Evidence-Based Chiropractic

There is a growing body of evidence in support of the chiropractic management of patients with musculoskeletal conditions; particularly for the spinal pain, through the delivery of spinal manipulation, mobilization and therapeutic exercise. As with all scientific literature, no single treatment or therapy can ever be the right answer for each individual patient, however large controlled studies certainly aid in showing some likelihoods of success with different musculoskeletal conditions.

"Chiropractors, like other health care providers, are aware of other elements that affect care such as natural history, placebo, and coincidence and are taught to consider these before associating their treatment approach directly to a result. However, notwithstanding, empirical observation coupled with the current scientific literature indicates that the effectiveness of chiropractic care extends beyond these other elements." ~ Souza

The Foundation for Chiropractic Progress recently developed a manuscript that includes a thorough review and summaries of Chiropractic Research available at http://www.foundation4cp.com/files/chiro_res_practice.pdf.

The following is a list of conditions that respond well to chiropractic management and a summary of some of the supporting research. Please read the studies in their entirety to fully understand the context, methods, weaknesses, and strengths of each. If there are questions regarding how to access the studies, please do not hesitate to email hanswbotteschDC@gmail.com with your queries.

Neck Pain


Prevelance of Neck Pain

The NBCE Job Analysis 2005 estimates that neck pain accounts for approximately 18.7% of all chiropractic visits.

National Board of Chiropractic Examiners. Job Analysis of Chiropractic: A project report, survey analysis, and summary of the practice of chiropractic within the United States. Greeley, CO: National Board of Chiropractic Examiners (NBCE); 2005.

Effectiveness of Spinal Manipulation/Mobilization/Exercise

In a Cochrane Review of the literature regarding the effectiveness of manipulation and mobilization for neck pain, it was concluded that the combination of manipulation or mobilization with neck exercise provided the best results.

Gross, A. R. Hoving, J. L. Haines, T. A. et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine 2004;29:1541-1548.

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The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders has reviewed the literature and made recommendations regarding evaluation and management. Manipulation is one of the approaches recommended for mechanical neck pain.

Haldeman S, Carroll L, Cassidy JD, Schubert J, Nygren A. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: executive summary. Spine. Feb 15 2008;33(4 Supp.l):S5-7.

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The UK Evidence Report on the Effectiveness of Manual Therapies reviewed the literature and concluded that thoracic (mid-back) spinal manipulation/mobilization has MODERATE quality POSITIVE evidence supporting its utilization in the treatment of acute/subacute neck pain.

Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3, http://www.chiroandosteo.com/content/18/1/3.

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The Koes Clinical Trial on neck and back pain was a Dutch project compared manipulative therapy (chiropractic) and physiotherapy for the treatment of persistant back and neck complaints. After 12 months, the manipulative therapy group showed greater improvement of the primary complaint as well as improvement in physical function, with fewer visits.

Koes BW, Bouter LM, et al. British Medical Journal; Vol. 304, No. 6827, pp. 601-605

Chronic Neck Pain

Effectiveness of Spinal Manipulation/Mobilization

For chronic neck pain, another Cochrane Review of the Literature concluded that there is MODERATE evidence that spinal manipulative (SMT) /mobilization (MOB) is superior to general practitioner management for short-term pain reduction and that SMT offers similar pain relief to high-technology rehabilitative exercise in the short and long term.

Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J 2004;4:335-356.

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The UK Evidence Report on the Effectiveness of Manual Therapies reviewed the literature and concluded that spinal manipulation/mobilization has MODERATE quality POSITIVE evidence supporting its utilization in the treatment of chronic neck pain.

Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3, http://www.chiroandosteo.com/content/18/1/3.

Low Back Pain

Patient Satisfaction

The level of satisfaction for patients seeking care from a chiropractor versus medical doctor was evaluated in the UCLA Back Pain Study. Satisfaction with chiropractic care was rated higher compared to medical care. The primary difference between satisfaction ratings was the perception that chiropractors communicated more giving advice and information about the
patients’ low back pain.

Hertzman-Miller RP, Morgenstern H, Hurwitz EL, et al. Comparing the
satisfaction of low back pain patients randomized to receive medical or chiropractic care: result from the UCLA
Low-Back Pain Study. Am J Public Heath 2002;92:1628-1633.

How often should patients be treated?

We do not know the answer but early evidence from a small study suggests that high-frequency care initially may have some short-term benefit.

Patients were randomly allocated to visits (1, 2, 3 or 4 visits/week for 3 weeks) and to treatment regimen (spinal manipulation only or spinal manipulation with PM). All patients received high-velocity low-amplitude spinal manipulation. Half received one or two of the following PM at each visit: soft tissue therapy, hot packs, electrotherapy or ultrasound. Pain intensity: At 4 weeks, there was a substantial linear effect of visits favoring a larger number of visits: 5.7 points per 3 visits (SE=2.3, p=.014). At 4 weeks, a visits effect was noted (p=.018); the slope for group means was approximately 5 points per 3 visits. There were no group differences at 12 weeks. CONCLUSIONS: There was a positive, clinically important effect of the number of chiropractic treatments for chronic low back pain on pain intensity and disability at 4 weeks. Relief was substantial for patients receiving care 3 to 4 times per week for 3 weeks.

A similar study was performed with patients diagnosed with cervicogenic headache demonstrating similar results.

Haas, M, Groupp, E, Kraemer, D. F. Dose-response for chiropractic care of chronic low back pain. Spine J 2004;4:574-583.

Effectiveness of Spinal Manipulation/Mobilization

The UK Evidence Report on the Effectiveness of Manual Therapies reviewed the literature and concluded that spinal manipulation/mobilization has MODERATE quality POSITIVE evidence supporting its utilization in the treatment of acute low back pain.

Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3, http://www.chiroandosteo.com/content/18/1/3.

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The Manga Study researched both the effectiveness and cost-effectiveness of the chiropractic management of low back pain. They found “on the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatment for low back pain.”

Manga P, Angus D, et al. The Effectiveness and Cost-effectiveness of Chiropractic Management of Low-back Pain. Ontario Ministry of Health, Ontario, Canada.

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The Koes Clinical Trial on neck and back pain was a Dutch project compared manipulative therapy (chiropractic) and physiotherapy for the treatment of persistant back and neck complaints. After 12 months, the manipulative therapy group showed greater improvement of the primary complaint as well as improvement in physical function, with fewer visits.

Koes BW, Bouter LM, et al. British Medical Journal; Vol. 304, No. 6827, pp. 601-605

Chronic Low Back Pain


Chiropractic vs Primary Care Treatment of Mechanical Low Back Pain

Fifty-one chiropractic and 14 general practice community clinics. A total of 2870 acute and chronic ambulatory patients with LBP of mechanical origin. A clinically important advantage for chiropractic patients was seen in chronic patients in the short-term (>10 VAS points), and both acute and chronic chiropractic patients experienced somewhat greater relief up to 1 year (P<.000). The advantage for DC care was prominent for chronic patients with leg pain below the knee (P<.001).

Haas, M, Goldberg, B, Aickin, M, Ganger, B, Attwood, M. A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up. J Manipulative Physiol ther 2004;27:160-169.

Effectiveness of Spinal Manipulation/Mobilization

The UK Evidence Report on the Effectiveness of Manual Therapies reviewed the literature and concluded that spinal manipulation/mobilization has HIGH quality POSITIVE evidence supporting its utilization in the treatment of chronic low back pain.

Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3, http://www.chiroandosteo.com/content/18/1/3.

Headaches (Cervicogenic, Migraine, Chronic Tension-Type)

Chiropractors, Doctors of Osteopathy (DO), and Physical Therapists (PT) all perform some form of spinal manipulation therapy. In reviewing the literature of evidence regarding chiropractic management of headache, there are some studies specific to chiropractic manipulation (also known as chiropractic adjustments) while others refer to manipulation or mobilization performed by other health professionals (i.e. DOs and PTs).

Taken as a whole, there is general agreement through systematic reviews that there is value in utilizing cervical spine manipulation for patients with certain types of headaches.

Some of the results and reviews are specific to certain headache types.




Effectiveness of Spinal Manipulation/Mobilization

Cochrane Review of the Literature[1], the Nelson Study [2], and the Boline Study [3]

For the prophylactic (preventive) treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment option with a short-term (3-month follow-up) effect similar to that of a commonly used drug (i.e. amitriptyline)[2]
For the prophylactic treatment of chronic tension-type headache, although amitriptyline is more effect during treatment, spinal manipulation is superior in the short-term (3-month follow-up) after cessation of both treatments [3]
For the prophylactic (preventive) treatment of cervicogenic headache, there is evidence that both exercise (low-intensity, endurance training) and spinal manipulation are effective in the short and long-term when combined and when compared to no treatment
A small study by Haas[4] indicates that for chronic cervicogenic headache high-frequency chiropractic care (3 to 4 times per week) for three weeks is more effective than low-frequency care (1 to 2 times per week).

1. Bronfort, G., et al., Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database Syst Rev, 2004(3): p. CD001878.

2. Nelson, C.F., et al., The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. J Manipulative Physiol Ther, 1998. 21(8): p. 511-9.

3. Boline, P.D., et al., Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther, 1995. 18(3): p. 148-54.

4. Haas, M., et al., Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study. J Manipulative Physiol Ther, 2004. 27(9): p. 547-53.

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The UK Evidence Report on the Effectiveness of Manual Therapies reviewed the literature and concluded that spinal manipulation has MODERATE quality POSITIVE evidence supporting its utilization in the treatment of migraine and cervicogenic-type headaches.

Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3, http://www.chiroandosteo.com/content/18/1/3.

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The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders has reviewed the literature and made recommendations regarding evaluation and management. Manipulation/mobilization/supervised exercises are "POSSIBLY LIKELY" to aid in the treatment of cervicogenic headaches.

Haldeman S, Carroll L, Cassidy JD, Schubert J, Nygren A. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: executive summary. Spine. Feb 15 2008;33(4 Supp.l):S5-7.

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The Duke Study was based on a literature review of several headache treatment options, a panel of 19 multidisciplinary experts concluded that spinal manipulation resulted in almost immediate improvement for cervicogenic headaches and had significantly fewer side effects and longer lasting relief of tension type headache than commonly prescribed medication. The researches concluded: “Manipulation appeared to result in immediate improvement in headache severity when used to treat episodes of cervicogenic headache when compared with an attention-placebo control. Furthermore, when compared to soft tissue therapies (massage), a course of manipulation treatments resulted in sustained improvement in headache frequency and severity.”

McCrory DC, et al. Evidence Report: Behavioral and Physical Treatments for Tension Type and Cervicogenic Headache. Duke University Evidence Based Practice Center, Durham, North Carolina.