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For patients with acute or chronic musculoskeletal conditions, guidelines recommend a variety of noninvasive pharmacologic and nonpharmacologic treatments as first-line management.1,2 However, many patients receive suboptimal care, including unneeded imaging, too many prescriptions for opioids, not enough evidence-based advice, and premature referrals for interventional or surgical procedures, without first exhausting conservative measures.3 These practices are associated with worse financial and clinical outcomes, including higher total healthcare costs and greater risk of developing chronic, disabling pain.4
Notably, many of the recommended frontline treatments outlined in clinical practice guidelines align with approaches central to the chiropractic profession. And some US healthcare systems now include chiropractors on interdisciplinary pain management teams.5,6 Integrating chiropractors into multidisciplinary care settings can help support high-value, guideline-concordant musculoskeletal care and may free up internists to see more patients with other problems.
Here, we outline for internists and other medical specialists the following aspects of chiropractic care:
The training that chiropractors undergo
What chiropractors do
Evidence supporting chiropractic care
Practical considerations when working with chiropractors.
CHIROPRACTORS UNDERGO EXTENSIVE TRAINING
Doctors of chiropractic (DCs) are licensed healthcare professionals trained to operate as point-of-contact practitioners for musculoskeletal complaints. To become licensed, DCs must successfully complete a 3- to 4-year accredited doctoral degree program and obtain satisfactory scores on a 4-part examination administered by the National Board of Chiropractic Examiners. These examinations involve both computer-based and structured practicums and assess knowledge in the areas of basic and clinical science, diagnostic imaging, and case management.
Matriculates into doctoral programs must hold a bachelor’s degree or have obtained a cumulative grade-point average of 3.0 (2.75 in select circumstances) or higher on a 4.0 scale for 90 semester credits at an accredited institution before admission. At present, applicants are not required to complete the Graduate Record Examination or other college admittance examination.
Didactic and clinical training consists of a minimum of 4,200 hours of basic and clinical science instruction correlated with analytical and practical skill development. A minimum of 1,000 contact hours are spent in a patient-care setting. Students are trained in standard medical history-taking and evaluative procedures (eg, orthopedic and neurologic assessment) to establish a diagnosis and formulate a management plan. Additionally, they learn how to order and interpret imaging and laboratory studies in accordance with accepted medical indications, such as those established by the American College of Radiology Appropriateness Criteria.
After completing the doctoral program, some DCs pursue advanced postgraduate training in integrated residency or fellowship programs. Such training is optional and not currently required for licensure in any state. Requirements to obtain and maintain active licensure are set forth by each state individually. States stipulate regular continuing education in topics such as documentation, ethics, law, and clinical practice to retain a license to practice.
WHAT DO CHIROPRACTORS DO?
Chiropractic is a healthcare profession and not a singular treatment approach. Chiropractors possess diagnostic autonomy and use nonpharmacologic, noninvasive therapies to treat musculoskeletal disorders and improve quality of life using an integrative, whole-person approach. The chiropractic profession is not categorically opposed to pharmacologic or invasive therapies; rather, chiropractors simply do not provide these types of treatment, and patients should not expect to receive them from chiropractors.
Chiropractors work in collaboration with patients to develop individualized treatment plans that emphasize patient education, positive lifestyle and behavioral changes, physical rehabilitation exercises, mind-body psychotherapies, and manual manipulative treatments targeting painful joints and myofascial structures. Many chiropractors also pursue certification in acupuncture or trigger point dry needling by completing additional coursework and hands-on training.
An initial trial of chiropractic care typically includes a cluster of treatment sessions within a short time (eg, 4–6 visits over 1–2 months), followed by a reevaluation to assess treatment effectiveness and determine the need for continued or escalated care.7 The high frequency of visits during the initial treatment trial fosters a strong therapeutic relationship between the chiropractor and patient to enhance clinical outcomes and allow for close monitoring for disease progression.
For chronic or more complex conditions, patients may benefit from supportive treatment beyond the initial trial of care. However, empowering patients to self-manage symptoms and minimize practitioner dependency remains a top priority. If treatment fails to help patients achieve their functional or pain-related goals or the chiropractor believes the patient has stopped getting better, chiropractors may order additional diagnostic testing or facilitate specialist referral as deemed appropriate.
CHIROPRACTIC CARE IS EVIDENCE-BASED
Spinal manipulative therapy as an isolated intervention has been shown to be as effective as other guideline-recommended treatments and more effective than non-recommended treatments in terms of relieving pain and improving function and quality of life in patients with acute and chronic back pain.8,9 Additionally, spinal manipulative therapy may allow patients to minimize their reliance on pain medications, with their attendant risks.10,11 While the degree of benefit varies, the combination of spinal manipulative therapy and other goal-oriented interventions such as rehabilitative exercise or neuromuscular reeducation is a well-rounded and patient-centered approach as recommended by clinical practice guidelines.1,2,7 Instructing patients on tailored home exercises not only aids in symptom management and physical functionality but also may foster patients’ internal locus of control and greater self-efficacy in managing their symptoms over time.
However, evidence remains scarce to support spinal manipulative therapy for treating nonmusculoskeletal conditions such as colic, hypertension, asthma, or primary dysmenorrhea. Internists and other medical specialists should not refer patients to chiropractors for treatment of these conditions unless they are accompanied by musculoskeletal complaints (eg, lower back pain associated with primary dysmenorrhea).
When considering the evidence supporting chiropractic care, it is most pragmatic to evaluate the benefits of multimodal integrative care rather than the efficacy of isolated interventions and single outcomes.
Clinical practice guidelines recommend treatments such as joint manipulation and mobilization, myofascial therapies, and exercise as part of a multimodal care plan for managing back and neck pain—all of which are central to the chiropractic scope of practice. Retrospective analyses of large administrative datasets report that patients who initially see a nonprescribing healthcare practitioner such as a chiropractor for back and neck pain complaints are more likely to receive guideline-concordant care (with less use of imaging, drugs, or interventional services) and less likely to need additional specialist referral compared with patients who initially contacted other types of practitioners.12 Additional studies found that patients undergoing chiropractic care received fewer opioids and got off of them faster than those not receiving chiropractic care.13,14
Chiropractic care is also cost-effective. In a recent retrospective analysis, patients who started care with a chiropractor for acute low back pain incurred total medical costs that were $8,848 lower than those who started care with primary care clinicians and $12,267 lower than those who started care in the emergency department.15
PRACTICAL CONSIDERATIONS WHEN WORKING WITH CHIROPRACTORS
Who should—or should not—see a chiropractor?
Conditions commonly managed by chiropractors include mechanical low back and neck pain, with or without associated extremity symptoms, cervicogenic and tension-type headaches, and musculoskeletal extremity complaints such as knee osteoarthritis, rotator cuff tendinopathy, and carpal tunnel syndrome.
Contraindications to certain chiropractic treatments can be broadly categorized as absolute or relative, depending on the resultant impact on treatment decisions. Absolute contraindications to spinal manipulative therapy include but are not limited to acute fractures or dynamic spinal instability, severe or progressive neurologic deficits related to the area of concern, and pain caused by cancer or infection; relative contraindications include diseases that cause bone softening, prior spinal surgery, bleeding disorders, and inflammatory diseases in the nonactive phase.16
Figure 1 shows a simplified algorithm that internists and other specialties may find useful when considering chiropractic referral.
Who should see a chiropractor?
Individual characteristics that may increase the likelihood of a positive response to either lumbar or cervical spinal manipulative therapy have been widely debated. Certain patient characteristics such as axial pain, recent onset, low fear-avoidance scores, positive treatment expectations, hypomobility of the spine, pain during articular provocation, and decreased hip internal range of motion have been used to create clinical prediction rules.17,18 However, in validation studies, these clinical prediction rules failed to identify patients most likely to benefit, performing no better than chance in predicting favorable treatment responses.
The best available evidence suggests that if patients obtain pain relief from chiropractic therapy, they get it quickly, whereas factors that predict lack of relief include poor psychological status (eg, depression, anxiety, kinesiophobia), adverse sleep and fatigue patterns, chronic pain, and high baseline pain intensity.19 However, the extent to which these factors can be systematically applied to guide clinical decision-making remains uncertain, and strength of association varied markedly across studies.
In most instances, it is not necessary to obtain imaging, laboratory work, or other specialty testing before referring patients for chiropractic care unless there is suspicion for sinister disease or treatment contraindications. In such cases, chiropractors may still be able to safely offer some measure of pain relief through careful selection of treatment alternatives. Low-force mobilizations, soft-tissue therapies, or patient-guided self-care exercises become the treatments of choice when an uncertain or heightened level of risk exists. Health systems should work with chiropractors to establish screening protocols to help minimize inappropriate referrals for chiropractic services and streamline appropriate care.
Chiropractors vs physical therapists
Internists and other medical specialists are likely familiar with indications for physical therapy and, at this point, may observe substantial overlap between it and chiropractic. So, what differentiates chiropractors from physical therapists?
While there are similarities between the 2 professions, including training in rehabilitative and manual therapies, chiropractors receive approximately twice as much academic and clinical training, and this is reflected by their broader scope of practice. Since DCs can establish a diagnosis and order or perform imaging or other diagnostic studies (eg, electrodiagnostics, musculoskeletal ultrasonography, laboratory studies), this authority eliminates the need for the referring physician or the patient’s primary care clinician to coordinate clinical decisions on the chiropractor’s behalf, leaving chiropractors to independently evaluate, diagnose, and manage patient care. By integrating chiropractors into a multidisciplinary pain management team, this autonomy greatly alleviates administrative burdens placed on the patient’s primary care clinician.
Does insurance cover chiropractic services?
Commercial, federal, and state plans differ. Currently, while most commercial insurers will cover 10 to 30 annual visits, encompassing an extensive list of billable Current Procedural Terminology codes, Medicare Part B only covers spinal manipulative therapy and denies coverage for all other services or tests ordered by a DC, including evaluation and management or physical rehabilitation codes. Moreover, only manipulation delivered to spinal regions (defined as cervical, thoracic, lumbar, pelvic, or sacral) is reimbursed, while extremity manipulation is not.
State Medicaid programs are highly variable, with 33 states currently covering some chiropractic services.20 While Tricare (the healthcare program for uniformed service members, retirees, and their family members) does not cover chiropractic services performed in private sector facilities, chiropractors are on the staff or contracted with many designated military hospitals and clinics, providing care for active-duty uniformed service members and their families. Similarly, many Veterans Health Administration facilities across the United States employ chiropractors or contract them through community providers. Select TriWest plans (ie, Tricare in the western United States) may allow retired veterans to receive chiropractic care at outside facilities pending authorization of external referral orders submitted by their primary care clinician.
A PRACTICAL SOLUTION
Integrating chiropractors into multidisciplinary healthcare teams offers a practical solution to the challenges faced by internists when managing painful musculoskeletal conditions. Their specialized training, evidence-based approaches, and ability to act as point-of-contact case managers offers a unique solution to provide guideline-concordant, cost-effective care without excessive administrative demands. By collaborating more with chiropractors, healthcare systems can improve patient outcomes, reduce costs, and alleviate burdens on primary care clinicians.
DISCLOSURES
The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
- Copyright © 2025 The Cleveland Clinic Foundation. All Rights Reserved.
REFERENCES
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