Chiropractic

Palmer and the first school

The World Health Organization (WHO) guidelines on basic training and safety in chiropractic, published in 2005, attribute the discovery of chiropractic to D. D. Palmer in 1895, with the first school for training chiropractors opening in Davenport, Iowa, in 1897. The document says Palmer drew on several sources, including medical manipulation, bonesetting and osteopathy, together with elements of his own design. It adds that the word chiropractic, from Greek roots meaning done by hand, was coined by a patient, the Reverend Samuel H. Weed.

A historical article on the early institutions states that Palmer was involved in at least ten schools in four states during the last sixteen years of his life, moving between Davenport, California, Oklahoma City, Portland and Los Angeles between 1897 and 1913. Only the abstract of that article was reviewed for this draft, so the details of each school are not verified here.

Setting and philosophy

WHO places the profession's development in the United States during a period of significant reform in medical training and practice, when conventional medicine and many alternative approaches offered a wide variety of treatments. The same document notes that spinal manipulation dates back to Hippocrates and the ancient Greek physicians. That is WHO's statement of precedent for the technique and should not be read as an unbroken lineage into modern chiropractic.

WHO states that a majority of practitioners would hold the philosophy of chiropractic to include holism, vitalism, naturalism, conservatism, critical rationalism, humanism and ethics. It describes the relationship between structure, especially the spine, and function, as coordinated by the nervous system, as central to the profession, and it presents the neurophysiological consequences of spinal dysfunction as hypothesized. Practitioners differ in how far they hold these ideas, and this page does not assume that every chiropractor does.

Core terms

The WHO glossary defines chiropractic as a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of those disorders on general health. It specifies an emphasis on manual techniques, including joint adjustment or manipulation, with a particular focus on subluxations. The phrase chiropractic care is used for the profession's services in general.

The same glossary separates several terms. An adjustment is any chiropractic procedure using controlled force, leverage, direction, amplitude and velocity at specific joints and adjacent tissues. Joint manipulation involves a directed thrust that moves a joint past its physiological range without exceeding the anatomical limit, whereas mobilization involves no thrust. Spinal manipulative therapy is the broadest term and includes traction, massage and stimulation. Research reviews usually use that broad term, and the trials they pool involve different kinds of clinician.

Subluxation

In the WHO glossary, subluxation is a lesion or dysfunction of a joint or motion segment in which alignment, movement integrity or physiological function is altered while the joint surfaces stay in contact. It is described as essentially a functional entity that may influence biomechanical and neural integrity. A footnote states that this differs from the current medical definition, in which subluxation is a significant structural displacement visible on static imaging.

A 2009 review in a chiropractic journal describes the claim that chiropractors can locate, analyze and diagnose a putative spinal lesion called subluxation and correct it with an adjustment. WHO calls the related vertebral subluxation complex a theoretical model. The word therefore carries two meanings, one within the profession and one in general medicine, and readers should check which is intended.

Assessment and manual care

WHO describes chiropractors as primary-contact practitioners who emphasize conservative management of the neuromusculoskeletal system without medicines or surgery and who refer to other providers when appropriate. Its core syllabus expects history-taking, physical examination, differential diagnosis and interpretation of imaging, along with chiropractic assessment such as gait and postural analysis, static and motion palpation of joints, and assessment of soft-tissue tone.

The syllabus lists manual procedures as spinal adjustment, spinal and other joint manipulation, joint mobilization, and soft-tissue and reflex techniques. It also lists exercise and rehabilitative programs, psychosocial aspects of management, and education on spinal health, posture, nutrition and other lifestyle matters. A review of care in older adults found chiropractor-delivered treatment that included spinal manipulation, soft-tissue techniques, exercise and electrical stimulation.

Consent and what sources do not cover

WHO includes consent obligations, documentation of each encounter and attention to confidentiality in chiropractic education. A person can ask which technique is planned and can decline it. The sources reviewed for this draft do not give a typical visit length, number of visits, or fees, and these vary by clinic and country.

Education and accreditation

For people without prior health care education, WHO sets a benchmark of not less than 4,200 student-teacher contact hours, or the equivalent, over four years of full-time study, including at least 1,000 hours of supervised clinical training. Shorter routes are described for medical doctors and other health professionals. The Council on Chiropractic Education, an accrediting body in the United States, states on its website that it accredits 19 Doctor of Chiropractic programs in 21 locations and 11 residency programs. Licensing rules differ by country and are not covered here.

Scope described by the profession

The profession's stated scope is disorders of the neuromusculoskeletal system and the effects of those disorders on general health. WHO also says practitioners hypothesize that spinal functional disturbance can have wider neurophysiological consequences, and its curriculum includes familiarity with wellness-care methods. In its safety section WHO states that the purpose of spinal manipulation is to correct a joint restriction or dysfunction, not necessarily to influence other disorders that may be present at the same time.

Uses studied beyond the spine

A 2007 systematic review identified 179 papers on chiropractic care for 50 nonmusculoskeletal conditions published before May 2005. A 2022 scoping review of manipulation and mobilization in people under 18 lists asthma, attention deficit hyperactivity disorder, autism spectrum disorder, infantile colic, nocturnal enuresis, otitis media and headaches among conditions for which these methods are used by a variety of health professionals. Use of a method for a condition is not evidence that it helps, and the findings are described under Research and Evidence.

Guidelines on low back pain

NICE guideline NG59 (published 30 November 2016, last updated 29 July 2026) advises considering manual therapy, meaning spinal manipulation, mobilization or soft-tissue techniques such as massage, for low back pain with or without sciatica, but only as part of a treatment package that includes exercise. It advises against offering traction. The 2017 American College of Physicians guideline lists spinal manipulation among nonpharmacologic options for acute, subacute and chronic low back pain, citing low-quality evidence. Neither text is specific to chiropractors.

Back pain and neck pain reviews

A 2017 review of acute low back pain (up to six weeks) found 26 eligible randomized trials. Fifteen trials with 1,711 patients gave moderate-quality evidence of a pooled pain improvement of about 10 points on a 100-mm scale (95% confidence interval -15.6 to -4.3), and twelve trials with 1,381 patients showed improved function. The authors called the gains modest and the heterogeneity large.

A 2019 review of chronic low back pain included 47 trials with 9,211 participants. Moderate-quality evidence suggested effects similar to other recommended therapies for short-term pain (mean difference -3.17, 95% CI -7.85 to 1.51) and a small better improvement in function; evidence against sham manipulation was low to very low quality. For acute neck pain, a 2025 review of eight trials with 965 patients reported lower pain and disability than controls, but its abstract does not describe the comparators.

Non-musculoskeletal conditions and children

The 2007 review found that 122 of its 179 papers were case reports or case series and that 14 were randomized trials covering 10 conditions. Its authors reported support for chiropractic care in asthma, cervicogenic vertigo and infantile colic, and promising signals for otitis media and pneumonia in older adults. A 2021 critique of a later chiropractic-convened review reread six trials and described no or equivocal effects of stand-alone manipulation for infantile colic, childhood asthma, hypertension, primary dysmenorrhea and migraine, adding that a lack of evidence is not evidence against.

A 2022 scoping review of 87 articles on people under 18 found no evidence explicitly supporting effectiveness for any condition, strong to very strong evidence of no significant effect for asthma (lung function), headache and nocturnal enuresis, and inconclusive evidence for the rest.

The subluxation concept

The 2009 review applied epidemiologic criteria for causation, among them strength of association, consistency, temporality, dose response, experimental evidence and biological plausibility, to the subluxation construct. It judged these criteria for the most part unfulfilled and concluded that the missing evidence does not support presenting subluxation as an established cause. None of the abstracts of the manipulation trials and reviews cited on this page reports testing whether a subluxation was present, so their findings concern manipulation as an intervention and not the subluxation model.

Limits of the manipulation evidence

The 2019 review could not explain its statistical heterogeneity, and about half of the trials examined adverse events, in most of which it was unclear whether events were recorded systematically. The 2017 review found that heterogeneity was not explained by the type of clinician, the type of manipulation, study quality, or whether manipulation was given alone or in a package. The 2022 scoping review noted that methodological quality varied and that adverse-event reporting needs to increase.

Common effects and rare serious events

In the 2017 review no randomized trial reported a serious adverse event, while minor transient events such as increased pain, muscle stiffness and headache were reported in 50% to 67% of patients in large case series. The 2019 review reported that most events were musculoskeletal, short-lived and of mild to moderate severity. One trial powered to examine risk (183 participants) found no increased risk against sham manipulation, and in another trial a safety monitoring board judged one serious event possibly related.

A 2026 systematic review of chiropractic treatment in people over 55 included 25 articles and counted 412 study-related adverse events, of which nine were severe and none catastrophic. Case reports described six severe events, four of them vascular. Many studies lacked adverse-event definitions. The review was partly funded by Clinical Compass and the NCMIC Foundation, and several authors hold chiropractic affiliations.

Arterial injury and stroke after neck manipulation

WHO says serious neurological and vascular complications have been reported but are rare, and it cites older estimates ranging from one fatality in several tens of millions of manipulations to one important complication in 400,000 cervical manipulations. A 2008 critical appraisal of 26 publications found weak to moderate evidence of causation between cervical manipulation and vertebral artery dissection and stroke, especially in young adults, with an odds ratio of 5.03 (95% CI 1.32 to 43.87) for manipulation within a week in young patients with vertebrobasilar stroke, and an estimated 1.3 cases per 100,000 people under 45.

A 2012 systematic review of five case-control studies found that each had quality limitations and that potential bias and confounding made the results inconclusive. Its authors concluded that conclusive evidence of a strong association is lacking, and equally lacking for no association.

Contraindications and suitability

WHO lists absolute contraindications to spinal manipulation including acute fracture, spinal cord tumor, acute spinal infection, malignancy of the spine, cauda equina syndrome, vertebral dislocation and internal fixation devices at the site. Signs of vertebrobasilar insufficiency and a history of stroke are a relative-to-absolute contraindication to cervical manipulation, and severe or painful disc pathology calls for non-forceful techniques. WHO also advises asking about coexisting disease and medicines, including steroids and anticoagulants.

WHO lists vertigo, dizziness, numbness on one side of the face or body, speech difficulty and sudden severe neck or head pain after manipulation as symptoms of vertebral artery syndrome; these need prompt medical assessment, and chiropractic care should not replace necessary medical care. In children, the scoping review found mild transient symptoms in trials and occasional moderate to severe events in systematic reviews and lower-quality studies.