[caption id="attachment_73490" align="aligncenter" width="500"] Pexels[/caption] Spinal manipulation has moved from contested intervention to first-line non-pharmacologic recommendation for several musculoskeletal conditions. The shift is documented in major clinical guidelines, supported by Cochrane reviews, and reinforced by comparative effectiveness data showing favorable risk profiles relative to standard pharmacologic care. The clinical question for primary care has changed from whether to consider chiropractic referral to which patients benefit most and what selection criteria identify evidence-based providers. The 2017 American College of Physicians clinical practice guideline placed spinal manipulation among the recommended first-line treatments for acute, subacute, and chronic low back pain, alongside heat, exercise, and acupuncture. Subsequent updates and parallel guidelines from the United Kingdom's NICE, the Canadian Chiropractic Guideline Initiative, and the Lancet Low Back Pain Series Working Group have reinforced the same position.