Chiropractors torn between patient care and research roles in trial, study finds

Chiropractors who signed up to help run a clinical trial on neck manipulation in Norwegian primary health care found themselves pulled between three competing loyalties: their patients, the research protocol, and their own livelihoods. A qualitative study published in Chiropractic & Manual Therapies on 1 October 2026 describes how 15 chiropractors acting as clinician co-researchers navigated these conflicting obligations, often at real personal and financial cost, and highlights how poorly supported clinician-researchers are in primary care settings.

The study, led by Anna Allen-Unhammer, Nina Køpke Vøllestad and Anne Marit Mengshoel, examined the experiences of chiropractors enrolled in a multicentre randomised trial (ClinicalTrials.gov identifier NCT05374057) testing spinal manipulation of the neck for acute neck pain. Participants in that trial were randomised to spinal manipulation, sham manipulation, ibuprofen, or placebo medicine. The chiropractors involved agreed to screen, enrol and randomise eligible patients, and to deliver the allocated treatments themselves, without reimbursement. Patients were asked to avoid other therapies during the 14-day intervention period before seeking additional care.

To understand what this dual role felt like from the inside, the researchers conducted five virtual focus group interviews between August and November 2023. All 43 chiropractors active in the trial until June 2023 were invited by telephone, and 15, or 35 percent, agreed to take part; none dropped out. The participants were a heterogeneous group of five men and ten women aged 32 to 59, with clinical experience ranging from 6 to 34 years. Four practised in rural areas and eleven in urban settings, and eleven worked in multidisciplinary clinics alongside general practitioners, physiotherapists or osteopaths. The interviews lasted between 60 and 90 minutes, and the analysis followed a thematic approach underpinned by social interactionism, a framework that treats people’s actions as rooted in the meaning a situation holds for them, continuously reshaped through interactions with others.

Motivation to join the trial ran deep. The chiropractors wanted to contribute to professional development and to build evidence on spinal manipulation for acute neck pain, a goal sharpened by public scepticism amid a media debate about the risks of neck manipulation. They were aware of the shortage of high-quality, clinically relevant evidence and saw a well-designed trial as necessary in an era of evidence-based practice. One informant described the study as “spot on”, saying there was far too little research on neck manipulation and that the trial spoke directly to what chiropractors do in the clinic every day. Some hoped the results would support the safety of spinal manipulation, counteract what they saw as recurrent scaremongering, show greater effectiveness than painkillers, and even influence national guidelines for acute neck pain.

Yet the realities of recruitment proved far harder than anticipated. The chiropractors had expected plenty of patients with acute neck pain but found few, realising their practices mostly saw chronic or episodic cases. Many potential participants failed the inclusion criteria because of age, language barriers or comorbidities. A recurring surprise was that patients with acute neck pain typically delayed seeking care longer than those with acute low back pain, often exceeding the trial’s definition of acute neck pain as onset within the previous 14 days, which the clinicians linked to patients perceiving neck pain as less disabling. Patients who learned about the study through newspapers or social media were more often eligible and willing, while those without prior knowledge commonly declined, fearing that randomisation would delay what they considered real treatment.

Randomisation itself was a stumbling block. Many patients balked when they learned they might be assigned to a medicine group rather than manipulation, particularly if they had already tried painkillers without benefit or disliked them. Some patients wanted a quick fix, including self-employed fishermen needing a rapid return to work and patients with employer-funded insurance who felt pressured to recover quickly. Even when patients were eligible and willing, clinicians sometimes chose not to recruit them because of their own time constraints, economic pressures and concerns about disrupting established patient relationships. Although they had known participation was unpaid, the unexpectedly long recruitment period created financial strain, with one informant noting that calculating the cost of being a co-researcher added up to a lot of money.

The most morally fraught element was delivering sham manipulation. Most clinicians found it morally problematic that sham treatment could delay a patient’s recovery and felt dishonest in the process. One said they felt very false, as if lying to the patient and withholding the help the patient needed. The difficulty intensified over five consecutive sessions, because sham manipulation took noticeably less time than a typical consultation, making the façade harder to maintain. Some clinicians responded by simply not recruiting patients at all. Others managed the discomfort by deferring to the protocol, telling patients that the protocol said the session was over. Dispensing pill boxes of placebo medicine was perceived as less awkward, involving a single visit and minimal personal interaction.

To cope, the chiropractors developed their own strategies, some of which carry scientific consequences. Several created their own informal inclusion criteria, for example inviting only new patients naïve to spinal manipulation, who would find sham treatment more convincing. This protected patient relationships and reputations but risks selection bias and threatens the representativeness of a trial, a problem the authors note is common among clinician-recruiters. Recruitment also threatened the clinicians’ standing in their communities, particularly for those with newly established clinics, who worried that dissatisfied participants assigned to sham treatment might not return or recommend them to friends and family. Some worked through lunch breaks, after hours or at weekends to recruit without disrupting regular patients, sacrificing their own free time.

The authors argue that these tensions are amplified in primary health care compared with hospitals. Large hospitals have the infrastructure, routines and employed positions that support research and distribute recruitment and intervention delivery across teams, buffering individual clinicians from the consequences of patients’ trial experiences. In primary care, by contrast, responsibility for recruitment and delivery of relational interventions like spinal manipulation falls largely on individual self-employed clinicians, who have limited tools to mitigate the dilemmas of trial design and must devise their own solutions. The authors recommend large-scale media promotion of trials by researchers and their institutions, reduced administrative burden, reimbursement for clinician-researchers, and strengthened research support systems in primary care.

The study’s conclusions rest on a small, self-selected sample: 15 of 43 eligible chiropractors, recruited by convenience, with reasons for non-participation not collected, and one focus group containing only two participants. The authors nonetheless consider the material to have sufficient information power, given the deliberate mix of participants who had recruited many, few or no trial participants, and they argue the findings are probably transferable to other primary care clinicians. Their broader message is that participating as a co-researcher in primary care is a social and relational activity in which clinicians act as moral agents, shifting loyalties between trial, patient and business depending on the situation. Better support systems, they conclude, will require political and organisational will to give researchers and clinical co-researchers the backing they currently lack.

Subject of Research: Chiropractors' experiences of balancing clinician and co-researcher roles in a primary care clinical trial on spinal manipulation for neck pain

Article Title: Between a rock and a hard place: balancing roles of clinician and co-researcher in a primary health care setting – A qualitative study

Article References: Allen-Unhammer, A., Vøllestad, N. K., & Mengshoel, A. M. (2026). Between a rock and a hard place: balancing roles of clinician and co-researcher in a primary health care setting – A qualitative study. Chiropractic & Manual Therapies, 34(1), Article 55. https://doi.org/10.1186/s12998-026-00681-9

Image Credits: AI Generated

DOI: 10.1186/s12998-026-00681-9

Keywords: chiropractic, primary health care, clinical trials, qualitative research, spinal manipulation, sham intervention, patient recruitment, research ethics, neck pain, co-researchers, focus groups, Norway