Several surveys that have been published show opinions regarding a change in the scope of chiropractic practice to include prescription rights. Currently, research into the attitudes of South African chiropractors towards having this right is non-existent.
To ascertain the attitudes of South African chiropractors towards the inclusion of drug prescription rights in their scope of practice.
The study was conducted on chiropractors registered with the Allied Health Professions Council of South Africa and members of the Chiropractic Association of South Africa.
A self-administrative online questionnaire was developed, and sent via email to all registered chiropractors in South Africa in February 2020. Descriptive statistics were used to analyse the data.
The response rate for this study was 15.9% (
The majority of South African chiropractor respondents indicated an interest in expanding their scope of practice to include limited prescription rights.
These findings could indicate a shift in the attitudes of chiropractors towards drug prescription rights within the profession.
The use of over-the-counter (OTC) and prescription drugs by chiropractors is a controversial issue worldwide (Emary & Stuber
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Emary and Stuber asserted that, in the approximately 120-year history of chiropractic, the profession has been known as a drugless and non-surgical healing profession (Emary & Stuber
Despite these assertions, in some jurisdictions in the world, chiropractors can gain licences to prescribe OTC and/or prescription-based medications such as non-steroidal anti-inflammatory drugs (NSAIDs), analgesics and muscle relaxants for common musculoskeletal conditions (Robert
Yet such rights are a requirement for those chiropractors within the chiropractic profession who are referred to as primary spine care providers, and fulfil their role as primary contact practitioners (Emary & Stuber
In Switzerland, the chiropractic profession gained limited prescription rights in 1995 and has a high frequency of interprofessional referrals for spinal disorders. This practice is valuable and considered necessary for Swiss chiropractors as they are integrated with the healthcare system as primary spine care providers and recognised as one of the five medical professions in Switzerland (Humphreys & Peterson
Some lessons can be learned from the international experiences in Switzerland and the State of New Mexico and applied to chiropractic practice worldwide. In sum, to be recognised as a primary spine care provider, the following criteria need to be met: practice should (1) be evidence-based, (2) be scientifically justifiable, (3) be clinically relevant and (4) incorporate an integrated and collaborative approach to healthcare (Innes et al.
Evidence-based practice has been identified as the integration of research evidence with clinical skill as well as patient-related values. This approach should be widely adopted and supported by health professions (Innes et al.
Because chiropractors in South Africa do not currently have prescription rights, the purpose of this study was to ascertain their attitudes towards attaining such rights.
This was a quantitative study utilising a self-administered, online English questionnaire, which the registered chiropractors accessed via email through a link.
This study was conducted by means of an online survey questionnaire which was sent to all chiropractors registered with the Allied Health Professionals Council (AHPCSA) in South Africa.
A minimum of 100 responses were required for the data to be statistically significant, which is a minimum of 11.5% (confidence level of 95% with margin of error of 8%) of the total population size according to the statistician assigned to this study. There were 867 registered chiropractors at the time of circulation of the survey. The information letter and link to the survey were circulated to all members. Of these, 138 completed the survey, making the response rate for this study to be 15.9%. All respondents complied with the inclusion criteria.
The questionnaire used for this study was based on Emary and Stuber (
Section 3 of the questionnaire used a 5-point scale ranging from ‘never’ to ‘routinely’ and focused on the frequency of OTC drug recommendations currently taking place in chiropractic practice. The questions were centred on whether chiropractors recommended OTC medication to either an acute or chronic patient as well as how often the chiropractor refers a patient to a general practitioner for an anti-inflammatory drug or muscle relaxant.
Section 4 focused on questions related to chiropractors’ current knowledge of drug prescription practices (i.e. indications, contraindications, dosages and drug interactions). The responses were recorded on a 5-point Likert scale ranging from ‘very high’ to ‘very low’. The questions addressed chiropractors’ perceptions of their current knowledge on prescribing medication for musculoskeletal conditions versus non-musculoskeletal conditions, whether the chiropractor feels that there should be a post-graduate programme for pharmacology and drugs (muscle relaxants and NSAIDs) that they believe assist in pain relief and faster recovery.
There are various advantages to this methodology, some of which include cost-effectiveness and simplicity in distribution and analysis. The application of this method of survey design and distribution, provides for a user-friendly platform allowing for the exportation of data and ease in analysis. The platform used to deliver the survey was QuestionPro. Confidentiality and anonymity were maintained with the survey by not directly asking for the participants’ name or surname or any further confidential questions. A disadvantage was that various questions were misinterpreted and led to unanswered questions. As such, certain responses were disqualified, which impacted reliability.
A pilot survey was sent out to five chiropractors to pre-test the efficiency of the survey and to elicit feedback on the survey regarding face validity. These chiropractors were then excluded from the final survey. Pre-testing aided in identifying where corrections were required, ensuring that there were no grammatical errors and verifying that questions were not misunderstood or misinterpreted. The feedback allowed the researcher to make the necessary changes to ensure validity.
The data was entered into the SPSS version 21 (IBM Corp, Armonk, NY), which was used to analyse the coded data. Descriptive analyses were used to explore the attitudes of chiropractors toward incorporating prescription rights into their scope of practice. The data was analysed by an independent entity, the statistician at the University of Johannesburg, STATKON division. Inferential statistics (Chi square) to determine the relationships between data were performed, but no significant differences were noted.
This study was approved by the University of Johannesburg (UJ), Faculty of Health Sciences, Research Ethics Committee (REC -133-2019). The participants were provided with the study information in an invitation email and the survey cover sheet. The study information described the purpose of the survey and provided an estimate of the time required to complete the survey. Participation was voluntary and all data were anonymous, as no personal information was obtainable from the responses. The right to withdraw from the study at any time without consequence was stipulated. The participants provided anonymous consent by agreeing to a statement outlining the study information before being able to proceed to the survey.
The survey obtained 15.9% (
Demographic data of study respondents.
Variable | Total number of valid responses ( |
Results | |
---|---|---|---|
SD | % | ||
Mean (SD) years in practice | 124 | 11 | 10.47 |
Mean age (SD) years | 23 | 38.1 | 11.16 |
125 | - | - | |
Male | 57 | 45.6 | - |
Female | 68 | 54.4 | - |
125 | - | - | |
Technikon Witwatersrand | 16 | 12.8 | - |
University of Johannesburg | 52 | 41.6 | - |
Durban University of Technology | 7 | 5.6 | - |
Natal Technikon | 34 | 27.2 | - |
Other | 7 | 5.6 | - |
SD, standard deviation.
The attitudes of South African chiropractors to drug prescription rights are summarised in
Attitudes of South African chiropractors to drug prescription rights.
Attitudes | Agree | Disagree | ||
---|---|---|---|---|
% | % | |||
Attitudes of chiropractors to prescribing |
105 | 84 | 20 | 10.4 |
Attitudes of chiropractors to prescribing prescription-based analgesics, anti-inflammatories and/or muscle relaxants | 94 | 75.2 | 31 | 19.2 |
Attitudes of chiropractors to prescribing all and any medication (e.g. antibiotics, anti-hypertensives, anti-depressants, corticosteroids etc.) | 27 | 13 | 98 | 79.6 |
OTC, Over the counter.
Most of the chiropractors who participated in the study believed that OTC drugs such as NSAIDs and muscle relaxants assist in speeding up the recovery of patients and a similar number of participants believed that OTC drugs, NSAIDs and muscle relaxants assist in relieving the pain of patients as shown in
The beliefs of chiropractors towards over the counter drugs assisting in speeding up recovery of patients.
The attitudes of chiropractors towards over-the-counter drugs assisting in relieving pain of patients.
Section 3 of the survey focused on the frequency with which chiropractors recommend OTC medication to either acute or chronic patients in clinical practice. The responses revealed that 33.6% of the respondents often, which equates to 51% – 75% of the time, recommend OTC drugs to acute patients and 37.9% of the participants rarely, which equates to 1% – 25% of the time, recommend OTC drugs to chronic patients as seen in
The frequency of over-the-counter drug recommendation to acute patients in chiropractic practice.
The frequency of over-the-counter recommendation to chronic patients in chiropractic practice.
The frequency of referrals by chiropractors to general practitioners to receive an anti-inflammatory or muscle relaxant.
Section 4 of the survey explored the self-reported current extent of knowledge of South African chiropractors on drug prescription.
Current perceived knowledge of South African chiropractors on drug prescription.
Current knowledge | High | Low | ||
---|---|---|---|---|
% | % | |||
Musculoskeletal drug prescription | 86 | 68.8 | 39 | 31.2 |
Non-musculoskeletal drug prescription | 22 | 17.6 | 103 | 82.4 |
The survey reflects whether South African chiropractors responding to this survey deemed it necessary to obtain a postgraduate certificate in pharmacology or drug administration in order to prescribe medication. In that regard, the vast majority (91.2%) of study participants believed that a postgraduate certificate programme in pharmacology or drug administration would be necessary for those in the profession who wish to prescribe drugs.
South African chiropractors’ perceptions on certain muscle relaxants and anti-inflammatories relieving pain and speeding up recovery of patients.
South African chiropractors perception response to | Total responses | No | Yes | ||
---|---|---|---|---|---|
% | % | ||||
Baclofen, for example, Lioresal | 112 | 44 | 39.3 | 68 | 60.7 |
Orphenadrine citrate, for example, Norflex | 122 | 15 | 12.3 | 107 | 87.7 |
Methocarbamol acetaminophen, for example, Robaxin | 118 | 20 | 16.9 | 98 | 83.1 |
Baclofen, for example, Lioresal | 109 | 74 | 67.9 | 35 | 32.1 |
Orphenadrine citrate, for example, Norflex | 115 | 62 | 53.9 | 53 | 46.1 |
Methocarbamol acetaminophen, for example, Robaxin | 110 | 55 | 50 | 55 | 50 |
Acetylsalicylic acid, for example, Aspirin | 117 | 35 | 29.9 | 82 | 70.1 |
Diclofenac, for example, Voltaren and/or Cataflam | 121 | 5 | 4.1 | 116 | 95.9 |
Ibuprofen, for example, Nurofen | 123 | 7 | 5.7 | 116 | 94.3 |
Naproxen sodium, for example, Alev | 111 | 31 | 27.9 | 80 | 72.1 |
Acetylsalicylic acid, for example, Aspirin | 111 | 85 | 76.6 | 26 | 23.4 |
Diclofenac, for example, Voltaren and/or Cataflam | 119 | 33 | 27.7 | 86 | 72.3 |
Ibuprofen, for example, Nurofen | 117 | 47 | 40.2 | 70 | 59.8 |
Naproxen sodium, for example, Aleve | 108 | 73 | 67.6 | 35 | 32.4 |
NSAIDS, non-steroidal anti-inflammatory drugs.
The primary findings of this study were that the majority of South African chiropractors who responded to this survey were in favour of expanding the scope of practice to include limited prescription rights. Although the response rate to this survey was above the minimum requirement for statistical significance, it was still lower than similar studies conducted in other countries. In a similar study conducted by Emary and Stuber in Ontario, the response rate was 22.9% (Emary & Stuber
These findings are consistent with several previous international studies regarding the chiropractors’ rights to prescribe specific medications for their patients (Emary & Stuber
Emary et al. stated in a commentary on the implications of medication prescription rights for the chiropractic profession that the arguments against prescribing rights mainly include the divisiveness within the profession around this topic (Emary et al.
Irrespective of these philosophical differences, there is sufficient evidence from the increasing number of published surveys that suggests that there appears to be a change in chiropractors’ attitudes toward prescription rights, with more chiropractors’ favouring an expansion in their scope of practice to include specific prescription rights. Surveys conducted in Australia (Jamison
The over-use and over-reliance on specific pain medications such as opioids are increasingly becoming an important issue to address as there is an over-prescription of these types of drugs in the US and many other countries (Gliedt et al.
Emary et al. stated in their commentary on the implications of medication prescription rights in the chiropractic profession that one of the arguments in favour of having limited prescriptive authority was a positive influence on public health (Emary et al.
This study showed that less than half of the respondents often (51% – 75%) recommend OTC drugs to acute patients and less than half of the respondents rarely (1% – 25%) recommend OTC drugs to chronic patients. As indicated by Wangler et al. in Switzerland, 72% of their respondents agreed that medications are necessary in extremely acute cases where absolutely no range of motion can be achieved (Wangler et al.
This study also showed that less than half of the respondents reported that they rarely (1% – 25%) refer their patients to a general practitioner to receive anti-inflammatory or muscle relaxant medications. Having limited prescription rights could benefit the profession’s efficiency and reduce the patient’s time and money spent on healthcare services. As indicated by Emary et al., having limited prescription authority could facilitate the chiropractic profession having better integration into the healthcare system (Emary et al.
In this study, most of the respondents were confident in their knowledge of musculoskeletal drugs but were not very confident in their knowledge of non-musculoskeletal drugs. Therefore, almost all of the respondents felt it necessary to obtain a postgraduate certificate in pharmacology or drug administration in order to be allowed to prescribe medication. These results corresponded with those of the study conducted in Ontario, Canada, where two-thirds of the respondents rated their knowledge on prescribing drugs for musculoskeletal conditions as ‘high’ to ‘very high’ (Emary & Stuber
In New Mexico, USA, where chiropractors currently have limited prescriptive authority, chiropractors must complete a 2-year postgraduate Master of Science degree in Advanced Clinical Practice before they can obtain the licence to prescribe a limited formulary in that state. Further training in pharmacology is offered in this postgraduate programme and it serves as a model for the chiropractic profession for other jurisdictions trying to obtain these rights (Emary & Stuber
Indeed, education and training are a concern when considering any expansion in the scope of practice in the chiropractic profession. As stated by Lehman et al., the institution that was considering to expand the training and education for chiropractors in New Mexico, USA was the National University of Health Sciences in Chicago, which included a 2-year Master’s degree in Advanced Practice (Lehman et al.
In Switzerland, 91% of the respondents stated that chiropractors should attend mandatory classes before they prescribe NSAIDs, muscle relaxants and analgesics. As stated by Wangler et al., the comments by the respondents were focused on continuing education in pharmacology and emphasised understanding dangers and possible interactions or side effects of medication. Because this field is often changing, continuing education is essential to remain updated with the latest knowledge (Wangler et al.
Although there was a high interest in prescribing drugs and completing a postgraduate certificate in pharmacology by South African chiropractors, 79.6% (
The respondents of this study were also asked about their perceptions of whether or not certain drugs either relieved pain or sped up the recovery of their patients. Almost all of the respondents agreed that the muscle relaxant Robaxin was more helpful in relieving the pain of their patients compared to the drugs Norflex and Lioresal. However, this data is only based upon personal opinion and not upon any previously published research. The general consensus of this study is that the respondents did not agree on whether or not muscle relaxants speed up the recovery of their patients. The respondents’ perception regarding NSAIDs in terms of relieving the pain of their patients revealed that the majority agreed that Voltaren (diclofenac sodium) and/or Cataflam (diclofenac potassium) most effectively relieved the pain of their patients, closely followed by Nurofen (ibuprofen). Furthermore, the respondents felt that these two drugs were also more effective in speeding up the recovery of their patients compared to Aleve (naproxen) and Aspirin (acetylsalicylic acid).
This study showed that chiropractors may support obtaining prescribing rights in South Africa. Evidence from the literature and results from the current study suggest that among chiropractors who hold favourable views toward drug prescription, prescription privileges limited to a musculoskeletal scope of practice would be preferred (Emary & Stuber
The response rate of 14.4% met the statistical significance (10%) for this study according to the statistician at the UJ but was lower in comparison to the international standards and similar studies conducted. Reminder notifications for the completion of the survey were not sent out as done in other countries, because of the protocols set out in the distribution of the survey from the AHPCSA at that stage. Thus, the results of this study may be because of a sampling bias if those chiropractors who were more interested in having limited prescription rights were more inclined to respond.
Furthermore, the data obtained on whether or not specific medications do result in more pain reduction or speed up recovery compared to other medications are only the perception of the participating chiropractors.
This study revealed that the majority of the South African chiropractors responding to this survey were in favour of having limited medication prescription rights within the chiropractic scope of practice. They were generally confident in their knowledge of medications regarding musculoskeletal conditions but also thought that additional post-graduate education should be required.
Further studies are needed to explore dialogue among professional bodies and chiropractic regulatory authorities to consider the expansion of the scope of practice of the profession to include limited prescription rights with the requisite training and legislation.
The authors thank Mr Anesu Kuhudzai, STATKON, University of Johannesburg, for his assistance in analysing the data. This manuscript is based on a Masters dissertation submitted by Thriya Huluman (supervised by Christopher Yelverton) in partial fulfilment of the MTech Chiropractic completed at the University of Johannesburg, which can be viewed at
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
T.H. and C.Y. were responsible for the conceptualisation and study design. Statistical analyses were performed by T.H. All the three authors (T.H., C.Y. and C.P.) were involved in drafting the manuscript, critically reviewing, editing and approving the final manuscript.
The study received funding via a Supervisor Linked Bursary, from the University of Johannesburg, South Africa.
The dataset used and/or analysed during the current study is available, in aggregated format to maintain participant anonymity, from the corresponding author on reasonable request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.