Thesis (M.Tech.: Chiropractic) -Dept. of Chiropractic, Durban Institute of Technology, 2006. xiii, 44 leaves, Annexures A-F / The purpose of this study is to determine whether the cumulative effect of studying, and practising manual therapeutic techniques (including receiving manipulation), is associated with chiropractic students experiencing low back pain (LBP). According to Smith (2005), students currently registered in the Durban Institute of Technology Health faculty were found to have the highest proportion of LBP when compared to students in other faculties. Thirty seven percent of the students with LBP were chiropractic students. In a study performed by Macanuel et al. (2005) on undergraduate chiropractic training, it was concluded that chiropractic students experience side effects during chiropractic technique class. There is epidemiological evidence that chiropractors are a high-risk group of health professionals who experience low back disorders (Tim 1996, Lorme and Naqv 2003, Rupert and Ebete 2004). Rupert and Ebete (2004) suggest that the majority of chiropractors have suffered an occupational injury primarily related to administering manual procedures.

Thesis(M.Tech.: Chiropractic)- Dept. of Chiropractic, Durban Institute of Technology, 2005 xi, 62 leaves / To compare the relative activation and endurance of core stability muscles in 2 different populations i.e. elite athletes and non-athletes, and establish whether these findings correspond to episodes of mechanical lower back pain.

Submitted in partial compliance for a Masters Degree in Technology: Chiropractic, Durban University of Technology, 2009. / The aim of this study was to investigate patient management protocols of low back pain (LBP) by chiropractors in the greater Durban metropolitan area. In this investigation a more generalized approach was chosen to investigate trends within the field of patient management and education for LBP. The study population of 80 chiropractors in the greater Durban metropolitan area, required a minimum response rate of 70% to obtain statistical significance (Esterhuizen, 2008), which was achieved. This study involved a quantitative descriptive design utilizing a questionnaire developed and validated by the researcher and focus group. The questionnaire was comprised of three sections, including personal information, treatment protocols and patient management with advice and education. Statistical analysis involved the use of SPSS version 15.0 (SPSS Inc., Chicago, Illinois, USA), a data analysis tool. Descriptive objectives were analysed with frequency tables and cross-tabulation tables (Esterhuizen, 2008). Demographic variables and practice variables were assessed for association with responses to the questionnaire using Pearson’s Chi square test in the case of categorical demographics and responses (Esterhuizen, 2008). Bar graphs were included to reflect the treatments that were always or frequently used by respondents (Esterhuizen, 2008). There appeared to be a wide range of influences on practice philosophy and methods, independent of demographics and training institute. A chiropractor’s age was regarded as significant with regard to philosophical orientation. However, the majority of these chiropractors obtained their qualifications from international colleges. vi Spinal manipulations directed at quadratus lumborum myofascial trigger points were strongly advocated by respondents. Specific short lever manipulations were the preferred manipulation technique for treatment of LBP. Sacroiliac joint manipulation was also considered important by a significant proportion of respondents. Respondents most commonly recommended the use of mobilizations and cryotherapy when contra-indications to manipulation were evident. There was consensus in the number of days before the first follow-up after an initial treatment for a presentation of acute LBP, where 96.42% of respondents recommended follow-up at day 1 or 2. In chronic LBP first follow-up after initial treatment was recommended by 41.1% of respondents on day 2; 28.6% day 3 and 8.9% on day 1. Management protocols for acute LBP appeared to be more uniform when compared to management of chronic LBP. Despite the variances in philosophy and management protocols amongst respondents, there remains consensus that manual articular manipulation remains the mainstay in chiropractic treatment protocols for both acute and chronic LBP.

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Durban University of Technology, 2009. / Through the literature review it has become apparent that low back pain is a very real problem in most societies. It has been suggested that there is enough evidence to prove the relationship between low back pain and local muscle dysfunction and that focus in management of these patients should be the rehabilitation of these muscles by exercise. Literature suggests that optimal core muscle strength, control and endurance working synergistically with the rest of the neuromusculoskeletal system is necessary for lumbar spine stability . Arthrogenic Muscle Inhibition is caused by distension and/or damage of a joint and is thought to disable the muscle from contracting all its muscle fibres. When a joint is injured it is thought that AMI causes muscle weakness, which in turn hampers the rehabilitation process of that joint despite complete muscle integrity. Spinal manipulative therapy has been shown to alter the excitability of spinal muscle motor neurons due to the stimulation of mechanoreceptors in the joint capsules suggesting that SMT could be a means to remove this inhibitory action. The literature supports the hypothesis that a decrease in the neurological deficit caused by AMI may result in a faster recovery rate. Aims The aim of this study is to determine the immediate effect of thoraco-lumbar spinal manipulation compared to lower lumbar spinal manipulation on core muscle endurance and activity in patients with mechanical low back pain by assessing the correlation between the objective and subjective measures. Method A prospective, convenience sample with purpose allocation (pre /post) clinical trial was used as the sampling method. Thirty participants where placed in two groups, group one and group two, of fifteen people each. Group one underwent spinal v manipulative therapy between L4 and S1 spinal levels. Group two underwent spinal manipulative therapy in between T8 and L1 spinal levels. The objective and subjective testing was done pre- and post-intervention. The objective data was that of a surface EMG attached bilaterally over the internal oblique as well as a prone abdominal draw in biofeedback test. The subjective data included a pain numerical rating scale (0-100). Results The results showed to partially favour group two (thoraco-lumbar), in both increased endurance time that would prove that AMI does in fact inhibit the transversus abdominis and obliques internus, thus it would hinder the rehabilitative process. Some of the statistics where not in favour of the aims, as there was no difference in the effect of group one or two on the NRS, as both improved consistently. It would be recommended that use be made of fine-wire EMG for testing the activity in both the obliques internus and the transversus abdominis, which would allow for more consistent readings, thus adding strength to the research.

Dissertation submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2009. / Manual therapists are susceptible to occupational low back pain. The aim of this study was to determine the prevalence and risk factors for occupational low back pain in manual therapists and to determine and compare the prevalence and risk factors for occupational low back pain among various types of manual therapists in South Africa. This study was conducted as a cross-sectional survey and a self-administered questionnaire, developed from the literature and validated prior to the study, was mailed to 1500 randomly selected manual therapists, including: physiotherapists, occupational therapists, biokineticists, chiropractors, reflexologists, aromatherapists and massage therapists. A total of 233 completed questionnaires were returned, giving a response rate of 15.53%. Results revealed that the point prevalence of low back pain in manual therapists was very high at 41%, the one-year prevalence was 59% and the career prevalence was 74%. The point prevalence of low back pain was highest in aromatherapists and biokineticists, while both the one-year and career prevalence of low back pain was highest in occupational therapists and massage therapists. The risk factors for low back pain in manual therapists were: BMI; previous abdominal surgery; previous trauma to the low back, hips, knees or ankles; a physically stressful job; not having an assistant and work in a hospital or other setting. In keeping with the literature, various workrelated factors were implicated in the development and / or exacerbation of low back pain in certain manual therapists more than others and low back pain history in the different manual therapists was also in accordance with the literature. To conclude, low back pain is prevalent among South African manual therapists and the development and implementation of preventative programs to reduce rates of occupational low back pain in manual therapists is mandatory.

Dissertation in partial compliance with requirements for the Masters Degree in Technology: Chiropractic, Durban University of Technology, 2010. / The aim of this study was establish if Leander versus Static traction was useful for the treatment of facet syndrome, a common type of mechanical lower back pain seen by chiropractors. Two groups of fifteen participants were chosen on the basis of the inclusion and exclusion criteria. The first objective was to determine if Static linear traction was effective for the treatment of lumbar facet syndrome in terms of subjective and objective findings. The second objective was to determine if Leander traction was effective for the treatment of lumbar facet syndrome in terms of subjective and objective clinical findings. Lastly the third objective was to compare the subjective and objective clinical findings for both groups. Design: A randomised, two group parallel controlled clinical trial was carried out between the two sample groups. Participants had to have had chronic lower back pain (> 3months). Thirty symptomatic volunteer participants between 25 and 55 were randomly divided into two equal groups – group A (Leander traction) received 5 treatments over a 2 week period. Similarly, group B (Static linear traction) also received 5 treatments over a 2 week period. Algometer readings, Numerical Pain Rating Scale (NRS101), Pain Severity Scale (PSS) and Oswestery Disabilty Index (ODI) were used as v assessment tools. Subjective and objective clinical findings were taken on the first and second visits (i.e. 48 hours) prior to treatment and immediately after treatment. Another set of subjective and objective readings were taken one week after the fifth treatment in order to gauge the long term effects of both treatments. No treatment was given on the sixth visit. Pressure tolerance measurements using an algometer were taken at the end ranges of motion in Kemp’s test and spinal extension. Outcome measures: SPSS version 15 (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis of data. A p value of <0.05 was considered as statistically significant. The two groups were compared at baseline in terms of demographics variables and location using Pearson’s chi square tests and ttests as appropriate. Intra-group comparisons were made between all time points. A significant time effect indicated successful treatment intervention. Inter-group comparisons were achieved using repeated measures ANOVA tests for each outcome measured separately. A significant time group interaction effect indicated a significant treatment effect. Profile plots were used to assess the trend and direction of the treatment effect. Results: The results of the study showed that Leander traction and Static linear traction were both effective for treating chronic lumbar facet syndrome and no statistically significant difference was found between subjective and objective clinical findings between the two groups.

Low Back Pain (LBP) is a condition that most people experience at least once in their lifetime and for which many will seek physiotherapeutic intervention. Recently published and internationally recognised clinical guidelines for the management of LBP recommend the use of spinal manual and manipulative therapy techniques alongside exercise, advice, education and pharmaceutical therapies, particularly in the early stages. Other areas of development in the last decade include classification systems, clinical prediction rules (CPR’s), patient-reported outcome measures (PROMS’s) and minimum clinically important difference (MCID) thresholds. Additionally, sympathetic nervous system (SNS) measures of treatment responses are now recognised as providing quantifiable indicators of peripheral, spinal and central effects of manual therapy interventions although research in the lumbar spine is very limited with none providing data on a patient population. The aims of the study were; to determine the reliability and stability of the Biopac System in recording skin conductance (SC) activity levels and calculate the smallest real difference (SRD) statistic; to generate data on the magnitude of SC response to two commonly utilised treatments for LBP; and to observe the changes in a clinical population receiving guideline-endorsed physiotherapy treatment for the management of acute and sub-acute LBP. Furthermore, clinical data analysis sought to identify correlations of SC measures to PROM’s and evaluate the feasibility of using SC responses as a predictive tool for therapeutic outcome. The ability of the Biopac System to reliably record SNS activity was established by using SC measurements with 12 participants on two occasions, one-week apart. Data was recorded within a natural, non-laboratory setting. Results established that SC measurements could be reliably recorded between data sessions with a measurement variability of; ICC=0.99 (p<0.005) with an SRD value of 0.315 μmho’s (4.633%). In conclusion, any SC change above the SRD could be regarded as an SNS change that is independent of any measurement error or variability thus representing a real change ascribable to the intervention under investigation. The pre-clinical investigation compared the magnitude of SC response (SCR) of two, independently administered, specific MT techniques, applied, after randomisation, to the Lumbar 4/5 segment of 50 asymptomatic healthy volunteers. Treatments included; a rotatory lumbar manipulation technique or a repeated McKenzie extension in lying exercise. Findings revealed that both techniques produced statistically significant changes in SNS activity in the lower limbs (> SRD) with manipulative technique SCR’s (76%) that were twice the size of the McKenzie repeated extension in lying exercise (EIL) technique (35.7%)( p=0.0005). Only the manipulation technique had a lasting effect that was carried into the final rest period (p=0.012) but the SNS response was not a side-specific phenomenon (p= 0.76). The final clinical study recruited 60 acute and sub-acute LBP patients (symptoms of up to 12 weeks duration) who received guideline-recommended physiotherapy treatment within a hospital-based musculoskeletal out-patient physiotherapy department. SCRs were recorded throughout all treatment episodes with standardised, validated PROM’s used for comparison of status at inception, mid-point and at discharge. Functional impairment was determined using the Oswestry Disability Index (ODI) and the Roland Morris Disability Questionnaire (RMDQ) with pain intensity evaluated with the Narrative Pain Rating Score (NPRS). A preliminary comparison, between the asymptomatic population and a random selection from the patient population, revealed that patients had treatment SCR’s that were significantly greater (three-fold) than those of the asymptomatic groups (manipulation, p=0.003; EIL exercises p=0.001). Analysis of the patient data indicated that pre-treatment/baseline SC activity levels in the inception data capture point were lower than at discharge (18 µMho’s; p<0.0005) but, conversely, that treatment SC levels were initially high, but diminished in magnitude by discharge (230 to 172 µMho’s; p<0.0005) representing a SCR reduction of 125%. Correlational analyses of change scores of maximum SCR’s to PROM’s, from inception to discharge suggested weak positive correlations of SCR treatment responses to functional disability score improvements (rho 0.278) and pain intensity reductions (rho=0.229) that were significant for function (p=0.033) but not significant for pain (p=0.080). The final analyses indicated that there were trends in the magnitude of response to specific elements of treatment with manipulation having the largest SCR (266%). Further evaluative analysis of SC readings as a predictor, at inception, of functional outcome, at discharge indicated that a critical/cut-off value of 195% may indicate those patients least and most likely to respond positively to MT treatment. Preliminary logistic regression analysis indicated that the 195% SCR value was excellent at identifying poor responders but less successful at identifying good responders, functionally, to treatment. Nonetheless, SCR was a better predictor of outcome than duration of symptoms and patient age. Characteristically, patients achieving the 195% value were most likely to have higher functional disability and pain intensity scores at inception but by discharge had required fewer treatments, had greater overall functional improvement and lower pain intensities than those not achieving this threshold. In conclusion, SC activity levels and SCR’s may be a reliable, stable, alternative and objective measure of LBP patients’ SNS status and changes that occur as a result of symptom abatement throughout a course of physiotherapy treatment. SC readings may (indirectly) reflect the state of dorsal horn (DH) sensitisation and of the central nervous system (CNS) processing system and its facilitatory capacity to activate the descending pain inhibitory system (DPIS). Further research, in patient populations (including chronic LBP patients), is recommended to verify these findings and validate the 195% SCR cut-off point. Definitive RCT’s are indicated to further the understanding of guideline-endorsed physiotherapy treatment (a complex intervention –MRC, 2000) and to determine whether the SNS activity measurements can be used to help classify, predict, and ultimately, direct the care of patients with LBP.

Thesis (MScPhysio (Physiotherapy))--University of Stellenbosch, 2007. / Objective The objective of this study was to establish the reliability and validity of a Portable Posture Analysis Method (PPAM). Design The design for the reliability section was a repeated measures observational study and the design for the validity section was a correlation study. Background The prevalence of spinal pain among high school learners is high (Murphy et al, 2002). It is also notable that the prevalence of back pain increases across the teenage years (Grimmer & Williams 2000, Burton et al 1996). In South Africa, the preliminary findings of a study conducted by a Physiotherapy masters candidate (Ms L Smith: ethics nr. N05/09/164) indicates that about 74% of high school learners in Cape Town complained of musculoskeletal pain. Posture has been identified by some researchers to be a primary predictor of the development of spinal, particularly upper quadrant pain among computer users (NIOSH 1997, Vieira et al 2004). Measurement of posture poses a real challenge to researchers wanting to accurately evaluate posture in research projects. Considering the practical implications in measuring posture, the validity and reliability of posture measurement are often reported to be poor. Many of these methods of indirect assessment of working posture have been reported on in the literature. These measures include; the goniometer, inclinometer, flexible electrogoniometer, flexicurve and photography (Harrison et al 2005, Christensen 1999, Nitschke et al 1999, Chen & Lee 1997). ...

Thesis (MScPhysio (Interdisciplinary Health Sciences. Physiotherapy))--University of Stellenobosch, 2010. / Background: Low back pain (LBP) has a high prevalence worldwide. LBP is significantly associated with a range of poor socio-demographic circumstances which should be addressed in preventive programs. Despite this there is a dearth of information about the prevalence and associated factors among low-income communities in South Africa. It is speculated that the burden of LBP may be most significant in these underprivileged communities. Objective: The objective of this study was to assess the prevalence of LBP among the lowincome communities in the Cape Town Metropole and to establish associated factors in order to make recommendations for management. Study design: A cross-sectional study was conducted among the visitors of eight community health centres (CHCs) in the Cape Town Metropole. Methodology: A new measurement tool was developed based on existing validated outcome measures and initial testing of the psychometric properties of the questionnaire was conducted. The questionnaire was administered to 489 eligible subjects. Descriptive analysis was used to describe the sample and logistic regression analytical techniques were applied to determine associated factors. Main findings: Lifetime prevalence for LBP was 76.49% (n=358). About 37% (n=133) suffered from chronic LBP. LBP was significantly associated with belonging to the black ethnic group, any co-morbidity, poor perceived general health, and any type of pain medication. Lifting weights > 20 kg and kneeling and squatting were physical factors significantly associated with LBP. Severe psychological distress was significantly associated with acute and chronic LBP. Having a better or same perceived general health compared to a year ago, was protective for LBP. Conclusion: LBP has a high prevalence among the low income communities, visiting the CHCs, in the Cape Town Metropole. Multiple factors were associated with LBP, which imply that a tailormade multidisciplinary program addressing lifestyle issues, self management strategies, medication use, chronic diseases and psychosocial factors may be required for this population to combat LBP.

published_or_final_version / Community Medicine / Master / Master of Public Health