Use of chiropractic, physiotherapy, and municipal rehabilitation before and after secondary care assessment for spinal pain: a Danish cohort study

Introduction: Spinal pain is a leading cause of disability worldwide, yet care pathways often remain fragmented despite international recommendations for integrated management. In Denmark, individuals with spinal pain may be referred to secondary care spine centres for specialised assessment. Objectives: To examine patterns and determinants of chiropractic, physiotherapy, and municipal rehabilitation service use before and after secondary care assessment for spinal pain in Denmark. Methods: We conducted a registry-based cohort study of 48,607 adults assessed at the Spine Centre of Southern Denmark (2016–2021), linking clinical registry data with national health, education, income, and social benefit registries. Healthcare utilisation one year before and after assessment was analysed using Poisson regression to estimate adjusted relative risks (RRs) for continued or new chiropractic and/or physiotherapy use, stratified by municipal rehabilitation referral and adjusted for sociodemographic, socioeconomic, and clinical factors. Results: Previous chiropractic (RR = 4.79, 95% CI 4.52–5.08) and physiotherapy (RR = 2.42, 95% CI 2.31–2.52) use were strongly associated with continued care. Initiation after secondary care was limited (8% chiropractic; 18% physiotherapy), and 37% had no recorded post-assessment care. This proportion corresponds to 17,984 of the 48,607 included patients who had no registered physiotherapy or chiropractic consultations at any point during the 12 months following their secondary care assessment. Lower use was associated with lower socioeconomic status, longer symptom duration, and higher disability. Municipal rehabilitation referral was linked to lower new care initiation but slightly higher continuation rates. Conclusion: Care continuity after secondary spine centre assessment is primarily associated with previous use and socioeconomic factors and varies by municipal rehabilitation referral. Structural and financial barriers may hinder equitable access to recommended conservative care.