**1. Introduction**

The novel coronavirus disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged in Wuhan, China, in December 2019 (COVID-19) was declared a global pandemic by the World Health Organization on 11 March 2020 [1]. Major human events and natural calamities such as global pandemics have the potential to affect human behavior and access to resources, including healthcare seeking behavior and service utilization. There is emerging evidence that the COVID-19 pandemic has impacted a wide range of health services, including stroke emergency services [2–4], medical imaging services [5,6], and hospice care [7]. However, the impact of the COVID-19 pandemic on manual therapy service utilization is unknown.

In Australia, chiropractors, osteopaths, and physiotherapists are registered healthcare practitioners trained to diagnose, treat, and manage patients with musculoskeletal conditions. As of the first quarter of 2020, there were 5383 chiropractors, 2627 osteopaths, and 33,299 physiotherapists with general registration to practice in Australia [8–10]. The manual therapy services provided by these professions are predominately paid for by non-government sources (i.e., private health insurers and individuals). Studies have documented increased utilization of manual therapy services over time in Australia, albeit with diverging trends across professions [11,12]. It has been estimated that approximately 21.6 million manual therapy services with a total cost of AUD 1.4 billion were provided within the Australian private healthcare setting annually in the period between 2013 and 2017, which represented a significant increase from the preceding five-year period [12]. It remains to be determined how these trends and figures have been impacted by the COVID-19 pandemic.

This study aimed to quantify the impact of the COVID-19 pandemic on manual therapy service utilization within the private healthcare setting in Australia. The specific objectives were to quantify the absolute and relative difference between forecasted and observed number and total cost of services during the first half of 2020 for each manual therapy profession.
