Study
Effectiveness and cost-effectiveness of chiropractic and physiotherapy for chronic low back pain: a multicenter RCT in Sweden.
Filip Gedin, Martin Skeppholm, Vibeke Sparring, Niklas Zethraeus · BMC musculoskeletal disorders · 2025
Read the original paper ↗The short version
This Swedish trial asked whether a chiropractor, a physiotherapist, or advice to stay active works best for low back pain lasting months — and the honest answer is that it could not tell the three apart. Eighty-eight people at ten primary care clinics around Stockholm were randomly assigned to one of four things: advice only, physiotherapy, chiropractic care, or both together. Six months later, everyone was better. Disability scores dropped in every group — most in the chiropractic group, least in the physiotherapy group — but the gaps between groups were well within what chance alone would produce. Pain scores and quality of life told the same story: improvement everywhere, no clear winner. Where the groups did differ was cost. The advice-only group ended up costing the health system about three times more than the others — around SEK 11,000 per person versus roughly SEK 3,000 — mostly because those patients went on to see doctors more, and one of them had spine surgery. Getting hands-on treatment early appeared to head off more expensive care later, though with numbers this small a single surgery moves the whole average. Combining chiropractic care with physiotherapy came out best on the economics: slightly more quality-adjusted life years for slightly less money. But "slightly" is doing a lot of work — the difference across all four groups was eight thousandths of a QALY, which is roughly three days of perfect health. The researchers are unusually candid about the limits. They wanted far more participants than they got, nearly half the people dropped out before six months, and the four groups were not well matched at the start. They present this as a lesson for whoever runs the definitive trial next, not as a result to act on. What it does support, gently: for chronic low back pain, staying active matters, and both chiropractic care and physiotherapy are reasonable, comparably effective options — with some signal that getting treatment rather than advice alone may save money downstream.
Key findings
- All four arms improved: mean six-month ODI reductions of 12.56 (chiropractic care), 11.58 (combination), 10.86 (advice) and 6.13 (physiotherapy) — none significantly different from one another (P=0.30).
- Advice alone cost the health system about three times more in direct care over six months (SEK 11,135) than physiotherapy (SEK 3,632), chiropractic care (SEK 3,170) or the combination (SEK 3,081), largely from downstream physician visits and one spine surgery.
- On point estimates the combination of chiropractic care and physiotherapy was cost-effective versus chiropractic care alone, and advice and physiotherapy were dominated — but the entire QALY spread across four arms was 0.008.
- The trial was pragmatic by design: treatment content, duration and visit count were left to each clinician, which reflects real Swedish primary care but means "chiropractic care" and "physiotherapy" are not standardized interventions here.
- The authors themselves treat this as feasibility groundwork rather than practice-changing evidence — 88 participants across four arms, 47% dropout at six months, imbalanced baselines and cross-over between arms.
Common questions
Does this trial show chiropractic care works better than physiotherapy for chronic low back pain?
No. Chiropractic care showed the largest average improvement in disability (12.56 ODI points versus 6.13 for physiotherapy), but the difference was not statistically significant (P=0.30) and the trial was far too small to detect one if it existed. With 24 people per arm and 47% dropout, this result is compatible with the two being equally effective.
Why did the advice-only group cost so much more?
Patients who received advice alone went on to consume more care: SEK 1,584 in physician visits versus SEK 234 in the combination arm, plus one spine surgery that averaged SEK 7,000 across the arm. The pattern suggests hands-on treatment may head off downstream costs, but a single surgery in an 18-person group moves the mean enormously, so this is a signal rather than a finding.
What does "pragmatic trial" mean here, and why does it matter?
It means clinicians decided the content, duration and number of treatment sessions themselves rather than following a fixed protocol. The advantage is external validity — this is what Swedish primary care actually delivers. The cost is interpretability: "chiropractic care" in this trial is whatever twenty-four different chiropractors chose to do, so a null result cannot distinguish between the technique not working and the technique not being applied consistently.
Is a 0.008 QALY difference meaningful?
Barely. A QALY is one year in perfect health, so 0.008 QALYs is about three days of perfect health over the six-month follow-up. The confidence intervals for all four arms overlap heavily. The cost-effectiveness conclusion rests on point estimates that a slightly different sample would likely reverse.
What should someone with chronic low back pain take from this?
Two things the trial does support. First, everyone improved — chronic low back pain in primary care tends to get better over six months across every management strategy tested. Second, chiropractic care and physiotherapy performed comparably, so the choice can reasonably rest on access, cost and personal preference. What the trial cannot tell is which approach works better for a given individual, and it offers no evidence about spinal manipulation for pain attributable to a specific pathology, which was an exclusion criterion.
This summary and its findings were generated by AI from the published paper and may contain imperfections. It describes a study and is not medical advice — talk to a qualified clinician about your own health (terms). The original study is always the source of truth — read it above.