Clinical Trials

The following is adapted from The Chiropractic Report

Editor: Lawyer David Chapman-Smith LL.B (Hons)

Reviewing the expert study1 from US economists from Mercer Health and Benefits2 and Harvard University3 which analyses chiropractic management of back and neck pain one finds the following comments…

Statistical analysis and many scientific and medical trials prove the:

Effectiveness: “Chiropractic care is more effective than other modalities for treating low back and neck pain”. “Chiropractic care is more effective than medical care or physiotherapy types of treatment including mobilisation, manipulation and exercises”.

Cost-effectiveness: “…chiropractic care for low back and neck pain is highly cost-effective and represents good value in comparison to medical care…” “Chiropractic care is more cost-effective than medical care or physiotherapy types of treatment including mobilisation, manipulation and exercises”

Patient satisfaction: “Studies consistently report very high patient satisfaction rates for chiropractic treatment, higher than other forms of health care providers for patients with back and neck pain”.

Health economists Stano and Smith4 analysed the health care records of over 7,000 patients and summarised their results:

  1. Medical costs were 47% higher than chiropractic costs for outpatient care…
  2. Medical costs were 61% higher for total care…

In addition the compensation costs are vastly reduced when a patient has chiropractic care. This is because…

  1. Time off work for matched group of patients is dramatically higher for medical/physiotherapy patients (20.7 days) compared to chiropractic patients (2.4 days)
  2. Compensation costs were nearly 10x higher if patients chose medical/physio care instead of chiropractic care.

These results concurred with the findings from Australia5 which found that not only was medical / physiotherapy care much more expensive but the percentage of patients who developed chronic pain was over 6 x greater (11.6%) than those patients who received chiropractic care (1.9%).

In the UK6 a direct comparison in the workplace for employees suffering from neck or back pain found that those employees receiving chiropractic care had an extremely high self-rated improvement and patient satisfaction. With chiropractic care in the first year there was an 18% saving in costs, a 30% saving in disability and sickness payments. In the second year there was a 40% net saving.

Another study7 found a saving of 30% using chiropractic care than medical / physio care. Annual spending on spine related problems in the US is estimated at $85 billion – an increase in 65% since 1997. The epidemic in other countries, including Britain, is expanding in a similar fashion.

“If exercise therapy/advice was given by chiropractors instead of physiotherapists the costs would fall dramatically”.

A vast scientific literature has now evaluated the effectiveness of chiropractic care for patients with common types of neck pain and concludes that “Chiropractic care combined with exercises is more effective than any other treatment for neck pain”.

The question is whether giving chiropractic care to all patients who need it would add to the overall health care costs even though it is cost-effective in itself or will the benefits truly substitute for more expensive medical care?

One four year study published in the American Medical Association’s Archives of Internal Medicine8 analysed data from 1.7 million members of a health care network.

One million members had medical cover only whereas 700,000 members had medical and chiropractic cover. The conditions seen included all conditions seen by chiropractors – including spinal pain, rib disorders, headache, extremity problems, myalgias and arthralgias.

The members who chose chiropractic care had significantly lower claim costs… The findings were:

  1. Overall costs reduced by 28%
  2. Reduced hospitalisation by 41%
  3. Reduced back surgeries by 32%
  4. Reduced medical imaging by 37%

The above figures would be even more impressive if they included in the medical care costs “the costs of medication”… and disallowed in the chiropractic costs “the cost of initial GP visit referring the patient to the chiropractor”.

The UK BEAM9 trial published in the BMJ in 2004 compared four different treatment approaches for 1,334 patients. The researchers stated that the trial shows convincingly that manipulation was the most cost-effective treatment and recommended that it should be made generally available to back pain patients on the NHS. The trial results showed that the group of patients receiving manipulation continued to additional benefit after 12 months.

This echoed the conclusions of the well known Meade trial10 that proved that chiropractic treatment was more effective and more cost-effective that physiotherapy and hospital outpatient treatment for low back pain – and that the difference in effectiveness continued to widen at 5-years after the trial… the chiropractic patients did not regress, adding dramatically to the cost-effectiveness of chiropractic treatment.

Renowned epidemiologist Professor Manga and others from the University of Ottawa, Canada in the 1990’s published studies including a comprehensive Government report titled The Effectiveness and Cost-effectiveness of Chiropractic11 12.

They concluded that:

  1. The effectiveness and cost-effectiveness of chiropractic management of low back pain…
  2. The untested and questionable or harmful nature of many current medical therapies…
  3. The economic efficiency of chiropractic care for low back pain compared with medical care…
  4. The safety of chiropractic…
  5. The higher satisfaction levels expressed by patients consulting chiropractors…

… all the above offer an overwhelming case in favour of much greater use of chiropractic services in the management of low back pain.

The recently published Bronfort Report13, a review the scientific and medical literature, looked for good quality evidence based proof of effectiveness of common conditions regularly treated by most chiropractors. The study reveals moderate or high-positive evidence for chiropractic treatment of the following conditions:- Acute low back pain; Chronic low back pain; Acute/sub-acute neck pain; Acute whiplash-associated disorders; Chronic neck pain; Shoulder girdle pain /dysfunction; Adhesive capsulitis (frozen shoulder); Tennis elbow; Hip osteoarthritis; Knee osteoarthritis; and Patello-femoral pain syndrome.

Chiropractic is the only profession that has scientific proof and high quality clinical trial (eg RCT) evidence proving that their treatment of all these common painful problems is effective.

The 1994 British Government Clinical Standards Advisory Group (CSAG14) report stated that patients with low back pain should, if they have not responded to simple anti-inflammatory drugs, be referred for expert manipulation. They should NOT have physicaltherapy such as ultrasound, interferential, exercises, hydrotherapy, traction, etc as these techniques have been proven to be of no value and therefore should NOT be recommended.

GP’s were informed of this at the time.

In 2004 the European Guidelines15 (largely replacing the CSAG guidelines)… stated exactly the same. Patients should be referred for expert manipulation… but should NOT have physicaltherapy such as ultrasound, interferential, exercises, hydrotherapy, traction, etc as these techniques have long been proven to be of no value and therefore should NOT recommended.

GP’s were again informed of this at the time.

The National Institute of Clincal Excellence (NICE16) guidelines published in 2009 again endorsed the fact that these old fashioned, unproven treatment regimes should NOT be recommended as they were of no value and stated that the most effective treatments were manipulation and acupuncture.

GP’s were again informed of this at the time.

In conclusion:

There is overwhelming evidence from all over the world that expert manipulative treatment and advice for many conditions – eg. back pain, neck pain and headaches – is the single most recommended, effective, safe and cost-effective type of treatment.

In addition, expert chiropractic manipulation is without doubt the single most evaluated and proven type of treatment.

Any patient who is not referred for this type of treatment should be concerned that:

  1. they have been given incorrect advice by the referring practitioner
  2. they are receiving poor quality treatment that does not have robust scientific or medical evidence to substantiate its use
  3. they will be unlikely to get good results from that type of treatment.

Chiropractic is both the third largest healing profession in the world (behind medicine and dentistry) and unquestionably the largest profession in the world that uses manipulation – massively outnumbering all the other professions put together.

Chiropractic is not new. It was founded in the 1890’s, in the year that Roentgen discovered X-Rays. The first College of Chiropractic was founded over 100 years ago – training students in musculoskeletal diagnosis, expert manipulation and in radiology. Interestingly, these chiropractic students were the first professionals to be qualified in the techniques of radiology – taking and interpreting X-Rays… 18 years before the first course was started to train medical radiologists.

Chiropractic is the “Gold Standard” for the treatment of many musculo-skeletal conditions. It is proven to be very safe, very effective and very cost-effective.

Contact: Dr Scott Middleton @ Wilmslow Chiropractic Clinic
Tel: 01625 531164 15 Lindow Parade Chapel Lane Wilmslow Cheshire SK9 5JL

Scott graduated in 1977 and now has the largest chiropractic practice in the North West of England. For c.15 years he was the only chiropractor allowed to work on the NHS. He has travelled extensively to Europe, the Middle East and the US to advise or treat patients, run clinics or lecture. He both writes medico-legal reports and is a Medical Expert for the Court. His practice protocol is: Patients should not be treated more than four times unless there is good evidence of improvement. This is proven by NHS audit to be very effective.


  1. The complete Mercer report can be found at
  2. Arnold Milstein MD, MPH holds degrees in economics, medicine and health services planning. He is chief physician in Mercer, Medical director of PBGH (the largest employer health care coalition in North America) and serves on the Permanent Advisory Commission for the US federal Medicare programme.
  3. Niteesh Choudhry MD, PhD is assistant Professor at Harvard Medical School. His PhD in Health Policy at Harvard was in statistics and evaluation sciences.
  4. Smith M Stano M (1997) Cost and recurrences of Chiropractic and Medical Care of Low back Pain. JMPT 20:5-12
  5. Ebrall PS (1992) mechanical Low Back Pain: A comparison of medical and chiropractic management… Chiro J. Aust 22:47-53
  6. Jay TC, Jones SL ewt al.(1998) A chiropractic service arrangement for musculoskeletal complaints in industry. Occup Med 48:389-95
  7. Moseley CD, CohenIG et al. (1996) Cost-effectiveness of chiropractic care in a managed care setting. Am J Managed Care 11:280-2
  8. Legoretta AP, Metz RD, Nelson CF et al (2004) Comparative analysis of individuals with or without chiropractic coverage. Patients characteristics, Utilisation and Costs. Arch Int Med 164: 1985-92
  9. UK BEAM Trial (2004) Randomised Trial: Cost-effectiveness of physical treatments for back pain in Primary Care. BMJ: 329:1381
  10. Meade TW, Dyer S et al (1990) Low back pain of mechanical origin. Randomised comparison of chiropractic and hospital outpatient treatment. BMJ 300:1431-37
  11. Manga P, Angus D et al. 1993. The effectiveness and cost-effectiveness of chiropractic management of low back pain. University of Ottowa.
  12. Manga P, Angus D et al 1998 Enhanced chiropractic coverage under OHIP as a means of reducing health outcomes and achieving equitable access to selected health care services. Ontario CA, Totonto.
  13. The Bronfort Report 2010 – Effectiveness of manual therapies: Professor Gert Bronfort, A systematic review of Randomised Controlled Trials (RCTs), and UK and USA Clinical guidelines, focussing on both musculoskeletal and non-musculoskeletal conditions.
  14. The 1994 British Government Clinical Standards Advisory Group (CSAG)
  15. The European Guidelines on Back Pain – November 2004.
  16. The National Institute of Clinical Excellence (NICE) guidelines – 2009