02/14/2026
Despite the clickbait headline, it is unfortunately true that there is a lot of pseudoscience surrounding physiotherapy and chiropractic healthcare. No one seriously doubts that manual and physical therapy can help reduce musculoskeletal (muscle and joint) pain and dysfunction, but sometimes the explanations for why these treatments work is dubious at best, and there is a lot of not useless but low value care, such as ultrasound, shockwave, taping, TENS and other passive modalities.
This article includes spinal manipulative therapy (SMT) as an example of pseudoscience, and I would like to explain why this is unfair. The best science we have tells us that SMT is a safe and effective treatment for mechanical low back pain (LBP). The American College of Physicians recommends spinal manipulation before considering drugs or surgery for the treatment of acute, subacute or chronic LBP.
"Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation. If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants," according to a 2017 study by Qaseem et al, published in the Annals of Internal Medicine [1].
"Spinal manipulative therapy (SMT) is definitely not just a chiropractor thing. Lots of physical therapists also manipulate spines. There are some technical and cultural differences, and physios and chiros often have turf battles where they accuse each other of habitually doing SMT badly. There are reasonable arguments for more conservative SMT, and hardly any physios subscribe to chiropractic subluxation theory. But they still manipulate the spine, for unclear reasons, and they do it despite evidence damning it with faint praise at best (Rubinstein et al, Nim et al.). As typically practiced by physios, SMT isn’t quite ‘quackery’, but it certainly qualifies as pseudo-quackery: it is promoted as a sophisticated clinical power tool, a ‘magic hands’ thing, knowing exactly what to press and pull and twist and how hard and why," according to Paul Ingraham writing for The Skeptic.
To explain why his criticism is unfair, it is worth reviewing the two studies he references (and a couple others).
"SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies. Our evaluation is limited by the small number of studies per comparison, outcome, and time interval. Therefore, future research is likely to have an important impact on these estimates. The decision to refer patients for SMT should be based upon costs, preferences of the patients and providers, and relative safety of SMT compared to other treatment options. Future RCTs should examine specific subgroups and include an economic evaluation," according to a 2012 study by Rubinstein et al, published in the Cochrane Database of Systematic Reviews [2].
Translation: Since SMT is no better (or just as good) as other recommended therapies (such as drugs or exercise), the decision to refer patients should be based upon costs (SMT is cost effective compared to other recommended therapies), preferences of the patients and providers (patients might love or hate spinal manipulation), and the relative safety of SMT compared to other treatment options (spinal manipulation is safe compared to other treatment options such as drugs or exercise). "Acute low back pain" is an umbrella term encompassing a plethora of different etiologies. If we could limit treatment to only those who might benefit from it (those with mechanical spinal joint dysfunction), future research could better estimate the real clinical and economic effectiveness of spinal manipulation.
"Most spinal manipulative therapy (SMT) procedures were equal to clinical guideline interventions and were slightly more effective than other treatments. There was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients’ preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant," according to a 2025 study by Nim et al, published in the Journal of Orthopaedic & Sports Physical Therapy [3].
"Pain and disability outcomes following SMT did not depend greatly on how the thrust was delivered, in what region it was performed, or whether it was targeted at a painful and restricted site or more generically. The highest probability of providing the greatest average treatment effects for reducing pain and disability was observed for more general and nonspecific SMT applications."
Translation: Chiropractors often treat multiple regions of the spine, in addition to the primary area of complaint. This study confirms that more general treatments are probably a good strategy for reducing spinal pain.
"Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms," according to a 2017 study by Paige et al, published in the Journal of the American Medical Association [4].
Translation: SMT is a safe and effective treatment for acute LBP.
"Multimodal strategies that combine manual therapy with exercise and patient education appear to be the most effective in managing LBP and preventing recurrence," according to a 2025 study by Grzegorczyk et al, published in the journal Healthcare [5].
“The findings suggest that no single method is universally superior. Instead, optimal outcomes are achieved through individualized treatment plans that integrate multiple techniques based on clinical presentation, pain chronicity, and functional limitations.”
Translation: Different things work for different people. Keep an open mind and be willing to try new things. “Multimodal strategies” that combine different therapies (an all of the above approach) generally work best. As a chiropractor, I combine manual therapy with exercise and patient education to manage low back pain and prevent reoccurrence.
The Skeptic author complains that chiropractors and physiotherapists manipulate the spine "for unclear reasons, and despite evidence damning it with faint praise." But for chronic low back pain, faint praise is all we have for any non-surgical treatment.
"The current evidence shows that one in 10 non-surgical and non-interventional treatments for low back pain are efficacious, providing only small analgesic effects beyond placebo," according to a 2025 study by Cashin et al, published in BMJ Evidence-Based Medicine [6].
Translation: This means that whatever treatment you choose, it only has a one in ten chance of helping! "The efficacy for the majority of treatments is uncertain due to the limited number of randomized participants and poor study quality," meaning more research is needed to truly understand which treatments help and how much they help and who they help.
"For patients with acute or subacute low back pain (LBP) at increased risk of chronic disabling LBP, clinician-supported biopsychosocial self-management showed statistically significant but small reductions in disability, but not pain, vs medical care over 1-year follow-up, and spinal manipulation alone showed no significant difference for either outcome," according to a 2026 study by Bronfort et al, published in the Journal of the American Medical Association [7].
Translation: What is the best treatment for acute low back pain, spinal manipulation, clinician-supported self-management or medical care? They are all about the same. Generally speaking, all of the above approaches are the best strategy for acute back pain. As a chiropractor, I provide both spinal manipulation and clinician-supported self-management to my patients. As this study suggests, lifestyle matters. Spinal manipulation and staying as physically active as possible are just as effective as taking medication for acute back pain, and probably better for managing disability.
Conclusion:
Chiropractic is a profession, not a treatment. We are most famous for spinal manipulative therapy, but chiropractors will combine many different treatments in clinical practice, most commonly stretching and strengthening. Yes, some therapies used by chiropractors and physiotherapists are more evidence-based than others. Clinicians will consider their own experience and patient preferences, along with the science, when making treatment recommendations, but that is how evidence-based medicine works. Manual therapy (hands on treatment), often provided by a chiropractor, physiotherapist or massage therapist, can help facilitate physical therapy by at least temporarily reducing musculoskeletal pain, which can open up a therapeutic window to become more physically active.
Many who rightly turn their nose up at chiropractic don’t realise much of ‘mainstream’ physiotherapy is just as flimsy in its evidence base
