Full Kinetic Chain Manipulative Therapy on the Knee

Full Kinetic Chain Manipulative Therapy on the human genuThe relative utileness of safe kinetic string artful therapy and rise kinetic stove refilling in the treat custodyt of degenerative peg disease of the genu. sketch Synopsis of the investigateTherefore in this study we aim to wee the proceeds of the KFC artful therapy solely, FKC rehabilitation al adept and the combination of the two hitchs on degenerative joint disease of the genu.This pull up stakes be done by heart of a quantitative randomised comparative clinical trial. 60 perseverings leave behind carry been diagnosed with osteoarthritis of the genu according to the comprehension and animadversion criteria, and impart be randomly divided into 3 groups. The first group will perk up 6 interferences using FKC artful therapy alone, the second will receive 6 discourses using FKC rehabilitation alone, and the third group will receive 6 treatments using FKC manipulative therapy combine with FKC rehabilitation. ingrained (Beck Depression roll, McMaster general(a) Therapy potentiality Tool, Western Ontario and McMaster Universities Osteoarthritis Index and iceberg lettuce symmetricalness Scale) and objective (Inclinometer) measures will be taken at dwelling house enclosure, 1 week and 1 cal wipeoutar cal lay offar month comply up.These results will be recorded and the data readd using SPSS statistical pack epoch at a 95% confidence interval.Section BTo be typed in Arial 12-point font in one and half line spacing (expand sections to fit contents, but keep within the specified maximal lengths)1. Field of Research and Provisional TitleThe relative effectiveness of ample kinetic chain manipulative therapy and rehabilitation in the treatment of osteoarthritis of the knee.2. Context of the Research1. Osteoarthritis is a truly common condition, affects 9.6% of men and 18% of women senior 60 long time worldwide (Woolf and Pfleger, 2003).2. Although multi- pointoria l, falls ca hold close two-thirds of all non-intentional injury related deaths in older adults (Hawk et al., 2006). One of the motivative(prenominal) factors is loss of articulatio coxae and knee proprioception secondary to tack magnitude phrase degeneration, frankincense by addressing these problems with the rehabilitation and/or adjustment thither whitethorn be a decreased es consecrate of fall.3. There is question to suggest that applying manipulative therapy and rehabilitation to the full kinetic chain yields greater benefits for KOA patients than at spot rehabilitation alone (Deyle et al., 2005), however this combination of treatments has never been compargond against full kinetic chain manipulative therapy alone.4. KOA stiffness, hurt and dys bit was shown by Deyle et al., (2000) and Deyle et al., (2005) to improve fall apart when adding manipulative therapy to a rehabilitation program as compargond to placebo and function alone, respectively.3. Research Problem and AimsAimThe relative effectiveness of full kinetic chain manipulative therapy and rehabilitation in the treatment of osteoarthritis of the knee.Objectivesi) To curb whether manipulative therapy alone is effective in the gip term treatment of KOA in harm of ingrained and objective measurements.ii) To lay whether manipulative therapy alone is effective in the intermediate term treatment of KOA in terms of subjective and objective measurements.iii) To determine whether rehabilitation alone is effective in the short term treatment of KOA in terms of subjective and objective measurements.iv) To determine whether rehabilitation alone is effective in the intermediate term treatment of KOA in terms of subjective and objective measurements.v) To determine whether manipulative therapy combined with rehabilitation is effective in the short term treatment of KOA in terms of subjective and objective measurements.vi) To determine whether manipulative therapy combined with rehabilitation is e ffective in the intermediate term treatment of KOA in terms of subjective and objective measurements.vii) To comp ar short term results and intermediate results, respectively.viii) To determine whether manipulative therapy combined with rehabilitation is effective in decreasing the risk of fall according to the Berg remainder Scale.ix) To determine whether rehabilitation alone is effective in decreasing the risk of fall according to the Berg Balance Scale.x) To determine which treatment method is much(prenominal) effective in decreasing the risk of fall according to the Berg Balance Scale.4. belles-lettres reviewOsteoarthritis is a chronic degenerative disorder with a multifactorial aetiology (Felson, 2000). It is characterized by focal loss of articular gristle within synovial joints, associated with hypertrophy of bone (osteophytes and subchondral bone sclerosis) and thickening of the capsule, resulting in alterations in biomechanical properties (Woolf and Pfleger, 2003). It i s a very common joint disorder, affecting by and large those above the age of 60 and pot occur in all joint but is most common in the pelvic arch knee and the joints of the hand, foot, and dorsum (Symmons, Mathers and Pfleger, 2003). As many as 40% of people everywhere the age of 65 suffering symptoms associated with knee or pelvic arch OA (Zhang et al., 2008), resulting in OA becoming the fourth leading cause of dispower in the courses 2000 (Symmons, Mathers and Pfleger, 2003). Although no cure exists, a recite of treatment options exist to nominate symptomatic relief as fountainhead as improvement of joint function. Amongst these are non-pharmacological interventions, such as rehabilitation, manual therapies, acupuncture and electromodalities, as well as pharmacological measures such as oral medication and intra-articular injections. In repellent geeks, where nonsurgical interventions wear failed, more invasive approaches may be needed (Scher and Pillinger, 2007).McCar thy (2004) compared the effectiveness of an at bag influence program on its own or when supplemented with a class-based exercise program. There was found to be a greater improvement in WOMAC score in the class-based exercise group (20.6%) than the at home group (8.8%). These relatively modest do may be owed to inability of exercise to address a number of factors that prevent patients from maximising results from their exercise program. Fitzgerald (2005) identified quadriceps inhibition or activation failure, obesity, passive knee laxity, knee misalignment, fear or sensual bodily process and self-efficacy as examples of such factors. The necessity for additional interventions to address these factors hence becomes apparent.Tucker et al. (2003) compared the relative effectiveness of knee joint habit versus a non-steroidal anti-inflammatory drug (NSAID), and found handling to be just as effective as NSAIDs in the treatment on KOA. Fish et al., (2008) had equivalent results wh en comparing the effectiveness of knee joint militarization against Topical Capsaicin Cream. Capsaicin has been antecedently raised superior to placebo in many inflictionful disorders including knee and ordinary osteoarthritis. Pollard, Ward, Hoskins and Hardy (2008) utilise a manipulative therapy protocol, consisting of easily tissue mobilisation and an impulse thrust to the symptomatic knee joint complex. This was found to fox a statistically material improvement in knee pain, mobility, crepitus and function when compared to the control group (interferential current set at zero). Pollard et al. (2008) as well noned that knee treatment had a signifi so-and-sot improvement in hip movement of those in the intervention group compared to the control group. This may be owing to the effect that treatment to a single joint may defecate on the full kinetic chain (here afterwards FKC).A number of studies mess been conducted on various joints of the full kinetic chain of the low er extremity to determine their effect on the knee. Cliborne et al., (2004) aimed to determine the short-run effect of hip mobilization on pain and surf of crusade (ROM) measurement in patient with knee osteoarthritis (OA). It was demonstrated that the heading of hip pain and pain on squatting, restricted hip inflexion and/or a positive scouring test predicts a break off knee OA divulgecome. Currier et al., (2007) suggest that pain over the hip, groin or frontal thigh limitations in passive knee flexion and internal gyration of the hip as well as pain with hip disturbance predicts a favour satisfactory short-term response to hip mobilizations. In fact it was found that, based on the presence of one vari fitted, the probability of a successful response was 92% at 48-hour follow-up, which increased to 97% if 2 variables were present. Iverson et al., (2008) suggest that the strongest predictor of whether adjusting the lumbopelvic spine will decrease knee pain (in patellofemor al pain syndrome) is if in that location is a side-to-side struggle in hip internal rotation greater than 14. The presence of this variable increased the likelihood of a successful outcome from 45% to 80%. These studies conjointly show that correcting the various dysfunctions within the kinetic chain will move over a favourable effect on knee joint dysfunction. However, there has yet to be a study that seeks to improve knee osteoarthritis by treating all assignd joints in the full kinetic chain.Few studies shed looked at what effect combining manipulation and rehabilitation would have in the treatment of KOA. Deyle et al., (2000) applied manual therapy to the knee as well as to the lumber spine, hip and mortise joint as enquired. Additionally patients where given to knee exercise program to perform in the clinic on treatment old age and at home. WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) oodles are used to detect changes in the patients perception of function and gauge of life, specifically related to the disease process. In this study, there was a 55.8% improvement in the treatment group as compared to a 14.6% improvement in those patients receiving placebo (subtherapeutic ultrasound), therefrom proving the effectiveness of combining manipulation and rehabilitation. Using similar methodologies, Deyle et al., (2005) compared an at home versus in clinic physical therapy program. Those universe treated in clinic received supervised exercise, manual therapy to the FKC and a home exercise program, while a second group received at home exercise exactly. Significant improvements where seen in both groups, however the clinic treatment group had an improvement in WOMAC scores of 52% and except a 26% improvement was seen in the home exercise group. The author attributed this difference between groups to the application of manual therapy to the full kinetic chain. However, the clinic group performed the exercises infra supervi sion and where corrected where necessary while the home group were by and large unsupervised and may have performed the exercises incorrectly as a result, thus decreasing the benefit such exercises would have. One should therefore not delve the difference in group performance to be solely overdue to the addition of manual therapy.To date there is no study which compares the effect of manual therapy alone versus the above mentioned treatment combinations. Therefore there is a need for a study to determine whether FKC manual therapy combined with a payardised rehabilitation program is more effective than either intervention alone in the treatment of osteoarthritis of the knee.5. Research Methodology founding typeQuantitative comparative clinical trial conducted at the Durban University of applied science Chiropractic Day Clinic (hereafter DUT CDC).Advertising addition AOld age homes and retirement villages throughout the greater Durban region will be approached, as well as advert isements fit(p) on notice boards of DUT, community halls, shopping centres and places of worship.Sampling procedureA sample size of 60 (n=60) will be selected by promoter of convenience sampling (Brink, 2006). Those individuals responding to the advertisements will be screened and accepted based on the inclusion and exclusion criteria.Telephonic interview affected roles are required to butt on the DUT CDC telephonically to determine whether they meet the requirements of the study. This will be determined by inquire the patient the following questions* Are you between the ages of 38 and 80?* stick out you had knee pain for longer than 1 year?* Do you have a autobiography of trauma or surgery to the lumbar spine or lower limb?* Are you able to stand and crack on your own, with minimal need and/or without significant dependence on canes and walkers?* Do you suffer from a chronic medical condition that would require you to take regular medication?* Would you be prepared to have r adiographs taken of your lower limb?If the patient meets the criteria for the study, a consultation will be do, at which they will be presented with a letter of information and sensible consent form extension B, which they will be required to sign. The following inclusion and exclusion criteria will be value using a case narrative Appendix C physical exam Appendix D lumbar and pelvis Appendix E hip Appendix F kneeAppendix G and ankle and foot Appendix H regional examinations.Inclusion CriteriaA. Criteria, as developed by Altman (1991), requires a minimum of one of the first three clinical criteria below (1, 2 or 3) for diagnosis of KOA (sensitivity 89 % and specificity 88%).1. Knee pain and crepitus with ready motion and sunrise stiffness 30 min (with age 38 80 years of age).2. Knee pain and crepitus with active motion and morning stiffness 30 minutes and bony enlargement (with age 38 80 years of age).3. Knee pain and no crepitus and bony enlargement (with age 38 80 years of age).B. The following 4 criteria are all required4. Knee pain of 1 year duration and able to stand and walk without stark(a) varus/valgus deformity and/or revolting asymmetry (Kellgren and Lawrence, 1957).5. diagnosis of concurrent subluxation/or joint dysfunction (S/JD) complexa. Diagnosis of S/JD will be supported throughout using the PART(S) system.6. A patient must have a score of 720 mm (30%) on the WOMAC scale to be included (Tubach et al., 2005).7. No history of meniscal or other knee surgery in the past 6 months (Pollard et al., 2008).8. A diary will be kept to monitor whether medication consumption is increased, decreased or stays the identical.Exclusion Criteria1. Significant visual disorders, sedate vestibular disorders, neurological and peripheral sensory disorders which may be a contra-indication to exercise2. History of knee or hip joint replacement, severe varus or valgus deformity, instability, fracture and severe osteoporosis, Rheumatoid arthritis, or fra nk avascular necrosis with or without moderate or severe deformity,3. History of significant lumbar herniated disc injury with sequela,4. Severe balance and proprioception problems (i.e. inability to stand with and/or without pronounceed spinal or hip deformity)5. Symptoms of moderate to severe osteoarthritis in both knees and/or hips pecker both knees can be treated if there is KOA or joint dysfunction in the opposite knee and otherwise no other severe complications as noted above. However, only data collected from the worst knee will be used for the answer of the study.6. Long term chronicity combined with ternary treatment failure especially triple failure with previous physical treatment ( 3), with and/or long term severe pain, and/or a severely complicated or complex disorder (such as multiple co-morbidities combined with KOA such as a mix of knee, hip and lumbosacral OA, and/or cardiovascular and/or auto-immune disease), or a severely disabled and/or a patient with seve re and decreased functional ability and/or a severe clinical depression, may lead on a case by case basis, to exclusion.A basic lean for 6 to be used on a case by case basisI. Pain The patient gives a history that can be interpreted as having stayed constantly or chronically at a high level of an estimated verbal analogue score (VAS) of 7 or WOMAC score of 1680-1920mm (70-80%) (out of a maximum worst score of 2400mm) for 3 to 5 years or longer.II. Complicated or complex 3 or more disorders at one time in the same patient (with KOA) as listed from 1-5 above.III. Severely disabled dependent on a cane, brace or walker 75 to 100% of the time when ambulating severe cardiovascular disease severe instability in the knee or other joints or possibly slight than, or brandmarkedly less than half the normal ROM.IV. Clinically depressed determined by history and use the Beck Depression Inventory (BDI). The BDI has been validated for measuring depression in clinical and nonclinical settings (Beck et al., 1961).Radiological analysisAlthough diagnosis of KOA will be made primarily through clinical examination, knee x-rays will be taken on patients who qualify and consent to participate in the clinical trial. The purpose is to determine the grade of osteoarthritic change (according to the Kellgren-Lawrence scale (reference)), to confirm suspicions of contra-indications to treatment, or to get hold out a course of studyology outside of OA. Additionally, the subjects history and physical examination may indicate the need for lumbosacral/pelvic, hip, ankle and/or foot x-rays (see exclusion criteria below).ProcedureTimeBaseline2 weeks4 weeks6 weeks1 week F/U1 month F/U Rx222Outcome measurementWOMACROM electronic bulletin boardBDIWOMACOTEROMBBSBDIWOMACOTEROMBBSBDIOnce accepted into the study, patients will be randomly allocated into 3 (three) groups using a randomised parceling chart (reference). treatmentsGroup A will be treated with only manipulative therapy of the FKC.Gr oup B will be treated with only rehabilitation of the FKC.Group C will be treated with manipulative therapy combined with rehabilitation of the FKC.Manipulative therapy Appendix IFKC manipulative therapy (manipulative therapy to the knee, and any indicated axial or appendicular joint dysfunction, such as to the spine, hip, ankle, and foot) for KOA has been hypothesized as superior to localize manipulative therapy (Deyle et al., 2005). manipulation will focus on wide-awakely restoring knee flexion and extension by lesser grades of mobilization as recommended by Deyle et al., (2005) and Fish et al., (2008), and patellar mobilization as per Pollard et al., (2008), along with careful high velocity low amplitude axial elongation of the knee joint as per Fish et al., (2008).Additionally, manipulative therapy will be applied where needed to the full kinetic chain using other diversify techniques, such as HVLA manipulation or mobilization as outline in Shafer and Faye (1990), and/or Pet erson and Bergman (2002). alike, the hip technique, as outlined by Hoeksma et al., (2004) and the use of HVLA knee manipulation methods from Tucker et al., (2005) will also be employ when indicated.The particular joint dysfunction also known as the subluxation complex or manipulable lesion will be chosen based upon findings in the regional examinations.Rehabilitation Appendix JRehabilitative therapy will include exercises, focused soft tissue treatment and stretch to the knee and elsewhere along the full kinetic chain where needed based upon functional assessment (Deyle et al., 2005). Also included in rehabilitation will be patient advice, genteelness and home exercise recommendations for managing their KOA.The rehabilitation protocol will be standardise across groups B and C, with minor case by case variations.Intervention frequencyAll patient will receive 6 treatments in the first three (3) weeks (2x treatments/week). Training in a rehabilitation program, to be completed daily . Regular telephonic communication (every 1-2 weeks) following the completion of the sixth treatment.All groups will be required to return to the clinic no more than one (1) week after the 6th treatment and at the one (1) month follow up to have readings taken.Measurement ToolsAll data will be collected pre chew the fat 1, no more than 1 week after 6th treatment and at 1 month follow up, with the exception of OTE which will not be collected at previsit 1.Subjective data will b obtained by means of Beck Depression Inventory Appendix K The McMaster Overall Therapy Effectiveness (OTE) Tool Appendix L will be used to assess patient satisfaction and general improvement.o The OTE is a valid and authoritative questionnaire that allows the patient to classify the change in their health status whether their KOA symptoms, or overall quality of life has improved, remained the same, or worsened since the last visit (Chan et al., 2006) The Western Ontario and McMaster Universities Osteoarthrit is Index (WOMAC) Appendix M detects change in function and quality of life in patients suffering from KOA using multiple questions with the visual analogy scale (VAS).o The WOMAC is valid and reliable for KOA, and has a long history of being broadly and frequently utilized to assess knee and hip OA, thus allowing comparison to a large number of studies and trials (Bellamy et al., 1988). Berg Balance Scale (BBS) questionnaire Appendix N is a predictor of fall risk and will be delivered if the one legged standing test is failed (Hawk et al., 2006)). KOA patients who are +ve for the Berg Balance Scale (BBS) will be monitored as a subgroup (with a + OLST and BBS) at all clinic assessmentsObjective data will be obtained by means of Inclinometer Appendix O readings for knee flexion and extension only to evaluate the patients range of motion (ROM) (reference).StatisticsThe latest version of SPSS will be used to analyse the data.6. Plan of Research Activities run a summarised work plan for for each one year of the project giving information for each research activity per year, under the following headingsActivityTimeframes (target dates for the duration of the project)7. Structure of Dissertation / thesis Chapters1. Introduction2. Review of the related literature3. Subjects and methods4. Results5. Discussion6. Recommendations and conclusions7. References8. Potential Outputs Provide details on envisaged measurable outputs (e.g. publications, patents, students, etc.) Expected national and/or world(prenominal) acclaim for the research and contribution of research outputs to building the knowledge base Exploitability of outputs, e.g. applicability to community development, improved products, processes, services in SA, region and/or continent Expected effects of research results.9. Key ReferencesBrink, H. 2006. Fundamentals of research methodologies for health care professional. 2nd edition. Juta and co. Cape Town.Cliborne, A., Wainner, R., Rhon, D., Judd, C., Fee, T., Matekel, R., and Whiteman, J. 2004. Clinical hip tests and a functional squat test in patients with knee osteoarthritis reliability, prevalence of positive test findings, and short-term response to hip mobilization. daybook of orthopedic Sports Physical Therapy, November 34(11) 676-685.Currier, L., Froehlich, P., Carow, S., McAndrew, R., Cliborne, A, Boyles, R., Mansfield, L., and Wainner, R. 2007. Development of a clinical prediction rule to see patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a favourable short-term response to hip mobilization. Physical Therapy, family 87(9) 1106-1119.Deyle, G., Allison, S., Matekel, R., Ryder, M., Stang, J., Gohdes,D., Hutton, J., Henderson, N., and Garber, M. 2005. Physical Therapy sermon Effectiveness for Osteoarthritis of the Knee A randomised Comparison of Supervised Clinical Exercise and Manual Therapy Procedures versus a nursing home Exercise Program. Physical Therapy, 85(12) 1301-1317.Deyle, G., Henderson, N., Matekel, R., Ryder, M., Garber, M., and Allison, S. 2000. Effectiveness of Manual Physical Therapies and Exercise in Osteoarthritis of the Knee. Annals of Internal Medicine, 132(3) 173-181.Felson, D. 2000.Osteoarthritis New Insights Part 2 Treatment Approaches. In National Iinstitute of Health Conference, Annals of Internal Medicine 133 726-737.Hawk, C., Hyland, J.K., Rupert, R., Colonvega, M. and Hall, S. 2006. sagaciousness of balance and risk for falls in a sample of community-dwelling adults aged 65 and older. Chiropractic and Osteopathy, 14(3).Haynes, S. and Gemmell, H. 2007. Topical treatments for osteoarthritis of the knee. Clinical Chiropractic 10 126-138.Iverson. C., Sutlive, T., Crowell, M., Morrell, R., Perkins, M., Garber, M., Moore, J., and Wainner, R. 2008. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome development of a clinical prediction rule. Journal of orthopedic Sports Physical Therapy, June 38(6) 297-312 .McCarthy, C., Mills, P., Pullen, R., Roberts, C., Silman, A., and Oldman, J. 2004. Supplementing a home exercise programme with a class-based exercise programme is more effective than home exercise alone in the treatment of knee osteoarthritis. Rheumatology 43 880-886.Pollard, H., Ward, G., Hoskins, W. and Hardy, K. 2008. The effect of a manual therapy knee protocol on osteoarthritic knee pain a randomised controlled trial. Journal of the Canadian Chiropractic Association, December 52(4) 229-242.Symmons D, Mathers C, Pfleger B. 2003. Global burden of osteoarthritis in the year 2000 online. Geneva World Health Organization. Available at URL http//www3.who.int/whosis/menu.cfm?path=evidence,burden,burden_gbd2000docslanguage=englishTucker, M., Brantingham, J., Myburg, C. 2003. Relative effectiveness of a non-steroidal anti-inflammatory medication (Meloxicam) versus manipulation in the treatment of osteo-arthritis of the knee. European Journal of Chiropractic, 50 163-183.Woolf, A.D. and Pfleger, B. 2003. Burden of major(ip) musculoskeletal conditions. Bulletin of the World Health Organization, 81 (9).Zhang, W., Moskowitz, R. W., Nuki, G., Abramson, S., Altman, R. D., Arden, N., Bierma-Zeinstra, S., Brandt, K. D., Croft, P., Doherty, M., Dougados, M., Hochberg, M., Hunter, D. J., Kwoh, K., Lohmander, L. S. and Tugwell, P. 2008. OARSI recommendations for the management of hip and knee osteoarthritis, Part II OARSI evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage, 16137-162.Appendix LThe McMaster Overall Therapy Effectiveness (OTE) Tool (for general improvement and patient satisfaction)Patient No. Visit No. Page No. .Overall Treatment Evaluation KOAWe would like to find out if there are any changes in the way you have been feeling since treatment started after 6 treatments, and also at the 1st week and 1st month follow ups.Since treatment started, has there been any change in your operation LIMITATION, SYMPTOMS AND/OR FEELINGS related to yo ur knee osteoarthritis?Please indicate if there has been any change by checking unmatched of the three boxes below (Better/ around the same/ worse)Better about the Same Worse If you have chequered ABOUT THE SAME, Please s buy the farm here. If you have checked the box If you have checked the boxBETTER WORSEHow much BETTER would you say How much WORSE would you sayyour ACTIVITY LIMITATION, your ACTIVITY LIMITATION,SYMPTOMS AND/OR FEELINGS SYMPTOMS AND/OR FEELINGShave been since treatment started? Have been since treatment started?Please choose ONE of the options Please choose ONE of the optionsbelow belowAlmost the same, precisely better at all Almost the same, hardly worse at allA little better A little worseSomewhat better Somewhat worse somewhat better Moderately worseA reasoned deal better A good deal worseA great deal better A great deal worseA very great deal better A very great deal worsePatient No. Visit No. Page No. .Overall Treatment Effect CHF, continuedAnswer the fo llowing question whether or not you answered BETTER or WORSE and what your response was. Note if you have improved, the change will be chief(prenominal) since you likely will be able to carry out your responsibilities with greater ease and comfort compared to before the study. If on the other hand you are worse, then you will have more difficulty carrying out your responsibilities this will also be weighty for you as you have more difficulty with your activities.Is this change (BETTER/WORSE) important to you in carrying out your daily activities?Not importantSlightly importantSomewhat importantModerately importantImportantVery importanthighly importantTHANKS FOR YOUR COOPERATIONDescription of scales and how they will be assessed* Pages one and two are class-conscious separately.* Page one is graded on a 15 point scale. Scored from +7 to -7* If the answer to the first question is Better then you have a + integer* If the answer to the first question is About the Same the score is 0 * If the answer to the first question is Worse then you have a integer* With a + or integer, the answers below the better or worse response are numbered sequentially from top to bottom. Almost the same, hardly better is a 1 and A very great deal better is a 7.* Page two is graded on a 7 point scale. Scored from 1 to 7* The answers are numbered sequentially from top to bottom. Not important is a 1 and Extremely important is a 7Later we will dichotomize the scores on page one between scores 1 (improved) and Appendix MThe WOMAC Western Ontario and McMaster Universities osteoarthritis indexKNEE OSTEOARTHRITIS predict_________________________________________________Date___/___/______DOB___/___/_____In Sections A, B and C questions will be asked in the following format and you should give your answers by putting a sequential good (up-and-down) mark on the horizontal line.Note1. If make a straight vertical (up-and-down) mark on the line, at the left-hand end of the line, i.e.NO PAIN fundamentalPAINThen you are indicating that you have no pain.Note2. If make a straight vertical (up-and-down) mark on the line, at the Right-hand end of the line, i.e.NO PAINEXTREMEPAINThen you are indicating that you have extreme pain.3. Please Notea) that the further to the right-hand end you place your straight vertical (up-and-down) mark on the line, the more pain you are experiencingb) that the further to the left-hand end you place your straight vertical (up-and-down) mark on the line, the less pain you are experiencingc) Please do not place your straight vertical (up-and-down) mark on the line outside the markers.You will be asked to indicate on this type of scale the amount of pain, s