Musculoskeletal pain among South African flight Attendants: A cross-sectional study

Abstract

Objective

The purpose of this study was to provide details on injuries and musculoskeletal pain among South African flight attendants and to explore their knowledge, perception, and utilization of chiropractic care.

Methods

The study employed a descriptive, cross-sectional design and used a survey for data collection. A total of 108 participants completed the questionnaire from April to November 2022. Data were analyzed descriptively using frequencies, percentages, and cross-tabulations. Mann- Whitney U tests compared 5-point Likert scale responses regarding chiropractic perceptions between users and non-users.

Findings

The study found that 58% of flight attendants experienced work-related musculoskeletal pain, mainly in the lower back (84.1%) and shoulders (39.7%). Common causes included long shifts (66.7%) and lifting luggage (44.4%). About 32% sought chiropractic care, which 90% found beneficial for both prevention and maintenance. Chiropractic utilization was higher among participants with musculoskeletal pain (41.3%) compared to those without (19.0%, P = .014). Knowledge scores did not differ significantly (P = .369). Positive perceptions (P = .004) and preferences (P < .001) were associated with increased utilization, while limited knowledge (P < .001) and discomfort (P = .046) were linked to decreased utilization.

Conclusion

Despite a significant number of flight attendants reporting work-related musculoskeletal pain, their limited knowledge of chiropractic influenced their perception and usage of the service. There is a need for the aviation industry to address musculoskeletal risks and provide adequate chiropractic education and care to flight attendants.

Introduction

Chiropractic care has increasingly been utilized to manage musculoskeletal conditions, particularly neck and back pain.1, 2, 3 Empirical evidence suggests that chiropractic treatment can significantly alleviate pain and disability in patients experiencing conditions such as osteoarthritis and spinal pain.^2,4 Furthermore, chiropractic care has been associated with a decreased likelihood of opioid prescriptions for spinal pain, underscoring its role as a non-pharmacological alternative in pain management strategies.⁵ Global health objectives have focused on musculoskeletal (MSK) disorders over the past century.⁶ As the world’s population grows, individuals become increasingly susceptible to non-communicable diseases, including MSK problems.⁷ Healthcare has become more diverse, combining conventional and alternate health therapies to manage ailments. However, it is unclear what healthcare alternatives individuals who are prone to MSK issues choose as a first line of therapy for MSK diseases.

Musculoskeletal disorders encompass more than 150 distinct ailments that affect joints, muscles, bones, ligaments, tendons, and the spine, and the economic impact of these issues is steadily increasing. MSD-related pain is a prevalent medical and socioeconomic problem that causes debilitation worldwide.⁸ Work-related MSDs arise when an injury is caused or exacerbated by work-related activities such as lifting, pushing, pulling, reaching, extended standing, prolonged bending, uncomfortable and constrained postures, and repetitive motions. Patients with work- related MSDs frequently experience disabling symptoms that limit the type or duration of work they can perform.^9,10 Pain resulting from musculoskeletal problems in the back, shoulder, knee, and multiple sites is becoming a common cause of poor quality of life and increased healthcare demands.¹¹ There are numerous treatment options for musculoskeletal pain, most of which are provided in primary care by first-contact clinicians such as general practitioners, physiotherapists, chiropractors, and osteopaths.¹¹

Work-related musculoskeletal disorders (WMSDs) have a significant impact on individuals, their families, and their work. These disorders, the leading cause of restricted or lost work time, are a significant health concern for workers in industrialized and emerging Asian countries.^12,13 Low back pain, a prevalent musculoskeletal issue, can cause disability, absenteeism, and activity limitations in various service industry jobs, including flight attendants. Low-back WMSDs are primarily caused by physical stress or load resulting from bodily biomechanical forces due to occupational responsibilities. Low back pain affects a significant portion of workers, accounting for up to 52% of the total direct workers’ compensation claims among Canadian flight attendants.^12,13 Therefore, health practitioners must evaluate the impact of their patients’ medical conditions on their work.^9,10

Flight attendants frequently experience musculoskeletal disorders, particularly in their lower back, due to the unique and adverse work-related exposures they endure.^12,14,15 Despite their rigorous preparation and training, they are at high risk of injuries and other physical hazards while operating on a moving plane.¹² Rapid work rate, regular motion patterns, insufficient recovery time, strenuous lifting, and other physically demanding tasks, along with awkward work postures and prolonged standing or lengthy working hours, exacerbate pain in this occupational group.^12,15 Spinal manipulation, a treatment option used by chiropractors, has been found to alleviate pain and improve function in individuals with lower back pain.¹⁶

Chiropractic is gaining widespread and growing use globally.¹⁶ Chiropractic care has become a popular alternative to conventional medicine, particularly in treating musculoskeletal disorders.¹⁷ Chiropractors use various treatment methods, including spinal manipulation, to treat people with neuromusculoskeletal conditions.¹⁶ Despite its advantages, many chiropractic patients with neck or back pain fail to adhere to recommended treatment frequency guidelines. This lack of adherence may indicate inefficient allocation of healthcare resources, resulting in patients potentially not receiving optimal care.¹⁸ Patterns of healthcare utilization among individuals with chronic pain exhibit variability, with some patients avoiding treatment entirely while others engage with healthcare services more frequently. Variables such as pain intensity, degree of disability, and psychological factors predict higher healthcare service utilization.¹⁹

Although the benefits of chiropractic care in the international environment are well-established, less is known about how flight attendants in South Africa utilize chiropractic care.²⁰ Flight attendants, an understudied occupational group exposed to high risks of injuries and musculoskeletal problems due to work conditions, may benefit from chiropractic care, particularly in managing musculoskeletal pain.

The aim of this study was, therefore, to provide details on MSK pain among South African flight attendants and to explore their knowledge, perception and utilization of chiropractic.

Methods

Study design

This study employed a descriptive, cross-sectional approach using a survey to gather insights into South African flight attendants’ knowledge, perception, and use of chiropractic services. Participants accessed the questionnaire through a QuestionPro link after reviewing informed consent.

Study population, setting and sampling

The study focused on flight attendants from a selected airline, whose headquarters is in Johannesburg, South Africa. The study focused on flight attendants from a selected airline to ensure a controlled and consistent sample for a more targeted examination of the research questions. This airline was also chosen for its convenience, providing accessible opportunities for participant recruitment and data collection.

To achieve the study’s objectives and the highest response rate, all registered South African flight attendants working for the selected airline who were available, willing to participate, and met the inclusion criteria were invited to participate in this study. Those who participated in the pilot study and did not meet the inclusion criteria were excluded. At the time, the selected airline employed 190 flight attendants. A total of 108 completed the questionnaire and met the inclusion criteria.

Data collection tool

The researcher created a questionnaire based on similar questionnaires.^21,22,23 The development of this questionnaire was guided by the research objectives and the literature reviews.²⁴ Furthermore, a pilot study was conducted with 3 flight attendants who received an electronic link to the questionnaire to assess face and content validity, but they were excluded from the main study.

Additional validation was obtained through a focus group discussion with experts. The questionnaire covered demographics, injury profiles, knowledge, perception, and utilization of chiropractic services. It included 33 questions with yes/no responses and a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree).

Data collection process

After obtaining permission, the questionnaire link was emailed to the selected airline’s flight attendant manager, who distributed it electronically. The QuestionPro software ensured anonymity and prevented duplicate submissions. Furthermore, QuestionPro’s Anti Ballot Box Stuffing (ABBS) feature prevented a participant from completing the study multiple times. The timeline for acquiring gatekeeper permission, recruiting participants, conducting the pilot study and collecting data extended from early April 2022 to late November 2022.

Data analysis

Data analysis was conducted using IBM SPSS version 21.02, with significance at p < .05. Descriptive analyses were performed on categorical variables (summarized as frequencies (n) and percentages (%), and continuous variables (summarized as mean and standard deviations). Knowledge was scored by summing up correct responses to 33 questions and expressed as a percentage correct out of 33. This quantitative, normally distributed score was treated as a continuous variable and compared between the groups who had and had not utilized chiropractic using independent group two-sided t-tests. Mann-Whitney two-sample tests were used to compare 5-point Likert scale responses around perception of chiropractic, with those who had and had not utilized chiropractic.

Ethical considerations

The study was approved by the university’s Institute Research Ethics Committee (Ethics number: IREC 237/22). Participants provided an information letter, online consent form, and confidentiality was maintained by not collecting personal data beyond demographics. Participation was voluntary, with the option to withdraw at any time.

Results

Demographic characteristics

Most participants were from Gauteng province (67.6%, n = 73), followed by the Western Cape (15.7%, n = 17). Smaller percentages were from KwaZulu-Natal (3.7%, n = 4), the Free State (1.9%, n = 2), and the Eastern Cape (0.9%, n = 1). All participants communicated in English. The sample had a higher proportion of women (88.0%, n = 95) than men (12.0%, n = 13). Half of the participants were under 30 years old (50.0%, n = 54), and the most common length of employment was over 10 years (43.5%, n = 47), followed by 4 to 5 years (25%, n = 27).

Injury profile of South African based flight attendants

Most participants (58.3%, n = 63) reported experiencing work-related musculoskeletal pain. Among those reporting pain, the lower back was the most affected area (84.1%, n = 53), which was followed by the shoulders (39.7%, n = 25) and upper back (34.9%, n = 22). The average pain severity was 2.9±1, ranging from 1 to 5. Most individuals rated their pain as severe (33.0%, n = 21). As displayed in Table 1, the most frequently cited causes of musculoskeletal pain were long shifts (66.7%, n = 42), assisting passengers with luggage (44.4%, n = 28), and wearing uncomfortable footwear (42.9%, n = 27).

Table 1.

Common sites and causes of musculoskeletal pain

Sites and causes of MSK pain	Variables	Frequency (n)	Percentage (%)
Common sites	Ankles	14	22.2
	Elbows	5	7.9
	Hips	4	6.3
	Knees	20	31.7
	Low back	53	84.1
	Neck	21	33.3
	Shoulders	25	39.7
	Upper back	22	34.9
	Other	2	3.2
Causes of musculoskeletal pain	Assist with passengers’ luggage	28	44.4
	Long work/shift hours	42	66.7
	Overhead activity	12	19.0
	Opening or closing air staircase doors	4	6.3
	Prolonged bending	24	38.1
	Pushing/pulling service trolley	24	38.1
	Repetitive motions patterns	12	19.0
	Turbulence	6	9.5
	Uncomfortable footwear	27	42.9
	Working in confined spaces	8	12.7
	Other	4	6.3

Table 2

Table 2.

Perceptions of flight attendants towards chiropractic (n = 108)

Indicators		Strongly agree	Agree	Neutral	Disagree	Strongly disagree	Total
I have never heard of chiropractic before; I do not know what it is	n	72	9	10	4	12	107
	%	67.3	8.4	9.3	3.7	11.2	100%
I have heard of it before, but I do not know much about it	n	21	18	29	18	21	107
	%	19.6	16.8	27.1	16.8	19.6	100%
Chiropractic does more harm than good	n	46	31	21	0	6	104
	%	44.2	29.8	20.2	0	5.8	100%
It is a very effective treatment for muscle, joint and nerve conditions	n	5	7	31	28	33	104
	%	4.8	6.7	29.8	26.9	31.7	100%
I am uncomfortable with chiropractic	n	41	21	23	7	8	100
	%	41.0	21.0	23.0	7.0	8.0	100%
It may be effective for some patients	n	9	7	26	28	31	101
	%	8.9	6.9	25.7	27.7	30.7	100%
I prefer chiropractic treatment over most other physical therapies	n	6	11	59	6	18	100
	%	6.0	11.0	59.0	6.0	18.0	100%
I am not informed enough to comment	n	14	21	26	15	23	99
	%	14.1	21.2	26.3	15.2	23.2	100%

n = frequency; % = percentage.

Knowledge of flight attendants towards chiropractic

The average knowledge score was 42.85%, with a standard deviation of 19.0% and a range from 3.0% to 94.0%, indicating a wide variation and generally low level of knowledge in this sample. More than half of the participants (56.1%, n = 60) were uncertain whether the chiropractic profession is legislated. The majority believed chiropractic could be studied at DUT (n = 40), followed by UJ (n = 37). Most participants (78.7%, n = 85) correctly identified that chiropractic is a full-time course, though 17.6% (n = 19) were unsure.

Regarding chiropractic clinical protocols, the majority were aware that chiropractors treat extremities (72.9%, n = 78) such as knees, elbows, and wrists, as well as neuromusculoskeletal issues (82%, n = 85), including nerves, muscles, bones, rehabilitation, and sports medicine. However, most were unaware that radiology (52%, n = 51) and pediatrics (46%, n = 46) are also part of chiropractic clinical practice. Additionally, many participants did not know that surgery (49%, n = 48) is not included in chiropractic protocols.

The responses regarding clinical assessments and treatment methods expected from chiropractors revealed a limited understanding of chiropractic care among participants. Specifically, there was a notable lack of awareness concerning the range of assessments, examinations, and treatment modalities utilised within chiropractic practice.

Perceptions of flight attendants towards chiropractic

The data reveals significant gaps in the participants’ awareness and understanding of chiropractic care. A large portion, 75.7% (n = 81), had never heard of chiropractic or did not know what it is, while 36.4% (n = 39) acknowledged having heard of it but knowing very little. Opinions on the effectiveness of chiropractic were mixed, with 74.0% (n = 77) believing that chiropractic does more harm than good and only 11.5% (n = 12) considering it an effective treatment for muscle, joint, and nerve conditions.

Many participants expressed discomfort with chiropractic care (62%), with 41.0% (n = 41) strongly agreeing that they were uncomfortable with it. Preferences for chiropractic over other physical therapies were largely neutral, with 59.0% choosing neither to agree nor disagree. Additionally, 35.2% (n = 35) felt they were not informed enough to comment on chiropractic, reflecting an overall lack of knowledge or uncertainty about the field. This data suggests a need for greater education and awareness around chiropractic care to address misconceptions and build confidence in its practice.

Utilization of chiropractic by flight attendants

Overall, 32.0% of participants (34 out of 106) had received treatment from a chiropractor. An association was observed between chiropractic utilization and perception, particularly when participants were asked whether they had experienced work-related musculoskeletal pain.

Participants who had experienced musculoskeletal pain were more likely to have been treated by a chiropractor (41.3%) compared to those who had not suffered from such pain (19.0%), with this difference being statistically significant (P = .014). Among those who had utilised chiropractic services, the average satisfaction level was 4, with a standard deviation of 1 and a range from 2 to 5.

Regarding the perceptions of chiropractic care, most participants (66.7%, n = 24) believe chiropractors are very competent in treating neuromusculoskeletal conditions, while 22.2% (n = 8) rate them as moderately competent. When asked which healthcare practitioner they would consult first for neuromusculoskeletal issues, 41.7% (n = 45) indicated they would prefer a GP specialist, followed by 24.1% (n = 26) who would consult a chiropractor, and 22.2% (n = 24) who would seek out a physiotherapist. Additionally, 89.8% (n = 97) believe it is helpful for patients to consult chiropractors for preventative or maintenance care, reflecting a strong belief in the value of chiropractic services.

The t-test between knowledge scores and whether they had used chiropractic or not indicated that there were no statistical differences (P = .369). However, the scores were slightly higher in those who had utilised chiropractic. Results about knowledge, perception and utilization of chiropractic revealed mixed awareness and opinions among the participants. Of the participants, 31.4% (n = 33) had never heard of chiropractic, while a slightly higher number, 68.6% (n = 72), were familiar with the term but lacked understanding of the practice. When considering effectiveness, 32.4% (n= 34) viewed chiropractic as beneficial for treating muscle, joint, and nerve conditions, and an identical percentage agreed it could be effective for some patients. However, concerns about the practice were also evident: 32.4% (n = 34) believed chiropractic does more harm than good, and 31.4% (n = 33) felt uncomfortable with it. Preference for chiropractic over other physical therapies was noted by 32.4% (n = 34), while 32.0% (n = 32) stated they were not informed enough to provide a solid opinion. These responses suggest a general awareness of chiropractic but also highlight hesitations and a lack of definitive consensus on its effectiveness or preference over others.

There were significant associations between chiropractic utilization and various perceptions. Those who believe chiropractic is an effective treatment for muscle, joint, and nerve conditions were more likely to have used chiropractic services (P = .004). A strong association was observed between chiropractic preference over other physical therapies and utilization (P < .001). Those who had heard of chiropractic but did not know much about it were significantly less likely to have been treated by a chiropractor (P < .001), as were those who felt they were not informed enough to comment (P < .001), or who were uncomfortable with chiropractic (P = .046). In contrast, there was no association between chiropractic utilization and the belief that “chiropractic does more harm than good” (P = .322).

Discussion

The study investigated chiropractic care utilization and perceptions among South African flight attendants, a cohort particularly vulnerable to musculoskeletal (MSK) disorders due to their physically demanding roles. The research assessed their knowledge, perceptions, and preferred treatment modalities for MSK conditions. Notably, 58% of participants reported work-related MSK pain, predominantly affecting the lower back (84.1%). These results were consistent with another study conducted in India ¹⁵, which found that 82% of flight attendants reported work- related pain in various body regions, including the lower back, feet, and neck.

Chiropractic manipulation is commonly utilized for musculoskeletal disorders, especially for low back and neck pain.^25,26 However, the evidence supporting its effectiveness is limited. Studies indicate uncertain benefits for chronic neck pain and only modest effectiveness for low back pain.²⁵ While some patients report feeling pain relief and satisfaction from chiropractic care²⁷, further research is necessary to reach more definitive conclusions regarding its effectiveness in managing musculoskeletal disorders.²⁵ A study conducted in Australia²⁸ found that participants used chiropractic for the treatment of musculoskeletal disorders (68.7%) and general health (21.2%). Additionally, personal beliefs are a significant motivator for seeking chiropractic care, and most patients (97.5%) were satisfied with the chiropractic services they received. Similarly, a study in the US ²⁹ found that public perceptions of chiropractic care indicated generally favorable views and high satisfaction rates among users.

The study revealed that flight attendants had limited knowledge of chiropractic care, achieving an average knowledge score of 42.85%. A study in Zimbabwe³⁰ found that 31.3% of surveyed general practitioners (GPs) were unfamiliar with chiropractic therapy. The low knowledge score could be attributed to minimal exposure to chiropractic care and a general lack of awareness of the profession. A similar trend was noted in a North American study that identified a spectrum of attitudes toward chiropractic care, ranging from highly positive to extremely negative.³¹

A study on n chiropractors' role in preventing work disability ³² revealed that public knowledge of chiropractors and their scope of practice is frequently mentioned as a barrier to effective sickness absence management in Norway and Sweden. Many patients are unaware of the full range of services chiropractors provide, including their ability to prescribe sick leave, which can hinder the integration of chiropractors into the primary healthcare system.³² Furthermore, the transition in self-image among chiropractors from being viewed as manual therapists or alternative care providers to becoming fully integrated members of the primary healthcare sector is crucial.³² This shift involves increased responsibility in communication, collaboration, and patient management, essential for enhancing their role in work disability prevention and sickness absence management.³²

Among those familiar with CT, 66.7% considered chiropractors competent in treating musculoskeletal disorders, while only 35.4% believed they were competent in addressing neurological conditions.³⁰ Although knowledge and perception of CT were positively correlated, the GPs’ knowledge level did not significantly affect their utilization of CT services. Conversely, their perception of CT competence significantly influenced their likelihood of referring patients to chiropractors.³⁰

Flight attendants in this study expressed a generally favorable impression of chiropractic care; however, their perceptions were influenced by prior experiences with such services. This was consistent with findings indicating that individuals more inclined to utilize chiropractic care tended to have more favorable views, whereas those less likely to seek treatment maintained more neutral or negative perceptions.²⁹ However, others ³⁰ reported that although knowledge and perception of CT were positively correlated, the GPs’ knowledge level did not significantly affect their utilization of CT services.

The chiropractic care utilization rate among flight attendants was low, with only 32% reporting usage. This was notably less than in Australia, where 52% to 68% of the population annually consulted a complementary and alternative medicine practitioner. Approximately 8% of adults in the US seek chiropractic care yearly.^17,20,33 Similarly, a study conducted in the US³⁴ found that about 32.2% of participants had used chiropractic care before. Most people believe that chiropractic treatment is effective for muscle and joint problems.

Furthermore, in the US ³⁴ participants who were hesitant to use chiropractic services mentioned worries about the training and safety of chiropractors and their overall reputation. They reported being more open to chiropractic care if their primary doctor recommended it. The lower utilization rate in South Africa may have been attributed to restricted access and financial barriers, as many South Africans could not afford private healthcare, including chiropractic treatment. Furthermore, general practitioners (GPs) often hesitate to refer patients to chiropractors, citing the financial burden on patients unless medical aid providers cover costs.³⁰

The study revealed a discrepancy between flight attendants’ knowledge and perceptions of chiropractic care. Even though flight attendants generally viewed chiropractic care positively, insufficient knowledge about the profession may have impeded the utilization of this profession. Given the prevalence of musculoskeletal disorders among flight attendants and the potential benefits of chiropractic care, there is an urgent need for enhanced awareness and access to chiropractic services in South Africa. Findings suggested that improving public perception of chiropractic care, alongside increasing knowledge, was critical for boosting utilization.

The study suggests incorporating chiropractic care within multidisciplinary health care for MSK disorders, such as low back pain²⁷, consistent with guidelines endorsing non-pharmacological interventions as the primary treatment modality. Based on the findings of this study, future recommends could include implementing educational programs on chiropractic care, introducing ergonomic training to mitigate injury risk and MSK disorders, and enhancing access to chiropractic services. As well further research, particularly longitudinal studies and comparative analyses across different regions. Further research is essential to elucidate the long-term outcomes of chiropractic interventions and the impact of patient characteristics and treatment variations on therapeutic responses. This underscores the need for continued investigations to optimize chiropractic treatment and enhance MSK pain management patient care.

This study on South African flight attendants has highlighted the prevalence and significance of musculoskeletal disorders within this profession. Utilizing a well-constructed survey with 108 participants, the study collects comprehensive data supported by robust statistical analysis.

LIMITATIONS

Its cross-sectional design restricts conclusions to correlations rather than causal relationships. Furthermore, reliance on self-reported data may introduce inaccuracies due to recall bias; participants may not accurately remember their experiences. Additionally, focusing exclusively on South African flight attendants limits the generalizability of the findings. To address these issues, the study recommends implementing educational programs on chiropractic care, introducing ergonomic training to mitigate injury risk, and enhancing access to chiropractic services. It also advocates for further research, particularly longitudinal studies and comparative analyses across different regions.

Conclusion

Despite the high incidence of MSK issues, such as lower back pain, few flight attendants currently use chiropractic services. This under-utilization may be due to limited knowledge and awareness, which affects perceptions and access. This study highlights that individuals with prior chiropractic experience generally have more favorable views, while those without exposure are often neutral or skeptical.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.