; likely received spinal manipulation.
Nyiendo23 2001 U.S. *Companion to Nyiendo22 2001 U.S.	Not applicable	Concurrent use evident but not stratified by therapy; likely received spinal manipulation
Stano20 2002 U.S. *Companion to Nyiendo2223 2001 U.S.	Not applicable	Physical therapy modalities were frequently used, with massage and trigger-point therapy used most often
Shekelle33 1995 U.S.	Not applicable	Not specified for massage but likely received chiropractic manipulation
Sherman18 2004 U.S.	Not specified	Not collected
Studies conducted outside the United States
Chenot51 2006 Germany	Not specified for massage	Not specified for massage
Groenendijk121 2007 Netherlands	Not applicable	Not specified, but likely used passive mobilizations
Walker119 2004 Australia	59% attended multiple providers 3.3% from a GP and D.C. 1.5% from a GP, D.C., and MT	NSCAM

Abbreviations: CAM = Complementary and Alternative Medicine; D.C. = Doctor of Chiropractic; GP = general practitioner; MT = Massage therapist; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy

Table 11A

Utilization of massage in persons with combined neck (more...)

Table 11A

Utilization of massage in persons with combined neck and back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Wolsko12 2003 U.S.	CS	TI	Past 12 months	644/ 2,055 (60%) reported back pain	Individuals who have had neck or back pain in the past 12 months	46% had pain in more than 1 location 38% had LBP only 16% had neck or upper back pain only	Use of a CAM therapy or visit with CAM practitioner	Massage used 14.1% (95% CI; 10.8–17.4) LBP (38%) Neck pain only (16%) Pain in more than 1 location (46%) Mean number of visits: 5.4 Estimated total visits: 32.8 million
Studies from outside the United States
Cote131 2001 Canada	CS	SAQ	Past 4 weeks	1,131/2,184 (55%) participated 907/1,131 (80%) had back or neck pain	Saskatchewan Health Insurance and Registration File	100% had back and/or neck pain in the past 6 months	Visit to health care provider	215 who saw a provider for neck or LBP within the last 4 weeks 7% consult massage therapist
Esmail117 2007 Canada Companion to Ramsay116 1999 Canada	CS	TI	Past 12 months	First wave: n = 1,500 28% reported back or neck problems Second wave: n = 2,000 30% reported back or neck problems	General adult population in Canada	30% reported back or neck problems in the past 12 months	Use of a CAM therapy or visit with a practitioner who is not a medical doctor	Massage use in persons with back pain 39% (2006) 42% (1997)

Abbreviations: CAM = Complementary and Alternative Medicine; SAQ = Self-administered questionnaire; SGPS = Single group prospective study; TI = Telephone interview

Table 11B

Utilization of massage in persons with combined neck (more...)

Table 11B

Utilization of massage in persons with combined neck and back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Wolsko12 2003 U.S.	25% had used both complementary medicine and a conventional provider	Used any CAM: back and neck pain, 29% had used CAM alone. However, concurrent use not specified. Relative frequency for CAM use did not differ by the location of the back pain.
Studies conducted outside the United States
Cote131 2001 Canada	M.D. & MT: 3.7% M.D., D.C., PT, MT : 2.8%	D.C. & MT: 5.1 % Care seeking did not differ between neck and back pain patients
Esmail117 2007 Canada *companion to Ramsay116 1999 Canada	25% had used both complementary medicine and a conventional provider	Not specified for massage

Abbreviations: CAM = Complementary and Alternative Medicine; D.C. = Doctor of Chiropractic; M.D. = Medical Doctor; MT = Massage therapist; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy; PT = Physical Therapist

The majority of publications^{9, 11, 16, 18, 20, 22, 23, 30} reported on massage use in persons with LBP and all of these publications evaluated chronic LBP, except two^{20, 30} which had combined acute and chronic groups. Two publications^{16, 20} using data from large health claims databases showed low rates of utilization, varying from 4 to 5 percent of the total sample. In contrast, publications that evaluated use of massage within smaller samples with chronic back pain, showed rates of use varying from 24 to 52 percent. One study¹² reported massage use for patients with combined neck and back pain also reported no difference in the relative frequency of massage use by location of the back pain.

Massage use as complementary care or combined with other CAM therapies. The majority of publications did not collect or report sufficient information to determine use of complementary or other CAM therapies specific to patients receiving massage. There was one exception¹⁵ and this study indicated that massage was used predominately with movement re-education and less frequently with energetic work, and reflexology.

Two publications reported use with other CAM therapies but were not specific to those respondents with back pain⁴⁴ or specific to those receiving massage.¹² Although not stratified by back pain, up to 29 percent of subjects receiving massage saw a medical or osteopathic physician.⁴⁴ Another study¹² suggested that CAM alone had been used by 25 percent of persons with back and neck pain; however, this was not specific to those receiving massage.

Quality assessment for U.S. massage publications. Three of the 12 eligible U.S. publications used cross-sectional study designs based on interviews.^{9, 12, 18} One publication¹² was based on a randomly sampled population cohort with adequate response rate while another¹⁸ obtained a low response rate (36 percent) creating the potential for selection bias. Another study recruited subjects from North Carolina, and reported baseline data for subjects with chronic back pain⁹ or acute back pain.³⁰ Four publications used retrospective administrative database information and employed methods to standardize coding for back pain classification, provider visits, and treatments; one was based on a large health plan database¹⁶ and the others from chiropractic practices across a state.^{20, 22, 23} There is greater potential for selection bias in studies stemming from samples obtained from provider clinics. Two related publications^{15, 44} randomly sampled licensed massage therapists and patients within their practices but was essentially a single group prospective design. The remaining studies employed single group prospective designs from specialized settings.^{11, 33} There is significant overlap with the studies included for acupuncture. These studies evaluating the use of massage within the U.S. are prone to some biases but these do not negate the validity of the results; the overall quality is rated as fair for these studies.

Summary of use for back pain in U.S. massage publications. Twelve U.S. publications evaluated the use of massage in persons with back pain. The majority of populations were from specialized clinical practices of back pain patients or CAM providers. Two publications^{16, 20} using data from large health claims databases showed low rates of utilization, varying from 4 to 5 percent of the total sample. One study with a population based sample¹² reported massage use for patients with combined neck and back pain as 14.1 percent (95 percent CI, 10.8–17.4). Publications that evaluated use of massage in smaller samples, showed rates of use varying from 17 to 52 percent. The timeframe of reported use was 1 year, with the exception of two studies evaluating lifetime use.^{11, 18} Only one of the publications,¹⁵ provided any detail as to the type of massage administered to back pain patients.

From 11 publications, the majority reported on low back problems (n = 9) and mostly for chronic pain; only one study⁴⁴ reported on utilization of massage in neck pain. A single publication¹² reported no difference in the relative frequency of massage use by location of the back pain.

Most publications did not collect or report sufficient information to determine use of complementary or other CAM therapies by patients receiving massage. There was one exception¹⁵ and this study indicated that massage was used predominately with movement re-education and less frequently with energetic work, and reflexology. Although several studies indicated that massage was used in combination with other CAM therapies, none indicated which other therapies were combined with massage.

Massage Utilization Outside the United States

From the eight publications undertaken outside of the U.S., four were from Canada,¹¹⁶–^{118, 131} two from the Netherlands,^{121, 130} one from Germany,⁵¹ and one from Australia.¹¹⁹ All the publications undertaken within Canada were cross-sectional design from randomly selected samples, predominately at a national level; all but one study¹³¹ was undertaken by telephone interview. The Australian study¹¹⁹ was also a population-based cross-sectional study using self-administered questionnaire. The two Dutch publications were both based on a single group prospective questionnaire completed by subjects selected from general medical practices¹³⁰ and from a retrospective analysis of an administrative database for physical therapy.¹²¹ Similarly, the study from Germany⁵¹ interviewed a single group prospective cohort from general practices.

Utilization of massage therapy was primarily defined as a visit with a CAM practitioner, or use as indicated in a health claims database. All subjects were asked about use of CAM within the last 12 months with the exception of three publications, which evaluated use within the last 6 months,¹¹⁹ past 4 weeks,¹³¹ or lifetime use.¹³⁰

Five publications¹¹⁶–^{119, 131} were cross-sectional in design recruiting randomly selected national or provincial samples. In these studies utilization rates varied from 7 percent¹³¹ within the past 4 weeks to 42 percent lifetime use.¹¹⁶ Generally, studies of single group prospective design showed higher rates of utilization from 56 percent from an administrative database¹²¹ to 30 percent.⁵¹ The exception to this was a single study that evaluated massage use in persons with neck pain reporting a 7 percent rate of use at baseline.¹³⁰

None of the publications provided detail as to the specific type of massage received by persons with back pain. The providers of massage were physical therapists in one publication,¹²¹ massage therapist in another,¹¹⁹ and were not specified in the remaining publications.

Massage utilization based on anatomical region. A single non-U.S. study¹³⁰ found that utilization specific to the neck and the use of massage was 7 percent. A single study¹¹⁸ evaluating unspecified back pain reported a rate of 55.5 percent (95 percent CI< 54.1–57.0) for massage use. Similarly, the three publications^{51, 119, 121} evaluating LBP reported high rates of use that varied from 15 to 56 percent. Three publications^{116, 117, 131} evaluated rates of massage use reported for neck and back pain combined; in one study¹³¹ 7 percent of respondents saw massage therapist. In the other two publications 39 to 42 percent received massage.^{116, 117}

Massage use as complementary care or combined with other CAM therapies. Of the five publications providing some information regarding conventional care with CAM, three¹¹⁶–¹¹⁸ had not stratified the proportions specific to persons reporting back pain and one did not stratify by practitioner type.¹¹⁹ A single study¹³¹ indicated that 4 percent of combined neck and back patients saw a medical doctor and a massage therapist; similarly, 3 percent saw a medical doctor, a chiropractor, a physiotherapist and a massage therapist.¹³¹

The majority of publications did not provide detail regarding concurrent or additional use of other CAM therapies with massage, specific to persons with back pain and stratified by therapy. In one study⁵¹ 37 percent of patients receiving massage, also received acupuncture concurrently. Similarly, one study¹³¹ reported concurrent use of massage and chiropractic in 5 percent of the sample. Another study¹³⁰ of persons with neck pain indicated that up to 12 percent of patients used other CAM therapies, including Reiki, energy healing, and acupuncture.

Quality assessment for non-U.S. massage publications. Five publications¹¹⁶–^{119, 131} were cross-sectional in design recruiting randomly selected national or provincial samples; although derived from large samples, the response rates were relatively low varying from 19 to 69 percent. The survey methodology employed within these studies was of high quality, using pre-tested questionnaires. Three studies employed single group prospective design with subjects recruited from general medical practices^{51, 130} or from an administrative database for physical therapy;¹²¹ one of these¹³⁰ recruited a small sample relative to the other studies. The overall quality of these studies would be rated as fair.

Summary of use for back pain for non-U.S. massage publications. Of the eight publications undertaken outside of the U.S., four were from Canada,¹¹⁶–^{118, 131} two from the Netherlands,^{121, 130} one from Germany,⁵¹ and one from Australia.¹¹⁹ Five publications¹¹⁶–^{119, 131} were cross-sectional in design recruiting randomly selected national or provincial samples. Within these studies utilization rates varied from 7 percent¹³¹ for seeing a massage therapist within the past 4 weeks to 42 percent for lifetime use.¹¹⁶ Generally, studies of single group prospective design showed higher rates from 56 percent from an administrative database¹²¹ to 30 percent.⁵¹ The exception to this was a single study that evaluated massage use in persons with neck pain which reported a 7 percent rate of use at baseline.¹³⁰

All but one publication¹³⁰ queried the use of massage within 12 months or less (as recent as 4 weeks). None of the publications provided detail as to the specific type of massage received by persons with back pain, or the type of provider.

The sole study evaluating neck pain¹³⁰ reported a rate of 7 percent utilization. Rates of use for LBP or combined neck and back pain were generally higher, varying from 15 (6-month use) to 42 percent (lifetime use). Based on this single study for neck pain, it is difficult to establish whether or not the rate of massage use varies based on anatomical location.

While five publications provided some information regarding conventional care with CAM, four of these did not present results stratified by back pain or practitioner. A single study¹³¹ indicated that 4 percent of combined neck and back patients receiving massage also saw an M.D. concurrently; similarly, 3 percent saw an M.D., a chiropractor, and a physiotherapist in addition to a massage therapist.¹³¹ Only three studies reported on concurrent use of massage with other CAM therapies such as acupuncture⁵¹ (37 percent), chiropractic¹³¹ (5 percent), or mixed therapies¹³⁰ (12 percent receiving either Reiki, energy healing, and acupuncture).

Specific CAM Therapy Utilization: Chiropractic/Spinal Manipulation

We retrieved the full text of 52 articles that potentially provided information on utilization of chiropractic/spinal manipulative therapy for back pain. One publication⁸³ is not summarized below, as this study included comparison data from three other publications already included. Of the 51 remaining publications, 31 were undertaken solely within the U.S., 15 in other eligible countries, and five included both U.S. and Canadian data. Although, one of the publications²⁵ with U.S. and Canadian data did not stratify results by country, we classified this as U.S. as the majority of data was not Canadian.

Chiropractic/Spinal manipulation utilization within the U.S. Thirty-six publications on chiropractic and spinal manipulation, were undertaken in the U.S. The study design varied and included 15 single group prospective cohort study publications,^{11, 15, 17, 20, 22}–^{25, 27, 30, 34, 38, 41, 43, 44} 10 retrospective reviews of patient records or claims data,^{16, 21, 28, 32, 33, 36, 37, 39, 40, 42} and 10 cross-sectional publications.^{9, 12}–^{14, 18, 19, 26, 29, 31, 35} One study was a randomized controlled trial.¹⁰

The majority (n = 24) focused on LBP.^{9, 11, 16}–^{24, 27, 28, 30}–^{33, 35, 37}–⁴² Three publications presented information on neck pain,^{25, 40, 44} one the thoracic spine,⁴⁰ six on combined spinal sites¹²–^{14, 26, 36, 39} and seven unspecified back region.^{10, 15, 25, 29, 34, 38, 44} Sixteen of 24 publications on LBP and the one study of neck pain provided details on the duration of patients' complaints. Twelve of the publications reported on chronic complaints,^{9, 11, 18, 21, 22, 24, 27, 28, 31, 37, 41, 42} three on acute pain,^{19, 20, 30} and two on a range of duration.^{20, 33}

Chiropractors were the providers of spinal manipulative therapy in 34 of the publications,⁹–^{29, 31}–^{34, 36}–⁴⁴ and physiotherapists in the remaining two.^{30, 35}

Details on the type of spinal manipulation was provided in three publications;^{15, 24, 33} one clarified that 75 percent of manual therapy provided was “manual, high-velocity, low-amplitude manipulation”,²⁴ and one defined the manual therapy provided as “specific, short-lever dynamic thrusts (or spinal adjustments) or non-specific, long-lever manipulation”.³³ The study by Sherman et al.,¹⁵ noted that the predominant manipulation provided was of the diversified type.

Table 12A

Utilization of chiropractic/manipulation in persons (more...)

Table 12A

Utilization of chiropractic/manipulation in persons with neck pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Cherkin44 2002 U.S. Companion to Sherman15 2006 U.S.	SGPS	SAQ	Visits to practitioner in a 12-month period	130 chiropractors/488 eligible practitioners	Practitioners from several professions	Any condition	Visit to practitioner	Massachusetts: 304/1,349 (22.5%) Arizona: 294/1,201 (24.5%)
Hawk25 2000 U.S.	SGPS	SAQ	17 week followup period	8,312 patients all ages ≥55: 805 (9.7%)	Undergoing chiropractic care	Acute, subacute, and chronic	Visit to a D.C.	All patients Neck Pain: 1,388/8,312 (16.7%) ≥55: 68/805 (8.5%)
Metz40 2004 U.S.	Retro Rev	AD	claims data from 1997 to 2001	patients with coverage 81,833 without coverage 121,049	Members of a health plan for regional managed care network	With and without coverage for chiropractic Neck pain with discopathy or radiculopathy	All services using ICD-9 codes with a maximum gap of 45 days between claims were called 1 episode of care	Rates of episodes of care (per 1,000 member years) Neck pain: with coverage 44.8% without coverage 30.7%
Studies from outside the United States
Cote135 Canada 2005	Retro Rev	AD SAQ	Claims data and practitioner use 1995	2,486	Patients claiming for disability benefits following an MVA	100% acute whiplash (<30 days since accident)	Visit to D.C.	227/2,486 (9.1%) D.C. care alone; 4.6% attended for 1–6 visits 4.5% attended for >6 visits
Hartvigsen134 2002 Denmark	CS	SAQ	Ever have treatment	176 Chiropractic clinics 1,897 patients within these practices	Chiropractic clinics	Neck or LBP	Any visit to a D.C.	Percent of patients seeing D.C. Neck: 9.2% Thorax: 7:0 % Low back: 40.7%
Hawk25 2000 Canada	SGPS	SAQ	17 week followup period	8,312 patients all ages ≥55: 805 (9.7%)	Undergoing chiropractic care	Any condition	Visit to a D.C.	All patients: 1,388/8,312 (16.7%) ≥55: 68/805 (8.5%)
Kilaver124 1997 Norway	CS	SAQ	Any visit to a D.C.	Patients within D.C. practices: 2,154 Patients 631 (29.3%) referred by M.D. 1,523 (70.7%) non-referred	Adult chiropractic patients	Various conditions	Ever seen a D.C.	Based on D.C. diagnosis cervicalgia and cervicobrachialgia 111/1,523 (7.3%) Non-referred patients 52/631 (8.3%) referred patients

Abbreviations: AD = administrative database; CAM = Complementary and Alternative Medicine; D.C. = Doctor of Chiropractic; ICD = International Classification of Diseases; LBP = Low back pain; M.D. = Medical Doctor; MT = massage therapist; MVA = Motor Vehicle Accident; SAQ = Self-administered questionnaire; SGPS=Single group prospective study

Table 12B

Utilization of chiropractic/manipulation in persons (more...)

Table 12B

Utilization of chiropractic/manipulation in persons with neck pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Cherkin44 2002 U.S. Companion to Sherman15 2006 U.S.	NSBP	NSCAM
Hawk25 2000 U.S.	NSBP	NSCAM
Metz40 2004 U.S.	NSBP	NSCAM
Studies conducted outside the United States
Cote135 2005 Canada	11.8% pursued D.C. and GP care concurrently	NSCAM
Hartvigsen134 2002 Denmark	NSBP	NSCAM
Kilaver124 1997 Norway	Not applicable	NSCAM

Abbreviations: CAM = Complementary and Alternative Therapy; D.C. = Doctor of Chiropractic; GP = General Practitioner; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy

Table 13A

Utilization of chiropractic/manipulation in persons (more...)

Table 13A

Utilization of chiropractic/manipulation in persons with unspecified back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Bruce10 2005 U.S.	RCT	SAQ	Past 12 months	Intervention: 190/296 (64.1%) Control: 231/ 284 (81.3%)	Recurrent back pain, not receiving any disability insurance	Recurrent back pain Mean duration of back pain 13.4 yrs (SD=10)	Baseline: “Ever tried D.C.” Could include ≥1 CAM therapy 1 year: “D.C. in past 6 months”	Baseline Intervention: 120/190 (63%) Control: 150/231 (65%) Outcomes Intervention: 8/190 (3.8%) Control: 10/231 (4.2%)
Cherkin44 2002 U.S.	SGPS	SAQ	Visits to practitioner in a 12 month period	130 chiropractors 488 eligible practitioners	Practitioners from several professions, were asked to collect patient information	Any condition	Visit to practitioner	% primary reason of chiropractic visit Massachusetts: 596/1,349 (44.2%) Arizona: 492/1,201 (41.0%)
Hawk25 2000 U.S.	SGPS	SAQ	17 week followup period	8,312 patients all ages 805 aged 55+	Undergoing chiropractic care	Any condition	Visit to a D.C.	All patients Back Pain: 3,142/8,312 (37.8%): ≥55: 265/805 (32.9%)
Hurwitz29 1997 U.S.	CS	TI	Past 12 months	4,790	Survey data from randomly sampled adults with reported back pain	Majority of conditions were chronic traumatic (36.5%) or non-traumatic (27.5%)	Visit to practitioner	3.5% (168) attended a D.C. during the 2-week reference period 43.6% of these had more than 1 visit
Shekelle34 1995 U.S. Shekelle43 1995 U.S.	SGPS	AD	Tracked use over a 3 to 5 year period	Data on 1,020 episodes of back pain care made by 686 different persons	From the RAND Health Insurance Experiment	100% had back pain, defined as “pain, swelling, injury of back region”	“A visit or series of visits that belong together”	D.C.s were primary providers for 40% of all episodes of back pain D.C.s were the first provider for 38% of all episodes of back pain D.C.s provided a mean number of 10.4 visits per episode D.C.'s had a retention rate of 92% for 2nd visits
Shekelle38 U.S. 1991	SGPS	AD	Tracked use over a 3 to 5 year period	5,279	Enrolled in Health Insurance Experiment; from these 395 (7.5 %) made at least one visit to a D.C.	Pain, swelling, injury for the back region	Visit to practitioner	Per 100 person-years from 19,021 person years: 17.4 (42.1%) specified that problems with the back region was the main reason for the D.C. visit Back problems plus adjustment accounted for 50% of visits overall (varying from 41 to 69% depending on the site)
Sherman15 U.S. 2006	SGPS	SAQ	Visits to practitioner in a 12-month period	130 randomly selected D.C.s provided data on 523 consecutive patient visits	Patients with chronic BP in two states	100% had chronic BP	visit to D.C.	Per 100 person-years from 19,021 person years: 17.4 (42.1%) specified that problems with the back region was the main reason for the D.C. visit Back problems plus adjustment accounted for 50% of visits overall (varying from 41 to 69 % depending on the site)
Studies from outside the United States
Foltz118 2005 Canada	CS	TI	Past 12 months	Complete sample 66,253 Non-specific chronic BP 11,736 (17.7%) CAM users 3,259 (39%)	Subset from a large national general sample collected from 1996 to 1998 groups identified as “chronic BP or musculo-skeletal disease”	Chronic BP was diagnosed by a health professional	‘CAM users’: 1) received or discussed CAM with a non-mainstream practitioner 2) used a support group for health problem 3) received care from D.C.	Of the chronic BP respondents, 39% had used CAM during the past 12 months 74.4% had attended a D.C. in the past 12 months
Giles126 2003 Australia	SGPS	HRR SAQ	Visits between 1995 and 2001	1,775	Patients attending a hospital based, multidisciplinary spinal pain unit	100% with spinal pain; 941 patients could recall when their symptoms began 92.7% reported CBP (>3 months duration)	Visit to D.C.	208/1,175 (11.7%) were managed with chiropractic manipulation
Ong136 2005 U.K.	CS	SAQ	3 months	1,377	Randomly selected adults in 4 counties of England	100% had back pain, including sciatica, lumbago and disc problems	Visit to practitioner	In the past 3 months 11.4% of respondents had sought osteopathy or D.C. care, and 2% had sought osteopathy or D.C. care and PT care

Abbreviations: AD = administrative database; BP = back pain; CAM = complementary and alternative medicine; CLBP = Chronic low back pain; CS = Cross-sectional; D.C. = Doctor of Chiropractic; FI = Face to face interview; HRR = Health record review; LBP = Low back pain; M.D. = Medical Doctor; MT = massage therapist; NP = Naturopathic Physician; RCT = randomized controlled trial; SD = standard deviation; SAQ = Self-administered questionnaire; SGPS = Single group prospective study; TI = Telephone interview

Table 13B

Utilization of chiropractic/manipulation in persons (more...)

Table 13B

Utilization of chiropractic/manipulation in persons with unspecified back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Bruce10 2005 U.S.	Not collected	Not reported but data presented indicated respondents had used 1 or more CAM therapy
Cherkin44 2002 U.S.	NSBP	NSCAM
Hawk25 2000 U.S.	NSBP	NSCAM
Hurwitz29 1997 U.S.	Not reported	Not reported
Shekelle34 1995 U.S. Shekelle43 1995 U.S.	Not reported	Not reported
Shekelle38 1991 U.S.	Not reported	Not reported
Sherman15 U.S. 2006	Not reported	Physiotherapeutics (hot, cold, electrical stimulation, ultrasound) Arizona 5% Massachusetts 4%
Studies conducted outside the United States
Foltz118 2005 Canada	CAM users reporting visit to: Any physician: 6.2% (95% CI 6.0–6.4) GP: 5.1% (95% CI 5.0–5.3) Specialists: 1.1% (95% CI 1.0–1.2) PT: 2.4% (95% CI 2.2–2.4) Psychologists: 0.3% (95% CI 0.3–0.3)	Concurrent use evident but data not stratified by type of CAM therapy
Giles126 2003 Australia	Not reported	Not specified
Ong136 2005 U.K.	Not reported	11.4% of respondents had sought osteopathy or D.C. care, and 2% had sought osteopathy or D.C. care and PT care

Abbreviations: CAM = Complementary and Alternative Therapy; D.C. = Doctor of Chiropractic; GP = General Practitioner; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy; PT = Physical Therapist

Table 14A

Utilization of chiropractic/manipulation in persons (more...)

Table 14A

Utilization of chiropractic/manipulation in persons with low back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Carey9 1995 U.S.	CS	TI	Past 12 months	269/4,437 (3.9%) CLBP 186/289 analyzed for care seeking	General population	100% with CLBP (functionally limited for >3 months or >25 episodes of back pain)	Visit with health provider, lifetime prevalence	24.6% attended a D.C. mean visits 15.7 22% received SMT
Carey31 1996 U.S.	CS	TI	Past 12 months	485 acute LBP 180 saw D.C. or M.D.	Adults	At least one occurrence of acute severe LBP in 1991	Visit to practitioner	13.6% (66) attended a D.C. during their most recent episode of pain
Carey 27 1999 U.S.	SGPS	TI	Followed for 22 months after initial episode of LBP	6 months: n = 921 22 months: n = 754 (81.9%)	Patients presenting with acute LBP	Recurrent episodes from 6 to 22 months	Visit to practitioner	Chiropractic care: 6 months: 354/921 (38.4%) 22 months: 294/754 (38.9%)
Cote17 2005 U.S. and Canada	SGPS	SAQ	6 months	1,017/1,104 (92%) received health care	Workers with incident episodes of LBP	All subjects made a workers' compensation claim for LBP, with or without leg pain or sciatica	Visit to practitioner	During the first 4 to 16 weeks after an episode of occupational LBP 4.1% attended a D.C. only
Feuerstein19 2004 U.S.	CS	TI and diaries	Not reported	Treated for back pain 1987: 1,053 1997: 1,082	Adults	All responders had non-specific LBP; 1987: 51.23% acute 1997: 53.22% acute	Visit to practitioner	1987: 40.48% of respondents sought D.C. care for mean 9.2 visits 1997: 30.63% of respondents sought D.C. care for mean 7.8 visits
Gilkey41 2002 U.S.	SGPS	SAQ	Recall 2 weeks, 1 year and lifetime	335	Hispanic (His):241 non-Hispanic (nHis):94 reported continuous LBP His = 15% nHis = 32%	Reported continuous LBP His = 15% nHis = 32%	Visit to practitioner	9.9% attended a D.C. 3% His went to D.C. 28% nHis went to D.C.
Hurwitz28 1998 U.S. and Canada Companion to Coulter21 2002 U.S. and Coulter42 2005 U.S.	Retro Rev	HRR	Records from 1985 to 1991	1,397 charts	1,397 charts from U.S. D.C.'s offices	65.9% sought care for LBP (21.2% >6 months duration) 42.8% sought care for face and neck pain 20.0% sought care for mid-back pain	A period of time with no more than 30 days between visits	920 patients with LBP: 84.0% received SMT Median duration of chiropractic treatment for LBP U.S. sites 29 days; mean 61.7 days Median visits 7; mean 15.6 visits
Jette35 1994 U.S.	CS	TI and SAQ	Out patient visits over 1 year	2,328	Patients discharged from outpatient PT services (private practice and hospital)	Primary reason for seeking care was either sprain/pain of the lumbar back or degenerative disk disease	Visit to practitioner	33.5% received manual therapy either in isolation or combined with other treatment
Lind16 2005 U.S.	Retro Rev	AD	Out patient visits over 1 year	104,358/601,044 (17.4%) had back pain and were eligible for study	Individuals enrolled in health insurance plans and allowed outpatient visits	Back pain	Visit to practitioner	46% LBP attended a D.C. 33% attended only a D.C. Median of D.C. visits: 4
Long11 1996 U.S.	SGPS	SAQ	Past 12 months	2,374/4,171 (56.9%) had complete data and followup	Adult patients presenting for orthopedic surgery or neurosurgery consultation	100% of patients presented with persistent LBP (mean duration of current episode was 2.52 years)	Treatments or visits to CAM practitioner	Prior to their surgical consultation 46.7% patients had consulted a chiropractor, and 41.3% patients had undergone chiropractic manipulation
Metz40 2004 U.S.	Retro Rev	AD	Claims data from 1997 to 2001	With coverage 124,727 without coverage 220,949	Members of a health plan for large regional managed care network	With and without coverage for chiropractic-LBP with discopathy or radiculopathy	Rates of episodes of care (per 1,000 member years)	LBP: 64.4% with coverage 57.8% without coverage
Mielenz30 1997 U.S.	SGPS	TI	Past 12 months	1,540 had acute LBP	Patients recruited from healthcare providers	100% with acute LBP (<10 week duration)	Visit with a healthcare provider, lifetime prevalence	21% received SMT or an adjustment
Nyiendo37 1991 U.S.	SEPS	AD	Disabling back claims filed June to Dec 1985	94	A random sample of adults who filed an insurance claim and attended a D.C. in Oregon	100% with LBP; 49% soft tissue injuries; none had persistent nerve root compromise	Patient visit to the treating physician or hospital or any auxiliary personnel	Over the duration of their claim patients attended a D.C.: 41 visits (SD = 47) average treatment period 53 weeks (SD = 49) 93.6% received manipulation as part of their treatment
Nyiendo24 2000 U.S.	SGPS	SAQ TI	Past 12 months	38	Patients recruited from clinics M.D.: 45 D.C.: 93	100% with chronic LBP (>6 weeks duration)	Patient visit to the treating physician or hospital or any auxiliary personnel	Over the duration of their claim, patients attended a D.C.: 41 visits (SD = 47) Mean treatment period was 53 weeks (SD = 49) 93.6% received manipulation as part of their treatment
Nyiendo22 2001 U.S.	SGPS	SAQ HRR	Past 12 months	268	M.D. clinics: n = 121 D.C. clinics: n = 147	100% with chronic LBP and sciatica (>6 weeks duration)	Visit to practitioner	Of those who received adjustments, 61% received full spine adjustment and 39% received an adjustment only to the lumbopelvic region Mean no. of visits to D.C. was 4.3 (SD=3.0)
Nyiendo23 2001 U.S.	SGPS	SAQ HRR	Past 12 months	835	M.D. clinics: n = 309 D.C. clinics: n = 526	100% with chronic LBP (>6 weeks duration)	Visit to practitioner	Mean # visits to D.C.: 8.72 (SD=9.27) 91.8% attending a D.C. received spinal manipulation
Shekelle33 1995 U.S.	Retro Rev	HRR	Past 12 months	80 patients records were selected (10 from each of 8 chiropractic practices)	Patient record from random sample of chiropractic practices	100% with LBP (56% <3 weeks duration; 25% >13 weeks duration)	First visit between specified interval	79% SMT 77% non-thrust 25% massage 12% U/S 8% electro-acupuncture
Sherman18 2004 U.S.	CS	TI	Past 12 months	249	Individuals registered with health care organizations	100% with chronic LBP (>3 months duration)	Reported ‘ever tried’	45% surveyed had previously tried chiropractic for LBP
Stano32 1996 U.S.	Retro Rev	AD	Claims data from 1988 to 1990	6,183	Patients with insurance claims	Each patient had a claim with a low back ICD-9-CM code	ICD9 code	45% surveyed had previously tried chiropractic for LBP
Stano20 2002 U.S. Companion to Nyiendo22,23 2001 U.S.	SGPS	HRR SAQ	Past 12 months	2,872 total 922 medical patients 1,950 chiropractic patients	Patients with ALBP and CLBP	Acute and chronic ambulatory LBP of mechanical origin	Frequency of therapy procedure codes used	8,712 regional manipulations 577 supplementary manipulations 406 manipulations of the spine
Wasiak39 2006 U.S.	Retro Rev	AD	Claims data from 1999 to 2002	13,734	Workman's Compensation claimants	100% with a compensable low back injury (of which 81% claimed low back strain)	At least one visit to a D.C. in a 4-year period	64.8% had all compensable D.C. services in 1 year Median annual visits to a D.C. 5 to 15
Studies from outside the United States
Armstrong132 2003 U.K.	Retro Rev	HRR	Patient records from 1995-1996	200	Patients in the U.K.	100% with LBP lasting more than 24 hours, with or without referral of symptoms into the lower extremities	Visit to a physiotherapist	3% of patients received manipulation
Burton122 2004 U.K.	SGPS	FI SAQ	12 months	151	Patients attended for manipulative care at a single U.K. clinic	100% presented with LBP	Visit to osteopath	76 respondents sought further care, of these 56.5% consulted an osteopath again
Caswell128 2002 U.K.	CS	SAQ	NR	50	U.K. patients not using CAM	100% with chronic LBP (at least 6 months duration)	Visit to CAM practitioner	40% using CT attended an osteopath 40% using CT attended a chiropractor
Hartvigsen134 2002 Denmark	CS	SAQ	Ever have treatment	176 chiropractic clinics and 1,897 patients	D.C. clinics	Neck or back pain	Any visit to a chiropractor	Patients seeing D.C. Neck: 9.2% Thorax: 7:0 % Low back: 40.7%
Hurwitz28 1998 Canada and U.S. Companion to Coulter21 2002 U.S. Coulter42 2005 U.S.	Retro Rev	HRR	Episodes of care from 1985 to 1991	519	Charts from Canadian D.C.'s offices	75.1% LBP (20.3% >6 months duration) 29.7% face and neck pain 13.1% mid-back pain	Period of time with no more than 30 days between visits	Of 390 patients with LBP: 80.8% received SMT Median duration of chiropractic treatment: Canadian sites 29 days mean 57.3 days Median visits: Canadian sites 6; mean 10.5 visits
Jacobs133 2004 Canada	CS	FI	Past 12 months	4,158	Adults	100% with CLBP (duration of ≥6 months)	Any visit to practitioner in past 12 months	32.1% of respondents attended a D.C.
Kilaver124 1997 Norway	CS	SAQ	Any visit to a D.C.	Within D.C. practices: 2,154 patients; 631 (29.3%) referred by M.D.; 1,523 (70.7%) non-referred	Adult chiropractic patients	LBP	Ever seen a D.C.	LBP: 59.4% referred 61.5% non-referred 58% from 0 to 3 months duration Sciatica: 11.3% referred sciatica 12.7% non-referred sciatica 44% from 0 to 3 months duration
Scheurmier129 1998 U.K.	SGPS and Retro Rev	HRR	Past 4 months	484	Patients from GP practices	100% with acute LBP (duration <6 weeks)	Visit to practitioner	Referred to D.C.: 2% before project 28% during project Mean project visits 5.7 Referred to OT: 0% before project 25% during project Mean project visits 4.2 Referred to PT: 72% before project 21% during project Mean project visits 5.0
Walker119 2004 Australia	CS	SAQ	Past 6 months	1,913/2,748 (69.6%) 1,228/1,913 (64.1%) ≥1 episode back pain	Individuals from the electoral roll	100% reported LBP in the last 6 months	Visit to CAM practitioner	547/1,228 (44.5%) sought care for LBP Of those who sought care, 78/547 (6.4%) exclusively from a D.C.

Abbreviations: AD = administrative database; ACBP = acute low back pain; CAM = Complementary and Alternative Medicine; CLBP = Chronic low back pain; CS = Cross-sectional; CT = complementary therapy D.C. = Doctor of Chiropractic; FI = Face to face interview; HRR = Health record review; LBP = Low back pain; M.D. = Medical Doctor; MT = massage therapist; NP = Naturopathic Physician; OP = occupational therapy; PT = physical therapist; SAQ = Self-administered questionnaire; SGPS = Single group prospective study; SMT = spinal manipulative therapy; TI = Telephone interview; U/S = ultrasound

Table 14B

Utilization of chiropractic/manipulation in persons (more...)

Table 14B

Utilization of chiropractic/manipulation in persons with low back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Carey9 1995 U.S.	NSCAM	NSCAM
Carey31 1996 U.S.	NSCAM	NSCAM
Carey 27 1999 U.S.	Patients with initial consult with D.C. more than twice the Number of patients seeking M.D. care D.C. vs M.D. OR = 2.5 (95% CI, 1.5–4.3)	NSCAM
Cote17 2005a U.S. and Canada	9.7% attended a M.D., D.C., & PT 5.3% attended a M.D. & D.C. 1.2% attended a D.C. & PT	Not reported
Feuerstein19 2004 U.S.	Not stratified by treatment	NSCAM
Gilkey41 2002 U.S.	Not stratified by therapy	No other CAM use reported
Hurwitz28 1998 U.S. and Canada Companion to Coulter21 2002 U.S. and Coulter42 2005 U.S.	Not applicable only D.C. in study	NSCAM
Jette35 1994 U.S.	8.0% received manual therapy and exercises	11.9% received manual therapy, exercises and modalities
Lind16 2005 U.S.	Not stratified by therapy 12% of CAM users also saw conventional provider	NSCAM
Long11 1996 U.S.	Not stratified by therapy	NSCAM
Metz40 2004 U.S.	NSBP	NSCAM
Mielenz30 1997 U.S.	Not applicable	NSCAM
Nyiendo37 1991 U.S.	Did not look at concurrent use of chiropractic and medical care	NSCAM
Nyiendo24 2000 U.S.	Did not look at concurrent use of chiropractic and medical care	NSCAM
Nyiendo22 2001 U.S.	Not applicable	NSCAM
Nyiendo23 2001 U.S.	Not applicable	NSCAM
Shekelle33 1995 U.S.	Not applicable	NSCAM
Sherman18 2004 U.S.	Hypothetical question posed in this report	NSCAM
Stano32 1996 U.S.	Examination of medical claims vs chiropractic claims	NSCAM
Stano20 2002 U.S.	Not applicable	PT modalities were frequently used with massage and trigger point therapy used most often
Wasiak39 2006 U.S.	Not applicable	NSCAM
Studies conducted outside the United States
Armstrong132 2003 U.K.	Not applicable	NSCAM
Burton122 2004 U.K.	Not stratified by practitioner	NSCAM
Caswell128 2002 U.K.	62% CAM users sought conventional care to manage their pain 36% using conventional treatment plus D.C., OT or AT	NSCAM
Hartvigsen134 2002 Denmark	NSBP	NSCAM
Hurwitz28 1998 Canada and U.S. Companion to Coulter21 2002 U.S. and Coulter42 2005 U.S.	Not applicable only D.C. in study	NSCAM
Jacobs133 2004 Canada	NSBP	NSCAM
Kilaver124 1997 Norway	Not applicable	NSCAM
Scheurmier129 1998 U.K.	NSBP	NSCAM
Walker119 2004 Australia	59% attended multiple providers 3.3% from a GP and D.C. 1.5% from a GP, D.C., MT	NSCAM

Abbreviations: AT = Acupuncture Therapy; CAM = Complementary and Alternative Therapy; D.C. = Doctor of Chiropractic; M.D. = Medical Doctor; MT = Massage therapist; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy; OR = Odds Ratio; OT = Occupational Therapy; PT = Physical Therapist

Table 15A

Utilization of chiropractic/manipulation in persons (more...)

Table 15A

Utilization of chiropractic/manipulation in persons with combined neck and back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Fleming13 2007 U.S.	CS	FI	Past 12 months	908	Patients receiving opioids for chronic pain	38.4% had chronic LBP (>3 months) 6.8% presented with chronic neck/upper back pain (>3 months)	Visit to practitioner	Of those who attended a D.C. for any complaint the average number of annual visits was 14.1
Hawk26 1999 U.S.	CS	TI	Past 12 months	1,511	Respondents to a 1994 population-based survey	Neck and back pain that required that respondent missed work	Visit to practitioner	44/103 (42.7%) attended a D.C.
Hurwitz14 2006 U.S. and Canada	CS	TI	Past 12 months	595/5,183 (11.4%)	Respondents to a population health survey (Joint Canada/U.S. Survey of Health 2002-2003)	Neck or back problems responsible for difficulties with performing activities of daily living	Number of visits or contacts with various types of health professionals in the past 12 months	Results for U.S. only: 16.3% of respondents who saw a D.C. were for back or neck problems 9.1% of total sample
Jarvis36 1991 U.S.	Retro Rev	HRR	12-month period	3,062 from 7,551 files (40.6%)	Back injury claims	Various conditions	Visit to D.C. practitioner	D.C.s provided patients with an average of 12.9 treatments over an average of 54.5 days Top 3 diagnoses were: sprain/strain lumbosacral spine (21.4%), sprain/strain cervical (15%) sprain/strain lumber (15%)
Wolsko12 2003 U.S.	CS	TI	Past 12 months	644/2,055 (60%)	Individuals who have had neck or back pain in the past 12 months	46% had pain in more than 1 location 38% had LBP only 16% had neck or upper back pain only	Use of CAM therapy or visit to CAM practitioner	19.8% attended a D.C. in the Mean number of visits 8.5
Studies from outside the United States
Cote131 Canada 2001	CS	SAQ	Past 4 weeks	2,184 in the sample 1,131(55%) participated 907/1,131 (80%) had back or neck pain	Health insurance and registration file	100% had back and/or neck pain in the past 6 months	Visit to healthcare provider	215/907 (24.7%) visited a healthcare provider in the past 4 weeks 28.8% saw a D.C. alone
Esmail117 2007 Canada Companion to Ramsay116 1999 Canada	CS	TI	Past 12 months	Second wave (Esmail): 2,000 respondents response rate 18.8%. 30% reported having back or neck problems	General adult population in Canada	30% reported back or neck problems in the past 12 months	Use of a CAM therapy or visit with a practitioner who is not a medical doctor	41% of respondents with back or neck pain had attended a CAM provider in the past 12 months, most commonly a D.C. 68% of all visits to D.C.s were for back and/or neck pain
Hurwitz14 2006 Canada and U.S.	CS	TI	Past 12 months	448/3505 (12.8%)	Population health survey (Joint Canada/U.S. Survey of Health 2002-2003) who received any chiropractic care	Neck or back problems responsible for difficulties with performing ADL	Number of visits or contacts with various types of health professionals in the past 12 months	Results for Canada only: 20.1% of respondents who saw a D.C. were for back or neck problems 10.4% of total sample
Ramsay116 1999 Canada	CS	TI	Past 12 months	1,500	Survey of randomly selected Canadian adults	30% reported back or neck problems in the past 12 months	Use of CAM therapy or visit with a practitioner who is not an M.D.	11% with back or neck problems in the past 12 months attended an alternative provider, most commonly a chiropractor

Abbreviations: AD = administrative database; ADL = Activities of Daily Living; CLBP = Chronic low back pain; CS = Cross-sectional; D.C. = Doctor of Chiropractic; HRR = Health Records Review; SAQ = Self-administered questionnaire; SGPS = Single group prospective study; TI = Telephone interview

Table 15B

Utilization of chiropractic/manipulation in persons (more...)

Table 15B

Utilization of chiropractic/manipulation in persons with combined neck and back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Fleming13 2007 U.S.	NSBP	NSCAM
Hawk26 1999 U.S.	NSBP	NSCAM
Hurwitz14 2006 U.S. and Canada	85.3% received both D.C. and GP care	Not specified
Jarvis36 1991 U.S.	Not reported	Not reported
Wolsko12 2003 U.S.	NSCAM 25% had used both complementary medicine and a conventional provider	Used any CAM: from those with back and neck pain, 29% had used CAM alone, concurrent use not specified
Studies conducted outside the United States
Cote131 Canada 2001	7.9% saw a GP and a D.C. 2.8% saw a GP, D.C., and PT 2.8% saw a GP, D.C., MT, and PT	5.1% saw a D.C. and a MT
Esmail117 2007 Canada Companion to Ramsay116 1999 Canada	25% had used both complementary medicine and a conventional provider	NSCAM
Hurwitz14 2006 Canada and U.S.	87.7% received both D.C. and GP care	Not specified
Ramsay116 1999 Canada	25% had used both complementary medicine and a conventional provider	NSCAM

Abbreviations: CAM = Complementary and Alternative Therapy; D.C. = Doctor of Chiropractic; GP = General Practitioner; MT = massage therapist; NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy; PT = Physical Therapist

Table 16A

Utilization of chiropractic/manipulation in persons (more...)

Table 16A

Utilization of chiropractic/manipulation in persons with thoracic back pain

Author Year Country	Study Design	Reporting Mode	Timing of CAM Visit	Sample Size	Population	Clinical Presentation	Episode of Care	Outcomes
Studies from the United States
Metz40 2004 U.S.	Retro Rev	AD	Claims data from 1997 to 2001	People with coverage 37,429 Without coverage 42,372	Members of a health plan for large regional managed care network	With and without coverage for chiropractic care of thoracic spine pain	ICD-9 codes used to identify neuro-muscular pain episodes. All services using any of these codes, with a maximum gap of 45 days between claims were aggregated into 1 episode of care	Rates of episodes of care (per 1,000 member years) Thoracic pain: 19.8% with coverage 10.0% without coverage
Studies from outside the United States
Hartvigsen134 2002 Denmark	CS	SAQ	Ever have treatment	176 chiropractic clinics and 1,897 patients within these practices	Chiropractic clinics	Neck or back pain	Any visit to a D.C.	Percent of patients seeing D.C. Thorax: 7:0 %

Abbreviations: AD = administrative database; CLBP = Chronic low back pain; CS = Cross-sectional; D.C. = Doctor of Chiropractic; LBP = low back pain; SAQ = Self-administered questionnaire; SGPS = Single group prospective study; TI = Telephone interview

Table 16B

Utilization of chiropractic/manipulation in persons (more...)

Table 16B

Utilization of chiropractic/manipulation in persons with thoracic back pain

Author Year Country	Use with Conventional Care	Concurrent use with Other CAM
Studies from the United States
Metz40 2004 U.S.	NSBP	NSCAM
Studies conducted outside the United States
Hartvigsen134 2002 Denmark	NSBP	NSCAM

Abbreviations: NSBP = Data not stratified by back pain; NSCAM = Not stratified by CAM therapy

Chiropractic/spinal manipulation utilization based on anatomical region. A single study⁴⁰ provided rates per 1,000 members episodes of care for all three spinal regions and showed a gradient with the thoracic spine being the region for which there was lowest use (10 to 20 percent), the neck, the second most common region (31 to 45 percent), and the low back, the most frequent region receiving chiropractic care (58 to 64 percent). A second study⁴⁴ reported rates of use for two spinal regions and showed lower rates for the neck (23 to 25 percent) relative to unspecified back (41 to 44 percent). A third study²⁵ showed a similar gradient for neck pain (17 percent for all subjects and 9 percent for those aged over 55 years) and unspecified back pain (38 percent for all subjects and 33 percent for those aged over 55 years).

Quality assessment for U.S. chiropractic/spinal manipulation publications. From 36 publications, 10 cross-sectional studies are based predominately on random samples,^{9, 12, 14, 26, 31} systematic samples,^{13, 18, 29} national probability samples,¹⁹ or not reported.³⁵ Response rates varied from 36 to 95 percent; the methods of the surveys and interviews were generally of high quality.

There are 15 single-group prospective cohort study publications;^{11, 15, 17, 20, 22}–^{25, 27, 30, 34, 38, 41, 43, 44} two of these^{15, 44} employed a random sampling of chiropractors. The majority of these papers recruited samples from chiropractic or other professional clinical practices, and as such represent selective groups of patients. From 10 retrospective publications, four were based on patient health records,^{21, 28, 33, 42} two were from large administrative health databases,^{16, 40} and four from workers' compensation databases;^{32, 36, 37, 39} the latter using standardized coding for back injury diagnosis and utilization. Overall, the quality of these studies would be evaluated as fair, noting that biases are present but not sufficient to negate the validity of results.

Summary of utilization in U.S. chiropractic/spinal manipulation publications. Thirty-six publications⁹–⁴⁴ on chiropractic and spinal manipulation, were undertaken in the U.S. The majority (n = 24) reported on LBP and the fewest on neck (n = 3) and thoracic spine (n = 1). Our review suggests that chiropractic care/spinal manipulation is commonly sought by patients with back pain. From 10 cross-sectional studies^{9, 12}–^{14, 18, 19, 26, 29, 31, 35} based predominately on random or systematic samples, rates of utilization varied from 16 percent¹⁴ to 45 percent.¹⁸ Eligible U.S. trials on LBP populations found that rates of attending for chiropractic/spinal manipulative therapy range from 10 to 47 percent.^{9, 11, 18, 19, 28, 30, 32, 35, 41} The number of visits for chiropractic care or other providers of spinal manipulative therapy ranged from a mean of 4.3 to 15.7^{9, 19, 22}–^{24, 28, 33} Between 79 percent and 94 percent of treatment by chiropractors included spinal manipulative therapy.^{9, 11, 22, 23, 28, 33, 37} Two studies provided some evidence for a gradient of use based on anatomical regions; LBP was treated most often,^{25, 40, 44} followed by neck, and then thoracic pain.⁴⁰

Chiropractors were the providers of spinal manipulative therapy in most publications (n = 34), and physiotherapists in two publications.^{30, 35} Details on the type of spinal manipulation provided was provided in three only publications.^{15, 24, 33}

The available information suggests that roughly equal proportions of LBP patients use chiropractic as complementary to conventional care and as an alternate. Current literature provides little insight into the manner in which chiropractic/spinal manipulation is combined with other therapies for back pain. Despite the common use of chiropractic/spinal manipulation by patients with back pain the current literature provides limited data on utilization.

Chiropractic/spinal manipulation utilization in non-U.S. publications. Nineteen publications^{14, 21, 28, 42, 116}–^{119, 122, 124, 126, 128, 129, 131}–¹³⁶ on the utilization of chiropractic and spinal manipulation, were undertaken within other eligible countries. The majority of these publications (n = 11) focused on LBP.^{21, 28, 42, 119, 122, 124, 128, 129, 132}–¹³⁴ Three publications presented information on neck pain,^{124, 134, 135} one on the thoracic spine,¹³⁴ three on combined spinal sites,^{116, 117, 131} and three on unspecified back regions.^{118, 126, 136}