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: Low back pain (LBP) is a major health problem and a leading cause of disability worldwide, accounting for numerous medical and chiropractic consultations. Risk factors for developing as well as perpetuating LBP have been recognised, including psychosocial factors and to a lesser extent organic diseases. There is good evidence for the role of biological, psychological, and social factors in the aetiology and prognosis of back pain. The biopsychosocial model developed by Waddell (1987) has become a dominant consideration in determining the aetiology and prognosis of back pain, and has led to the development and testing of many back pain care interventions. This includes a focus on identifying and treating ‘yellow flags’ which are psychosocial factors that may result in LBP becoming chronic, and incorporating the treatment of these ‘yellow flags’ as a component of LBP care. AIM: The aim of this study was to determine a psychometric profile of patients attending the Durban University of Technology (DUT) Chiropractic Day Clinic (CDC) with non-specific LBP using the Keele STarT Back Screening Tool (SBST) and Bournemouth Questionnaire (BQ). METHODOLOGY: Once ethical clearance was obtained to conduct the research study at the DUT CDC, all patients over the age of eighteen presenting to the DUT CDC with non-specific LBP as new patients, or as former or current patients presenting with non-specific LBP as a new complaint, were directly approached by the researcher. The prospective participants were asked a series of screening questions in order to ensure that they qualified for the study. A total of 132 participants completed an informed consent, a pre-validated questionnaire, the SBST and the BQ. The questionnaires took approximately ten to fifteen minutes to complete; participants were given the choice to complete them either before or after their appointment so as not to interrupt the treatment time. All informed consents and completed questionnaires were collected by the researcher and stored in separate sealed ballot boxes. All questionnaires were kept confidential and only seen by the researcher and supervisor. A code was allocated to each questionnaire before data was captured on a spreadsheet for data analysis. The IBM SPSS version 22 was used for data analysis by a biostatistician. RESULTS: A total of 132 questionnaires were utilised for statistical analysis. Based on the SBST, 47.7% (n = 63) of the total population (N = 132), had a low risk of developing chronic LBP, 28.8% (n = 38) had a medium risk of developing chronic LBP, and 23.5 % (n = 31) had a high risk of developing chronic LBP. The BQ indicated that 63.6% (n = 84) of the total population (N = 132) scored 35 or less and thus had a low risk of developing chronic LBP, while 36.4% (n = 48) scored above 35 and thus had a medium to high risk of developing chronic LBP. A very strong association was found between the SBST and BQ risk groups (p = <0.001). A total of 87.1% (n = 27) of the participants who had a high risk of chronicity according to the SBST (N = 31) also had a high risk of chronicity according to the BQ. The female gender, being a current smoker and partaking in little or no physical activity were found to be statistically significant risk factors for chronic LBP. CONCLUSION: The results in this study suggest that patients presenting to the DUT CDC supports the notion that chronic LBP is a multifactorial condition with significant psychosocial implications and should be approached as such. / M

Submitted in fulfillment of the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2017. / Mid-back pain (mbp) is defined as pain occurring within the limits of the third thoracic (T3) and ninth thoracic (T9) vertebrae, caused by the dysfunction of the musculoskeletal structures in the thoracic spine. It can present as pain and/ burning between the shoulder blades with reduced thoracic spine mobility and increased muscle tension. Congenital disorders such as scoliosis and Scheuermann’s disease, or acquired disorders such as thoracic facet and costovertebral joint dysfunction may cause mbp. The thoracic facet and costovertebral joints are similar in anatomy and share a mutually dependent biomechanical relationship. There were a handful of controlled studies that highlighted the effectiveness of thoracic facet manipulation on mbp, but there were none on the effects of costovertebral manipulation on mbp. Objectives The aim of this study was to investigate the immediate effects of the combination of thoracic facet and costovertebral joint manipulation on mbp in terms of pain perception, pressure pain thresholds (PPT) and thoracic spine range of motion (ROM). Design A prospective single-blind randomised comparative clinical trial. Setting This study was conducted in a university setting at the Durban University of Technology Chiropractic Day Clinic Participants Fifty participants were recruited via responses to advertisements placed around the Durban University of Technology (DUT) campuses and individuals presenting at the Chiropractic Day Clinic (CDC). Intervention The participants were divided into two groups of twenty-five. Group A received the thoracic facet joint manipulations and Group B received a combination of the thoracic facet and costovertebral joint manipulations. Outcome measures All subjective and objective measurements were taken before and after the application of the manipulations. Pain perception i.e. subjective measurement) was measured by the Numerical Pain Rating Scale (NPRS), pressure pain thresholds (PPT) (i.e. objective measurement) were measured by the Wagner’s FDK Force Gage Algometer and thoracic spine range of motion (ROM) i.e. objective measurement was measured by the Saunders Digital Inclinometer. Results The data was analyzed using the latest version of SPSS and a p-value = 0.05 was used to determine statistical significance. Descriptive statistics in the form of univariate analysis described the data in terms of measures of central tendency and measures of dispersion. Data that was distributed normally was analyzed using the t-test and ANOVA. Data that was distributed abnormally was analyzed using the non-parametric Wilcoxon ranked and Mann Whitney tests. Nominal and ordinal data was analyzed using the Chi squared test. The results of the intra-group analysis indicated a statistically significant decrease in pain perception (p ≤ 0.000), increase in PPT (p ≤ 0.05) and decrease in thoracic spine ROM (p ≤ 0.000). However, the results for the inter-group analysis indicate there was no statistically significant difference in pain perception (p = 0.386), PPT (p > 0.05) and thoracic spine ROM (p >0.05) between Group A and Group B. Conclusions These results showed that the combination of thoracic facet and costovertebral joint manipulation was as effective as thoracic facet joint manipulation alone, in the treatment of mbp. These findings suggested that manipulation of the costovertebral joints may not be necessary for the effective treatment of mbp. / M

Submitted in compliance with the requirements for the Master's Degree in Technology: Nursing, Durban University of Technology, 2014. / Background : Tuberculosis (TB) is a global public health concern and is identified as the leading cause of morbidity and mortality in the population infected with Human Immune Deficiency Virus (HIV). South Africa (SA), particularly the KwaZulu-Natal Province, is burdened with persistently high rates of both TB and HIV infections. In an attempt to improve TB and HIV co-infection outcomes the South African health care system has adopted the World Health Organisation (WHO) guidelines for intensified TB case findings in all HIV positive individuals for regular screening of TB symptoms in order to promptly diagnose and treat active TB disease or to exclude TB for initiation Isoniazid Prophylactic Therapy (IPT). IPT has proven effective in preventing TB disease in People Living with HIV or AIDS (PLWHA). This critical first step of TB symptom screening is regarded as the intervention that could significantly reduce the challenge currently faced with TB-HIV co-infection. The study was conducted in selected eThekwini Municipality Primary Health Care (PHC) facilities with the focus on an investigation to determine the extent of the implementation of the TB symptom screening tool in HIV infected individuals, in addition to identifying treatment initiation or further investigations based on the tool implementation. It has been found during the literature review, that there is a lack of research in SA to show that this critical first step in TB identification has been investigated, yet one in six South African’s is HIV positive and the incidence of TB-HIV co-infection is not declining. Methodology : A quantitative, descriptive approach was utilised to conduct a retrospective patient chart review. A multistage cluster sampling technique comprising three stages was implemented to identify the sample. There was a random selection of clinics, and the required number of client records was obtained through convenience sampling from the selected clinics. Results : The findings of this study revealed there is inadequate implementation of the current national and provincial TB protocols. The study provides varied levels of information about TB symptom screening in HIV infected individuals in the PHC clinics of eThekwini Municipality. It was observed that Health Care Worker’s (HCW) in some facilities carried out TB symptom screening to an extent. However, the inconsistent and partial application of this screening tool warrants improvement to facilitate the broad success of TB-HIV care strategies.

Submitted in fulfillment of the requirements for the Degree of Master of Technology in Nursing, Durban University of Technology, 2014. / Brief background to the study The national guidelines for maternity care in South Africa recommend that a standardised maternity case record be used by all facilities at all levels of care in order to improve the quality of care for pregnant women. According to the National Department of Health, this will facilitate continuity and quality of care for women during pregnancy, labour and post-partum. Aim of the study The aim of the study was to assess whether the implementation of the new maternity case record has improved the quality of care for pregnant women. Methodology An exploratory, descriptive study using both quantitative and qualitative design was used to conduct the study. Data was collected through a retrospective record review using a checklist for the quantitative strand, and from midwives using unstructured interviews for the qualitative strand. The quantitative data set was analysed using the Statistical Package for the Social Sciences version 21.0 and the qualitative strand was analysed using the Tesch’s method of data analysis. Results The results of the record review revealed that although the recording was done fairly well, there were a number of activities and interventions that were recorded poorly or not recorded at all in some primary health care clinic. The midwives verbalised that many mistakes and mismanagement of ante-natal care clients emanated from the structure and the design of the new maternity case record. Recommendations Recommendations include the following: communication of policies and protocols to the midwives should be done timeously, provision of in-service education and/or updates on new developments, strengthening of supportive supervision, the Nursing colleges be kept up-to-date with new developments in nursing practice and that a broader study involving other districts and provinces be conducted.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2015. / Background: The 19th Iteration of the World Transplant Games was hosted in Durban, South Africa in 2013. This biennial, international, multisport event showcases the talents of transplant athletes, whilst demonstrating the benefits of organ transplantation. To date, limited research is available on transplant athletes. This study aimed to determine the injury profile of transplant athletes who presented to the Durban University of Technology Chiropractic Treatment Facilities during the 2013 World Transplant Games. Methods: This retrospective, descriptive cohort study analysed the data collected at the Chiropractic Treatment Facilities at the 2013 World Transplant Games. For inclusion, each WTG Form required completion, reflecting all the elements of that participant’s chiropractic consultation. The data recorded on the World Transplant Games Form generated the data analysed in this study. The data described the frequency (frequency tables), nature and management of injuries treated at the Chiropractic Treatment Facilities during the 2013 World Transplant Games. In order to determine relationships cross tabulations were used. Results: There were 964 athletes registered for the 2013 World Transplant Games, of which 153 presented to the Chiropractic Treatment Facilities (an utilisation rate of 15.9%). A total of 259 consultations by the athletes (n = 223; 86.1%) and non-athletes (n = 36; 13.9%) were recorded. The majority of the treated athletes were White (n = 91; 59.5%), males (n = 109; 71.2%), in which kidney transplant recipients accounted for 37.3% (n = 58) of the total number. Track athletics had the highest injury rate (34.5% of all reported injuries). Athletes sustained injuries to 14 different anatomical regions, with the thigh (26.9%) and shin/calf (20.5%) being the most frequently injured. The majority of injuries (n = 164; 66.4%) were “overuse” injuries, with myofasciitis, muscle strains and thoracic facet syndrome being the most frequently obtained diagnoses (25.5%, 16.6% and 6.5% respectively). The most frequently employed treatment modalities were those of massage (32.1%), ischemic compression (16.3%) and manipulation (13.4%). It was noted that the most injuries sustained (88.3%) were not severe enough to result in an inability to continue current or future participation. Conclusions and Recommendations: Transplant recipient athletes injuries concur with the literature on non-transplant athletes, indicating that solid organ transplantation does not predispose the athlete to different or more serious injuries which would require different management protocols by health care personnel treating these athletes. Further investigation into individual sports is encouraged, to develop accurate, effective injury management and preventative strategies to more appropriately diagnose and treat injuries incurred by transplant athletes and then to prevent them from recurring. An informed healthcare approach towards event organising and athlete treatment will improve preventative strategies and athlete management.

submitted in fulfillment of the requirements for the Doctoral Degree in Nursing, faculty of Health Sciences, Durban University of Technology, Durban, South Africa, 2016. / Globally antenatal care is advocated as the cornerstone for reducing children’s deaths and improving maternal health. The World Health Organization designed and tested a Focussed Antenatal Care model for the developing countries to improve their quality of antenatal care services. South Africa has not successfully implemented this approach, referred to by South Africa as the Basic Antenatal Care approach. A convergent parallel mixed methods design was used to assess how the Basic Antenatal Care approach was implemented in the eThekwini district. Data were collected from 12 Primary Health Care clinics using observations, retrospective record reviews and semi-structured interviews conducted with pregnant women. The quantitative data was analysed using version 21.0 of the Statistical Package of Social Services and qualitative data was analysed using Tech’s method of data analysis. The Basic Antenatal Care approach was not being successfully implemented in the Primary Health Care clinics. Several aspects of planning, people, processes and performance were not done according to the Basic Antenatal Care Principles of Good Care and Guidelines. Although good communication was observed between the clinic staff members and the referral institutions, communication problems existed between the Primary Health Care clinics and the Emergency Medical Rescue Services and also with the pregnant women. Antenatal care and delivery plans and the midwives’ counter checking of maternity charts were not recorded. Some pregnant women had positive perceptions about the antenatal care services but others had negative perceptions. Recommendations pertaining to institutional management and practice, nursing education and research were made. A tailored practice framework and an implementation guide were developed based on setting and client-specific factors to facilitate the implementation of the Basic Antenatal Care approach. The framework highlights the importance of cooperation between management and administration, in-service education and skills development departments/units and the operational level. Effective implementation of the Basic Antenatal Care approach could help to reduce South Africa’s high maternal and neonatal mortality rates. Thus the tailored practice framework and implementation guide, developed as part of this study, could help to improve maternal and neonatal health-related outcomes in South Africa. / D

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2016. / Background: Thoracic spine pain (TSP) is a very common condition and can be just as disabling as cervical and lumbar pain. The causes of thoracic spine pain are numerous, ranging from less serious non-specific mechanical causes to serious specific underlying pathology. Chiropractors used to request routine radiographs as part of their diagnostic work-up, however limited correlation currently exists between radiographical findings and clinical symptoms in non-specific mechanical thoracic spine pain. The overutilization of plain film radiographs worldwide emphasises the need to investigate which clinical conditions in patients with TSP are sent for radiographs and if they were ethically indicated. Literature is currently limited on the role of thoracic spine x-rays and their influence on the management of patients with TSP. Objectives: The objectives of this retrospective study were: 1) to record the consultation at which thoracic spine radiographs were requested by the student or clinician and the reasons therefore, 2) to determine the number of incidental radiographic findings in the selected patients‟ radiographs, 3) to determine the suspected clinical diagnosis and management of the selected patients prior to referral for thoracic spine radiographs, 4) to determine any change in the clinical diagnoses and management following radiographic reporting of the selected patient‟s radiographs, 5) to determine the correlation between the suspected clinical diagnosis and the radiographic diagnosis of patients with thoracic spine pain. Method: The archives of the Chiropractic Day Clinic (CDC) at the Durban University of Technology (DUT) were searched for all available thoracic spine radiographs and corresponding patient files of patients who presented to the clinic with thoracic spine pain from 1 January 1997 to 31 December 2014. The ABCS (Alignment, Bone, Cartilage, Soft tissue) System was utilised to record data of the radiographs without any knowledge of the patient‟s main compliant. The corresponding patient files were then evaluated with selected clinical variables being recorded. Statistical analysis and interpretation included frequency counts, percentages, mean, standard deviation and ranges for the descriptive objectives. The radiographic and clinical diagnoses were then compared in a two-by-two table to determine any possible relationships in diagnoses of patients with thoracic spine pain. Results: Thirty clinical files and their corresponding thoracic spine radiographs were analysed in this study. The mean age of the patients was 43.6 (± 19.1) years with a gender distribution of 40% males and 60% females. Statistical testing using paired t-tests in order to assess the correlation between the clinical and radiological diagnoses was not possible, as the categories were too different. The most frequent primary radiological diagnosis was both old trauma and scoliosis at 33.3%, followed by thoracic spondylosis at 20%. The majority of thoracic spine radiographs were requested at the initial consultation. The most common reasons for radiographic referral were severe, progressive TSP at 58.6%, trauma at 48.3% and persistent, localised TSP for more than four weeks at 37.9%. The diagnosis remained unchanged in 70% of the patients following radiographic examination. However, in 30% of the cases the clinical diagnosis was changed following radiographic examination. Most patients were diagnosed with non-specific mechanical causes of thoracic spine pain. A wide variety of treatment modalities were utilised before and after radiographic examination, including soft tissue therapy, electro modalities, spinal manipulative therapy and dry needling. A total of 66.6% of the patients in the study had changes made to their management protocol following radiographic evaluation. There was a greater use of spinal manipulative therapy, following radiographic evaluation at 56.7% versus only 26.7% of cases prior to radiographic imaging. Conclusion: Thoracic spine radiographs have little impact on the diagnosis and management of patients with thoracic spine pain as the majority of clinical diagnoses were non- specific mechanical causes of thoracic spine pain. Thoracic spine radiographs were influential in the diagnosis and management of 30% of the cases. Thoracic spine radiographs may therefore be over-utilised at the DUT CDC. However, the use of spinal manipulative therapy more than doubled following radiographic evaluation of the thoracic spine in patients with thoracic spine pain. / M

Dissertation submitted in fulfillment of the requirements for the Degree in Masters of Technology: Nursing, Durban University of Technology, 2011. / Background South Africa is burdened by consistently high maternal and perinatal mortality rates. In a move to alleviate this burden the South African National Department of Health (DoH) instructed the adoption of the Basic Antenatal Care (BANC) approach in all antenatal care (ANC) facilities. Whereas many facilities have begun the implementation of the BANC approach, in the eThekwini district, not all of the facilities have been successful in doing so. The study was conducted in those eThekwini Municipality Primary Health Care (PHC) facilities that have been successful in order to identify the factors influencing their success in implementing BANC. Methods The facilities that had been successful in implementing BANC were identified, followed by a review of the past records of the patients who had completed their ANC and had given birth. This was done in order to establish whether the facilities that were said to be implementing BANC, were in fact, following BANC guidelines. The factors that influenced successful implementation of BANC were identified based on information obtained from the midwives who were working in the ANC facilities that were successfully implementing BANC. The sample size was comprised of 18 PHC facilities that were successfully implementing BANC from which a total of 59 midwives were used as the study participants. Results Several positive factors that influenced successful implementation of BANC were identified. These factors included; availability and accessibility of BANC services: Policies, Guidelines and Protocol; various means of communication; a comprehensive iii package of services and the integration of services; training and in-service education; human and material resources and the support and supervision offered to the midwives by the PHC supervisors. Other factors included BANC programme supervisors’ understanding of the programme and the levels of experience of midwives involved in implementation of BANC. There were, however, certain challenges and negative factors that were identified and these included: shortage of staff; lack of cooperation from referral hospitals; lack of in-service training; problems in transporting specimens to the laboratory; lack of material resources; lack of management support and the unavailability of BANC guidelines.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2017. / Background: The increasing cost and prevalence of chronic low back pain (LBP), has resulted in more resources being devoted to its treatment and management than ever before, despite only approximately 10% of acute cases progressing to chronicity. Determining prognostic factors for the short-term improvement of acute and chronic patients with LBP has become a research focus area to try and identify baseline factors that may affect a patients’ improvement with conservative treatment. Internationally studies have been conducted in developed countries however similar studies are lacking in developing settings like South Africa. It is unclear if the prognostic factors identified would be similar across populations. Thus, this study aimed to determine if pain, disability (social and physical), anxiety, depression, work fear-avoidance and locus of control, were associated with short-term prognosis, as determined by self-reported improvement using a Patients Global Impression of Change (PGIC) scale, in acute and chronic LBP patients attending the Durban University of Technology Chiropractic Day Clinic (DUT CDC). Method: Consecutive patients seeking treatment at the DUT CDC with a new episode of non-specific LBP, who met the study criteria, were approached for participation in the study. On agreeing to participate they were given the Bournemouth Questionnaire (BQ), a demographic questionnaire and a letter of information and consent (LOIC) at the initial consultation by student chiropractors. Those participants that were still attending treatment at the 4th/5th and tenth visit were required to complete the BQ and the PGIC. Results: A hundred participants were enrolled in the study, 65% had acute LBP and 52% were male. Only 20% of the initial group were still attending treatment at the 4th/5th follow-up. Baseline comparisons of those with acute and chronic pain revealed no significant difference in gender or age. Acute patients at the initial visit had higher levels of disability (social and physical), anxiety, depression and fear-avoidance beliefs than the chronic pain participants. At the 4th/5th treatment, the acute pain patients showed a significant decrease in pain (p=0.002) and disability (p=0.032), with all other measures decreasing from baseline measures. Similarly, chronic pain participants had a significant decrease in pain (p=0.038) but a significant increase in depression (p=0.015) scores, with all other prognostic factors being rated higher than at the initial consultation. The majority of participants (85%) in this study reported a clinical improvement in their LBP. In the acute pain sufferers, all but one participant reported improvement, thus identification of prognostic factors or this group was not possible. In the chronic pain participants, no factors were identified as prognostic for improvement, regardless of the low numbers still attending at the 4th/5th visit. Conclusions: Trends suggested that chronic pain sufferers were less likely to report decreases in the prognostic factors (except for pain), when compared to the acute pain participants. In the chronic LBP participants, no factors were associated with improved prognosis. The predictive value in determining which patients were less likely to improve was limited in the current study due to a small sample size. / M