The Importance
of the Neck Pain Treatment Provider
The primary reason that people go to chiropractors is for the management of spine pain (1):
- 63% of chiropractic patients seek care for lower back pain
- 30% of chiropractic patients seek care for neck pain
- 91% of these patients report acceptable positive clinical outcomes to chiropractic care for these complaints
The primary subject of this publication is neck pain, and specifically the facet joints. The facet joints are innervated by nociceptive nerves. Facet joint irritations, inflammations, injuries, degenerations, etc., can initiate an electrical signal that is interpreted by the brain as being painful, specifically as neck pain:
- In 1982, it was established that the cervical spine facet joints are innervated with nociceptors, thus allowing the facet capsules to be a source of neck pain (2).
- In 1988, it became clear that the cervical spine facet joints are a common source of neck pain (3).
- By 1992, it was established that the cervical spine facet joints were the primary source of neck pain (4).
- In 2011, it was confirmed that the cervical facet joints are the primary source of neck pain (5).
Chiropractic spinal adjusting (specific line-of-drive manipulations) often produces an audible sound called joint cavitation. It is established that this audible sound emanates from the facet joint (6). In other words, chiropractic neck adjusting is mechanically influencing the joints (facets) that are the primary source of neck pain.
Historically, chiropractic adjusting of the cervical spine has been shown to help people suffering from neck pain:
•••
In 1996, a study was published in the journal Injury titled (7):
Chiropractic Treatment of Chronic ‘Whiplash’ Injuries
The 28 patients in this study had initially been treated with anti-inflammatory drugs, soft collars, and physiotherapy. These patients had all become chronic, and were referred for chiropractic care at an average of 15.5 months (range was 3–44 months) after their initial injury.
Following chiropractic care 93% of the patients had improved. These authors state:
“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash injury.”
•••
In 1999, authors from the University Department of Orthopaedic Surgery, Bristol, UK, published a study in the Journal of Orthopaedic Medicine titled (8):
A Symptomatic Classification of Whiplash Injury
and the Implications for Treatment
The objective of this study was to determine the benefit of chiropractic care to chronic whiplash-injured patients. The study involved 93 consecutive patients. Patients underwent a mean of 19.3 treatments (range 1-53) over a period of 4.1 months.
The authors note that following whiplash injury, 57% of patients will make a full recovery, and 43% do not make a full recovery. The authors state:
“Conventional treatment of patients with whiplash symptoms is disappointing.”
“In chronic cases, no conventional treatment has proved successful.”
“Our results confirm the efficacy of chiropractic, with 69 of our 93 patients (74%) improving following treatment.”
“The results from this study provide further evidence that chiropractic is an effective treatment for chronic whiplash symptoms.”
“Chiropractic is the only proven effective treatment in chronic [whiplash] cases.”
•••
In 2002, a study was published in the Annals of Internal Medicine, titled (9):
Manual Therapy, Physical Therapy, or Continued Care
by a General Practitioner for Patients with Neck Pain
The authors note that manual therapy includes high-velocity thrust manipulation techniques. They state:
“According to the International Federation of Orthopedic Manipulative Therapies, ‘Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities.’”
The authors compared the effectiveness of manual therapy, physical therapy, and care by a general practitioner (pharmacology) in the treatment of neck pain. They used a randomized controlled trial design. The study involved 183 patients. These authors concluded:
“Manual therapy scored consistently better than the other two interventions on most outcome measures.”
“In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.”
“The success rates for manual therapy were statistically significantly higher than those for physical therapy.”
“Manual therapy scored better than physical therapy on all outcome measures…”
“The postulated objective of manual therapy is the restoration of normal joint motion, was achieved, as indicated by the relatively large increase in the range of motion of the cervical spine.”
“Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued [drug] care.”
“Manual therapy seems to be a favorable treatment option for patients with neck pain.”
“Primary care physicians should consider manual therapy when treating patients with neck pain.”
•••
In 2004, the American Academy of Orthopaedic Surgeons published a monograph titled Neck Pain (10). Chapter seven of the reference is titled “Manual Therapy Including Manipulation for Acute and Chronic Neck Pain.” This chapter is authored by a chiropractor and details the benefits of chiropractic spinal manipulation for the management of neck pain.
•••
In 2004, the Journal of Whiplash & Related Disorders published a study titled (11):
Manipulative Treatment vs. Conventional Physiotherapy Treatment in Whiplash Injury
This study assessed 380 acute whiplash injured patients. They found that manipulation therapy was superior to physical therapy (active exercises, electrotherapy, ultrasound therapy, and diathermy). Spinal manipulation achieved a superior result in fewer patient visits as compared to the physical therapy group. The authors state:
“Patients who had received manipulative treatment needed fewer sessions to complete the treatment than patients who had received physiotherapy treatment.”
“Results showed that the manipulative group had more benefits than the physiotherapy group.”
“Our clinical experience with these patients has demonstrated that manipulative treatment gives better results than conventional physiotherapy treatment.”
“This clinical trial has demonstrated that head and neck pain decrease with fewer treatment sessions in response to a manipulative treatment protocol as compared to a physiotherapy treatment protocol among patients diagnosed with acute whiplash injury.”
“Manipulative treatment is more effective in the management of whiplash injury than conventional physiotherapy treatment.”
•••
In 2015, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (12):
Prognostic Factors for Recurrences in Neck Pain Patients
Up to One Year After Chiropractic Care
This is a prospective cohort study assessing 545 neck pain patients. After a course of chiropractic, they were followed up for one year regarding recurrence of neck pain:
- Fifty-four (54) participants (11%) were identified as “recurrent.”
- Four hundred ninety-one (491) participants (89%) were not recurrent.
This study indicates that chiropractic is effective in the treatment of neck pain and that its benefits are stable and long lasting. The authors state:
“The results of this study suggest that recurrence of neck pain within one year after chiropractic intervention is low.”
Provider Types and Timing
It is clear that chiropractic care is effective for the treatment of neck pain. Is chiropractic care for neck pain cost effective? These publications below address that question.
•••
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?
The authors noted:
- The annual cost for treatment of neck pain by chiropractors was lower than treatment from medical physicians.
- “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 2017, a study was published in the journal Mayo Clinic Proceedings and titled (14):
Influence of Initial Provider on Health Care Utilization
in Patients Seeking Care for Neck Pain
The authors of this study were from the Department of Orthopaedic Surgery, Physical Therapy Division, Duke University, and from the Department of Physical Therapy, University of Utah. The authors note:
“It is imperative to evaluate the difference in health care process and outcomes in patients initially consulting with non-pharmacological providers (ie, chiropractors [DCs] and physical therapists [PTs]) and pharmacological providers (ie, specialists [such as physiatrists and neurologists]) in comparison to PCPs.”
The study used a retrospective cohort of 1,702 patients with a new episode of neck pain who consulted a primary care provider (PCP), physical therapist (PT), a chiropractor (DC), or specialist. The authors also note:
“These specific provider types were included in the analysis because they are the most common providers consulted for neck pain.”
“Physical therapists and chiropractors primarily treat neck pain with exercise therapy and manual therapy, which has been found to have good effectiveness in treating nonspecific neck pain.”
In contrast, “primary care provider’s first line of treatment often includes medication, imaging, specialist referral, or a combination of those factors.”
Compared with initial consultation with a primary care provider, the odds of undergoing advanced imaging (MRI or computed tomography) within 1 year “was reduced when the initial provider was a chiropractor and increased when the initial provider was a specialist or a physical therapist.”
“When patients in the sample initially consulted with a chiropractor, the odds of MRI use decreased compared with consulting with a primary care provider.”
“We found that initial consultation with a non-pharmacological provider, such as a chiropractor or physical therapist, is associated with a decrease in the downstream utilization of health care services, and importantly a decrease in opioid use 30 days and 1 year after the initial consultation.”
“Initiating care with a specialist was associated with an increase in the odds of receiving spinal injections and undergoing MRI and radiography and had the highest percentage of patients undergoing surgery.”
“Initially consulting with a specialist for a new episode of neck pain appears to escalate the level of care patients with neck pain receive.”
“These findings support that initiating care with a non-pharmacological provider for a new episode of neck pain may present an opportunity to decrease opioid exposure (chiropractor and physical therapist) and advanced imaging and injections (chiropractor only).”
“Radiography is routinely ordered as part of a [chiropractic] treatment plan and is often performed at the initial visit. It is plausible that the use of radiography may have paradoxically shielded patients from undergoing more advanced imaging such as MRI.”
“Stronger alignment of physical therapists and chiropractors as front-line providers by health care systems may be needed in light of the widespread [drug] addiction, which has been identified as a public health epidemic.”
In this study, chiropractic care had the best outcomes in all assessed categories:
- lowest rate of opioid prescription
- lowest use of advanced imaging
- lowest referrals for injections
- lowest use (referrals) for surgery (in fact the number was zero)
These authors note that low back pain guidelines already advocate non-drug interventions as the primary approach and suggest that neck pain guidelines should “catch-up” with that perspective.
•••
In 2019, a study was published in the Journal of Chiropractic Humanities, titled (15):
Cost-Efficiency and Effectiveness
of Including Doctors of Chiropractic
to Offer Treatment Under Medicaid
This article is an in-depth appraisal of the cost effectiveness for the inclusion of chiropractic services under Missouri Medicaid. The 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 and conclusions:
“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.”
“Hospitalization expenditures were significantly lower for those who used complementary and alternative providers, including chiropractic.”
“Research shows that chiropractors are the safest and most effective alternative to surgery for most cases of back pain.”
“[Chiropractic care] 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.”
“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.”
“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.”
•••
In 2023, a study was published in the journal Spine, titled (16):
Longitudinal Care Patterns and Utilization Among Patients
with New-Onset Neck Pain by Initial Provider Specialty
This study is 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. The provider specialties included:
- Chiropractor
- Primary care, including family practice and internal medicine
- Emergency medicine
- Orthopedics
- Physical therapy/occupational therapy (PT/OT)
- Neurology
- Rehabilitation medicine
The authors noted:
- “The most common initial provider specialty was chiropractor (45.2%), followed by primary care (33.4%).”
- 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.
- “Compared with patients initially seen by physician providers, patients treated initially by chiropractors or therapists received fewer and less costly imaging services.”
- “While uncommon after initial visits with chiropractors (≤2%), CT, or MRI scans occurred in over 30% of patients with initial visits with emergency physicians, orthopedists, or neurologists.”
- “Compared to patients with PCP or specialist physician initial providers, patients with chiropractor initial providers had substantially lower rates of imaging and invasive therapeutic interventions, including injections and surgery, during a 180-day follow-up period.”
- “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.”
- “Even after extensive adjustment for sociodemographic and clinical characteristics, patients who started with an orthopedic surgeon, ... had substantially higher rates of therapeutic injection and major surgery within 180 days of follow-up than patients who started with a chiropractor.”
- “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.”
- “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 (17):
Cost of Chiropractic Versus Medical Management of Adults
with Spine?related Musculoskeletal Pain
The purpose of this study was to update, summarize, and 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).
In this review, no studies found that chiropractic care had higher overall costs. No studies found higher long-term healthcare costs in those using chiropractic care. These authors found:
“This study .... 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 where chiropractors were involved early in the case.”
“When considering this evidence, 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.”
“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 European Spine Journal, titled (18):
Patterns of Initial Treatment and Subsequent Care Escalation
Among Medicare Beneficiaries with Neck Pain
The authors examined Medicare claims spanning a four-year period for beneficiaries with new episodes of neck pain. They calculated the cumulative frequency and propensity for escalated care encounters for treatment cohorts:
- Spinal manipulative therapy
- Primary care without prescription analgesics within 7 days
- Primary care with prescription analgesics within 7 days
The authors found:
“The spinal manipulative therapy cohort was associated with a 64% lower rate for long-term care escalation encounters, while the primary care with prescription analgesics cohort was associated with an 8% higher rate.”
“Initial spinal manipulative therapy was associated with a significant reduction in downstream care escalation encounters among Medicare beneficiaries with new episodes of neck pain.”
•••
Also in 2025, a study was published in the Archives of Physical Medicine and Rehabilitation, titled (19):
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 a significant reduction in costs for the Medicare Beneficiaries with chiropractic manipulation as compared to the care of primary care providers. The authors note:
For older adults with new NP episodes, initial chiropractic spinal manipulation was associated with lower health care costs, particularly for Part-A total and NP-related claims, than primary care provider strategies.
“These findings suggest potential for health care savings based on the initial treatment choice.”
Summary
For decades, evidence has found that chiropractic care is both effective and safe for the management of neck pain syndromes. The evidence presented in this publication also shows that chiropractic care is exceptionally cost-effective as well. This adds to the position that chiropractic care should be the “go-to” provider for neck pain syndromes.
REFERENCES:
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- Hoving JC, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, Mameren H, Devillé WLJM; Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain; A Randomized Controlled Trial; Annals of Internal Medicine; May 21, 2002; 136; No. 10; pp. 713-722.
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- Langenfeld A, Humphreys K, Swanenburg J, Cynthia K. Peterson CK; Prognostic Factors for Recurrences in Neck Pain Patients Up to 1 Year After Chiropractic Care; Journal of Manipulative and Physiological Therapeutics; September 2015; Vol. 38; No. 7; pp. 458-464.
- 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.
- Horn ME, George SZ, Fritz JM; Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain; Mayo Clinic Proceedings: Innovations, Quality & Outcomes; October 19, 2017; Vol. 1; No. 3; pp. 226-233.
- 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.
- Fenton JJ, Fang SY, Ray M, Kennedy J, Padilla K, Amundson R, Elton D, Haldeman S, Lisi AJ, Jason 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.
- 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.
- Anderson BR, MacKenzie TA, Lurie JD, Grout L, Whedon JM; Patterns of Initial Treatment and Subsequent Care Escalation Among Medicare Beneficiaries with Neck Pain: A Retrospective Cohort Study; European Spine Journal; February 2025; Vol. 34; No. 2; pp. 724-730.
- 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.
“Authored by Dan Murphy, D.C. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”