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DISSERTATION SYNOPSIS
SUBMITTED TO
RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
TOWARD PARTIAL FULFILMENT OF
MASTER OF PHYSIOTHERAPY DEGREE COURSE
By
CRISSY D’ ALMEIDA
UNDER THE GUIDANCE OF
B A BOOMADEVI
VIKAS COLLEGE OF PHYSIOTHERAPY
MARYHILL, KONCHADY, MANGALORE-575006
2009-11
RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
REGISTRATION OF SUBJECTS FOR DISSERTATION
1.
Name of the Candidate
and Address
CRISSY D’ALMEIDA
VIKAS COLLEGE OF PHYSIOTHERAPY
AIRPORT ROAD
MARYHILL, KONCHADY
MANGALORE – 575008
2.
Name of the Institution
VIKAS COLLEGE OF PHYSIOTHERAPY
Mangalore.
3.
Course of study and subject
Master of Physiotherapy (MPT)
Physiotherapy in Musculoskeletal Disorders and
Sports Physiotherapy
4.
Date of admission to Course
19-06-2009
5.
Title of the Topic
THE EFFECTS OF TRANVERSUS ABDOMINIS, GLUTEUS AND BICEPS
FEMORIS
MUSCLE
STRENGTHENING
IN
GOLFERS
WITH
SACROILIAC DYSFUNCTION
6.
BRIEF RESUME OF THE INTENDED WORK
6.1 Need for the study
Sacroiliac pain is a specific form of low back pain reported in approximately 40
percent patients which can occur separately or in conjunction with low back pain,
lumbar disc herniation and lumbar facet syndrome. This occurs because the low
back and pelvis rely on many common structures to ensure normal stability and
function. Hence functionally the pelvis cannot be studied in isolation. Diagnosis of
sacroiliac pain is difficult because the presenting complaints are similar to those of
other causes of back pain.
The typical anatomy of the sacroiliac joint which is characterized by a coarse
cartilage texture, cartilage covered grooves and ridges, a wedge like shape of the
sacrum and a propeller like shape of the joint surface leads to the highest coefficient of friction of diarthrodial human joints. This friction can be altered
according to the loading situation and serves to stabilize the pelvic girdle. The
main movements are forward rotation of the sacrum relative to the iliac bones and
backward rotation of the sacrum relative to the ilia. Nutation of the sacrum
(flexion of the sacrum relative to the ilia) is generally the result of load bearing and
a functional adaptation to stabilize the pelvic girdle. More research is needed in
patients with sacroiliac pain to verify whether counter nutation of the sacroiliac
joint (anterior rotation of the ilia relative to the sacrum) in load bearing situation is
a typical sign of non optimal stability of the pelvic girdle.
One study on the relationship between lumbar curve, pelvic tilts, and joint mobility
reported a high correlation between the angle of lumbar lordosis and pelvic tilt.
Subjects who have reported low back pain have also shown an increase in lumbar
lordosis.5 A study by Simpson examined subjects with and without low back pain
and found that there is a significant difference in lumbar lordosis between the two
groups, thus implying that pelvic positioning plays a role in low back pain. 6 We
can conclude that the positioning of the pelvis is correlated with back pain. Pelvic
tilt and lumbar stabilization exercises are frequently prescribed to patients to
relieve low back pain.7 Focusing attention on abdominal muscles may not be the
most efficient or effective way in training patients to normalize lumbopelvic
alignment. Studies measuring the relationship between pelvic tilt and abdominal
muscle performance have shown that there is no correlation between the two. This
study hypothesizes that there are other muscles that are attached to the pelvis that
affect the motion, stability, and position of the pelvis, or that neuromotor patterns
determine posture.
Multiple studies have examined the benefits of exercise in treating patients with
low back pain; however, there have been very few published reports describing
specific program designs as it relates to golfers. Golf injuries to the low back are
the most common problems in both the professional and amateur player. It is the
poor technique and the repetition of hitting balls that usually leads to an injury.
Combine that with the typical sedentary lifestyle (in which people drive to/from
work in a seated position and work in a seated position for most of the day) and we
begin to understand why there is such a high incidence of back pain among
golfers. A back injury results from excessive stress placed on the spine, usually
when the body does not perform the correct sequence during the golf swing. Here
is an astonishing fact: Eight times your body weight is forced through your spine
as you make contact with the ball. So if you have poor mechanics combined with a
weak back you are more likely to cause yourself a significant amount of injury.
The golf swing is considered a very unnatural movement for most people,
especially for people with a sedentary lifestyle. As with most sports, golf is a sport
that requires a lot of rotary movement. When we sit for the most part of the day,
certain muscles get used to that position and become “tight”, while other muscles
get “stretched out”. This leads to significant muscle imbalances that then put
unnecessary stress on the back. In all likelihood, their golf muscles have “shut
down” due to sitting for long periods. Effectively, the muscles that absorb force
and reduce load in a golf swing (that is, the lower and deep abdominals) are
relatively weak and aren't able to work together. And if your hips and shoulders
are tight, there is a greater chance of moving incorrectly.
In an idealized pelvic alignment the anterior superior iliac spines (ASIS) are in a
horizontal plane with the posterior superior iliac spines (PSIS) and on a vertical
plane with the pubic symphysis. The most common deviation seen in golfers is
excessive anterior tilt of the pelvis (PSIS significantly higher than the ASIS). A
study by Levine and whittle showed that excessive anterior tilt caused increased
lumbar lordosis. The common short/tight muscles in this mal-alignment are psoas
major, quadratus lumborum and hip adductors. The common long/inhibited
muscles are gluteus maximus, hamstrings, tranversus andominus and internal
obliques.
There has been research regarding the pelvis and its relationship to the lumbar
spine. An excessive anterior tilt of the pelvis causes compression of the posterior
vertebral bodies, which increases the posterior interdiscal pressure; especially at
L5-S1. It also creates shearing forces at L5-S1 and a likelihood of forward
slippage of L5 on S1. When the pelvis tilts forward, the lumbar vertebrae are
displaced anteriorly, thereby increasing lumbar lordosis. Increases in the
compressive forces of the posterior annuli and the tensile forces on the anterior
annuli in the lumbar spine adversely affect the diffusion of nutrients to the
posterior portion of the lumbar intervertebral disks and excessive compression
may be applied to the zygapophyseal joints. To compensate for the increased
anterior lumbar convexity, there is an increase in thoracic kyphosie and an anterior
convexity of the cervical spine to bring the head over the sacrum.
Research has shown that the pelvis can play a role in low back pain due to its
influence on the lumbar spinal curvature. The position of the pelvis has also been
shown to play a role in sacroiliac pain. Since the hamstrings attach to the ischial
tuberosities, they play an important role in extrinsic pelvic stability and the
lumbopelvic rhythm. The hamstrings can also play an important role in stability of
the sacroiliac joint due to the common attachment sites of both the hamstrings and
the sacrotuberous ligament on the ischial tuberosities. The long head of the biceps
femoris frequently attaches to the sacrotuberous ligament through a tendon. Force
of the biceps femoris can be transferred to the sacrotuberpus ligament. Since
increased tension of the sacrotuberous ligament decreases sacroiliac joint range of
motion, contraction of the biceps femoris can play a role in stabilization of the
sacroiliacjoint.
Specific spinal exercises were developed to target the local muscles of the
lumbar–pelvic region. The local muscle system includes deep muscles such as the
transverses abdominis and the lumbar multifidus that are attached to the lumbar
vertebrae and sacrum and are capable of directly controlling the lumbar segments.
By contrast, the global muscle system encompasses the larger and more superficial
muscles of the trunk that are more concernedwith producing and controlling trunk
movements (e.g., the external oblique and erector spinae muscles). Whereas
conventional exercises generally work to increase the strength of the global
muscles, the specific exercise approach aims to improve the dynamic stability role
of the local muscles in providing stiffness to the segments of the spine and pelvis
during functional postures and movements. The concept that has become the basis
of the specific exercise treatment techniques is the ability to cocontract the
transversus abdominis and the lumbar multifidus independently of the other larger
trunk muscles. This exercise is based on evidence of the stability roles of the
muscles as well as on evidence that the transverses abdominis functions
independently of the other global abdominal muscles. The active co-contraction of
these muscles is completed at a very low level of muscle activity and has been
variously described as forming a deep muscle corset or performing self bracing.
Progression of treatment has consisted, in principle, of increasing the patient’s
efficiency at performing this independent deep corset action while at the same time
minimizing the contribution of the global trunk muscles. These new specific spinal
exercises have already been shown to be effective for patients with acute
idiopathic LBP. The influence of this exercise approach on muscle size and
function as well as on recurrence of symptoms has been investigated.7,8
Individuals in the intervention group performed gentle coactivation of the
multifidus and transversus abdominis muscles with real-time ultrasound imaging
as feedback. There were significantly fewer recurrences in the intervention group
than in the control group.9,19 In addition, the specific exercises are effective in the
treatment of patients with LBP associated with a specific diagnosis. O’Sullivan et
al1 have demonstrated decreased pain and disability in patients with chronic LBP
who have a radiologically confirmed diagnosis of spondylolysis or
spondylolisthesis. The exercises are also proving beneficial in LBP conditions
arising from the pelvic region. The specific co-contraction of the transversus
abdominis and the multifidus is recommended on the basis of a biomechanical
model of the stability of the lumbosacral region.
6.2 Review of Literature
1. Casey Moeller et al in an electromyographical study of the muscle activity
during a posterior pelvic tilt concluded that the hamstrings (lateral hamstrings) are
active during a static posterior pelvic tilt in the standing position, as well as the
external abdominal oblique and the gluteus maximus. These muscles may be the
most active due to the mechanical advantage they have on the pelvis. Since the
hamstrings attach to the pelvis via the ischial tuberosity, they are capable of
pulling the posterior half of the pelvis inferiorly, producing a posterior pelvic tilt
during muscle contraction when the femur is fixed. The external abdominal
oblique attaches to the anterior half of the iliac crest, which provides a lever arm
for the muscle to pull the ASIS superiorly, producing a posterior pelvic tilt. The
gluteus maximus’s major function is to extend the thigh, and like the hamstrings,
when the femur is fixed the gluteus maximus is capable of pulling the posterior
half of the pelvis inferiorly and producing a posterior pelvic tilt.
2. M.Hossain and L.D.M.Nokes proposed that sacroiliac joint dysfunction can
result from malrecruitment of gluteus maximus motor units during weight bearing.
This results in compensatory biceps over activation. The resulting soft tissue strain
and joint instability may manifest itself in low back pain.
3. Hungerford et al. (2003) showed altered firing patterns of these muscles in SIJ
patients. Higher tension of the hamstrings will force the pelvis as a unit to rotate
backwards, leading to a flattening of the lumbar spine.
4. Van Wingerden et al. (2004) studied several muscles which could contribute to
compression of the pelvic joints and influence the stiffness characteristics. SIJ
stiffness was measured using DIV in six healthy women. SIJ stiffness was
measured both in a relaxed situation and during EMG recorded isometric voluntary
contractions. The biceps femoris, gluteus maximus, erector spinae, and
contralateral latissimus dorsi were included in this study whereas the deeper lying
muscles were not included. Pelvic stiffness significantly increased after activation
of the erector spinae, the biceps femoris and the gluteus maximus muscles. Based
on these data it is concluded that optimal function of the pelvic girdle during leg
loading is based on tailored force closure/compression of the SIJ due to activation
of multiple muscle slings. The study concludes that SIJ stiffness increased even
with slight muscle activity, supporting the notion that effective load transfer from
spine to legs is possible when muscle forces actively compress the SIJ preventing
shear.
5. Vleeming et al. [31] defined the posterior layer of the thoracolumbar fascia as a
mechanism of load transfer from the contralateral gluteus maximus (Fig. 3). This
load transfer is critical during rotation of the trunk, helping to stabilize the lower
lumbar spine and pelvis. This was demonstrated through cadaveric and
electromyelographic (EMG) studies [32]. The stretched tissue of the posterior
thoracolumbar fascia assists the muscles by generating an extensor influence, and
by storing elastic energy during lifting to improve muscular efficiency.
6. Sullivan et al. looked at the effect of different positions of the pelvis while
stretching the hamstrings. The results showed that if the pelvis was placed in an
anterior tilt, it permitted increased hamstring elongation and this was significantly
influential on the flexibility of the hamstrings during stretching exercises.13 They
found that the anterior pelvic tilt position was significantly more effective in
increasing hamstring muscle length than the posterior pelvic tilt position. Also,
there was no significant effect of the stretching method or interaction of pelvic
positions and stretching techniques.13 There appears to be a strong relationship
between the hamstring muscle group and pelvic positioning.
7. Hodges and Richardson from an experimental model concluded, individuals
with a history of low back pain show a delay in contraction of the transversus
abdominis muscle during a trunk disturbance leading to an inappropriate
stabilization pattern which causes recurrences. Spinal segmental stabilization
exercises were developed (Richardson and Jull) with the aim of correcting the
transversus abdominis contraction delay and also to recover the activation of
lumbar multifidus muscle. This motor control approach focuses on an isolated
cocontraction of such muscles while keeping the lumbar spine in
a neutral position (Richardson et al.).
8. Ferreira et al conducted a systematic review of randomized clinical trials which
demonstrated the efficacy of such exercises in relation to the chronic pain and
recurrences in patients with low back pain and pelvic pain.
9. Comerford et al defend the training of the global system of stabilization
muscles with the aim of correcting the movement impairment. This approach
focuses on correcting the movement patterns as well as inappropriate postures and
also the lumbopelvic imbalance through therapeutic exercises.
10. Richardson et al conducted a comparative study of tranversus abdominis
contraction to bracing action of all abdominal muscles in relation to sacroiliac joint
laxity. He concluded that the independent transversus abdominis contraction
decreased sacroiliac joint laxity (or rather increased sacroiliac joint stiffness) to a
significantly greater degree than the general abdominal exercise pattern.
11. O’Sullivan et al have demonstrated decreased pain and disability in patients
with chronic LBP who have a radiologically confirmed diagnosis of spondylolysis
or spondylolisthesis. The exercises are also proving beneficial in LBP conditions
arising from the pelvic region. The specific cocontraction of the transversus
abdominis and the multifidus is recommended on the basis of a biomechanical
model of the stability of the lumbosacral region.
12. Van Wingerden et al proposed that active contraction of the long head of BF is
considered to contribute towards force closure of the SIJ via force transmission
through the sacrotuberous ligament, synergistically with other muscle groups inserting
on structures of this joint.
13. A.Vleeming et al proposed that load application along the direction of
hamstring and gluteus maximus muscles significantly diminished ventral rotation
of the sacrum. The results imply that loading the sacrotuberous ligament restricts
nutation of the sacrum. Consequently, muscles which attach to the sacrotuberous
ligaments, such as the gluteus maximus, and in certain individuals the long head of
the biceps, can dynamically influence movement and stability of the sacroiliac
joints.
6.3 Objectives of the study
The main objective of the study is to find out the effect of muscle strengthening in
golfers with sacroiliac dysfunction specifically to determine the effects of
1. Strengthening of transversus abdominus in golfers with sacroiliac
dysfunction
2. Strengthening of gluteus maximus in golfers with sacroiliac dysfunction
3. Strengthening of biceps femoris in golfers with sacroiliac dysfunction
The study will formulate a rationale to support the proposition that sacroiliac pain
is a specific form of back pain.
7.
Materials and methods
7.1 Source of data
Data will be collected from golfers, who are referred to the outpatients
Physiotherapy department of Vikas College of Physiotherapy, Mangalore with
diagnosis of sacroiliac pain after obtaining informed consent.
7.2 Method of collection of data
Hypothesis:
There is significant effect of transversus abdominus, gluteus and biceps femoris
strengthening in golfers with sacroiliac dysfunction
Null Hypothesis:
There are no significant effect of transversus abdominus, gluteus and biceps
femoris strengthening in golfers with sacroiliac dysfunction
Research Design:
Pre – post Experimental design will be used in this study.
Significance of the study:
1. Results of the study may help health professionals to identify and use the best
way of treating patients with chronic sacroiliac joint pain in order to reduce their
functional limitation and impairments.
2. This study may also help professionals to plan adequate home exercise program
for golfers as a preventive measure.
3. This study will help professionals to understand the cause provoking the pain
and treat it suitably with static and dynamic exercises.
Methodology
15 Golfers who are diagnosed to have sacroiliac pain and fulfilling the following
inclusion and exclusion criteria will be selected for the study after obtaining
informed written consent.
Inclusion Criteria:
1. Clinically diagnosed patients of sacroiliac pain
2. History of pain in the sacroiliac joint (PSIS) for more than 2 months with or
without radiating down to the buttocks
3. On initial assessment should exhibit pain on passive anterior pelvic tilt
4. Tenderness on palpation on the PSIS
5. Age group 40 to 60 years
6. Both male and female subjects
7. Positive following special tests
Special tests:
1. Patrick’s (Faber) test
2. Gaenslen test
3. Iliac compression test
4. Yeoman’s test
5. Gillet test
6. Seated flexion test
Exclusion Criteria:
1. Patients with back or hip pain other than sacroiliac joint pain like disc prolapse,
spondyolisthesis, spondylosis, fracture or dislocation of the hip joint
2. Sacroiliac joint pain due to inflammatory disorders like spondyloarthropathies
3. Patients who have had local anaesthetic / corticosteroid injections in the last 3
months
4. Patients with history of spine surgery like stabilization, internal fixations, hip
replacement, arthroscopy, etc.
5. Patients using analgesics, anti-inflammatory, steroid medications, spinal braces
or corsets
6. Patients with cardiovascular instability and neuromuscular problems
9. Patients less than 40 years and more than 60 years of age
10. Fever
11. Neoplasms
12. Impaired sensations
13. Pregnancy
14. Acute TB
15. Acute inflammation before 72 hrs
Study Design
The selected subjects will be given 3 sessions per week for 2 weeks, isolated
contraction of the transversus abdominis muscle in supine and in co-contraction
with lumbar multifidus in prone as well as an isometric contraction exercise to
gluteus maximus in prone (Richardson and Jull, 1995; Sahrmann, 2002;
Richardson et al., 2004) ensuring trunk flexion via the hips kept a neutral lumbar
lordosis (Sahrmann, 2002). To partially restrict the lumbar flexion in the first 48
hours, tape was placed on the patient’s lower back only at the first visit
(Sahrmann, 2002). Mild resisted isotonic contractions of the hamstrings were also
given.
Evaluation: Before the beginning and immediately after exercises, all patients will
be evaluated in the following outcome measures.
1. Pain measured in a 10 cm Visual Analog scale. VAS is a 10 cm line with pain
descriptors marked “no pain” at 1 end and “the worst pain imaginable” at the
other. The patients will be asked to report their perceived pain level, both at rest
and on most painful movement, by marking the VAS with a perpendicular line.
2. Muscle power using Manual muscle testing (Oxford scale)
3. OSWESTRY functional ability scale
Statistical tests:
The following statistical tests will be used to analyze the collected data:
Paired t-test, unpaired t-test, Wilcoxan sign rank test and Manwhitney U test will
be used to analyze the data.
7.3 Nature of Investigations and Interventions:
The study requires non-invasive investigations and interventions to be conducted
on patients. They include physical examination like inspection, palpation, and
measurement of range of motion, MMT, special tests, etc. Treatment interventions
include bridging, static abdominal, gluteal and hamstring strengthening exercises.
7.4 Ethical clearance:
Ethical clearance has been obtained from the ethical committee of our institutions
to carry out the investigations and interventions on patients necessary for this
study.
8.
References:
1. Adams MA, Dolan P, Burton K, Bodguk N (2002) The biomechanics of back
pain. Edinburgh:Churchill Livingstone
2. A. Vleeming, J.P. Van Wingerden, C.J. Snijders, R. Stoeckart, T. Stijnen. Load
application to the sacrotuberous ligament; influences on sacroiliac joint mechanics.
Clinical Biomechanics, Volume 4, Issue 4, November 1989, Pages 204-209.
3. C.J. Snijders, A. Vleeming, R. Stoeckart. Clinical Biomechanics, Volume 8,
Issue 6, November 1993, Pages 285-294. Transfer of lumbosacral load to iliac
bones and legs: Part 1: Biomechanics of self-bracing of the sacroiliac joints and its
significance for treatment and exercise.
4. Broadhurst NA, Bond MJ (1998) Pain provocation tests for the assessment of
sacroiliac joint dysfunction. J Spinal Disord 11:341-345
5. Bakland O & JH Hansen (1984) The "axial sacroiliac joint". Anat Clin 6(1):2936.
6. Buyruk HM, Stam HJ, Snijders CJ, Vleeming A, Laméris JS, Holland WPJ
(1995a) The Use of Colour Doppler Imaging for the Assessment of Sacroiliac
Joint Stiffness: a Study on Embalmed Human Pelvises. Eur J Radiol 21:112-116
7. Fairbank JCT, Davies JB, Couper J, O`Brien JP (1980) The Oswestry Low Back
Pain Disability Questionnaire, Physiotherapy 66: 271-273
8. Greenman PE (1992) Sacroiliac dysfunction in the failed low back pain. In:
Vleeming A, Mooney V, Snijders C J, Dorman T (eds) First interdisciplinary
world congress on low back pain and its relation to the sacroiliac joint. San Diego,
CA, 5-6 November, 329-352
9. Hagen R (1974) Pelvic girdle relaxation from an orthopaedic point of view.
Acta Orthop Scand 45:550-563
10. Hodges PW, Kaigle Holm A, Holm S, Ekstrom L, Cresswell A, Hansson T,
Thorstensson A (2003) Intervertebral stiffness of the spine is increased by evoked
contraction of transversus abdominus and the diaphragm in in vivo porcine studies.
Spine 28:2594-2601
11. Mens JM, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ (1999) The active
straight leg raising test and mobility of the pelvic joints. Eur Spine J 8:468-473
12. Mens JMA, Stam HJ, Stoeckart R, Vleeming A, Snijders CJ (1992) Peripartum
pelvic pain: a report of the analysis of an inquiry among patients of a Dutch patient
society. In: Vleeming A, Mooney V, Snijders C J, Dorman T (eds) First
interdisciplinary world congress on low back pain and its relation to the sacroiliac
joint. San Diego, CA, 5–6 November, 521–533
13. Mooney V, Pozos R, Vleeming A, Gulick J, Swenski D (2001) Exercise
treatment for sacroiliac joint pain. Orthopedics , vol 24, no 1, 24:29-32
14. Panjabi MM (1992) The stabilizing system of the spine. Part I: Function,
dysfunction, adaptation, and enhancement. J Spinal Dis 5: 383-389
15. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J (2002) The
relationship between the transversus abdominus muscle, sacroiliac joint mechanics
and low back pain. Spine 27: 399-405
16. Van Wingerden J P , Vleeming A, Snijders C J, Stoeckart R (1993) A
functional-anatomical approach to the spine–pelvis mechanism: interaction
between the biceps femoris muscle and the sacrotuberous ligament. Eur Spine J
2:140-144
17. Van Wingerden J P, Vleeming A, Buyruk H M, Raissadat K (2004)
Stabilization of the Ssacroiliac joint in vivo: Verification of muscular contribution
to force closure of the pelvis. Eur Spine J 13: 199-205
18. Walker ML, Rosthein JM, Finucane SD. Lamb RL. Relationships between
lumbar lordosis, pelvic tilt, and abdominal muscle performance. Phys Ther. 1987;
67(4): 512-516.
19. Arnold GS. The Diagnosis and Treatment of Sacroiliac Joint. As cause of low
back pain –The Management of Pain in the Butt. Jacksonville Medicine 1995 ; 1-5.
20. Levine D, Whittle MW. The effects of pelvic movement on lumbar lordosis in
the standing position. J Orthop Sports Phys Ther. 1996; 24(3): 130-135 Wong TK,
Lee RY. Effects of low back pain on the relationship between the movements of
the lumbar spine and hip. Human Movement Science. 2004;23:21–34. [PubMed]
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1673. [PubMed
9.
Signature of the candidate
10.
Remarks of the Guide
11.
Name and Designation of
12.
:
11.1 Guide
: B A BOOMADEVI M.P.T.
Assoc Professor
11.2 Signature
:
11.3 Co-Guide
:
11.4 Signature
:
11.5 Head of the Department
: Prof. S. NATARAJAN M.P.T.
11.6 Signature
:
-
12.1 Remarks of the Chairman and Principal
12.2 Signature
: