Manual therapy, chiropractic and osteopathy.
Cracking, and what it does.
Movement & therapy
NICE: only within a package
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Score per situation
Spinal manipulation for chronic back pain
Beats placebo by a small margin, on weak evidence.
Spinal manipulation for acute back pain
No better than ordinary medical care in a 1,000-person trial.
Manual therapy as part of a package with exercise
The only form NICE recommends.
Manual therapists, chiropractors and osteopaths all use their hands on your back, and all three are widely used in the Netherlands. The techniques overlap more than the professions like to admit: mobilisation (moving a joint through its range), manipulation (the quick push that often makes a click) and soft tissue work.
The click is not a joint being "put back". It is gas coming out of solution in the joint fluid. Nothing moves back into place, and nothing was out of place to begin with.
What the evidence shows
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
For chronic back pain there is genuine support. A review of 301 placebo-controlled trials covering 56 treatments found that only about one in ten works better than a placebo, and spinal manipulation was one of them (Cashin et al., BMJ Evid Based Med 2025).
Early in 2026 Cochrane published the largest analysis so far: 76 trials with 11,866 people. That is where you can see how big the difference actually is. Against a fake treatment it comes to about 7 points on a pain scale of 100 after a month. Against doing nothing at all, around 14 points; against other ordinary treatments, about 5. The researchers add that they have little confidence in those figures themselves: the trials differed a lot from one another and many were weakly set up (de Zoete et al., Cochrane 2026).
So the two best sources disagree about how solid the evidence is: Cashin calls it reasonably certain, Cochrane calls it weak. What they do agree on: if there is an effect, it is small. That puts manipulation in the same modest company as exercise and antidepressants, which is better than most things on offer and still not a cure.
For acute back pain the picture is different. The PACBACK trial (JAMA 2025) randomised 1,000 people with recent back pain at raised risk of it becoming chronic. Spinal manipulation on its own did not beat ordinary guideline-based medical care. What did help was supported self-management: less disability at 12 months, and 67% of that group improved by at least half, against 54% with medical care.
NICE lands where you would expect: consider manual therapy (manipulation, mobilisation or massage), but only as part of a treatment package that includes exercise. Not as a course of treatment on its own.
Who is who in the Netherlands
Worth knowing- Manual therapist: a physiotherapist with a master’s degree in manual therapy. Registered in the BIG register as a physiotherapist, and covered by supplementary insurance in the same way as physiotherapy.
- Chiropractor: trained abroad in most cases, and not a protected title in the Netherlands. There is no BIG registration, so quality control runs through their own professional association.
- Osteopath: also not a protected title and not in the BIG register. Osteopathy contains ideas about the body that have no scientific basis; the hands-on techniques it shares with the others are the part with evidence behind them.
A practical rule: judge the treatment, not the label. Whoever you see, the sensible package is the same: explanation, exercise, and hands-on work as a bonus.
Safety
Manipulation of the lower back is generally safe. Short-lived soreness or stiffness afterwards is common and harmless. Serious complications are rare, and the well-documented risk (arterial damage) concerns the neck, not the lower back. Do not have your back manipulated if you have alarm symptoms, if a fracture, tumour or infection has not been ruled out, or if you have increasing weakness or numbness in a leg. A good therapist screens for this before touching you and refers you on if anything is off.
Check the alarm symptomsA sensible approach
Before you start
Ask about the plan
How many sessions, and what do we do if it does not help?
Session 1–4
Notice the effect
Relief usually comes quickly if it comes at all.
Session 5–6
Evaluate honestly
No clear improvement? Then stop; more of the same rarely adds anything.
Throughout
Keep exercising
The hands are the extra; the exercise is the treatment.
Key message
Hands-on treatment of the back is not quackery and not a cure. For chronic back pain manipulation genuinely beats a placebo, by a small margin. For recent back pain it adds nothing over ordinary care. Use it the way the guidelines do: alongside exercise, for a limited number of sessions, and stop if nothing changes.
Sources
- de Zoete A, et al. Spinal manipulative therapy for adults with chronic low back pain. Cochrane (2026)
- Cashin AG, et al. Analgesic effects of non-surgical and non-interventional treatments for low back pain. BMJ Evid Based Med (2025)
- Bronfort G, et al. Spinal manipulation and clinician-supported biopsychosocial self-management for acute back pain: the PACBACK randomized clinical trial. JAMA (2025)
- NICE Guideline NG59: Low back pain and sciatica
- KNGF-richtlijn Lage rugpijn en lumbosacraal radiculair syndroom (2021)
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