Clinical Practice Guidelines

This section provides information on clinical practice guidelines with respect to low back pain, neck pain, and headaches.


The Canadian Chiropractic Guideline Initiative (CCGI), supported by professional chiropractic organizations in Canada provides useful resources on recommendations and guidelines for best practice. Visit for up-to-date information on current guidelines, as well as tools and resources for patients and clinicians, including webinars, videos, research news and much more. You can also follow CCGI on LinkedIn.

Low Back Pain

Toward Optimized Practice and Institute of Health Economics, (2011). Guideline for the evidence-informed primary care management of low back pain.

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Key Finding(s): The Toward Optimized Practice (TOP) “Guideline for the Evidence-Informed Primary Care Management of Low Back Pain” (2010) targeting adults, ages 18 and over, makes a series of recommendations, many of which include the use of chiropractic and manual therapy. The Guidelines specifically notes that “Patients with disabling back or leg pain, or significant limitation of function including job related activities should be referred within 2 to 6 weeks to a trained spinal care specialist” such as a chiropractor. Similarly, TOP suggests “Patients who are not improving may benefit from referral for spinal manipulation provided by a trained spinal care specialist”, including a chiropractor.

National Institute for Health and Clinical Excellence. (2009).Low back pain early management of persistent non-specific low back pain. London, England.

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Key Finding(s): The National Institute for Health and Clinical Excellence (NICE) in England released a clinical practice guideline—“Early management of persistent non-specific low back pain”—in which they recommend that clinicians “Consider offering a course of manual therapy, including spinal manipulation, comprising up to nine sessions over a period of up to 12 weeks.”

Chou, E., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.

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Key Finding(s): This joint CPG from the American College of Physicians and American Pain Society recommend that “For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).”

van Tulder, M., Becker, A., Bekkering, T., Breen, A., Gil del Real, M., Hutchison, A. … Malmivaara, A. (2004). Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. European Spine Journal, 15(Supplement 2), s169– s191.

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Key Finding(s): The European Guidelines suggest that primary care providers consider referral for spinal manipulation for acute non-specific low back pain patients who are failing to return to normal work and activities.

Neck Pain

Haldeman, S., Carroll, L., Cassidy, J., Schubert, J., & Nygren, A. (2008). The bone and joint decade 2000–2010 task force on neck pain and its associated disorders: Executive summary. Spine, 33(4S), S5-S7.

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Key Finding(s): Among the Task Force’s key findings are that most people can expect to experience neck pain in their lifetimes, and that 11-14% of workers report being limited by neck pain each year. A significant finding from the perspective of chiropractic is that “There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke.”  This suggests there is no evidence indicating that chiropractic care, when compared to standard medical care, is more strongly associated with stroke. This report suggests both a new classification system and a new conceptual model for neck pain.


Bryans, R., Descarreaux, M., Duranleau, M., Marcoux, H., Potter, B., Reugg, R., White, E., & , (2011). Evidence-based guidelines for the chiropractic treatment of adults with headache. Journal of Manipulative and Physiological Therapeutics,34(5), 274-289.

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Key Finding(s): This evidence-informed set of recommendations on chiropractic treatment of headaches in adults is based on 21 articles which met the inclusion criteria. The authors conclude that: “Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal.”