Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2016. / Aim: To determine the intra- and inter-examiner reliability of the radiographic assessment of the cervical lordosis of asymptomatic adult males. Participants: Eighty lateral plain film radiographs of the cervical spine of asymptomatic males aged 18-45 years (taken in a previous study) were utilised for this study. However, due to the obstruction of the C7 vertebral body by the trapezius muscle, the examiners were unable to assess the CL on all 80 plain film radiographs. Three examiners took part in the study viz. Examiner One who was a qualified chiropractor with three years of clinical experience, Examiner Two who was a qualified chiropractor with six years of clinical experience and Examiner Three who was a chiropractic master’s student. Methodology: The initial set of assessments of the CL using the C1-C7 and C2-C7 modified Cobb methods was completed by Examiner One and captured on an Excel spread sheet for Round One. The procedure was then repeated for Examiners Two and Three. The process was repeated for the second set of assessments (Round Two). Each examiner was given a maximum of two weeks to complete their assessments for each round. The data was statistically analysed using SPSS 22.0 and Stata 13. Descriptive data was presented in tables as mean and standard deviation at a 95% confidence interval while intra- and inter-examiner reliability was determined using the Kappa coefficient. Results: The mean (± SD) CL values obtained by each examiner using the C1-C7 modified Cobb method for Round One was: Examiner One: 45.6˚ (± 10.4˚) (n = 70), Examiner Two: 44.0˚ (± 11.0˚) (n = 75) and Examiner Three: 43.8˚ (± 12.0˚) (n = 72). The mean (± SD) CL values obtained by each examiner using the C1-C7 modified Cobb method for Round Two was: Examiner One: 46.7˚ (± 10.7˚) (n = 72), Examiner Two: 43.3˚ (± 11.1˚) (n = 74) and Examiner Three: 43.8˚ (± 11.5˚) (n = 72). The mean (± SD) CL values obtained by each examiner using the C2-C7 modified Cobb method for Round One was: Examiner One: 15.9˚ (± 9.2˚) (n = 72), Examiner Two: 22.6˚ (± 9.7˚) (n = 75) and Examiner Three: 17.2˚ (± 9.7˚) (n = 72). The mean (± SD) CL values obtained by each examiner using the C2-C7 modified Cobb method for Round Two was: Examiner One: 16.3˚ (± 9.4˚) (n = 72), Examiner Two: 20.5˚ (± 9.0˚) (n = 74) and Examiner Three: 16.9˚ (± 9.2˚) (n = 72). The intra-examiner reliability obtained by each examiner using the C1-C7 modified Cobb method for Round One and Round Two was: Examiner One: K = 0.16, Examiner Two: K = 0.11 and Examiner Three: K = 0.16. The intra-examiner reliability obtained by each examiner using the C2-C7 modified Cobb method for Round One and Round Two was: Examiner One: K = 0.21, Examiner Two: K = 0.04, Examiner Three: K = 0.22. The inter-examiner reliability obtained by each examiner using the C1-C7 modified Cobb method for Round One and Round Two respectively was: Examiner One vs Examiner Two: K = 0.03; K = 0.09, Examiner One vs Examiner Three: K = 0.19; K = 0.15, Examiner Two vs Examiner Three: K = 0.03; K = 0.08. The inter-examiner reliability obtained by each examiner using the C2-C7 modified Cobb method for Round One and Round Two respectively was: Examiner One vs Examiner Two: K = 0.00; K = 0.01, Examiner One vs Examiner Three: K = 0.19; K = 0.11, Examiner Two vs Examiner Three: K = 0.02; K = 0.05. There was a significant difference in the intra-examiner findings for both the modified Cobb methods (p < 0.05). Using the C1-C7 modified Cobb method, there was a significant difference in the inter-examiner reliability findings between all three examiners for both rounds (p < 0.05). There was no significant difference in the inter-examiner findings of the CL using the C2-C7 modified method between Examiner One versus Examiner Two for Round One (p = 0.33) and Round Two (p = 0.23) but there was a significant difference in the findings between Examiner One versus Examiner Three (p < 0.05) and between Examiner Two versus Examiner Three (p < 0.05) for Round Two only. Conclusion: The results of this study are in agreement with those of a previous study which reported that the C1-C7 modified Cobb method over-valued the magnitude of the curve while the C2-C7 modified Cobb method under-valued the curve. A significant difference in the intra-examiner findings suggests that recall bias did not significantly affect the assessments while inter-examiner findings suggest that experience and skill of the examiners as well as assessments that require drawing of lines and measuring of angles might lead to differences in the results obtained. Further studies which would utilise a large number of digitised radiographic images from both asymptomatic and symptomatic individuals are required to confirm the findings of this study. / M

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2016. / Background Literature has shown that clinical and radiological diagnoses do not always correlate in patients with neck pain (Ferrari and Russel, 2003; Peterson and Hsu, 2004). It is not known if this applies to the Chiropractic Day Clinic (CDC) at the Durban University of Technology (DUT) and if the radiological diagnosis leads to a change in the patient’s initial management plan. The impact of cervical spine plain film radiographs will therefore be investigated in the diagnosis and management of patients that presented with neck pain to the CDC at the DUT. It is also not known whether the reason for referral for cervical spine plain film radiographs is always indicated as per the indications in the clinic handbook and radiological referral guidelines. Objectives Objectives were: (1) To determine the suspected pre-radiographic clinical diagnosis and management of the selected clinical records prior to referral for cervical spine plain film radiography; (2) To record the reasoning to send for cervical spine plain film radiographic imaging and to establish whether these are in line with proposed guidelines for referral as found in the literature; (3) To determine the relationship between the suspected pre-radiographic clinical and the radiological diagnoses of patients with neck pain; (4) To determine the number of incidental findings in the selected patients’ plain film radiographs; (5) To determine any change in the pre-radiographic clinical diagnoses and management following radiological reporting of the selected patient’s plain film radiographs. Method This was a quantitative, retrospective, clinical study. The archives at the CDC at the DUT were searched for cervical spine plain film radiographs between 1 January 1997 to 31 December 2013 and these were matched with the corresponding clinical records. After applying the inclusion and exclusion criteria, 73 records were included in the study. The patient’s personal information was coded to ensure confidentiality (Appendix A) and specific clinical and radiological information was recorded (Appendix B). Statistical analysis included the use of frequency counts, percentages, mean, standard deviation and range for the descriptive objectives. Results A total of 73 clinical files and corresponding plain film radiographs were assessed. The mean age of the patients was 44 years. The gender distribution was 64.4% (n=47) females and 35.6% (n=26) males. The most frequent primary radiological diagnosis was loss of lordosis at 41.1% (n=30) followed by cervical spondylosis at 35.6% (n=26) and old cervical spinal trauma at 12.3% (n=9). Sixty four percent (n=47) of patients in this study were sent for cervical spine plain film radiographs after their initial clinical consultation. Reasons that are not considered relevant indications for plain film radiographic referral were present in 46.2% (n=34) of cases; these described non-specific mechanical disorders. The most common reason for plain film radiographic referral was due to positive orthopaedic tests 57.5% (n=42). A total of 27.4% (n=20) of clinical files reviewed had a change in their initial clinical diagnosis and 72.6% (n=53) of these patients had no change in diagnosis. All of the post-radiographic clinical diagnoses were non-specific mechanical conditions. Numerous treatment modalities were utilized by the students with the most common pre-radiographic treatment being soft tissue therapy at 63.0% (n=46). A total of 75% (n=55) of patients had a change of treatment after plain film radiographs were performed and spinal manipulative therapy (SMT) was the main treatment added in 41% of cases. Conclusion Cervical spine plain film radiographs have little impact on the diagnosis of patients with non-specific mechanical neck pain without red flags. It was however found that plain film radiographs had an impact on the management in the majority of cases, especially with an increase in SMT use after plain film radiographs. / M