In Australia, acupuncture, chiropractic and osteopathy are generally regarded as complementary therapies. Each involves services provided by practitioners in contrast to many other forms of CAM therapy which are self-selected and self-administered. The majority of users choose acupuncture, chiropractic and osteopathy to manage pain and specific medical conditions, back pain and related problems being particularly prominent considerations. All chiropractic and osteopathy practitioners receive degree-level training and the majority of acupuncture practitioners receive either university training or complete courses accredited by a national professional association. Each discipline is subject to regulation by either a statutory body and/or a national professional association (see below). Acupuncture treatments may be provided by accredited medical practitioners and by accredited non-medical personnel. From a patient's perspective the main difference between receiving acupuncture from a medical practitioner and a non-medical acupuncturist is the availability of government universal health insurance (Medicare) rebates when the acupuncture is provided by an accredited medical practitioner. The number of acupuncture services rebated by Medicare in 2005/2006 was 607,349 [6
], which is only about 6% of the total number of annual acupuncture services estimated in our survey.
Previous studies on the use of much broader ranges of CAM therapies found that certain socio-demographic factors were correlated with CAM use, such as gender (CAM being more popular with females than males), age (the highest rates of CAM use being by the middle-aged), and household income and level of education (both being positively correlated with CAM use) [7
]. Some of these associations also appear to be applicable to the use of one or more of the three complementary manipulative therapies investigated in the present study. Thus, osteopathy was considerably more popular amongst females than males but there was no gender difference in the use of acupuncture or chiropractic services. The prevalence of chiropractic use was significantly higher among those with household incomes more than A$20,000 per annum. In contrast, osteopathy appears to be more popular amongst those with household incomes less than A$20,000. In regard to level of education, the only association observed was that acupuncture was more commonly used by those with higher (post-secondary) education. A recent large-scale longitudinal study on women's health, found that middle-aged Australian women living in non-urban areas and women with a lower level of education were more likely to use chiropractic or osteopathy [9
]. However, our data do not allow us to draw such conclusions.
We found that chiropractic was considerably more popular amongst those born in Australia than those born overseas. However, this was not so for acupuncture or osteopathy. It seems likely that the greater prevalence of use of chiropractic by those born in Australia than by those born overseas is due to the profession being well established in Australia, with university trained practitioners and being subject to statutory regulation, whereas in many other countries, particularly Asian countries, chiropractic is a less well known health-care service. It is worth noting that osteopathic medicine is not generally considered as a form of CAM in the US and thus has been excluded from most CAM population studies conducted in the US [8
It is of interest that users of acupuncture and chiropractic in our survey tended to have also consulted a medical practitioner during the 12 month period investigated. In the case of osteopathy, there was not a significant correlation between osteopathy use and medical practitioner visits per se
; however, both osteopathy and chiropractic users with back problems were highly likely to have also visited a medical practitioner. Similar to findings reported in the US [10
] and from a previous Australian study [11
], we found that acupuncture, chiropractic and osteopathy were most commonly used to treat chronic somatic and musculoskeletal conditions. Although our data do not allow us to draw conclusions about the clinical benefits of the manipulative therapies, a large majority of users of acupuncture, chiropractic and osteopathy considered that their treatment was effective, particularly in respect of relief of pain and other symptoms of their condition. It is also of interest that substantial proportions of the respondents who used each of the three manipulative therapies did so with the objective of enhancing their general health and well-being.
There have been no previous studies that have investigated the popularity of acupuncture, chiropractic and osteopathy in individual Australian states. Our data indicate that the prevalence of use of chiropractic is consistent in all five mainland states and our estimate of the prevalence of chiropractic use in South Australia (17.0%) is in agreement with that of a 2004 study (16.7%) [12
]. In contrast to chiropractic, the popularity of acupuncture and osteopathy across Australia is much more variable. It is particularly striking that acupuncture and osteopathy were used by relatively low proportions of the Western Australians and South Australians in our sample, a situation that is likely to be due to there being relatively low numbers of practitioners of the two therapies in these states [13
The substantial use of acupuncture, chiropractic and osteopathy by adult Australians involves considerable personal expenditure by users. Although rebates for acupuncture, chiropractic and osteopathy services are available from most private health insurance funds, the maximum annual rebates are usually limited. Acupuncture services by accredited medical acupuncturists are rebated by Medicare, although the number of services for which such rebates were provided is relatively low (see above). Practitioner fee structures are complex, there usually being a lower fee for a return visit to practitioners. Based on advice from the relevant professional associations, the fee for an acupuncture consultation is in the range $AU 35 – 50, that for chiropractic, $AU 35 – 60 and that for osteopathy, $AU 60 – 100. Taking the means of these ranges, from our survey findings, we estimate that the total annual personal expenditure nationally, before insurance rebates, for acupuncture, chiropractic and osteopathy services are $AU 432 million, $AU 905 million and $AU 246 million, respectively. Obviously, the limits set by health insurance funds for rebate might have impact on the frequency of use of these therapies. Given the limitation of current sample size, a larger national survey would be necessary to confirm these projections of expenditure.
The adverse events reported by users of acupuncture and chiropractic in our study were mild and low in frequency, with only one event, in chiropractic, considered (by the patient) as severe. The most frequent complaint by acupuncture users was mild needling pain; however, given that skin penetration is inherent in this therapy, such a subjective sensation should probably not be considered to be an adverse event. There was a somewhat higher frequency of adverse events reported by osteopathy users; however, some caution needs to be exercised in extrapolating this observation, due to the relatively low number of osteopathy users in the study. The safety profiles of these three manual therapies based on the user-reported events may also be partially explained by the fact that these professions are under statutory regulation in Australia (Victoria only for acupuncture). One of the main objectives of practitioner registration in Australia is the maintenance of standards of clinical practice, consistent with public safety.
Health-care providers now operate in a multi-disciplinary environment, which includes many forms of CAM practice. However, poor communication between practitioners of both conventional medicine and CAM therapies and their patients about the totality of their treatment and treatment options is a common finding of surveys of CAM use conducted in Australia [12
] and other countries [14
]. It has been reported that, frequently, patients do not disclose their use of CAM to their medical practitioner on the assumption that the "doctor does not need to know" and that "the doctor did not ask" [15
]. This communication gap is certainly not in the best interests of patients or the providers. On the other hand, it is encouraging that our findings indicate that one in five users of acupuncture and chiropractic, were referred to a practitioner of these therapies by medical practitioners. Indeed it has been reported that chiropractic and acupuncture were the most frequently referred CAM modalities in the US [16
]. Further, it has been estimated that approximately one in six medical general practitioners in Australia use acupuncture in their day-to-day practice (15.1%) [17
There are several limitations to be considered in interpreting the findings of our study. Firstly, we achieved a participation rate of approximately only 15%, and therefore, there is a possible non-response bias. However, we consider that, by employing a rigorous sampling strategy, we obtained a sample representative of the target population [1
]. Secondly, there were relatively small numbers of users of acupuncture, chiropractic and osteopathy in our survey sample of 1,067.