A core function of healthcare providers is to limit the spread of COVID-19, both within their practice settings and through the promotion of evidence-based public health information. Variations in jurisdictional mandates for infection control will vary between regions, including in response to the ongoing regional changes in pandemic circumstances. This study primarily investigated the COVID-19 public health response of practicing chiropractors broadly (independent of specific regional standards at the time of data collection) and examined if paradigm predicts awareness and implementation of COVID-19 public health standards. Our study found that a substantial percentage of responding chiropractors, internationally, adopted a range of COVID-19 infection control measures in their practice settings and promoted COVID-19 public health information to their patients, to help reduce disease spread. These activities have the potential to assist wider government efforts to reduce the impacts of the pandemic on society. In addition, our findings show that the COVID-19 pandemic has had a substantial impact on the business and finances of chiropractors.
The infection control measures initiated by participants include increased disinfecting of practice areas and treatment equipment, increased personal hand sanitising, provision of patient hand sanitiser and the implementation of patient social distancing. The infection control measures used by respondents were mostly consistent with the information/resources advised by their professional regulatory bodies [15, 16] and this appears consistent with advice from government authorities and public health agencies (World Health Organisation and Centers for Disease Control and Prevention) [17, 18].
Interestingly, a much lesser percentage of Hong Kong chiropractors who participated reported implementing patient social distancing, changing the spacing of patient bookings and restricting patient care to emergency cases. While professional regulator links to government health directives in Hong Kong had included advice on social distancing  we speculate that these findings may reflect a comparatively reduced concern overall by Hong Kong practitioners at this early time point when the COVID-19 outbreak had been less severe to date and where no widespread government directed lockdowns nor stay-at-home orders had yet occurred.
The majority of participants reported implementing all the advised use of PPE provided by their respective government and/or health regulator. However, this majority was smaller for Australian (59%) and US (70%) chiropractors, which appears to suggest that chiropractors in these countries were more inconsistent in their approach to PPE recommendations despite recommendations made by health authorities [20,21,22] and major chiropractic professional associations providing links to COVID-19 health advice [23,24,25]. The low number of COVID-19 cases in Australia may be one reason for the relatively lower levels of PPE implementation by Australian chiropractors . In addition, government advice on mask use at US state and federal levels has likely been more conflicting [27,28,29] and research has identified that this has influenced the level of mask use in different US regions . Since, primary healthcare professionals in close physical contact with patients have an increased risk of COVID-19 cross infection without the appropriate use of PPE [3, 30], more research is needed to better understand the factors that influence the use of PPE by chiropractors, including the potential influence of contextual factors, such as the mainstream and social media [31, 32].
Our study found that the overall use of telehealth by chiropractors rose to one in four (26%) compared to one in twenty (5%) before the COVID-19 pandemic began. While this increase may be considered substantial for a profession that has traditionally relied on doing things 'by hand', by comparison, a near tenfold uptake of telehealth has been reported within other healthcare professions, such as medicine [33, 34] and physiotherapy . Limited information does suggest that many chiropractors may have concerns that patient needs will not be met through telehealth . However, evidence suggests the effectiveness of telehealth may be comparable to standard care for the management of spinal pain and other musculoskeletal conditions [37,38,39,40]. Importantly, many of the telehealth patient management strategies identified encompass approaches to patient care that appear to be commonplace within chiropractic settings, including patient education, advice on physical exercise, stress management, coping strategies and the use of pain medications [9, 41]. Our study findings also identified substantial regional variations in the use of telehealth. These variations may reflect differences in the occurrence of stay-at-home orders and closure of non-essential businesses between countries. For example, substantial periods of stay-at-home orders had occurred in the UK where the highest use of telehealth was reported (45%), while Australia (except for one state)  and Hong Kong  had experienced limited stay-at-home orders where the lowest use of telehealth was reported, at 12% and 1%, respectively. However, given and the knowledge that patients report telehealth appointments as helpful in addressing their concerns while providing a greater protection from COVID-19 transmission , more studies are needed to understand the limited comparative uptake of telehealth by chiropractors.
Chiropractors participating in the study were divided on whether the public health procedures for manual therapy practitioners warranted independent guidelines to those needed for other healthcare professionals, as found for dental settings . Future research may therefore be needed to understand if chiropractors, and other manual therapy providers, present unique risks to the spread of infectious diseases. Such concerns have contributed, in-part, to the development of a recent guideline, led by chiropractic researchers, for the management of spinal disorders without face-to-face patient consultation in periods of mandated social distancing during a pandemic . These guidelines advocate for patient consultation through telehealth for the management of uncomplicated spinal pain as well as providing practitioner guidance on the triage of patients with more serious underlying diseases.
More than 80% of surveyed chiropractors reported providing patients with public health information on COVID-19 infection control measures. This included during routine patient consultations, patient phone calls and through placing COVID-19 brochures and posters within their practice environment. The provision of reliable and accurate public health information by trusted healthcare professionals can improve patient protection from COVID-19 infection  and reduce confusion caused by COVID-19 misinformation  that undermines health authority advice, including scientifically proven treatments [49, 50]. Most chiropractors in our study identified recognised government agencies and professional bodies as their most trusted sources when seeking COVID-19 public health information. However, a smaller number of chiropractors have made claims on social media that chiropractic spinal manipulation reduces the adverse impact of COVID-19 [11, 12, 14], claims that appear to conflict with current clinical research evidence [51, 52]. In response, leaders of the chiropractic research community , chiropractic regulatory bodies [15, 16] and chiropractic professional associations [54,55,56,57] have made efforts to redress such claims within the profession.
Our study substantiated that the COVID-19 pandemic has had considerable negative impacts on the business and finances of chiropractors, which concurs with findings reported for other healthcare professions [5, 6]. Overall, nearly half of the participants reported a complete suspension of face-to-face patient care (49%) and around one in four (26%) reported a ≥ 50% decrease in face-to-face patient care during the peak of the pandemic. Additionally, around two-thirds reported needing to seek financial assistance because of their loss of income during the pandemic. However, practice suspension varied between countries, with the highest levels occurring in the UK (78%) and Canada (65%) and least in Hong Kong (1%) and Australia (11%). The relatively high proportion of chiropractors reporting a ≥ 50% decrease in face-to-face patient care could be attributed primarily to the responses from the UK and Canada. Findings also suggest seeking financial assistance was more frequent in those regions where a higher-level face-to-face patient care had ceased during the peak of the COVID-19 outbreak. Financial and employment uncertainty has been identified as an important contributor to healthcare workers’ stress and burnout during the COVID-19 pandemic [58,59,60]. In these circumstances, resolving the struggle of risking life or livelihood may not be an easy decision for many healthcare practitioners. However, the timely provision of government financial support, without discrimination or delays, is vital to healthcare practitioners during such rapidly changing employment conditions to help balance the potentially competing demands of business survival with adherence to public health policy objectives.
The practice paradigm study variable as operationalized in our survey did not allow the option for participants to self-select identifying with both paradigms in more equal measure, although chiropractors can practice under both paradigms as has been reported in other studies [61,62,63]. For public health responses collected in this study, participants who self-reported practising under a musculoskeletal spine-care paradigm differed from those reporting more closely practising under a chiropractic subluxation-based paradigm. This includes being more likely to adopt telehealth, demonstrate greater knowledge of regulator recommendations on the use of PPE, implement regulator advice on the use of PPE and not increase their face-to-face care during the peak of the COVID-19 outbreak. Since our study also found musculoskeletal spine-care chiropractors are more likely not to practice in a sole practitioner setting and are more likely to practice in multidisciplinary settings, it may be that multidisciplinary clinical settings foster greater knowledge translation of evidence-based public health initiatives. Such a finding has been identified in previous research , including for the control of COVID-19 infection .
Musculoskeletal spine-care chiropractors were also more likely to trust COVID-19 public health information provided by government, public health authorities and professional associations/boards—information sources with key responsibilities toward disseminating COVID-19 information based on current scientific consensus. This finding may also help to explain why musculoskeletal spine-care chiropractors are more likely to be aware of and implement certain COVID-19 infection control measures when compared to subluxation-based practitioners. It is vital that all chiropractors remain up to date with the advice provided by recognised health authorities to protect themselves and the public they serve during infectious disease outbreaks.
While our study identified that subluxation-based chiropractors constitute a smaller percentage of practitioners, more research is needed to understand how self-report practice paradigms may influence the public health knowledge and behaviours of chiropractors. Findings from this research may assist any knowledge translation strategies or infection control training for chiropractors if necessary to reduce the risk of communicable disease transmission, such as COVID-19, within chiropractic settings .
Strengths and limitations
The study is the first chiropractic COVID-19 study to be conducted across several international regions. However, this study has several limitations. Self-reported data collection is subject to recall bias which may be further influenced by the timing of the survey relative to the previous peaks COVID-19 spread in the different countries. Those who self-selected to participate in the study may be different to non-participants and there is a risk of social desirability bias in the answers provided by those who did participate. The generalizability of the study is unknown because it was not possible to report the survey response rate accurately with an unknown number of chiropractors who viewed the survey preventing a precise assessment and acknowledge that the raw data should not be assumed to be representative of the greater population. This includes how often the survey was shared via social media connections and through personal emails and because the survey was not shared as a single email message, but most often embedded within another email within other online pages of information by chiropractic associations and professional online magazine. The reasons for why some chiropractors choose to participate and others did not, and the reasons for why some participants only partially completed the survey is unknown [67, 68]. There are many reasons why an individual may choose to not participate in this type of research. While difficult to speculate, we imagine some of these reasons may include: time constraints; forgetting to complete the survey or distraction, inadequate internet access, lack of interest in the topic; negative views toward COVID-19 or survey questions; concern about the security or confidentiality of the information that might be revealed during the survey; distrust of the motives of the researchers undertaking the survey; disinterest due to lack of direct personal benefit from participation (e.g., perceived value of the time necessary to complete the survey does not the outweigh the perceived potential benefit).
Further, representativeness of the sample is unknown because there was no reliable demographic information for chiropractors in most countries surveyed, hence non-response bias was unable to be measured. Response bias may exist because the survey dissemination was limited to those with email and internet access and to members of the professional associations and subscribers of the professional magazine utilised for the survey distribution and the unequal representation of participants across geographical regions and regulatory frameworks. Aside from face validity, items in this survey have not been assessed for their property measurements, including the question used for the identification of practice paradigm, which was limited to only three options i.e., those more closely musculoskeletal or subluxation-based, or neither. This leaves the possibility of additional paradigm subgroups to exist that are not accounted for in this study, such as chiropractors who practice more equally under both paradigms. This lack of choice may have impacted our response rate and representativeness of our survey since our respondents may not sufficiently represent the true self-identity professed by some practitioners within the general chiropractic population, as reported in other studies [61,62,63]. Therefore, the differences found between paradigms must be interpreted with considerable caution. While it was beyond the scope of this study to report on the exact mandates within each jurisdiction, this study has examined practitioner’s perceptions of what mandates were important to them and how they responded.