Journal of Eeetrmyosraphy and Kneilory 22 (2012) 648-658 Contents lists available at SciVerse ScienceDirect Journal of Electromyography and Kinesiology journal homepag www.elsevier.com/locate/jelekin ELSEVIER Review Epidemiology: Spinal manipulation utilization Eric L. Hurwitz Deparomen of Publi Heath Snes, John A Bars Schoo! of Medicine, Univesity of How, Mano, Homa, HI S582, United Sates ARTICLE INFO ABSTRACT iors The objectives of this article are fo (1) describe spinal manipulation use by ime, place, and person, and Epicemilogy (2) identity predictors ofthe use of spinal manipulation. We conducted 2 systematic review ofthe Eng- Iishlanguage literature published from January 1, 1980 through June 30,2011. Of 822 citations ident- fied, 212 were deemed potentially relevant: 75 were inchided ater further consideration. Twenty-one aéditional articles were identified from reference lists. The literature is heavily weighted toward North “America, Europe, and Australia and thus largely precludes inferences about spinal manipulation use in other parts ofthe world. Inthe regions covered bythe literature, chiropractors, osteopath, and physical therapists are most likely to deliver spinal manipulation, often in conjunction with other conservative therapies Back and neck pain ate the most Frequent indications for receiving spinal manipulation: non-musculoskeletal conditions comprise a very small percentage of indications. Although spinal manip. ‘lation s more commonly used in adults than chien, evidence suggests that spinal manipulation may ‘be more key useé for non-muscuoskeletalalments in chiléren than in adults Patent satisfaction with spinal manipulation is very high © 2012 Elsevier Ltd. All rights reserved 1. Introduction Although spinal manipulation has been practiced for thousands of years in several cultures spanning the globe, itis most com- ‘only associated with chiropractic and osteopathy, which origic nated in the late 1800s inthe United States (Petiman, 2007), The purpose of this article is to review the literature on the use of spinal manipulation, Specifically, our objectives are twofold: (1) To describe spinal manipulation use by time (temporal trends). place (geographic distribution), and person (practitioner and pax tient), and (2) to identify predictors of the use of spinal ‘manipulation, For the purpose of this paper, spinal manipulation is defined ‘operationally as manual therapy techniques referred to as “spinal ‘manipulation’ or “spinal manipulative therapy” in the literature. These techniques include high-velocity, low amplitude (HVLA) ‘manipulation as well as low-force techniques such as spinal mabi- lization, Massage and other manual tnerapy techniques non-spe- Gifie to the spine are excluded. 2. Methods We conducted a systematic review of the English-language lit- ‘erature using the following steps: Formulation ofthe review ques- tion; definition of inclusion and exclusion criteria; locating studies Bina addres eharwitapnavaiieds 1050-6411 se font matter © 2012 Elsevier 4, Al gh ceserved. or 10. 1015201203 008 and development of a search strategy: selection of studies; assess- ment of study quality using a best-evidence synthesis approach: extraction of data; and analysis and interpretation of results (Egger etal, 2002). We defined inclusion and exclusion criteria in terms of patticipants, interventions and comparisons, outcomes, study de- signs, and methodological quality (Carroll etal, 2008). Our search strategy included a Medline search from January 1, 1980 through June 30, 2011, checking of reference lists, and hand-searching of key journals. We kept a log of excluded studies with reasons for exclusions ‘We used the following search string to obtain articles that may have relevance: (spinal manipulation) OR (spinal manipulation therapy) OR (spinal manipulative therapy) OR (spinal mobiliza- tion) OR (chiropractic) OR (manual therapy) OR (osteopathic ‘manipulation) OR (osteopathic manipulation therapy) OR (o: pathic manual therapy) OR (osteopathic manipulative therapy)) AND ((use) OR (utilization). We limited the search to human studies published in English between January 1980 and June 2011. Reference lists from selected articles were searched for addi- tional relevant articles Of 822 citations identified, 213 were deemed potentially rele- vant after an intial screen of the title and abstract. OF the articles retrieved, 138 were excluded after further review; 75 were in- cluded, We identified an additional 21 articles through reference list ofthese articles (Fig, 1). The vast majority of retrieved articles, ‘were deemed irrelevant primarily because the articles (a) focused fn chiropractic or osteopathic care in general; (b) did not include data on the use of spinal manipulation in particular; or (c) wereEL Hurt oural of leewomyoraphy and Kinesiology 22 (2012) 688-854 69 Literature search: PubMed Limits: English-language articles only Dates: January 1, 1980 through June 30, 2011 Search resuls ( Articles screened on basis of tile and abstract “Manascript review and review of references Tacluded ‘From references =21) Excluded (0=138) y t t 4 ‘Temporal | [ Geographic | [ Practitioners | [ Predictors or | [ Manipotation ‘wends distribution} | and patents use in children (0-20) (=) (056) (0222) (o=12) ig 1. How diagram commentaries or article types without empirical data, No studies ‘were specifically excluded because of poor methodological quality Portions of the PRISMA statement for systematic reviews applica- bile to utilization studies were used as a guide for reporting our ‘methods and results (Liberati etal, 2009). The PRISMA statement (Preferred Reporting Items for Systematic reviews and Meta-Anal- ‘yses) consists of a 27-item checklist and a four-phase flow dia gram, The checklist includes items deemed essential for transparent reporting of a systematic review. 3. Results 3.4. Temporal trends Spinal manipulation has increased in use over the past several decades and is one of the most frequently reported complementary and alternative medicine modalities in the US (Fisenberg et al, 1993; Niet al, 2002; Barnes et al, 2008: Su and Li, 2011) and else- where (eg. Menniti-ippolito et al, 2002; Yamashita et al, 2002: ‘Al-Windi, 2004), Under the assumption that the vast majority (greater than 80%) of chiropractic patients receive spinal manipu- lation (Nyiendo and Haldeman, 1987; Shekelle and Brook, 1991: Hurwitz et al, 1998; Nyiendo et al, 2001; Mootz et al, 2005), about 4% of persons in the US had spinal manipulation in 1980 (Mugge, 1984), whereas between 1974 and 1982, 7.5% (41 visits per 100 person-years) received chiropractic services (Shekelle ‘nd Brook, 1991). An estimated 10% of the US population sought chiropractic care in 1990 with an average 13 visits per patient (Eisenberg et al, 1993); however, estimates declined from 9.9% in 1997 to 7.6% in 1999 (Ni et al, 2002) and 7.4% in 2002 (Tindle et al. 2005; Bares et al, 2004). Estimates of annual chiropractic use rates from several studies range from 612% (Lawrence and Meeker, 2007); estimates of chiropractic or osteopathic manipula tion use have not increased between 2002 and 2007 (Barnes etal 2008) ‘A comprehensive literature review of spinal manipulation for low-back pain using data mostly from the 1980s revealed the rate of chiropractic services at approximately 50 visits per 100 person- years (5% of the total population per year; 32-45% of visits for low ack pain with spinal manipulation accounting for 61-82% of all reimbursed services and an average of 5-18 visits per episode) (Shekelle etal, 1992). More recent data from North America sug- ‘gest that visit rates more than doubled to 101.2 visits per 100 pet- son-years in the US and 1409 visits per 100 person-years in Ontario (Hurwitz et al, 1998). However, changes in legislation andjor health policy in the past few years in Canada and the US ‘may have resulted in reductions in visit rates of practitioners of spinal manipulation (Votova etal, 2010; Davis etal, 2010). 3.2. Geographic distribution Although spinal manipulation is used all over the worl, given, ‘that the two professions most identified with spinal manipulation originated in the United States and the vast majority of their mem- ‘bers reside in North America, the literature base is weighted heav- lly toward the US and Canada (Meeker and Haldeman, 2002). Nevertheless, evidence indicates significant geographic variation ‘within and between countries that cannot be explained by simple630 EL HurwitzJoura of Blectromyoeraphy and Kinsley 2 (2012) 8-854 publication bias, For example, in the 1974-1982 RAND Health Insurance Experiment which was designed to represent (a) the four ‘major census regions, (b) both rural and urban areas, and (c dffer- ing levels of demand for health services, chiropractic visit rates be- tween the six sites differed by more than sevenfold (Shekelle and Brook, 1981). Data from 1985-1991 from the US and Canada indi- cate more than twofold differences in the number of visits per epi- sode of low-back-pain care across sites (Hurwitz etal, 1998), Spinal manipulation has become much more common in Aus- tralia and Europe in recent years as the populations of spinal ‘manipulation practitioners have increased markedly with the ‘opening of chiropractic schools, integration into local health-care systems, and the renewed interest in manual therapies among cur- rent health-care providers. In general, findings in Australian and European studies are consistent with the North American patterns of use (Xue etal, 2008; Leboeul-Vée et al. 1997; Hartvigsen etal 2002), though differences exist, For example, chiropractic and oste- ‘pathy are the mast common modes of spinal manipulation in ‘Australia (Zhang etal, 2007; Xue etal, 2008), whereas chiroprac- tic and naprapathy, which are among the four most frequently used complementary therapies, are the most common in Sweden (Al-Windi, 2004). Compated to North America, annual spinal ‘manipulation use rates are generally lower in England {Thomas et al, 2001) and Great Britain (Thomas and Coleman, 2004) but fairly similar in Japan (Yamashita et al, 2002) and italy (Menniti- Ippolito et al, 2002), 433, Practitioners Chiropractors deliver the vast majority of spinal manipulative care in North America (Shekelle et al, 1992; Cété et al, 2001) [Ninety-four percent (84%) of spinal manipulation for which reim- bbursement is sought inthe US is delivered by chiropractors (Shek- elle et al, 1992); osteopathic spinal manipulation accounts for about 4% but has declined in recent years in the US (Johnson et al, 1997; Liceiatdone and Herron, 2001; Johnson and Kurtz, 2002}, possibly because of the increasingly allopathic nature of taining programs that de-emphasize manual therapy (Johnson and Kiurtz, 2002; Johnson and Kutz, 2001), Osteopaths and physi- cal therapists are the second and third leading providers of manip- lative services (Pettman, 2007); however, spinal manipulation is not a common practice among North American and European physical therapists (Li and Bombardier, 2001; Flynn et al. 2006), Data from other parts of the world ate scant, though chiroprac- tors are prevalent in Europe (Leboeut-Yee et al. 1997; Hartvigsen et al, 2002) and Australia (Xue et al, 2008; Sibbritt and Adams. 2010) and likely deliver much of the spinal manipulation in these areas, The 12-month prevalence of chiropractic and osteopathy use in Australia is about 16.1% and 4.6%, respectively (Xue et al. 2008) In contrast to most countries, general practitioners and ambulatory orthopedic surgeons in Germany are often specially trained in spinal manipulation and offer it to their patients (Chenot et al, 2007). For example in a recent cohort study of low-back pain pa- tients consulting GPs in Germany, the majority received some form ‘of CAM and spinal manipulation was the third most common ther- apy alter focal heat and massage (Chenot et al, 2007). Australian physiotherapists frequently employed manipulation, in patients enrolled in a clinical tral of treatment for cervicogenic headache: however, manipulation was used in tandem with other ‘therapies, such as exercise and passive mobilization (Jull, 2002), 2 ‘common practice in chiropractic and osteopathy as well (Christen- sen et al, 2010; Johnson and Kurtz, 2002). Mobilization has been reported to be much more common than manipulation (59% vs. ‘9%) among physiotherapists treating back pain patients in the Uni- ted Kingdom in general (Foster et a. 1999; Gracey etal, 2002) and within a clinical trial of treatments for low back pain (Hurley etal, 2005), 34, Patients ‘Across all geographic regions studied, patients receiving spinal ‘manipulation most commonly report musculoskeletal symptoms of the low-back or neck. For example, in the 1974-1982 RAND Health Insurance Experiment in the US, two-thirds ofall visits to chiropractors were for head, neck or back pain (Shekelle and Brook, 1991), a finding mirroring more recent data indicating that an even greater percentage of chiropractic patients (68%) may be seeking care for low-back complaints (Hurwitz et al, 1998). with non-mus- culoskeletal symptoms comprising a very small minority (Coulter et al, 2002; Coulter and Shekelle, 2005). Low back, neck and head pain accounted for about three-quarters ofall visits to chiroprac- tors in Massachusetts and Arizona, 85% of which included spinal ‘manipulation (Mootz et al. 2005). Similar findings have been re- ported from surveys in California (Gordon and Lin, 2004) and in ‘Arizona, Connecticut, Massachusetts, and Washington State (Cher~ kin et al, 2002). Data from osteopathic practices inthe US suggest that osteopathic manipulative treatment may be used relatively ‘more frequently than chiropractic spinal manipulation for non- ‘musculoskeletal conditions (Johnson and Kurtz, 2002) Chiropractic is the most frequently reported complementary. therapy for back or neck pain in Australia (Walker et al. 2004) and in the US, used by 20% of those with these symptoms in the past year (Wolsko et al, 2003). Sizable use rates have been ob- served in population subgroups, for example 39% among long-term lymphoma survivors (Habermann et al, 2009), 24.5% among pr ‘mary care outpatients (Palinkas ané Kabongo, 2000), 29% among Intercollegiate athletes (Nichols and Harrigan, 2008) and rehabi {ation outpatients (Wainapel et al, 1998), 25.5% in multiple sclero- sis patients (Nayak et al, 2003), and 22% among chronic tension- type headache patients (Rossi et al, 2006), and somewhat lower use rates in others, such as older adults (Astin etal, 2000; Foster et al, 2000; Najm et al, 2003; Cheung et al, 2007), cancer patients, in Washington State (Lafferty et al, 2004), health maintenance organization members in Wisconsin (Hansen and Futch, 1997), ang patients with chronic liver and gastrointestinal diseases in: wan (Yang et al, 2002). Utilization patterns in Europe are generally similar to those of, North America, where the most frequently used complementary and alternative modalities for back pain are chiropractic manipula- tion, massage, and acupuncture (Santaguida et al, 2009), Osteo- paths or chitopractors were seen by 13.4% of respondents with back pain in the past 3 months vs. 8.8% who consulted physiother- apists in the United Kingdom (Ong et al, 2004). In Sweden, low- back pain is the most common teason for seeking chitopractic care and the vast majority receive a short (2-3 treatments) course of spinal manipulation (Leboeuf-Yée et al. 1997), Sixty-five percent of chiropractic patients in Denmatk reported low back (50%) or neck (15%) pain (Hartvigsen etal, 2002), Asin the US and Canada, ‘musculoskeletal complaints make up all but a very small percent age (less than 102) of patients receiving chiropractic care o spinal ‘manipulation, Patients have reported very good or excellent satisfaction or perceived helpfulness with care that has included spinal manipula- tion (Nyiendo and Haldeman, 1987; Hansen and Futch, 1997; Coul- teret al. 2002; Coulter and Shekelle, 2005; Licciardone and Herron, 2001; Hertzman-Miller et al, 2002; Hurwitz et al, 2005; Wolsko etal, 2003; Gaumer, 2006; Boudreau et al. 2006). Ninety-four per- cent of participants treated with chiropractic spinal manipulation ina recent World Games reported immediate improvement (Nook and Nook. 2011).EL Mura ournal of ecwomyoraphy and Kinesiology 22 (2012) 68-854 61 35, Predictors of use Health services researchers have investigated socio-demo- graphic and health-related factors that differentiate users from hhon-users of chiropractic services for the past 30 years or so: how- ever, studies addressing predictors of spinal manipulation use vs other treatment modalities are few and far between. Compared to non-users, chiropractic patients have been shown to be mi dle-aged (Shekelle and rook, 1991; Ni et al, 2002) or older (Cleary, 1982; Mugge, 1984), high school (Shekelle and Brook, 1991; Shekelle et al, 1995; Hurwitz and Morgenstern, 1997) ot college educated (Ni et al, 2002), married (Shekelle and Brook, 1991), single (Hurwitz and Morgenstern. 1997), female (Mugge, 1984; Niet al. 2002), male (Shekelle et al, 1995; Hurwitz and Morgenstern, 1997), white (Mugge, 1984; Deyo and Tsui-Wa, 1987; Shekelle and Brook, 1991; Pedersen et al. 1993; Shekelle et al, 1995; Hurwitz and Morgenstern, 1997; Hawk and Long, 1999; Ni et al, 2002; Mikuls et al, 2003; Grahama etal, 2005; Quan, et al, 2008), non-Hispanic (Mugge. 1984; Ni et al. 2002: Najm et al, 2003; Graham et al, 2005), living in a rural (Hawk and Long, 1999; Laffery etal, 2006; Lind eta, 2009; Sibbrit et al, 2005) vs, urban (Coté et al, 2001) atea or in the West (Deyo and Tsui-Wu, 1987; Hurwitz and Morgenstern, 1997), more acculturated (Lee et al, 2010), and employed (Hurwitz and Morgenstern, 1997); to hhave worse overall health status (Palinkas and Kabongo, 2000: Coulter et al, 2002) including mental (Coulter et al, 2002) and emotional (Palinkas and Kabongo, 2000) health, better overall health status (Carey et al, 1995; Hurwitz and Morgenstern, 1999), multiple chronic health conditions (Cleary, 1982) including. chronic fatigue syndrome (Jones et al, 2007). better social and physical function (C8té et al, 2001), more activity limitations (Mugge, 1984), fewer disabling comorbidities and testricted-activ- ity days (Hurwitz and Morgenstern, 1997) and bed days (Hurwitz and Morgenstern, 1999), longer term pain (Hurwitz, 1994; Hurwitz and Morgenstern, 1997; Smith and Stano, 1997; sibbritt and ‘Adams, 2010), less severe pain (Carey et al. 1995), recent personal jury (Sibbritt etal, 2006); to be high users of conventional med ical care (Cleary, 1982; Hurwitz and Morgenstern, 1997; Ni etal, 2002: sibbritt etal, 2006; sibbritt and Adams, 2010) and comple- mentary care (Sibbritt ane) Adams, 2010); and to have difficulty Midete-aped o ler High shoal or callege educated ‘White o aon spaic Living al urban ae Living the West ce acutuated Employed Heath ‘Warseoveal health stator Recent eran ry Heath care High use of conventional medical cae High use of compiemencary and aernatve medal care Ditty accessing co medal decors Adequate heath insurance accessing medical doctors (Cleary, 1982) or to have adequate health insurance (Carey et al, 1995) (Table 1) ‘A comptehensive analysis of chiropractic and general practice patients in North America revealed that compared with GP only patients in the US and Canada, chiropractic patients tend to be un- ‘der 65 and white, with arthritis and disabling back or neck pain, US chiropractic patients are more likely than GP only patients to be ‘obese and to lack a regular doctor; Canadian chiropractic patients are mare likely than GP only patients to be college educated, to have higher incomes, and dissatisfied with medical care. Compared with seekers of both GP and chiropractic care, chiropractic only pa- tients in both countries have fewer chronic conditions, take fewer «drugs, and have no regular doctor. US chiropractic only patients are ‘more likely than patients using both types of providers to be unin- ssured and dissatisfied with health care; Canadian chiropractic only patients are more likely than patients of both provider types to be under 48, male, less educated, smokers, and not obese, without dis- bling back ar neck pain, on fewer drugs, and lacking a regular doc- tor (Hurwite and Chiang, 2008), In one study evaluating the appropriateness of chiropractic spinal manipulation use in low-back pain patients, manipulation ‘was judged to be appropriate in 46% of cases, uncertain in 25% of cases, and inappropriate in 29% of cases (Shekelle et al, 1998) findings generally consistent with other medical procedures 3.6 Spinal manipulation in children ‘Many studies document the prevalence of spinal manipulation, ‘use among children in the US and elsewhere. According to data from the 2007 National Health Interview Survey, an estimated 2.8% of children in the US received chiropractic or osteopathic ‘manipulation in the past 12 months, second only to non-vitamin, nnon-mineral or natural products among CAM therapies (Barnes et al, 2007). Use rates among pediatric patients are estimated to bbe much higher, for example 18% according to one survey (Saw- nisSikand et al, 2002), Chiropractors are the most frequently seen alternative care provider by children in Canada (S00 et al, 2005), ‘Australia (Smith and Eckert, 2006) and in the US, with approxi- ‘mately 20 million US visits in 1993 (Spigelblatt et al. 1994: Lee et al, 2000) and 30 million in 1997, an increase of 50% (Lee etal 2000}, Spinal adjustments in children were reportedly used by '89% of chiropractors in a Boston area survey (Lee et al, 2000), 2 finding consistent with data from the 2010 practice analysis ofchi- ropractic (Christensen et al, 2010), Two pereent of pediatric pa- tients in Denmark consulted chiropractic in the preceding mont (Madsen et al. 2003), Compared to adul¢ patients, non-musculoskeletal complaints comprise a larger proportion of pediatric chiropractic practice (Spigelblatt et al, 1984): however, chiropractic visits by children are still much more likely to yield musculoskeletal-related diagno- ses (Bellas et al, 2005; Smith and Eckert, 2006). Children with can- cer or other life-threatening conditions or in tertiary settings may ‘be more likely than children in primary care to use chiropractic (Lim etal, 2005; Post-White et al, 2008). One study suggests arel- atively higher proportion of non-musculoskeletal diagnoses among children treated with osteopathic manipulative treatment (43.5% of visits) than chiropractic (Lund and Carreiro, 2010), 4. Discussion This review shows that spinal manipulation is prevalent in ‘many countries and that its use has increased overall in the past several decades at least in the US and Europe, largely in tandem with the rise in complementary and alternative medicine utilization, Evidence from the most recent studies indicates thatost EL Hurwitz Journal of Blectromyoeraphy and Kinsley 2 (2012) 8-854 Utilization rates have stabilized, however. Chiropractors, osteo- paths, and physical therapists are the three types of providers most likely to deliver spinal manipulation. Medical doctors and other practitioners tse spinal manipulation less frequently, though the literature does not enable computation of specific estimates of use. ‘Musculoskeletal conditions are by far the most frequent indica- tions for receiving spinal manipulation, with low back and neck pain being the most common. Non-musculoskeletal conditions comprise a very small percentage of indications. Episodes of care are quite variable ranging from one to hundreds of visits over sev- eral years. A typical pattern of care encompasses visits from 1 to 3 times weekly for several weeks and would depend on the patient's specific condition, treatment outcomes, and reimbursement or insurance plan. Spinal manipulation is often used in conjunction with other modes of therapy. Several studies have shown high pa- tent satisfaction for spinal manipulative care. Factors associated with health care that includes spinal manip- ulation are wide-ranging, from certain socio-demographic vari- ables to health-related indices, though the literature is not entirely consistent, possibly due to (a) temporal and geographic differences between studies, (b) variations in health and reim- Dbursement systems that may affect provision of certain types of care (including spinal manipulation), and (c) use of different com- parators (non-users vs. users of other types of health care) or inclu- sion of specific populations at risk (eg, back pain vs. general populations). Spinal manipulation is more commonly used in adults than children; however, some evidence suggests spinal manipulation may be more likely used for non-musculoskeletalail- ‘ments in children than in adults, Limitations of our review include the exclusion of non-English= language articles and thus an inherent bias toward European, [North American, and Australian literature, Our search strategy lar~ sgely precludes estimates of spinal manipulation use in Asia and other areas in which publications are likely to be in languages cther than English, Many articles that may have information on the epidemiology of spinal manipulation embedded within them, such a8 general wiiization studies of chiropractic, osteopathy of physical therapy, were for the most part excluded from our review unless we could make reasonable assumptions regarding the use of spinal manipulation, 5. Conchusion Spinal manipulation is used around the world for mostly mus- cculoskeletal concitions, primarily back and neck pain. Chiropra tors, osteopaths, and physical therapists deliver the vast majority of spinal manipulation, which is often combined with other man- ual therapies. physical modalities. or exercise. Although children receive spinal manipulation less frequently than adults, they are ‘more likely than adults to have non-musculoskeletal ailments. Pa- tients are generally very satisfied with care that includes spinal ‘manipulation. 6. Conflict of interest The author has no conflict of interest to declare. References ALWing A. 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Soo tat Rtlow Ke Hamtivit Ly Wiel & Use of complementary and ternative medic] therapies fn 3 pcitrie neurology cline Can |New St Soossaa) 594-8 Spigebl 1 Lane-Ammara les Guyver A The use of aeratve meicne by “hlgren Pedsines 1934-94811~4 ‘Thomas K, Coleman P Use of commplernentay of alternative medicine i @ general pepaiatonin rea Britain Rens rom the tonal Orbs survey. Subic Faia (ont 2008 2512)452-7, ‘omnis Neda Clan? se and expense oncoplenty edie Tinle HA Davis RB Pals RS. senberg DM, Tends nue of erplementary ane Slteative medicine by US ait” 1997-2002" Altern Ther Health Mee Votova Penning Ml, Zheng C Beckley ME Teenés and predictors of publy Pabiedcopraci sce se among dt gS Aen Cope ‘uipatents. Arch Phys Med Rehabil 1996;79(8) 1003-5. Walker F Mule R rane WD La back pin I Alstalan aéuts. eat provider llzaloa and eae seeing. | Manipulaive Physio, The! 2004273) 327-35. Wilsto P Esenderg DML Dav RB Kesler Pils RS Pattern te perceptions ‘ue CC, Zhang AL, Lin V. Myers R, Plus Story DE Acupuncture. chiropractic and xcopy ie masta a aoa poplin uy. abi athose EL. HurwitzJoura of lectromyosraphy and Kinsley 2 (2012) 8-854 Yamashea Hh, Taukayama H, Sugita C.Populnty of complementary and ‘erate meine in apn + eepone ses. Catpenent Tet Mes Yang. 2G Yang Siang 58. Chen DS. hospital-based sty on the we of ‘erative medicine inpatients with eon ier and) gates diseases Am] Chin Me 2002 90:47637~83 ‘thd! hate Aan Rea Seon Tao ee Dr, Ene Marwitz i Pofesior and Graduate Chair of Epdemiology i the Deparment of Pub Health Se ‘ences af Joh A Burns Schoo of Medicine a he Un vers of Hawa a Maen, He graduated tom the University of caf, Bevel. andthe Los Angeles College of Chicopee with bachelor's ane decorate degrees in physoiny and chiropractic respectively. Hurwtesdbsequentyeeesed MS. and PRD. dezres in epidemilogy fom UCLA where he conducted post doctoral research and taught epieemoloicrestarch ‘method nthe Schaaf Pubic ealh and serve aco: {rector for epicemiaenie esi the Sothern Ca ori nary Prevention Resear Center Dr rt reveuch interests include the epidemiology and treatment of musclacelet (dsarders and chronic diseases: the sly and ellecivenes of Cerapeutc and preventive incerventions td methods in observational and cnc epidemilgy Fe has served a pinpal or avavestigavr oa several prneeingepcemiologie ana health series research projec, Including randomized cea tals abd Systematic reviews of conventional complementary and alterasive interventions for lbck and neck pan. Dr. Hurts research ha ben fermaly recognised ational and international through a numbec prestigious awards and Res an Zithor of conuthor of sx book ehapters and more tian 90 scene aries $ppeaing in feang journals Dr Morte recently served onthe Sintie Seee- tanto he World Health Organization (WHO)-edersed The Bore ad Joint Dee ‘de 2000-2010 Task Force on Neck Pain ane Is Avoctee Divareets, ad 6 furceny a deputy edtr of The Spine Journal and member ofthe Naina nite tutes of Hels Behavioral Medicine Interventions and Osteomes Study Section Center for Seti Review. He president the Cama (Unwersity af Hawa Chapter ofthe Delta OmegeHnrary Society fr Pub Hell and serves 08 the txecutve dou af Dela Omega nal afee