Analysis of Acute Non-specific Back Pain Content on TikTok: An Exploratory Study

Introduction In this study, we evaluated the scope of acute non-specific back pain (ANSBP) content available on TikTok (ByteDance Ltd, Beijing, China) in 2021. It is plausible that TikTok’s popularity among teenagers, adolescents, and young adults may influence decision-making about what constitutes appropriate ANSBP self-care among a younger age cohort. Methods We examined 157 of the most viewed videos available through the hashtag #backpain available on TikTok in September 2021. We examined the following research questions: (1) What are the metadata characteristics of the videos in the final data set?, (2) What are the creator identities reflected in the final data set in this study?, (3) What are the ANSBP self-care content themes in the final data set?, and (4) What are the characteristics of the data set based on a low back pain reference checklist based on consensus guidelines?. Results We identified clear differences based on TikTok creator identity in our data set of most popular videos. We examined videos created by chiropractors, fitness professionals, influencers, physicians, physiotherapists, and other creator identities. We found that the TikTok videos created by chiropractors were consistently among the most viewed, most commented, and most shared. Conversely, chiropractic TikTok videos consistently had the lowest self-care reference checklist scores relative to all other disciplines. That is, TikTok videos created by chiropractors were least likely to reflect the scientific consensus on treating ANSBP. Discussion TikTok is an increasingly popular medium for disseminating short health messages. The main cohort using TikTok is young and at risk of ANSBP. However, we postulate that the messages reaching young TikTok users overall do not generally reflect the self-care advice described in consensus guidelines. Conclusion TikTok is a popular social media channel among young people. However, the most viewed TikTok videos about ANSBP are not produced by mainstream health professionals and the videos featuring the #backpain hashtag do not generally reflect contemporary evidence-based practice. There is considerable scope for mainstream health professionals to provide evidence-informed self-management and self-care content for ANSBP on TikTok.


Introduction
This exploratory study aims to increase the understanding of acute non-specific back pain (ANSBP) content available on TikTok (ByteDance Ltd, Beijing, China). This paper will also examine whether approaches used to analyse YouTube (Google LLC, Mountain View, California, United States) health videos can be applied to TikTok health content. Low back pain imposes a high social and financial burden in all countries across the globe [1]. In the introduction, we have examined the epidemiology of low back pain in younger populations, self-management and self-care of back pain, an overview of TikTok, and approaches to the analysis of health information on TikTok.

Epidemiology of ANSBP in younger populations
Acute low back pain is generally regarded as lasting less than six weeks [2]. In most cases, acute low back pain is non-specific [3,4]. The diagnosis of non-specific low back pain implies no known causes such as

About TikTok
TikTok is a video-sharing focused social networking service launched in 2018 [12,13]. TikTok hosts a variety of short videos, in fixed categories, including dance and fashion. The duration of these videos ranges from 15 seconds to 3 minutes. Since 2018, TikTok use has grown rapidly. In December 2018, TikTok globally had more than 271 million active monthly users, and 1 billion by September 2021 [14]. A 2021 national United States (US) Pew Research study found phone application users aged 18 to 24 years were likely to report using Instagram (76%), Snapchat (75%), or TikTok (55%) [15]. In 2020, 69% of the TikTok user base were aged 13 to 24 years [16]. In summary, TikTok is a popular social medium used by a younger age cohort. This age cohort is also likely to experience ANSBP.

Health information on TikTok
Google Scholar suggests scientific engagement with TikTok began in 2018. In 2021, health content on TikTok had still not been widely examined in scientific literature. In 2021, there was nascent literature on analysing TikTok videos for health self-care. Among the health care conditions researched were COVID-19 [17], diabetes [18], mental health [19], safe sex [20], dermatology [21], chronic obstructive pulmonary disease (COPD) [22], and oral health [23]. We did not identify any peer-reviewed papers examining TikTok video use for ANSBP.
TikTok has been associated with misinformation in the mass media. In 2021, media monitoring organisation NewsGuard reported COVID-19 vaccine misinformation directed at children aged under 13 on TikTok [24]. The creators suggested TikTok was not adequately monitoring health disinformation. Conversely, TikTok community guidelines are directed at preventing health disinformation [25]. TikTok has reported that community guidelines for creators, including health content, are strictly enforced [26].

Approaches to TikTok Health Video Analysis
TikTok in 2021 was a relatively novel medium for health content. The limited peer-reviewed health literature on TikTok in 2021 revealed heterogeneous approaches to research into this social media platform. However, by 2021, there was a larger body of research describing the use of YouTube videos to reach specific groups with condition-specific health messages. In 2021, YouTube was the second most popular social medium and the most popular video social medium [27]. The approaches to analyses of YouTube videos are more mature than that of TikTok. Given the similarities between YouTube and TikTok, we suggest that the methods of analysis of YouTube videos may be applicable to that of TikTok.
Several investigators have examined the methods used to analyse YouTube health content. Drozd and colleagues noted that most researchers develop independent scoring systems and that no commonly agreed on methods exist [28]. Systematic reviews of YouTube analysis methods have focused on the use of validated reference checklists and described the range of approaches and indicators across multiple studies [29,30]. In 2020, Zheluk and Maddock described three broad approaches to the analysis of YouTube health content [31]. These approaches were: (1) analysis of the video metadata exclusive of the content; the most common metadata elements included the number of views, video length, likes, date posted, and language of the video, (2) information quality of videos using validated instruments such as DISCERN (no abbreviation), Journal of the American Medical Association (JAMA) Benchmark Criteria, and Health on the Net Foundation Code of Conduct (HONcode) to evaluate the quality of health information directed at consumers and clinicians; Lee and colleagues reviewed several approaches to assessing health information quality and among the common dimensions by these researchers were accuracy, completeness, consistency, timeliness, validity, and uniqueness [32], and (3) evaluation of video content by expert clinicians by comparing content to reference standards.
Researchers have adopted the methods used for analysing YouTube videos for analysing TikTok health content. These approaches include analysis of information quality using the DISCERN instrument, by creator professional background, by expert clinical review, or by metadata (for example, the number of views, number of comments and likes) [18,21,33]. This research study aims to increase the understanding of ANSBP content on TikTok and to further develop methods for analysing TikTok video content.

Materials And Methods
This exploratory study aimed to evaluate the scope of ANSBP content available on TikTok in September 2021. In order to evaluate the scope of ANSBP TikTok content, we examined the following research questions (RQs). RQ1: What are the metadata characteristics of the videos in the final data set?, RQ2: What are the creator identities reflected in the final data set in this study?, RQ3: What are the ANSBP self-care content themes in the final data set?, and RQ4: What are the characteristics of the data set based on a low back pain reference checklist?.
We modified the methods developed by Zheluk and Maddock for their analysis of YouTube videos about acute non-specific low back pain (ALBP) [31]. First, in this study, we have assumed that ANSBP TikTok videos are viewed by patients for self-care guidance only (i.e., TikTok videos are viewed independent of health advice). The study by Zheluk and Maddock primarily focused on self-management guidance (i.e., videos intended to complement advice from health and fitness professionals). Second, we have modified the definition of ALBP used by Zheluk and Maddock to include all spinal pain. TikTok videos tagged with #backpain were included in our data set and, thus, include all spinal pain including neck pain. We have expanded the scope of included TikTok videos, as the result of limited anatomical localisation of the pain site in most videos reviewed in the final dataset. Third, in this project, we did not analyse information quality. Zheluk and Maddock found that the Brief DISCERN information quality instrument was less sensitive in identifying differences in the self-management content of YouTube videos than an evidence-based reference list [31]. Similarly, Azer and colleagues suggested that information quality tools were not suitable for analysis of YouTube video content [34].

Data collection and cleansing to obtain the final data set
We first identified ANSBP TikTok videos for analysis through three steps.

Step 1: Selection of Search Terms for Content Discovery
Users can access TikTok videos through the TikTok algorithm or hashtags (#). The TikTok algorithm will serve individualised content to each TikTok user [35]. Hashtags are a facilitator for discovery of specific themed content on TikTok. A single TikTok video may have multiple hashtags. We identified the hashtag "#backpain" as the most viewed relevant TikTok search term ( Table 1). By September 2021, TikTok videos with #backpain had produced 1.3 billion views [36]. From a temporal perspective, the views on TikTok represent the aggregate global views of each individual #backpain TikTok video since publication. No national or subnational TikTok view data is publicly available  Step 2: Raw Data Set We initially identified a raw data set of the 200 most viewed TikTok videos by searching for #backpain in the TikTok app on September 30, 2021. These 200 TikTok videos were our raw data set, which represented approximately 47% of all TikTok views for #backpain as of September 2021 [36]. Second, we downloaded the metadata for these TikTok videos. We used the TikTok scraper and downloader tool (TSDT) version 1.4.36 in order to scrape the metadata for #backpain TikTok videos in the raw data set [37]. Data scraping is the process of importing data from a website into a spreadsheet for further analysis [38] . The TSDT allows for downloading of metadata and video content for specified number of videos for a specific TikTok hashtag. The relevant fields contained in the metadata include the number of views of each video at the specified date, length, internet address, publisher, and date of publication. Step

Research Questions
We used the final data set in order to answer four RQs.

RQ1: What are the Metadata Characteristics of Videos in the Final Data Set?
We used the metadata obtained via the TSDT to answer this question. Zheluk and Maddock used descriptive statistics to examine length of YouTube videos, the number of views, and channel names [31]. In this study, we used the following data fields: days since published to September 30, 2021, views (PlayCount), video duration, likes (DiggCount), shares, and comments. Through this approach, we were able to describe the metadata characteristics of the final data set.

RQ2: What are the TikTok Creator Identities in the Final Data Set?
We coded the 157 unique TikTok videos in the final data set according to the creator's identity. We used the same author identities as Zheluk and Maddock did in their analysis of back pain YouTube videos [31]. We used the following six creator identities: chiropractor, fitness professional, influencer, physician, physiotherapist, and other. See Table 2 for creator identity definitions. Researchers have suggested that the creator's identity contributes to user assessments of source credibility online [39].

Creator identity Definition
Chiropractor Self-identifies as chiropractor OR student of this discipline in TikTok video OR creator identity obtained through Internet search Fitness Self-identifies as fitness professional therapist in TikTok video OR creator identity obtained through Internet search

Influencer
No professional or commercial affiliation explicitly listed.

Physician
Self-identifies as medical /osteopathic physician OR student of this discipline in TikTok video OR creator identity obtained through Internet search. Note: US physicians may obtain medical registration through an osteopathic educational pathway.

Physiotherapy
Self-identifies as physiotherapist/physical therapist OR student of this discipline in TikTok video OR creator identity obtained through Internet search Other Commercial or other organisational affiliation listed explicitly in TikTok video OR creator identity obtained through Internet search.
This includes religious healers, massage providers, yoga, sales, and education providers. We first coded each TikTok video according to one of three intervention themes: education, real-time exercise, or real-time treatment. See Table 3 for definitions of intervention themes. These intervention themes were used by Zheluk and Maddock to assess ALBP YouTube content [31]. Second, we analysed the three intervention themes according to creator identities. The six creator identities were: chiropractor, fitness professional, influencer, physician, physiotherapist, and other.

Education
More than 50% (i.e., the majority of the video) is dedicated to discussion of back pain content or associated aggravating or ameliorating factors including physical and mental health considerations Exercise More than 50% (i.e., the majority of the video) is dedicated to real time exercise by clinician or other identity Treatment More than 50% (i.e., the majority of the video) is dedicated to real-time hands-on treatment by clinician or other identity on another person, that does not involve exercise or education. We analysed the final data set based on the ALBP reference checklist originally developed for the analysis of YouTube videos by Zheluk and Maddock [31]. See Table 4 for the reference checklist codebook. The YouTube checklist was based on recommended first-line ALBP items described by Foster et al. [40]. The checklist included items that an individual patient may reasonably be expected to independently implement as part of a self-management or self-care intervention for ALBP. For the purposes of this TikTok project, we have assumed ALBP self-care guidance is also suitable for ANSBP. NO: The exercises are not suitable as described above.
ADL (Activities of daily living) "Advice to remain active" [40] YES: At least ONE mention of ADL via narration, desk or visual images. This includes walking, modifying the environment, sport and recreation, modifying ADL, maintaining ADL.
NO: No mention of ADL as described above Analgesia Superficial heat NSAIDs [40] YES: At least one mention of: (1) OTC pharmacological analgesia OR (2) non-pharmacological self-management described in guidelines (for example NSAIDs, heat, ice, pacing, ergonomics) NO: No mentions of pharmacological or non-pharmacological analgesia; use of spinal manipulation.
Soothing affect CBT/mindfulness-based stress reduction education [40] YES: Is the video emotionally soothing overall? This includes education content, editing, music, encouraging fear or catastrophizing, loud or frantic narration NO: Not soothing overall as per the description of the soothing affect as described above.

Intercoder reliability
Coding was conducted by the three authors of this study. Intercoder reliability was achieved through intercoder consensus [41,42]. Following initial coding by Author A, we conducted team-based coding with Authors B and C. We identified an initial discrepancy of 20 individual items within the 157 TikTok videos in the final data set. Following team negotiations, changes to TikTok coding and changes to the codebook were introduced. The final data set and codes represent a team consensus position. No Cohen's Kappa or Krippendof Alpha tests were performed. In summary, by examining the characteristics of individual TikTok videos, we aimed to determine the relative concordance of TikTok videos produced by different creator identities with the consensus-based low back pain self-management guidelines.

Results
We identified clear differences based on the creator's identity in the TikTok final data set. We found that the TikTok videos created by chiropractors were consistently among the most viewed, most commented and most shared. Conversely, chiropractic TikTok videos generally had the lowest self-care reference checklist scores relative to all other disciplines. That is, TikTok videos created by chiropractors were least concordant with the reference checklist and, thus, these were least likely to reflect scientific consensus on treating ANSBP.

Metadata characteristics of the videos in the final data set
We examined six different metadata characteristics (

TikTok creator identities in the final data set
We coded the 157 TikTok videos in the final data set into six creator identities ( Table 6). Chiropractors were the most common identity creating TikTok videos in the final data set (46%; n=72), followed by fitness professionals (22%; n=34), physicians (3%; n=5), and physiotherapists (3%; n=5). In summary, the highest proportion of the final data set was created by chiropractors (

Intervention themes in the final data set
We examined TikTok videos in the final data from the perspective of three types of intervention: education, exercises, or treatment ( Table 7). The salient findings were: (1) videos by fitness professionals (71%; n=24) and chiropractics (63%; n=45) primarily featured exercise content; these TikTok videos generally offered a single exercise, with no information about frequency or duration, (2) videos by influencers primarily featured educational content (73%; n=22); these TikTok videos often featured suggestions about managing ANSBP throughout activities of daily living. The remaining creator identities were represented by a small number of TikTok videos, in which we could not identify a specific theme.

Characteristics of the final data set based on a reference checklist
We analysed the final data set based on the reference checklist. We found differences in the self-care advice contained in TikTok videos based on creator identity ( Table 8). Most notably, few videos under any creator identity carried any information about when to visit a medical professional, or red flags indicating potentially serious underlying pathology. Other salient findings were: (1) physiotherapy TikTok videos were most suitable for individuals in acute pain (100%; n=5), most frequently discussed analgesia (60%; n=3), and most frequently provided an appropriate prognosis (60%; n=3); however, the overall number of physiotherapist TikTok videos was small, and this result should be interpreted with caution, and (2) influencer created TikTok videos focused on personal experiences of pain resulting from activities of daily living (70%; n=21) and were most likely to feature an affective dimension (27%; n=8) than other creator identities. Finally, the data in Table 8 is nominal data and is not suitable for statistical analysis.

Discussion
TikTok is an increasingly popular medium for disseminating short health messages. This exploratory study aimed to evaluate the scope of ANSBP content available on TikTok as of September 2021. The main cohort using TikTok is young and at risk of ANSBP. However, we suggest that the messages reaching young TikTok users overall do not generally reflect the self-care advice described by Foster et al. [35,40]. We found that methods used for the analysis of YouTube videos may also be adapted to the analysis of TikTok videos.

Metadata
The metadata for the final data set revealed that chiropractic TikTok videos were consistently the most viewed, commented, and shared in our data set. Zheluk and Maddock (also studying ANSBP) similarly found chiropractic videos were consistently the most commonly viewed and most commented videos on YouTube [31]. We did not identify peer-reviewed literature describing the popularity of chiropractic on social media. However, we identified grey literature describing the use of TikTok, YouTube, and Instagram as an important marketing channel by the chiropractic profession [43]. Specifically, this literature describes the focus on cracking sounds associated with spinal manipulation as a form of Autonomous Sensory Meridian Response (ASMR). These ASMR videos are explicitly directed at marketing the chiropractic profession [44]. ASMR refers to the sensations elicited in response to a range of sounds including whispering, spinal manipulation, and eating [45]. Further, chiropractic TikTok videos frequently feature young female patients wearing tight or limited clothing. See for example the TikTok video created by chiropractor Dr Alex [46]. In summary, this suggests TikTok is being actively used by the broader chiropractic profession as a marketing channel.

Creator identities
Chiropractors were the main creator identity identified in our study. Chiropractic TikTok videos in our data set were the oldest of all identities, with an average (mean) of 316 days since publication. This suggests chiropractors have been early adopters of TikTok as a medium. Chiropractic TikTok videos were also the most popular. The higher average age of chiropractic TikTok videos may partially account for their higher view counts. Zheluk and Maddock similarly found a high number of ANSBP videos on YouTube were created by chiropractors [31]. Further, in comparison with YouTube, we found a near absence of physiotherapists (3%; n=5), physicians (3%; n=5), and no videos from yoga instructors (0%) in the final data set. The absence of physiotherapists, physicians, and yoga instructors in #backpain TikTok videos is noteworthy. Zheluk and Maddock suggested video content created by these three disciplines was more consistently aligned with ALBP self-management guidelines than those created by chiropractors or fitness professionals.

Intervention themes
We examined education, exercise, and treatment as potential intervention themes. The most common intervention theme in our data set was exercise. The limited information about duration, frequency, progression of exercises, and precautions suggest that individuals using this information may be more likely to gain little benefit or risk further pain and injury from conducting these exercises. The short mean duration of TikTok videos in our dataset (e.g., 19.97 seconds for chiropractic videos) compared to YouTube ALBP videos may influence content considerations. TikTok videos in our final dataset frequently featured a single activity. Activities included an exercise, a discussion of pain, or chiropractic manipulation. By contrast, YouTube videos generally offer a slower-paced and more comprehensive examination of low back pain topics. Influencers describing pain and activities of daily living were another notable finding. We coded these influencer TikTok videos as education.

Reference checklist
Overall, we found limited concordance between popular chiropractic and fitness TikTok videos and the ANSBP reference checklist. Most notably, few videos carried any information about when to visit a medical professional or any other precautionary information. This suggests that by excluding disclaimer information, the short duration of TikTok videos may expose creators to some medicolegal risk. Most identities similarly demonstrated limited concordance with the reference checklist. However, TikTok offers creators the option of creating three and five-minute videos. We found some of the longer videos offered greater scope for presenting content similar to YouTube. This suggests that TikTok has the potential to offer guidelineconcordant content and more complex advice. Conversely, these longer videos may be less appealing to TikTok audiences [47].

Translation of methods from YouTube to TikTok
We believe that methods translated from YouTube, as described in this paper, may also be appropriate for the analysis of ANSBP video content on TikTok. Specifically, the methods that may be applied to TikTok videos include: (1) the analysis by creator identity to analyse TikTok metadata. The constantly changing popularity of individual TikTok videos suggests individual videos may not offer the optimal unit of analysis. We suggest an analysis of data sets aggregated by creator identity may provide a more consistent approach to the analysis of broader trends in TikTok health information; (2) The analysis of TikTok videos by intervention themes such as education, treatment, and exercise, in combination with creator identity and metadata appears to offer insights into the scope of health information available beyond simple description. These themes should be grounded themes, i.e., they should be based on analysis of the specific data set; and (3) the use of a reference checklist to assess TikTok videos against consensus guidelines as an approach to evaluating ANSBP content across social media.

Limitations
This paper had several limitations. First, we did not examine the literature on digital health interventions. This study examined the scope of ANSBP TikTok videos available in 2021. By conducting this study we also aimed to extend the methods used for the analysis of TikTok videos. Second, we did not examine TikTok videos from the perspective of misinformation. Suarez and colleagues define health misinformation as a "health-related claim that is based on anecdotal evidence, false, or misleading owing to the lack of existing scientific knowledge" [48]. In this study, we identified the use of misleading TikTok videos for marketing purposes by chiropractors. We suggest these TikTok videos appeared motivated by financial gain rather than lack of scientific knowledge and are thus not consistent with this definition of heath disinformation. While the presentation of misleading ANSBP information on TikTok merits consideration, this is beyond the scope of this study.

Further research
In this paper, we made limited comparisons between YouTube and TikTok from the perspective of translating methods for analysing videos across social media platforms. We believe further research that examines the optimal use of the unique features of each popular social media platform by various health disciplines is merited.
Second, there appear to be several opportunities for health professionals seeking to use TikTok for the dissemination of ANSBP information. We identified a potential demand for information about ADL based on TikTok videos produced by influencers. We suggest that the limited presence of mainstream health professionals such as physicians and physiotherapists offer opportunities to reach younger age cohorts with health messages about ANSBP and other health conditions. The use of TikTok by younger age cohorts to self-care and self-manage ANSBP thus also merits further research.
Third, we believe chiropractic TikTok videos merit further research. Chiropractic TikTok videos featuring young women and ASMR represent a novel health marketing phenomenon. We found TikTok videos created by chiropractors to be consistently rated poorly by coders against the ANSBP reference checklist. This marketing phenomenon may be influencing future expectations of what constitutes appropriate ANSBP care among younger TikTok users.
Fourth, content analysis cannot examine the actual impact of TikTok videos on individual decision making. Future research may establish this causal relationship. In summary, TikTok is a popular social medium that is under-researched. This paper contributes to the TikTok methods literature and to the understanding of the scope of ANSBP information available on TikTok.

Conclusions
TikTok is a popular social media channel among young people and it is plausible that it may influence decision making about what constitutes appropriate ANSBP self-care in young people. However, we found that most messages reaching younger people about ANSBP self-care do not reflect evidence-informed guidelines. The most viewed TikTok videos about ANSBP are not produced by mainstream health professionals. There is scope for mainstream health professionals to provide evidence-informed selfmanagement and self-care content for ANSBP. This requires that mainstream health professionals adopt creative approaches to transmit their ideas effectively via the novel TikTok social media platform.

Additional Information Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.