Background: The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, with most research and media focus placed on acute care settings. However, healthcare professionals working outside hospital environments, such as manual therapists, also faced challenges amidst the pandemic. Considering manual therapists work in close contact with their patients during treatment, the pandemic potentially posed work environmental, and infection control challenges. Further, the pandemic posed potential threats to the therapists’ individual health directly through infection risk, and indirectly through occupational stress, disruptions in routines and social activities, and the stressors related to the pandemic at large. Most manual therapists in Sweden are private practitioners in the form owner operated businesses, working outside of the conventional healthcare – and may suffer economic hardship due to patient cancellations considering public health recommendations of social distancing.

Overall aim and methods: This thesis investigated the impact of the COVID-19 pandemic on manual therapists in Sweden, including chiropractors and naprapaths, in terms of their health, lifestyle, work environment, and business. The research is based on the CAMP cohort, a nationwide study of 816 manual therapists (46% women, mean age 44 SD 11) who were followed through four web-based surveys conducted between November 2020 and November 2021. Five sub studies form the basis of this thesis.

Study I-V: In study I, the aim was to describe the prevalence of psychological distress, and musculoskeletal pain, as well as factors associated with these health problems. The study was of crosssectional design, and used data from the baseline survey collected in November 2020, during the second wave of the COVID-19 pandemic in Sweden. The sample was based on 762 participants with valid data on psychological distress, and musculoskeletal pain. The vast majority had no/normal levels of psychological distress symptoms. Nonetheless, musculoskeletal pain problems were highly prevalent in the sample. Pain was most commonly reported in the neck, low back, upper back, and shoulders. Activity-limiting pain were most prevalent in the low back, and wrists/hands. Business owners with a reduced revenue, those residing in a municipality with a high spread of infection, and those reporting clinical disruptions due to the pandemic had higher levels psychological distress.

In study II, the aim was to assess the one-year trajectories of psychological distress, and of spinal pain intensity, and whether participant characteristics were associated with trajectory membership. The study was of cohort design, using psychological distress, and spinal pain intensity data from all four time-points over the one-year period. The study sample was 775 for psychological distress trajectories, and 779 for spinal pain intensity trajectories. The vast majority of participants had no or minimal symptoms of psychological distress, stable throughout the study. Whilst most of the participants also reported no/low spinal pain intensity during the one year period, a quarter reported fluctuating or moderate-stable pain intensity levels. Those reporting with impaired sleep, inadequate physical activity, and maladaptive coping had a higher probability of worse spinal pain trajectories.

In study III, the aim was to assess changes in health, lifestyle, and psychological factors, and potential differences with regards to age, sex, and business constellation. The study was of mixed methods design, using data from the baseline, 6-month follow-up, and 12-month follow-up surveys. Quantitative data on physical activity, sedentary time, impaired sleep, tobacco use, alcohol consumption, coping strategies, COVID-19-related worries, as well qualitative data in the form of free-text responses were analyzed over time. The study sample consisted of all 816 manual therapists in the CAMP cohort. The therapists maintained good lifestyle habits and other health aspects, with little change over the one-year period. The participants were conscientious regarding different health promotion activities, including exercise, nutrition, sleep, stress management and social activities.

In study IV, the aim was to examine the clinical activity, and business impact due to disruptions caused by the pandemic, in manual therapy business owners. The study was of cohort design and used data from all four time-points in the CAMP cohort. The study sample consisted of 443 clinically active manual therapists who reported being business owners. Clinical activity, business disruptions, and turnover was measured over time. Half of the participants reported a decreased business turnover, disruptions due to the pandemic was common, and associated with reduced clinical activity. Those with decreased turnover early tended to remain with decreased turnover over time. Also, receiving governmental economic support was also associated with reduced turnover. The therapists reported adapting their practices to cutting costs, and finding alternative revenue sources.

In study V, the aim was to describe the work environment and practices of manual therapists during a year of the pandemic. The study was of mixed methods design, using quantitative data on various work environmental aspects including infection control competency, protective equipment availability, ability to comply with official recommendations, and perceived ability to provide adequate care. Qualitative data included answers to free-text questions related to their work situation during the pandemic. All 816 participants of the CAMP cohort formed the study sample. Infection control competency, protective equipment availability, and ability to provide adequate care during the pandemic improved over time. The therapists adapted their practices and adjusted their routines to comply to recommendations. Further, many experienced a decrease in patient numbers, the inability to care for vulnerable patient groups, and less personalized care.

Overall conclusions: Manual therapists in Sweden maintained good mental health with low symptoms of psychological distress throughout the pandemic. However, a considerable proportion suffered from musculoskeletal problems, primarily back pain – associated with lifestyle and psychological factors. The therapists were conscientious regarding health promotion and maintained good lifestyle habits with minimal changes during the pandemic. The pandemic disrupted therapists’ businesses in terms of clinical activity and economic turnover. However, they showed resilience amidst the challenges imposed by adapting their practices, including cost cutting, and finding alternative revenue sources for their business to persist. Despite the work environment challenges encountered by manual therapists, including infection control competency, protective equipment availability, and changes in clinical routines, they reported being able to deliver adequate patient care by adapting treatment given to conform to official recommendations.