physiotherapy or chiropractic care? know which one you may need

NICE Guidelines Position Exercise-Based Approaches as First-Line Treatment

The distinction between physiotherapy and chiropractic care matters significantly. Neither physiotherapists nor chiropractors should rely on manipulation alone. However, physiotherapy's core identity centres on exercise prescription and active rehabilitation, whilst chiropractic traditionally emphasises passive spinal adjustments.

NICE NG226 (Osteoarthritis, October 2022) reinforces this pattern by recommending therapeutic exercise and weight management as first-line treatments, with manual therapy receiving limited supporting evidence. For neck pain, European guidelines provide "weak or moderate" recommendations for combining manual therapy with exercise therapy programmes—the evidence base here remains weaker than for low back pain.

What the Clinical Evidence Actually Shows

The Cochrane Collaboration's systematic reviews provide perhaps the most rigorous assessment of spinal manipulative therapy (SMT). Here's what the research tells us:

For Acute Low Back Pain

Cochrane's review of 20 randomised controlled trials involving 2,674 participants concluded that SMT is "no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention." The evidence quality was rated low to very low.

For Chronic Low Back Pain

Findings were slightly more favourable: "High-quality evidence that spinal manipulative therapy for chronic low back pain has a small, short-term greater effect on pain and functional status compared with other interventions." A 2019 BMJ meta-analysis found SMT produces effects similar to NSAIDs—approximately 9.9 points versus 8.4 points reduction on a 100-point pain scale.

For neck pain, a 2023 JOSPT systematic review found only "very low certainty evidence" supporting cervical SMT for reducing pain and improving disability. Safety data showed only transient side effects such as muscle soreness.

Why Active Physiotherapy Outperforms Passive Treatments for Chronic Conditions

A 2025 Bayesian network meta-analysis published in the Journal of Orthopaedics and Traumatology provides compelling evidence for physiotherapy's active approach. Researchers found that "active physiotherapy showed better results than passive physiotherapy" for chronic low back pain management in terms of both pain and disability reduction.

This aligns with our understanding that patients with chronic low back pain show atrophy of multifidus and paraspinal muscles—structural changes that passive manipulation simply cannot address. Our physiotherapy treatments focus on active rehabilitation through:

• Motor control exercises that retrain movement patterns
• Therapeutic strengthening programmes targeting weak muscle groups
• Pilates-based rehabilitation for core stability
• Progressive resistance training to build lasting strength
• Aerobic conditioning to support overall recovery

The evidence consistently shows that whilst passive treatment can help with immediate pain relief, active treatment keeps patients functional long-term. At 6-12 month follow-up, differences between treatment approaches typically diminish, but active rehabilitation approaches show superior disability outcomes over time.

Regulatory Frameworks Reveal Significant Scope Differences

Both professions operate under statutory regulation in the UK, with protected titles that only registered practitioners may use. However, the scope and integration of these professions differ markedly.

The Chartered Society of Physiotherapy (CSP), founded in 1894 and granted a Royal Charter in 1920, represents over 65,000 members and provides the postnominal 'MCSP' for Chartered Physiotherapists—a widely recognised quality marker. All our physiotherapists at CK Physio are HCPC registered and members of the CSP.

NHS Pathways Favour Physiotherapy as the Standard Treatment Route

The structural integration of physiotherapy within the NHS creates practical advantages for patients. First Contact Practitioner (FCP) roles mean most adults in England can access MSK physiotherapy at their GP practice without requiring a GP referral.

This model shows significant cost benefits: £41-44 per patient for FCP-led consultation versus £105.50 for GP-led models over six-month follow-up, with FCP consultations also demonstrating lower opioid prescribing rates.

NHS physiotherapy covers an exceptionally broad scope:

• Musculoskeletal: Joint, muscle, tendon, and bone conditions
• Neurological: Stroke, Parkinson's, MS, spinal cord injury
• Respiratory: COPD, asthma, cystic fibrosis, pulmonary rehabilitation
• Cardiac: Post-cardiac event rehabilitation
• Paediatric: Developmental conditions, cerebral palsy
• Women's health: Pelvic floor dysfunction, pregnancy-related conditions

Chiropractic care is not routinely available on the NHS, with most patients paying privately at typical rates of £45-80+ per session. Some integrated care boards commission limited chiropractic services, but this remains exceptional rather than standard practice.

Red Flags: When to Seek Emergency Medical Attention

Additional Red Flags Warranting GP Referral:

• Unexplained weight loss
• History of cancer
• Fever
• Relentless night pain
• Age under 20 or over 55 with new symptoms

Absolute contraindications to spinal manipulation include vertebral fractures, spinal malignancy, spinal infections, vertebrobasilar insufficiency, and severe osteoporosis. Any reputable practitioner—whether physiotherapist or chiropractor—will screen for these conditions before treatment.

Making Your Decision: When to Choose Physiotherapy

When selecting a practitioner, always verify registration with the appropriate regulatory body:

• Physiotherapists: HCPC Register
• Chiropractors: GCC Register

Based on Current Evidence, Physiotherapy Is Typically More Appropriate For:

Chiropractic may be considered for uncomplicated acute spinal pain where patients prefer a manipulation-focused approach and are prepared to pay privately. However, current evidence suggests outcomes are similar to physiotherapy, and NICE guidance emphasises that manual therapy should always be combined with exercise—physiotherapy's core strength.

Questions to Ask Any Practitioner:

• What is your experience treating my specific condition?
• What does the evidence say about this treatment approach?
• What is your recommended treatment plan and expected timeline?
• What are the risks and what should I do if symptoms worsen?

Frequently Asked Questions

Our Conclusion

The evidence supports a clear position: whilst both physiotherapy and chiropractic can effectively treat certain musculoskeletal conditions, physiotherapy offers broader scope, stronger NHS integration, prescribing capabilities, and alignment with NICE recommendations emphasising active rehabilitation.

The 2025 meta-analysis finding that active physiotherapy outperforms passive approaches for chronic conditions reinforces physiotherapy's exercise-based philosophy. For UK patients navigating treatment choices, physiotherapy represents the evidence-based mainstream option, with chiropractors occupying a narrower niche primarily in private practice for uncomplicated spinal pain.

The critical message from current guidelines remains consistent: whatever manual therapy approach is chosen, it should form part of a comprehensive treatment package including exercise. This positions physiotherapy—with its fundamental emphasis on active rehabilitation, patient education, and exercise prescription—as optimally aligned with contemporary clinical evidence.

References & Further Reading

1. NICE (2016, updated 2020). Low back pain and sciatica in over 16s: assessment and management [NG59]. Available at: https://www.nice.org.uk/guidance/ng59
2. Health and Care Professions Council (HCPC). Check the Register. Available at: https://www.hcpc-uk.org/check-the-register/
3. General Chiropractic Council (GCC). Find a Chiropractor. Available at: https://www.gcc-uk.org/
4. Chartered Society of Physiotherapy (CSP). About the CSP. Available at: https://www.csp.org.uk/
5. Cochrane Library. Spinal manipulative therapy for chronic low-back pain. Available at: https://www.cochranelibrary.com/
6. NHS England. Musculoskeletal conditions. Available at: https://www.england.nhs.uk/
7. GOV.UK. Register as a physiotherapist. Available at: https://www.gov.uk/find-licences/register-physiotherapist