The primary reason (93%) patients go to chiropractors is for the management of spinal pain complaints (1). Specifically, 63% go to chiropractors for low back pain, and 30% go to chiropractors for neck pain.

Chiropractic care is primarily mechanical-based care. The distinguishing difference between the mechanical-based care of chiropractic as compared to other mechanical-based disciplines is the spinal adjustment (2, 3, 4, 5).

The spinal adjustment is a form of manipulation that is delivered in a specific line of direction. A good description of the chiropractic adjustment is found in the publication by orthopedic surgeon William H. Kirkaldy-Willis that notes (4):

“[Chiropractic] spinal manipulation is essentially an assisted passive motion applied to the spinal apophyseal and sacroiliac joints.”

There are three categories of joint motion:

1) Active exercise range of motion.

2) “Beyond the end of the active range of motion of any synovial joint, there is a small buffer zone of passive mobility.” A joint can only move into this zone with passive assistance, and going into this passive range of motion “constitutes mobilization.”

3) “At the end of the passive range of motion, an elastic barrier of resistance is encountered. This barrier has a spring-like end-feel.”

“If the separation of the articular surfaces is forced beyond this elastic barrier, the joint surfaces suddenly move apart with a cracking noise.”

“This additional separation can only be achieved after cracking the joint and has been labeled the paraphysiological range of motion.”

“This constitutes manipulation.”

“[Joint manipulation (adjusting)] requires precise positioning of the joint at the end of the passive range of motion and the proper degree of force to overcome joint coaptation [to overcome the resistance of the joint surfaces in contact].”

“With experience, the manipulator can be very specific in selecting the spinal level to be manipulated.”

The effectiveness of chiropractic care for spinal pain is well-documented. Chiropractic care (spinal manipulation) is routinely included in spine pain clinical practice guidelines (6, 7, 8, 9, 10).

The effectiveness of chiropractic care for spine pain is beyond question. This presentation looks at the cost effectiveness of chiropractic care for musculoskeletal pain syndromes, primarily for back and neck pain complaints.

•••••

In 2004, a 4-year study compared health care expenditures of 700,000 health plan members who had a chiropractic benefit with 1 million members of the same plan without the same benefit. The study was published in the journal Archives of Internal Medicine, titled (11):

Comparative Analysis of Individuals with and Without Chiropractic:
Characteristics, Utilization, and Costs

The authors concluded that systematic access to chiropractic care lowers overall health care costs and results in improved clinical outcomes.

•••••

Another study in 2004 was published in the Journal of Occupational Environmental Medicine, titled (12):

Chiropractic Care:
Is it Substitution Care or Add-on Care in Corporate Medical Plans?

The authors found that chiropractic care was primarily used as a substitution for other types of medical care that is often less effective and costlier. The authors concluded that chiropractic care “lowers cost when compared with treatment from traditional medical providers.”

•••••

In 2009, researchers from Mercer Health and Benefits and Harvard Medical School published a paper titled (13):

Do Chiropractic Physician Services for Treatment of Low-back and Neck Pain Improve the Value of Health Benefit Plans?
An Evidence-based Assessment of Incremental Impact on Population Health and Total Health Care Spending

The authors noted that the annual cost for treatment of neck pain by chiropractors was lower than treatment from medical physicians. They specifically state:

“When considering effectiveness and cost together, chiropractic physician care for low back pain and neck pain is highly cost-effective and represents a good value in comparison to medical physician care.”

“Our findings in combination with existing U.S. studies published in peer-reviewed scientific journals suggest that chiropractic-delivered care for the treatment of low back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorably to most therapies that are routinely covered in US health benefit plans.”

“Both value and clinical outcomes show marked improvement with the addition of chiropractic coverage for the treatment of low back and neck pain in US employer-sponsored health benefit plans.”

•••••

In 2010, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (14):

Cost of Care for Common Back Pain Conditions Initiated with Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician:
Experience of One Tennessee-based General Health Insurer

 The authors examined a fully BlueCross/BlueShield insured population of 85,000 people over a 2-year period. The authors noted:

“Patients who experience low back pain and seek treatment first from a chiropractor rather than an MD/DO save 40% on average of health care-related costs.”  

“Insurance companies may be inadvertently paying more for care with restricted access to chiropractic-initiated care than if such restrictions were removed.”

The authors concluded that for BlueCross/BlueShield of Tennessee, chiropractic-initiated episodes of care could lead to an annual cost savings of approximately $2.3 million. This is substantial.

•••••

Another study in 2010 was published in the Spine Journal, titled (15):

The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study:
A Randomized Controlled Trial on the Effectiveness of Clinical Practice Guidelines in the Medical and Chiropractic Management of Patients with Acute Mechanical Low Back Pain

The authors noted that chiropractor-delivered spinal manipulations were very effective for low back pain compared to usual care administered by primary care medical doctors.

•••••

In 2013, a study was published in the journal Spine, titled (16):

Early Predictors of Lumbar Surgery After Occupational Back Injury:
Results from a Prospective Study of Workers in Washington State

The authors showed that spine surgeries can be avoided through chiropractic care. Specifically, the odds of surgery for those who first saw a chiropractor were only 1.4%, while the odds for those who first saw a surgeon were 42.7%. Despite this vast difference in surgery rate, the patients scored similarly on the Roland-Morris Disability Index prior to the intervention (chiropractic care versus surgery).

•••••

In 2014, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (17):

Cost-effectiveness of Manual Therapy for the Management of Musculoskeletal Conditions: A Systematic Review and Narrative Synthesis of Evidence from Randomized Controlled Trials

The authors found that chiropractic-delivered manipulation is less costly than physiotherapy or general physician practitioner care. They also noted that chiropractic-delivered manipulations are less costly and more effective for neck pain than the alternatives. The authors specifically state:

“Manual therapy techniques are more cost-effective for low back and shoulder pain and disability than care delivered by general practitioners (GPs) alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management.”

“Evidence showed manual therapy to be economically advantageous compared with other treatments of musculoskeletal conditions.” 

“Chiropractic-delivered therapy is equally effective and more cost-efficient than usual medical care.”

•••••

In 2015, a study was published in the journal Spine, titled (18):

Comparison of Spinal Manipulation Methods and Usual Medical Care for Acute and Sub-acute Low Back Pain:
A Randomized Clinical Trial

The authors found:

• Of patients receiving chiropractic manipulation, 94% had a 30% reduction in low back pain after 4 weeks, while only 56% of medical care recipients had the same reduction.
• “This suggests a 38% increase in effectiveness by seeing a chiropractor first.”

•••••

In 2019, a study was published in the Journal of Chiropractic Humanities, titled (19):

Cost-Efficiency and Effectiveness of Including Doctors of Chiropractic to Offer Treatment Under Medicaid:
A Critical Appraisal of Missouri Inclusion of Chiropractic Under Missouri Medicaid

This article was an in-depth appraisal of the cost effectiveness for the inclusion of chiropractic services under Missouri Medicaid. The article proposes that chiropractors deliver care that is more effective and less costly than medical care.

These authors assessed 3 cost saving values attributed to chiropractic care:

• Cost savings from chiropractic care v. traditional MD/DO care
• Cost savings from reductions in spinal surgery
• Cost savings from reduced use and abuse of opioid prescription drugs

The authors make these points:

“Spine pain is a pervasive health care problem in the United States.”

“There is an 80% chance that people will have back pain at some point in their lives.”

“In the U.S., neck pain is one of the top musculoskeletal disorders in the adult population.”

“More U.S. adults have chronic pain (headache, neck or back pain, arthritis, or joint pain) than heart disease, diabetes, and cancer combined.”

“Chiropractic-delivered services for back and neck pain are significantly more cost-effective when compared with all alternative approaches.”

“The benefits of care provided by doctors of chiropractic (DCs) have been demonstrated by research throughout the U.S. health care system.”

“Although there are potentially numerous beneficial clinical outcomes from DC treatment, perhaps the greatest clinical outcome is the reduction of neck and low back pain.”

The authors note that seeing a chiropractor does not increase overall healthcare spending. They note that overall medical spending is not increased from seeking care from a chiropractor.

The authors observed that chiropractor-delivered spinal manipulations are very effective for low back pain compared to usual care administered by primary care physicians. They state:

“Hospitalization expenditures were significantly lower for those who used complementary and alternative providers, including chiropractic.”

The authors also understand that an important but often under-appreciated benefit of chiropractic care is its ability to reduce the incidence of spinal surgery, as well as reducing the use of opioid drugs. The authors make these points:

“Research shows that chiropractors are the safest and most effective alternative to surgery for most cases of back pain.”

“60% of patients with sciatica benefited from spinal manipulation after attempting medical management and failing to experience any improvement.”

“[Chiropractic treatment] leads to 60% reduction in spinal surgery.”

“In light of the research showing that chiropractic-managed care can reduce the incidence of spinal surgery, it is reasonable to suppose that a number of surgeries could be avoided through routine chiropractic management.”

“The Missouri Medicaid system would benefit from the avoidance of spinal surgeries, and this would lead to significant cost savings for the state.”

“Chiropractors treat low back and neck pain without resorting to the prescription of opioids or any other type of drugs.”

“People with insurance coverage that includes chiropractic had lower annual health care costs.”

“Those who seek chiropractic-guided treatment first saved an average of 40% on annual health care costs.”

“Seeking treatment from a chiropractor did not add to overall medical spending.” 

“Chiropractic-directed treatment led to a 60% decrease in spinal surgeries.”

“Chiropractic-directed care was 38% less costly than usual medical care.”

“Chiropractic-delivered care lowered costs and increased positive outcomes.” 

“Too often, people who seek relief from lower back pain through usual medical care end up taking painkillers, which are addictive and lead to negative outcomes.”

“Patients who visit DCs not only find relief from neck and lower back pain at lower annual cost, but also they report their outcomes to be more effective.”

“Chiropractic care leads to cost savings from reduced use and abuse of opioid prescription drugs.”

“There are now a dozen states that have embraced alternative therapies such as chiropractic care to combat the cost of the opioid abuse epidemic.”

“This study supports the proposition that treatment by chiropractors for neck and lower back pain may reduce the use and abuse of opioid prescription drugs.”

“Chiropractic treatment and care leads to a reduction in cost of spinal surgery.”

•••••

In 2021, a study was published in the Journal Spine, titled (20):

Longitudinal Care Patterns and Utilization Among Patients with New-Onset Neck Pain by Initial Provider Specialty

This study was a retrospective cohort design involving 777,326 patients, aged 18 to 89 years. Its objective was to compare utilization patterns for patients with new-onset neck pain by initial provider specialty. In this analysis, chiropractic care was the most often healthcare provider seen for patients with new-onset neck pain. All patients had a new-onset neck pain.

The authors discovered that patients who initially saw a chiropractor for their neck pain were 40% less likely to have injections compared to patients who initially saw an orthopedic surgeon. Patients who initially saw a chiropractor for their neck pain were 97% less likely to have major surgery compared to patients who initially saw an orthopedic surgeon. Patients seeing chiropractors were significantly less likely to use expensive advanced imaging, particularly CT and MRI. The authors concluded:

“Within [this] large, national cohort of patients with new-onset neck pain, we found that chiropractors were the initial provider for a plurality of patients and that patients with chiropractor or PT/OT initial providers received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions, such as injection or major surgery, during follow-up.” 

“Starting with a chiropractor was associated with lower rates of invasive therapeutic interventions and surgery, our study suggests initial care for new-onset neck pain by chiropractors is likely associated with lower longer-term care intensity and costs.”

“Our findings raise the question whether more frequent referrals from physicians to chiropractors or PT/OTs might enhance the efficiency of care for patients with new-onset neck pain.”

“Health systems may also seek means of engendering more frequent referrals from primary care or specialist physicians to chiropractors for patients with new-onset neck pain.”

•••••

In 2024, a study was published in the journal Chiropractic & Manual Therapies, titled (21):

Cost of Chiropractic Versus Medical Management of Adults with Spine‑related Musculoskeletal Pain:
A Systematic Review

The purpose of this study was to evaluate the evidence for the cost of chiropractic care compared to conventional medical care for management of spine-related musculoskeletal pain. The literature search used 44 studies (26 cohort studies, 17 cost studies, and 1 randomized controlled trial).

The authors note that in the U.S., chiropractic care is one of the most utilized approaches to treatment of spine-related musculoskeletal pain. The authors found no studiesthat chiropractic care had higher overall costs. No studies found higher long-term healthcare costs in those using chiropractic care. Specifically, these authors found:

• Fifteen studies found that diagnostic imaging, particularly advanced imaging like MRI, was used less with chiropractic care.
• Eleven studies found that fewer opioid prescriptions were dispensed or filled with chiropractic care.
• Eight studies found fewer surgeries with chiropractic care.
• Seven studies found fewer hospitalizations with chiropractic care.
• Six studies found that having a chiropractor as the first care provider was associated with lower downstream costs.
• Five studies found decreased use of injection procedures with chiropractic care.
• Five studies found fewer referrals for specialist visits with chiropractic care.
• Two studies found that fewer emergency department visits were associated with chiropractic care.

These authors state:

“This study adds further confidence in the emerging body of evidence on provider-related cost differentials and provides a compelling case for the influence of conservative care providers as the first provider managing for spine-related musculoskeletal pain.”

“Diagnostic imaging, opioid utilization, surgery, hospitalizations, injection procedures, specialist visits, and emergency department visits were all reduced when chiropractors were involved early in the case.”

 “It may be in society’s best interest for U.S. healthcare organizations and governmental agencies to consider modifying benefit designs to reduce barriers to access chiropractic providers.”

“Eliminating these barriers would allow easier access to chiropractic services, which based on currently available  evidence consistently demonstrates reduced downstream services and  associated costs.”

“Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management.”

“The recurrent theme of the data seems to support the utilization of chiropractors as the initial provider for an episode of spine-related musculoskeletal pain.”

“Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals, and injection procedures.”

•••••

In 2025, a study was published in the journal Archives of Physical Medicine and Rehabilitation, titled (22):

Comparative Cost Analysis of Neck Pain Treatments for Medicare Beneficiaries

The objective of this study was to evaluate cost outcomes of initial treatment strategies for new neck pain (NP) episodes among Medicare beneficiaries from 291,604 patients. The authors found that spinal manipulation by chiropractors resulted in a 36% reduction in neck pain costs and a 13% reduction in prescription analgesic costs.

The authors concluded that for Medicare patients with new neck pain, the initial use of chiropractic spinal manipulation is associated with lower health care costs, particularly as related to the interventions from primary care providers.

Summary

The best evidence has found that chiropractic care is both effective and safe for the management of spinal pain syndromes. The evidence presented here also shows that chiropractic care is exceptionally cost-effective as well. This adds to the prospective that chiropractic spinal manipulation should be the “go-to” initial provider for spine pain syndromes.

References

1. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
2. Haldeman S; Modern Developments in the Principles and Practice of Chiropractic; Appleton-Century-Crofts; New York; 1980.
3. Kirkaldy-Willis WH; Managing Low Back Pain; Churchill Livingston; 1983 and 1988.
4. Kirkaldy-Willis WH, Cassidy D; Spinal Manipulation in the Treatment of Low-Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-40.
5. Fischgrund JS; Neck Pain; Monograph 27; American Academy of Orthopaedic Surgeons; 2004.
6. Chou R; Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK; Diagnosis and Treatment of Low Back Pain; Annals of Internal Medicine; October 2007; Vol. 147; No. 7; pp. 478-491.
7. Chou R, Huffman LH; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain; Annals of Internal Medicine; October 2007; Vol. 147; No. 7; pp. 492-504.
8. Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, Walters S, Kaeser M, Dehen M, Augat T; Clinical Practice Guideline:
   Chiropractic Care for Low Back Pain; Journal of Manipulative and Physiological Therapeutics; January 2016; Vol. 39; No. 1; pp. 1-22.
9. Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ, Stern PJ, Ameis A, Southerst D, Mior S, Stupar M, Varatharajan T, Taylor-Vaisey A; Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration; European Journal of Pain; February 2017; Vol. 21; No. 2 ; pp. 201-216.
10. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians; For the Clinical Guidelines Committee of the American College of Physicians; Annals of Internal Medicine; April 4, 2017; Vol. 166; No. 7; pp. 514-530.
11. Legorreta A, Metz D, Nelson S, Ray H, Chernicoff O, DiNubile N; Comparative analysis of individuals with and without chiropractic: characteristics, utilization, and costs; Archives of Internal Medicine; October 11, 2004; Vol. 164; No. 18; pp. 1985-1992.
12. Metz R, Nelson C, LaBrot T, Pelletier K; Chiropractic care: is it substitution care or add-on care in corporate medical plans?; Journal of Occupational Environmental Medicine; August 2004; Vol. 46; No. 8; pp. 847–855.
13. Choudhry N, Milstein A; Do chiropractic physician services for treatment of low-back and neck pain improve the value of health benefit plans? An evidence-based assessment of incremental impact on population health and total health care spending; Mercer Health and Benefits; 2009.
14. Liliedahl R, Finch M, Axene D, Goertz CM; Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer; Journal of Manipulative and Physiological Therapeutics; Nov-Dec 2010; Vol. 33; No. 9; pp. 640–643.
15. Bishop P, Quon J, Fisher C, Dvorak M; The chiropractic hospital-based interventions research outcomes (CHIRO) study: A randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain; Spine Journal; December 2010; Vol. 10; No. 12; pp. 1055–1064.
16. Keeney B, Fulton-Kehoe D, Turner J, Wickizer T, Chan K, Franklin G; Early predictors of lumbar surgery after occupational back injury: Results from a prospective study of workers in Washington State; Spine; May 15, 2013; Vol. 38; No. 11; pp. 953–964.
17. Tsertsvadze A, Clar C, Court R, Clarke A, Mistry H, Sutcliffe P; Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: A systematic review and narrative synthesis of evidence from randomized controlled trials; Journal of Manipulative and Physiological Therapeutics; Jul-Aug 2014; Vol. 37; No. 6; pp. 343–362.
18. Schneider M, Hass M, Glick R, Stevans J, Landsittel D; Comparison of spinal manipulation methods and usual medical care for acute and sub-acute low back pain: A randomized clinical trial; Spine; February 15, 2015; Vol. 40; No. 4; pp. 209–217.
19. McGowan JR, Suiter L; Cost-Efficiency and Effectiveness of Including Doctors of Chiropractic to Offer Treatment Under Medicaid: A Critical Appraisal of Missouri Inclusion of Chiropractic Under Missouri Medicaid; Journal of Chiropractic Humanities; December 2019; Vol. 10; No. 26; pp. 31-52.
20. Fenton JJ, MD, Fang SY, Ray M, Kennedy J, Padilla K, Amundson R, Elton D, Haldeman S, Lisi AJ, Sico S, Wayne PM, Romano PS; Longitudinal Care Patterns and Utilization Among Patients with New-Onset Neck Pain by Initial Provider Specialty; Spine; October 15, 2023; Vol. 48; No 20; pp. 1409–1418.
21. Farabaugh R, Hawk C, Taylor D, Daniels C, Noll C, Schneider M, McGowan J, Whalen W, Wilcox R, Sarnat R, Suiter L, Whedon J; Cost of Chiropractic Versus Medical Management of Adults with Spine‑related Musculoskeletal Pain: A Systematic Review; Chiropractic & Manual Therapies; March 6, 2024; Vol. 32; No. 1; Article 8.
22. Anderson BR, MacKenzie TA, Grout LM, Whedon JM; Comparative Cost Analysis of Neck Pain Treatments for Medicare Beneficiaries; Archives of Physical Medicine and Rehabilitation; May 2025; Vol. 106; No. 5; pp. 801-804.