Masters Degrees (Physiotherapy)

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The aetiology of upper quadrant musculoskeletal pain in high school learners using desktop computers : a prospective study
(Stellenbosch : Stellenbosch University, 2008-03) Prins, Yolandi; Crous, Lynette; Louw, Quinette; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
The Western Cape Education Department initiated a project that aims to provide all the learners from the province with computer access and to promote computer use in schools. Prolonged sitting in front of computers and psychosocial factors have been associated with musculoskeletal symptoms internationally. However, the impact of computer use on musculoskeletal pain among South African high school learners is yet to be determined. Objective The objective of the study was to determine whether sitting postural alignment and psychosocial factors contribute to the development of upper quadrant musculoskeletal pain in grade ten high school learners working on desktop computers. Study design An observational analytical study was performed on a sample of 104 asymptomatic high school learners. Methodology Six high schools in the Western Cape metropole were randomly selected 322 grade ten learners who are using desktop computers, were screened for upper quadrant musculoskeletal pain. Measurements at baseline were taken of the 104 asymptomatic learners, 49 girls and 55 boys. The sitting postural alignment was measured by using the Portable Posture Analysis Method (PPAM), which measured head tilt; cervical angle; shoulder pro- and retraction angle and thoracic angle in the sagittal plane. Depression and anxiety were described by using the Beck Depression Inventory (BDI) and the Multidimensional Anxiety Scale for Children (MASC) respectively. The exposure to computer use was described in terms of duration and frequency of daily and weekly computer use. At three and six months post baseline, the onset and area of upper quadrant musculoskeletal pain was determined by using the Computer Usage Questionnaire. Results After six months, 27 of the 104 learners developed upper quadrant musculoskeletal pain due to seated or computer-related activities. There was no difference in computer exposure between the learners who developed upper quadrant musculoskeletal pain symptoms and the learners who remained asymptomatic. An extreme cervical angle (<34.75° or >43.95°; OR 2.6; 95% CI: 1.0-6.7) and a combination of extreme cervical and thoracic angle (<63.1° or >71.1°; OR 2.19; 95% CI: 1.0-5.6) were significant postural risk factors for the development of upper quadrant musculoskeletal pain. There was a tendency for boys to be at a greater risk for upper quadrant musculoskeletal pain than the girls (OR 1.94; 95% CI: 0.9-4.9). Weight greater than 54.15kg and a depression score greater than 11 was found to be significantly associated with a poor posture (OR 3.1; 95% CI: 1.0-9.7; OR 1.02; 95% CI: 1.0-1.1). Discussion and conclusion The study concluded that poor posture, relating to extreme cervical and thoracic angles, is a risk factor for the development of upper quadrant musculoskeletal pain in high school learners working on desktop computers. South African boys were at a greater risk of developing upper quadrant musculoskeletal pain than the girls. However the study found no causal relationship between depression, anxiety and upper quadrant musculoskeletal pain among South African high school learners and computer usage.
Computer-related musculoskeletal dysfunction among adolescent school learners in the Cape Metropolitan region
(Stellenbosch : University of Stellenbosch, 2007-03) Smith, Leone; Louw, Quinette; Crous, Lynette; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
INTRODUCTION Computer use has been identified as a risk factor for the development of musculoskeletal dysfunction among children and adolescents internationally. Computer exposure has increased in the Western Cape since 2002, with the inception of a project to install computer laboratories in all schools in the province. As musculoskeletal dysfunction experienced during adolescence is predictive of musculoskeletal disorders in adulthood, it is essential to identify all risk and/or associative factors. METHODOLOGY A descriptive study was conducted with the aim to investigate whether the musculoskeletal dysfunction of high school learners in the Cape Metropolitan region was related to their computer use. This study was conducted in two phases. Phase 1 of the study entailed the completion of a new questionnaire, the Computer Usage Questionnaire, by grade 10-12 learners. The learner sample was divided in a computer and a non-computer group depending on their exposure to the school computer. Phase 2 of the study involved the assessment of the ergonomic design of the computer laboratories at randomly selected high schools within the Cape Metropolitan region. RESULTS A total of 1073 learners (65% girls & 35% boys), aged 14-18 years, completed the CUQ in phase 1 of the study. The results indicated that learners in the computer group had greater weekly exposure to computers than the non-computer group. The prevalence of musculoskeletal dysfunction among this learner sample was 74%. The most common body areas of dysfunction were the head, low back and neck. The female gender, playing sport and using the school computer for more than three years were associated with musculoskeletal dysfunction. Weekly computer use of more than seven hours was predictive of general musculoskeletal dysfunction, low back pain and neck pain. Twenty nine computer laboratories within 16 selected high schools were assessed by means of the Computer Workstation Design Assessment (CWDA). Out of a total score of 40, the computer laboratories obtained average scores of less than 45%, indicating compliance with less than half of the standard ergonomic requirements. The average scores for the workspace environment was less than 40%. The design of the desk, chair and computer screen had the poorest compliance to ergonomic guidelines. DISCUSSION AND CONCLUSION The prevalence of musculoskeletal dysfunction among this sample was higher than among other similar samples on the same study topic. The higher prevalence may be attributed to the poor ergonomic design of the computer laboratories in the Cape Metropolitan region. Learners’ reduced participation in activities such as sport and working on a computer due to their musculoskeletal dysfunction, may impact on their choice of a future career. The tendency of learners not to seek medical advice for their musculoskeletal dysfunction may predispose the development of chronic musculoskeletal disorders. Education of related parties on safe computing habits as well as advice on the ergonomic design of computer laboratories is recommended to prevent the progression of adolescent musculoskeletal dysfunction into chronic disorders in adulthood.
The correlation between passive and dynamic rotation in both the lead and trail hips of healthy young adult male golfers during a golf swing
(Stellenbosch : Stellenbosch University, 2014-04) Alderslade, Villene; Crous, Lynette; Louw, Quinette; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
ENGLISH ABSTRACT: Introduction-The golf swing is a complex, sequenced movement of body segments. This movement is smooth and well timed and is referred to as the kinematic golf sequence. This kinematic sequence illustrates the rotational speed, which occurs between the upper and lower body segments. Hip rotation plays an integral part to a sound kinematic sequence by providing a pivotal point between the upper and lower body segments, ensuring a synchronised golf swing. Hip rotation kinematics during a golf swing has received relatively little attention compared to other body segments’ movements. However, clinicians need to have a clear understanding of the rotational contribution that each hip make during golf swing in order to enhance the athlete’s performance and reduce the risk of injury. The aim of this descriptive research project was to obtain and investigate the total passive and total dynamic rotation range of movement in both the lead and trail hips of healthy, young adult, male golfers. Methodology-Seven, low handicapped, male golfers between the ages of 18 and 40 years were randomly selected in the Western Cape region from areas surrounding Stellenbosch University’s Tygerberg campus. A questionnaire gathered participant demographics that determined participatory eligibility. A preliminary reliability study established a baseline measurement for passive total articular hip rotation. Seatadjusted total passive hip rotation ranges of motion (ROM) measurements were collected with a hand-held inclinometer. Dynamic total hip rotation kinematic data was captured during a golf swing with an 8-camera video analysis system (VICON). Data analyses were performed with Statistica version 10. Hand-held inclinometer intra-rater reliability was determined with a two-way interclass correlation, standard error of measurement and a 95% confidence interval level. A Spearman correlation coefficient determined correlation between the total passive and total dynamic rotation range of movement in both the lead and trail hips. Results-Passive intra-rater reliability was reported as 0.81 (95% CI: 0.46-0.96). The total average passive articular range between the lead (62.1° ±6.4°) and trail hip (61.4° ±3.8°) did not report any significant difference (p=0.8). The total average dynamic golf swing articular range between the lead (29° ± 6.5°) and trail hip (35.° ±7.8°), was reported as significantly (p=0.04) asymmetric. The findings also demonstrated a positive correlation between the passive and dynamic total articular range in a lead hip, whereas a negative correlation was reported in a trail hip. During the golf swing the lead hip utilised 46.4%(± 8) of the total passive available hip rotation, whereas the trail hip utilised 58.8% (±13.2). Discussion and Conclusions-The findings of this study show that, the passive rotation ROM in a hip (LH=62°; TH=61°) of a golf player does not exceed the available range it has during a golf swing. The golfer’s hip utilises 46% of the available passive range of movement in the lead hip and 59% in the trail hip. In the clinical field careful consideration should be given to the motivation behind mobilizing, treating or stretching the hips of a golf player. These findings can be incorporated in future research on the relationship between hip-rotation ROM and reduction in the incidence of injuries amongst golfers.
Development and validation of an evidence based educational program for adults undergoing anterior cruciate ligament reconstruction surgery in the United Arab Emirates
(Stellenbosch : University of Stellenbosch, 2010-03) Alzaabi, Hana; Louw, Quinette; Crous, Lynette; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
Patients’ knowledge about the effectiveness of interventions is now recognized as an important facilitator of the implementation of evidence in practice. Evidence-based, patient education programs aim to impart knowledge about the efficacy and effectiveness about interventions to individuals. However, there is currently a lack of structured evidence-based educational programs to educate patients about the evidence-base for interventions prescribed by the health professionals in the field of orthopaedics. OBJECTIVE: The main objective of this study was to develop and validate an Arabic version of an evidence-based educational program for patients who are scheduled to undergo ACL reconstruction surgery in UAE, based on available evidence collated through a systematic review process. METHODS: A systematic review was conducted to generate clinical recommendations which were used to develop the evidence-based educational program. The evidence-based information was derived from secondary research to determine which rehabilitation strategies were most effective in improving outcome measurements following ACL reconstruction surgery. A pre-final draft of the evidence-based educational program was prepared and forward and back translated from English into the Arabic language. Feedback groups of ACL patients and physiotherapists were used to determine the content and face validity of the program. The final draft was validated in a group of 40 ACL patients waiting to undergo ACL reconstruction surgery at Zayed Military hospital and Abu Dhabi Knee and Sports Medicine Centre in the UAE, using checklists. RESULTS: A total of 40 patients undergoing ACL reconstruction surgery consented to participate in this study. All the subjects were male. The age range was between 18 to 38 years old with mean age of 28.5 years (SD 5.75). Most of the patients (65%) underwent ACL reconstruction surgery to the right knee. Of the total sample (n=40), the majority of the subjects who participated in this study (90 %), had ACL surgery for the first time. Most of the responses to the evidence-based educational program checklist were positive. iv CONCLUSION: It can be recommended that the newly-developed evidence-based educational program is a valid tool which can be given to ACL patients prior to ACL reconstruction to prepare them for the rehabilitation postoperatively. By informing patients of their condition, the expected outcomes of their condition and the effect of doing exercises to improve their condition, the patients will be more encouraged to partake in rehabilitation, as they know it is for their own good. This will ultimately improve overall patient care and improve management of ACL patients.
Effect of a low-cost virtual reality system on reducing pain and anxiety in adult burn injury patients during physiotherapy
(Stellenbosch : University of Stellenbosch, 2009-12) Morris, Linzette Deidre; Louw, Quinette; Crous, Lynette; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
ENGLISH ABSTRACT: Background Albeit Virtual Reality (VR) has been shown to be a useful adjunct in the reduction of pain during burn care and therapy, the current VR systems are expensive and may not be economically feasible for developing countries such as South Africa, where health budgets are stringent. Objective The purpose of this study was to ascertain the effect of a lowcost VR system (eMagin Z800 3DVisor), used in conjunction with pharmacologic analgesics, on reducing pain and anxiety in adult burn injury patients undergoing physiotherapy treatment, compared to pharmacologic analgesics alone at a South African hospital. Study design Single-blinded, within-subject study design. Methods Pain and anxiety outcome measures were measured by a blinded assessor using the Numeric Pain Rating Scale and Burn Specific Pain and Anxiety Scale. Descriptive statistics, Chi-square tests as well as the Student’s paired t-test were used to analyze data. Main findings Eleven eligible adult burn injury patients consented to participate in this study (3 female, 8 male; median age 33 years: range 23-54 years). A marginal (p=0.06) to insignificant (p=0.13) difference between the two conditions (analgesics with VR and analgesics alone) in reducing pain was found. No significant difference (p=0.58) was found between the two conditions (analgesics with VR and analgesics alone) for anxiety. Interpretation There is a trend that a low-cost VR system, when added to routine pharmacologic analgesics, is an economically feasible and safe adjunct therapy and could be of considerable benefit if implemented into the current pain management regimen of burn injury patients at a South African Hospital.
Investigation of hip kinematics in adult sports participants during single leg drop landing with chronic groin pain
(Stellenbosch : Stellenbosch University, 2014-04) Dare, Michael Robert; Crous, Lynette; Louw, Quinette; Williams, Leonie; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
ENGLISH ABSTRACT: Introduction-Groin injuries are among the top six most cited injuries in soccer and account for 10-18 per cent of all injuries reported in contact sport. Groin pain can result from a variety of pathologies, but according to literature, 63 per cent of groin pain is due to adductor pathology. Objective-The objective of this study was to explore if there are kinematic differences in the hip joint in sports participants with groin pain compared to matched healthy controls. Study design A cross sectional, descriptive study was conducted. Study setting-The study was conducted at the FNB -3D motion analysis laboratory at the University of Stellenbosch, South Africa. Outcome variables-The dependent variables included hip kinematics in the sagittal, frontal and transverse planes at foot strike, lowest vertical point of the pelvis and total range of hip motion during a single leg drop landing. Methodology-The study sample comprised 20 male club level soccer-and, rugby players, running and cycling participants between the ages of 18-55 years of age. Ten of the subjects had chronic groin pain and the other ten were healthy matched controls. An eight-camera Vicon system was used to analyse the kinematics of the hip joint during single leg drop landing. For the purpose of comparison, the data was analysed for participants with unilateral groin pain and matched controls (n=14) and participants with bilateral groin pain and controls (n=6). The full set of data was subdivided for analysis into three distinct sub-groups. Unilaterally injured groin cases (n=7) were matched with seven healthy controls for analysis. Bilaterally injured groin cases (n=3) were matched with three healthy controls. Results-Cases with unilateral groin pain at initial contact had significantly more abduction of the hip joint when compared to controls (p<0.05). The effect size of this difference was large (0.94). Cases with unilateral groin pain also demonstrated greater hip internal rotation while the controls had external rotation (p<0.05) during a drop landing activity. Bilaterally injured groin cases landed with significantly (p=?) greater ranges of hip flexion as well as in significantly (p=?) more hip abduction during a drop landing activity. They also demonstrated greater total range of motion in the frontal plan when compared to controls. Groin pain cases overall demonstrated greater ranges of motion and tended to land in more abduction compared to controls. Conclusion-This study found that during a single leg drop landing, sports participants with unilateral chronic groin pain landed with significantly greater hip abduction and exhibited larger total range of motion in the transverse plane, which may indicate impaired stability of the hip complex when compared to controls.
Low back pain and front foot hip joint kinematics in Western Province first league fast bowlers
(Stellenbosch : University of Stellenbosch, 2011-03) Saayman, Merike; Louw, Quinette; Crous, Lynette; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Dept. of Physiotherapy.
ENGLISH ABSTRACT: Aim: The aim of the study was to improve understanding of the hip joint kinematics in cricket fast bowlers and to ascertain whether a relationship exists between hip joint biomechanical parameters, including kinematics, ROM characteristics and lumbar symptoms. Study design: A descriptive cross-sectional study was conducted. Participants: Sixteen adult male fast bowlers between the ages of 18 and 40 years old, playing first-club league, were featured in the study. Main outcome measures: To obtain data with regards to the training history, as well as the nature of lumbar-spine symptoms experienced by the cricket fast bowlers, a newly designed questionnaire was compiled. For analysis of the front foot hip joint ROM and kinematics, the biomechanical equipment used included: a two-dimensional Canon MV950 Digital Video Camcorder, a Kodak EasyShare C310 camera and XSENS Motion Tracking equipment (Xsens Technologies B. V., Enschede, Netherlands). Results: Eight of the sixteen bowlers in our study experienced LBP in the season with seven of these bowlers presenting with recent symptoms most of which are experienced after bowling a spell and described as “tightness” or a “stabbing pain” in the lower back. Intensity of LBP ranged between 1/10 to 8/10. Front foot hip joint kinematics of fast bowlers showed highly individualised patterns of movement between different subjects. Medium amplitude movements in the flexion/extension as well as the rotation plane of movement showed a significant difference in bowlers with- and without LBP. No significant differences between groups with LBP and without LBP were found in the three passive hip ROM measurements. Conclusions: It has proved to be very difficult to improve the understanding of the front foot hip biomechanics in cricket fast bowlers due to the high inter-subject variability. Variability in movement patterns remains under-researched by sports biomechanics. Although decreased hip mobility could alter mechanical forces transmitted to the lumbar spine and therefore predispose or be a causative factor in LBP development, this study found no significant relation between these parameters. The sample size was very small in this study which will influence the validity of results. Our study confirmed the high incidence of LBP and preventative efforts for bowlers should therefore be strongly supported.
Neck and shoulder pain in nurses working in seven wards of Tygerberg hospital : quantifying the problem and exploring the risks
(Stellenbosch : University of Stellenbosch, 2011-03) Altmann, Janet Rosemary; Crous, Lynette; Louw, Quinette; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences.
ENGLISH ABSTRACT: Background: There is a high prevalence of musculoskeletal problems, including neck and shoulder pain (NSP) among nurses worldwide. Tygerberg hospital (TBH) is the second largest hospital in South Africa with a large complement of nurses. The prevalence of NSP and risks associated therewith have not previously been determined at TBH. It is unknown how the nurses at TBH experience NSP in their workplace. Objective: This study questioned whether the 12 month prevalence of neck pain, shoulder pain and combined NSP is similar to worldwide reports, and questioned the degree of association of NSP with lower back pain and demographic risk factors in the nursing population at TBH. Thereafter the qualitative experiences of nurses with NSP at TBH were elucidated. Methodology: A self-designed Neck and Shoulder Pain Questionnaire for nurses (NSPn) was distributed among seven wards of TBH from March to May 2009. The NSPn was compiled using the pain definition from the Nordic Musculoskeletal Questionnaire and elements of the Dutch Musculoskeletal Questionnaire. The NSPn gathered information regarding the presence of neck and shoulder pain as well as demographic and workplace risk factors. Thereafter semi-structured interviews were conducted with eight nurses working at TBH. Results: The 12 month prevalence of neck pain, shoulder pain and combined NSP was 29%, 34% and 43% respectively among a sample of 143 nurses. A high correlation of neck pain with lower back pain and of neck pain with shoulder pain was observed. No significant associations were found between age, ward module, tenure of work, and the nurses' perception of their general health and fitness with the presence of NSP. The qualitative results describe the conflict between the nurses' beliefs and their symptoms. The nurses named work-related stress as the most prevalent cause or aggravator of NSP. The main underlying cause of their stress was a shortage of nursing staff. Discussion and Conclusions: The prevalence of neck pain (29%) and shoulder pain (34%) among the surveyed TBH nurses was lower than the worldwide prevalence summary statistic of 50% and 52% respectively. However, the NSP prevalence (43%) was within the range of three international studies, suggesting that NSP is a significant concern for TBH nurses. The nurses' desire to hide pain and continue working perpetuates the problem of NSP. The underlying causes of NSP are multifactorial, with physical factors interacting with psychosocial factors. Preventative drives need to consider staffing levels and nurses' methods of coping with stress along with improvements in manual handling practices.
Physiotherapeutic management of acute ankle sprains : a survey of clinical practice in the Western Cape and comparison thereof to evidence based guidelines
(Stellenbosch : Stellenbosch University, 2013-12) Simpson, Helene; Crous, Lynette; Louw, Quinette A.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
ENGLISH ABSTRACT: Ankle sprains are reportedly the most common lower limb injury amongst active individuals. Aim: The aim of this study was to investigate whether treatment interventions employed by physiotherapists during the first week of functional rehabilitation of an ankle sprain, at primary care level, were aligned with evidence-based guidelines for acute ankle sprains. Design: A descriptive cross-sectional study was conducted. Participants: A total of 91 physiotherapists from the Western Cape Metropole (WCM) completed questionnaires. Method: Physiotherapists' treatment interventions were recorded based on a case study of a typical moderately sprained ankle. According to classification of the West Point Ankle Grading System, a moderate sprain is a partial macroscopic tear of the ligaments with moderate pain, swelling and tenderness with some loss of motion and mild to moderate instability of the joint. Anticipated return to sport is two to six weeks. Relative occurrence of selected interventions during the first week of rehabilitation was calculated. Chi-square tests were used to compare differences between physiotherapists' responses and the recommendations of the practice guidelines. Results: Physiotherapists' overall selections of treatment interventions were in alignment with the "Koninklijk Nederlands Genootschap voor Fysiotherapie" (KNGF) guidelines and correlated positively to the recommendations stipulated by KNGF therein. Physiotherapists indicated many interventions for which good evidence exists: compression, cryotherapy, early mobilisation, and neuromuscular exercises. It is of concern that 49% – 91% (n = 91) physiotherapists indicated some form of manual mobilisations for which there is a lack of evidence, and more than two-thirds indicated the application of an electrotherapy intervention, which is not recommended in the guidelines. Conclusion: Physiotherapists should reconsider interventions for which there is no evidence as this may reduce cost of care, without compromising patient outcomes.
Self-reported prevalence, type, severity and management of musculoskeletal injuries among high school rugby players in the Nelson Mandela Bay metropole
(Stellenbosch : Stellenbosch University, 2019-04) Louw, Cecilia Elizabeth; Morris, Linzette; Crous, Lynette; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Health & Rehabilitation Sciences. Physiotherapy.
ENGLISH SUMMARY : Background: The number of rugby players and match activities has increased and heightened the risk of injuries since the introduction of Rugby’s professional status by the International Board of Rugby in 1995. Several types of cohort studies were done on the epidemiology of rugby injuries, including studies in the adolescent population, as the adolescent player aspires to play professionally. Fewer studies involved a self-reported questionnaire. Aim of study: This study aimed to determine the self-reported prevalence, type and severity of rugby-related musculoskeletal injuries, as well as the treatment of the relevant injuries, if any, as reported by high school rugby players attending top rugby schools in the Nelson Mandela Bay Metropole (NMBM), Eastern Cape situated in South Africa, using a specifically designed questionnaire. Methods: A self-reported questionnaire to determine the prevalence, type, severity and management of adolescent rugby injuries in the NMBM was developed in this study. The questionnaire was administered to adolescent rugby players at top rugby schools in the NMBM area. The questionnaire was completed electronically via SurveyMonkey® or in paper format to collect information related to the prevalence, type, severity and management of injuries in the adolescent rugby player was collected. Results: A detailed self-reported questionnaire was developed using previous questionnaires. Focus was placed on the clarification of terms so that adolescents would understand what was being asked. Findings regarding the prevalence of injuries among this group found that head and face injuries, including concussions, shoulder and knee injuries were mostly reported. Similar findings have been found in other national and international studies. Most of the injuries were described as soft tissue-injuries and were predominant muscular injuries. Overall, most of the injuries were described as mild. The respondents indicated physiotherapy as the treatment option most utilised, whereas other studies identified first aiders, medication and other medical treatment as the chief management options. However, the response of 41.9% could not be considered representative of the chosen population and the results have to be viewed with caution. Conclusion: The prevalence of injuries among high school rugby players attending top rugby schools in the NMBM area of South Africa was found to be on par with other studies. A specifically-developed self-reported questionnaire describing the prevalence, type, severity and management of injuries in the adolescent rugby player can provide easy and significant information to be used in the development of preventative, curative and rehabilitative strategies and programmes among similar populations. Clarifying of the terminology used in the questionnaire with the help of a trained medical person during the rugby season could provide more reliable and clear answers and could minimise possible bias. Better accessibility to the questionnaire could improve the response rate to make the collected data more representative. Further reliability and validation of similar questionnaires is however required.

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