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This study assessed health and change in lifestyle factors in Swedish manual therapists during one year of the COVID-19 pandemic, and potential differences with regards to age, sex, and business constellation. Further, therapists' strategies for health promotion during the pandemic were explored. In this cohort study, 816 clinically active manual therapists were followed with web-based surveys during a year of the COVID-19 pandemic in Sweden, measuring physical activity, sedentary time, COVID-19-related worries, maladaptive coping, alcohol and tobacco consumption. Health promotion and impact of the pandemic on physical and mental health were explored in free text questions. Generalized estimating equations were conducted to assess changes in sample averages over time, and qualitative content analysis was used to code and categorize free-text answers. There was a decrease in physical activity and sedentary time increased as well as subjective mental health impact by the pandemic over one year. Maladaptive coping decreased during follow-up, and alcohol and tobacco consumption decreased in younger participants, and women, respectively. Participants stated that the pandemic affected their physical and mental health and reported using health promoting activities primarily targeting physical activity, nutrition, and sleep. Swedish manual therapists maintained good lifestyle habits except for a small decrease in physical activity and slight increase in sedentary behavior and subjective mental health impact by the pandemic over time. There were small differences in terms of maladaptive coping, alcohol consumption, and tobacco consumption, however, these differences were not likely clinically relevant. The therapists seemed conscientious regarding health promotion measures during one year of the COVID-19 pandemic.

The Swedish governmental strategy during the COVID-19-pandemic was to impose voluntary recommendations to limit viral spread, but to keep health care and important societal functions running. The objective of this study was to describe the work environment and practice of manual therapists, who were challenged by this strategy, in Sweden during a year of the pandemic. The cohort study Corona And Manual Professions (CAMP) was studying chiropractors and naprapaths, registered in the public register of licensed manual therapists in Sweden, during the pandemic. Mixed methods were used to answer the research aims. Surveys were distributed in November 2020, during the second wave, and in February, May and November of 2021. The quantitative data were presented descriptively, with the development over time illustrated in graphs. The qualitative data from the free-text answers were analyzed using content analysis. In total, 816 manual therapists (47% of the invited sample) were included in the study, of which between 275 and 662 participants answered the free-text questions. At baseline, most (60-65%) rated their knowledge of viral infections and their spread, of vulnerable patient groups, and of protective gear as fairly good or good. Most (68-70%) were able to follow the official recommendations, but decreased numbers of patients and changes in clinic routines were reported. There was a positive trend in caring adequately for patients and having access to protective gear. Manual therapists reported that they were unable to care for vulnerable patient groups, had to adhere to routines perceived as onerous, and found care to be less personalized. At the time of the outbreak of the COVID-19 pandemic, manual therapists in Sweden encountered challenges regarding knowledge about pandemics and availability of protective equipment. Sweden's official recommendations were possible to implement by the manual therapists, but had adverse impacts on clinic activities and patient care. Despite this, over 50% were able to deliver adequate care for their patients.

The aim of this study was to assess the one-year trajectories of psychological distress and of spinal pain intensity in manual therapists during the COVID-19 pandemic in Sweden, and to assess characteristics’ association with trajectory membership. In this cohort study, 816 clinically active licensed manual therapists answered four web-based surveys during a year of the COVID-19 pandemic in Sweden, measuring psychological distress and spinal pain intensity. Trajectory modelling was conducted to cluster individual trajectories over time. Association between baseline characteristics and cluster membership of psychological distress, and spinal pain intensity trajectories were analyzed using multinomial logistic regression models, adjusted for posterior probability, age, and sex. Five clusters of psychological distress and five of spinal pain intensity were identified. A majority of participants’ psychological distress (89%), and spinal pain intensity (75%) were clustered into low/mild levels. One cluster of increasing psychological distress (2%) were identified. Two fluctuating clusters of moderate/mild (14%), as well as one cluster of stable moderate (11%) spinal pain intensity were identified. Impaired sleep, and not meeting physical activity recommendations were associated with worse trajectories of spinal pain. In conclusion, most manual therapists had favorable trajectories of psychological distress and spinal pain intensity during a year of the COVID-19 pandemic in Sweden.

This study examined manual therapy business owners' perception of official recommendations during the COVID-19 pandemic and the impact on their clinics' economic performance, including clinic activity hours and business turnover. In a longitudinal study design, data were collected in November 2021 (baseline), and after three months, six months, and 12 months. Participants were manual therapists who were business owners. A growth curve model was used to analyze differences in clinical activity trajectories. Multinomial logistic regression analysis was used to assess the relationship between perceived disruptions in business and turnover. Qualitative text analysis was used to examine participants' responses to open-ended questions concerning economic measures taken to sustain their business during the pandemic. This study of 443 manual therapy business owners found that clinics were initially active with minimal variation, but activity changed following COVID-19 recommendations. Business owners perceived that the disruptions had no significant impact on turnover during the initial stages of the official recommendations. Economic support and the previous decrease in turnover increased the likelihood of experiencing a decreased turnover at 12 months. Business owners implemented cost-cutting measures and diversified income sources to navigate COVID-19 challenges and sustain their businesses. The official recommendations in Sweden had an impact on manual therapists' businesses as the COVID-19 pandemic lingered. Some business owners were concerned at the early stages about lower turnover but showed financial resilience by cutting costs and finding new revenue sources to overcome COVID-19 challenges.

Background The prevalence of back pain and neck/shoulder pain among nurses is high. This study reports a detailed description of health related characteristics of experienced nurses with and without severe back pain or severe neck/shoulder pain in Sweden. Methods Cross-sectional data was collected in a national investigation of nursing graduates from 26 Swedish universities to identify three groups of nurses 11–15 years after graduation: nurses with severe back pain ( n  = 212), nurses with severe neck/shoulder pain ( n  = 277), and nurses with no or little such pain ( n  = 1525). Severe pain was defined as much discomfort from pain the preceding four weeks. Descriptive statistics were used to summarise general health and pain characteristics, use of health resources and impact of pain on work. Results Nurses with severe back or neck/shoulder pain described worse general state of health and lifestyle, such as personal or mental health problems, fatigue, dizziness and pain in other body regions, less physical activity and lower sleep quality, than those with no or little pain. They used more health resources as over-the-counter and prescription painkillers and care seeking for physical ailments. The course of the severe pain was often persistent, and those nurses commonly reduced their working hours, changed work tasks, and had days off work. Conclusions This study describes variations of nurses’ health related characteristics by pain levels. Experienced nurses with severe back or neck/shoulder pain describe worse states of general health and lifestyle, and more use of health resources than experienced nurses with no or little such pain. The course of the severe pain is often persistent and affects work capacity. Clinical trial number Not applicable.

Background The COVID-19 pandemic had an unprecedented impact on healthcare, and the health of healthcare workers has been subject of much research. However, studies of health-related factors in manual therapists during the COVID-19 pandemic are scarce. Research in this field can provide valuable insights for future crises policy and guidelines, including in regions where the public health response to COVID-19 contrasts with that of most other international jurisdictions. The aim was to describe the prevalence of psychological distress and musculoskeletal pain, and to investigate factors potentially associated with high psychological distress and activity-limiting musculoskeletal pain in clinically active chiropractors and naprapaths during the second wave of the COVID-19 pandemic in Sweden. Methods A cross-sectional survey was distributed to a representative sample of Swedish manual therapists, between November 2020 and January 2021. High psychological distress and activity-limiting musculoskeletal pain were investigated regarding associations with residing in a municipality with a high spread of infection, a previous/ongoing SARS-CoV-2 infection, clinical interferences and economic consequences associated with the pandemic. Generalized Linear Models with log link and binomial distribution were used, computing prevalence ratios (PR) with 95% confidence intervals (95% CI). Results A total of 762 participants were included, representing 46% of the source population. The prevalence of depressive, anxiety, and stress symptoms was 17%, 7%, and 12%, respectively. Neck (50%), low back (46%), upper back (40%), and shoulders (39%) were the most prevalent musculoskeletal pain areas. Economic consequences due to the pandemic were associated with high psychological distress (PR = 2.30, 95% CI: 1.48–3.53). Conclusions During the second wave of the COVID-19 pandemic in Sweden, manual therapists primarily suffered from musculoskeletal pain related to the back and shoulders, while depressive symptoms were the most common symptom of psychological distress. Owners of businesses that suffered economic consequences had a higher prevalence of high psychological distress, which may call for targeted support of this group in future similar contexts. Future longitudinal studies during the pandemic are warranted to assess these associations further.

Background Neck and back pain are common musculoskeletal conditions in university students and associated with unhealthy lifestyle behaviors such as physical inactivity, unhealthy dietary habits, smoking and risky alcohol use. Cohort studies have investigated the effect of a healthy lifestyle including several lifestyle behaviors on the risk and prognosis for neck and back pain. Studies of an association between an unhealthy lifestyle and musculoskeletal conditions in university students are lacking. This study aimed to assess the association between an unhealthy lifestyle and incident activity-limiting neck/back problems (ALNBP) in university students. Methods Participants enrolled in the Sustainable UNiversity Life (SUN) study who did not report baseline ALNBP in the past three months were included ( n  = 3492). The baseline web-survey assessed unhealthy lifestyle behaviors (physical inactivity, high sitting time, meal skipping and risky use of alcohol, tobacco, and illicit drugs) with valid instruments and single-item questions. Participants with ≥ 3 unhealthy lifestyle behaviors were categorized as exposed to an unhealthy lifestyle. Responses to web-based follow-up surveys every third month until first reporting ALNBP or to the end of the one-year follow-up were used. The outcome ALNBP was defined as reporting limitations in daily activities due to a neck, low back and/or midback problem the past three months, assessed with a modified version of the Nordic Musculoskeletal Questionnaire. Crude and adjusted Cox regression models were built to assess the association between an unhealthy lifestyle and incident ALNBP, reported as a hazard rate ratio (HRR) with a 95% confidence interval (CI). Results Sixty percent of the participants were women, and the mean age was 24.5 ± 6.0 years. A total of 574 participants (16%) were exposed to an unhealthy lifestyle at baseline. Having an unhealthy lifestyle generated an adjusted HRR of 1.35 (95% CI 1.12, 1.63) for incident ALNBP, compared to not having an unhealthy lifestyle. Conclusions An unhealthy lifestyle, categorized as ≥ 3 unhealthy lifestyle behaviors, is associated with incident ALNBP in university students.

Background In Sweden, almost 60% of patients seeking care at primary healthcare centers do so due to musculoskeletal disorders. These patients constitute a strain on the healthcare system. Manual therapists are experts in diagnosing patients with these conditions but are usually not part of healthcare centers in Sweden. Further, there is a significant societal problem with overuse of medications, injections, medical imaging, and unnecessary surgeries, so-called low-value care, for back and neck pain. We aimed to explore the current management of patients with back and neck pain in primary healthcare centers, staff’s perceptions regarding the need for improvement, and incentives and concerns about having licensed chiropractors and naprapaths (manual therapists) triage these patients as part of the primary healthcare center team. Methods In this qualitative study, we conducted semi-structured focus group interviews with 20 participants employed at three primary healthcare centers in the Stockholm region, chosen based on location, organization, and exposure to manual therapists. Participants were purposefully selected from different professions. Data were analyzed using inductive qualitative manifest and latent content analysis. Results The current management of patients with back and neck pain was described in terms of long waiting times and patients’ expectations of seeing a medical doctor and receiving imaging. Thus, there was room for improvement by reducing low-value care. Participants had limited knowledge about the competence of chiropractors and naprapaths and were concerned about the boundaries of professional identity. Decreased physician workload and more choices for patients were mentioned as incentives for manual therapists to take on a triaging role. Conclusions Staff at three primary healthcare centers in the Stockholm area described the current management of patients with back and neck pain as navigating the expectations of patients and their overreliance on seeing their physician, not other caregivers, resulting in long waiting times. Alongside patients expecting imaging, these were incentives for chiropractors and naprapaths triaging these patients as an opportunity to improve care. A lack of knowledge about the competence of manual therapists was a concern, and assigning manual therapists to the primary healthcare team would necessitate a reconfiguration of the care process, potentially challenging the boundaries of professional identity.

Background Changes in Swedish university students’ lifestyle behaviors during the COVID-19 pandemic are unknown. This study aimed to assess physical activity, sitting time, meal frequency and risk substance use (alcohol, tobacco, and illicit use of drugs) in Swedish university students before and during the first six months of the COVID-19 pandemic, for all and stratified by age and sex. Methods Data were obtained from the Sustainable University Life cohort study in which web-based surveys were sent to university students repeatedly for one year. Baseline assessment (before the pandemic) was between August 2019-March 2020, follow-up 1 (FU1) between March-June 2020, and follow-up 2 (FU2) between June–September 2020. Participants reported weekly minutes of physical activity, daily sitting hours, meal frequency by weekly intake of different meals, and motivation for eating irregularly, if so. Also, harmful use of alcohol, tobacco and illicit drugs was assessed. Population means and differences with 95% confidence intervals (95% CI) in lifestyle behaviors between time points were calculated with Generalized Estimating Equations. Results 1877 students (73% women, mean age 26.5 years) answered the baseline survey. Weekly exercise decreased by -5.7 min (95% CI: -10.0, -1.5) and -7.7 min (95% CI: -12.6, -2.8) between baseline and FU1 and FU2, respectively. Weekly daily activities increased by 5.6 min (95% CI: 0.3, 11.7) and 14.2 min (95% CI: 7.9, 20.5) between baseline and FU1 and FU2. Daily sitting time decreased by -1.4 h (95% CI: -1.7, -1.2) between baseline and FU2. Breakfast intake increased by 0.2 days per week (95% CI: 0.1, 0.3) between baseline and FU2. Lunch intake decreased by -0.2 days per week (95% CI: -0.2, -0.1) between baseline and FU1 and by -0.2 days per week (95% CI: -0.3, -0.0) between baseline and FU2. Dinner intake decreased by -0.1 days per week (95% CI: -0.2, -0.0) between baseline and both FU1 and FU2. Only minor differences in risk substance use were observed. Similar changes were observed in analyses stratified by age and sex. Conclusions Lifestyle behaviors in Swedish university students slightly improved during the first six months of the COVID-19 pandemic compared to before. Trial registration ClinicalTrials.gov, NCT04465435 . 10/07/2020.