Chiropractic Clinical/Cost Effectiveness Research:


For Low Back Pain:

1) After a systematic review of literature on CLBP Haldeman et al. suggests that a reasonable approach to chronic LBP would include:      education strategies, exercise, simple analgesics, and a brief course of manual therapy in the form of manipulation, mobilization, or massage. 

Haldeman S, Dagenais S. What we have learned about the evidence-informed management of chronic low back pain? The Spine Journal. 2008 (8): 266-277

2) “Chiropractic Manipulative Therapy in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute low back pain.

Goertz CM, Long CR, Hondras MA, et al. Adding chiropractic to standard medical therapy for nonspecific  low back pain. Spine (Philadelphia, Pa 1976). 2013;38:627–34

3) This randomized clinical trial compared outcomes of patients suffering from low back pain when managed in a hospital by either a regional pain clinic or chiropractor. The review found that for patients with chronic low back pain (>12 weeks in length), chiropractic care resulted in a substantially greater reduction in pain and disability when compared to outpatient pain management. 

Wilkey, et al. A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low Back Pain in a National Health Service Outpatient Clinic. Journal  of Alternative and Complimentary Therapies: Volume 14, Number 5, 2008, pp. 465-473.

4) The American College of Physicians publishes updated Clinical Practice Guideline recommending that for acute, subacute or chronic low back pain, physicians and patients initially utilize spinal manipulation and delay pharmacologic management.

Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee of the American College of  Physicians Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice  Guideline From the American College of Physicians. Ann Intern Med. [Epub ahead of print 14 February 2017]           

5) The Journal of the American Medical Association (JAMA) recently published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain. The authors concluded:

“Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and  Harm  for Acute Low  Back Pain; Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460

For Neck Pain:

1) “Mobilization, (cervical & thoracic) manipulation, and clinical massage are effective interventions for the management of neck pain."

Wong JJ, et al. Are manual therapies, passive physical modalities, or acupuncture effective for the    management of patients with whiplash associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration. Spine J. 2016 Dec;16(12):1598-1630

2) A randomized controlled clinical trail in 2002; evaluated 3 different therapies for cervical spine pain. Manual therapy scored consistently better than the other two interventions on most outcome measures. 

Hoving JL, Koes BW, de Vet HCW, et al. manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Annals of Internal Medicine, Volume 136, 2002, pp. 713-722

For Headaches:

1) In 2004, a Cochrane review found evidence that suggests spinal manipulation may be effective for migraine, tension headache and cervicogenic headache.

Bronfor G, Nilsson N, Haas M, et al. (2004). "Non-invasive physical treatments for chronic/recurrent headache". In Bronfort, Gert. Cochrane Database Syst Rev (3)

2) "Cervical spine manipulation was associated with significant improvement in headache outcomes in trails involving patients with neck pain and/or neck dysfunction and headache."

McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence Report: Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache. Duke University Evidence-based Practice Center for Clinical Health Policy Research. - 2001

3) This studies results showed that spinal manipulation therapy is an effective treatment for tension headaches. Amitriptyline therapy was slightly more effective in reducing pain at the end of the treatment period, but was associated with more side-effects, four weeks after cessation of treatment. However, the patients who received spinal manipulative therapy experienced a sustained therapeutic benefit in all major outcomes in contrast with the patients that received amitriptyline therapy, who returned to baseline values.

Boline PD, Kassak K, et al. "Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial." Journal of Manipulative and Physiological Therapeutics, Volume 18, Number 3, March/April 1995, Pages 148-154.

Patient Satisfaction:

1)  “Chiropractic is the largest, most regulated, and best recognized of the complementary and alternative medicine (CAM) professions. CAM patient surveys show that chiropractors are used more often than any other alternative provider group and patient satisfaction with chiropractic care is very high. There is steadily increasing patient use of chiropractic in the United States, which has tripled in the past two decades.”

Meeker WC, Haldeman S. Chiropractic: A Profession at the Crossroads of Mainstream and  Alternative Medicine. Ann Intern Med. 2002;136(3):216-227

Safety of Manipulation:

1) Kosloff et al. extracted 3 years of commercial insurance and Medicare advantage plan data for approximately 39 million insured patients. This represents approximately 5% of the total US population. The study analyzed a potential correlation between chiropractic visits, PCP visits, and stroke.

The study found:  “No significant association between VBA stroke and chiropractic visits.  We conclude that manipulation is an unlikely cause of VBA stroke.”  The study did, however find “a significant association between PCP visits and VBA stroke.  The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection.”

This study suggests that chiropractic manipulation may not increase the risk of VBAI stroke, rather, impending VBAI stroke patients may have a higher likelihood to seek care from a variety of providers, including chiropractors.

Kosloff TM,  Elto D,  Tao J,  Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results  of a case-control study in  U.S. commercial and Medicare  Advantage populations. Chiropractic & Manual  Therapies (2015) 23:19

2) A Systematic Review and Meta-analysis of data concerning spinal manipulation and VBAI and concluded: “There is no convincing evidence to support a causal link between chiropractic manipulation and Cervical Artery Dissection.”

Church E W, Sieg E P, Zalatimo O, et al. (February 16, 2016) Systematic Review and Meta-analysis of  Chiropractic Care and Cervical  Artery Dissection: No Evidence for Causation. Cureus 8(2): e498. doi:10.7759/cu  reus.49

3) Researchers reviewed more than 15,000 carotid artery stroke cases admitted to Ontario, Canada hospitals over a 9-year period.  They compared the incidence of stroke following a visit to a chiropractor vs. a medical provider and concluded: ”no excess risk of carotid artery stroke after chiropractic care”. Researchers concluded that the equally increased incidence of stroke following either type of care was: “likely due to patients with early dissection-related symptoms seeking care prior to developing their strokes”

Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic  Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis. 2017 Apr;26(4):842-850

4) “Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and   Harm for Acute Low Back Pain; Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460.

5) "It is unlikely that chiropractic care is a significant cause of injury in older adults. In fact, among Medicare beneficiaries aged 66-99 years, risk of injury to the head, neck or trunk within 7 days, was 76% lower among subjects with a chiropractic office visit than those who saw a primary care physician."

Whedon JM, Mackenzie TA, Phillips RB, Lurie JD. Risk of Traumatic Injury Associated With Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66 to 99 Years. Spine 2015;40:264–270

Cost Effectiveness of Chiropractic:

1) A prospective study of 1885 workers in Washington state found that following work-related low back injury, patients who visited a chiropractor were nearly 30 times less likely to require surgery as compared to those who chose a surgeon as their first provider (42.7% vs. 1.5%). Choice of provider shows "excellent ability to discriminate between workers who would versus would not have surgery.”

Benjamin J. Keeney , PhD, Deborah Fulton-Kehoe, PhD, MPH, Judith A. Turner, PhD, Thomas M. Wickizer, PhD, Kwun Chuen Gary Chan, PhD, and Gary M. Franklin, MD, MPH. Early Predictors of Lumbar Spine Surgery After Occupational Back Injury. SPINE Volume 38, Number 11, pp 953–964

2) A comprehensive systematic review that compared health care costs for spine pain patients who received chiropractic care vs. care from other health care providers concluded: “Overall, cost comparison studies from private health plans and WC plans reported that health care costs were lower with chiropractic care.”

Dagenais S, Brady O, Manga P. A systematic review comparing the costs of chiropractic care to other  interventions for spine pain in the United States. BMC Health Serv Res. 2015 Oct 19;15:474.

3) “The rate of opioid use was lower for recipients of chiropractic services (19%) as compared to non-recipients (35%). The likelihood of filling a prescription for opioids was 55% lower in the chiropractic recipient cohort. Average annual per-person charges for opioid prescription fills were 78% lower for recipients of chiropractic services as compared to non-recipients. Average per person charges for clinical services for low back pain were also significantly lower for recipients of chiropractic services. (Avg. $1513 for chiropractic management vs. $6766 for medical management)” 

Whedon J. Association between Utilization of Chiropractic Services and Use of Prescription Opioids among Patients with Low Back Pain. Presented ahead of print at the National Press Club in Washington DC on March 14, 2017.    Accessed online at:

4) “For Medicare patients with back and/or neck pain, availability of chiropractic care reduces the number of primary care physician visits, resulting in an annual savings of $83.5 million.” 

Davis MA, et al. Regional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain Journal of the  American Board of Family Medicine: JABFM.              2015;28(4):481-490.

5) In older adults with chronic neck pain, incorporating spinal manipulation decreases overall societal costs 5% and results in greater improvements in pain and disability when compared to a home exercise program alone. Furthermore, adding spinal manipulation to a home exercise program resulted in 47% lower costs compared to supervised rehabilitation.

Leininger B, et al. Cost-effectiveness of spinal manipulation therapy, supervised exercise, and home exercise for older adults with  chronic neck pain. Spine J. 2016 Nov;16(11):1292-1304.

6) “Low back pain care initiated with a doctor of chiropractic (DC) saves 40 percent on health care costs when compared with care initiated through a medical doctor (MD).” 

Liliedahl RL, Finch MD, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with a chiro-   practic doctor vs medical doctor/ doctor of osteopathy as first line physician: experience of one Tennessee-based    general health insurer. J Manipulative Physiol Ther. 2010;33:640–643

Chiropractic and Medical Co-Management:  

1) Chiropractic co-management of DOD recipients shows significant improvement and high patient satisfaction.

 Green BN, et al. Integration of Chiropractic Services in Military and Veteran Health Care Facilities: A Systematic   Review of the Literature. Journal of Evidence-Based Complementary & Alternative Medicine. 2016 Apr;21(2):115-30

2) A report from the FDA regarding the management of chronic pain concluded: "Non-pharmacologic therapies, including chiropractic, should be used" 

FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain. May 2017.  Accessed on May 12, 201

3) Regarding the management of chronic pain, a prescribing guideline from the CDC concluded: “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred" 

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain- United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49

4) The 2018 Joint Commission Guideline enhanced the pain assessment and management requirement for hospitals to include “nonpharmacologic pain treatment modalities” that were defined in 2015 to include “chiropractic therapy”.

The Official Newsletter of The Joint Commission. Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals. July 2017 Volume 37 Number 7. Ahead of print in 2018 Comprehensive    Accreditation Manual for Hospitals.

Joint Commission Online. Revision to Pain Management  Standards.

5) The American Medical Association goes on record endorsing chiropractic care in a patient information synopsis: “Many treatments are available for low back pain... people benefit from chiropractic therapy."

 Denise M. Goodman, Alison E. Burke, Edward H. Livingston. Low Back Pain. JAMA. 2013;309(16):1738.