Masters Degrees (Physiotherapy)

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Open Access
Association between deformity correction and clinical outcome post total knee arthroplasty
(University of the Free State, 2020-06) Hartzenberg, F.; Van der Merwe, J. F.
Background: The aim of this study was to establish if the degree of deformity correction during total knee arthroplasty (TKA) has an influence on post-operative patient satisfaction. Patient and methods: This was a retrospective, descriptive analytical study of 180 patients that underwent an elective TKA using computer assisted software. Patients were divided into two groups according to the degree of deformity correction required to obtain a neutral mechanical axis: 3-degrees-andmore or less-than-3-degrees. Knee injury and Osteoarthritis Outcome Scores (KOOS) were collected at the pre-operative, 6 week and 1 year post-operative intervals. The mean KOOS scores were compared at each interval and the difference between mean KOOS scores were compared for the following intervals: pre-operative to 6 weeks postoperative; pre-operative to 1 year postoperative; 6 weeks to 1 year postoperative. Results: The pre-operative mean KOOS scores for the group of patients that required a 3-degree-andmore deformity correction were statistically higher than the group requiring less-than-3-degreedeformity correction. At 6 week and 1 year follow ups there was no statistical difference between the two comparison groups. With respect to mean KOOS score improvement between intervals, the group that required less than 3 degrees of deformity correction showed statistically significant improvement in symptoms for the pre-operative to 1 year follow up period. Conclusion: Results of the study showed that patients requiring a lesser correction of their malalignment do better after TKA.
Open Access
Carpal tunnel syndrome in physiotherapists in Bloemfontein
(University of the Free State, 2016-01-29) Human, Nadia; Barnes, R. Y.
English: Introduction: Carpal tunnel syndrome (CTS) is the most common compression neuropathy of the upper limb with a 3-5% prevalence among the worldwide general adult population. It is associated with specific personal factors, certain medical conditions, repetitive and forceful hand and wrist movements and occupation. This study aimed at investigating the prevalence of CTS among physiotherapists. Method: The cross-sectional study included 64 participants, chosen by means of convenience sampling from a population of 158 physiotherapists. Demographic data, details of occupational activities; possible personal, medical and occupational causative factors and arm and hand symptoms were gathered by a structured interview. A participant-completed Katz hand diagram was used to clarify information on upper limb symptoms. Typical CTS signs, height and weight were determined by a physical examination. Results: According to the case definition the prevalence of definitive CTS was 7.8% and of probable CTS was 7.8%. Age over 40 years and rheumatoid arthritis as personal or medical history causative factors was statistically significant among the definitive diagnosis group. Overweight showed a tendency towards a definitive CTS diagnosis. Years in practice, hours working overtime and working in the neurosurgery field was occupational causative factors in the definitive CTS diagnosed group. No occupational activities or treatment techniques could be found to be associated with the CTS diagnosis. Longer resting periods between patients was the only statistically significant management strategy among the definitive CTS diagnosed group. Conclusion: Physiotherapy is an at risk occupation for the development of CTS with a prevalence of 15.6% when combining the definitive and probable diagnosis groups, but with no clear occupational activities or treatment techniques as possible risk factors identified.
Open Access
Classification system for cerebral palsy wheelchair rugby players
(University of the Free State, 2006-05) Malan, Hetta; Grobler, L.; De Man, L.
English: Wheelchair rugby originated in 1977 in Canada, as a sport for athletes with tetraplegia (quadriplegia).The game has grown into an intense physical team sport for both female and male with a variety of disabilities involving all four limbs. Athletes are systematically grouped into sport classes according to their ability to move and perform basic functional skills in their specific sport. This allows for fairness. Cerebral palsy (CP) players joined the wheelchair rugby. Because the CP’s disability lies on a total different level, classifiers find it difficult to classify them correctly. The aim of the study as to explore whether the present classification system disadvantages the CP wheelchair rugby players. An explorative descriptive research design was used. Data was gathered by the use of the nominal group technique. The research took place at the 2005 International Wheelchair Amputee Sport championships in Brazil. Seven specialists in the field of wheelchair rugby participated in the study. The findings of the study and the conclusion reached indicated that there is a definite need for a different and more functional approach to bench testing cerebral palsy wheelchair rugby players. A new bench test format should be developed and could then be suggested to the International Wheelchair Rugby Federation for possible future inclusion in the classification manual.
Open Access
Community health workers’ perception, attitudes and practices with regard to their role and interaction with physiotherapists regarding health promotion and prevention of illness
(University of the Free State, 2015-06) Lowe, Zanette; Janse van Vuuren, E. C.; Van Vuuren, S.
Introduction The Department of Health has proposed a new health plan to re-engineer primary health care within South Africa which will shift the focus from hospitalisation towards the treatment of conditions at primary care level in the community (RSA DoH 2011:1). Community health workers (CHWs) will be identified and trained to be involved in the promotion of health and the prevention of illness. In order to achieve these health goals it will be important that the contribution of each team member, including Physiotherapists and the CHWs, is clear and known to the rest of the health care team. Aim The main aim of this study was to determine the perceptions, attitudes and practices of CHWs in the Thabo Mofutsanyane District (Free State) with regard to health promotion and prevention of illness, as well as inter-professional referral or cooperation with physiotherapists related to this. Methodology In realising the main aim of this study, after ethical approval (ECUFS NR 174/20134) data were collected by means of a short demographic questionnaire, as well as focus group interviews. Findings The central perceptions, attitudes and practices of CHWs in this study focused on training, support and support systems as well as service delivery and patient care. CHWs expressed a need for improved and continuous structured training opportunities. These training opportunities could further be enhanced by the establishment of good support structures, and improved interdisciplinary teamwork, which would in return improve service delivery, patient care and ultimately health outcomes. Conclusion and Implementation of findings The findings of this study portrayed some limitations within the CHW-context of the piloted re-engineered primary health care system within South Africa. These findings could assist the DoH of the Free State to improve, amongst others the training and support systems for CHWs within the re-engineered primary health care system.
Open Access
Concussion knowledge among South African rugby players
(University of the Free State, 2016-07) Viljoen, Carel Thomas; Brandt, C.; Schoeman, M.
Background: Concussion is one the most frequently reported injuries among rugby players. Potential dangerous long term side-effects such as neurological deficits and chronic traumatic encephalopathy (CTE), explain why concussion is currently an extensively debated topic in the media. The largest part of South Africa’s rugby playing population consists of amateur players. Anecdotal evidence suggest that only a very limited proportion of amateur clubs and schools offer medical assistance at matches or practices, generally due to a lack of funding. BokSmart currently leans towards educating coaches and referees to recognize concussion signs and symptoms and to remove concussed players from the field. However, in a country where field side medical assistance is scarce, the players themselves can play a pivotal role to report possible concussions to their coach or the referee. Currently, no rugby safety management programme is focussing on concussion education among South African rugby players. Further research on concussion knowledge among rugby players are warranted to generate benchmark data needed to inform development and motivate implementation of educational programmes among rugby players, as an addition to the current BokSmart programme. Aims: To evaluate the knowledge on concussion and attitudes/behaviours regarding concussion and return to play (RTP) among South African amateur high school and club rugby players. Methods: A descriptive, cross-sectional study design was used to achieve the aims. The participants (n = 294) were divided into two groups namely; junior amateur high school (JAHS) (n = 216) and senior amateur club (SAC) (n = 78) rugby players. All participants completed the modified Rosenbaum Concussion Knowledge and Attitudes Survey – Student Version (RoCKAS-ST) in order to evaluate their concussion knowledge and attitudes/behaviours regarding concussion and RTP. Descriptive statistics were used to summarise continuous data with means and standard deviations or medians and percentiles as appropriate. Frequencies and percentages were calculated for categorical data while significance was set at p < 0.05 for comparative analyses. Results: The Concussion Knowledge Index (CKI) mean correct answered questions in the JAHS group was 10.46 ± 2.36 (range 3 – 15) of a maximum score of 17 points. Participants of the JAHS on average identified 62.4% of the CKI questions correctly. The CKI mean correct answered questions in the SAC group was 10.17 ± 2.35 (range 4 – 14) of a maximum score of 17 points. Participants of the SAC group on average identified 60.2% of the CKI questions correctly. On average the JAHS participants identified 66.3% of concussion symptoms correctly, while the SAC participants only identified 62.7% correctly. The Concussion Attitudes Index (CAI) mean correct answered questions in the JAHS group was 56.49 ± 8.81 (range 36 – 75) of a maximum score of 90 points. Participants of the JAHS group had a mean safe response of 65.6% when answering the attitude/behaviour regarding concussion and RTP questions. The CAI mean for correct answered questions in the SAC group was 55.88 ± 11.42 (range 20 – 75) of a maximum score of 90 points. Participants of the SAC group had a mean safe response of 67% when answering the attitude/behaviour regarding concussion questions. No statistical significance were found between the mean concussion knowledge scores (p > 0.37) of the JAHS and SAC participants. A p-value of p > 0.98 was noted, also showing no statistical significance between the JAHS and SAC participants’ mean concussion attitude scores. Conclusion: It was concluded that both junior and senior South African amateur rugby players had insufficient knowledge on concussion. The participants’ lack of concussion knowledge were further emphasised during the poor concussion symptom identification. Both groups showed unsafe attitudes/behaviours towards concussion and RTP.
Open Access
The development of a physiotherapy intervention program for closed or open reduction and/or internal fixation of mandibular condyle fractures
(University of the Free State, 2014-09-16) Van der Merwe, Anke; Barnes, R.; Brandt, C.
English: Introduction: The need for physiotherapy intervention in the treatment of mandibular condyle fractures has been highlighted. No unifying criteria are currently available regarding a postsurgical functional exercise program for patients who sustained mandibular condyle fractures. Aim: The research study conducted aimed to perform a needs analysis amongst maxillo-facial surgeons and physiotherapists in South Africa, regarding the perceived need for a postoperative physiotherapy intervention program for patients who sustained mandibular condyle fractures. The study also aimed to develop a post-operative functional exercise program for patients who sustained mandibular condyle fractures. Methodology: The first part of the research comprised of a needs analysis questionnaire, sent out to qualified experts: one physiotherapist and one maxillo-facial surgeon from each of the training institutions in South Africa. The data obtained from the needs analysis questionnaire was used to compile an online questionnaire with statements regarding the type and dosage of a suitable physiotherapeutic treatment protocol. The Delphi method was used, and this questionnaire was sent out to a further 20 experts (national and international) in the fields of physiotherapy, maxillo-facial surgery and dental surgery. A convenience sampling method was used to select appropriately trained participants for the needs analysis and Delphi questionnaire. Results: A definite need for physiotherapy intervention for mandibular condyle fracture patients was proposed by the needs analysis participants (100%). A total of 85.7 % (needs analysis) and 100 % (Delphi questionnaire) of respondents indicated that all mandibular condyle fracture patients should receive in-hospital physiotherapy intervention. By utilising the Delphi method, a suitable physiotherapy intervention program for mandibular condyle fracture patients was developed. Inter-reviewer consensus was reached regarding what each exercise entails, as well as what in-hospital physiotherapy visits should be comprised of. Stability was reached regarding the commencement and dosage of the various jaw exercises. Conclusion: Experts in the field proposed that physiotherapists should provide post-operative rehabilitative therapy to patients who have sustained mandibular condyle fractures. The proposed post-surgical intervention program provided in this study can serve as a baseline for implementation in further research studies. The advantages of referring mandibular condyle fracture patients to physiotherapy were also presented.
Open Access
The effect of a core stability, m. gluteus medius and proprioceptive exercise program on dynamic postural control in netball players
(University of the Free State, 2014-11) Wilson, Marelise; Barnes, R. Y.
English: Dynamic postural control is the ability to perform a functional task with purposeful movements that translates the body’s centre of gravity without compromising a stable base of support. The functional task might involve jumping or hopping to a new location and immediately attempting to remain as still as possible or attempting to create movements such as reaching or throwing without compromising the base of support (Winter, Patla and Frank, 1990; Kahle and Gribble, 2009, Gribble, Hertel and Plisky, 2012). Maintaining dynamic postural control is essential for netball players as netball players frequently find themselves on one leg having to make an accurate pass. Research by Ferreira and Spamer (2010) evaluated the physical profile of elite university netball players and found poor balance in these netball players during pre-season. No literature could be found regarding studies investigating a programme that utilized the combination of core stability, m.gluteus medius (GMed) strengthening and proprioceptive balance exercises on dynamic postural control or studies investigating the effect of an exercise programme on dynamic postural control in netball players. The research study was undertaken to determine if an exercise programme that incorporates core stability, m.GMed strengthening and proprioceptive balance exercises would lead to a significant improvement (p˂0.05) in dynamic postural control in a group of netball players. A cross-over randomised clinical trial was performed. Sixteen female university netball players selected in the top junior group participated in this study. Participants were randomly divided in two groups. Group A participated three times a week for six weeks in the exercise programme while group B was considered as the control group after which the roles were reversed. The simple Star Excursion Balance Test (SEBT) with three trials and four directions were used to measure dynamic postural control of the participants. All participants were assessed at baseline, after six weeks and after 12 weeks. Participants from both groups were tested simultaneously, and the data collector and assistant were blinded to which group the participants belonged. Data were analyzed by a biostatistician using student’s and paired t-tests. Dynamic postural control as measured with the SEBT demonstrated a statistically significant improvement (p<0.05) across three reach directions (anterior, medial and posterior) in a group of netball players post participation in an exercise programme that incorporated core stability, m.GMed strengthening and proprioceptive balance exercises. The study proposes that an exercise programme that incorporates core stability, m.GMed and proprioceptive balance exercises could be beneficial for improving dynamic postural control in a group of netball players. The results of the study provided substantial evidence for the use of a combination of core stability, m.GMed strengthening and proprioceptive balance exercises in programmes rehabilitating netball players with poor dynamic postural control. The present study also provides a baseline for further research whether an exercise programme that incorporated core stability, m.GMed strengthening and proprioceptive balance exercises would contribute towards improved performance and injury prevention in netball players. The effectiveness of the exercise programme described in the present study could be implemented and investigated in other sporting codes requiring dynamic postural control. Netball players can also confidently use the developed exercise programme in the present study to eliminate shortcomings in their physical profile, with regards to dynamic postural control.
Open Access
The effect of physiotherapeutic Kinesio taping on selected physical symptoms associated with major depressive disorder
(University of the Free State, 2014-01-24) Erasmus, Karen; Bodenstein, K.; Du Toit, M.
English: Kinesio® taping is a relatively new form of therapeutic taping that has a variety of applications. Physiotherapists can use the tape to treat certain physical symptoms for example, pain, swelling and dysfunctional muscle activation. Major depressive disorder (MDD) is a mood disorder and physical symptoms most associated with MDD, and tested in this study were muscle tension, pain complaints, restricted breathing, less flexibility and centring of movement. The aim of this study was to investigate the effect of physiotherapeutic Kinesio® taping on selected physical symptoms associated with MDD. A double-blind, randomised controlled design was used, following a quantitative study approach. The study population consisted of 40 patients with MDD admitted to a private and public psychiatric institution in Bloemfontein. The majority (77.5%) of participants complained of pain during the study period (24 hours) and 58% complained of multiple areas of pain. The sensory and affective components associated with pain and tested by the Short Form McGill Pain Questionnaire (SF-MPQ) showed improvement in combined scores for both the experimental and placebo groups. The results of the Manual Assessment of Respiratory Motion (MARM) displayed improvement in both the placebo and experimental groups for balance of breathing and percentage ribcage motion. The Tinetti Mobility Test which assesses balance and gait showed no distinct results possibly due to the scale not being sensitive enough for the movement disorders tested Limitations of the study could have influenced the outcomes measured and it should be taken into account that of the 40 participants, 21 received physiotherapy. Other therapies received by participants during the study were not standardised and could not be controlled due to the multitude of stakeholders involved in the care of the patients. The treatment of physical symptoms associated with MDD with Kinesio® taping had mixed results, but Kinesio® taping could be a valuable adjuvant treatment modality. The importance of physiotherapy as part of the treatment regime for patients suffering from MDD was highlighted.
Open Access
The 𝘪𝘯 𝘷𝘪𝘵𝘳𝘰 effects of 𝘔𝘰𝘳𝘪𝘯𝘨𝘢 𝘰𝘭𝘦𝘪𝘧𝘦𝘳𝘢 on chaperone-mediated autophagy in human HepG₂ liver cancer cells
(University of the Free State, 2023) Bopape, Matlola Abel; Ntsapi, Matlakala Claudia; Tiloke, Charlette
𝐈𝐧𝐭𝐫𝐨𝐝𝐮𝐜𝐭𝐢𝐨𝐧: The impact of hepatocellular carcinoma (HCC) is most significant in developing countries, including South Africa. Emerging evidence suggests that the cell survival mechanism, chaperone-mediated autophagy (CMA), promotes HCC tumour progression and chemotherapeutic drug resistance. Current treatment approach for HCC is guided by the Barcelona Clinic Liver Treatment Strategy (BCLTS), which recommends different treatment approaches depending on the level of tumour progression. Despite their efficacy, currently available chemotherapeutic options have numerous limitations such acquired resistance, recurrence, and hypertension. To address these limitations, phytochemical extracts are increasingly being investigated for the anti-cancer potential. The phytochemical extracts of the medicinal plant, Moringa oleifera (MO) have been shown to induce apoptosis of HCC cells. MO leaves have the greatest abundance of phytochemicals displaying anticancer potential. Investigating the interplay between all-trans-retinoic acid (ATRA), a potential inhibitor of CMA, and MO regarding their effects on CMA holds potential in identifying adjuvant therapeutic approaches for treatment modalities for HCC. 𝗔𝗶𝗺: This study aimed to investigate the 𝘪𝘯 𝘷𝘪𝘵𝘳𝘰 effects of MO aqueous leaf extract on CMA activity in human HepG₂ cancer cells. 𝗠𝗲𝘁𝗵𝗼𝗱𝘀: HepG₂ cells were cultured and exposed to MO and ATRA for 24 hours. Thereafter, a cell viability assay was performed and an inhibition concentration 50 (IC50) was determined which was used for all subsequent experiments. The cells were allocated to three treatment groups: MO, ATRA and a combination group of MO and ATRA. A Caspase-Glo™ cell death assay and western blot analysis were also conducted to evaluate changes in lysosome-associated membrane protein type 2A (LAMP2A) and hexokinase II (HK2) protein expression levels. 𝗥𝗲𝘀𝘂𝗹𝘁𝘀: The cell viability assay results displayed a concentration-dependent decline in reductive capacity following MO and ATRA exposures. An IC₅₀ of 1415 μM (ATRA) and 2198 μg/mL (MO) were observed. The cell death assay revealed decreased caspase-9 activity following the respective treatment exposures. There was a corresponding decline in caspase-3/7 activity following respective treatment exposures, except for MO, where an increase in caspase-3/7 activity was observed. Western blot analysis showed a decline in the expression of LAMP2A and a corresponding increase in the expression of the CMA cargo protein HK2. 𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻: The results revealed that MO and ATRA could inhibit the growth and proliferation of HCC cells, offering a promising adjuvant therapeutic approach against HCC. Further investigation into these compounds and their underlying mechanisms of action may contribute to developing novel treatment modalities for HCC.
Open Access
Fisioterapeutiese behandeling van kroniese hoofpyne in depressiewe pasiënte; 'n vergelyking tussen individuele behandeling en 'n kombinasie van individuele behandeling en kollektiewe behandeling
(University of the Free State, 1999-11) Griessel, M. E.; Krause, M. W.
English: The incidence of depression today is so high, that it is described as "The common cold of mental illness". As Physiotherapist in a private practice, in Bloemfontein, a large part of the researchers daily work consisted of the treatment of chronic headaches in depression patients. The researcher discovered that the intensity of the patients headaches often varied occording to the frame of mind of the patient. The treatment of these headaches included individual physiotherapy that consisted of: spinal mobilization of the effected joints, pressure of the triggerpoints, massage and ultrasound. In this study the above mentioned treatments were compared to a combination of individual and collective treatments. It was determined which type of treatment was most effective in decreasing the total pain pattern (intensity, periodicity, reaction to analgesics) of the headache during treatment as well as one month after the treatment was ended. The study population consisted of patients which were diagnosed with major depression. All the depression patients that attended the two week depression programme in Hospital Park Clinic in Bloemfontein met the criteria to qualify and were referred for physiotherapy were therefore included in the study. So too were all the depression patients that attended the two week depression programme at Universitas Groupcentre in Bloemfontein that met with the necessary criteria and which were referred for physiotherapy included in the study programme. There was a total of fifteen test subjects in the control group and fifteen test subjects in the experimental group. The control group were treated individually and the experimental group received individual physiotherapy as well as collective treatment sessions. Results were obtained through evaluations, re-evaluations as well a re-evaluation that was conducted telephonically with the subjects one month after there discharge from the sentrum or clinic. Special attention was given during evaluations and re-evaluations to the total pain pattern of the test subjects headaches. From the results the observation was made that the control group and the experimental group were very comparitive groups as far as test subjects were concerned, subjective evaluations as well as objective evaluations. The two groups as median of the total pain pattern after the first evaluation were also exactly the same (II out of 15 for both groups). There was no statistical indicative difference with regard to the change of the total pain pattern from treatment to treatment between the two groups. There was a statistical indicative difference between the improvemnt of the total pain pattern from the first evaluation to the re-evaluation after one month. The control group's median of the total pain pattern one month after the treatment was 8 out of 15, while the experimentle group's median was 4 out of 15. The pain pattern of the experimental group was statistically indicative of more improvement than the control group. From this research the conclusion can therefore be made that the results from physiotherapy treatments of chronic headaches in depression patients differ during individual treatments and a combination of individual and collective treatments. A combination of individual and collective treatments deliver better long term results and therefore is the most recommended type of treatment for depression patients with chronic headaches.
Open Access
Fisioterapie rehabilitasiedienste en behoeftes in die Barkly-Oos Distrik
(University of the Free State, 1999-11) Kriel, Helena; Krause, M. W.
Afrikaans: Inleiding en doel van die studie 'n Gedetaileerde opname oor rehabilitasiedienste en -behoeftes van die Drakensberg Streeksdiensteraad in die Barkly-Oos distrik is in 1995 gemaak. Die distrik is 'n tipiese landelike gebied met 22 000 mense. Metodiek Die beskrywende studie het uit twee dele bestaan. Met die eerste deel is bepaal wat die rehabilitasiebehoeftes van persone wat in die studie ingesluit is, was. Eenhonderd-vyf-en-dertighuishoudings is d.m.v. eenvoudige ewekansige steekproeftrekking identifiseer wat deur die navorser en 'n navorsingshulp besoek is. 'n Totaal van 610 persone is in die studie ingesluit. Siftingstoetse is gebruik om enige persoon wat rehabilitasiedienste op die spesifieke tydstip sou benodig, te identifiseer. Die navorser het die persone evalueer om die aard van rehabilitasiedienste te bepaal wat benodig is (fisioterapie, arbeidsterapie, spraakterapie en "ander" wat maatskaplik en sielkundig ingesluit het). Aangesien die navorser 'n fisioterapeut is, kon slegs 'n beraming gemaak word van die ander rehabilitasiedienste as fisioterapie wat benodig is. Slegs die persone wat fisioterapie rehabilitasiedienste benodig het, is verder evalueer om die behoeftes en die spesifieke probleme aangaande rehabilitasie te bepaal, Met die tweede deel van die studie is die beskikbaarheid van rehabilitasiedienste in die area bepaal. Vraelyste oor die aard van rehabilitasie is aan persone gegee wat hulself as betrokke by rehabilitasie beskou het. Resultate Agt-komma-vyf persent van die persone wat nagevors is, is identifiseer wat rehabilitasiedienste sou kon benodig. Vier-komma-drie persent het fisioterapie rehabilitasiedienste benodig. Van dié persone het slegs 42% al vantevore kontak met rehabilitasiedienste gehad. Agt-en-tagtig-en-'n-half persent het die afgelope jaar geen rehabilitasiedienste ontvang nie. Die nie-beskikbaarheid van dienste was die belangrikste rede, asook 'n gebrek aan kennis dat rehabilitasiedienste beskikbaar was. Dertig-komma-agt persent het sentrale senuwee-probleme gehad, met 19.2% ortopediese probleme van die onderste ledemaat. Daar was baie min instellings en persone wat rehabilitasiedienste gelewer het. Dit was hoofsaaklik die verpleegpersoneel van die plaaslike hospitaal en die Streeksdiensteraad wat betrokke was met rehabilitasie. Daar is slegs een fisioterapeut in privaat praktyk en 14 verpleegkundiges, verpleegkunde assistente en lekewerkers identifiseer wat betrokke was met rehabilitasie. Met uitsondering van die fisioterapeut, was die selfaangeduide vlakke van kennis, selfvertroue en ervaring van die persone oor rehabilitasie onvoldoende. Gevolgtrekking Met baie min rehabilitasiedienste wat in die gebied aangebied word, en 4,3% van die persone wat fisioterapie rehabilitasiedienste benodig, kan die gevolgtrekking gemaak word dat daar 'n groot behoefte aan rehabilitasiedienste in die Barkly-Oos distrik is.
Open Access
An investigation into the inflammatory properties of tenofovir in HepG₂ human liver cells
(University of the Free State, 2023) Vazi, Songezo; Tiloke, C.; Van Zyl, Sanet
𝗜𝗻𝘁𝗿𝗼𝗱𝘂𝗰𝘁𝗶𝗼𝗻: Since the introduction of antiretroviral (ARV) drugs in 1996, the life expectancy of HIV-infected individuals has been nearly comparable to that of HIV-uninfected individuals. However, increasing evidence shows that antiretroviral therapy (ART) is associated with increased metabolic disorders, systemic inflammation, and hepatotoxicity. Tenofovir induces oxidative stress via mitochondrial DNA polymerase inhibition in HepG2 cells at chronic exposure. Although in vitro and in vivo studies have been performed to determine the effect of tenofovir on the inflammatory response, the inflammatory effect of this antiretroviral drug in liver cells still needs elucidation. 𝗔𝗶𝗺: This study aimed to investigate tenofovir's potential pro- and anti-inflammatory properties in HepG₂ human liver cells at different time frames. 𝗠𝗲𝘁𝗵𝗼𝗱𝗼𝗹𝗼𝗴𝘆: HepG₂ cells were treated with tenofovir (1.2 μM) over 24h and 120h; pro- and anti-inflammatory cytokines levels were assessed using a SimpleStep human ELISA kit specific to each analyte (IL-6, IL-1β, TNF-α, IL-10). Protein expression of p-NF-ĸBp65, NF-ĸBp65, p-IĸBα, and IĸBα was determined with Western blotting. A quantitative polymerase chain reaction assessed the mRNA expression of 𝘕𝘍-κ𝘉𝘱65 and 𝘐𝘬𝘉α. 𝗥𝗲𝘀𝘂𝗹𝘁𝘀: Tenofovir significantly increased IL-6 and 10 levels, 𝘕𝘍-κ𝘉𝘱65 mRNA expression and NF-κBp65, p-NF-κBp65 and p-IκBα protein expression. Additionally, a significant decrease in IL-1β levels and 𝘐κ𝘉α mRNA expression at 24h were observed. After 120h, tenofovir-treated cells showed increased p-NF-κBp65 and IκBα protein expression. Furthermore, a significant decrease in IL-6 and IL-10 levels, 𝘕𝘍-κ𝘉𝘱65 and IκBα mRNA expression and NF-κBp65 and p-IκBα protein expression were observed. 𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻: The study demonstrated that tenofovir elevated the anti-inflammatory cytokines at acute exposure. Tenofovir increased pro-inflammatory cytokines and downregulated anti-inflammatory cytokines at chronic exposure of tenofovir in HepG₂ human liver cells. The knowledge obtained from tenofovir-induced inflammatory changes can provide valuable information regarding tenofovir’s clinical use.
Open Access
Invloed van kinesiologie pleister op EMG-aktivering van skapulêre stabiliseerders en balspoed van `n tennisafslaan
(University of the Free State, 2015-02) Van der Lingen, Anna Sophia; Brandt, Corlia
English: Introduction: The effects of Kinesiology Tape on the neuromuscular system have been discussed in recent literature. The effects on power, range of motion, proprioception, and muscle strength can be vital to reach optimal functional performance. There is no research available that studies the effect of Kinesiology Tape on the scapular stabilisers in tennis players. Aim: The aim of the study was to determine if Kinesiology Tape can have i) an effect on the muscle activation of serratus anterior and lower trapezius muscles and ii) the ball speed of the tennis serve. Method: The study was a quantitive analitical case study on 19 male and 11 female (n = 30) tennis players (mean age = 19.83 years). The muscle activation of the serratus anterior and lower trapezius muscles were measured by means of EMG. Ball speed were measured with a Radar Speedgun. The intervention was the application of Kinesiology Tape on the scapular stabilisers. Results: The lower trapezius muscle`s mean highest measurement (p = 0.7143; t = 0.37; df = 29) and maximum measurements (p-value = 0.5376; t-value = -0.62; df = 29) improved, but were not statistical significant. The p-values for the serratus anterior muscles were 0.2181 (highest measurement) (t-values = 1.26; df = 29) and 0.0045 (mean measurement) (t-value = 3.08; df = 29) which are statistical significant. The mean minimum service speed improved after the application of Kinesiology Tape with 3.1 km/h, the mean maximum speed with 1.666 km/h and the mean mean speed with 1.9233 km/h. There was a statistical significant improvement of 1.9233 km/h in the mean serve speed (p = 0.218; t-value = 1.26; df = 29). Discussion and conclusion: It appears that there can be a statistical significant improvement in the mean EMG activity of the serratus anterior muscle after the application of Kinesiology Tape on the scapular stabilisers. No conclusion can be made on the effect the taping has neither on the ball speed of the serve nor on the activation of the lower trapezius muscle. The results are difficult to interpret because of the complex biomechanical interaction of the kinetic chain.
Open Access
Knowledge, attitude, beliefs and practices of South African physiotherapists regarding the management of tension-type headaches
(University of the Free State, 2021) Robertson, M. C.; Barnes, R.; Stander, C.
Background: Tension-type headaches (TTH) are primary headaches that have been indicated by the Global Burden of Disease study as the third most common pain condition worldwide and are more prevalent than migraines. People living with TTH may experience significant decreases in their ability to participate in work, social or leisure activities and housework. Often persons living with TTH are managed by physiotherapists, and therefore physiotherapists should be knowledgeable regarding the therapeutic management of the condition. Currently, there is a paucity of literature in South Africa regarding the knowledge, attitude and beliefs, and practices of South African physiotherapists concerning the management of TTH. Aim of the study: The aim of the study was to explore the knowledge, attitude, beliefs and practices of South African physiotherapists regarding the management of persons living with tension-type headaches. Methodology: A cross-sectional research study was performed using a self-developed questionnaire sent via an electronic survey platform. All ethical considerations were taken into account during this process. Privacy and confidentiality were strictly maintained throughout the research process. Results: One hundred and thirty-four physiotherapists provided electronic consent and completed the questionnaire. The participants were mostly female (89.5%) with a mean age of 36.5 and the median number of years of practice was 13 years. The majority of the participants were working in the private sector and most participants had an interest in Musculoskeletal and Pain management conditions. For the knowledge section, 79 participants (58.96%) obtained a median score of 60%, which indicated that they had average knowledge regarding TTH. The majority of participants enjoyed providing treatment for TTH, favoured the multi-disciplinary team approach and agreed that evidence-based outcome measures should be utilized. In the belief section once again the majority favoured the multi-disciplinary team approach and believed that patients should be provided with alternative pain management strategies. The frequency of treatment varied from one to three times per week in the practice section and the participants preferred a combination of pharmacological and non-pharmacological interventions in the management approach. Discussion and conclusion: This KABP study regarding the management of persons living with TTH among South African physiotherapists demonstrated that the majority of the participants in this study had average knowledge regarding TTH. Many of the participants were not able to identify all of the muscles involved in the symptoms of TTH, which is a concern in the physiotherapy profession since the anatomy of the body is a fundamental part of the understanding of presenting conditions and the development of treatment strategies. Intervention programmes in the form of accredited professional development training to address this shortcoming through online discussions or webinars could be undertaken. This study found that the participants were in favour of a multi-disciplinary team and an evidence-based practice approach in the management of persons living with TTH. It is recommended that further research should be done around this topic within the South African context.
Open Access
Lower limb muscle fatigue on grass and artificial turf playing surfaces among elite soccer players
(University of the Free State, 2016-07) Greyling, J. A. T.; Brandt, C.; Coetzee, D.
INTRODUCTION: Fatigue and hard playing surfaces have been indicated as risk factors for injury in soccer players. Recent literature, however, has found contradictory results on the prevalence of injuries on different playing surfaces, as well as regarding the interaction between fatigue and the type of playing surface. This raises the question as to the true mechanisms underlying the cause of injury on different playing surfaces. AIM: The aim was therefore to compare lower limb muscle fatigue on grass and artificial surfaces in elite soccer players. METHODS: Twenty two elite soccer players (mean age 24.8 years) were included in a cross-over study design. The players were randomly allocated to two conditions. It involved exposure to the same soccer-specific fatigue protocol on a grass and artificial surface respectively. A force plate was used for pre-test and post-fatigue measurements on force generation, force rates and jump height. The Pearson correlation coefficient was used to determine associations between baseline variables and interpreted by means of effect sizes and p-values. The Wilcoxon signed-ranks test was used to determine statistical significant changes from pre-test to post-test for each condition while the Chi-square test was used to compare the findings between the two conditions. RESULTS: Statistical significant correlations were found at baseline between propulsion and concentric forces (r=0.66, p<0.001); propulsion force and body mass (r=0.78, p<0.001); propulsion force and BMI (r=0.645, p<0.01); landing force and body mass (r=0.82, p<0.001); landing and eccentric forces (r=-0.75, p<0.001); jump height and concentric force (r=0.84, p<0.001); and body mass and concentric force (r=0.76, p<0.05). Propulsion and concentric forces increased statistical significance after fatigue on the grass surface (p=0.026 and 0.005 respectively). On the artificial surface there was a statistical significant increase in propulsion force and propulsion force rate post-fatigue (p=0.0001 and 0.0153 respectively). Comparison of the changes from baseline to fatigue between the two conditions yielded no significant differences (p>0.05). CONCLUSION: Limited significant differences were found comparing forces after fatigue on artificial and grass surfaces. The inconsistency in the behaviour of forces in response to fatigue indicate the possible variability in adaptation strategies to cope with a speculated fatigue state. Surface-specific training could therefore be recommended in order for muscle and sport/surface-specific adaptation to take place, thereby decreasing the risk for injury
Open Access
Lumbo-pelvic core stability: profiles of female long-distance runners
(University of the Free State, 2016-10) Pool, Lindie; Brandt, C.
Running is a sport characterised by a 90% prevalence of predominantly lower-limb overuse injuries. Stress urinary incontinence (SUI) is also prevalent and its hindrance in terms of participation falls within the definition of running injuries. Neuromuscular mechanisms within the proximal kinetic chain have been correlated to these injuries and conditions, however contrasting views exist. Adaptations within the tonic and phasic characteristics of core musculature have been shown to elicit a series of kinetic adaptations within the movement system predisposing injury/recurrence of injury. The aim of this research was to discuss the changes in core muscle characteristics in relation to risk of injury after exposure to a functional activity. Changes were presented by means of profiling. A secondary objective was to identify numerous internal and external risk factors of running-injury. A descriptive, cohort analytical study design was used with a convenience sample of fifteen (15) eligible experienced female long-distance runners registered in Bloemfontein-based accredited running-clubs. The baseline- and post-exercise profiling test battery included electromyography (EMG) of the pelvic floor muscles (PFM) and M. Transversus Abdominus (TrA)(ICC 0.98), pressure biofeedback testing (PBU) (ICC 0.90) and functional endurance testing (ICC 0.97). Any 24+ km functional longrun served as functional task. External, internal and demographic factors were identified using a self-compiled questionnaire. The majority of the TrA EMG, PBU and Dominant-Side lateral muscle group profiles displayed an increase in post-exercise value. The profiles illustrated both failure (decrease in value) and or possible neuromuscular mechanisms (increase in value) attempting to augment stability. These mechanisms are suggestive of a loss of stability on a more central level. The cohort also displayed remarkably low-level integrated stability activity (PBU) both at baseline and post-exercise. There were no statistical significant difference between the baseline and post-exercise profiles for any of the PFM (p=0.7957), TrA (p=0.2769), PBU (p=0.1875), Anterior Muscle Group (p=0.1688), Posterior Muscle Group (p=0.1909), Lateral Dominant Muscle Group (p=0.5897) or Non-Dominant Lateral Muscle Group measurements (p=0.1848). Knee injury was identified as the most prevalent previous running injury (47%). Only 20% of the 67% of participants that included muscle conditioning in training programs included the PFM. Running training errors were the most significant external causative factors present within the cohort together with insufficient periodisation and recovery from longruns. The results of this research support the inclusion of core-stability components in running injury risk management and rehabilitation. The major limitations of this research were the small sample size and absence of a control group. This may be addressed by future research on valid functional core testing. Future research should also establish scientific indicators of fatigue and correlation between corecharacteristics and risk of injury.
Open Access
Oefen- en beseringsprofiel van Griffons en Puma rugbyspelers
(University of the Free State, 2011) Du Plessis, Sanell; Janse van Vuuren, Corlia
English: Rugby is a very popular, fast paced, high intensity team sport. The players are permanently in motion and contact with one another, and for this reason the risk of injury is very high. The number of injuries in professional, as well as amateur rugby has dramatically increased since rugby has become a professional sport. The fact that the style of play has also changed to a more running form of rugby also increases the potential of injuries for the players proportionally. Various research studies have been carried out on the epidemiology of rugby injuries at different levels of the game, but limited data exists on the exercise and injury profile of rugby players. This area is the aim of the study. A qualitative, descriptive, retrospective study is performed. The study population exists of the Griffons and Puma rugby players that competed in the 2010 Vodacom and Currie cup competitions in South Africa. Data of the incidence and treatment of injuries, pre-season fitness tests and exercise regimes for each union is included in this study, obtained through either a data vorm or questionnaire. A total of 89 injuries are recorded for 55 players over a period of nine months for February 2010 to October 2010. Physical contact between players caused more than half the injuries. There was a high incidence of lacerations to the head and face, while soft tissue injuries were also prominent. Forwards were injured more frequently than backline players, and the lower limb was the anatomical body part that was injured the most. The majority of injuries occurred during the second half of the match and was very mild to mild. The results of this study correspond greatly to previous literature and are of value in that it adds to the current existing databases of rugby injuries in South Africa. These databases can be well utilized in the structuring of injury prevention strategies by the rugby unions. The research also indicates that physiotherapy and rehabilitation plays aan important role in the treatment of sports injuries.
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Parity and motor control in female recreational runners
(University of the Free State, 2016-07) Bouwer, Rochelle T.; Brandt, C.; Schoeman, M.
Female recreational runners are more prone to injuries than their male counterparts. Considering the associated risk for sustaining sport-related injuries with impaired core proprioception and the effect pregnancy has on females’ core structures, this study aimed to investigate the trunk motor control in parous and nulligravid female recreational runners. A descriptive cross sectional, case-control study was conducted and 29 female recreational runners were assessed. Eight parous participants were matched with eight participants from the nulligravid group. The matched nulligravid participants were significantly younger [95% CI: - 16 ; - 1] compared to the parous group and no significant difference [95% CI: - 45.9% ; 22.8%] was seen in comparison of sport-related injuries. When testing the muscle activation and endurance of the pelvic floor muscles, the nulligravid group performed better during the surface electromyography test, although no difference was found during the PERFECT test. No statistical significance was found between groups during the surface electromyography test for muscle activity of the Transverse Abdominis muscle [95% CI: - 201.3 ; 504.5], activation of local stabilisers using the pressure biofeedback unit test [95% CI: - 1 ; 1] as well as the Sahrmann test [95% CI: - 2.5 ; 2] to assess global mobility. The parous group tended to perform better during the sport specific plank test, to assess global core muscle function, but in contrast performed weaker in the active straight leg raise test used to assess global stability. During the single leg stand test as well as the unilateral squat (balance and control) no significant difference was found between groups. No significant difference was found between the parous and nulligravid group regarding injuries and only a few tests of trunk motor control showed statistical significant differences between the groups. Due to the small sample size of the matched groups and limited statistical differences that were found conclusive recommendations could not be made. Further research is warranted to investigate motor control in parous athletes.
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Pelvic organ prolapse and pelvic floor muscle strength
(University of the Free State, 2006) Nieuwoudt, Elizabeth Maria; Cronje, H. S.; Prollius, A.; Krause, M. W.
English: The objective of the study was to research the relationship between pelvic floor muscle strength (PFMS) and pelvic organ prolapse (POP), and to find a threshold of PFMS where POP will manifest itself. A clinical cross-sectional analytic study was indicated. PFMS was tested with digital assessment using the modified Oxford scale and EMG testing with a vaginal electrode. Prolapse was assessed with the Pelvic Organ Prolapse Quantification (POP-Q) terminology. The analysis included 117 women. The correlation (-0.57) of the digital assessment of PFMS with POP is significant (p < 0.0001). 100% of women with grade 0 PFMS had a POP (POP-Q stage I-IV), while only 30% of women with a grade 5 PFMS had a POP of lesser severity (only stage I). Regarding EMG measurement of PFMS, there was a moderately significant correlation (r = -0.62; p < 0,001). However, one of the most interesting findings of the study was a significant correlation (-0.55) between the endurance of the PFM as was measured with EMG and POP (p < 0.0001). Women with either a stage 0 or I POP could hold a PFM contraction at a target set at 50% of the average of their three maximum contractions for a median of 12 seconds, while women with a more severe POP (stage II, III and IV) could hold the contraction for only 1 to 3 seconds. The results confirm clinical observations of the correlation between a weak PFM and a more severe POP. The study demonstrated that the threshold of PFMS where symptomatic POP manifests itself is grade 2 regarding digital testing using a modified Oxford scale (positive predictive value 60%; negative predictive value 85%; accuracy 73%) and 15μV when using EMG-testing (positive predictive value 60%; negative predictive value 68%; accuracy 74%). These results have clinical implications: women with a risk for developing symptomatic POP can be identified earlier and treated conservatively.
Open Access
Physical activity, lifestyle habits and general health status of recreational sport participating and non-recreational sport participating males in Kimberley, Northern Cape
(University of the Free State, 2020-01) Johnson, Shabnam; Janse Van Vuuren, Corlia; Bodenstein, Karen; Smith, Robyn; Nel, Heleen
Introduction: An individual’s health is based on his or her mental and physical well-being (WHO, 2020a), while general health status may refer to the level of health of an individual as well as the level of health of the general population or an individual (Durstine & Moore, 2003). In line with this, the United Nations (UN) has set 17 sustainable developmental goals for the year 2030 (UN, 2015), which are aimed at encouraging and informing relevant health professionals on how to improve the general health status of the global community (UN, 2015). Goal 3 is specifically aimed at ensuring healthy lives and promoting well-being for all people of all ages, with the main objective being to reduce premature death resulting from non-communicable diseases (i.e. chronic lifestyle diseases (CLD)) (UN, 2015). Good lifestyle habits such as regular physical activity are associated with an improved life expectancy and an improved general health status (Kaptoge et al., 2018). The concept “lifestyle” refers to the way in which an individual lives and copes in his/her physical, psychological, social and economic environments on a day-to-day basis (Trovato, 2012). A healthy lifestyle improves the general health status of an individual by lowering the risk of developing CLD, being or becoming seriously ill or even early mortality (Takashi et al., 2013). Positive lifestyle habits such as regularly eating, and participating in physical activity can improve general health status whereas lifestyle habits such as excessive alcohol consumption, smoking and unhealthy eating are adverse lifestyle habits and can predispose the individual to CLD and poor general health (Borgan et al., 2015). Physical activity is one of the most important contributors to a good general health status. Physical activity is crucial in improving muscular strength and improving aerobic capacity (Garber et al., 2011). There is a decrease in sport participation after leaving school (Bloemhoff, 2010) which is where physical activity guidelines could become even more helpful. According to the American College of Sports Medicine’s (ACSM) recommendations for physical activity, a minimum of 150–300 minutes of moderate-intensity aerobic exercises or 75–150 minutes of vigorous aerobic exercises per week is advised in order to achieve health benefits (Riebe et al., 2018). The more time spent participating in physical activity, the better the health benefits which are achieved. However, Kyu et al. (2016) warn that exceeding the optimal physical activity levels and intensity may cause detrimental effects on the body. In particular, with regard to physical activity prescription, leisure-time physical activity is the most neglected area of physical activity. Recreational sport (as a form of leasuretime physical activity) can lead to increased opportunities to improve health by increasing aerobic capacity and strengthening muscles. It also provides social support and motivation while participating in physical activity which additionally allows for an improved mental state (Moore et al., 2012). Participation in recreational sports creates a sense of belonging, and provides positive and motivating social interaction (Eime et al., 2015). Chen et al. (2017) agreed that recreational sport has physiological and psychological benefits, but found the promotion of recreational sport by health professionals, such as physiotherapists, to be lacking. Recreational cricket is the most structured amateur sport in Kimberley making the inclusion of these players into a research study convenient. Cricket, as a professional or recreational sport, is a technical game and a test of endurance – mentally and physically (Webster, 2017). Physically, cricket improves stamina, endurance (aerobic fitness) and hand-eye coordination as well as perceptual skills. According to Ainsworth et al. (2011), the MET value of cricket was updated to 4.8 METS in 2011 after the previous two versions of the Compendium of Physical Activities listed the MET value as five. Mentally, cricket requires toughness and perseverance as individuals have to endure harsh conditions for long periods at a time, constantly and consistently thinking on their feet to plan and strategies (Filbay et al., 2017). Physiotherapists play an important role in the screening of patients and the prevention of complications from disease by means of health promotion. They also have the knowledge to prescribe exercises and incorporate everyday activities into a treatment programme considering current chronic diseases (O’Donoghue et al., 2012), such as type 2 diabetes, hypertension, increased cholesterol levels and obesity (UN, 2015). Physiotherapists are thus in an ideal position to promote healthy lifestyle habits such as physical activity and, in particular, promote recreational physical activity (Lowe et al., 2016) whilst improving the general health status of individuals and communities (Holm et al., 2015) and supporting the global drive towards better health for all. Aim The primary aim of this research study was to investigate the physical activity levels, lifestyle habits and general health status of recreational sport participating and nonrecreational sport participating adult males in Kimberley, Northern Cape Province, South Africa. Methods: A quantitative research design was used in this case-control study to compare the general health status, lifestyle habits and physical activity levels of recreational sport participating and non-recreational sport participating participants. Participants willing to partake in this study provided written consent before their participation. Data was collected using four self-administered questionnaires: a demographic questionnaire (compiled by the researcher), and three standardised questionnaires, the International Physical Activity Questionnaire (IPAQ), the Belloc and Breslow seven lifestyle habits questionnaire and the SF-36v2 health survey. Results and discussion: A total of 102 participants were included in this study with 51 participants in the recreational sport participating group and 51 in the non-recreational sport participating group. The recreational sport participating group had an overall higher level of physical activity per week compared with the non-recreational sport participating group. These results are in agreement with literature that found that recreational sport participation was a way of increasing physical activity levels and MET-minutes per week and limiting sedentary behaviour which is often associated with sedentary occupational duties (Owen et al., 2010). The majority of participants in both the recreational sport participating and nonrecreational sport participating group presented with moderately healthy lifestyle habits. Recreational sport participation is found to be associated with healthy lifestyle habits (Eime et al., 2015), however, in this research study the same level of lifestyle habits were found in the sport participating and non-recreational sport participating groups. Both groups had a similar number of participants who smoked, but more participants in the non-recreational sport participating group consumed alcohol. This could be as a result of the social or environmental influences as well as the socioeconomic environment (Keates et al., 2017), such as the occupational environment. The self-perceived general health status of both groups were comparable whereas the recreational sport participating group presented with slightly more participants with an improved mental health status. This could be attributed to the evidence that cricket, in particular, requires and improves mental concentration more than other sport types (Webster & Travill, 2018). However, participating in any recreational sport increases the overall level of physical activity of an individual which is associated with an improved mental and physical health status (Eime et al., 2015). Whilst this improved mental and physical functioning in return leads to an improved general health status of the individual (Eime et al., 2015). Conclusion: Participating in recreational sporting activities can increase the level of physical activity in an individual and promote the benefits associated with higher physical activity levels. It is, however, also important to include healthy lifestyle habits in general to optimise these health benefits and improve the general health status of an individual. Physiotherapists can play an important role in elevating physical activity levels and promote healthy lifestyle choices by education and referral to other members of the interprofessional team. Based on physiotherapists’ knowledge of exercise prescription and general health status, recreational sport should be promoted by physiotherapists to improve physical activity levels and general health status of individuals, and more importantly on community level to reach a larger portion of the population. Participation in recreational sport provides mental and physical health benefits, and could play an important role in health promotion and long term disease prevention, as expected through the UN’s sustainable development goals. This study provides important baseline information on physical activity levels, lifestyle habits and general health status of the 25-35-year-old male population in Kimberley, Northern Cape (by including both recreational sport participating and non-recreational sport participating individuals). This baseline information can now be utilised to inform, especially community interventions by physiotherapists, to support the UN’s drive towards ensuring “healthy lives and promote well-being for all at all ages”.