The chiropractic profession is responsible for diagnostic work, intervention and prevention of mechanical disorders of the musculoskeletal system. Its philosophy postulates that manual adjustments of musculoskeletal system affect the regulation of the nervous system and one’s overall well-being.1

Most of the literature examining perceptions of chiropractic care was primarily conducted with medical doctors. In a review of 20 studies covering Australia, New Zealand, North America and Europe, results were inconclusive to report any representative medical attitude toward chiropractors. However, the analysis split attitudes into positive and negative themes. Major themes which depicted positive aspects of chiropractic care included ‘effective for MSK conditions,’ ‘high referral rates,’ ‘interest in learning more about chiropractic,’ ‘open to communicate with chiropractor,’ ‘patient interest,’ and ‘safety’ Negative themes identified concerned the ‘safety’ of chiropractic care, ‘lack of knowledge about chiropractic care,’ ‘not evidence based,’ ‘low referral rates,’ and ‘sceptics.’2

In a European study, 49%of physiotherapist felt that chiropractic complemented their practice, 19% viewed chiropractors as competing with them, 41% endorsed the fact that they were expensive , 55% thought they should be part of primary care, 10% stated they lacked scientific knowledge, 63% had no opinion or they didn’t know enough, and 52% of physiotherapists did not view chiropractors to be competent practitioners. Yet, some physiotherapist viewed chiropractors only providing a ‘quick’ intervention, and they viewed themselves as providing more long-lasting interventions.3

Despite negative themes, there has been growing support of evidence-based treatment and cost effectiveness of chiropractor care.4,5 This should increase recommendations and referrals, but it is not evident in the literature.

Referrals and Recommendations to Health Professionals

Most research of health professionals’ views of chiropractors were associated with the referral rates to chiropractors. With this in mind, some doctors will ‘recommend’ that patients go to a chiropractor, but they would not make a proper referral. Nearly 88% of the medical doctors preferred that patients contact a chiropractor after their recommendation. Potential reasons offered were that some doctors may be fearful of malpractice litigation, wary of complementary medicine, ignorant of chiropractic care, or had a negative view of chiropractors.6

In a North American study, approximately 50% of patients asked their surgeons for a referral to a chiropractor. Yet, often other patients were reluctant to disclose that they sought out chiropractic treatment for fear of disapproval from their surgeons.7

In a study amongst nurses across the United States, it was reported that 27% of nurses would recommend patients occasionally, 14% would recommend patients periodically, and 9% of the nurses in the cohort would recommend patients on a regular basis. Twenty-two percent of the nurses perceived chiropractors to be effective treatment providers and 50% considered them safe.8 A similar study, conducted in South Africa, reported that most midwives would refer pregnant women for a variety of ailments and most of the midwives were positive about chiropractic care.9,10

There was only 1 study exploring health professionals’ referrals to chiropractors in Aotearoa, New Zealand, in which 95% of medical doctors in this sample referred their patients to chiropractors.2

Although there is ample research exploring views of chiropractor care from medical doctors on an international scale, there is a paucity of research in the literature, exploring views of other professionals such as nurses, midwives and physiotherapists. This study fills this gap, which includes health professionals such as nurses and physiotherapists from Aotearoa, New Zealand.

This study explored the health professionals’ perceptions of chiropractors and whether they would refer or recommend their patients to chiropractic care. Therefore, the aims include:

  • To gain an understanding of what issues exist to help resolve why chiropractors may not be referred to or recommended for treatment.

  • To find out how chiropractors are perceived by health professionals and where they sit in relation to other health providers.

  • To identify the barriers and motivations to recommending or referring to a chiropractor

  • To determine where there are opportunities to encourage health professionals to recommend chiropractor care and the best messaging to do so.


The New Zealand Chiropractors Association (NZCA) commissioned this study and provided guidelines to the marketing research company, Colmar Brunton, what to investigate . The intention of the data collection was not intended to be a scientific research study, but rather a survey. The marketing company had a list of volunteers who were already willing to participate in studies, therefore, ethics review wasn’t warranted. Colmar Brunton also developed questions, reviewed by the NZCA council. The chiropractor council added suggestions as well as providing questions from other international surveys to give them some context before the set of questions were finalized. Sampling for this study was conducted between August 12th and September 2nd, 2019, using the Medidata’s health care professional database which is New Zealand’s foremost data base of medical and related professions. Medidata have partnered with Colmar Brunton, New Zealand’s best-known market and social research company, on a study about different types of health providers. Recruitment was based upon selecting health professionals by the NZCA who were likely to recommend or refer their patients to a chiropractor. The online survey would take about 10 to 15 minutes to finish. Participants who have completed the survey could choose to either receive a $20 Prezzy Card voucher or the research team would donate the monetary value of the voucher to UNICEF on their behalf. They would also go into a draw to potentially win $500 in cash.


There were 353 health professionals who completed the surveys, an 8.6% response rate. The sample included general medical practitioners (GPs), locums, nurse practitioners, physiotherapists, and midwives. 32% were males and 68% female. The age ranges were grouped as follows: 18-29 years of age (7%), 30-39 years of age (23%), 40-49 years of age (17%), 50-64 years of age (42%), and 65 + (11%). Forty-four percent of the sample came from urban areas, 34% from suburban, and 22% from rural areas.

Both practice nurses and midwives (over 60%) linked chiropractic care with being ethical, knowledgeable, and professional more than the other professions in the sample.

The highest percentage of professionals who related negative stories about chiropractors were physiotherapists, at 79% GPs and locums a 73%, and nurses at 62%. Seventy-seven percent of GPs and locums, 73% nurses, 39% midwives, and 53% of physiotherapists admitted to knowing little to nothing about chiropractic care.

Health professionals who referred their patients to chiropractors reported that their primary reason to refer a patient would be if they ‘would receive effective care,’ followed by if they perceived ‘chiropractors as knowledgeable’ and if the chiropractors’ interventions were evidence-based.

Eight out of 10 health professionals knew chiropractors were ACC registered, but they were least likely to know that chiropractors were considered a primary healthcare provider, or that a chiropractor is licensed to take x-rays or refer patients for x-rays.

Seven in 10 health professionals who have recommended chiropractic care in the past year would at least seriously consider referring in the future. Only 3% would not consider at all. The main reasons preventing recommendations to a chiropractor are cost of care, lack of knowledge, and having more suitable options.

Regarding GPs and locums in the sample, there is potential to increase the number of referrals or recommendations to chiropractors, as one-third agreed that chiropractic care could complement their own client’s care. Practice nurses were the most open to recommending patients to chiropractors. Fifty-six percent of practice nurses would at least consider referrals for NMSK conditions.

Midwives would likely recommend patients to chiropractor care and over 50% agreed that chiropractic care could complement their patients. They would, at least, seriously consider recommending chiropractors for general wellness and NMSK conditions for clients.

Physiotherapists were the least likely to refer patients, with only 13% who would seriously consider referring for NMSK conditions. Some of the physiotherapists disliked the perceived dependency model and that they viewed that chiropractic care involved multiple treatments which did not promote self-management (see Table 1).

Table 1.Survey results.
Question Scale of response Health professional
GP/ Locumm Practice
Midwife Physiotherapist
Not aware
chiropractors …
know a little/nothing about chiropractic 77% 73% 39% 53%
are primary health care provider 47% 52% 26% 30%
are registered with ACC 14% 22% 26% 0%
Can take/refer for X-rays 34% 67% 61% 10%
chiropractic care
with being …
good value for money 5% 24% 26% 3%
scientifically rigorous 10% 33% 35% 3%
trustworthy 17% 46% 52% 27%
safe 22% 44% 48% 17%
effective 22% 49% 35% 40%
ethical 28% 62% 70% 30%
at least partly funded by ACC 81% 73% 78% 93%
knowledgeable 36% 67% 65% 57%
professional 37% 76% 70% 67%
Awareness of NZCA Yes 66% 65% 61% 73%
Effectiveness would be able to make a noticeable improvement to a medical condition or injury 18% 37% 48% 30%
first choice/ would seriously consider 23% 56% 52% 13%
Agree chiropractic
care …
has a range of safe options for infants and children 18% 27% 61% 30%
is effective for MMSK and spinal condition 48% 60% 70% 57%
could compliment my own practice and patients Agree 34% 44% 57% 37%
Disagree 54% 21% 22% 53%
Think that
chiropractic care
often make claims not backed up by evidence 70% 29% 30% 87%
is not scientifically proven 72% 32% 30% 73%
heard a lot of negative stories 73% 62% 52% 90%

The following are quotes from health professionals explaining why they wouldn’t refer someone to a chiropractor:

One nurse remarked:

Don’t trust the way they charge or what they say to patients based on my visit to one years ago. I felt like I was talking to a used car salesperson in the way that he used ridiculous examples of how my back would be in the future if I didn’t take on a long-term treatment plan with their service.

Some of physiotherapists stated:

I work with an excellent one I trust her, but I hear too many stories of other practitioners doing very quick treatment with little or no reassessment.

It depends on the chiropractor training skill, experience, and ability to treat clients.

Can be quite short-sighted with the overall progression of the treatment.

The have potential to harm patients with the x-ray images They take all patients spines and scare them into believing they need adjustment and manipulation for extended periods.

Some of the comments explained why GPs and locums wouldn’t refer someone to a chiropractor:

Don’t think they are effective:

Not sure about effectiveness and safety, especially in older patients’ group. (GP)

Consider them alternative therapy, not comfortable recommending something. I don’t know to be effective. (GP)

Patients came in after being to chiropractors requesting treatment.’ (GP)

Some GPs and locums perceived that chiropractor employ unnecessary multiple visits:

They have a tendency to keep bringing patients back for frequent costly treatments. (locum)

I feel chiropractors are unethical, getting patients back again and again unnecessarily. I think the way they take x-rays and use them to con people is wrong. (locum)

The relief they give seems to be short lived and patients have to keep returning. (GP)

They continue to see patients regularly when not making progress. (GP)

A percentage of GPs and locums wouldn’t consider chiropractor care for general wellness or NMSK conditions as they may create more harm than good:

I think they potentially put people at-risk with their type of treatment. (GP)

Potential harm with manipulations, would need to be confident in their skill. (GP)

I do not believe they practice safe medicine as a profession. (GP)

A percentage of doctors sampled, viewed chiropractor care as lacking evidence base practice:

Little scientific basis. Philosophy doesn’t make sense. Only really good for clicking and placebo effect. (GP)

Ethical considerations based on rigorous scientific practice. (GP)

A small percentage of doctors admitted that they didn’t know enough about chiropractor care:

Not many available. Don’t know who is around locally. (GP)

I don’t understand what they do, and I don’t trust the manipulation. (locum)

Partly due to being retrained in UK they are not funded by NHS so were re not trained in how they work, unlike physios who are part of our training, and we learn what they can do for our patients and how to work as a team with them for the benefit of the patient. (GP)

Some doctors viewed chiropractor care as costly:

Recommends expensive but useless supplements or homeopathic. (GP)

Cost, over treating. Adjusting to the point where patient was going daily at huge cost. (GP)

Potentially expensive. (Locum)


On a positive note, the highest percentage of professionals who had positive responses to chiropractic care were practice nurses and midwives. Over half of the sample of the health professionals viewed chiropractors as ethical and nearly half of this cohort perceived chiropractors as safe, and trustworthy. This aligns with previous research.2

However, a subset of health professionals had relatively unfavourable perceptions of chiropractic care. These perceptions may have reflected the high percentages of health professionals who admitted to knowing little or nothing about chiropractic care.

The greatest number of comments about chiropractors in New Zealand came from GPs and locums. Reasons for not referring patients were aligned with previous findings of the negative themes in a systematic review such as concerns regarding ‘safety of chiropractic care,’ ‘lack of knowledge about chiropractic care,’ ‘not evidence based’ and ‘low referral rates.’2 In line with positive themes. Reasons for referrals were: ‘effective for NMSK conditions’ and ‘safety.’ Doctors and locums in the study were unlikely to view chiropractic care as safe (22%), 48% of this cohort group were positive regarding chiropractors treating NMSK conditions effectively.

Midwives had the most positive responses regarding chiropractic care. Research supported the supposition that chiropractic care can reduce chances of a traumatic birth or injury to the mother’s neuro-musculoskeletal system as well as preventing the risk of dystocia. Chiropractic intervention can also provide a better positioning for the baby to fit in the pelvic brim to ease the labor process (19). With this knowledge, 61% of midwives in the sample believed that chiropractors have a range of safe options for infants and children. Midwives had the highest endorsement (57%) that chiropractors would complement their practice. They also had positive perceptions of chiropractors’ effectiveness, where they endorsed that chiropractors would make a noticeable improvement to a medical condition or injury, and they would seriously consider chiropractors as first choice. These results support the potential of interprofessional collaboration working with midwives.11,12

Physiotherapists were the least likely to refer patients to chiropractors and one comment from a psychotherapist posited that chiropractor care is based upon the dependency model in which patients must continue to see chiropractors for many sessions. This can be supported by views of surgeons in another study.7

Recommendations from the cohort of health professionals to improve knowledge of chiropractic care were to present case studies, receive endorsements, present or publish relevant papers and research, with a particular emphasis on NMSK conditions, as these already have a high association and acceptance towards this area of chiropractic care. It is also important to communicate the rigorous qualifications and the ongoing training of NZCA members to potential health practitioners who can refer or share care of clients. In addition, some felt that it would be advantageous to inform health professionals that NZCA has a website containing a database of registered chiropractors which they can easily identify qualified, competent, and local practitioners to become part of their primary health care team for clients.

Overall, there was a high percentage of health professionals who admitted they know little about chiropractic care; these same people reflected the high negative views. A further question to clarify these responses would be to ask what do health professionals do to change their views on chiropractors (e.g. conferences, read journals regarding evidence-based practice).

Future research could warrant more qualitative research to explore where the negative perceptions originated, what was the content of the information people received, and who shared this with them. In addition, more investigations of the links between low perceptions of chiropractic care, lack of knowledge and negative stories associated with chiropractic care. Interdisciplinary education, commencing early in their studies is a path forward.

Strengths and Limitations

The strength of this study filled a gap to specifically explore the referrals and attitudes towards chiropractors by health professionals in Aotearoa New Zealand.

A limitation of the study was a low response rate, which may have created a response bias in the results. The low response rate at 8.6% align with some other studies on chiropractic care, which also had low response rates at 14% and 17% respectively.13,14 Another limitation is the methodology of the study. It was a survey carried out by a marketing company. If there were statistical computations, associations could demonstrate greater insight into the reasons for biased views toward chiropractors.


Most health professionals have relatively low perceptions of chiropractor care. Improving perceptions of value for money, safety and being scientifically rigorous would have the biggest impact on the consideration of chiropractor care. Due to the existing acceptance of chiropractor care for NMSK conditions, it is recommended to focus on these benefits in communication first. Interdisciplinary education and collaboration may address these issues.