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For individuals with recurrent or persistent non-specific low back pain (LBP), exercise and exercise combined with education have been shown to be effective in preventing new episodes or in reducing the impact of the condition. Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies. The aim of this trial was to investigate the effectiveness of MC on pain trajectories for patients with recurrent or persistent LBP. This pragmatic, investigator-blinded, two arm randomized controlled trial included consecutive patients (18-65 years old) with non-specific LBP, who had an early favorable response to chiropractic care. After an initial course of treatment, eligible subjects were randomized to either MC or control (symptom-guided treatment). The primary outcome was total number of days with bothersome LBP during 52 weeks collected weekly with text-messages (SMS) and estimated by a GEE model. Three hundred and twenty-eight subjects were randomly allocated to one of the two treatment groups. MC resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment. During the 12 month study period, the MC group (n = 163, 3 dropouts) reported 12.8 (95% CI = 10.1, 15.5; p = <0.001) fewer days in total with bothersome LBP compared to the control group (n = 158, 4 dropouts) and received 1.7 (95% CI = 1.8, 2.1; p = <0.001) more treatments. Numbers presented are means. No serious adverse events were recorded. MC was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific LBP but it resulted in a higher number of treatments. For selected patients with recurrent or persistent non-specific LBP who respond well to an initial course of chiropractic care, MC should be considered an option for tertiary prevention.

Objective To evaluate the effectiveness and cost-effectiveness of physiotherapy, chiropractic care, and the combination of physiotherapy and chiropractic care compared with information and advice for the treatment of patients with nonspecific chronic low-back pain (CLBP) in Sweden. Design A multicentre pragmatic randomized controlled trial. Setting Ten primary care rehabilitation units in Sweden. Participants Eighty-eight participants with nonspecific CLBP. Interventions The participants were randomly assigned to receive physiotherapy, chiropractic care, combination treatment, or information and advice. Main outcome measures This study measured the Oswestry Disability Index (ODI), health-related quality of life (HRQoL), quality-adjusted life-years (QALYs), working status, and costs. Results The study revealed no statistically significant differences in any of the outcome measures when physiotherapy, chiropractic care, and combination treatment with information and advice were compared ( p  > 0.05). The ODI changes between baseline and the 6-month follow-up ranged from 6.13 to 12.56 across the treatment groups, indicating reduced disability in all groups. Compared with the other treatment options, the combination treatment resulted in the greatest QALY gain (0.418) and lowest cost (SEK 3,081). Conclusion Compared with alternative standalone treatment options, the combination treatment strategy resulted in greater QALY gain and lower costs from a heath care perspective. Although the study did not detect statistically significant differences in outcomes or costs among the treatment options, the combination treatment showed promising potential for cost-effectiveness. Given the small sample size and low statistical power of the study, further clinical trials with fewer treatment arms and a focus on the combination group are warranted to confirm these findings. The insights gained from this study are important for informing the design and conduct of future clinical studies investigating the effectiveness, costs and cost-effectiveness of treatments for CLBP. Trial registration The study is registered in the ISRCTN registry (2017-02-20: ISRCTN15830360).

ObjectivesThere is no current detailed profile of people seeking chiropractic care in Canada. We describe the profiles of chiropractors’ practice and the reasons, nature of the care provided to their patients and extent of interprofessional collaborations in Ontario, Canada.DesignCross-sectional observational study.SettingPrimary care setting in Ontario, Canada.ParticipantsWe randomly recruited chiropractors from a list of registered chiropractors (n=3978) in active practice in 2015. Of the 135 randomly selected chiropractors, 120 were eligible, 43 participated and 42 completed the study.Outcome measuresEach chiropractor recorded information for up to 100 consecutive patient encounters, documenting patient health profiles, reasons for encounter, diagnoses and care provided. Descriptive statistics summarised chiropractor, patient and encounter characteristics, with analyses accounting for clustering and design effects.ResultsChiropractors provided data on 3523 chiropractor-patient encounters. More than 65% of participating chiropractors were male, mean age 44 years and had practised on average 15 years. The typical patient was female (59% of encounters), between 45 and 64 years (43%) and retired (21%) or employed in business and administration (13%). Most (39.4%) referrals were from other patients, with 6.8% from physicians. Approximately 68% of patients paid out of pocket or claimed extended health insurance for care. Most common diagnoses were back (49%, 95% CI 44 to 56) and neck (15%, 95% CI 13 to 18) problems, with few encounters related to maintenance/preventive care (0.86%, 95% CI 0.2 to 3.9) and non-musculoskeletal problems (1.3%, 95% CI 0.7 to 2.3). The most common treatments included spinal manipulation (72%), soft tissue therapy (70%) and mobilisation (35%).ConclusionsThis is the most comprehensive profile to date of chiropractic practice in Canada. People who present to Ontario chiropractors are mostly adults with a musculoskeletal condition. Our results can be used by stakeholders to make informed decisions about workforce development, education and healthcare policy related to chiropractic care.

Longer-term effects of chiropractic care on neuroplasticity, stress, and immune biomarkers remain unclear. This study evaluates the effects of chiropractic care on physiological biomarkers, including brain-derived neurotrophic factor (BDNF), cortisol (saliva, blood, hair), and inflammatory cytokines [interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), interferon-gamma (IFN-γ), C-reactive protein (CRP), B-lymphocytes (CD19), T-helper cells (CD4), cytotoxic T cells (CD8), and natural killer cells (CD56)] in subclinical spinal pain patients. Parallel-group, pragmatic randomized controlled trial conducted at the Rehabilitation Center of Railway General Hospital, Rawalpindi, Pakistan. Intervention: 12 weeks; follow-up: 16 weeks (May-December 2022). Participants with subclinical spinal pain were randomly assigned by using simple lottery method to either 12 weeks of chiropractic or sham care. We aimed to recruit up to 150 participants over three months; however, given the pragmatic nature of the trial and logistical constraints, including the availability of chiropractors, the final number enrolled was determined by how many eligible participants could be recruited during this time. Adults aged 20-60 years with subclinical spinal pain (n = 106 randomized; 88 completed 12-week measures; 73 completed 16-week follow-up). Among those who finished 12 weeks: chiropractic, 26 males/15 females, mean age 37.49 ± 12.39 years; sham, 24 males/23 females, mean age 26.85 ± 7.13 years. The primary outcome blood BDNF and secondary outcome, including saliva, blood and hair cortisol, IL-6, TNF-α, IFN-γ, CRP, CD19, CD4, CD8, and CD56 levels were measured at baseline, after 12 weeks of intervention, and at a 16-week follow-up. Linear and linear mixed-effects regression models were used to assess the effect of care and time on biological measures. Significant between-group differences were observed after 12 weeks of intervention, with higher salivary cortisol 5 ± 2 [0, 10], p = 0.045 and blood BDNF150 ± 60 (40, 270), p = 0.009 and IL-6 1.0 ± 0.3 [0.5, 1.5], p < 0.001 levels in the chiropractic care group. At the 16-week follow-up, blood cortisol -9 ± 4 [-17, -1], p = 0.024, IFN-γ - 22 ± 7 [-35, -9], and TNF-α -2 ± 1 [-5, 0], p = 0.028 levels increased in the sham group. Within-group comparisons showed a non-significant 10 ± 20 [-20, 50], p = 0.439 reduction in hair cortisol levels in the chiropractic group at 12 weeks, along with increased levels of blood cortisol, BDNF, CD8, CD4, IL-6, and CD19. 12 weeks of Chiropractic care modulates biomarkers linked to neuroplasticity, inflammation, and stress. Increases in brain-derived neurotrophic factor and interleukin-6 suggest enhanced neuroplasticity and inflammatory responses, while decreases in tumor necrosis factor-alpha indicate a regulatory effect on systemic inflammation. These findings support the notion that chiropractic care modulates physiological systemic biomarkers, which may underscore its benefits on clinical outcomes. ClinicalTrials.gov NCT05369156.

Background Clinical training within chiropractic education relies on exposure to diverse case mix to develop clinical competence. South African institution-based chiropractic clinics are essential learning environments and providers of affordable musculoskeletal healthcare. Periodic evaluation of patient profiles tracks evolving populations and healthcare utilisation, informing longitudinal comparisons. The purpose was therefore to describe the demographic and clinical characteristics of new patients presenting to the University of Johannesburg Chiropractic Clinic (UJCC) in 2023. Methods A retrospective, descriptive, cross-sectional review screened all new patient files created between January 1, and June 30, 2023. Routinely documented information from initial consultation to extraction (May–July 2025) was manually captured from eligible files using a structured form, including age, sex, complaint regions, number of visits, and modalities utilised over complaint stages (primary/secondary/tertiary). Descriptive statistics (frequencies, percentages, means, standard deviations) were generated using IBM SPSS v30, with non-parametric tests applied where appropriate. Results Of 1435 files screened, 880 were included [54% female; mean age 40.9(± 17.51) years]. Secondary and tertiary complaints were reported in 39.1% and 14.8% of patients. When aggregated across all complaint stages lumbar (41.5%) and cervical (32.8%) regions predominated. Treatment episodes were brief [primary: mean 2.31(± 2.06) sessions, 72% ≤2 visits; secondary: mean 2.88(± 2.98), 62.2% ≤2 visits; overall: mean 4.24(± 4.98), 49.6% ≤2 visits]. Management was multimodal and manual-therapy-led: manipulation/mobilisation (primary: 94.8%; secondary 98.5%), massage (68.1%; 65.1%), and myofascial dry needling (40.1%; 59.9%) used in most cases; shockwave was utilised for 15.8% of primary and 23.3% of secondary cases, while laser therapy (0%; 0.2%) was rare. Sex- and age-related patterns of regional examinations were generally consistent. Age showed a weak positive correlation with the number of secondary-complaint sessions (ρ = 0.151, p  = 0.005, n = 344). Conclusion UJCC’s 2023 case mix was predominantly adult, spine-dominant, featuring brief treatment courses consisting of multimodal, manual-therapy-led care with selective use of adjunctive soft-tissue and electrophysical modalities. This study provides an updated baseline for curriculum review, resource planning, and longitudinal benchmarking with other training clinics and private practices.

Individuals with subclinical neck pain (SCNP) exhibit altered cerebellar processing, likely due to disordered sensorimotor integration of inaccurate proprioceptive input. This association between proprioceptive feedback and SMI has been captured in cervico-ocular reflex (COR) differences where SCNP showed higher gain than healthy participants. Previous neurophysiological research demonstrated improved cerebellar processing in SCNP participants following a single treatment session, but it is unknown whether these neurophysiological changes transfer to cerebellar function. In a parallel group, randomized control trial conducted at Ontario Tech University, 27 right-hand dominant SCNP participants were allocated to the 8-week chiropractic care (n = 15; 7M & 8 F) or 8-week control (n = 12; 6M & 6 F) group. COR gain (ratio of eye movement to trunk movement) was assessed using an eye-tracking device at baseline and at post 8-weeks (treatment vs. no treatment). COR gain (10 trials): participants gazed at a circular target that disappeared after 3 s, while a motorized chair rotated their trunk at a frequency of 0.04 Hz, with an amplitude of 5º, for 2 minutes. A 2 × 2 repeated measures ANOVA was performed. COR gain was significantly reduced following 8-weeks of chiropractic care compared to the SCNP control (8-weeks of no treatment) group (p = 0.012, ηp2 = 0.237). The decrease in COR gain following treatment is likely due to normalized proprioceptive feedback from the neck, enabling improved processing and integration within the flocculonodular lobe of the cerebellum.

Background Veteran Response to Dosage in Chiropractic Therapy (VERDICT) was a pragmatic randomized trial testing chiropractic dosage effects in 766 veterans with chronic low back pain (CLBP) of ≥ 3 months. This cross-sectional analysis compares baseline characteristics of younger (18-to-64 years) and older veterans (≥ 65 years). Methods Data were collected from February 22, 2021 to May 21, 2025 via electronic health records and REDCap questionnaires. Descriptive statistics and tests of group differences were performed using SAS. Results VERDICT enrolled 188 older veterans (25%; mean 72 years) and 578 younger veterans (75%; mean 44 years). More female (24.7% vs. 10.6%, p  < .001), Black (18.9% vs. 12.2%), and Hispanic (11.8% vs. 3.7%, p  = .001) veterans comprised the younger cohort. Employment differed ( p  < .001) with older veterans retired (78.2% vs. 14.2%) and younger veterans employed (59% vs. 16.5%). About 14% lived rurally and period of military service was similar. Pain profiles were similar between younger and older veterans for > 5 years duration (78.4% vs. 73.4%), high-impact chronic pain (64.5% vs. 62.2%), mean pain interference [63.8(4.8) vs. 63.2(5.0)], and mean back-related disability (primary outcome) [11.9(5.2) vs. 13.3(4.9)]. Younger veterans scored significantly higher than older veterans for depression (44.8% vs. 31.4%, p  = .001), anxiety (41.5% vs. 20.7%, p  < .001), post-traumatic stress (38.4% vs. 17.6%, p  < .001), sleep disturbance (57.1% vs. 34.6%, p  < .001), and high-risk alcohol use (25.4% vs. 18.1%, p  = .05). Previous chiropractic use was similar (younger 75.4% vs. older 80.3%). Medications in past 3 months differed with younger veterans reporting cannabis (25.8% vs. 12.8%, p  < .001) and muscle relaxants (31.7% vs. 17.6%, p  < .001) and more older veterans reporting acetaminophen (63.3% vs. 49.3%, p  < .001) and gabapentin (34% vs. 20.1%, p  < .001). NSAIDs use was highest among both younger (62.8%) and older (56.9%) veterans. While two-thirds had tried exercise in the past 3 months, only 16% reported exercising for their pain condition, with older veterans more likely to report providers encouraging physical activity. Conclusions Similar pain profiles were reported among older and younger veterans seeking chiropractic care for CLBP within a clinical trial. However, potentially important age differences were noted in demographics, mental health and substance use, and CLBP treatments. Trial registration ClinicalTrials.gov: NCT04087291. Date of Registration: 9/12/2019. Enrollment Duration: 2/22/2021 (first participant enrolled) through 5/10/2024 (last participant enrolled).

Background Dizziness in older people is a risk factor for falls. Neck pain is associated with dizziness and responds favourably to neck manipulation. However, it is unknown if chiropractic intervention including instrument-assisted manipulation of the neck in older people with neck pain can also improve dizziness. Methods This parallel two-arm pilot trial was conducted in Melbourne, Australia over nine months (October 2015 to June 2016). Participants aged 65–85 years, with self-reported chronic neck pain and dizziness, were recruited from the general public through advertisements in local community newspapers and via Facebook. Participants were randomised using a permuted block method to one of two groups: 1) Activator II™-instrument-assisted cervical and thoracic spine manipulation plus a combination of: light massage; mobilisation; range of motion exercises; and home advice about the application of heat, or 2) Sham-Activator II™-instrument-assisted manipulation (set to zero impulse) plus gentle touch of cervical and thoracic spinal regions. Participants were blinded to group allocation. The interventions were delivered weekly for four weeks. Assessments were conducted one week pre- and post-intervention. Clinical outcomes were assessed blindly and included: dizziness (dizziness handicap inventory [DHI]); neck pain (neck disability index [NDI]); self-reported concerns of falling; mood; physical function; and treatment satisfaction. Feasibility outcomes included recruitment rates, compliance with intervention and outcome assessment, study location, success of blinding, costs and harms. Results Out of 162 enquiries, 24 participants were screened as eligible and randomised to either the chiropractic ( n  = 13) or sham ( n  = 11) intervention group. Compliance was satisfactory with only two participants lost to follow up; thus, post-intervention data for 12 chiropractic intervention and 10 sham intervention participants were analysed. Blinding was similar between groups. Mild harms of increased spinal pain or headaches were reported by 6 participants. Costs amounted to AUD$2635 per participant. The data showed a trend favouring the chiropractic group in terms of clinically-significant improvements in both NDI and DHI scores. Sample sizes of n  = 150 or n  = 222 for dizziness or neck pain disability as the primary outcome measure, respectively, would be needed for a fully powered trial. Conclusions Recruitment of participants in this setting was difficult and expensive. However, a larger trial may be feasible at a specialised dizziness clinic within a rehabilitation setting. Compliance was acceptable and the outcome measures used were well accepted and responsive. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000653763 . Registered 13 June 2013. Trial funding: Foundation for Chiropractic Research and Postgraduate Education (Denmark).

Background Injuries sustained during healthcare consultations are a significant concern, and compensation claims relating to injuries in health systems are increasing. Extensive research has addressed injuries in the secondary sector, whereas knowledge about injuries sustained in primary care remains sparse. This retrospective register-based study aimed to describe compensation claims involving chiropractors in Denmark between 2013 and 2022. Methods All claims related to chiropractors from 2013 to 2022 were accessed in the Danish Patient Compensation Association Register and analyzed using the Healthcare Complaints Analysis Tool. Data on patient characteristics, injuries, processing time, decisions, appeals, and financial compensation were collected. Claims were categorized as relating to clinical, management, or patient-clinician relationship, alongside nine symptom-based injury classifications. Data relating to cervical artery dissection were examined separately and in greater detail, including information on presenting symptoms, International Classification of Primary Care, Second Edition code recorded by the chiropractor, treatment modalities used, time from treatment to onset of symptoms, and type of vascular injury subsequently diagnosed. Descriptive statistics summarized findings. Results A total of 535 chiropractor-related claims were identified, with 519 included for analysis. The number of claims per 100,000 consultations increased from 1.03 in 2013 to 3.57 in 2022. Most claims (84%) concerned treatment outcomes and side effects, primarily worsening of symptoms (23%) or delayed referral (23%). Of the 519 claims, only 32 (6%) were approved for compensation. Cervical artery dissection-related claims had the highest approval rate within category (29%; ~ 0.7 approved claims per million consultations) and accounted for 94% of total financial compensation (14 approved claims, 3,025,000 €). Conclusion Compensation claims related to chiropractic care in Denmark increased between 2013 and 2022, but approval rates remained low. Most claims concerned dissatisfaction with treatment outcome or worsening of symptoms. Cervical artery dissection-related claims had the highest approval rate and accounted for the highest compensation. When approved, they were compensated based on the fairness rule stating that the outcome could neither have been predicted nor expected from patients’ individual cases. Better communication between patients and chiropractors about expectations for treatment, natural course of conditions, and expected reactions to treatment will likely reduce the number of claims.