Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Durban University of Technology, 2017. / Title: A profile of patients presenting with spinal pain at Mahalapye and Shoshong World Spine Care clinics in Botswana Background: Spinal pain such as low back and neck pain, are common and can cause severe long term pain which results in a major burden on individuals and health care systems (Woolf and Pfledger, 2003; Hondras et al., 2015a). Low-income countries often have few resources for adequately addressing musculoskeletal (MSK) pain (Louw et al., 2007). Thus, World Spine Care (WSC), a non-governmental organization, opened two clinics in Botswana to help improve spinal health care by providing access to MSK specialists (Haldeman et al., 2015). These clinics have been functional since 2012, and to date the profile of patients attending these clinics has not been investigated. Studies on patients attending chiropractic clinics have been carried out internationally (Hartvigsen et al., 2002; Giles et al., 2002; Coulter and Shekelle, 2005; Holt and Beck, 2005; Mootz et al., 2005; Sorensen et al., 2006; Garner et al., 2007; Stevens, 2007; Rubinstein et al., 2008; Martinez et al., 2009; Ailliet et al., 2010; Lischyna and Mior, 2012) and locally (Benjamin, 2007; Jaman, 2007; Mohamed, 2007; Venketsamy, 2007; Higgs, 2009; McDonald, 2012; Hitge, 2014), and yet very little information exists on the patients presenting to clinics in the public sector of Botswana. Demographic and disease profiles of patients vary by clinical setting, from country to country, and within regions of the same country (Hoy et al., 2010a). Thus, this study aimed to determine the demographic and disease profile of spinal pain patients attending the WSC clinics in Mahalapye and Shoshong in Botswana. Method: A retrospective, descriptive study design was used to extract data from the WSC patient files at the Mahalapye and Shoshong WSC clinics from 1 November 2012 to 31 March 2016. The research proposal was approved by the Institutional Research Ethics Committee (IREC); REC 53/16 (Appendix A), WSC (Appendix B) and Botswana MoH (Appendix C). Patient files included had provided consent for their files to be used for research purposes (Appendix F). Data recorded included demographic characteristics, factors related to spinal pain, the presenting complaint and the presence of co-morbid conditions. The data was analysed using Statistical Package for the Social Science (SPSS) version 24.0. Descriptive statistics in the form of graphs and cross tabulations were used to describe the demographic and disease profile of the spinal pain patients. Inferential statistics like chi-square, Fischer’s exact test for categorical variables and Independent student’s t tests for numerical variables were used to determine differences between the two clinics. A p-value of less than 0.05 was used to indicate statistical significance (Singh, 2016). Results: The sample size was 65% (n=714). There was a female preponderance (75.2%, n=537), a mean age of 50.6 years (±SD 16.13). Most patients were married (38%) and the most common occupations were either farmers (18.2%, n=129) or unemployed (16.3%, n=115). The majority of patients suffered from chronic (88%), idiopathic (59.5%), low back pain (69.9%), followed by upper/mid back (19.1%), with the least visits occurring for neck pain (8%). The most frequent diagnosis was joint dysfunction with associated soft tissue disorders. The patients reported mild disability with moderate pain intensity and most patients had not experienced previous spinal pain (60%). The patients did not report a secondary area of MSK pain (28.6%) and 73.9% of patients presented with at least one comorbid condition. Patients attending the rural clinic were older on average (52.7 years, ±SD 16.92) than those at the urban clinic (48.9 years, ±15.29) (p = 0.002). There were more women attending the urban clinic when compared to the rural clinic (p = 0.009), with those attending the rural clinic most often reporting a primary school level of education in contrast to those in the urban clinic having most likely obtained a more than secondary school education (p < 0.001). More patients in the urban clinic had “other mechanical” e.g. joint dysfunction as an aetiology for their spinal pain when compared to the rural clinic (p = 0.039). In terms of pain duration, the rural clinic patients were more likely to present with acute and subacute pain than at the urban clinic (p = 0.001). The rural clinic patients also reported more previous episodes of spinal pain in contrast to those from the urban clinic (p <0.001). Conclusion: The spinal pain patients attending the WSC clinics had many similarities to spinal pain patients internationally and in SA, however unique differences were found specifically when the urban and rural clinic patients were compared. The findings of this study can assist WSC to provide more targeted healthcare at each clinic and within this region. / National Research Fund / M

Dissertation submitted in partial compliance with the requirements for the Masters Degree in Technology: Chiropractic, Durban University of Technology, 2010. / The aim of this study was to determine the inter-examiner reliability of motion palpation to detect joint dysfunction in hindfoot and midfoot joints of asymptomatic feet and feet with chronic ankle instability syndrome. The rationale for this study was that motion palpation is a commonly used assessment tool that is used by the chiropractic profession to detect the need for manipulation of the spine and extremities. Also until the reliability of motion palpation is known, other studies using motion palpation as an assessment tool to detect the need for manipulation in the hindfoot and midfoot are questionable. The study was conducted at Durban University of Technology (DUT). Patients that responded to the adverts were then screened via telephonic interview. The researcher performed a case history, physical examination and a foot and ankle regional examination on each patient. Three masters chiropractic students then independently assessed both the symptomatic and asymptomatic feet of each patient and recorded their results. The data was then statistically analysed using SPSS version 15. It was found that the inter-examiner reliability of motion palpation for detecting restrictions in feet with chronic ankle instability syndrome was fair and for detecting instability, there was moderate reliability. In the asymptomatic group the examiners showed to have poor reliability in detecting restrictions and moderate reliability in detecting instability. Inter-examiner reliability was better in the symptomatic group and in this group examiners had more agreement on detecting instability as opposed to restrictions. This study has showed that inter-examiner reliability ranged from poor to moderate in the symptomatic and asymptomatic group with the reliability ranging from poor to moderate. Therefore, one can conclude that motion palpation can be used as an assessment tool to detect joint dysfunction in hindfoot and midfoot joints. However, further studies are warranted to address other subjective and objective measurements such as tenderness and range of motion together with motion palpation.

Dissertation submitted in partial compliance with the requirements for a Masters Degree in Technology: Chiropractic, Durban University of Technology, 2009. / Headaches are one of the most common clinical conditions in medicine, and 80% of these are tension-type headaches (TTH). TTH has a greater socioeconomic impact than any other type of headache due to its prevalence. Within the TTH category, episodic TTH are more prevalent than chronic TTH. The mainstay in the treatment of TTH are simple analgesics and NSAIDs. Unless contraindicated, NSAIDs are often the most effective treatment for ETTH. However patients suffering with TTH tend to relate their headaches to increased muscle stiffness in the neck and shoulders and thus the non-pharmacological treatment of ETTH could be directed at the associated musculoskeletal components of ETTH. It is therefore proposed that the Kinesio Taping® Method may have an effect in the treatment of the muscular component of ETTH. Method: This study was a prospective randomised clinical trial with two intervention groups (n=16) aimed at determining the relative effectiveness of a NSAID and the Kinesio Taping® Method in the treatment of ETTHs. The patients were treated at 5 consultations over a 3 week period. Feedback was obtained using the: NRS – 101, the CMCC Neck Disability Index and a Headache Diary. Results: The Headache Diary showed a reduction in the presence and number, mean duration and pain intensity of ETTH in both groups. These treatment effects were sustained after the cessation of treatment with the exception of mean pain intensity in the Kinesio Taping® Method group. The mean NRS score decreased in both groups but at a slightly faster rate in the Kinesio Taping® Method group. The CMCC showed an improvement in the functional ability of the patients in both groups. Conclusion: There seems to be no significant difference in the relative effectiveness of the treatment modalities. We can thus state that the overall short-term reduction in symptomatology supports the use of NSAIDs or Kinesio Taping® Method in the treatment of ETTH.

Dissertation submitted in partial compliance with the requirements for the Masters Degree in Technology: Chiropractic, Durban University of Technology, 2010. / The 1 year overall prevalence of Episodic Tension-Type Headache (ETTH) is 38.3%; with lifetime prevalence at 46% for TTH. Little literature exists to support the effectiveness of spinal manipulation in the treatment of ETTH. Therefore aim of this study was to determine the relative effectiveness of cervical spine manipulation and a Nonsteroidal Anti-inflammatory drug (NSAID) (Ibuprofen®) in the treatment of ETTH. Method: This study was a prospective randomised clinical trial with two intervention groups (N=32, n1=16 and n2=16). The allocation of participants to the two groups was completed by means of simple randomization. Group one were treated using cervical spine manipulation. Group two were treated using Ibuprofen. Subjective measurements included the Numerical Rating Scale 101 Questionnaire (NRS-101), Short Form McGill Pain Questionnaire (SF-MPQ), CMCC Neck Disability Index (CMCC) and Headache Diary. A p value <0.05 was considered as statistically significant. Results: The subjective measurements of the NRS-101, SF-MPQ and CMCC showed a significant time effect in both treatment groups. Several of the subjective Headaches Diary outcomes followed this trend with significant time effect in both groups. There was a significant treatment effect for the NRS-101. Several subject outcomes from the Headache Diary showed a significant treatment effect in favour of manipulation, namely frequency and duration of headaches. Conclusion: The findings in this study have shown that cervical spine manipulation is more effective than Ibuprofen® for the treatment of ETTH in terms of several subjective outcomes namely: pain intensity (NRS-101), and the frequency and the duration of headache per day.

Dissertation submitted in partial compliance with the requirements for a Masters Degree in Technology: Chiropractic, Durban University of Technology, 2011. / The relationship between TMD and dysfunction in the cervical spine has been reported in the literature and there are many case studies which have shown favourable results when treatment was aimed at the TMJ, cervical spine relationship. However, the numerous TMD treatment protocols described in the literature concerning this relationship, and the effectiveness of these treatments have not been well established. In spite of this many chiropractors treat TMD. TMD is a multifactoral condition and conservative treatment options need to be further investigated in order to determine if manual interventions directed at the cercival spine in the treatment of TMD are beneficial. Objectives: The purpose of this study was to compare myofascial trigger point therapy and manipulative therapy of either the TMJ, cervical spine or a combination of the two in order to determine their effectiveness for the TMD. Method: Thirty participants with TMD were randomly assigned to one of three treatment groups. Participants in each group received two treatments per week for two weeks with a follow up consultation in the third week. Data were collected before the commencement of the first, second, and fourth treatments and at the follow up consultation. Outcome measures included algometer readings, CROM, Mouth opening readings, NRS and a disability questionnaire. SPSS version 15.0 was used for analysis of the data. A p value <0.05 was considered as statistically significant. Multivariate testing was used for intra- and inter-group comparisons. Profile plots were generated to assess the direction and trend of the effect and to visually compare the trends in the different treatment groups. Results: Inter-group comparisons did not reveal any statistically significant different improvements between the three treatment groups. Conclusion: All groups responded favourably to treatment and showed trends towards improvement. However, statistically analysis revealed that no one treatment protocol was superior to the other. Although no definitive inferences may be drawn regarding the effectiveness of each treatment approach, within group trends indicated that the combination of the two treatment approaches may be preferred.

Submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Durban University of Technology, 2013. / Background: A triathlon comprises of a combination of swimming, cycling and running. Triathlons are usually classified as sprint distance, Olympic distance, and Ironman or ultra-distance. Triathlon was popularized in the 2000 Summer Olympic Games and, despite this, there is insufficient data relating to injuries in the South African context. This study aimed to determine the injury profile of amateur and semi-professional Kwa-Zulu Natal triathletes. Methods: This Institutional Research Board approved, cross sectional study, included 80 active members of the Kwa-Zulu Natal Triathlon Association. All triathletes completed a questionnaire on training and injury profiles; with only those having had a musculoskeletal complaint additionally completing a clinical consultation. In order to assess associations between presence of injury and explanatory variables, binary logistic regression using backward selection based on likelihood ratios was used. Data was described using frequency tables for categorical data and summary statistics for continuous data. Odds ratios was reported and a p value <0.05 was considered statistically significant. For triathletes reporting injuries, linear regression was used for factors associated with injury severity. Results: Fifty seven triathletes responded giving a response rate of 71% (68% male, 32% female). The point and period (year) prevalence of triathlon-related musculoskeletal pain was 17.5% and 68.4% respectively. The ranking of the most common site of injury in the last 12 months included the knee (64%), low back (21%) and thigh (18%); with females having had a significantly higher risk of injury than males (p=.019). Additionally, injury risk also increased with weight (p=.055), number of triathlons undertaken in the previous year (p=.031), number of triathlons in the last 4 months (p=.009) and running distance during competition times (p=.011). Injury risk decreased with increasing distance of cycling (p=.061) and swimming (p=.030) in a competition, and length of training in- and off-season (p=.105 and p=.043 respectively). Strong trends were demonstrated between injury severity and long-slow training distance (p=.006) and weight (p=.006). By contrast to risk of injury, injury severity was negatively associated with weight, while a long-slow distance was positively associated with the severity of the injury. Of all the health professions, chiropractic was the most utilized health profession. Conclusion and recommendations: The results concur with previous research, but add insights into factors predisposing triathletes to injury. The most common injuries require investigation to develop preventative interventions to reduce injuries in triathletes. Health professionals require education about triathlon-related injuries to improve preventative and curative interventions.

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 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: Tennis is one of the most popular sports globally with over 75 million players around the world. Most studies have focused on junior or elite level players although the majority of players around the world are presumed to be recreational/non-professional players. To date, limited research is available pertaining to the epidemiology of tennis related musculoskeletal in non-professional league tennis players in South Africa. This study aimed to determine the profile of musculoskeletal injuries amongst league tennis players in the northern eThekwini region. Methods: This was a quantitative, cross-sectional, descriptive study utilizing a self-administered questionnaire, developed specifically for this research utilizing an expert group and pilot study. The questionnaire contained sections on demographics, tennis history, training and nutrition, court surface and equipment as well as a section on tennis related musculoskeletal injuries. Risk factors for injury were first tested using chi square tests in the case of categorical variables, and t-tests in the case of continuous variables. In order to assess the relationship between injury and potential risk factors for injury, a binary logistic regression using backward selection based on likelihood ratios was used. Odds ratios and 95% confidence intervals of the variables remaining in the model at the end were reported. A p value <0.05 was used to indicate statistical significance. Results: Eighty league tennis players responded giving a response rate of 70.16%. The period prevalence, and the point prevalence of tennis related musculoskeletal injury was 68.75% and 36.25% respectively. A predominance of injuries to the upper extremity were recorded (49%) compared to the lower extremity (27.5%) and the back and trunk (23.5%). The elbow was the most common anatomical site of injury (21.4%) followed by the shoulder (19.4%), the lumbar spine (17.3%) and the knee (8.2%). Age was considered to be a risk factor for injury (p=0.049) as older players in the study (49.32 (17.547) years of age) were less likely to contract an injury than younger players (48.38 (13.210) years of age). The likelihood of injury decreased with a higher Body Mass Index (p=0.042). The relationship between consumption of spirit alcohol and injury was significant (p=0.043). Ex-smokers had a higher chance of contracting an injury (p=0.013). It was also found that those who cycled weekly were less likely to contract an injury (p=0.040). Conclusion: The results concur with other studies on recreational/non-professional tennis players and add insight into risk factors predisposing this population to injury. Health care practitioners need to understand the risk factors for injury in this population so that players can be better managed. Using the results of the study, an injury prevention strategy such as a strength and conditioning program, needs to be implemented with the goal to reduce or prevent common injuries in this population of players. / 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 There has been a remarkable increase in the participation of sport for athletes with disabilities. Consequently, there have been many international studies on injuries in athletes which have shown a high prevalence in wheelchair basketball, largely attributed to the fast-paced, high intensity nature of the sport. This sport has grown worldwide including South Africa, however, very little research has been published on South African wheelchair basketball players and more research is, therefore, needed. Aim To determine the prevalence and profile of musculoskeletal pain in elite wheelchair basketball players of different point classifications in South Africa. Hypothesis 1: Upper extremity (including neck and back) pain is experienced more commonly in lower point classified wheelchair basketball players than in higher point classified players. Hypothesis 2: Lower extremity pain is experienced more commonly in higher point classified players than in lower point classified players Method This study was a quantitative, cross-sectional, questionnaire-based study. The questionnaire comprised of sub-sections on demographics and disability characteristics; activity levels pertaining to wheelchair basketball and other sport/physical activity; the prevalence of pain and the impact thereof on wheelchair basketball and/or activities of daily living. This questionnaire was administered to 48 wheelchair basketball players who were competing in the 2015 Supersport League. A response rate of 70% was decided as the lower limit cut-off for statistical power. Results Fourty-three participants responded yielding an 89.58% response rate. The mean age of participants was 33.3 (SD:9.5) years and the majority of participants (n=35) were male and African (n=29). Out of the 43 participants, 79.1% (n=34) used mobility devices, the majority (n=20) used wheelchairs. Most of the participants (n=41) played wheelchair basketball for more than five years and 32 participants did not participate in other sport. Almost half of the participants (n=25) experienced musculoskeletal pain in the last twelve months or at present, 75% of whom (n=12) visited a Physiotherapist for the pain. More than half of these participants (n=15; 60%) reported that the pain negatively affected their basketball performance. It was established that arm pain occurred frequently in lower point classified players (1.0-2.5 point players) and that hand and wrist pain was also more prevalent in lower point players than in higher point players. The prevalence of lower extremity pain was low and there was no statistically significant difference between higher and lower point classified players. Conclusions and Recommendations The finding that upper extremity pain occurred more frequently in lower point classified players was in keeping with the first hypothesis (the null hypothesis was, therefore, rejected). The second hypothesis was, however, rejected (and the null hypothesis was, therefore, accepted) as lower extremity pain did not occur more frequently in higher point classified players than in lower point classified players. The Eta scores may have been higher and may have shown a much larger than typical relationship between point classification and the prevalence of musculoskeletal pain had there been a larger sample size. Notwithstanding this limitation, it is a challenge to obtain a significantly larger sample size due to the nature and limited number of participants in this sport. More studies are warranted on this group of individuals, as a large number experienced pain which affected more than half of the participants’ performance in wheelchair basketball. These studies are important for the future success of the South African players and the sport in South Africa. / M

Dissertation submitted in partial compliance with the requirements for a Masters Degree in Technology: Chiropractic, Durban University of Technology, 2011. / The relationship between TMD and dysfunction in the cervical spine has been reported in the literature and there are many case studies which have shown favourable results when treatment was aimed at the TMJ, cervical spine relationship. However, the numerous TMD treatment protocols described in the literature concerning this relationship, and the effectiveness of these treatments have not been well established. In spite of this many chiropractors treat TMD. TMD is a multifactoral condition and conservative treatment options need to be further investigated in order to determine if manual interventions directed at the cercival spine in the treatment of TMD are beneficial. Objectives: The purpose of this study was to compare myofascial trigger point therapy and manipulative therapy of either the TMJ, cervical spine or a combination of the two in order to determine their effectiveness for the TMD. Method: Thirty participants with TMD were randomly assigned to one of three treatment groups. Participants in each group received two treatments per week for two weeks with a follow up consultation in the third week. Data were collected before the commencement of the first, second, and fourth treatments and at the follow up consultation. Outcome measures included algometer readings, CROM, Mouth opening readings, NRS and a disability questionnaire. SPSS version 15.0 was used for analysis of the data. A p value <0.05 was considered as statistically significant. Multivariate testing was used for intra- and inter-group comparisons. Profile plots were generated to assess the direction and trend of the effect and to visually compare the trends in the different treatment groups. Results: Inter-group comparisons did not reveal any statistically significant different improvements between the three treatment groups. Conclusion: All groups responded favourably to treatment and showed trends towards improvement. However, statistically analysis revealed that no one treatment protocol was superior to the other. Although no definitive inferences may be drawn regarding the effectiveness of each treatment approach, within group trends indicated that the combination of the two treatment approaches may be preferred. / M