23 For 2023

Once again, our annual review of the research literature to find some of the most relevant for the practicing chiropractor. Below are 23 for 2023 of some the best. Use them to educate yourself and your patients to provide better care for the new year!


  1. Patients with low back pain who see a chiropractor as their first provider of care have lower total costs of care, fewer MRI’s ordered, fewer hospitalizations, and less opioid prescriptions written. [1]

2. Low back pain patients treated with multidisciplinary integrative care (consisting of spinal manipulation, exercise, acupuncture, cognitive behavioral therapy, self-care strategies, and others) were no better than those treated with chiropractic care alone. [2]

3.  Patients with primary headache disorders are likely to have chronic low back pain [3]

4. Among older Medicare beneficiaries with spinal pain, use of chiropractic care is associated with significantly lower risk of filling an opioid prescription.[4]

5. SMT provides similar outcomes to recommended interventions (mainly exercise) for pain and functional status in the older adult with chronic LBP and is recommended as a treatment for this patient population.[5]

6. Patients with newly diagnosed lumbar disc herniation or lumbosacral radiculopathy who receive Chiropractic SMT have significantly reduced odds of discectomy over 2-year follow-up. [6]


7. During cervical spine manipulations (using cervical spine extension and rotation) using human cadavers, the vertebral artery was not stretched, merely elongated during the manipulation.  [7]

8. Among Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups.[8]


9. The lumbar flexion-distraction procedure was found to decrease intradiscal pressure, and to improve subjective and objective outcomes in patients with lumbar spinal stenosis [9] [10]

10. The presence or absence of an audible pop may not be important regarding pain outcomes with spinal manipulation. [11]

11. Subjects with neck pain had hypermobility of the lower cervical spine and hypomobility of the cervico-thoracic junction and upper thoracic spine compared with subjects without neck pain. [12]

12. Manipulation and mobilization to the upper cervical spine segments both help patients with cervicogenic headache. [13]

13. Chiropractic manipulation can effectively relieve pain, improve lumbar function, and improve the Cobb angle in patients with degenerative scoliosis. [14]

14. Patients with back pain want most of all an explanation of what is causing the problem, improvement in their pain, and improvement in their ability to perform daily tasks. They did not place as much importance on diagnostic tests, medications and surgery as their doctors assumed.  [15]

15. In patients with chronic back or neck pain, chiropractic visit frequency over a 3-month period found that those with worse baseline pain and function used more visits, but only visits more than once per week were associated with significantly better improvement. [16]

16. Manual therapy and exercise provides superior and clinically important short-term improvement in symptoms and function for patients with lumbar spinal stenosis, compared with medical care or community-based group exercise. [17]

17. Exercise is as effective as surgery for large to massive rotator cuff tears.[18]

18. Private practice physicians who made recommendations for chiropractic care indicated that they were influenced by scientific evidence in peer-reviewed journals and patient requests. A lack of perceived benefit was the most frequently reported reason for not recommending. [19]

19. The correction of the cervical lordosis, in hypolordotic spines of patients suffering from cervical spondylotic radiculopathy, had improved pain and neurophysiology. [20]

20. For most conditions with sufficient available data on pain, function and quality of life, there were no clinically relevant differences between interventions with and without surgery for musculoskeletal (MSK) conditions.[21]


21. The MRI findings in the lumbar spines of asymptomatic elite male adolescent soccer player found most had abnormalities, such as facet degeneration, synovial cysts, disc degeneration, disc herniation, and pars injury. [22]

22. It is possible to calculate an “age estimate” of someone on lumbar MRI by assessing their age-related changes, such as disc signal intensity, disc height, facet joint size, ligamentum flavum thickness, Schmorl nodes, Modic changes, vertebral osteophytes, etc.[23]

23. Ordering an MRI within the first 4 to 6 weeks of conservative management of acute low back pain is associated with increased length of disability in patients with acute LBP without red flags. [24]

About the Author:

Dr. David Graber is nationally known presenter on chiropractic technique and is a member of the ANJC board of directors. He maintains a private practice in Parsippany, NJ. He blogs on chiropractic and clinical topics at: drgraber.wordpress.com.  He can be reached at: DrDavidGraber@gmail.com.

[1] Harwood, K.J., Pines, J.M., Andrilla, C.H.A. et al. Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US. BMC Health Serv Res 22, 694 (2022). https://doi.org/10.1186/s12913-022-08092-1

[2] Bronfort G, Maiers M, Schulz C, Leininger B, Westrom K, Angstman G, Evans R. Multidisciplinary integrative care versus chiropractic care for low back pain: a randomized clinical trial. Chiropr Man Therap. 2022 Mar 1;30(1):10. doi: 10.1186/s12998-022-00419-3. PMID: 35232482; PMCID: PMC8886833.

[3] Vivekanantham, A., Edwin, C., Pincus, T. et al. The association between headache and low back pain: a systematic review. J Headache Pain 20, 82 (2019). https://doi.org/10.1186/s10194-019-1031-y

[4] Whedon, J.M., Uptmor, S., Toler, A.W.J. et al. Association between chiropractic care and use of prescription opioids among older medicare beneficiaries with spinal pain: a retrospective observational study. Chiropr Man Therap 30, 5 (2022). https://doi.org/10.1186/s12998-022-00415-7

[5] Jenks, A., de Zoete, A., van Tulder, M. et al. Spinal manipulative therapy in older adults with chronic low back pain: an individual participant data meta-analysis. Eur Spine J 31, 1821–1845 (2022). https://doi.org/10.1007/s00586-022-07210-1

[6] Trager RJ, Daniels CJ, Perez JA, et alAssociation between chiropractic spinal manipulation and lumbar discectomy in adults with lumbar disc herniation and radiculopathy: retrospective cohort study using United States’ dataBMJ Open 2022;12:e068262. doi: 10.1136/bmjopen-2022-068262

[7] Gorrell LM, Sawatsky A, Edwards WB, Herzog W. Vertebral arteries do not experience tensile force during manual cervical spine manipulation applied to human cadavers. J Man Manip Ther. 2022 Nov 15:1-9. doi: 10.1080/10669817.2022.2148048. Epub ahead of print. PMID: 36382347.

[8] Whedon, J.M., Petersen, C.L., Li, Z. et al. Association between cervical artery dissection and spinal manipulative therapy –a medicare claims analysis. BMC Geriatr 22, 917 (2022). https://doi.org/10.1186/s12877-022-03495-5

[9] Maruti R. Gudavalli, Gregory D. Cramer, and Avinash G. Patwardhan.

Changes in Intradiscal Pressure During Flexion-Distraction Type of Chiropractic Procedure: A Pilot Cadaveric Study.

Integrative Medicine Reports.Dec 2022.209-214.http://doi.org/10.1089/imr.2022.0002

[10]  Smith, Dean L. et al. The influence of flexion distraction spinal manipulation on patients with lumbar spinal stenosis: A prospective, open-label, single-arm, pilot study, Journal of Bodywork and Movement Therapies, Volume 32, 60 – 67

[11] Moorman, A.C., Newell, D. Impact of audible pops associated with spinal manipulation on perceived pain: a systematic review. Chiropr Man Therap 30, 42 (2022). https://doi.org/10.1186/s12998-022-00454-0

[12] Ryota Yoshida, Toru Yasuda & Hironobu Kuruma (2022) Analysis of cervical and upper thoracic spinal segmental rotation angles during end-range neck rotation: Comparison with and without neck pain, Journal of Manual & Manipulative Therapy, 30:6, 328-333, DOI: 10.1080/10669817.2022.2056309

[13] Lerner-Lentz A, O’Halloran B, Donaldson M, Cleland JA. Pragmatic application of manipulation versus mobilization to the upper segments of the cervical spine plus exercise for treatment of cervicogenic headache: a randomized clinical trial. J Man Manip Ther. 2021 Oct;29(5):267-275. doi: 10.1080/10669817.2020.1834322. Epub 2020 Nov 5. PMID: 33148134; PMCID: PMC8491670.

[14] Li LG, Gao JH, Gao CY, Sun W, Luo J, Yang KX, Yu J, Li JG, Wang BJ, Yang W, Zhuang MH. [Clinical observation of chiropractic manipulation in the treatment of degenerative scoliosis]. Zhongguo Gu Shang. 2022 May 25;35(5):442-7. Chinese. doi: 10.12200/j.issn.1003-0034.2022.05.007. PMID: 35535532.

[15] Smuck M, Barrette K, Martinez-Ith A, Sultana G, Zheng P. What does the patient with back pain want? A comparison of patient preferences and physician assumptions. Spine J. 2022 Feb;22(2):207-213. doi: 10.1016/j.spinee.2021.09.007. Epub 2021 Sep 20. PMID: 34551322.

[16] Herman PM, Edgington SE, Sorbero ME, Hurwitz EL, Goertz CM, Coulter ID. Visit Frequency and Outcomes for Patients Using Ongoing Chiropractic Care for Chronic Low-Back and Neck Pain: An Observational Longitudinal Study. Pain Physician. 2021 Jan;24(1):E61-E74. PMID: 33400439; PMCID: PMC8667562.

[17] Ammendolia C, Hofkirchner C, Plener J, Bussières A, Schneider MJ, Young JJ, Furlan AD, Stuber K, Ahmed A, Cancelliere C, Adeboyejo A, Ornelas J. Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review. BMJ Open. 2022 Jan 19;12(1):e057724. doi: 10.1136/bmjopen-2021-057724. PMID: 35046008; PMCID: PMC8772406.

[18] Fahy, Kathryn & Galvin, Rose & Lewis, Jeremy & Mccreesh, Karen. (2022). Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis. Musculoskeletal Science and Practice. 61. 102597. 10.1016/j.msksp.2022.102597.

[19] Stussman BJ, Nahin RL, Barnes PM, Scott R, Feinberg T, Ward BW. Reasons Office-Based Physicians in the United States Recommend Common Complementary Health Approaches to Patients: An Exploratory Study Using a National Survey. J Integr Complement Med. 2022 Aug;28(8):651-663. doi: 10.1089/jicm.2022.0493. Epub 2022 May 12. PMID: 35549394; PMCID: PMC9467636.

[20] Moustafa IM, Diab AA, Harrison DE. The Efficacy of Cervical Lordosis Rehabilitation for Nerve Root Function and Pain in Cervical Spondylotic Radiculopathy: A Randomized Trial with 2-Year Follow-Up. J Clin Med. 2022 Nov 2;11(21):6515. doi: 10.3390/jcm11216515. PMID: 36362743; PMCID: PMC9658907.

[21] Søren T. Skou, et al. Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis

Journal of Orthopaedic & Sports Physical Therapy 2022 52:6, 312-344

[22] Carmody S, Rajeswaran G, Mitchell A, Kryger KO, Ahmad I, Gill M, Rushton A. Lumbar spine MRI findings in asymptomatic elite male academy footballers: a case series. BMC Sports Sci Med Rehabil. 2022 Oct 24;14(1):184. doi: 10.1186/s13102-022-00576-1. PMID: 36280886; PMCID: PMC9590204.

[23] Sneath RJS, Khan A, Hutchinson C. An Objective Assessment of Lumbar Spine Degeneration/Ageing Seen on MRI Using An Ensemble Method-A Novel Approach to Lumbar MRI Reporting. Spine (Phila Pa 1976). 2022 Mar 1;47(5):E187-E195. doi: 10.1097/BRS.0000000000004159. PMID: 34224512.

[24] Shraim BA, Shraim MA, Ibrahim AR, Elgamal ME, Al-Omari B, Shraim M. The association between early MRI and length of disability in acute lower back pain: a systematic review and narrative synthesis. BMC Musculoskelet Disord. 2021 Nov 24;22(1):983. doi: 10.1186/s12891-021-04863-9. PMID: 34819061; PMCID: PMC8614033.

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