Chiropractic is one of the most widely used — and most litigated — forms of alternative medicine in the United States. In New Jersey alone, there are roughly 2,000 licensed chiropractors, and the industry has fought aggressively in courtrooms and legislatures to expand its legal status, secure insurance reimbursement, and position itself on equal footing with medical doctors. In a previous post, I examined the legal status of homeopathy in New Jersey. Chiropractic raises many of the same questions — and some that are uniquely its own.
This post examines what the science actually says about chiropractic, why it remains legal and insurance-covered despite persistent scientific controversy, and how New Jersey courts and regulators have shaped the profession’s reach over the years.
Origins of Chiropractic
Chiropractic was founded in 1895 by Daniel David Palmer, a magnetic healer from Iowa who claimed he received the practice’s core principles from the spirit of a deceased physician. Palmer’s central theory was that nearly all disease originates from “vertebral subluxations” — misalignments of the spinal vertebrae that he believed interfered with the body’s “innate intelligence” flowing through the nervous system. Adjust the spine, the theory went, and you restore the body’s natural healing power.
The problem is that the chiropractic subluxation, as defined by Palmer and his followers, has never been demonstrated to exist. It is distinct from the orthopedic concept of a subluxation — which refers to a partial dislocation of a joint that is visible, measurable, and clinically meaningful. The chiropractic subluxation is a metaphysical concept rooted in vitalism, not anatomy. No peer-reviewed study has ever established that spinal “nerve interference” from a subluxated vertebra causes organic disease.
This foundational problem has never been resolved. The chiropractic profession remains deeply divided between “straight” chiropractors who still adhere to Palmer’s subluxation theory and “reform” or evidence-based chiropractors who limit their practice to neuromusculoskeletal conditions like back pain and neck pain.
What the Evidence Actually Shows
To be fair to the evidence-based faction of the chiropractic profession, there is legitimate support for spinal manipulation as a treatment for specific musculoskeletal complaints. Some studies have found spinal manipulation to be a reasonable option with modest benefit for low back pain in some patients. That is a significant but narrow finding. It does not validate chiropractic as a system of medicine. It does not support the claim that spinal manipulation treats asthma, ear infections, colic, high blood pressure, or any of the other conditions that many chiropractors continue to market for treatment. Systematic reviews have consistently found no reliable evidence that chiropractic care is effective for conditions other than certain types of back and neck pain — and even there, the benefit is modest and comparable to physical therapy.
More concerning is the safety profile. High-velocity neck manipulation — the kind involving a rapid twisting motion of the cervical spine — carries a known risk of vertebral artery dissection, a tear in the artery wall that can cause stroke. The risk is low in absolute terms but not negligible, and the potential modest benefit does not outweigh the significant risk of injury.
Chiropractic Versus the American Medical Association
The same question I asked about homeopathy applies here: if the foundational science is so contested, why is chiropractic not only legal but actively reimbursed by health insurance and Medicare?
The answer is largely historical and political. Chiropractic has been licensed in all 50 states since the 1970s, the result of sustained lobbying over nearly a century. In 1972, Congress amended the Social Security Act to include chiropractic services under Medicare — but only for spinal manipulation for back conditions, a limitation that chiropractors have fought to expand ever since. The American Medical Association declared chiropractic an “unscientific cult” in 1966 and advised its members that associating with chiropractors was unethical. That posture backfired legally when, in 1987, a federal court found in Wilk v. American Medical Association that the AMA had engaged in an unlawful conspiracy to restrain trade — essentially, an illegal boycott of a competitor. The AMA’s aggressive opposition to chiropractic, whatever its scientific merit, had crossed the line into an antitrust violation as far as the court was concerned. The Wilk case is a stark reminder that scientific fact and consensus versus the search for truth in a courtroom are vastly different concepts. In other words, the legal merit of the Wilk case did not depend on whether chiropractic was a scientifically sound medical discipline. Rather the case turned on varying factors that have nothing to do with the scientific method, including US antitrust law, the ability of the lawyers involved, the biases and ability of the few judges involved, the burden of proof in a civil case (often described as “more likely than not”), the law and court rules governing expert testimony (which has created “experts” that only exist in courtrooms), the rules of evidence, and the truthfulness and likeability of the witnesses.
To summarize, the Wilk decision did not validate chiropractic science. It simply established that the AMA could not use coordinated institutional pressure to drive chiropractors out of business. The practical effect, however, was to legitimize chiropractic further in the eyes of insurers, regulators, and the public.
New Jersey: The Fight for Insurance Reimbursement
New Jersey has been a significant battleground for chiropractic insurance reimbursement. The state’s largest health insurer, Horizon Blue Cross Blue Shield of New Jersey, became the target of a class action lawsuit brought on behalf of thousands of NJ chiropractors.
The case, DeMaria et al. v. Horizon Healthcare Services, Inc., centered on Horizon’s practice of “bundling” chiropractic claims. When a chiropractor provided chiropractic manipulative therapy (CMT) together with evaluation and management services (E/M) or physical therapy (PT) during the same visit, Horizon automatically denied payment for the E/M and PT, folding everything into a single global fee for the CMT — regardless of what services were actually rendered.
In 2009, following a regulatory complaint by the Association of New Jersey Chiropractors (ANJC), the New Jersey Department of Banking and Insurance (DOBI) declared Horizon’s bundling practice a violation of New Jersey’s Unfair Claim Settlement Practices Act, and issued a cease and desist order effective 2010. The class action lawsuit, filed in 2011, sought damages for the period before the DOBI order — from December 2005 through April 2010.
In June 2015, a federal court certified two classes of chiropractors — an ERISA class and a non-ERISA class — covering over 9,500 practitioners whose claims had been systematically denied. In 2016, Horizon agreed to a $33 million settlement, one of the largest ERISA benefit class action settlements involving healthcare providers in the country at that time.
DeMaria was not an isolated case. New Jersey chiropractors also obtained a significant settlement against CIGNA Insurance and American Specialty Health Network (ASHN) over out-of-network reimbursement practices. That matter resulted in an $11.75 million settlement, with a former president of the Association of New Jersey Chiropractors serving as the lead out-of-network plaintiff.
The DeMaria case established an important precedent: an insurer’s systematic denial of provider claims based on an undisclosed internal bundling policy can be challenged as a class action under both ERISA and New Jersey contract law. As with the Wilk case, it is important to keep in mind that DeMaria the CIGNA cases had nothing to do with the scientific merit of chiropractic.
Are Chiropractors Equal to Medical Doctors Under New Jersey Law?
Chiropractors have long sought to be treated as equivalent to physicians under the law — particularly in the context of expert witness testimony, scope of practice, and professional titles. New Jersey law draws a clear but sometimes contested line.
Under N.J.S.A. 45:9-14.5, the practice of chiropractic in New Jersey is defined as a philosophy, science, and healing art focused on the reduction of chiropractic subluxation and the examination, adjustment, and treatment of the articulations and soft tissue of the body. Chiropractors in New Jersey may use the title “doctor” but it must be qualified with the words “doctor of chiropractic,” “chiropractor,” or “chiropractic physician,” or the abbreviation D.C. Critically, chiropractors cannot prescribe medications, perform surgery, or conduct endoscopy. When a patient’s condition falls outside the scope of chiropractic, the chiropractor is required to refer the patient to a licensed physician.
Chiropractors as Expert Witnesses: The Permanency Certification Problem
The question of whether a chiropractor qualifies as a “physician” under New Jersey law is not merely academic. It has significant practical consequences in personal injury litigation — particularly in automobile accident cases governed by the Automobile Insurance Cost Reduction Act (AICRA), N.J.S.A. 39:6A-8.
Under AICRA’s verbal threshold provision, a plaintiff who has selected the limitation on lawsuit option cannot sue for pain and suffering unless they can demonstrate, among other things, that they have sustained a permanent injury. To survive a defense motion for summary judgment on that issue, the plaintiff must provide a certification from a “licensed, treating physician” asserting that a permanent injury was sustained. The question of whether a chiropractor qualifies as a “physician” for that purpose produced a sustained split in the New Jersey courts.
Early opinions struggled with the definitional ambiguity. In Pensabene v. Straus, 342 N.J. Super. 196 (Law Div. 2001), the court noted that the definitional portion of the verbal threshold statute is confusing and relied on how other courts had construed “physician” in other statutory contexts — concluding that it would be unjust to deprive an injured plaintiff of their claim simply because they chose to treat with a chiropractor rather than a medical doctor. Olarte v. Crocker, 380 N.J. Super. 203 (Law Div. 2002), reached the same conclusion by reasoning that since chiropractors were not specifically excluded from the statutory definition, the legislature must have intended to include them.
Those conclusions were challenged in subsequent unpublished opinions by a trial judge who took a more textually rigorous approach. In Afram v. Heller, the trial judge reasoned that chiropractors are not permitted to diagnose or treat the systems and conditions that physicians are trained and licensed to address, and that they lack the authority to administer the objective diagnostic tests — such as MRI interpretation — that the AICRA statute requires before a permanency opinion can be rendered. A chiropractor, on that view, cannot produce the foundational clinical work that a permanency certification is supposed to represent.
The Appellate Division resolved the split by siding with the more permissive line of cases, holding in Afram v. Heller that a chiropractor’s permanency certification is sufficient to survive a summary judgment motion under AICRA. That holding, combined with the Supreme Court’s decisions in Serrano and DiProspero — which reduced the plaintiff’s burden on the subjective impact element of the verbal threshold — significantly shifted the balance in favor of plaintiffs in automobile injury litigation.
The Accutane Problem: Why the Science Should Matter in Court
The Afram holding sits in uncomfortable tension with a more fundamental question that the court never confronted: what is the scientific basis for treating a chiropractor’s opinion on permanent injury as reliable expert testimony in the first place?
In the case In re Accutane Litigation, 234 N.J. 340 (2018), the New Jersey Supreme Court adopted Daubert-based reliability principles for expert testimony in civil cases. Under that standard, a trial court acts as a gatekeeper whose responsibility is to assess whether an expert’s opinion is grounded in “sound, adequately-founded scientific methodology involving data and information of the type reasonably relied on by experts in the scientific field.” Mere credentials are not enough. The methodology itself must be reliable. Where it is not, the expert opinion is inadmissible.
That standard creates a serious problem for chiropractic expert testimony that courts have largely chosen to ignore. Consider what the scientific record actually establishes. The foundational theory of chiropractic — that vertebral subluxations interfere with the body’s innate intelligence and cause disease — has no support in peer-reviewed science. The best available evidence for the practice’s most defensible application, spinal manipulation for back and neck pain, shows efficacy roughly comparable to physical therapy. That is not a fringe critique of chiropractic; it is the mainstream scientific consensus.
Now apply the Accutane standard to that baseline. If a physical therapist were to take the stand in a personal injury case and offer an opinion that a car accident caused a plaintiff’s permanent spinal injury, that testimony would not survive a gatekeeping motion. Physical therapists are not licensed to diagnose, cannot interpret imaging studies, and are not trained in the clinical evaluation of permanent impairment. No plaintiff’s attorney would seriously propose calling a physical therapist for that purpose, and no court would permit it. The evidentiary logic is straightforward: the witness’s training and methodology do not support the opinion being offered.
If chiropractic’s evidence base is genuinely comparable to physical therapy for the conditions at issue — and the scientific literature says it is — then there is no principled reason to reach a different conclusion for a chiropractor’s permanency opinion. A chiropractor in New Jersey cannot interpret MRI films, cannot prescribe medications, and cannot perform the diagnostic workup that a meaningful permanency evaluation requires. The opinion rests on a clinical foundation that is, at best, no more rigorous than what a physical therapist could offer.
The Afram court did not engage with this problem because it was resolving a question of statutory interpretation, not evidentiary reliability. The question before it was whether the AICRA statute’s use of the word “physician” included chiropractors — and the court answered that question yes, largely on the grounds that excluding chiropractors would be unjust to plaintiffs who chose to treat with one. That is a pragmatic policy judgment, not a scientific one. And it has the effect of bypassing the gatekeeping function that Accutane subsequently demanded.
The result is a structural inconsistency in New Jersey civil litigation. In a toxic tort or product liability case, plaintiffs’ experts must demonstrate that their methodology meets a rigorous reliability standard or face exclusion. In an automobile personal injury case, a chiropractor’s certification of permanent injury — resting on a professional framework whose foundational theory has no scientific validity — is treated as legally sufficient to defeat summary judgment. The same New Jersey court system that demands sound scientific methodology in one context has, in another, institutionalized a workaround that insulates chiropractic opinions from that scrutiny entirely.
That inconsistency has real consequences. Defense attorneys in automobile injury cases would be well-served by exploring whether Accutane’s reliability principles can be used to challenge the admissibility of chiropractic expert testimony at the trial level, even where Afram controls the certification question at summary judgment. The two analyses are not the same: Afram addresses whether a chiropractor’s certification is sufficient under AICRA as a matter of statutory interpretation; Accutane addresses whether the underlying expert opinion is scientifically reliable enough to be placed before a jury.
The Ongoing Push to Expand Scope of Practice
The chiropractic industry in New Jersey has pursued legislative expansion of its scope of practice over the years. A significant legislative effort, led over a five-year period by the ANJC’s legislative chairman, resulted in an expanded Chiropractic Practice Act signed into law by Governor Jon Corzine — the first expansion of the scope of chiropractic practice in New Jersey in 57 years. The same effort produced the first Licensed Chiropractic Assistant legislation in the United States, later signed into law by Governor Chris Christie.
These expansions are significant because they reflect the chiropractic profession’s sustained political strategy: use the legislature and the courts to steadily widen the boundaries of what chiropractors are permitted to do, regardless of whether the underlying science supports those expanded claims.
Final Thoughts
Chiropractic occupies an unusual position in American healthcare: a profession with a pseudoscientific foundation that has nonetheless secured legal standing, insurance coverage, and political influence through a century of determined advocacy. Some of what chiropractors do — spinal manipulation for back pain — has legitimate, if modest, evidence behind it. Much of what the profession claims beyond that does not.
New Jersey’s legal landscape reflects this tension at every level. Courts and regulators have pushed back against insurance abuse while simultaneously expanding the profession’s legal footprint through legislation. And in the personal injury context, the courts have allowed a statutory interpretation decision — Afram — to effectively shield chiropractic expert opinions from the scientific reliability scrutiny that In re Accutane demands of every other category of expert testimony in civil litigation. A profession whose best-supported application is comparable in efficacy to physical therapy has been granted, through a combination of statutory ambiguity and judicial pragmatism, an expert witness status that the science does not justify.
Consumers are best served by approaching chiropractic with the same critical eye they would apply to any healthcare decision: ask what the evidence says, understand the limits of the treatment, and consult a licensed physician for any condition that may require diagnosis or medical management.
