Low Back Pain — Clinical Practice Guideline
Whalen et al., Journal of Manipulative and Physiological Therapeutics, 2022/2023
Clinical practice guidelines support evidence-informed chiropractic management of mechanical low back pain, including appropriate evaluation, treatment, reassessment, co-management, and referral when indicated.

Spinal Manipulative Therapy for Chronic Low Back Pain
Rubinstein SM, et al. BMJ. 2019. Systematic review and meta-analysis of randomized controlled trials.
What the research found: Spinal manipulative therapy produced outcomes similar to other recommended treatments for chronic low back pain. It also produced greater short-term improvements in function than treatments considered non-recommended.

Spinal Manipulative Therapy for Acute Low Back Pain
Paige NM, et al. JAMA. 2017. Systematic review and meta-analysis.
What the research found: For adults with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function for up to six weeks. Reported adverse effects were generally temporary, minor musculoskeletal symptoms.

Spinal Manipulation for Chronic Primary Low Back Pain: WHO Guideline
World Health Organization. 2023.
What the evidence says: The World Health Organization includes spinal manipulative therapy among the non-surgical interventions that may be offered as part of care for adults, including older adults, with chronic primary low back pain.

Spinal Manipulation for Chronic Sciatica
2025 systematic review and network meta-analysis, 50 RCTs / 4,920 participants.
What the research found: Among nonsurgical interventions for chronic sciatica, spinal manipulative therapy was among the treatments associated with the largest reductions in leg pain compared with placebo.

Spinal Manipulation for Acute and Subacute Low Back Pain
2024 evidence review and international expert consensus.
What the research found: Following review of 21 systematic reviews and 21 randomized controlled trials, an international expert panel recommended spinal manipulative therapy among treatment options for acute low back pain and among several conservative interventions for subacute low back pain.

Spinal Manipulation and Exercise for Adolescent Low Back Pain
2024 systematic review and meta-analysis.
What the research found: In adolescents with low back pain, spinal manipulation combined with exercise may increase the likelihood of clinically important pain reduction compared with exercise alone. The authors concluded that spinal manipulation and group exercise may help reduce low back pain intensity.

Neck Pain — Best-Practice Recommendations
Whalen et al., Journal of Manipulative and Physiological Therapeutics, 2019
Best-practice recommendations support chiropractic manipulation and multimodal care for appropriately selected adults with uncomplicated neck pain, alongside careful assessment, informed consent, and referral when appropriate

Manual Therapy for Neck Pain, Cervical Radiculopathy, and Cervicogenic Headache
2025 umbrella review of 35 systematic reviews
What the research found: Across 35 systematic reviews, manual therapy combined with exercise was more effective than either treatment alone for nonspecific neck pain. Evidence also supported cervical and thoracic mobilization/manipulation as part of conservative care for cervical radiculopathy and cervicogenic headache.

Spinal Manipulative Therapy for Acute Neck Pain
2025 systematic review and meta-analysis, 8 RCTs, 965 patients
What the research found: Spinal manipulative therapy produced greater improvements in pain, cervical range of motion, and disability than control interventions in patients with acute neck pain. No serious adverse events were reported in the included trials.

Manipulative Therapy for Chronic Neck Pain
2023 systematic review and meta-analysis, 17 RCTs, 1,190 participants
What the research found: Manipulative therapy significantly reduced pain intensity and neck-related disability in people with chronic neck pain. The researchers found no significant difference in adverse events between manipulation and control groups.

Clinical Guidelines Recommend Manipulation and Mobilization for Neck Pain
2025 systematic review of international clinical practice guidelines
What the research found: Researchers evaluated nine international clinical practice guidelines, including five rated as high quality. All five high-quality guidelines recommended manipulation or mobilization, either alone or together with exercise, as an option for people with neck pain.

Manual Therapy for Cervical Radiculopathy
2025 systematic review and network meta-analysis
What the research found: Manual therapy improved pain and disability among patients with cervical radiculopathy. The review evaluated manual therapy alone and in combination with treatments such as exercise and traction, with manual therapy alone showing the greatest improvement in pain and disability among the approaches studied.

Chiropractic/SMT and Health Care Costs for Older Adults With Neck Pain
2025 retrospective cohort study, 291,604 Medicare beneficiaries
What the research found: Among Medicare beneficiaries with a new episode of neck pain, patients whose initial care involved chiropractic/spinal manipulative therapy had 36% lower neck-pain-related Medicare Part B costs, as well as lower analgesic medication costs over 24 months, compared with primary medical care strategies.

Headache Disorders — Clinical Practice Guideline
Trager et al., Journal of Integrative and Complementary Medicine, 2026
A 2026 clinical practice guideline supports spinal manipulation as an option for cervicogenic headache and recommends a multimodal approach when managing tension-type headache, together with appropriate diagnosis, screening, referral, and other nonpharmacologic care.

Manual Therapy for Cervicogenic Headache
2025 systematic review and network meta-analysis, 14 studies, 1,297 patients
What the research found: Manual therapy, including spinal manipulation and mobilization, improved pain and function in people with cervicogenic headache. Cervical spinal manipulation ranked among the most effective short-term approaches for reducing pain and disability, while mobilization techniques such as SNAGs also produced meaningful benefits.

Manual Therapy and Exercise for Cervicogenic Headache
2022 systematic review and meta-analysis, 20 studies, 1,439 patients
What the research found: Manual and exercise therapies reduced cervicogenic headache intensity, frequency, and disability. Pooled results favored manual therapy in the short term, while lower-risk-of-bias trials still showed smaller benefits in both short- and longer-term outcomes.

Manual Therapy Plus Exercise for Cervicogenic Headache
2024 randomized controlled trial, 99 patients
What the research found: Adding Mulligan manual therapy to exercise reduced headache frequency more than exercise alone, with benefits still evident at 26 weeks. Patients also improved in headache intensity, duration, disability, upper-cervical movement, and satisfaction.

Manual Therapy for Tension-Type Headache
2022 systematic review and meta-analysis, 15 studies, 1,131 participants
What the research found: Some manual approaches, particularly soft-tissue interventions, reduced headache intensity and frequency in people with tension-type headache.

Chiropractic SMT and Medication Use in Tension-Type Headache
2025 retrospective cohort study, 3,116 patients
What the research found: Adults with tension-type headache who received chiropractic spinal manipulative therapy were less likely to receive butalbital prescriptions and had a lower observed incidence of medication-overuse headache than matched patients who did not receive SMT.

Understanding Safety: All health care interventions involve potential benefits and risks. Research on chiropractic and spinal manipulation generally finds that most reported adverse effects are mild and temporary, such as soreness or stiffness. Serious complications have been reported but appear to be rare. Appropriate patient evaluation, recognition of contraindications and warning signs, informed consent, and evidence-based clinical decision-making remain essential components of safe care.

Safety of Chiropractic Care in Older Adults With Neck Pain
2025 retrospective cohort study, 291,604 Medicare beneficiaries
What the research found: Among older adults with a new episode of neck pain, chiropractic care was associated with lower rates of the adverse outcomes measured than primary medical care, including care involving prescription analgesics. The prescription-drug group had the highest rate of measured adverse outcomes.

Severe Adverse Events Following Chiropractic Spinal Manipulation
2023 cohort study, 54,846 patients and 960,140 treatment sessions
What the research found: Across nearly one million chiropractic spinal manipulation sessions, researchers identified 39 adverse events. Two were classified as severe, both rib fractures in older women with osteoporosis. No life-threatening or fatal events were identified, and the estimated incidence of severe adverse events was 0.21 per 100,000 treatment sessions. No stroke or cauda equina events were reported.

Adverse Events After Cervical Spinal Manipulation
2024 systematic review and meta-analysis of 14 randomized trials
What the research found: Cervical high-velocity, low-amplitude manipulation was not associated with a higher rate of mild or moderate adverse events than comparison interventions in the included trials. Reported adverse events were mild, and no serious events occurred.

Cervical Artery Dissection and Spinal Manipulation
2022 case-control and case-crossover study of Medicare beneficiaries
What the research found: Among adults age 65 and older, researchers did not find a greater risk of cervical artery dissection following cervical spinal manipulation than following comparison evaluation-and-management visits. Results were similar for both vertebral and carotid artery dissection and across 7-, 14-, and 30-day periods.

Vertebral Artery Strain During Cervical Spinal Manipulation
2025 systematic review and meta-analysis of biomechanical studies
What the research found: In cadaveric studies, cervical spinal manipulation produced less vertebral artery strain than passive cervical range of motion, particularly during rotation. The authors found vertebral artery strain during manipulation was consistently lower than strain occurring during ordinary passive neck movement.

Initial Chiropractic Care and Long-Term Costs for Neck Pain
2025, 291,604 Medicare beneficiaries
What the research found: Older adults whose initial care for a new episode of neck pain included chiropractic spinal manipulation had lower health-care costs over the following 24 months than comparison groups receiving primary medical care. The chiropractic cohort had 6% lower Medicare Part B costs, 36% lower neck-pain-related costs, and lower prescription-drug costs, including 13% lower analgesic costs.

Cost-Effectiveness of SMT, Exercise and Self-Management for Spinal Pain
2025, economic analysis of 8 U.S. randomized trials
What the research found: The economic value of spinal manipulative therapy varied substantially by condition, age, and what it was compared with. SMT showed favorable cost-effectiveness in several populations, including acute neck pain, chronic back-related leg pain, some chronic neck-pain populations, and chronic back pain in adults. In other groups, exercise or home exercise and advice were more cost-effective.

Health Care Charges by Provider Type for Low Back Pain
Hurwitz et al., 2016, North Carolina State Health Plan
What the research found: Using nearly a decade of health-plan data, researchers found that uncomplicated low back pain managed by a chiropractor alone, or through a combination of chiropractic and medical care, generated appreciably lower charges than medical care alone or medical care combined with physical therapy.

Chiropractic Care, Episode Length and Medicare Costs for Chronic Low Back Pain
Weeks et al., 2016, Medicare population
What the research found: Among older adults with chronic low back pain and multiple health conditions, patients receiving chiropractic spinal manipulation had lower overall Medicare costs and shorter episodes of back pain than patients receiving medical care alone. Patients receiving both chiropractic and medical care had the next-lowest costs, while medical care alone was associated with the highest costs.

Costs When Low Back Pain Care Begins With a Chiropractor
Liliedahl et al., 2010, approximately 85,000 BCBS Tennessee beneficiaries
What the research found: In a health plan that allowed patients to choose either medical or chiropractic care without referral restrictions, episodes of low back pain beginning with a chiropractor were associated with 20% to 40% lower costs than episodes beginning with a medical physician. Researchers estimated potential annual savings of approximately $2.3 million for the health plan if chiropractic-initiated care were more widely utilized.

Chiropractic Care and Opioid Prescriptions in Veterans With Low Back Pain
2025 longitudinal cohort study, 128,377 opioid-naïve veterans
What the research found: Among opioid-naïve Veterans with low back pain, 13% of those receiving chiropractic care received an opioid prescription within one year, compared with 16.8% of those who did not receive chiropractic care. The authors concluded that chiropractic care may be an important component of opioid-sparing strategies for patients with low back pain.

Chiropractic Spinal Manipulation, Sciatica and Opioid-Related Adverse Events
2025 retrospective cohort study, 744,942 matched patients
What the research found: Adults with sciatica receiving chiropractic spinal manipulation had a lower one-year incidence of opioid-related adverse events than matched patients receiving usual medical care. They were also less likely to receive an oral opioid prescription.

Chiropractic Care and Opioid Use Among Older Medicare Beneficiaries
2022 retrospective cohort study, 55,949 Medicare beneficiaries
What the research found: Among older Medicare beneficiaries with spinal pain, those receiving chiropractic care had a significantly lower risk of filling an opioid prescription during the following year. After adjustment, chiropractic recipients had a 56% lower risk of filling an opioid prescription than nonrecipients.

Chiropractic Use and Opioid Receipt for Spinal Pain
2020 systematic review and meta-analysis
What the research found: Across six studies involving adults with noncancer spinal pain, people receiving chiropractic care had 64% lower odds of receiving an opioid prescription than people who did not receive chiropractic care.

Initial Provider Choice and Subsequent Opioid Use for Low Back Pain
Kazis et al., BMJ Open, 2019; 216,504 opioid-naïve adults
What the research found: Patients with new-onset low back pain who initially saw a chiropractor, physical therapist, or acupuncturist had substantially lower odds of both early and long-term opioid use than patients who initially saw a primary care medical physician.

Opioids for Acute Low Back and Neck Pain: The OPAL Trial
2023 triple-blind, placebo-controlled randomized trial, 347 adults
What the research found: Opioid medication did not provide significantly better pain relief than placebo for acute nonspecific low back or neck pain at six weeks. The researchers concluded that opioids should not be recommended for these conditions.

Last reviewed:
September 2026