Changes to Chiropractic Practice in Response to COVID-19: a survey of all 50 United States

Shawn M Neff (  shawn.neff@va.gov ) Martinsburg VA Medical Center https://orcid.org/0000-0002-8979-8260 Christopher B Roecker Veterans Affairs Nebraska-Western Iowa Health Care System Casey S Okamoto Minneapolis Veterans Affairs Medical Center Samuel L Holguin Martinsburg VA Medical Center Jason G Napuli St Louis Veterans Affairs Health Care System Ross Mattox St Louis Veterans Affairs Health Care System Nathan A Hinkeldey Veterans Affairs Central Iowa Health Care System David J Paris VA Northern CA Health Care System


Introduction
In December 2019, a novel coronavirus (SARS-CoV-2) was identi ed as it spread within China and described as causing coronavirus disease 2019 (COVID- 19). This infectious disease spread quickly around the globe; the World Health Organization declared COVID-19 to be a Public Health Emergency of International Concern in January, 2020 and a pandemic in March of 2020. 1 The rst case of COVID-19 was reported in the United States on January 21, 2020 and by April 10, 2020 there were approximately 500,000 con rmed cases in the U.S. and over 1.5 million cases, worldwide. 2,3 These statistics should be considered along with widespread scarcity of testing supplies and frequent testing delays, 4 which likely resulted in underestimation of the true prevalence of COVID- 19. In an effort to slow the spread of COVID-19 and reduce strain on the U.S. healthcare system, various U.S. state governments offered guidance in the form of stay-at-home orders (i.e. directives). These directives outlined how travel should be limited to essential purposes, such as obtaining food or reporting for essential employment, but such directives often amounted to recommendations, rather than enforceable mandates. 5 State Governors were instructed to make independent decisions regarding their respective state's response to the COVID-19 pandemic. 6 This led to vastly different responses among individual U.S. states. 7 Chiropractors were described as essential healthcare workers in a memo by the U.S. Department of Homeland Security made available on March 28, 2020. 8 Since the nature of this memo was advisory, rather than a formal federal directive, chiropractors were left to rely on their individual state's board of chiropractic examiners (i.e. state licensing board or state board) for direction. 9 At a time when our healthcare system is stressed to its limits, doctors of chiropractic have been described as serving to mitigate the demand of musculoskeletal pain patients on primary care providers, urgent care providers, and emergency departments (E.D.). 10 The bene t of providing this service must be balanced with the public health risks that come with providing direct patient care and potentially increasing the spread of COVID-19. 11 The objective of this study was to summarize the guidance provided in each of the 50 United States related to chiropractic practice during the COVID-19 pandemic and to report these results using descriptive statistics.

Methods
Websites for U.S. Governors' o ces as well as individual state chiropractic licensing boards were searched between April 3, 2020 and April 10, 2020. These websites were manually searched for guidance related to the status of chiropractic practice during the COVID-19 pandemic. Any changes made to these publicly facing websites after April 10, 2020 were not captured and, therefore, not included within this report. Information obtained and reported within this report was limited to statements directly from, or hyperlinked to, by the state Governor's website or individual state chiropractic licensing board's websites. Governors' websites were accessed using internet search engines (e.g. Google searches) while individual state chiropractic boards' websites were accessed via hyperlinks provided by the Federation of Chiropractic Licensing Board's online directory.
Seven policy domains relevant to chiropractic practice during the COVID-19 pandemic were identi ed via consensus by the authors of this report. These 7 domains were established by attempting to anticipate the most relevant guidance necessary to inform general chiropractic practice for doctors of chiropractic located throughout the United States. The seven domains involve: 1.) shelter-in-place or stay-at-home orders/directives, 2.) classi cation of chiropractic as essential healthcare providers, 3.) restriction of chiropractic practice to urgent/emergent presentations, 4.) recommendations for infectious disease control or use of personal protective equipment (PPE), 5.) chiropractic telehealth recommendations, 6.) alterations to continuing education (CE) or license renewal requirements (e.g. deadline extensions or changes to distance learning limitations), and 7.) warnings against false, deceptive, or misleading claims related to spinal manipulation/adjustments conferring protection against infection or COVID-19.
In an attempt to capture all relevant policy information and recommendations relevant to this project, a minimum of two authors independently reviewed each of the seven domains involved with this project for each of the 50 United States.
Any disagreements or ambiguities were discussed with the remaining authors and determinations were made based on consensus discussion. Such ambiguities often involved information that was not directly provided by state board's websites, but was able to be discovered after a breadcrumb trail of multiple hyperlinks were followed to identify the relevant information. For pragmatic reasons, this project was limited to only including information that was available within two or fewer hyperlinks from the original Governor's website or state chiropractic licensing board's website.

Results
Each of the 50 United States' chiropractic licensing board (i.e. state board) websites and each state Governor's website was able to be accessed and reviewed as part of this project (see Appendix A, Additional File 1 ). Results from each of this survey's 7 domains were reported for induvial U.S. states in Tables 1 through 4.
Forty-three U.S. states (86%) issued shelter-in-place (SIP) or stay-at-home (SAH) orders in response to the COVID-19 pandemic, while 7 states (14%) did not (see Table 1). Two states (Arkansas and Oklahoma) did not issue SIP/SAH orders, but did go onto describe chiropractors as essential healthcare providers. The remaining states without SIP/SAH orders offered little guidance on any of the 7 domains. In the absence of SIP/SAH orders, restricting business or, additional guidance regarding chiropractic practice may have been considered unnecessary.
Guidance regarding chiropractors' status as essential healthcare providers was provided by 27 U.S. states (54%); 26 of these states classi ed chiropractors as essential, while one state (Kentucky) expressly stated that chiropractors were non-essential. 12 The remaining 23 states (46%) failed to provide guidance regarding whether or not chiropractors were considered essential in their respective states (see Table 1). In this study, we classi ed chiropractors in Colorado as essential. On March 19, 2020 an executive order by the Colorado Governor was issued, ordering all chiropractic clinics to close, unless they were operating within a medical facility and restricting visits to only urgent/emergency situations. On April 6, 2020 the Colorado Governor reversed that order and permitted community-based chiropractors to resume clinical practice in situations where delaying care may result in rapid progression of the patient's condition or deterioration of the patient's health. 13,14 Guidance varied regarding whether chiropractors were to maintain "business as usual" or restrict their face-to-face clinical practice to only those patient interactions which constituted urgent, acute, or emergency patient care (i.e. restricted practice). Fourteen state chiropractic licensing boards (28%) provided guidance to restrict face-to-face chiropractic appointments to only those patients deemed to have urgent, acute, or emergency conditions; the remaining 36 states (72%) provided no guidance on whether chiropractors should continue with business as usual or restrict their practices (see Table 2).
Guidance regarding physical distancing and the use of personal protective equipment (PPE) has been provided at a national level by the Centers for Disease Control and Prevention (CDC), 5 but such information may be customized and disseminated by chiropractic state boards to meet speci c state and professional requirements. Twenty-seven state chiropractic boards (54%) provided information, or hosted links to information, regarding patient safety or PPE; the remaining 23 state boards (46%) provided no guidance regarding patient safety or the use of PPE (see Table 2).
Telehealth is the delivery of healthcare services via the use of telecommunication technologies and allows for remote patient care, including screening for red ags, providing patient education, and recommending self-care activities.
Twenty-two state chiropractic licensing boards (44%) provided guidance on whether chiropractors were appropriate for providing telehealth services, in their respective states. Of the 22 states that provided telehealth guidance, 21 states indicated that chiropractors were eligible to provide telehealth services, while one state (Alabama) indicated that that chiropractors were ineligible to provide telehealth services. 15 The remaining 28 state chiropractic boards (56%) failed to provide guidance regarding chiropractors' ability to serve the individuals in their state, via telehealth (see Table 2).
Alterations in continuing education (CE) requirements or license renewal requirements may be appropriate during the COVID-19 pandemic, due to disrupted travel and widespread cancelations of academic conferences. A total of 17 state chiropractic licensing boards (34%) provided information regarding such CE or license renewal alterations (see Table 3).
Alterations included the following: 6 states increased the allowed number of online credit hours to allow for all of the annual CEs credits to be earned from online sources, 8 states extended their CE deadlines, 1 state (Vermont) accepted all CEs from online sources while also extending CE deadlines, and 2 states (California and Connecticut) waived their annual CE requirements.
State chiropractic licensing boards are responsible for protecting the health, welfare, and safety of the public through licensure, education, and enforcement. That responsibility includes protecting patients from public health misinformation. In response to unsubstantiated claims and advertisements from chiropractors regarding the clinical effects of spinal manipulation/adjustments on increased immune function, some state chiropractic boards issues warning against providing unsubstantiated information. A total of 8 state chiropractic licensing boards (16%) issued warnings against making false, deceptive, or misleading statements about spinal manipulation and its in uence on immune function or inferring that spinal manipulation provides increased protection from COVID-19 (see Table 4).

Discussion
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 di cult for leaders to forecast the overall effect and generate effective safety recommendations. Some of the state chiropractic boards utilized a format that dramatically improved the our ability to discover COVID-19-related information for their respective states. These involved calling attention, often using a banner or other indicator, to a speci c website or dedicated area of their main website that contained consolidated information related to the ongoing COVID-19 pandemic. These dedicated websites served as a single location for licensees, or members of the public, to acquire necessary information. There was often a summary of the most relevant information with hyperlinks to more detailed source information (e.g. Governor's stay-at-home order). Visitors of these websites were encouraged to regularly return 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 assessing 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 identi ed by the authors of this manuscript as a "best practice" when attempting to inform state licensees and the general public about guidance or recommendations. Conversely, the authors of this project were frequently left having to resort to searching disparate websites for the relevant information involved changes in chiropractic practice during the COVID-19 pandemic. Having a single site with consolidated information seems to expedite 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. 16 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. 17,18 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 o ce as opposed to an emergency department (ED). 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 de nition of "urgent or emergent" is not entirely clear. 19 Differences in patient 20 and professional 21,22 perception of what constitutes an urgent or emergent situation results 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. 23 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 ags increases the likelihood that patients may have more urgent or serious conditions, such as fracture, cancer, infection, or vascular complication. 24 One can elicit a history and answers to red ag screening questions via telephone, allowing for triage if red ags are present or reassurance if red ags are absent. Atlas and Deyo cited several reasons to consider in-person evaluation, including the presence of any red ags, the presence of radicular symptoms, if symptoms persist for longer than 2-weeks, or if a patient desires in-person evaluation despite reassurance. 25

Limitations
There are many limitations associated with this study. It is possible that Governors or state chiropractic licensing boards posted information that was missed during our search. Every attempt was made to thoroughly review each website and capture relevant information, but due to variations in the ways content may have been described or variations in how relevant material may have been hyperlinked, it is possible that information was overlooked and omitted from this report. State chiropractic licensing boards may have also communicated information to their constituents via methods other than their website (e.g., mail, e-mail, or social media). For pragmatic reasons, the methods of this project were limited to reviewing public facing websites. Lastly, information made available after April 10, 2020 was not captured or reported as part of this project. It is possible that updates were in development at the time our search was performed, but had not yet been made publicly available or were only available via direct personal communication with personnel associated with individual state chiropractic licensing boards. Unfortunately, personally communicating with every state board was unfeasible for this project and information limited direct personal communication was not included in this report.

Conclusion
The responses to the COVID-19 pandemic from individual state chiropractic licensing boards were heterogenous and, in many cases, provided little-to-no guidance regarding changes to chiropractic practice during the COVID-19 pandemic. Authors' contributions: SN was a major contributor to study design, participated in data collection and analysis, and was a major contributor in writing the manuscript. CR was a major contributor to study design, participated in data collection and analysis, and was a major contributor in writing the manuscript. CO was a major contributor to study design, participated in data collection and analysis, and was a major contributor in writing the manuscript. SH was a major contributor to study design, participated in data collection and analysis, and was a major contributor in writing the manuscript. JN , participated in data collection and analysis, and contributed to writing the manuscript. RM participated in data collection and analysis, and contributed to writing the manuscript. NH participated in data collection and analysis, and contributed to writing the manuscript. DP participated in data collection and analysis, and contributed to writing the manuscript. All authors read and approved the nal manuscript.