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FOI 24/25-0223 
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Efficacy of chiropractic treatment 
The content of this document is OFFICIAL. 
Please note: 
The research and literature reviews collated by our TAB Research Team are not to be shared 
external to the Branch. These are for internal TAB use only and are intended to assist our 
advisors with their reasonable and necessary decision-making. 
Delegates have access to a wide variety of comprehensive guidance material. If Delegates 
require further information on access or planning matters, they are to call the TAPS line for 
advice. 
The Research Team are unable to ensure that the information listed below provides an 
accurate & up-to-date snapshot of these matters 
Research question: Is chiropractic treatment effective in comparison to other 
recommended treatments such as physiotherapy? 
Date: 23/08/2022 
Reviewed: 05/12/2023 
Requestor: s47F - personal privacy 
Endorsed by: n/a 
Researcher: Aaron Hs47F - personal priva 
Cleared by: Stephanie Ps47F - personal   
privacy
Next review date: December 2024 
Efficacy of chiropractic treatment 
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1.  Contents 
Efficacy of chiropractic treatment ............................................................................................... 1 
1. 
Contents ....................................................................................................................... 2 
2. 
Summary ...................................................................................................................... 2 
3. 
Review, December 2023 ............................................................................................... 2 
3.1  Other TAPIB research ............................................................................................... 2 
3.2  Recent external research ........................................................................................... 3 
4. 
Musculoskeletal conditions ........................................................................................... 4 
5. 
Non-musculoskeletal conditions .................................................................................... 4 
6. 
References ................................................................................................................... 5 
 
2. Summary 
Review (December 2023): We considered additional relevant research published since 
August 2022 and findings of RES 322 Manual therapy to address neuromusculoskeletal 
function. Evidence from clinical guidelines into musculoskeletal conditions suggests 
manual therapy including chiropractic should only be recommended alongside active 
exercise. A 2023 systematic review of 28 randomised controlled trials found very low 
certainty evidence that spinal manipulation therapy reduces pain and disability more 
than other treatments in persistent non-specific neck pain. New evidence does not alter 
this paper’s previous conclusions. 
There is moderate level evidence that spinal manipulation therapy (SMT) as practiced by 
chiropractors is comparable to other recommended interventions for the treatment of lower 
back pain. Evidence regarding effectiveness of chiropractic treatment on other musculoskeletal 
conditions is more tentative. 
There is evidence that SMT is not effective in the treatment of non-musculoskeletal conditions. 
3.  Review, December 2023 
3.1  Other TAPIB research 
RES 322 Manual therapy to address neuromusculoskeletal function considered efficacy and 
recommendations around manual therapy in general. This can include spinal manipulation 
therapy performed by a chiropractor, but also other manual techniques including massage and 
joint mobilisation offered by osteopaths and massage therapists. RES 322 found evidence 
that: 
 
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manual therapy can be effective at managing pain and discomforsct and improving 
physical functioning for people with musculoskeletal-related pain conditions, especial y 
low back pain and neck pain. Minimal evidence exists related to improvements in 
function for people with non-pain related conditions. While some evidence points to 
improvements in quality of life, most functional outcomes relate to improving range of 
motion or mobility. No evidence was found that manual therapy leads to a reduction in 
other activity limitations or participation restrictions. 
Clinical practice guidelines generally offer conditional acceptance of manual therapy. 
Stronger evidence exists for the benefits of short-term manual therapy, with less 
evidence that it is efficacious as a long-term management strategy. Further, evidence 
suggests manual therapy is most optimally delivered alongside active exercise 
treatment. However, there is also some suggestion that manual therapy, as a form of 
passive exercise, may be offered as an alternative to patients who are unable to 
engage in an active exercise program. 
Regarding chiropractic, RES 322 reviews a Delphi consensus statement of 58 Doctors of 
Chiropractic regarding best practice treatment for musculoskeletal pain. They recommend 
active exercise alongside manual therapy. This contrasts with other clinical guidelines which 
suggest manual therapy should only be prescribed if active exercise is also prescribed. 
3.2  Recent external research 
Minucci et al (2023) reviewed 28 randomised controlled trials and found very low certainty 
evidence that SMT is more effective than guideline-recommended interventions for reducing 
pain and disability in persistent non-specific neck pain. 
Gorrell et al (2023) reviewed 154 studies of spinal manipulation to determine reporting of 
adverse events. 61% of studies reported adverse events. No serious adverse events were 
reported in any of the studies. However, there was considerable variation in terms and only 
23% of studies offered a definition of adverse event. 
Kushnir et al (2023) reviewed 35 articles relating to SMT for people with neurological 
conditions. Evidence was too limited to draw conclusions regarding the efficacy of SMT on 
neurological symptoms. 
Grabowski et al (2022) reviewed evidence that chiropractic care may reduce the incidence of 
falls. The authors found evidence that chiropractic may affect risk factors associated with falls, 
but there is insufficient evidence to determine whether chiropractic does reduce the frequency 
or severity of falls. 
Fernandez et al (2022) reviewed 15 studies and found most chiropractors were confident in 
discussing and supportive of exercise and physical activity alongside their other 
recommendations. However, the included studies were al  moderate to high risk of bias. 
 
 
 
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4.  Musculoskeletal conditions 
Rubinstein et al (2019) and Blanchette et al (2016) found moderate quality evidence that SMT 
has similar effects to other recommended therapies (e.g physiotherapy) for treatment of 
chronic low back pain. However, the authors note limitations including high level of 
heterogeneity between studies, the potential for conflict of interest and publication bias and the 
overall smal  number of good quality clinical trials. The results of Rubinstein et al (2019) and 
Blanchette et al (2016) differ from earlier studies mainly in upgrading evidence from low/very 
low to moderate (Rubenstein et al, 2012). 
Coulter et al (2019) found low-moderate quality evidence that different types of manual therapy 
wil  reduce pain and improve function for chronic nonspecific neck pain compared to other 
interventions. The same team found moderate quality evidence that manual therapy wil  
reduce pain and improve function for chronic low back pain (Coulter et al, 2018). However, 
these studies merge results from chiropractic, osteopathic and physiotherapy settings and so 
effect of manual therapy in a chiropractic setting is not clear. 
Prevost et al (2019) reviewed the literature on manual therapy for children under 18 years. 
They found moderate quality evidence for benefit in low back pain and pulled elbow and 
inconclusive results for all other conditions including scoliosis, torticollis, cerebral palsy and 
postural asymmetry. 
A 2019 systematic review considered the use of maintenance care among chiropractors, that 
is, ongoing preventative treatment for patients not necessarily presenting with symptoms (Iben 
et al, 2019). The authors conclude that maintenance care can be considered an evidence 
based preventative method. However, they draw this conclusion without considering the 
quality of the included studies and despite 2 out of 3 effectiveness studies showing no benefit 
to maintenance care. 
5.  Non-musculoskeletal conditions 
An international group of researchers and representatives from chiropractic organisations 
recommend that SMT should not be used to treat non-musculoskeletal conditions. In 
particular, they found SMT is not effective for treating infantile colic, childhood asthma, 
hypertension, primary dysmenorrhea or migraine (Cote et al, 2021). 
This systematic review agrees with other studies including high quality clinical trials. For 
example, in their 2018 systematic review, Goncalves et al found no evidence of effectiveness 
of chiropractic care on prevention or early treatment of any condition. Of the reviewed articles, 
the authors found only 2 which were of sufficient methodological quality and level of evidence 
to demonstrate an effect. One article found no effect of SMT on prehypertension or stage 1 
hypertension. The other found no effect of SMT on primary dysfunctional breathing (Goncalves 
et al, 2018). 
 
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Cote et al also contrasts with some other systematic reviews. For example, Rist et al (2019) 
found that spinal manipulation may be an effective therapeutic technique to reduce migraine 
days and pain/intensity of headache. However, significant concerns with methodological 
quality and risk of bias in included studies means the results of the systematic review are 
preliminary at best. 
Cote et al note that the reviews which show a likely effect of chiropractic treatment on non-
musculoskeletal conditions all suffer from significant methodological issues, include low quality 
studies, or include study designs which do not demonstrate efficacy (for a brief overall 
assessment of the evidence see Cote et al, 2021, pp.17-18). 
6.  References 
Blanchette, M.-A., Stochkendahl, M. J., Borges Da Silva, R., Boruff, J., Harrison, P., & 
Bussières, A. (2016). Effectiveness and economic evaluation of chiropractic care for the 
treatment of low back pain: A systematic review of pragmatic studies. PloS One, 11(8), 
e0160037. https://doi.org/10.1371/journal.pone.0160037 
Côté, P., Hartvigsen, J., Axén, I., Leboeuf-Yde, C., Corso, M., Shearer, H., Wong, J., 
Marchand, A.-A., Cassidy, J. D., French, S., Kawchuk, G. N., Mior, S., Poulsen, E., 
Srbely, J., Ammendolia, C., Blanchette, M.-A., Busse, J. W., Bussières, A., Cancel iere, 
C., … Yu, H. (2021). Response to Lawrence DJ: the global summit on the efficacy and 
effectiveness of spinal manipulative therapy for the prevention and treatment of non-
musculoskeletal disorders: a systematic review of the literature. Chiropractic & Manual 
Therapies, 29(1), 26. https://doi.org/10.1186/s12998-021-00380-7 
Coulter, I. D., PhD. (2019). Manipulation and mobilization for treating chronic nonspecific neck 
pain: A systematic review and meta-analysis for an appropriateness panel. Pain 
Physician, 2(22.2), E55–E70. https://doi.org/10.36076/ppj/2019.22.e55 
Coulter, I. D., Crawford, C., Hurwitz, E. L., Vernon, H., Khorsan, R., Suttorp Booth, M., & 
Herman, P. M. (2018). Manipulation and mobilization for treating chronic low back pain: 
a systematic review and meta-analysis. The Spine Journal: Official Journal of the North 
American Spine Society, 18(5), 866–879. https://doi.org/10.1016/j.spinee.2018.01.013 
Fernandez, M., Young, A., Milton, K., Pinhiero, M., de Luca, K., Ferreira, P., & Hebert, J. 
(2022). Physical activity promotion in chiropractic: a systematic review of clinician-
based surveys. Chiropractic & manual therapies, 30(1), 55. 
https://doi.org/10.1186/s12998-022-00467-9 
Goncalves, G., Le Scanff, C., & Leboeuf-Yde, C. (2018). Effect of chiropractic treatment on 
primary or early secondary prevention: a systematic review with a pedagogic approach. 
Chiropractic & Manual Therapies, 26(1). https://doi.org/10.1186/s12998-018-0179-x 
 
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Gorrell, L. M., Brown, B. T., Engel, R., & Lystad, R. P. (2023). Reporting of adverse events 
associated with spinal manipulation in randomised clinical trials: an updated systematic 
review. BMJ open, 13(5), e067526. https://doi.org/10.1136/bmjopen-2022-067526 
Grabowska, W., Burton, W., Kowalski, M. H., Vining, R., Long, C. R., Lisi, A., Hausdorff, J. M., 
Manor, B., Muñoz-Vergara, D., & Wayne, P. M. (2022). A systematic review of 
chiropractic care for fall prevention: rationale, state of the evidence, and 
recommendations for future research. BMC musculoskeletal disorders, 23(1), 844. 
https://doi.org/10.1186/s12891-022-05783-y 
Iben, A., Lise, H., & Charlotte, L.-Y. (2019). Chiropractic maintenance care - what’s new? A 
systematic review of the literature. Chiropractic & Manual Therapies, 27(1), 63. 
https://doi.org/10.1186/s12998-019-0283-6 
Kushnir, A., Fedchyshyn, B., & Kachmar, O. (2023). Review of effects of spinal manipulative 
therapy on neurological symptoms. Journal of bodywork and movement therapies, 34, 
66–73. https://doi.org/10.1016/j.jbmt.2023.04.009 
Minnucci, S., Innocenti, T., Salvioli, S., Giagio, S., Yousif, M. S., Riganel i, F., Carletti, C., 
Feller, D., Brindisino, F., Faletra, A., Chiarotto, A., & Mourad, F. (2023). Benefits and 
Harms of Spinal Manipulative Therapy for Treating Recent and Persistent Nonspecific 
Neck Pain: A Systematic Review With Meta-analysis. The Journal of orthopaedic and 
sports physical therapy, 53(9), 510–528. https://doi.org/10.2519/jospt.2023.11708 
Parnel  Prevost, C., Gleberzon, B., Carleo, B., Anderson, K., Cark, M., & Pohlman, K. A. 
(2019). Manual therapy for the pediatric population: a systematic review. BMC 
Complementary and Alternative Medicine, 19(1), 60. https://doi.org/10.1186/s12906-
019-2447-2 
Rist, P. M., Hernandez, A., Bernstein, C., Kowalski, M., Osypiuk, K., Vining, R., Long, C. R., 
Goertz, C., Song, R., & Wayne, P. M. (2019). The impact of spinal manipulation on 
migraine pain and disability: A systematic review and meta-analysis. Headache, 59(4), 
532–542. https://doi.org/10.1111/head.13501 
Rubinstein, S. M., Terwee, C. B., Assendelft, W. J. J., de Boer, M. R., & van Tulder, M. W. 
(2012). Spinal manipulative therapy for acute low-back pain. Cochrane Database of 
Systematic Reviews, 9, CD008880. https://doi.org/10.1002/14651858.CD008880.pub2 
Rubinstein, S. M., de Zoete, A., van Middelkoop, M., Assendelft, W. J. J., de Boer, M. R., & 
van Tulder, M. W. (2019). Benefits and harms of spinal manipulative therapy for the 
treatment of chronic low back pain: systematic review and meta-analysis of randomised 
controlled trials. BMJ (Clinical Research Ed.), 364, l689. 
https://doi.org/10.1136/bmj.l689 
 
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