some countries such as the united states. media ccsvi has received a great deal of attention in all media, the scientific literature and on the internet. moreover, the ccsvi case has been considered a good example of how new communication technologies and social media are modifying the traditional relationship between science, politics, medicine, and the general public. in this sense they have played a key role in effectively promoting the theory. media coverage has been perceived by some as "hype", with exaggerated claims that have led to excessive expectations. this has been partially attributed to some of the investigators of the theory. mainstream media initial approximations to zamboni's theory were enthusiastic and emphasized zamboni's effort to find a cure for his wife, along with the improvement of some patients after its alleged treatment. initial difficulty reproducing results connecting ms and ccsvi, combined with reports of secondary effects of the surgical procedure, led to a more cautious discourse proposing that more investigation in the relationship between ccsvi and ms was needed. the first fatality related to ccsvi treatment was a pivotal development in this trend towards a less optimistic media view of the theory. the internet has been extensively used by patient groups to obtain and disseminate information on ccsvi. people with ms often read extensively about the ccsvi theory and its development on internet sites, and a search for "liberation procedure" in google as of august 2010 yielded more than 2.5 million hits. the internet has also been used to advertise places where stenting for ccsvi is performed, and to more generally disseminate all the information on ccsvi. social media have served patient groups in their attempt to pressure official bodies to make decisions favoring funding of clinical trials, or the public coverage of stenting and venoplasty as treatments of ms. likewise, social media have been accused of creating a division between ccsvi supporters and those who say it does not work. indeed, they have been repeatedly used by advocates of the ccsvi theory to attack those who were more critical or cautious, most commonly with accusations of being tainted due to commercial relationships with pharmaceutical companies. many patients who have had the surgical procedure report their improvements on social media websites such as structured patient databases and youtube. such stories are only anecdotal evidence of efficacy, and do not constitute a scientific proof of the efficacy of the treatment since, for example, those who have had a positive result are more prone to post their cases than those who had little or no improvement, and the reported improvements in patients' condition can be attributed to the placebo effect. patients' reasons for not publishing negative results may include embarrassment about the money spent in the procedure without effect and the negative reaction they expect from other people with ms. caution has been recommended regarding patients' self-reports found on the web. scientists and physicians transmitted their arguments regarding ccsvi inadequately, especially after the initial rising of the hypothesis. their communication was characterized by an excessive hesitation and a lack of clear statements, as opposed to ccsvi proponents, who "won the communication battle, at least in the early rounds." a positive effect of the important media coverage may be that it forces the world of medical research to be self-critical and give appropriate responses to the questions that globalization of the theory raises, especially among people with ms. reception in canada while reasons are not completely clear, the ccsvi theory was received differently in canada than other places. the public interest and number of media appearances were much greater than elsewhere, including italy, and debate has been heated regarding funding. as an example, by the end of 2009, a public petition to the country health authorities in support of the "liberation treatment" had received over 17,000 signatures. the debate regarding funding in canada has been considered to be specially informative as an example of extreme involvement of politics, due to public pressure, in decisions usually governed by scientific evidence. in 2009, the multiple sclerosis society of canada committed to funding research on the connection between ccsvi and ms, although later in 2010 it came under criticism for opposing clinical trials of ccsvi therapy. the ms society of canada in september 2010 reserved one million dollars toward ccsvi research "when a therapeutic trial is warranted and approved." at a political level there have been contradictory positions, with some provinces funding trials, others stating that since therapy is unproven they should wait, and others urging for a pan-canadian trial. british columbia, alberta, and newfoundland and labrador funded observational studies in which patients who had already received the treatment were included. over 2 million dollars were allocated to these studies. the province of saskatchewan was more aggressive and provided 2.2 million dollars for some of its residents to be included in a clinical trial. the canadian institutes of health research (cihr), the federal agency responsible for funding health research, recommended in 2010 against funding a pan-canadian trial of liberation therapy because there was a lack of evidence on the safety or efficacy of the procedure. it suggested a scientific expert working group made up of the principal investigators for the seven ms society-sponsored studies. the health minister accepted the cihr recommendation and said that canada was not going to fund clinical trials. the expert panel was created by the end of 2010 together between the cihr and the ms society of canada. it has been proposed that the creation of this expert panel was partly directed to cope with the high levels of social pressure the ccsvi theory had raised and at the same time try to maintain a scientific perspective in the funding and investigation of ccsvi. the main task of the panel was to monitor the results of the ongoing studies in the relationship between ccsvi and ms and recommend the funding of a clinical trial in case that there was evidence of a true relationship between the two. in 2011, the canadian federal government announced that they would fund clinical trials of the procedure to widen the veins since cihr considered that evidence of venous abnormalities in ms was enough for small treatment trials. it has been proposed that the recommendation to fund phase i and ii trials instead of a big study was a compromise between the high levels of social and political pressure and the low level of evidence on the theory. two qualitative studies have investigated the motives and experiences of canadian patients traveling abroad to get the "liberation procedure". one of the studies identified three factors contributing to patients going abroad seeking treatment: a loss of faith in the canadian health system when it did not provide access to ccsvi treatment in canada, hope in the new treatment as a solution for their worsening health, and trust in the ms community and the organizations, clinics and doctors facilitating or providing the desired operation. conversely, the other study concluded that sense of community and cooperation (from family, ms groups and the general population) was a key motivating factor. other motivating factors included media reports, perception of approval from their health providers, the apparent low risk of the operation, or accessibility of the hospital that offered the procedure directly or through a medical tourism company. on the other hand, hesitating factors included the cost and effort required for the operation, the mistrust of foreign health systems, the underlying rationale for the operation, or advice against the procedure from trusted health providers. in 2013, a case-control study found evidence against the involvement of chronic cerebrospinal venous abnormalities in ms. later in 2013 a study found that vein narrowing appears to be present equally in those with and without ms on ultrasound and catheter venography. the results of the study were described as a "death knell" for zamboni's theory. another study released by the university of british columbia in 2017 was described as a "definitive debunking" of liberation therapy. organizations several national and international organizations have been created to further the research and dissemination of the ccsvi theory, such as the international society for neurovascular disease and the national ccsvi society of canada. they are working together with already existing organizations like the international union of phlebology (union internationale de phlébologie-uip- in french, its original working language) of which zamboni is a member. the uip for example proposed that developmental abnormalities were the primary cause of ccsvi. research there were further studies aimed at clarifying if there is a relationship between ms and ccsvi. in particular, the us and canadian ms societies launched seven such studies. recent reviewers have shown "no significant difference in prevalence of ccsvi in people with ms compared to people without ms". in 2014 imaging criteria for venous abnormalities were published to help with research on this topic.