The study was conducted by researchers from, among others, the University of Southern Denmark, Spine Centre of Southern Denmark, the Chiropractic Knowledge Hub, and international partners. The results have been published in the Journal of Public Health.
90% use almost no treatment – but the remaining 10% account for half of all consultations
Researchers followed the use of physiotherapy and chiropractic care by Danes over four years (two years before and two years after assessment at a spine centre). The results showed clear patterns:
- The largest group consisted of back‑pain patients who did not seek treatment at all, accounting for more than half of all patients.
- Another approx. 40% sought treatment a few times.
- Around 10% had a moderate, high, or increasing level of treatment use – but this group accounted for up to 50% of all treatments.
This shows that even among people with substantial and long‑term pain—where their GP has assessed that primary treatment options are exhausted—continuous treatment by a physiotherapist or chiropractor is far from the norm.
Differences in the use of physiotherapy and chiropractic care
The study highlights clear differences between the two professions:
Physiotherapy
- Used by more patients.
- Delivered over longer periods.
- Particularly common among older adults, people with multiple health conditions, and those previously operated on for back issues.
Chiropractic care
- Typically used in short, time‑limited episodes, often just before assessment at the spine center.
- Strongly associated with patients having private health insurance.
- More common among younger individuals and those in employment.
Socioeconomic and demographic factors matter more than the severity of pain
One of the study’s most striking findings is that:
Demographic and socioeconomic factors are stronger predictors of treatment use than pain intensity or functional level.
Examples:
- Women, people with higher education, and people with higher income use treatment more.
- Individuals with non‑Danish backgrounds use treatment less.
- People on sick leave or social benefits use less chiropractic care but, in some cases, more physiotherapy.
- Clinical factors such as pain severity and disability scores showed only weak associations with how much and what type of treatment patients received.
The researchers suggest that this may indicate inequity in access to treatment—even within a tax‑funded healthcare system like Denmark’s.
“A small group has complex needs”
Although most people have little to no contact with healthcare providers, the group with high treatment use tends to have:
- longer‑lasting and complex problems.
- higher levels of comorbidity.
- increased risk of having had surgery and having been on sick leave.
The researchers assess that this relatively small group likely accounts for a significant share of overall healthcare spending for back pain.
May influence future services for back‑pain patients
The study does not compare the effectiveness of treatments but maps usage patterns. This provides valuable knowledge for:
- municipalities planning preventive or rehabilitative services.
- health authorities examining inequality in healthcare use.
- GPs deciding on the most relevant referral options.
- regions considering structured care pathways for back‑pain patients.
The researchers recommend that future studies examine:
- the relationship between treatment patterns and the patients’ future employment status or sick leave.
- the impact of health insurance and out‑of‑pocket costs.
- how new standardized treatment packages affect treatment use.
Conclusion
The study shows that:
- Most patients with severe and long‑standing back pain do not use physiotherapy or chiropractic care regularly.
- A very small group accounts for most of the healthcare use.
- Socioeconomic and demographic factors are more influential than clinical characteristics in determining who receives treatment.
- There are marked differences between who chooses physiotherapy and who uses chiropractic care.
The researchers note that these findings should contribute to discussions about equity in healthcare and future services for people with back pain.
Casper Nim, Jan Hartvigsen, Christian V. Skovsgaard, Alice Kongsted, Aron Downie, Stine Clausen. Physiotherapy and chiropractic healthcare utilization in adults with spinal pain: four-year trajectories of 47,777 Danish individuals. Journal of Public Health 2025.
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