COVID-19-specific adult basic life support guideline strategies for chiropractors and other healthcare providers to maximize the safety and efficacy of resuscitation: a commentary.

BACKGROUND: The emergence of an unprecedented novel severe acute respiratory syndrome coronavirus-2 (SARS-C0V-2), which causes the coronavirus disease 2019 (COVID-19) pandemic, has created new scenarios in basic life support (BLS) management. According to current evidence, SARS-CoV-2 can be transmitted airborne in aerosol particles during resuscitation. Research evidence found an alarming global increase in out-of-hospital cardiac arrests during the COVID-19 pandemic. Healthcare providers are legally obliged to respond to cardiac arrest as soon as possible. Chiropractors will likely encounter potential exercise-related and non-exercise-related cardiac emergencies at some point in their professional lives. They have a duty of care to respond to emergencies such as cardiac arrest. Chiropractors are increasingly involved in providing care, including emergency care, for athletes and spectators at sporting events. Also, exercise-related cardiac arrest in adult patients may occur during exercise testing or rehabilitation with exercise prescriptions in chiropractic and other healthcare settings. Little is known about the COVID-19 BLS guidelines for chiropractors. Knowledge of the current COVID-19-specific adult BLS guidelines is essential to developing an emergency response plan for the on-field and sideline management of exercise-related cardiac arrest and non-athletic, non-exercise-related cardiac arrest. MAIN TEXT: Seven peer-reviewed articles on the COVID-19-specific BLS guidelines, including two updates, were reviewed for this commentary. Responding to the COVID-19 pandemic, the national and international resuscitation organizations recommended interim COVID-19-specific BLS guidelines with precaution, resuscitation, and education strategies. BLS safety is paramount. A precautionary approach with the bare minimum of appropriate personal protective equipment for resuscitation is recommended. There was disagreement among the COVID-19 BLS guidelines on the level of personal protective equipment. All healthcare professionals should also undergo self-directed BLS e-learning and virtual skill e-training. The summarized COVID-19-specific adult BLS guideline strategies and protocols are tabled, respectively. CONCLUSIONS: This commentary provides a practical overview and highlights current evidence-based intervention strategies of the COVID-19-specific adult BLS guidelines that may help chiropractors and other healthcare providers reduce BLS-related exposures to SARS-CoV-2 and the risks of SARS-CoV-2 transmission and maximize the efficacy of resuscitation. This study is relevant to and impacts future COVID-19-related research in areas such as infection prevention and control.

Barriers to the Engagement of Complementary and Integrative Health Providers in Public Health Responses to COVID-19: Recommendations From a Multidisciplinary Expert Panel.

OBJECTIVE: The purpose of this project was to explore barriers to the involvement of complementary and integrative health (CIH) providers in the public health response to COVID-19 and potential solutions for future involvement in public health crises. METHODS: An expert panel of 10 people, which included doctors of chiropractic, naturopathic doctors, public health practitioners, and researchers from the United States, was convened for a day-long online panel discussion. Facilitators asked panelists how CIH practitioners could contribute and be mobilized. We summarized themes and recommendations from the discussion. RESULTS: Despite their skills and resources, few CIH providers participated in public health efforts like testing and contact tracing during the COVID-19 pandemic. Panelists described that CIH professionals may not have participated in those efforts due to the CIH providers possibly not having sufficient public health training and limited contact with public health professionals, as well as policy and financial challenges during the pandemic. Panelists proposed solutions to these barriers, including more public health training, stronger formal relationships between CIH and public health organizations, and improved financial support for both CIH care and public health efforts. CONCLUSION: Through an expert panel discussion, we identified barriers that hindered the involvement of CIH providers in the public health response to the COVID-19 pandemic. During future pandemics in the United States, public health planners should recognize CIH providers as part of the existing labor resource, with clinical expertise and community-level connections that can be called upon in a crisis. During future events, CIH professional leaders should be more proactive in seeking out a supportive role and sharing their knowledge, skills, and expertise.

Characteristics of Chiropractic Patients in the Veterans Health Administration During the COVID-19 Pandemic: A Cross-Sectional Analysis.

OBJECTIVE: The purpose of this study was to determine whether patient characteristics were associated with face-to-face (F2F) and telehealth visits for those receiving chiropractic care for musculoskeletal conditions in the US Veterans Health Administration (VHA) during the COVID-19 pandemic. METHODS: A retrospective cross-sectional analysis of all patients (veterans, dependents, and spouses) who received chiropractic care nationwide at the VHA from March 1, 2020, to February 28, 2021, was performed. Patients were allocated into 1 of the following 3 groups: only telehealth visits, only F2F visits, and combined F2F and telehealth visits. Patient characteristics included age, sex, race, ethnicity, marital status, and Charlson Comorbidity Index. Multinomial logistic regression estimated associations of these variables with visit type. RESULTS: The total number of unique patients seen by chiropractors between March 2020 and February 2021 was 62 658. Key findings were that patients of non-White race and Hispanic or Latino ethnicity were more likely to attend telehealth-only visits (Black [odds ratio 1.20, 95% confidence interval {1.10-1.31}], other races [1.36 {1.16-1.59}], and Hispanic or Latino [1.35 {1.20-1.52}]) and combination telehealth and F2F care (Black [1.32 {1.25-1.40}], other races [1.37 {1.23-1.52}], and Hispanic or Latino [1.63 {1.51-1.76}]). Patients younger than 40 years of age were more likely to choose telehealth visits ([1.13 {1.02-1.26}], 66-75 years [1.17 {1.01-1.35}], and >75 years [1.26 {1.06-1.51}] vs those 40-55 years of age). Sex, visit frequency, and Charlson Comorbidity Index showed significant relationships as well, while marital status did not. CONCLUSION: During the COVID-19 pandemic, VHA patients with musculoskeletal complaints using chiropractic telehealth were more ethnically and racially diverse than those using F2F care alone.

An Adult Patient With Acute Ischemic Stroke and Carotid Stenosis Presenting to a Chiropractor: A Case Report.

A 59-year-old male, with a recent history of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, presented to a chiropractor with a one-week history of numbness in the right upper and lower extremity that was triggered by neck movement, and lightheadedness/dizziness. On examination, the chiropractor noted limited, painful cervical spine range of motion, right upper extremity weakness, patellar hyperreflexia, positive Hoffman's and Trömner's signs bilaterally, nystagmus, a sluggish right pupillary light reflex, and carotid bruit. Cervical radiographs were suggestive of Klippel-Feil syndrome. The chiropractor suspected a vascular cause such as a transient ischemic attack and referred the patient to the emergency department, which the patient visited the following day. The patient was admitted, and MRI revealed multiple tiny acute to subacute cortical infarcts of the left frontal and parietal lobes while sonography demonstrated left internal carotid artery stenosis. The patient was treated with anticoagulant and antiplatelet medications and carotid endarterectomy with a positive outcome. Given the overlap between symptoms of stroke and those of the cervical spine, chiropractors should be prepared to recognize potential stroke patients and refer them for emergent medical management.

Undiagnosed Osteoporotic Vertebral Fractures in an Octogenarian During the Coronavirus Disease Pandemic.

Osteoporotic vertebral fractures are frequently misdiagnosed or under-recognized in the older population, leading to disease progression and reduced quality of life. This case of an 87-year-old woman with acute back pain highlights the importance of early diagnosis and management of fragility fractures. During the coronavirus disease (COVID-19) pandemic, patients with a history of well-managed osteoporosis experienced worsening symptoms of vertebral collapse due to activity limitations and prolonged immobilization. The initial diagnosis of spinal stenosis delayed appropriate treatment for four months. Serial magnetic resonance imaging revealed compression fractures at L1 and L3, and a dual-energy x-ray absorptiometry scan showed osteoporosis with a T-score of -3.2. Pharmacological therapy, including bisphosphonates, was initiated. A comprehensive rehabilitation program with a multidisciplinary approach, with bracing, and lifestyle changes helped stabilize the spine, reduce pain, and maximized function. Her condition improved with close monitoring and guidance during home exercises. This case exemplifies the necessity of a precise and timely diagnosis of osteoporotic vertebral fractures to initiate management and mitigate disease progression.

Meeting Future Demand for Chiropractic Services in Hong Kong: A Strategic Manpower Planning Approach.

Chiropractic treatment in Hong Kong has demonstrated high effectiveness in cases where traditional therapies have failed, with minimal associated adverse events. The growing aging population, prevalence of disabilities, and musculoskeletal conditions have increased the demand for rehabilitation services. Over the past few years, the chiropractic profession has raised awareness of treatment benefits. Providing high-quality training and education, licensing/regulation, interprofessional collaboration, increased accessibility, and research are factors influencing the chiropractic workforce and meeting the population's health needs. To achieve the number of chiropractors required by Hong Kong for adequate service according to international standards, future efforts could include increased licensing/registration efficiency, expanded coverage of public/private insurance, system integration/interprofessional collaboration, public education, and local research to build evidence and to support workforce growth and acceptance.

Knowledge, attitudes and perceived behavioral modification of chiropractic students returning to clinical training in South Africa amid the COVID-19 pandemic.

OBJECTIVE: The purpose of this study was to determine the knowledge and attitudes toward COVID-19 and perceived behavioral modification of South African chiropractic students returning to clinical training during the COVID-19 pandemic. METHODS: An online survey was administered to students registered for clinical training in South African chiropractic programs. The survey consisted of questions related to knowledge and attitudes toward COVID-19 and perceptions on behavioral modification in the form of personal protective equipment (PPE) use to prevent transmission. RESULTS: Out of 129 participants, there was a 69% response rate (n = 89), with a mean age of 25 (±2.39) years and 75% were females. They had an acceptable level of knowledge (67.9%). There was a favorable perception score about COVID-19 (98.8%) but a poor perception of the role of PPE. They expressed concern about returning to clinical training (62.9%) but were prepared to return to serve their patients during the pandemic (72%). CONCLUSION: Chiropractic students within South Africa demonstrated good attitudes, knowledge, and perception toward the measures required to return safely to the clinical environment during the COVID-19 pandemic. There was a level of stress associated with potential infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), mostly for onward transmission to family members.

First-person video experiences as a vicarious, virtual alternative to in-person basic science labs.

OBJECTIVE: The global COVID-19 pandemic required the teaching of basic science instructional laboratories be done in a remote, online format termed emergency remote teaching (ERT). The aims of this study were to: (1) share strategies for ERT of basic science instructional laboratories and (2) assess student perceptions of the experience of virtual demonstrations that were recorded from the first-person perspective of the professor. METHODS: Laboratories for courses in gross anatomy, neuroanatomy, and clinical microbiology were adapted to ERT by creating videos that allowed the students to view the laboratory activities through the eyes and hands of the faculty. A unique 5-question survey instrument was created to collect students' perceptions of gross anatomy, neuroanatomy, and clinical microbiology virtual lab experiences. Percentage of responses were calculated for 4 close-ended questions. Qualitative content analysis was conducted on the single open-ended question. Two additional close-ended questions were used for assessing perception of gross anatomy labs only. RESULTS: Videos of gross anatomy, neuroanatomy, and clinical microbiology laboratory activities mimicked the student experience through the camera lens as labs were performed by faculty members engaged in either dissection, viewing structures or doing experiments, respectively. In all 3 basic science courses, over 70% of students strongly agreed or agreed that the videos created a sense of being in the laboratory. CONCLUSION: Use of video technology allowed faculty to mimic the student experience of being in basic science laboratories, and, importantly, allowed the student to virtually participate in the learning experience.

A two-year follow-up: Twitter activity regarding misinformation about spinal manipulation, chiropractic care and boosting immunity during the COVID-19 pandemic.

BACKGROUND: Spinal manipulative therapy (SMT) is offered by many health professions, most often by chiropractors. While SMT can be effective for some musculoskeletal disorders, there is no evidence that SMT improves human immunity in a clinically meaningful way. Despite this, we showed previously that Twitter misinformation about chiropractic/SMT  improving immunity increased sharply at the start of the COVID-19 pandemic. Here, we perform a two-year follow-up. METHODS: We previously employed specialized software (i.e. Talkwalker) to search the entirety of Twitter activity in the  months before and after the COVID-19 pandemic was declared (March 11, 2020). In this paper, we conducted follow-up searches over two successive 12 month periods using terms related to SMT, immunity and chiropractic. The resulting tweets were then coded into those promoting/refuting a relation between SMT and immunity (tone) and messaging about chiropractic/interventions (content). Further analyses were performed to subcategorize tweet content, tally likes, retweets and followers, and evaluate refuting tweets and the country of origin. Finally, we created a chronology of Twitter activity superimposed with dates of promoting or refuting activities undertaken by chiropractic organizations. RESULTS: Over the 27 month study period, Twitter activity peaked on March 31, 2020 then declined continuously. As in our first paper, our follow-up data showed that (1) the ratio of refuting/promoting tweets remained constant and (2) tweets that refuted a relationship between SMT and immunity were substantially more liked, retweeted and followed than those promoting. We also observed that promoting tweets suggesting that SMT improves immunity decreased more rapidly. Overwhelmingly, promoting tweets originated in the USA while refuting tweets originated in Canada, Europe and Australia. The timing of the decline in peak Twitter activity, together with a parallel decline in tweets claiming that SMT improves immunity, was coincident with initiatives by chiropractic organizations and regulators targeting misinformation. CONCLUSION: Overwhelmingly, Twitter activity during the COVID-19 pandemic focussed on refuting a relation between chiropractic/SMT and immunity. A decline in Twitter activity promoting a relation between SMT and immunity was observed to coincide with initiatives from chiropractic organizations and regulators to refute these claims. The majority of misinformation about this topic is generated in the United States.

Spontaneous Cervical Epidural Hematoma Following COVID-19 Illness Presenting to a Chiropractor: A Case Report.

Cervical epidural hematoma (CEH) is a rare and potentially fatal condition in which blood accumulates in the epidural space of the cervical spine. A 64-year-old man presented to a chiropractor with a two-week history of sudden-onset neck pain, shoulder pain, occipital headache, and numbness in the shoulders and upper extremities. He had recovered from a mild course of coronavirus disease 2019 (COVID-19) illness one month prior. The patient's primary care provider had previously prescribed a nonsteroidal anti-inflammatory drug for his neck pain. However, his symptoms worsened, and he visited the emergency department where he had unremarkable cervical spine radiographs and was discharged with a diagnosis of neck strain. The chiropractor ordered cervical spine magnetic resonance imaging (MRI), revealing a ventral CEH extending from C2 to C5. The chiropractor referred the patient to a nearby hospital for urgent management. The patient was admitted and observed, progressively improved, and did not require surgery. After 10 weeks in the hospital the patient was asymptomatic, a follow-up MRI revealed resolution of the CEH, and the patient was discharged. While the current case highlights a temporal relationship between COVID-19 and CEH, further research is needed to determine if COVID-19 is a risk factor for this condition. Clinicians who encounter patients with spinal disorders must be able to recognize the clinical features of CEH and refer these patients for emergency care and/or neurosurgical evaluation.

Chronic Bilateral Occipital Neuralgia After the Johnson & Johnson COVID-19 Vaccination: A Case Report

Case Diagnosis: A 37-year-old woman with daily headaches after Johnson & Johnson (J&J) COVID-19 vaccine. Case Description or Program Description: A patient with 10 months of daily headaches notes an inability to care for her son and complete daily tasks. Headaches started immediately after receiving the J&J COVID-19 vaccination. Headaches are burning, aching, throbbing, and begin occipitally "creeping" bilaterally over the scalp. The patient has no past medical history including headaches or migraines. Over 10 months, she has seen multiple specialties. Initial differential included atypical migraine, immune reaction post-vaccine with possible underlying Lyme disease activation, and atypical shingles. Therapy, chiropractic services, and multiple pharmacological treatments offered no relief. Imaging of the brain and neck was normal. Setting(s): Physical Medicine and Rehabilitation (PM&R) clinic. Assessment/Results: Upon evaluation in PM&R, palpation of bilateral greater occipital nerves reproduced symptoms. Based on this chronic bilateral occipital neuralgia was diagnosed. Bilateral greater occipital nerve blocks were offered for diagnostic confirmation and therapeutic relief. To ensure relaxation of the neck musculature therapeutic exercises were provided. Discussion (relevance): Neurological side effects after J&J COVID-19 vaccine are reported including Guillain-Barre syndrome, Bell's Palsy, and cerebral venous sinus thrombosis. 1 Additionally, mild neurological events such as headache, anxiety-related syncope, and dizziness are frequently reported after vaccination. Each of these cases is characterized as acute, and symptoms tend to resolve within a month.1 To our knowledge, this is the first reported case of chronic bilateral occipital neuralgia developing following a standard dose of the J&J COVID-19 vaccine. Conclusion(s): These findings suggest chronic bilateral occipital neuralgia is a potential side effect of the J&J COVID-19 vaccine. It is necessary to consider bilateral occipital neuralgia on the differential for headache following vaccination, as chronic pain can impair a patient's ability to perform activities of daily living.

Sleep Quality Of College Students During COVID-19 Outbreak In China: A Cross-Sectional Study

Introduction * Poor sleep quality among college students is a global problem. Chinese college students were required to home quarantine, social distance and participate in online learning during the COVID-19 epidemic. This study aimed to investigate the sleep quality of college students during the epidemic and identify the factors related to poor sleep quality. Methods · Study participants completed an online survey that included questionnaires about sleep symptoms and lifestyle during the COVID-19 outbreak. The study participants included 3416 college students (mean age 20.4 ± 1.8 years). The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality, and a PSQI score >7 was defined as poor sleep quality. A logistic regression model was used to analyze the factors related to sleep quality. Results · The percentage of college students with poor sleep quality was 15.97 % in southern Anhui province during the COVID-19 pandemic. The majority of the students were female (67.4%) and most were from urban areas (53.9%). Single-parent (adjusted odds ratio [aOR], 1.39;95% CI, 1.02-1.89) domestic violence incidents ≥5×/yr (aOR, 3.68;95% CI, 1.70 to 7.96), nap time >4 hr/d (aOR, 1.90;95% CI, 25-2.90) were significantly associated with poor sleep quality. While knowledge of COVID-19 was prevalent (aOR, 0.71;95% CI, 0.53 to 0.96) light exercise >1 hour/day (aOR, 0.47;95% CI, 0.28 to 0.78), parent-accompanied exercise >3×/wk (aOR, 0.59;95% CI, 0.38 to 0.90) were protective factors against poor sleep quality. Conclusions · The present study found that college students in single-parent families and students who had experienced domestic violence had a high risk of poor sleep quality during the COVID-19 pandemic in China. College students who were familiar with COVID-19 and had light exercise habits or parent-accompanied exercise habits had better sleep quality. At the time of writing, COVID-19 was still pandemic worldwide, so targeted sleep health interventions must be established to actively guide college students' healthy living habits. In addition, the sleep disorders and other health problems that may occur in college students should be dealt with in advance, and should be part of the routine work of global disease prevention.

The positive and negative impacts of the COVID-19 pandemic on the European Council on Chiropractic Education accredited programs: A mixed methods audit and thematic analysis.

OBJECTIVE: The objectives of this study were to: (1) determine the impact of COVID-19 on the operations within the 9 sections of the European Council on Chiropractic Education (ECCE) 'Standards'; (2) identify specific rapid changes to the programs; and (3) identify positive changes that will continue post-pandemic. METHODS: This was a mixed methods audit and thematic analysis of data from interviews conducted via a cloud-based video conferencing tool with program leaders of the ECCE accredited institutions. A validated questionnaire designed around ECCE's "Standards" was used, consisting of 3 sections: (1) Severity of the COVID-19 impact on each ECCE Standard section; (2) Description of program changes made for each section; (3) Identification of positive changes continuing post-pandemic. Descriptive statistics were calculated for Part 1 and compared for significant differences via the Kruskal-Wallis test. Verbal responses to Parts 2 and 3 were evaluated independently by 3 researchers using a modified "thematic analysis" approach. Final thematic categories and themes were agreed upon by the researchers. RESULTS: There was a 100% response rate. Outpatient teaching clinics were most severely affected, followed by teaching chiropractic technique courses. Curricular structure and duration and program management were least affected (p =.033). Four thematic categories were identified: Extreme Stress, Courses Most Severely Affected, Integrity of Examinations and Assessments, and Positive Changes That Will Continue. CONCLUSION: Final-year students were most negatively impacted due to restricted opportunities in outpatient clinics. Integrity of examinations was also a problem. Positive, innovative teaching materials and methods were quickly developed and should continue.

Depression, Anxiety, and Stress Among Chiropractors in South Africa During the Early COVID-19 Pandemic.

Objective: The purpose of this study was to assess the self-reported depression, anxiety, and stress responses of chiropractors in South Africa during the first year of the COVID-19 pandemic. Methods: This was an explorative cross-sectional survey. The survey was distributed to 884 chiropractors through the membership databases of the Chiropractic Association of South Africa and the Allied Health Professions Council of South Africa from July 9, 2020, until August 4, 2020. The study was conducted through Google Forms and included the Depression, Anxiety, and Stress Scale questionnaire. Data were analyzed using the Kolmogorov-Smirnov and Shapiro-Wilk tests and comparatively using the Mann-Whitney U and Kruskal-Wallis tests. Results: The response rate was 17%. The chiropractor scores for depression, anxiety, and stress were within the normal range (7.35, 5.42, and 11.58, respectively). Female chiropractors under the age of 40 years old were found to be affected to a greater degree than the other participants in this study (9.87, 7.56, and 14.14). Conclusion: Self-reported levels for stress, anxiety, and depression among chiropractors in South Africa were found to be within normal limits during the initial phase of the COVID-19 pandemic.

The John A. Sweaney Lecture: Virtual, September 2021, Given by Dr Michele Maiers. A Time to Lead: Reflections During a Pandemic.

The following is The John A. Sweaney Lecture delivered by Dr Michele Maiers at the biannual Congress of the World Federation of Chiropractic that was held virtually on September 25, 2021.

Education and patient care in a chiropractic teaching clinic: An organizational approach to health and safety during the COVID-19 pandemic.

OBJECTIVE: The academic teaching clinic at our chiropractic college in California remained open beginning in the early stages of the COVID-19 pandemic and shelter-in-place order requiring individuals to stay at home except for essential activities. We report the experiences described by health center personnel who were present during the shelter-in-place early stages. METHODS: Narrative approach and descriptive thematic analysis of transcripts of 15 interviews with faculty, staff, and student interns. Report of key events and processes for developing ongoing COVID-related policies and procedures to conform with state and county public health mandates. RESULTS: Themes included (1) Organizational processes and procedures; (2) Perceptions of safety; (3) Successful adaptations and responses; (4) Challenges; (5) Mental health and well-being; (6) Unanticipated benefits and opportunities; and (7) Reflections on chiropractic philosophy. Participants' initial fears diminished as they gained confidence in the safety conferred by the new procedures and a returning sense of normalcy. They discussed the importance of social connection, chiropractic wellness philosophy, and their personal beliefs within the context of the pandemic and public health mandates. Despite initial reductions in numbers of patients and procedures that could be performed, patients received continuing chiropractic care and interns were able to complete their academic requirements while experiencing unique learning opportunities. CONCLUSION: Despite substantial challenges, the rapid response in the early stages of the pandemic enabled the college to fulfill the multiple missions of providing patient care, community support, and uninterrupted clinical education to student interns while conforming to public health mandates and guidelines.

Telehealth Content From United States Chiropractic State Board Websites Compared With Medical and Physical Therapy Websites During the Early Stages of the COVID-19 Pandemic.

Objective: The purpose of this descriptive study was to evaluate the presence of telehealth content on chiropractic state board websites compared with websites from the medical and physical therapy professions during the early COVID-19 pandemic. Methods: State board websites for chiropractic, medicine, and physical therapy for each of the 50 United States and the District of Columbia were searched for the word "tele" to determine if there was a link on the homepage for content related to telehealth guidance. If there was none, the homepage was queried for the word "COVID" to determine if there was a link for COVID-19-related guidance. If yes, that linked COVID-19 page was queried for the word "tele." Consensus of 4 of 5 reviewers was sought. Binary results were entered into a separate spreadsheet for each profession (telehealth content easily accessible, yes or no). Easily accessible was defined as information found within 1 or 2 clicks. This search was performed between January 1, 2021, and March 1, 2021. Results: There were 11 of 51 (21%) chiropractic state board websites that provided content regarding telehealth on the main page, 8 of 51 (16%) provided content on a separate COVID-19-related page, and 32 of 51 (63%) did not provide content that was accessible within 1 or 2 clicks. Comparatively, 9 of 51 (18%) medical state board websites provided content regarding telehealth on the main page, 20 of 51 (39%) provided content on a COVID-19-related page, and 22 of 51 (43%) did not provide content that was accessible within 1 or 2 clicks. Lastly, 10 of 51 (20%) physical therapy state board websites provided content regarding telehealth on the main page, 19 of 51 (37%) provided content on a COVID-19-related page, and 22 of 51 (43%) did not provide content that was accessible within 1 or 2 clicks. Conclusion: Telehealth content was more readily available on medical and physical therapy state board websites compared with chiropractic state board websites in the early stages of the COVID-19 pandemic.

Use of Telemedicine in the Diagnosis of Cervical Spondylotic Myelopathy in a US Veteran During the COVID-19 Pandemic: A Case Report.

Objective: The purpose of this case study was to describe the diagnosis of cervical spondylotic myelopathy through telemedicine during the COVID-19 pandemic. Clinical Features: A 57-year-old male patient was evaluated at a Veterans Affairs chiropractic clinic via video telemedicine for evaluation regarding neck pain and bilateral arm paresthesia. Intervention and Outcome: During the initial evaluation performed by video telemedicine, the doctor of chiropractic was concerned about the possibility of cervical spondylotic myelopathy. This prompted a face-to-face consultation with the patient for further evaluation. The face-to-face evaluation revealed correlating objective findings, including brisk reflexes and transient clonus. Noncontrast magnetic resonance imaging of the cervical spine was performed, which showed evidence of cord compression with associated myelomalacia in the cervical spine at the C4-C5 level. After a neurosurgical consultation, the patient underwent successful anterior cervical decompression and fusion at the C4-C5 level. Conclusion: Chiropractic services through live video telemedicine in conjunction with face-to-face evaluation resulted in a timely neurosurgical consultation and successful decompression of the affected region. In this case, telemedicine facilitated a positive outcome for a patient with cervical spondylotic myelopathy.

Veterans Health Administration's National Delivery of CIH Therapies, Whole Health Services and Chiropractic Care in 2020 and the Pivot to Telehealth

Methods: Databases were searched using CPT codes (acupuncture, chiropractic, and massage therapy), clinic stop codes (chiropractic care), clinic location names, internal accounting codes, clinic note titles, and structured coding templates (Health Factors) unique to VHA's electronic medical record. Results: A total of 441,891 Veterans used 2,930,700 of these services in FY20, representing a slight decrease from FY19 (3,083,806 total visits). Prior to the COVID19 pandemic, VHA was on track for expanded utilization in FY20. Of these visits, 422,313 (14%) were delivered through telehealth. Over 8.1% of all Veterans receiving VHA care in FY20 received at least oneCIH therapy, Whole Health service, or chiropractic care service. Use was highest among women (14.3%), patients with chronic pain (18.1%), opioid use disorder (15.6%), rheumatoid arthritis (13.3%), obesity (12.9%), or a mental health condition (12.8%). VHA medical centers worked quickly during the pandemic to expand telehealth offerings;comparing against FY19, nearly onethird of the monthly in-person visit volume was provided through telehealth by the end of 2020 for therapies including Core Whole Health services, yoga, Tai Chi/Qigong, meditation, biofeedback, guided imagery, and hypnosis. Background: Given that VHA is the largest healthcare system provider of CIH therapies in the U.S., we examined the VHA's national provision of nine CIH therapies (acupuncture, battlefield acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/Qigong, and yoga), chiropractic care, and Whole Health services for fiscal years (FYs) 2017 to 2020 using data from electronic medical records and community-based claims, and assessed utilization as VHA expanded CIH offerings and pivoted to tele-CIH and tele-Whole Health in response to the COVID19 pandemic. Conclusion: Despite the impact of COVID19 on reduced FY20 in-person visits, including group CIH therapies, VHA continued to provide nearly the same number of visits as the prior year, in part due to expansion of telehealth services.

Complementary and Integrative Health in the Community: Expanding Access for Veterans Seeking Care through the Veterans Health Administration

Methods: Data were pulled from an internal administrative dashboard. Referrals include services for Veterans who live a prescribed driving distance from a VAMC, wait times over threshold, services unavailable, or for reasons of the best medical interest. Data was pulled for fiscal years 2020 through 2021 and included: chiropractic care, acupuncture, biofeedback, neuron feedback, clinical hypnosis, massage therapy, meditation (specifically MBSR), Tai Chi/qigong, and yoga. Standardized tracking of referrals began with the implementation of Standard Episodes of Care (SEOC) which define care requested and include number of visits permitted and timeframe. Results: Referrals increased for all approaches from FY20-21 shown as (FY20;FY21): chiropractic (104,197;197,357), acupuncture (59,787;100,908), massage therapy (5,021;17,646), biofeedback (31;69), neuron feedback (27;74), clinical hypnosis (10;40), MBSR (2;8), Tai Chi (2;8) and Yoga (1;2). Background: The Veterans Health Administration (VHA) Directive 1137: Provision of Complementary and Integrative Health (CIH) identifies the inclusion of evidence-based CIH approaches in the VHA's Medical Benefits Package (acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/qigong, and yoga). The purpose of this administrative data review is to identify which approaches are being referred to Community Care from VHA medical centers (VAMC), and to identify if COVID-19 has had an impact on referrals to the community. Conclusion: CIH is expanding across the VHA and could be useful in supporting a cultural transformation that includes integrative health approaches within conventional medical systems. While all VAMCs provide some CIH in-house, a substantial amount is provided through Community Care. As the largest integrated healthcare system in the United States, this could impact growth of CIH and the need for more providers in the community. By hiring CIH professionals onstation and expanding the network to the community, VHA could be one of the largest providers and users of CIH.