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Chiropractic

GMJ News knowledge hub · last reviewed August 2026 · Georgian Medical Journal

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Chiropractic — founded by D.D. Palmer in 1895 on the theory that spinal “subluxations” cause disease by impinging on nerves — has evolved into a profession with a significant evidence base for musculoskeletal conditions: NICE England lists spinal manipulation therapy (SMT) as a treatment option for chronic low back and neck pain, and Cochrane systematic reviews confirm SMT is comparable in effectiveness to physiotherapy and other active treatments for these conditions (WHO). However, a critical safety issue requires clear disclosure: cervical (neck) manipulation is associated with vertebral artery dissection (VAD) and posterior circulation stroke — estimated at approximately 1 in 20,000–120,000 cervical manipulations — and informed consent discussion of this risk, however rare, is mandatory before any cervical manipulation procedure, particularly in young patients presenting with new neck pain.

Key messages

Evidence for LBP and neck pain — NICE lists it as an option
NICE England lists spinal manipulation therapy (SMT) as one of several treatment options for chronic low back and neck pain, alongside physiotherapy and acupuncture. Cochrane systematic reviews confirm SMT is comparable (not superior or inferior) to physiotherapy, exercise and other active treatments for these conditions.
Cervical manipulation and vertebral artery dissection — must be disclosed
Cervical (neck) manipulation is associated with vertebral artery dissection (VAD) leading to posterior circulation stroke. Risk estimates: approximately 1 in 20,000 to 1 in 120,000 cervical manipulations. Causation vs temporal coincidence is debated, but pre-manipulation informed consent discussion of this risk — however small — is mandatory. A young patient presenting with new-onset neck pain after a motor vehicle accident who subsequently strokes is a recognised medico-legal scenario.
Modern vs vitalist chiropractic — a spectrum within one profession
Evidence-based chiropractors (the majority) focus on spinal manipulation for musculoskeletal conditions, using the same outcome measures as physiotherapy. Vitalist chiropractors retain D.D. Palmer's original theory of "vertebral subluxations" causing systemic disease by impinging spinal nerves — and claim chiropractic treats asthma, otitis media, ADHD, colic and other non-musculoskeletal conditions. No peer-reviewed evidence supports these claims. The profession is internally divided.
The subluxation theory — the original basis, not supported by science
D.D. Palmer's 1895 founding theory: misaligned vertebrae ("subluxations") compress spinal nerves, disrupting vital force flow and causing disease throughout the body. No scientific evidence supports the existence of pathological subluxations as originally defined, or the claim that spinal adjustment cures or prevents systemic disease beyond musculoskeletal pain. Most national chiropractic associations have moved away from subluxation theory; some practitioners still use it.
What chiropractic does NOT have evidence for
No reliable evidence for chiropractic treatment of: asthma; otitis media (ear infections); colic; ADHD; hypertension; immune function; or any condition other than musculoskeletal pain syndromes. Parents should be aware that infant/child chiropractic — particularly for colic or ear infections — has no evidence base and carries a risk of serious injury in young children (cervical manipulation in infants has caused strokes and death in case reports).
Scope of practice and the physiotherapy comparison
Evidence-based chiropractic for musculoskeletal conditions (LBP, neck pain, some headache) is clinically comparable to physiotherapy/physical therapy. The outcome evidence does not demonstrate superiority of chiropractic over physiotherapy for any musculoskeletal condition. Both are reasonable options for chronic LBP and neck pain where active treatment is preferred.

Key statistics

NICE listed
SMT as treatment option for chronic LBP and neck pain (alongside physio)
NICE NG59
Cochrane evidence
SMT comparable to physiotherapy for LBP/neck pain — not superior
Cochrane 2011-12
1 in 20K–120K
estimated VAD (vertebral artery dissection) risk per cervical manipulation
Haldeman/Boyle
100M+
chiropractic consultations per year (USA alone)
ACA
1895
year D.D. Palmer founded chiropractic, Davenport Iowa
History
No evidence
for chiropractic in asthma, otitis, colic, ADHD, hypertension
Cochrane/WHO

Chiropractic evidence by condition — Cochrane/NICE assessment

Source: Cochrane/NICE. Evidence confined to musculoskeletal pain; no evidence for non-musculoskeletal claims.

Glossary of key terms

Spinal manipulation therapy (SMT)
WHO/PhysioHigh-velocity, low-amplitude (HVLA) thrust to a spinal joint — the clinical technique used in both chiropractic and osteopathic manipulation. The characteristic "crack" sound (cavitation) results from gas bubble formation in the joint fluid, not from bones "going back into place." SMT produces an immediate reduction in joint stiffness and pain sensitivity in the target area. The effect size is modest and comparable to physiotherapy exercise for chronic LBP.
Vertebral subluxation (chiropractic definition)
History/ScienceD.D. Palmer's original concept: a vertebra "out of alignment" that compresses a spinal nerve and disrupts nervous system function, causing disease throughout the body. Key problems with this model: (1) Vertebrae are held by strong ligaments and cannot casually sublux without major trauma; (2) No imaging study has demonstrated the pathological subluxations Palmer described; (3) The nervous system is not mechanically compressed in the way Palmer claimed; (4) No causal pathway from spinal subluxation to systemic disease has been demonstrated. Chiropractic subluxation is distinct from the orthopaedic/medical use of the same term (partial joint dislocation).
Vertebral artery dissection (VAD)
Neurology/VascularA tear in the wall of the vertebral artery (which runs through foramina in the cervical vertebrae) causing intramural haematoma → dissection → thrombus → posterior circulation ischaemia (brainstem, cerebellum, occipital lobe). Symptoms: sudden severe occipital/neck pain + signs of posterior fossa stroke (vertigo, diplopia, ataxia, facial numbness, Horner's syndrome). Young patients with VAD may present to chiropractors with neck pain before stroke symptoms develop — then subsequent cervical manipulation occurs in an already-compromised artery. The causal-vs-coincidental debate: people with evolving VAD get neck pain and seek treatment, so temporal association does not prove causation.
Evidence-based vs vitalist chiropractic
WHO/ChiropracticA significant internal division within the chiropractic profession: Evidence-based chiropractors: treat musculoskeletal conditions using spinal manipulation as one tool alongside exercise, rehabilitation and lifestyle advice; use outcome measures; acknowledge limitations of evidence; do not make claims beyond evidence. Vitalist chiropractors (sometimes called "straight" or "principled" chiropractors): maintain the subluxation model as the basis for all chiropractic; claim chiropractic addresses innate intelligence and systemic disease; may advise against vaccination or conventional medicine. Patients cannot always distinguish between these approaches by reading clinic advertising.
Chiropractic in children — serious safety concerns
WHO/PaediatricsCase reports exist of serious neurological injury in infants and young children from chiropractic cervical manipulation: spinal cord injury; vertebral artery dissection and stroke; subdural haematoma. The paediatric cervical spine is anatomically different from adults (hypermobile, vertebral bodies cartilaginous) — manipulation carries higher injury risk. Ernst et al. systematic review (2007): no reliable evidence that chiropractic is effective for any paediatric condition; serious adverse events documented. Parents should be informed that infant/child chiropractic for colic, ear infections or developmental conditions has no scientific evidence base.
Dry needling — not acupuncture
WHO/PhysioDry needling (inserting acupuncture-like needles into "trigger points" — tender muscle knots) is performed by physiotherapists and some chiropractors. It uses the same needles as acupuncture but different theoretical framework (myofascial trigger points, not acupoints or meridians). Evidence: limited but some RCT evidence for neck and shoulder myofascial pain. Controversy: acupuncturists argue dry needling is acupuncture without adequate training; physiotherapy organisations argue it is a distinct technique within scope.

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Low back pain (#1 disability globally)Musculoskeletal healthAcupuncture (NICE-listed alternative)Traditional medicineExercise for musculoskeletal healthOsteoporosis (SMT contraindicated)

About this hub. Produced by the GMJ News Editorial Team as a public-good service. Every statistic is linked to its primary source. Documents are preserved in the GMJ Repository with full attribution. Georgian Medical Journal · Contact the editorial team
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