Download Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

Rajiv Gandhi University of Health Sciences,
Bangalore, Karnataka
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.
Name of the Candidate and
RAHUL RAJAGOPAL.K.P
Address
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,
BALLALBAGH
MANGALORE-1
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,
2.
Name of the Institution
BALLALBAGH.
MANGALORE- 575003
MASTER OF PHYSIOTHERAPY(MPT)
3.
Course of study and subject
2 YEARS DEGREE COURSE
(MUSCULOSKELATAL AND SPORTS)
12th MAY 2010
4.
Date of Admission to Course
5.
Title of the Topic “ EFFECTIVENESS OF MCCONNELL PATELLAR TAPING
AND MAITLAND’S MOBILISATION IN PATIENTS WITH PATELLOFEMORAL
OSTEOARTHRITIS- A COMPARATIVE STUDY ”
1
6.
Brief Resume of the intended work :
6.1 Need for the study
Osteoarthritis is a complex response of joint tissues to aging, genetic and environmental
factors, characterized by degeneration of cartilage, bony remodeling, and overgrowth of
bone.1
Osteoarthritis is the 2nd most common rheumatological disorder and is a non specific term
denoting an inflammatory, degenerative joint process without auto-immune component
which may affect the articular cartilage and the other soft tissue associated with the joint.
Osteoarthritis has been defined by the American College of Rheumatology as heterogeneous
group of conditions which lead to joint symptoms and signs associated with defective
integrity of the underlying bone the joint margins.Osteoarthritis is becoming increasingly
recognized in both developed and developing countries as a major cause of pain and
disability, with 44%-70% of people over the age of 55 years having radiological evidence.
The peak onset for development of osteoarthritis is between 50 years to 70 years of age.2
Osteoarthritis is a disorder of diathrodial joint characterized by pain and functional limitation,
radiological by joint space narrowing and histopathologically by alterations in cartilage
integrity.3
The exact mechanism of osteoarthritis is not known, but research has shown that it appears
due to imbalance between the synthesis ad degeneration of articular cartilage, its extracellular
matrix, and subchondral bone resulting in loss of integrity. The incidence of osteoarthritis
increase with age and also patients who are overweight as per WHO body mass index.2
The osteoarthritic changes are usually confined to one of the following three arbitrary
sites: retro patellar or patellofemoral compartment, medial tibiofemoral compartment and
2
lateral tibiofemoral compartment.
Patellofemoral joint comprises of the patella and trochlear groove. Medial condyle is larger
and more curved thereby projects further than the lateral condyle. An angle is accounted
between the two condyles namely the sulcus angle. It accommodates the patella during rest as
well as while performing flexion and extension activity of the knee joint. Patella functions to
enhance the lever arm of the quadriceps mechanism by increasing the distance between the
quadriceps muscle and axis of the knee joint. This adds to the mechanical advantage of the
knee joint.4
Patellofemoral joint osteoarthritis is one of the most common musculoskeletal disorders. It is
reported affect 15-30% active adult population 21-25% of the adolescent and greater than
25% among the athletic group. Incidence reported to be higher in females. It is consistently
reported with the activities such as ascending and descending stairs, squatting.5
The most widely accepted etiological factors that predispose to patellofemoral osteoarthritis
is excessive joint stress due to abnormal tracking of patella, altered mechanism of lower
extremity, increased Q angle and decreased strength of quadriceps muscle. Patellofemoral
pain in elderly patient is usually due to degenerative arthritis of the knee joint. Symptoms
presented in the patellofemoral osteoarthritis are pain around and anterior to patella, crepitus,
giving away of the kneeand episode of patellofemoral instability along with stiffness and
swelling.6
Osteoarthritis has a variable progression with some patients rapidly progressing to disability,
where as others may continue to have mild symptoms. Currently, osteoarthritis has no cure
but the disease can be palliated.7 Thus treated should be tailored to fit the individual patient,
clinical severity of the disease and requires intense and co-ordinated efforts of variety of
3
health professionals including physical therapist.
Physiotherapy is concerned with maximizing mobility and quality of life by applying the
appropriate treatment. Physiotherapy is directed towards the attainmentof posture, muscular
strength and alleviation of inflammation. The goals are attained by using various approaches
including manual therapy in form of patella mobilization prescription of foot orthosis, patella
taping, electrotherapy modalities, strengthening exercises and stretches of soft tissues.8
Taping is an effective technique and is widely used in a variety of musculoskeletal diagnosis
and conditions. Knee taping is one strategy recommended by American College of
Rheumatology.9 Taping is an effective tool for reminding the patient, by skin drag, not to
perform a specific movement which is contrary to the treatment of condition.
The use of tape is as a technique in general rehabilitation was popularized in the 1980s by
Jenny McConnell an Australian physiotherapist.10
Knee taping is one of the strategies recommended by American College of
Rheumatology, based on the theory of patellar maltracking. McConnell has devised a system
of treatment for patellofemoral osteoarthritis by taping the patella in medial and lateral
direction.11It also has been theorized that the tape allows the quadriceps muscle to function
more efficiently by altering the timing contraction between the vastus muscle. Research
found a significant reduction of pain (visual analogue scale ), improved loading response
with knee flexion in taped patients and concluded that the pain reduction allowed increased
quadriceps activity, and improved tolerance to patellofemoral joint reaction forces.12
Another treatment technique to reduce pain in knee osteoarthritis is manualtherapy which
consists of range of interventions, including hands on technique such as joint mobilization. It
4
is concept of musculoskeletal evaluation and treatment in physical therapy that applied the
principles of kinesiology, histology, neurophysiology and pathophysiology. The manual
therapy treatment were selected based on the presence of limitation in activity or passive joint
motions, such as passive movement techniques, joint mobilization and manipulations are
used to promote the well being of patients. Joint mobilizations are passive, skilled manual
therapy techniques applied to joint and related soft tissues at varying speed and amplitudes
using physiologic and accessory motions, for therapeutic purposes. Joint mobilization
techniques are used when patient dysfunction is due to joint stiffness or hypo mobility. Based
on the knowledge of anatomy of joint surfaces and the findings from joint examination, the
therapist applies specific passive movements to a joint either oscillatory or sustained.One of
the common techniques of joint mobilization is Maitland mobilization technique which helps
to increase range of motion and to reduce pain by using various grades of mobilization.13
Maitlandmobilization technique involves the application of passive and accessory oscillatory
movements to spinal, vertebral and peripheral joints to treat pain and stiffness of mechanical
nature. The techniques aim to restore motions of spin, glide and roll between joint surfaces
and are graded according to their amplitude.14
Short wave diathermy (SWD) is non-pharmacologic management approach that involves the
application of deep heat and this treatment has been reported to have a measurable effect of
for patients with knee osteoarthritis. Short wave diathermy frequencies approved by the
Federal Communication Commissions (FCC) ARE 13.56 MHZ (22 m wavelength), 27.12
MHZ (11 m) and 46.68 MHZ (7.5 m). The 27.12 MHZ band is most commonly used because
it is relatively easy to generate. Application of short wave diathermy to the involved tissues
may increase vascular circulation with change of tissue temperature, which directly results in
5
vascular dilatation, increase in pain threshold, decrease pain and swelling. Such vascular
improvement also decelerates the inflammatory process by increasing nutrition and oxygen
supply and by removing metabolic waste products.15
Therapeutic exercise is a systemic and planned performance of bodily movements designed
by physical therapists and is individualized to the unique needs of each patient. Knee
movements are important from the functional point of view and depend on normal anatomical
and physiological integrity of its components and surrounding structures such a muscles. A
variety of muscle programs can be effective in improving strength, endurance and function
without exacerbation of pain or disease activity.
Isometric quadriceps exercise is the one
which improves or maintains muscle strength. Quadriceps isometric exercise frequently used
in physiotherapy science to improve muscle tone, static endurance, and strength and prepare
joints for more vigorous activity.16
Both McConnell patellar taping and Maitland’s mobilization have been proved effective in
decreasing pain and disability in patient having patellofemoral osteoarthritis, but literature is
scare on comparison of these two techniques. Hence the present study aims to evaluate the
comparative effectiveness of McConnell patellar taping and Maitland’s mobilization in
patellofemoral osteoarthritis in aspect of pain relief and improvement in functional abilities.
Research Question
Which technique is more effective in pain relief and functional ability improvement in
patients with patellofemoral osteoarthritis- McConnell patellar taping or Maitland’s
mobilization?
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Null hypothesis
1) There is o no effect of McConnell patellar taping in patients with patellofemoral
osteoarthritis.
2) There is no effect of Maitland’s mobilization in patients with patellofemoral
osteoarthritis.
Alternate hypothesis
1) McConnell patellar taping is more effective than Maitland’s mobilization in patients with
patellofemoral osteoarthritis.
2)
Maitland’s mobilization is more effective than McConnell patellar taping in patients with
patellofemoral osteoarthritis.
6.2 Review of literature
Therapeutic knee taping was proved as an effective treatment technique when compared with
control group of patients with osteoarthritis, in a study conducted on 87 patients with
osteoarthritis symptoms.17
Studies done on the effect of corrective taping of the patella on 20 ( 10 men, 10 women)
subjects with patellofemoral pain has shown marked decrease in pain after the application of
the tape at 00 and 300 flexion.18
Randomized, single blind, cross over trial of 3 different types of taping ( medial, lateral or
neutral ) of knee joint on 14 patients with osteoarthritis of the knee having both clinical and
radiological evidence of patellofemoral compartment disease says that medial taping of
patella resulted in a 25% reduction in knee pain in just 4 days and was better than neutral and
lateral taping and is also an easy cost effective means of short term pain relief.19
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Comparative study of 18 healthy women ( mean age 22.28±2.02 yrs) regarding the
effectiveness of McConnell in maintaining the medial glide of the patella before and after
exercise concludes that McConnell medial glide taping will be effective in rehabilitation of
knee in which the intensity of exercise is less.20
A study done in a research unit using 52 healthy volunteers ( 27 women, 25 men, age 23.2±
4.6 yrs, body mass index, 23.3± 3.7 ) to evaluate the effect of patellar tape on knee joint
proprioception mentions about the studies that have shown the patellar taping helps to
decrease pain in patients with patellofemoral pain syndrome and in osteoarthritis.21
Study testing 29 mature able-bodied subjects to examine the immediate effect of patellar
taping with a standard force on the onset of VMO and VL activities before after muscle
fatigue has concluded that patellar taping does not enhance the temporal activation of VMO
in both fatigue and non-fatigue conditions on able-bodied subjects.22
Studies on the effect of patellar taping on knee kinetics of 14 women ( 24.4 ± 5.8 yrs ) with
unilateral patellofemoral pain syndrome reveals the patellar taping may improve the knee
extensor moment and power during weight bearing activities such as the lateral step-up
exercise and vertical jump compared with no tape ( Ernst GP, Kawaguchi J, et a, 1999 ).23
A study to examine the effect various patellar taping procedures on 30 women ( 27.3 ± 1.53 ),
half diagnosed with patellofemoral pain syndrome reveals that patellar taping can be useful in
patellofemoral pain syndrome rehabilitation.24
Therapeutic knee tape showed an immediate effect in decreasing pain when compared with
neutral knee tape for patients with osteoarthritis, in a study conducted on 18 subjects.25
Combined use of dynamic thermotherapy and taping is more effective treatment for
management of osteoarthritis knee with patellofemoral arthritis than only taping.26
8
Evidence from a well designed RCT support the efficacy of knee taping for the management
of pain and disability in patients with knee osteoarthritis. The therapeutic tape group reported
a greater reduction in pain on VAS pain score and showed benefits of therapeutic taping were
maintained three after stopping treatment.27
A randomized controlled trial conducted on 38 ambulatory care patients with anterior knee
pain showed that six sessions of manual therapy increase knee flexion and improve activity in
people with anterior knee pain.28
A randomized controlled clinical trial conducted on 83 patients with osteoarthritis of the
knee suggested that a combination of manual physical therapy and supervised exercises
yielded functional benefits for patients with osteoarthritis of the knee and may delay or
prevent the need for surgical intervention.29
A randomized controlled trial conducted on 43 patients with a chronic non-progressive
history of osteoarthritic knee pain aged between 47 and 70 suggested that a short term
manual therapy knee protocol significantly reduced pain suffered by participants with
osteoarthritic knee pain and resulted in improvements in self reported knee function
immediately after the end two weeks treatment period.30
A double blind, controlled study employed to 38 subjects with mild to moderate knee pain
provided experimental evidence that accessory mobilization of an osteoarthritic knee joint
immediately produces both local and widespread hypoalgesic effects. Therefore it is an
effective technique for reducing pain.31
A randomized comparison of supervised clinical exercise and manual therapy procedures
versus home exercise program conducted on 134 patients with osteoarthritis knee indicated
that the application of manual therapy and supervised exercises yielded greater symptomatic
9
relief.32
Journal article on analysis of subjective knee complaints using VAS on 117
conservative patients who had undergone knee surgery and 65 patients with knee disorder has
shown that VAS is valid and comparable to other established subjective evaluation bringing
greater sensitivity and statistical power to data collection and analysis. It is also removed bias
from examiner questioning and has given higher patient affinity.33
A validation study shown that WOMAC has got greater reliability, validity, and
responsiveness than the other functional scales.34
6.3 Objectives of the study
1) To evaluate the effectiveness of McConnell patellar taping in patients with patellofemoral
osteoarthritis.
2) To evaluate the effectiveness of Maitland’s mobilization in patients with patellofemoral
osteoarthritis.
3) To compare the effectiveness of McConnell patellar taping and Maitland’s mobilization in
patients with patellofemoral osteoarthritis.
Materials and methods :
7.1 Source of data
1) Physiotherapy out patient unit of Shree devi college of physiotherapy Mangalore.
2) Wenlock district government hospital Mangalore.
7.2 Method of collection of data
Data will be collected from the patients those who are reporting in the OPD’s of Shree devi
college of physiotherapy and Wenlock districtgovernment hospital in the span of three
10
months.
Inclusion Criteria:
1) Radiographic evidence of patellofemoral osteoarthritis.
2) Both men and women > 40 years of age.
3) Anterior or retro-patellar knee pain aggravated by at least two activities that load the
patellofemoral joint like stair climbing, squatting and/or rising from sitting.
4) Average knee pain ≥ 3 on visual analogue scale.
5) Subjects with both unilateral and bilateral knee osteoarthritis.
6) Subjects who can understand the study procedure.
7) Subjects who are willing to participate in the study.
Exclusion criteria:
1) Concomitant pain from other knee structures, hip or lumbar spine.
2) Acute exacerbation.
3) Traumatic injury to the knee joint within 6 months of study.
4) Any recent surgical intervention to the knee joint.
5) Intra-articular steroid injection (previous 6 months).
6) Systemic arthritic condition.
7) Severe medical condition precluding safe testing or past allergic tape reaction.
8) Subjects with mental disorders.
9) Peripheral vascular disorders.
10) Tumors / malignancies.
11) Metallic implants in the lower limbs.
12) Impaired thermal sensation.
11
Study Design:
Experimental study design (randomized clinical trial).
Sampling :
Total of 40 participants of which 20 will be allocated to Group A and 20 to Group B.
Statistical Test(Statistical Analysis):
Students paired’ t’ test, Chi-square test, Unpaired‘t’ test.
Sample size:
The study sample consists of 40 participants.
Study duration:
The total duration of the study is three months.
Outcome Measure
1) visual Analogue Scale:
2) Western Ontario and McMaster University Osteoarthritis Index ( WOMAC ):
METHODOLOGY:
This study is to be conducted on the patients with patellofemoral osteoarthritis who are going
to report in the OPD of Shree devi college of physiotherapy and Wenlock district government
hospital. They will be screened clinically by Patellar grind (scrape) test and Waldron’s test.
By considering inclusion and exclusion criteria select 40 patients who are willing to
participate in this study. Collect demographic data. Initial evaluation of pain intensity is to be
done using Visual analogue scale (VAS) and pain, stiffness, function outcome is to be scored
using Western Ontario and McMaster University Osteoarthritis Index (WOMAC) as a preinterventional outcome measures. Participants will divide into 2 groups- Group A and Group
B, contain 20 participants each. Group A will receive Short wave diathermy + McConnell
12
patellar taping + supervised exercises and Group B Short wave diathermy + Maitland’s
mobilization + supervised exercises. Both groups will receive treatment for 2 weeks
(14days). The post interventional response will be recorded on the 14th day of treatment in the
form of VAS and WOMAC. The outcome measures of pre and post treatment will be
subjected to statistical analysis for significance.
TOOLS USED:
1) Hypo-allergic micropore tape
2) Adhesive Leukotape.
3) Couch
4) Turkish towel
5) Measuring tape
11) Short wave diathermy
7.3
Does the study require any investigations or interventions to be conducted on
patients or other humans or animals? If so, please describe briefly.
No.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes.
13
List of References:
1) Nancy E.Lane, Daniel J Wallace: All about osteoarthritis: The definitive resource for
arthritis patients; 2002.
2) Carol David, Jill Lloyd, Chadwick A. Rheumatologicalphyther. Mosby 1999: 83-95 pp.
3) GoidmanAusiello. Cecil textbook of medicine. Elseviers 2004; 2nd edition vol.2: 16981700.
4) Dyes SF, Companga Pinto D, Dye C, Shefflett S, Eiman T. Soft tissue anatomy anterior to
human patella. J Bone Joint surgA m 2003; 85: 1012-7.
5) Naslund J, Nusland UB, OnderingS, Lundeberg T. Comparison of symptoms and clinical
findings in subgroups of individuals with patellofemoral pain. Physiotherapy and practice
2006; 22(3); 105-18.
6) Cibulka MT, ThrelkeldJ.Walkens patella femoral pain and asymmetrical Hip Rotations
2005; 85(11):1201-7.
7) Hochberg, M.C; Altman R.D; Brandt K.D:Guidelines for the medical management of OA.
Part II: Osteoarthritis of the knee. Arthritis and rheumatology 1995; 38: 1541-44.
8) Crossley K, Bennell K, Green S, Cowman S, McConnell J. Physical therapy for
patellofemoral pain a randomized, double blinded placebo control trial. American Journal of
Sports Medicine 2002; 30(6): 857-65
9) American College of Rheumatology subcommittee on Osteoarthritis Guidelines.
Recommendations for the medical management of osteoarthritis of hip and knee. Arthritis
14
and Rheumatism 2000; 43(9): 1905-15.
10) Crossley K, Cowman SM, Bennell KL, McConnell J: Patellar taping: Is clinical success
supported scientific evidence? Manual therapy 2000; 5(3):142-150.
11) G Kelly Fitzgerald and CarolOatis. Role of physical therapy in management of knee
osteoarthritis. Current Opinion in Rheumatology, 2004; 16:143-147.
12) Powers CM, Landel R, Sosnick T, et al: The effect of patellar taping on stride
characteristics and joint motion in subjects with patellofemoral pain. Journal of Orthopedic
Physical Therapy 1997; 26:286-291.
13) Deyle G D et al. Effectiveness of manual physical therapy and exercise in osteoarthritis
off the knee. A randomized control trial. Ann Intern Med, American Academy of Family
physician 2000; 132: 173-81.
14) G.D.Maitland. Peripheral manipulation, 3rdedition; 2003:250-55. Butter worthHeinemann.
15) Klotis LC, Ziskir MC: Diathermy and pulsed electromagnetic fields. In Micholovitz SL:
Thermal agents in rehabilitation. Philadelphia, F.A. Davis company 1986; 2ndED:170-197.
16) Guide to physical therapist practice. American P Therapy Association. Physical therapy
2001; 81(1):9-746.
17) Hinman RS, Crossley KM, McConnell J, Bennell KL. Efficacy of knee tape in the
management of osteoarthritis of the knee: Blinded randomized controlled trial. BMJ.2003 jul
19; 327(7407):135.
15
18) L Herrington, CJ Payton. Effects of corrective Taping of the patella on patients with
patellofemoral pain. Physiotherapy. November 1997, 83(11): 566-571.
19) Cushnaghan J, McCarthy C, Dieppe P. Tapping the patella medially: a new treatment for
osteoarthritis of the knee joint? BMJ. 1994 Mar 19; 308(6931):753-5.
20) Ronald P. Pfeiffer, Mark DeBeliso, Lorrie Kelley, Bobbie Irmischer, Chad Harris.
Kinematic MRI Assessment of McConnell Taping before after exercise. The American
Journal of Sports Medicine 2004, 32:621-628.
21) Michael J. Callaghan, James Selfe, Pam J. Bagley and Jacqueline A. Oldham. The effects
of patellar taping on knee joint proprioception. J Athl Train. 2002 January- March; 37(1):1924.
22) Ng GY. Patellar taping does not affect the onset of activities of vastusmedialisobliques
and vastuslateralis before and after muscle fatigue. Am J phys Med Rehabil.2005 Feb; 84(2):
106-11.
23) Ernst GP, Kawaguchi J, Saliba E. Effect of patellar taping on knee kinetics of patients
with patellofemoral pain syndrome. J Orthop Sports PhysTher. 1999 Nov; 29(11):661-7.
24) Christou EA. Patellar taping increases vastusmedialis oblique activity in the presence of
patellofemoral pain. J Electromyography Kinesiol. 2004 Aug; 14(4):495-504.
25) Hinman RS, Bennell KL, Crossly KM, McConnell J. Immediate effects of adhesive tape
on pain and disability in individuals with knee osteoarthritis, Rheumatology, 2003 Jul;
42(7):865-9.
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26) Manjusha Vagal. Medial taping of patella with dynamic thermotherapy- A combined
treatment approach for osteoarthritis of knee. The Indian Journal of Occupational Therapy:
Augest-November’04; Vol. XXXVI (II):31-36.
27) Caroline Brand, BhaskerAmatya, Toni Tosti. Osteoarthritis management: summary of
literature review. May 2006:1-40.
28) Vav den Dolder and Roberts. Manual therapy for anterior knee pain. Australian Journal
of Physiotherapy: 2006; 261-264.
29) Deyle GD, Hendrson NE, Matekel RL, Ryder MG, Garber MB, Allison SC.
Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: A
randomized controlled trial. Ann Intern Med 2000.
30) Pollard H, Ward G, Hoskins W, Hardy K. The effect of manual therapy knee protocol on
osteoarthritic knee pain: A randomized controlled trial. The Journal of the Canadian
Chiropractic Association; 2008 December.
31) Penny Mossa, Kathleen Slukah, Anthony Wrigtha. The initial effect of knee joint
mobilization on osteoarthritic hyperalgesia: International Journal of Musculoskeletal
Therapy; September 2004.
32) Deyle GD, Allison SC, Matekel RL, Stang JM. Physical therapy treatment effectiveness
for osteoarthritis of the knee; A randomized comparison of supervised clinical exercise and
manual therapy procedure versus a home exercise program: PhysTher, 2005 dec; 85(12):
1301-17.
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33) F.Flandry, JP Hunt,GC Terry and JC Hughston. Analysis of subjective knee complaints
using visual analogue scale. American Journal of Sports Medicine, 1991,19(2):112-118.
34) Bellamy N, Buchanan WW, Godsmith CH, Cambell J, Stitt JW. Validation study of
WOMAC: A health status instrument for measuring clinically important patient relevant
outcomes to anti rheumatic drug therapy in patients with osteoarthritis of hip and knee.
Journal of rheumatology 1988;15:1833-1840.
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9.
Signature of the Candidate
10.
Remark of the Guide
11.
Name and Designation of
DR. HARIPRIYA. S
(In Block Letters)
ASST. PROFESSOR
11.1 Guide
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MANGALORE-03.
11.2 Signature
11.3 Co-guide
DR. SUKUMAR. S
ASST. PROFESSOR
11.4 Signature
11.5 Head of Department
DR. VIJAY. P
PRINCIPAL,
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MANGALORE-03.
11.6 Signature
12.
12.1 Remark of the
Chairman And Principal
12.2 Signature
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