Download (b) hypothesis

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1.
NAME OF THE CANDIDATE AND ROBY VARGHESE
ADDRESS
C\O C K SAMUEL
KARIMPIL HOUSE
KADAMANKULLAM PO
KALLOOPPARA
PATHANAMTHITTA DISTRICT
KERALA
2.
NAME OF THE INSTITUTION
3.
COURSE OF THE STUDY AND MASTER OF PHYSIOTHERAPY IN
SUBJECT
MUSCULOSKELETAL DISORDERS AND
SPORTS PHYSIOTHERAPY
4.
DATE OF ADMISSION TO THE
COURSE
5.
TITLE OF THE TOPIC:
KRUPANIDHI
COLLEGE
PHYSIOTHERAPY, BANGALORE
OF
20th JULY-2012
“ EFFECT OF RHYTHEMIC STABILIZATION OVER PASSIVE STRETCHING
ON INJURY PREVENTION IN BASKETBALL PLAYERS : A RANDOMIZED
CONTROLLED TRIAL ”
1
RESUME OF THE INTENDED WORK
6. INTRODUCTION
Basketball is a team sports,objective is to shoot a ball through a basket positioned to
score following a set of rules.Two teams of five players play on a marked rectangular
court with a basket at each width end.Basketball is one of the most popular and
widely viewed sports in the world.
According to a study of high school basketball players by the National Athletic
Trainers Association (NATA) :Approximately 42% of the injuries were to the
ankle/foot,far outnumbering other injured body categories such as hip/thigh(11%) and
knee (9%).Sprain were the most common type of injury (43%).59% of game-related
injuries occured during second half of the game.With modern basketballs fastpace
game come many oppertunities for injuries.It is estimated that more than 1.6 million
injuries are associated with basketball each year.The common injuries occuring in
basketball are ankle sprain,jammed finger,knee injuries,deep thigh bruises,facial cuts
and stress fractures commonly in foot and lower leg(tibia).[1]
Basketball injuries can be seperated into two general categories : overuse injuries and
traumatic injuries.Injuries caused by stressing an area over and over until it is
damaged and begins to hurt are described as overuse injuries.Common of them are
patellar
tendinitis
or
"jumpers
knee",Achilles
tendinitis
and
rotator
cuff
injuries.Traumatic injuries are those caused by sudden forcefull injury.Common ones
are jammed finger,muscle pull or tear,ankle or knee sprain,meniscal tear and ACL tear
injuries.
Injury prevention is mainly by warm up exercise followed by stretching exercises
which are usually a combination of active and static stretches.Key areas to stretch are
the muscles of the legs (including the buttocks) as well as the pectorals and shoulder
musculature.Strength and power are important in both basketball performance as well
2
as injury prevention.Due to explosive nature of the game ,plyometrics are often used
to improve performance.These are explosive drills using jumps and bounds often from
a height.Basketball is played in 12 minutes periods,throughout which a player must
perform repeated bouts of strenuous exercise with little rest in between.An excellent
aerobic(low intensity) base should be maintained during the offseason,which can be
developed during pre-season into aerobic fitness.This is done with short burst of
intense exercise are interspersed with rest periods.If a player is not fit for the sports
then fatigue kicks in and fatigue leads to injury.Players wear knee and elbow pads
which protects these areas from abrasions and bruising in the event of
fall.Taping ,bracing and low or high top basketball shoes are used especially by those
with previous ankle injuries and to prevent injuries.
The constant movement that occurs during basketball can help build muscle
endurance and stamina.This can improve ability to run,jump and shoot by
strengthening the muscles that we use when playing basketball.The major muscles of
use are core muscle group which include midsection,lowerback and hips.The upper
limb muscles like pectoral muscles,deltoid,arm muscles, neck muscles etc.Lower limb
muscles include hamstring ,quads and the calf which are very prominent for running
all around the court,bending,stabilizing the legs and jumping for the shot.
Rhythemic stabilization alters between isometric contraction of agonistic and
antagonistic pattern.The strength of the contraction is gradually increased as the range
of motion is progressively reduced during the entire sequence.Rhythmic stabilization
improves active and passive range of motion,increase holding power,increase stability
and balance,improves local circulation and aids later relaxation.[2]
The term rhythmic stabilization is commonly used to describe exercise that are
designed to develop stability in proximal muscle joints.These are forms of isometric
exercises designed to develop joint and postural stability.Rhythmic stabilization is a
form of isometric exercise in which manual resistance is applied to one side of a
3
proximal joint and then to the other as the patient holds a closed chain position to
facilitate a simultaneous isometric contraction of muscles on both sides of the
joint.Manual resistance can also be applied alternately to opposite sides of an
extrimity as a patient holds an isometric contraction in an open kinematic chain.When
using manually resisted isometric technique to develop stability.Manual contact
should be maintained all time as the isometric contraction are repeated.As a transition
is made from one muscle contraction to another ,no distinct relaxation phase or joint
movement should occur between the opposing contraction.[3]
In the manual passive stretching,another person or therapist moves the clients body
into the stretching positions.The therapists control the force,direction,speed and
duration of the stretch.To perform this type of stretching safely,the therapist must be
knowledgeable about of the physiology and kinesthetics of the involved
structures.The therapist must maintain close communication with the client and stay
within the clients pain and comfort tolerances.The client should remain as relaxed as
possible as the body part is moved through its range to the point of tightness and then
just beyond.The force used must be enough to put the tension on the structures but not
enough to cause pain or injury.The client should feel a sense of pulling or tightness in
the tissue that are being stretched,but not pain.Manual stretches are generally held for
15-30 seconds and repeated several time.[4]
Stretching is a passive technique used to increase the flexibility of musculoskeletal
tissues and hence aid movement and activity,improve performance and decrease the
incidence of sporting injuries.Stretching exercises are also necessary in the treament
of musculoskeletal sporting injuries to relieve pain and to restore or increase the range
of movement.The stretching program must be preceded by a warmup as this allows a
greater degree of flexibility to be gained.Passive stretching also needs to be used with
active exercises to increase and retain the joint range that has been attained.Normally
passive range of motion of a joint is greater than active range and a furthur small
range can be attained with passive over pressure.This extra range is lost in muscle
4
injuries and can be restored by passive stretching with over-pressure.The strength of
passive stretching is dependent on the diaganosis and assessment of the degree of the
injured tissue and the pain response.[5]
Stretching movements should be commenced early in the management of soft tissue
lesions within the limit of pain.In grade 1 and 2 ligament sprains early gentle passive
stretching should be used,governed by the pain response.Grade 1 injuries can be
stretched much more strongly than grade 2 injuries.[5]
6.1 NEED FOR THE STUDY
Basketball injuries occurs commonly due to its explosive movements.About 42% of
the injuries were occurring to the ankle/foot followed by hip/thigh and knee.For the
injuries,common treatments like heat ,cold,bandaging,rest
etc are given.Stretching
has also been used before and after the session of activities to improve exercise
performance and in reducing injuries.Rhythemic stabilization havn`t been used widely
as its effect on injury prevention in sports are studied limitedly.

However,the studies on passive stretching and rhythemic stabilization has
been done before but the combined effect of rhythemic stabilization and
passive stretching in injury prevention has not yet been studied.We conducted
a trial to determine whether giving a four month combined rhythemic
stabilization and passive stretching technique on basketball players will
reduce their injuries or not.

There have been no publications in western biomedical literature that shows
that the combined effect of rhythemic stabilization and passive stretching
technique reduces injuries in basketball players.We designed a clinical trial to
evaluate its effectiveness and outcome for baskeball players.
5

The study will focus on scientific and theoretical basis of using the combined
effect of rhythemic stabilization and passive stretching technique.
6.2 OBJECTIVE OF THE STUDY
(A) OBJECTIVES
1.To find out the effectiveness of passive stretching to prevent injuries in basketball
players.
2.To find out the effectiveness of rhythemic stabilization to prevent injuries in
basketball players.
3.To find out the combined effect of rhythemic stabilization and passive stretching in
preventing injuries in baskeball players.
(B) HYPOTHESIS
NULL HYPOTHESIS
There is no significant difference exists between combination of rhythmic
stabilization and passive stretching in prevention of injuries in basketball players.
EXPERIMENTAL HYPOTHESIS
There is significant difference exists between combination of rhythmic stabilization
and passive stretching in prevention of injuries in basketball players.
6
6.2 REVIEWS OF LITERATURE
1.Malliaropoulos N 2004
The results suggested that stretching is of great importance in treating muscle strain
injuries in that it improves the effectiveness of the rest rehabilitation program.[6]
2.Herbert R D,Gabriel M 2002
Stretching before or after exercising does not confer protecion from muscle
soreness.Stretching before exercising does not seem to confer a practically useful
reduction in the risk of injury,but the generality of the finding needs
testing.Insufficient research has been done with which to determine the effects of
stretching on sporting perfomance.[7]
3.McHugh M P 2008
Stretch induced strength was dependent on muscle length,such that strength was
decreased with the muscle group in a shortened position ,but not with the muscle
group in lengthened position.Strength loss and pain after eccentric exercise were
generally unaffected by prior stretching ,with the exception that stretching prevented
strength loss when assessed with the muscle in lengthened position.[8]
4.Park D Y 2011
Stretching or warmup alone and combined did not demonstrate statistically significant
differences.Stretching and warmup may have an equivalent effect on Achilles tendon
biomechanics.Prolonged and more intense protocols may be required for changes to
occur.[9]
5.Bello M 2011
Indoor athlets were randomly divided into two groups :a rhythemic stabilization(RS)
group(7athlets) and passive stretching(PS) group(7athlets).During four months,athlets
of both group had lower limb injuries.Although no significant difference was found
7
between RS and PS a trend suggests RS may be more effective than PS to prevent
muscular and ankle joint lesions in indoor soccer athlets,but more research is
needed.[10]
6.Andersen L L 2006
This study examined the level of knee joint neuromuscular activation during four
conventional therapeutic exercises (quadriceps femoris muscle setting,manual
lateralization of patella,rhythmic stabilization and the pelvic bridging exercise) and
four heavy resistance exercises(free weight squat with a barbell,horizontal seated leg
press,isolated knee extension wih a cam mechanism and isolated hamstring muscle
curl)in young untrained men who are healthy.Results indicate that heavy resistance
exercises should be included in rehabilitation program to induce sufficient level of
neuromuscular activation to stimulate muscle growth and strength.[11]
7.Herman K 2012
Effective implementation of practical neuromuscular warmup strategies can reduce
lower extremity injury incidence in young amateur female athletes and male and
female military recruits.This is typically a warmup strategy that includes
stretching,strengthening,balance exercise,sports-specific agility drills and landing
techniques applied consistently for longer than three consecutive months.Inorder to
optimize the strategies,the mechanisms for their effectiveness require further
evaluation.[12]
8. Thacker S B 2004
This study showed that there is not sufficient evidence to endorse or discontinue
routine stretching before or after exercise to prevent injury among competetive athlets
or recreational athlets.Furthur research especialy well-conducted randomized trial is
urgently needed to determine the proper role of stretching in sports.[13]
8
9.Coppack R J 2011
A simple set of lower limb stretching and strengthening exercise resulted in a
substantial and safe reduction in the incidence of anterior knee pain in a young
military population undertaking a physical conditioning program.Such exercises could
also be beneficial for preventing this common injury among nonmilitary participants
in recreational physical activity.[14]
10.Mc Nair P J 1996
Both jogging and static stretching exercises appear to be beneficial to individuals
participating in sports activity.[15]
7. MATERIALS AND METHODOLOGY
7.1 SOURCES OF DATA
A.POPULATION
Basketball players in Krupanidhi College and around Bangalore.
B.SAMPLE SIZE
45 subjects with age groups of 17-28 years satisfying the selection criteria will be
selected from the population and to be divided into three groups with 15 subjects in
each group.
7.2 METHOD OF COLLECTION OF DATA
7.2.1 A.SAMPLING TECHNIQUE
Convenient sampling
9
B.MEASUREMENT TOOL
Visual Analog Scale (VAS)
7.2.2 STUDY DESIGN
ANNOVA will be used.
7.3 SELECTION CRITERIA
A.INCLUSION CRITERIA
Inorder to participate in this study, subjects will have to fulfill following criteria:

Healthy individuals who play basketball.

Age groups: 17-28years.

Both male and female subjects.
B.EXCLUSION CRITERIA

Subjects over 28 years and below 17 years.

Uncooperative patients.

Subjects with any progressive health problem.
7.4 DURATION
Four months
7.5 MATERIALS USED FOR STUDY

Paper

Pen

Goniometer
10

Inchtape
7.6 PROCEDURE
All subjects who play basketball will be included in the study based on selection
criteria.The formal informed consent shall be obtained and signed by the subjects
themselves.
The subjects fulfilling the inclusions criteria will be randomly divided into three
groups-
Experimental Group 1: Passive Stretching alone(15 subjects)
Experimental Group 2: Rhythmic Stabilization alone(15 subjects)
Controlled Group 3: Combined Rhythemic stabilization and passive stretching(15
subjects).
Pre intervention measurements:
Outcome measures including Visual Analog Scale (VAS) was assessed at baseline and
4 months in three groups.
Intervention for Experimental Group 1:
Passive Stretching
Passive stretching is a technique in which the subject make no contribution to range of
motion, instead an external force is created by a manual force.The therapist controls
the force,direction,speed and duration of stretch.This is done with patient in a relaxed
position,The examiner holds the limb into movement.The subject doesn’t take part in
the stretching as the therapist does the action.The movement is done fully and an end
11
stretch is made within the pain limit and maintained for 15-20 seconds and repeated
two times at once.After a particular movement rest is given in between for 30
seconds.In the same way all the movements of the lower limb from hip
flexion,extension,abduction,adduction,knee flexion,extension,ankle dosiflexion and
plantar flexion are done.Passive stretching is done on every day before and after the
game.
For stretching the hip flexors,hip extension must be done.For this,patient in made
sidelying on the opposite side of the leg to be stretched with knee flexed and the leg to
be stretched kept straight and above the other leg.The therapist takes the leg to be
stretched to backward and extend with one hand and the other hand supports the back
from moving.The hip is taken in a pain free range then to an end stretch within the
pain limit of the patient.This position is maintained for 15-20 seconds and is repeated
2 times with 5 seconds rest in between.For stretching the hip extensors,the hip is to be
flexed.The patient is in supine lying.The therapist takes one leg to flexion with knees
flexed and with the other hand support the other thigh from moving.The hip is taken
to a pain free range and then to an end stretch within the pain limit of the patient.This
position is maintained for 15-20 seconds and is repeated 2 times with 5 seconds rest in
between.
For stretching the hip abductors,hip adduction must be done.For this,patient in made
supine lying.The therapist takes the other leg which is not been stretched to an
abducted position and is kept still with one hand and with the other hand hip
adduction is done to the muscle which needs the stretch with knees straight.The hip is
taken to a pain free range and to an end stretch within the pain limit of the patient.This
position is maintained for 15-20 seconds and is repeated 2 times with 5 seconds rest in
between.For stretching the hip adductors,the hip is to be abducted.The patient is in
supine lying.The therapist takes the leg to be stretched to abduction and with the other
hand support the other leg from moving keeping the knees straightThe hip is taken to
a pain free range and then to an end stretch within the pain limit of the patient.This
12
position is maintained for 15-20 seconds and is repeated 2 times with 5 seconds rest in
between.
For stretching the knee flexors,knee extension must be done.For this,patient in made
supinelying.The therapist takes the leg to knee extension from knee flexion with the
hip straight with one hand, and the other hand supports the hip from moving.Firstly
the knee flexors are taken to a pain free range then to an end stretch within the pain
limit of the patient.This position is maintained for 15-20 seconds and is repeated 2
times with 5 seconds rest in between.For stretching the knee extensors,the knee has to
be flexed.The patient is in side lying.The therapist takes
leg to flexion
from
extension and with the other hand support the hip from moving.The knee is taken to a
pain free range and then to an end stretch within the pain limit of the patient.This
position is maintained for 15-20 seconds and is repeated 2 times with 5 seconds rest in
between.
For stretching the ankle dorsiflexors,ankle plantarflexion must be done.For
this,patient in made supine lying or sitting.The therapist takes the foot to ankle
plantarflexion with one hand and the other hand supports the ankle joint of same leg
from moving.Firstly it is
taken to a pain free range then to an end stretch within the
pain limit of the patient.This position is maintained for 15-20 seconds and is repeated
2 times with 5 seconds rest in between.For stretching the knee plantarflexors,the ankle
is to be dorsiflexed.The patient is in supine lying or sitting.The therapist takes the leg
to dorsiflexion and with the other hand support the knee joint of same leg from
moving.It is taken to a pain free range and then to an end stretch within the pain limit
of the patient.This position is maintained for 15-20 seconds and is repeated 2 times
with 5 seconds rest in between.
13
Intervention for Experimental Group 2:
Rhythemic stabilization
Rhythemic stabilization involves alternate contraction of the agonist and the
antagonistic muscles that are resisted by the examiner to keep the muscles
isometrically stretched at their maximum.Each cycle of resisted contraction permit
gradual lengthening of the affected muscle group because of increased
relaxation
induced through reciprocal inhibition.As a transition is made from one muscle
contraction to another no distinct relaxation phase or joint movement should occur
between the opposing contraction of limbs.Rhythemic stabilization on hip
flexion,extension,abduction,adduction,knee flexion,extension and ankle dorsiflexion
and plantar flexion are done.Rh.Before starting the schedule deep breathing exercise
are initiated to attain relaxation.The stabilization exercise starts from the hip joint and
ends up in the ankle joint by repeating each rhythemic stabilization pattern exercise 5
times holding up for 30 seconds without rest in between for the agonist and
antagonistic muscle.This is done on both the lower limb.It is repeated four times a
week on alternate days in the first month ,then three times a week on alternate days in
the second month and two times a week for the third and fourth month following
passive stretching.
Patient in sidelying position.The therapist resist an isometric contraction of the hip
flexor group muscles (iliopsoas ,psoas major, psoas minor, illiacus, rectus femoris,
sartorius) by placing one hand over the anterior of thigh and avoiding compensatory
movements by supporting the hip with the other hand.The patient maintains the
positions of the part without trying to move.The resistance is increased slowly as the
patient builds a matching force for 30 seconds.When the patient is responding
fully,the therapist moves one hand to begin resisting the hip extensor muscles(gluteus
maximus,biceps femoris,semitendinosus,semimembranosus) by placing the hand over
the posterior of thigh and the other hand supporting the hip for stability.Neither the
therapist nor the patient relaxes as the resistance changes.The new resistance is build
14
up slowly.This is done without any interval at a time in between.This is repeated 5
times and then to other muscle groups.
Patient in supine lying position.The therapist resist an isometric contraction of the hip
abductor group muscles(gluteus minimus,tensor fascia lata,gluteus maximus,gluteus
medius) by placing one hand over the lateral part of thigh near to knee joint.The
patient maintains the positions of the part without trying to move.The resistance is
increased slowly as the patient builds a matching force for 30 seconds.When the
patient is responding fully,the therapist moves one hand to begin resisting the hip
adductor muscles(adductor magnus,brevis,minimus)by placing one hand over medial
aspect of thigh near knee joint.Neither the therapist nor the patient relaxes as the
resistance changes.The new resistance is build up slowly.This is done without any
interval at a time in between.This is repeated 5 times and then to another muscles.
Patient in high sitting with knee hanging at 90 degree and thigh supported
comfortably. The therapist resist an isometric contraction of the knee flexor group
muscles(hamstring group) by placing one hand over the posterior of tibia.and the
other on knee jointThe patient maintains the positions of the part without trying to
move.The resistance is increased slowly as the patient builds a matching force for 30
seconds.When the patient is responding fully,the therapist moves one hand to begin
resisting the knee extensor muscles(quadriceps group) by placing the hand over the
anterior of tibia and the other hand supporting the knee joint.Neither the therapist nor
the patient relaxes as the resistance changes.The new resistance is build up
slowly.This is done without any interval at a time in between.This is repeated 5 times
and then to other muscle groups.
Patient is sitting with legs hanging.The therapist resist an isometric contraction of the
ankle dorsiflexor group muscles(tibialis anterior,extensor hallucis longus,extensor
digitorum longus,peroneus tertius) by placing one hand over the anterior of foot and
the other hand supporting ankle joint or heel.The patient maintains the positions of the
15
part without trying to move.The resistance is increased slowly as the patient builds a
matching force for 30 seconds.When the patient is responding fully,the therapist
moves one hand to begin resisting the ankle plantarflexors muscles(calf group) by
placing the hand over the sole of foot and the other hand supporting the ankle joint or
foot.Neither the therapist nor the patient relaxes as the resistance changes.The new
resistance is build up slowly.This is done without any interval at a time in
between.This is repeated 5 times and then to other muscle groups.
Intervention for Controlled Group 3:
Rhythemic Stabilization
It involves alternate contraction of the agonist and the antagonistic muscles that are
resisted by the examiner to keep the muscles isometrically stretched at their
maximum.Relaxation phase is not there as the transmission is made from one muscle
to the another.Here rhythemic stabilization alone is done without any kind of passive
stretching.Rhythemic stabilization is always done following the stretching
technique.The
stabilization
of
hip
flexors,extensors,abductors,adductors,knee
flexors,extensors,ankle dorsiflexors and plantarflexors are done.The pattern of
exercise is such that an exercise session of 5 times,holding for 30 seconds without any
interval.This is repeated four times a week on alternate days in the first month ,then
three times a week on alternate days in the second month and two times a week for
the third and fourth month.The procedures are same as the above rhythemic
stabilization.
Passive Stretching
Passive stretching is a technique in which the person make no contribution to range of
motion, instead an external force is created by a manual force.The therapist controls
the force,direction,speed and duration of stretch.This is done with patient in a relaxed
position,The examiner holds the limb into movement.The subject doesn’t take part in
the stretching as the therapist does the action.The movement is done fully and an end
16
stretch is made within the pain limit and maintained for 15-20 seconds and repeated
two times at once.After a particular movement rest is given in between for 30
seconds.In the same way all the movements of the lower limb from hip
flexion,extension,abduction,adduction,knee flexion,extension,ankle dosiflexion and
plantar flexion are done.Passive stretching is done on every day before and after the
game.The procedure are same as the above passive stretching.
Post-intervention measurements:
Outcome measure including the Visual Analogue Scale (VAS) for pain is assessed at
baseline for the four months in three groups.
STATISTICAL ANALYSIS
7.7 Does the study require any investigation or intervention to be conducted on patients
or other humans or animals? If so please describe.
Yes,the study will be done on two groups and informed consent will be taken.
7.8 Has ethical clearance been obtained from the subject and the institution?
Yes, ethical clearance has been obtained from the institution.
8. LIST OF REFERENCES
1.Miyasaka K C,D M Daniel,M L Stone 1991 The incidence of knee ligament injuries
in the general population AMJ knee surgery.4:43-48
2.Brian Corrigan,G D Maitland Musculoskeletal and sports injuries pg 32-35
17
3.Caroyln Kisner,Cynn Allen Colby Therapeautic exercise foundation and technique
third edition pg 20,72,83,736
4.Mark F Beck Miladys theory and practice of therapeautic massage third edition
pg 615
5.Michael J Alter Science of flexibility third edition pg 170
6.Malliaropoulos Medical Science Sports Exercise 2004 may;36(5):756-59
7.Herbert R D British Medical Journal 2002 August 31;325(7362):468
8.McHugh Medical Science Sports Exercise 2008 Mar;40(3):566-73
9.Park D Y Foot Ankle International 2011 April;32(4):407-13
10.Bello M Journal for Body Work and Movement Therapy 2011 July;15(3):380-83
11.Anderson L LPhysical Therapy 2006 May;86(5):683-97
12.Herman K Bio Med Central Medicine 2012 July 19;10:75
13. Thacker S B Medical Science Sports Exercise 2004 March;36(3):371-78
14.Coppack R JAmerican Journal of Sports Medicine 2011 May;39(5):940-48
15.Mc Nair P J British Journal of Sports Medicine 1996 December; 30(4):313-17,
discussion 31
18
9
SIGNATURE OF CANDITATE
(ROBY VARGHESE)
10
REMARKS OF GUIDE
11.1
NAME AND DESIGNATION
11.2
SIGNATURE
11.3
CO-GUIDE (IF ANY)
11.4
SIGNATURE
11.5
HEAD OF THE DEPARTMENT
11.6
SIGNATURE
MR.RAJA RAM
ASSISTANT PROFESSOR MPT
(MUSCULOSKELETAL DISORDERS
SPORTS PHYSIOTHERAPY)
MR.MASIH MUHAMMAD KHAN
MPT (MUSKULOSKELETAL
DISORDERS AND SPORTS
PHYSIOTHERAPY)
12.1
REMARKS OF THE CHAIRMAN AND PRINCIPAL
12.1
SIGNATURE
19
AND