Chiropractic’s Cost Effectiveness

The Manga Study – A Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain

1. Pran Manga, Ph.D. 1
2. Douglas E. Angus, M.A.2
3. Costa Papadopoulos, MHA3
4. William R. Swan, B.Comm.4

August 1993
1. Professor and Director, Masters in Health Administration Program, University of Ottawa; and President, Pran Manga and Associates Inc., Ottawa.
2. Adjunct Professor, University of Ottawa and Project Director, The Cost-Effectiveness of the Canadian Health Care System, Queen’s – University of Ottawa Economic Projects. Health Care Consultant and Associate of Pran Manga and Associates, Inc. Consultant in Health Care Economics.

The support of the Ministry of Health, Government of Ontario, which solely funded the project, is gratefully acknowledged. The views and opinions expressed in this report are those of the authors only, and should not be attributed to the MHA Program, University of Ottawa, the Ministry of Health or the Ontario Chiropractic Association.


The Magna Report, commissioned by the Ontario Ministry of Health and prepared by highly respected health economists at the University of Ottawa, represents the largest and most thorough analysis of the scientific literature on low back pain ever. It clearly demonstrates that chiropractic management of low back pain is more effective, more cost effective and produces higher levels of patient satisfaction than other forms of management. The report recommends that chiropractic services in Ontario be fully funded by OHIP and be fully integrated into the health care system, including hospitals. The following is a summary of the report.


The serious fiscal crisis of all governments in Canada is compelling them to contain and reduce health care costs. It has brought a new and unprecedented emphasis on evidence-based allocation of resources, with an overriding objective of improving the cost-effectiveness of health care services.

The area of low-back pain (LBP) offers governments and the private sector an excellent opportunity to attain the twin goals of greater cost-effectiveness and a major reduction in health care costs. Today LBP has become one of the most costly causes of illness and disability in Canada – a phenomenon which does not appear to be generally appreciated or understood in medical and government circles in Canada. Studies on the prevalence and incidence of LBP suggest that it is ubiquitous, probably the leading cause of disability and morbidity in middle- aged persons, and by far the most expensive source of workers’ compensation costs in Ontario – as indeed in most other jurisdictions.

Much of the treatment of LBP appears to be inefficient. Evidence from Canada, the USA, the UK and elsewhere shows that there are conflicting methods of treatment, many with little – if any scientific evidence of effectiveness, and very high costs of treatment. Despite this, levels of disability from LBP are increasing.

In the Province of Ontario LBP is managed mostly by physicians and chiropractors, with physiotherapists also playing a significant role. While medical services are fully insured under Medicare, chiropractic care services are only partially covered. LBP patients incur the highest out-of-pocket expenses for chiropractic services. Virtually no out-of-pocket expenses are incurred for medical treatment, with the exception of drugs, and out-of-pocket expenses incurred for physiotherapy services fall somewhere in between the two.

Medical physicians, chiropractors, physiotherapists and an assortment of other professionals together offer about thirty-six therapeutic modalities for the treatment of LBP. In this study we focused principally on the effectiveness and cost effectiveness of chiropractic and medical management of LBP.


F1. On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP. Many medical therapies are of questionable validity or are clearly inadequate.

F2. There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low-back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic complications for LBP patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low-back pain.

F3. While it is prudent to call for even further clinical evidence of the effectiveness and efficacy of chiropractic management of LBP, what the literature revealed to us is the much greater need for clinical evidence of the validity of medical management of LBP. Indeed, several existing medical therapies of LBP are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal m