Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Department of Chiropractic and Somatology, Durban University of Technology, Durban, South Africa, 2016. / Background Chiropractic is practiced in over 100 countries and is considered to be the fastest growing health care profession internationally. Several studies investigating the practice characteristics of chiropractors have been conducted in selected countries, however, as far as is known, no study has been conducted where chiropractors from countries across the globe are assessed for their practice characteristics in order to determine if regional differences exist. Gaining insight into chiropractic practice and its influencing factors, relating to both the profession itself and the chiropractor can enable organisations such as the World Federation of Chiropractic to have a greater understanding of how chiropractors are currently practicing and how the profession is being utilised by the public. Improved insight into the profession provides a baseline description for the public and other health care practitioners to fully comprehend what chiropractors can offer to the health care system. Aim: The aim of this study was to determine the demographic profile and practice characteristics of chiropractic delegates attending the World Federation of Chiropractic’s 12th Biennial Congress 2013. Method A pre-validated questionnaire and letter of information and consent was distributed to all registered chiropractic delegates (N = 406) attending the World Federation of Chiropractic Congress in Durban, Kwa-Zulu Natal 2013. The questionnaire was part of the delegate packages and they self-selected to participate. Due to a low response rate at the congress, the questionnaire was made available electronically on Survey Monkey®, for six weeks after the congress. Questions relevant to this study were coded, reduced where necessary and utilised for data analysis with IBM SPSS Version 21. Descriptive data was then summarised and presented using tables and graphs. The study was approved by the Durban University of Technology’s Institutional Research Ethics committee. Results: The response rate was 34.72%, with 52.5% being female, mean age was 42 (SD ± 13years, and all seven geographical regions were represented. The majority of respondents were from Africa (51.1%), followed by North America (22.7%) then Europe (14.2%). South Africa (48.6%) was the most represented country. Respondents held either a Master’s degree in Chiropractic (51.8%) or a Doctor of Chiropractic (DC) degree (48.2%). The mean years since graduating as a chiropractor was 15.7 years (SD ± 3.6). The majority of respondents (71.2%) engaged in full-time clinical practice, for between 5 to 15 years (39.8%) with 51.4% purporting to have an evidence based philosophical approach to practice. The majority (72.5%) viewed the role of a chiropractor in the health care system as a primary health care practitioner with a focused scope of practice. The majority of respondents (n = 52) personally treated 50 patients or less per week, with approximately one third of the respondents (n = 34) having high volume practices (>100 patients weekly). The respondents favoured being one of two chiropractors (36.9%) in a practice setting followed by sole practices (31.6%). The top chiropractic technique utilised was the diversified technique (74.5%) followed by extremity adjusting (68.8%). Various adjunctive, active and passive, axillary techniques were utilised in the daily management of patients. The patient demographics were majority female (55.7%), older than 30 years of age (66.7%) and Caucasian (77%), complaining of head, neck, mid-back and low back pain, which was mostly acute in nature. Trends suggested that females were more likely to select an evidence-based philosophical orientation than males. Females were more likely to delegate adjunctive therapies to non-chiropractic assistants (p = 0.029), and favoured sending patients to a physical therapist (p = 0.018), whereas males were more likely to refer to nutritionists and paediatricians (p = 0.030 and p = 0.038, respectively). Females were less likely to utilise mobilisation techniques (p = 0.008), massage therapy (p = 0.018) and nutritional counselling (p = 0.032). In terms of age, those selecting an evidence-based approach were significantly older than those who adopted a mixer approach to practicing (p = 0.002). The mean age of the respondents, irrespective of the region, was not significantly associated with the number of patients treated per week (p = 0.377) or the hours worked per week (p = 0.474). Trends show that the number of years spent in practice differed among the regions with North American chiropractors spending more years in practice than those from Europe and Australasia. The respondents from South Africa spent fewer years in practice (15 years or less) than respondents from Asia, Australasia, Europe and North America. Geographic region was not significantly associated with practice setting (p = 0.182). The only chief complaint that differed between regions was patients presenting with headaches accompanied by neck pain (p = 0.007), where Asian and North American respondents reported seeing less patients than their colleagues from other regions. Trends suggested that the respondents who attained a Masters of Technology in Chiropractic were more inclined to select a mixer orientation whereas those with a DC qualification selected an evidence-based philosophical approach. Conclusion: The WFC congress provided a platform to successfully determine the demographic profile and practice characteristics of chiropractors from various regions. Similar demographics were evident, with males no longer showing dominance within the profession. Chiropractors adopting an evidence-based and mixer philosophical orientation are synonymous in the role that they play in the health care system and display similarities in chiropractic practice and patient management. Investigating chiropractors who adopt a straight philosophical approach would be beneficial as it will allow for better comparison of demographics and practice characteristics. It is evident that selected demographics do influence how one would opt to practice, with regional differences showing that the chiropractic profession in South Africa is still relatively young. / M

Dissertation presented to the Faculty of Health at Durban University of Technology in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, 2008. / Aims and Objectives: To assess the demographics, career paths and factors affecting chiropractic graduates of Durban University of Technology (DUT) from June 1994 to June 2007. Method: A retrospective qualitative survey was conducted on 62 chiropractic graduates of DUT. The sample represented 25.5% of the total chiropractic population. Raw data regarding the demographics, respondents’ perception of their education, current career paths, the factors responsible for affecting these career paths, as well as a profile of chiropractic practices in South Africa (SA) was obtained. All data acquired was assessed using SAS (Statistical Analysis System) version 9.1.3. The data was purely descriptive, describing respondents’ career paths and their experiences, and no specific hypothesis was investigated. Results: The average respondent was found to be a married, white male who started his chiropractic career at age 25-26 years. A total of 98.4% (n = 61) of the respondents were currently in practice, with 80.6% (n = 50) indicating career satisfaction. The majority (62.9%; n = 39) of respondents perceived there to be a growing acceptance of chiropractic within the medical community, whilst 98.4% (n = 61) stated that they are currently part of an active referral system between various other medical practitioners. 46% (n = 23) listed DUT as their preferred choice of chiropractic institution. Conclusion and Recommendations: The majority of respondents’ indicated DUT as the preferred choice of chiropractic institution due to its location and the system of chiropractic taught (diversified). However, shortcomings in the education were highlighted to be a lack of practically applicable knowledge taught at undergraduate level, most especially business skills and speciality areas and that respondents’ perceived the qualification not to be as versatile and widely accepted as other international chiropractic qualifications. Factors responsible for positively affecting the career paths of chiropractic graduates were indicated to be the personality type of the graduate, the means to finance a practice, support from parents and spouse or partner and the level of acceptance graduates received from the public and other professions within the medical sector. A recommendation for future studies is that a longer time period be given for questionnaires to be returned and a larger sample group be established in order to ensure that the sample group and total population is homogenous.

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 Masters Degree in Technology: Chiropractic, Durban University of Technology, 2009. / Objectives: The aim of this study was to determine the current role of the Chiropractor in the Patient-Centred Approach to Stress Management. Methods: Chiropractors were contacted telephonically in order to discuss a convenient time in which they are free to receive the questionnaire at their practice. The questionnaire was developed specifically for this particular research project and verified through the use of a focus group and pilot testing. The researcher waited outside the room whilst the Chiropractor completed the questionnaire. The questionnaire was then collected after completion prior the researcher leaving the practice, in order to improve the return of the questionnaires. Results: Seventy-five percent of chiropractors, in the study indicated that they took a psychosocial history which may indicate that they utilised the fundamental biopsychosocial theme of ‘patient-centeredness’. 68.9% of chiropractors who took a psychosocial history indicated that they are equipped with the necessary skills to evaluate psychosocial stressors in patients and 55.6% indicated that their patients responded ‘Very Positively’ to their stress management protocols. All the Chiropractors in the study indicated that they had consulted patients who had associated their main complaint with stress related issues. 38.3% of Chiropractors felt that their patients ‘Often’ associated their main complaint with stress-related issues whilst 35% felt that their patients ‘Very Often’ relate their main complaint with stress-related issues. Muscle spasm (85%) was the most common symptom or sign found or elicited in a patient suffering with chronic stress. Referral was the most common primary method of treatment with 36% of Chiropractors utilising this method in the clinical setting when dealing with a stressed patient. iii Conclusion: Chiropractors in the study indicated that they took a psychosocial history therefore they utilised the fundamental biopsychosocial theme of ‘patientcenteredness’ and that the majority indicated that they are equipped with the necessary skills to evaluate psychosocial stressors in patients and that patients responded positively to their stress management protocols.

Dissertation submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2012. / The Chiropractic profession has made significant progress with regard to the production of high quality and clinically relevant research in the last 20 years. This correlates with a spike in development within the chiropractic profession as well as its acceptance by the medical fraternity and public. The responsibility for continuing this positive trend is dependent on the chiropractic graduates and practitioners of the future. Therefore, it is important to establish the current perceptions and utilization of research by Chiropractors, so that future research can be built around the needs and requirements of today’s practitioners, thereby ensuring the profession’s continued development and future in health care. The aim of this study was to determine the perceptions that Chiropractors have of research and its relevance / utilization in practice. Method: The study was a quantitative questionnaire based, self administered survey. The sample group included all Chiropractic practitioners currently practising in South Africa (N=515). Results: There was a response rate of 35% (n=174). The results indicated that the perception of research was very positive overall, with the strongest positive response being that research adds credibility to the profession. However, most respondents disagreed with the statement that chiropractors who had done research had an advantage above those who had not. There was a positive, albeit weak correlation between perceptions and utilization of research, indicating that as perceptions increased, so did utilization of research. The area of greatest concern was that even though a high degree of research utilization was reported by chiropractors, research was least likely to be used to change conditions, policies or practices in practice. v Conclusion: The most significant factors associated with positive perceptions and utilization were found to be publishing in a journal and receiving referrals from other health care practitioners. Chiropractors who indicated an interest in doing research again were also very positively linked to utilization. It would seem that even though chiropractors perceive research positively, their implementation into practice has some hurdles that impede the full integration of research into practice. As very few demographic and personal attributes of the South African chiropractor were found to be primarily responsible for low utilization of research in practice, it can be hypothesised that the factors impeding research implementation are most likely environmental in nature.

A dissertation submitted in partial compliance with the requirements for a Master's Degree in Technology: Chiropractic, Durban University of Technology, 2013. / Objectives: Collaboration between health care practitioners has many advantages including a focus on disease prevention and health promotion, improving service access and the provision of multidisciplinary health care teams. To achieve this ideal health care provision, understanding the current landscape of referral/interaction between practitioners and the factors which influence this network are important. This enables effective delivery of health care demanded by the public. As identified factors impacting the inter-referral of patients between practitioners are contextual, they differ in different contexts. Thus, this study aimed to investigate the factors affecting the referral of patients between chiropractors and physiotherapists in the eThekwini municipality.

BACKGROUND: Complementary and alternative medicine (CAM) use has steadily increased globally over the past two decades and is increasingly playing a role in the healthcare system in the United States. CAM practice-based effectiveness research requires an understanding of the settings in which CAM practitioners provide services. This paper describes and quantifies practice environment characteristics for a cross-sectional sample of doctors of chiropractic (DCs), licensed acupuncturists (LAcs), and licensed massage therapists (LMTs) in the United States. METHODS: Using a cross-sectional telephone survey of DCs (n = 32), LAcs (n = 70), and LMTs (n = 184) in the Tucson, AZ metropolitan area, we collected data about each location where practitioners work, as well as measures on practitioner and practice characteristics including: patient volume, number of locations where practitioners worked, CAM practitioner types working at each location, and business models of practice. RESULTS: The majority of practitioners reported having one practice location (93.8% of DCs, 80% of LAcs and 59.8% of LMTs) where they treat patients. Patient volume/week was related to practitioner type; DCs saw 83.13 (SD = 49.29) patients/week, LAcs saw 22.29 (SD = 16.88) patients/week, and LMTs saw 14.21 (SD =10.25) patients per week. Practitioners completed surveys for N = 388 practice locations. Many CAM practices were found to be multidisciplinary and/or have more than one practitioner: 9/35 (25.7%) chiropractic practices, 24/87 (27.6%) acupuncture practices, and 141/266 (53.0%) massage practices. Practice business models across CAM practitioner types were heterogeneous, e.g. sole proprietor, employee, partner, and independent contractor. CONCLUSIONS: CAM practices vary across and within disciplines in ways that can significantly impact design and implementation of practice-based research. CAM research and intervention programs need to be mindful of the heterogeneity of CAM practices in order to create appropriate interventions, study designs, and implementation plans.

Submitted in partial compliance for a Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2016. / Introduction There is a worldwide need for research into headaches in order to improve and add to the current model of literature to develop more efficient management strategies for headaches. Headaches can present clinically similarly and present a diagnostic challenge. Currently it is not known what the clinical accuracy of headache diagnosis is or which management strategies chiropractors prefer to use in practice to manage certain headaches. The aim of this study was to investigate the diagnosis of certain headaches by chiropractors in the greater Durban area and to determine how certain headaches commonly treated by chiropractors were managed. Methodology Based on the quantitative paradigm, this is a descriptive questionnaire based study involving a population of 88 chiropractors practicing in the greater Durban area. The final sample size was 63, a response rate of 72%. The questionnaire was developed specifically for this study and was validated by an expert group and tested by a pilot study to ensure construct and face validity. Data regarding demographic information, diagnostic approach to cervicogenic headache (CEH), intracranial haemorrhage, meningitis, migraine (MEH) and tension type headache (TTH) and management of CEH, TTH and MEH was collected from the sample. SPSS version 22 was used to analyse the data. Descriptive statistics were reported in frequency tables. Continuous variables were compared between independent categories using one way ANOVA tests. Trends were shown in cross tabulations and interpreted descriptively where Chi square tests could not be calculated. Results The sample size consisted of 63 chiropractors in the greater Durban area, South-Africa, of which 49.2% (31) were male and 50.8% (32) were female. The mean age was 37 years (range 25 to 71 years). The majority of the sample had between six- to nine years of practice experience, with the majority being in full time practice (82.5% (52)). The majority (92.1% (58)) of the sample had graduated from DUT. Seventeen point five percent (11) of the sample had additional tertiary qualifications, the most common of which was a Master’s degree of Medical Sciences (Sports Medicine), with a total of 19 additional short courses being reported by 79.4% (50) of the sample. Seventy five point one percent (41) of the sample indicated usage of chiropractic specific journals, with 38.1% (24) of the sample indicating that these journals had an impact on the way they manage headaches in practice. Seventy seven point eight percent (49) of the sample attended health related conferences on a regular basis, with 38.1% (24) of the sample indicating that these conferences influenced their management of headaches in practice. Seventeen point five percent (11) of the sample had practiced internationally, with a range of international practice from one month to 12 years. The majority of the sample indicated that they practiced according to a combination of mixer and evidence based philosophy. The accuracy of diagnostic outcome for meningitis was 98.4% (62), TTH was 47.6% (30), MEH was 82.5% (52), CEH was 82.5% (52) and intracranial haemorrhage was 30.2% (19). The results for the management of CEH, TTH and MEH indicated that a minimum of 98.6% (62) would adjust a patient with these headaches; the sample predominantly preferred application of specific adjustments to fixated segments in the cervical and thoracic spine. A minimum of 66.7% (42) regarded spinal manipulative therapy (SMT) as the primary focus of treatment across all three headaches. The most commonly selected modality to be used in conjunction with SMT was massage therapy (with a minimum selection frequency of 68.3% (43) across CEH, MEH and TTH). Massage therapy was the most commonly selected modality to be used when SMT is contra-indicated (minimum selection frequency of 61.9% (40) across CEH, MEH and TTH). A minimum of 98.4% (62) of the sample indicated that they would treat MFPTs if associated with headaches, most commonly using dry needling. For the majority of the sample, the interval of choice for a second appointment was two to three days and the number of treatments expected for relief of symptoms was two to three treatments. Further investigations were considered necessary by the majority of the sample after seven days without any relief of symptoms. The majority of the sample recommended pain free care. Regarding patient advice and education, there was agreement on postural and ergonomic advice, home stretching, stress management techniques and proprioceptive exercises. If treatment goals were not obtained, the majority of the sample agreed to change the treatment plan, reassess all of the previous findings and if necessary refer the patient to another non-chiropractic health care provider. Conclusion Based on the case scenarios used in this study, meningitis, CEH and MEH were accurately diagnosed by the majority of the sample. There appeared to be some confusion with regard to the diagnosis of TTH as nearly half of the sample confused it for CEH. The accuracy with regard to the diagnosis of intracranial haemorrhage was concerning as the minority of the sample correctly diagnosed this condition. A relatively similar approach was used by chiropractors to treat headaches, with relatively little change in the treatment options between CEH, TTH and MEH. Most of the treatment methods, used by most of the sample, have moderate evidence for efficacy in treatment of musculoskeletal conditions. The management options chosen by the majority of the sample could be of potential benefit for the management of the respective headaches. Few differences were noted with regard to the impact of demographic information on the diagnostic outcome and management approaches. Some, but not enough, evidence indicates that the older participants provided less accurate diagnoses. The headaches which were less accurately diagnosed possibly due to an age difference were meningitis, TTH and MEH. With regard to management of headaches the only statistically significant differences were noted for the management of TTH for which age appeared to influence the specificity of adjustments used in TTH. / M

The high prevalence of back and neck pain results in enormous social, psychological, and economic burden. Most seeking help for back or neck pain consult general practitioners or chiropractors. Chiropractic is a regulated health profession (serving approximately 10 – 15% of the population) that has contributed to the health and well-being of North Americans for over a century. Despite available evidence for optimal management of back and neck pain, poor adherences to guidelines and wide variations in services have been noted. For instance, overuse and misuse of imaging services have been reported in the chiropractic literature. Inappropriate use of spine imaging has a number of potential adverse outcomes, including inefficient and potentially inappropriate invasive diagnosis and subsequent treatment, and unnecessary patient exposure to ionizing radiation. Although evidence-based diagnostic imaging guidelines for spinal disorders are available, chiropractors are divided on whether these guidelines apply to them. While guidelines can encourage practitioners to conform to best practices and lead to improvements in care, reviews have demonstrated that dissemination of guidelines alone is rarely sufficient to optimise care. Evidence regarding effective methods to promote the uptake of guidelines is still lacking. There is growing acceptance that problem analysis and development of interventions to change practice should be guided by relevant theories and tailored to the target audience. To date, very little knowledge translation research has addressed research-practice gaps in chiropractic. This thesis reports rigorous methods to: (1) assess practice and providers’ characteristics, (2) determine baseline rates and variations in spine x-ray ordering, (3) evaluate the impact of disseminating guidelines to optimise spine x-ray ordering, and (4) assess determinants of spine x-ray ordering and potential targets for change prior to the design of a tailored intervention. A mixed method using two disciplinary perspectives (epidemiology and psychology) was undertaken. A cross-sectional analysis of administrative claims data was carried out on a sample of chiropractors enlisted in a large American provider network. Despite available clinical practice guidelines, wide geographical variations in x-ray use persist. Higher x-ray ordering rates were associated with practice location (Midwest and South US census regions), setting (urban, suburban), chiropractic school attended, male provider, employment, and years in practice. The impact of web-based guideline dissemination was evaluated over a five year period using interrupted time series and demonstrated a stepwise relative reduction of 5.3% in the use of x-rays. Passive guidelines dissemination appeared to be a simple, cost effective strategy in this setting to improve but not optimise x-ray ordering rates. Focus groups using the theoretical domains framework were conducted among Canadian and US chiropractors to explore their beliefs about managing back pain without x-rays. Findings were used to develop a theory-based survey to identify theoretical constructs predicting spine x-ray ordering practice. Psychological theories and theoretical constructs explained a significant portion of the variance in both behavioural simulation and intention. Results from this thesis provide an empirically-supported, theoretical basis to design quality improvement strategies to increase guidelines adherence and promote behaviour change in chiropractic. Other researchers interested in improving uptake of evidenced-based information could use this method in their own setting to investigate determinants of behaviour among other professional groups. Future research may use knowledge gained to inform the development and evaluation of a theory-based tailored intervention to improve guideline adherence and reduce the use of spine x-rays among targeted providers.

A dissertation presented in partial fulfilment of the requirements for the Masters Degree in Technology: Chiropractic, Durban University of Technology, 2006. / The aim was to evaluate the prevalence of hand and wrist pain, as well as the relationships between occupational overuse syndromes in the hands and wrists of chiropractors in South Africa as a result of their daily use of manual therapy techniques while at work. There are very few statistics available that disclose the nature and incidence of work related injuries. However those statistics that do exist suggest that hands on patient activities place physical therapists at greater risk of injury in comparison to other health care workers (Lunne et al., 2000). A study conducted by Bork et al.(1996) determined the prevalence of work-related musculoskeletal injuries sustained by physical therapists. Hand pain (29.6%) and back pain (45%) where the leading cause of pain in physical therapists (Bork et al., 1996.) Chiropractic and physiotherapy are both health care professions that specialize in the treatment of disorders pertaining to the neuro-musculo-skeletal system (Hunter, 2004). Physical therapists use manual therapy techniques as part of their daily working activities, so it can be assumed that chiropractors too will have a high prevalence of hand and wrist pain as they utilize similar therapeutic techniques to physical therapists. Cromie et al.(2000) evaluated the prevalence, severity, risks, and responses of disorders in physical therapists. He identified 4 categories of major risk factors commonly associated with workers musculo-skeletal disorders in physical therapists 1. Risk factors related to specific activities. 2. Postural risk factors. 3. Risk factors with regard to work load issues 4. Risk factors in regard of work capacity and health of the participant (Cromie et al., 2000). Physical risk factors found to be associated with neck, shoulder, or hand and wrist disorders in cross sectional studies are heavy lifting, monotonous work, static work postures, vibrations and repetitive jobs, and a high work pace (Alfredsson et al., 1999). Other factors that have been associated with musculoskeletal pain are higher age and female gender (de Zwart et al., 2001; Wahlstedt et al., 2001; Feveile et al., 2002). / M