Pandemics, while infrequent, necessitate timely communication in order to ensure that the public, along with licensed healthcare providers, have the information needed to keep themselves, as well as others safe. Uncertainty regarding the various aspects of COVID-19 has made it difficult for leaders to forecast the overall effect and generate effective safety recommendations. Some of the state chiropractic boards utilized a format that dramatically improved our ability to discover COVID-19-related information for their respective states. These involved calling the user’s attention, often using a banner or other indicator, to a dedicated website or area of their main website containing consolidated information related to the ongoing COVID-19 pandemic. The dedicated websites provided a single location for licensees, or members of the public, to quickly and easily acquire necessary information. Often the dedicated site provided a summary of the most relevant information while providing hyperlinks to more detailed source information (e.g. governor’s stay-at-home order). Visitors of these websites were encouraged to return regularly to this site for updates and included the date and time the website was last updated; occasionally, newly added information was highlighted to aid in identifying recent changes. These sites were perceived as having the user of the website in mind and were designed to be easily discovered, easily interpreted, and to have maximum overall utility. This model was identified by the authors of this manuscript as a “best practice” when attempting to inform state licensees and the general public about guidance or recommendations. For the majority of states, the authors of this project were left having to search disparate websites to locate fragmented information related to chiropractic practice during the COVID-19 pandemic. Having a single site, with consolidated information, seems to reduce the time required to access key information and ensure that all relevant information is communicated from the licensing body to the licensee.
The COVID-19 pandemic emerged in the midst of a global pain crisis and opioid epidemic, complicating clinical decision making [18]. Chiropractors and other providers must balance a responsibility to limit contagion with their responsibility to provide access to pain management, which some organizations have deemed a fundamental right [19, 20]. The clear need for ongoing pain management, in some form, likely contributed to the nearly universal designation of chiropractors as essential healthcare providers. As portal-of-entry providers, chiropractors can perform triage, evaluation, management, differential diagnosis, deliver treatment, or coordinate necessary referral. There may be advantages to seeking care for musculoskeletal complaints at a chiropractic office as opposed to an emergency department. Such advantages include reduced risk of COVID-19 transmission from those presenting to the ED with upper respiratory symptoms as well as conservation of ED resources.
In the 28% of states where chiropractic was deemed an essential healthcare service, the state chiropractic licensing boards uniformly provided guidance that chiropractic care was to be restricted to urgent, acute, or emergent presentations. The definition of “urgent or emergent” is not entirely clear [21]. Differences in patient [22] and professional [23, 24] perception of what constitutes an urgent or emergent situation could result in variable interpretation and practice behaviors. There are several avenues by which the urgency of a condition may be assessed. Low back pain is one of leading complaints evaluated in U.S. emergency departments, accounting for 4.4% of all visits [25]. A review of more than 40,000 patient visits revealed that 2.5–5.1% of patients required immediate attention for spinal pain complaints. The presence of red flags increases the likelihood that patients may have more urgent or serious conditions, such as fracture, cancer, infection, or vascular complication [26]. One can elicit a history and answers to red flag screening questions via telephone, allowing for triage if red flags are present or reassurance if red flags are absent. Atlas and Deyo cited several reasons to consider in-person evaluation, including the presence of any red flags, the presence of radicular symptoms, persistence of symptoms beyond 2 weeks, or if a patient desires in-person evaluation despite reassurance [27]. Telehealth and triage are not methods traditionally used by chiropractors; however, chiropractors are certainly capable of adapting to provide such services, if permitted. Twenty-two state chiropractic licensing boards supported chiropractic implementing telehealth services, 1 state board recommended against the use of such services, and 27 state boards failed to provide guidance. Without clear guidance from their state board, chiropractors are left with uncertainty regarding appropriate clinical practice in the setting of a public health crisis. Such uncertainty may delay care to the public or place the provider at risk of disciplinary action if utilizing a service that is not recommended.
The COVID-19 pandemic represents a global health crisis where there are currently no effective vaccines, treatments, or cures [28]. Therefore, public health measures aimed to minimize the transmission of this viral pathogen, such as practicing good hand hygiene, maintaining physical distancing, and wearing face masks lie at the heart of limiting the spread of this condition. Reports of reduced susceptibility to or recovery from infectious disease following spinal manipulation surfaced during the 1918 influenza pandemic [29,30,31]. Interest in such a connection has persisted in segments of the chiropractic and osteopathic professions over the past 100 years [32, 33]. Research investigating the relationship between spinal manipulation and immune function has been limited to basic science (non-clinical) studies, involving small sample sizes, and deemed insufficient to validate such claims [34,35,36,37,38]. As the world struggles with a novel virus that has no known treatment or cure, notions of immunomodulation through spinal manipulation have resurfaced on social media, which led to national and international chiropractic organizations providing guidance to their membership. Currently, the American Chiropractic Association (ACA), the International Chiropractic Association (ICA), and the World Federation of Chiropractic (WFC) have all issued statements indicating there is no evidence that spinal manipulation/adjustments have been shown to influence the prevention or treatment of COVID-19 [33, 38, 39]. Additionally, “a united statement of the global chiropractic research community against the pseudoscientific claim that chiropractic care boosts immunity” was signed by approximately 150 researchers [28]. At the time of our data collection only 16% of state boards of chiropractic had made statements regarding false, deceptive, or misleading statements. It is unclear why the majority of state boards had not chosen to issue statements, but that may change as the pandemic progresses and such claims continue to attract unfavorable media attention. Infection rates have differed drastically from state-to-state which may have impacted decision making and resulted in variability regarding the content and timing of board guidance.
