Rajiv Gandhi University of Health Sciences



|A RANDOMIZED CONTROL STUDY TO FIND THE EFFECT OF PHYSICAL THERAPY TECHNIQUES ON LUNG FUNCTION AND HEALTH RELATED QUALITY OF LIFE |

|IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE |

| |

|SUBMISSION OF SYNOPSIS FOR THE REGISTRATION OF THE DISSERTATION FOR MASTER OF PHYSIOTHERAPY |

|SUBMITTED TO |

|RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES |

|BANGALORE, KARNATAKA |

|SUBMITTED BY |

|MOIRANGTHEM JAMES |

| |

| |

|NAVODAYA COLLEGE OF PHYSIOTHERAPY |

|P.B. NO. 26 MANTRALAYAM ROAD, RAICHUR |

|KARNATAKA |

|SEPTEMBER 2009 |

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE - II

|1. |NAME OF THE CANDIDATE AND ADDRESS: |MOIRANGTHEM JAMES |

| | |NAVODAYA COLLEGE OF PHYSIOTHERAPY, MANTRALAYAM ROAD, RAICHUR. KARNATAKA.|

|2. |NAME OF THE INSTITUTION: |NAVODAYA COLLEGE OF PHYSIOTHERAPY, MANTRALAYAM ROAD, RAICHUR. KARNATAKA.|

|3. |COURSE OF STUDY AND SUBJECT: |MASTER OF PHYSIOTHERAPY (MPT) |

| | |PHYSIOTHERAPY IN CARDIO-RESPIRATORY DISORDERS |

|4. |DATE OF ADMISSION TO COURSE: |12 NOVEMBER 2009 |

|5. |TITLE OF THE TOPIC: |

| |“A RANDOMISED CONTROL STUDY TO FIND THE EFFECT OF PHYSICAL THERAPY TECHNIQUES ON LUNG FUNCTION AND HEALTH RELATED QUALITY OF LIFE IN|

| |PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE” |

PROFORMA FOR THE REGISTRATION OF SUBJECT OF DISSERTATION

|6. |RESEARCH QUESTION: |

| |Is there any significant effect of physical therapy technique on lung function and health related quality of life in patients with |

| |chronic obstructive pulmonary disease (COPD)? |

|6.1 |BRIEF RESUME OF THE INTENEDED WORK: |

| | |

| |The American Thoracic Society (ATS) defined Chronic Obstructive Pulmonary Disease (COPD) as “a disease state characterized by the |

| |presence of airflow limitation due to chronic bronchitis or emphysema; the airflow obstruction is generally progressive, may be |

| |accompanied by airway hyper-reactivity, and may be partially reversible.”5 |

| | |

| |The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defined COPD as a disease state characterized by airflow |

| |limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal |

| |inflammatory response of the lungs to noxious particles or gases.35 |

| | |

| |Chronic Obstructive Pulmonary Disease (COPD) encompasses the Chronic bronchitis and Emphysema. Chronic bronchitis is defined in |

| |clinical terms as a cough with sputum production on most days for 3 months of a year, for 2 consecutive years.24Emphysema is |

| |defined as enlargement of the air spaces distal to the terminal bronchioles, with destruction of their walls.24 |

| | |

| |The prevalence of COPD range from 14 million to 20 million persons in the United States and is steadily increasing.9 COPD now ranks|

| |as the fourth leading cause of death. It is also a major contributor to job absenteeism and the overall cost of caring for COPD |

| |patients has been estimated as high as $40 billion annually with $1.6 billion for long-term oxygen alone.34 The largest portion of |

| |health-care cost is borne in the last year of the patient's life.9,10,38,40 |

| | |

| |Risk for COPD is related to an interaction between genetic factors and many different environmental exposures, which could also be|

| |affected by comorbid disease. Risk factors for the disease are Genetic factors,47 Tobacco smoke,25 Outdoor air pollutants,25 |

| |Occupational dust, vapours, and fumes,18 Infections,49 Indoor air pollutants,25 Asthma,23,46 Gender,11 Socioeconomic and related |

| |factors.7,44,28 |

| | |

| |A variety of pathological changes have been observed in the central airways, peripheral airways and lung parenchyma of patients |

| |with chronic obstructive pulmonary disease (COPD). The characteristic changes in the central airways include inflammatory cellular|

| |infiltration into the airway wall and mucous gland enlargement. In the peripheral airways, various morphological changes are |

| |observed, including mucous plugging, epithelial abnormalities, inflammatory cellular infiltrates, fibrosis and distortion; these |

| |changes lead to airway narrowing. Although the major sites of airflow limitation in patients with COPD are most likely the |

| |peripheral airways, lesions in both the peripheral airways and the lung parenchyma contribute to chronic airflow limitations.32 |

| | |

| |Patients with chronic obstructive pulmonary disease (COPD) exhibit characteristics of airway mucus hypersecretion, including |

| |sputum production, increased luminal mucus, goblet cell hyperplasia and submucosal gland hypertrophy. These features are not |

| |common to all patients. However, current evidence indicates that airway hypersecretion has pathophysiological and clinical |

| |significance in COPD.41 |

| | |

| |The presence of clinical symptoms such as cough, sputum, or dyspnea on exertion, or middle aged or older people who have risk |

| |factors such as a history of smoking, COPD must always be suspected. Typical physical findings in COPD usually do not appear until|

| |the disease is severe.48 |

| | Spirometry is essential for diagnosis of COPD. Airflow limitation is judged to be present when the FEV1/FVC ratio is less |

| |than 70% after administration of bronchodilators. For a definitive diagnosis, it is necessary to exclude various other diseases by|

| |means of diagnostic imaging and detailed pulmonary function examinations.48 |

| |The spirometer was invented and introduced into medicine in 1846 by John Hutchinson, a surgeon.19 Spirometer is one of the |

| |equipments used for basic Pulmonary Function Tests (PFTs). It is useful as a preliminary test of the health condition for |

| |patient's lung. Besides, it often used for finding the cause for shortness of breath, assess the effects of contaminants on lung |

| |functions, effect of medication, and progress for disease treatment.31 |

| |Six Minute Walk Test is a valuable tool to evaluate functional aerobic exercise capacity and endurance. The area tested include |

| |distance walked, number and duration of rests in 6 minutes, perceived exertion, dyspnea, oxygen saturation, heart rate, overall |

| |aerobic exercise capacity and endurance. This test is objective and has limited costs.26,42 |

| |Chronic Respiratory Questionnaire (CRQ) is used to assess Health Related Quality of Life (HRQL). The questionnaire includes 20 |

| |items in four domains: dyspnea (five items), fatigue (four items), emotional function (seven items), and mastery (four items). 16 |

| | |

| |Traditionally COPD is treated by Medication, Pulmonary Rehabilitation, Disease management, Supplemental Oxygen and Surgery.5 |

| | |

| |Pulmonary rehabilitation has been well established as a means of enhancing standard therapy in order to control and alleviate |

| |symptoms, optimize functional capacity, and reduce the medical and economic burdens of disabling lung disease. Benefits include |

| |improved exercise tolerance, symptoms, and quality of life and decreases health care expenditures; results of published trials |

| |provide a sound scientific basis for the overall intervention as well as specific components.1,2,6,21 |

| | |

| |A comprehensive rehabilitation programme for respiratory patients includes: medical therapy, reinforcement of smoking cessation, |

| |education of the patient and family, exercise reconditioning, nutritional, occupational therapies, and physical therapy |

| |techniques. 13 |

| | |

| |Respiratory Physical therapy assesses and provides treatment to enhance functional capacity, increase lung expansion, reduce |

| |dyspnea, remove excessive bronchial secretion and restore maximum movement and function throughout life.3 |

| | |

| |Physical therapy techniques includes Exercise training,8 Arm exercise,22,30 Respiratory muscle training,45 Breathing retraining |

| |techniques,10 Chest physiotherapy4,51 and Education.10,29 |

| | |

| |Therefore, almost all COPD patients may be incorporated into such programme, including one or more of these various forms of |

| |therapy on the basis of an in- or out-patient programmed or even at home.12 ,39 |

| | |

| |Although in Pulmonary Rehabilitation Physical Therapy Technique plays a major role, its effect has not been studied extensively. |

| | |

| |Thus the aim of this study is to evaluate the effect of Physical Therapy Techniques on lung function and health related quality of|

| |life in patients with moderate COPD. |

|6.2 |HYPOTHESIS: |

| |NULL HYPOTHESIS (H0): |

| |There will be no significant difference in outcomes of both experimental and control group following Physical Therapy Techniques. |

| |ALTERNATIVE HYPOTHESIS (H1): |

| |There will be a significant difference in outcomes of both experimental and control group following Physical Therapy Techniques. |

|6.3 |REVIEW OF LITERATURE: |

| | |

| |1) Paz-Diaz, Hildegarde MD et al (2007)36 conducted a randomized study on 24 patients with COPD to determine the impact of an 8-wk |

| |program of comprehensive pulmonary rehabilitation on depression, anxiety, dyspnea, and health-related quality of life in patients |

| |with chronic obstructive pulmonary disease (COPD). The PR program included disease education Physical Therapy techniques, |

| |relaxation, and exercise including 20-min arm elevation with dumbbells and 20-min leg exercise sessions three times a week for 8 |

| |wks. They found that there was a significant improvement in the severity of depression (P < 0.01), a decrease in symptoms (P < |

| |0.05), an increase in daily living activities (P < 0.05), and a decrease in the total score of the SGRQ (P < 0.01). Dyspnea measured|

| |by the MRC scale was significantly better in the PR group (P < 0.01).Hence this study shows that in patients with COPD; pulmonary |

| |rehabilitation induces important changes on depression and anxiety independent of changes in dyspnea and health-related |

| |quality-of-life. |

| | |

| |2) Laura B et al (2006)27 have studied the spirometric values of patients with COPD with the objective of finding the suitable |

| |criterion to use, to find the variability of FEV1 and FVC among absolute and percentage variations. The samples were taken from |

| |two different centers, National Emphysema Treatment Trial (NETT) and Lung Health Study (LHS). The method used for the purpose was |

| |repeated measures. The baseline values of LHS was2.64+/-60 L and 0.68+/-0.22 L for NETT. As the degree of obstruction increased |

| |(with the mean number of days between sessions 24.9+/-17% for LHS and 85.7+/-21.7% for NETT, intersession percent difference of |

| |FEV1 increased. However absolute difference between the tests remained relatively constant despite the severity of obstruction |

| |over 90% of participants had an intersession FEV1 difference less than 225 ml irrespective of severity of obstruction. So they |

| |conclude that absolute changes in FEV1 rather than percent change should be used to determine the changes in COPD status. |

| | |

| |3) Hideki Katsura et al (2004)17 conducted a study to evaluate the long-term effects of rehabilitation in elderly COPD patients. |

| |The patients were monitored for 1 year after they completed a 2-week inpatient pulmonary rehabilitation program which included |

| |Physical Therapy techniques. Fifty-nine elderly COPD patients (mean age 72.8 years) were studied. They underwent a comprehensive |

| |2-week inpatient pulmonary rehabilitation program incorporating 10 exercise sessions, each of which included aerobic exercise |

| |training of the lower extremities, peripheral muscle conditioning training of the upper and lower extremities, and stretching, |

| |along with various education sessions. The effects of pulmonary rehabilitation were evaluated at 3, 6, and 12 months after |

| |completion of the program. Exercise capacity assessed by a 6-min walking distance test (6MWD) was significantly improved. However,|

| |there was some fall-off in terms of the distance walked 12 months after pulmonary rehabilitation. |

| | |

| | |

| | |

| | |

| |4) Ghassan F et al (2003)14 conducted a randomized controlled to determine the effectiveness of rehabilitation in patients with |

| |chronic obstructive pulmonary disease (COPD). Rehabilitation group received at least 4 weeks of rehabilitation; control group |

| |received no rehabilitation; and outcome measures included exercise capacity and shortness of breath. They identified 69 trials, of|

| |which 20 trials were included in the final analysis. They conclude that COPD patients who received pulmonary rehabilitation with |

| |Physical Therapy Technique have a better exercise capacity and they experience less shortness of breath than patients who do not |

| |receive rehabilitation. COPD patients may benefit from rehabilitation programs that include at least lower-extremity training. |

| |Patients with mild/moderate COPD benefit from short- and long-term rehabilitation. |

| | |

| |5) Lacasse et al. (2002)20 evaluated the impact of rehabilitation on health-related quality of life (HRQL) and exercise capacity |

| |in patients with COPD. A total of 23 Randomized control trial met the inclusion criteria for this review. Study results |

| |demonstrated clinically and statistically significant improvements in dyspnea, fatigue and mastery. These results were reported to|

| |strongly support PR, including at least four weeks of aerobic exercise training as part of the management for individuals with|

| |COPD. When compared with other modalities of treatment for COPD (e.g., bronchodilators). Physical Therapy Technique in Pulmonary |

| |rehabilitation showed greater improvements in important areas of HRQL and functional exercise capacity. |

| | |

| |6) Normandin EA et al (2002)33 conducted a prospective, randomized, 8-week trial to compare the effectiveness of two forms of |

| |exercise training in pulmonary rehabilitation in COPD patients. Forty patients with COPD were divided into two groups. The |

| |high-intensity group trained predominately on the stationary bicycle and treadmill, with a goal of exercising at > or = 80% of |

| |maximal level determined from incremental testing for 30 min per session. The low-intensity group performed predominately |

| |classroom exercises for approximately 30 min per session. For both groups, twice-weekly sessions were held for 8 weeks. The |

| |primary outcome measure was health status, measured using the Chronic Respiratory Disease Questionnaire. Patients in the |

| |high-intensity group showed greater increases in treadmill endurance and greater reductions in exertional dyspnea, whereas those |

| |in the low-intensity group showed greater increases in arm-endurance testing. Both groups had similar improvements in overall |

| |dyspnea, functional performance, and health status. Hence they conclude that despite differences in exercise performance, both |

| |high-intensity, lower-extremity endurance training and low-intensity calisthenics led to similar short-term improvements in |

| |questionnaire-rated dyspnea, functional performance, and health status. |

| | |

| |7) R H Green et al (2001)37 conducted a randomized controlled trial on 44 patients to identify four weeks versus seven weeks of |

| |rehabilitation which included Physical Therapy Technique in chronic obstructive pulmonary disease. Rehabilitation programmes have |

| |been shown to improve both exercise tolerance and health status in patients with chronic obstructive pulmonary disease (COPD). |

| |Patients were randomized to either standard seven week twice weekly outpatient based programme or a comparable but shortened four |

| |week course. They were assessed at baseline and at completion by the Chronic Respiratory Questionnaire (CRQ), the Breathing |

| |Problems Questionnaire (BPQ), the incremental shuttle walking test (SWT), and the treadmill endurance test (TET). Patients who |

| |completed the seven week rehabilitation programme had greater improvements in all outcome measures than those undertaking the four|

| |week course. Hence they concluded that seven week course of pulmonary rehabilitation provides greater benefits to patients than a|

| |four week course in terms of improvements in health status. |

| | |

| |8) Sherra Solway et al (2001)43 performed a qualitative systematic overview of the measurement properties of the most commonly |

| |utilized walk tests in the cardiorespiratory domain: the 2-min walk test (2MWT), 6-min walk test (6MWT), 12-min walk test (12MWT),|

| |self-paced walk test (SPWT), and shuttle walk test (SWT). Only studies conducted on patients with cardiac and/or respiratory |

| |involvement were included. They found fifty-two studies examining measurement properties of the various walk tests, 5 studies on |

| |the 2MWT, 29 studies on the 6MWT, 13 studies on the 12MWT, 6 studies on the SPWT, and 4 studies on the SWT. Measurement properties|

| |were most strongly demonstrated for the 6MWT. Correlations of 6MWT distance and maximal oxygen consumption ranged from 0.51 to |

| |0.90. A change in distance walked of at least 54 m was found to be clinically significant for the 6MWT. They conclude that |

| |measurement properties of the 6MWT have been the most extensively researched and established. In addition, the 6MWT is easy to |

| |administer, better tolerated, and more reflective of activities of daily living than the other walk tests. Therefore, the 6MWT is |

| |currently the test of choice when using a functional walk test for clinical or research purposes. |

| | |

| |9) Gordon H Guyatt et al (1987)15 Since the relationships between pulmonary function, exercise capacity, and functional state or |

| |quality of life are generally weak, a self report questionnaire has been developed to determine the effect of treatment on quality|

| |of life in clinical trials. One hundred patients with chronic airflow limitation were asked how their quality of life was affected|

| |by their illness, and how important their symptoms and limitations were. The most frequent and important items were used to |

| |construct a questionnaire evaluating four dimensions: dyspnoea, fatigue, emotional function, and the patient's feeling of control |

| |over the disease (mastery). Reproducibility, tested by repeated administration to patients in a stable condition, was excellent: |

| |the coefficient of variation was less than 12% for all four dimensions. |

|6.4 |OBJECTIVE OF THE STUDY: |

| |To determine the impact of 8 week program of Physical Therapy Techniques on lung function and health related quality of life in|

| |patients with moderate Chronic Obstructive Pulmonary Disease (COPD). |

| |To study the effect of Physical Therapy Techniques as an adjunct to Medical Management in patients with Chronic Obstructive |

| |Pulmonary Disease (COPD). |

|7. |MATERIALS AND METHOD: |

| |Manual Treadmill |

| |Stethoscope |

| |Sphygmomanometer |

| |Stop watch |

| |Incentive Spirometry |

| |Inch tape |

| |Tilt table |

| |Computerised Spirometry |

| |Mouth piece |

| |Nose clip |

| |chair with back rest |

|7.1 |SOURCES OF DATA: |

| |For the purpose of data collection 30 subjects with the mean age of 30-50 years diagnosed as moderate COPD by the Physician and |

| |will be referred to cardiorespiratory Physiotherapy department in Navodaya Medical College Hospital And Research Centre, Raichur. |

| |Only Male population will be chosen for this study. |

|A. |RESEARCH DESIGN: |

| |The Pre-Test, Post-Test Control Group Study Design which is true experimental in nature. |

|B. |SETTING OF STUDY: |

| |Department of cardiorespiratory Physiotherapy, Navodaya Medical College Hospital and Research Center, Raichur which is 950 bedded |

| |multi speciality hospital with fully equipped cardiorespiratory unit. |

|C. |VARIABLES: |

| |Independent Variable: Physical Therapy Techniques. |

| |Dependent Variables: Lung function (FEV1, FVC, FEV1/FVC %, MVV), Functional level (6 minute walk test) and Health Related Quality |

| |Of Life (CRQ). |

|D. |SAMPLE AND SAMPLING TECHNIQUES |

| |Since the study is true experimental in nature, Randomized sampling technique is adopted to select the subjects who are all |

| |attending the cardiorespiratory physiotherapy Department. |

| |Total sample consists of 30 subjects with moderate COPD. |

| |15 Patients are in Group A will be receiving Physical Therapy Techniques. |

| |15 Patients are in Group B will not be receiving any treatment except medication. |

|E. |INCLUSION CRITERIA: |

| |Patients having moderate COPD (GOLD criteria). |

| |The age between 30-50 years male population. |

| |smoking male population |

| |Patients taking same medication prescribed by the physician |

|F. |EXCLUSION CRITERIA: |

| |Mild COPD patients (GOLD criteria) |

| |Severe COPD patients (GOLD criteria) |

| |Fracture ribs |

| |Lung cancer |

| |Tuberculosis patients |

| |Non Smokers |

| |Lower limb impairment |

| |Patients with cardiac disease |

| |Respiratory paralysis |

| |Female population |

|7.2 |METHODS OF DATA COLLECTION: |

| |Lung function of FEV1, FVC, FEV1/FVC %, MVV will be assessed by SpirowinR Spirometry before and after the treatment. |

| |Functional level of the patient will be assessed before and after the treatment by using Six Minute Walk Test. |

| |Health related quality of life will be assessed before and after the treatment by using Chronic Respiratory Questionnaire (CRQ). |

|A. |STATISTICAL TEST: |

| |The student’s‘t’ test will be used to analyze the obtained data between experimental groups and control group. |

| |Intra group analysis will be done by using Paired‘t’ test. |

|7.3 |PROCEDURE: |

| |The subjects who will be diagnosed as Moderate COPD (GOLD criteria) and referred to the Cardiorespiratory Physiotherapy |

| |Department by the Physician will be taken into this study. |

| |A brief explanation of the process shall be given to prepare the subjects after obtaining the informed consent. |

| |Group A will be receiving Physical Therapy Techniques with medication. |

| |Group B will be receiving medication alone. |

| | |

| |For Spirometry: |

| |To measure FVC: |

| |The subject will be asked to sit comfortably in a chair. |

| |Tight clothing will be loosened. |

| |Appropriate FVC technique will be demonstrated and enthusiastic coaching will be given to the subject. |

| |A mouthpiece will be inserted into the mouth of the subject with lips closed tightly. |

| |The subject will be asked to take a deep breath and to blow out the air as rapidly, forcibly and completely as possible. |

| |To measure MVV: |

| |The subjects will instruct and demonstrated the maneuver prior to testing. Subjects will tested in the sitting position wearing |

| |nose clip and instructed to do maximum inhalation and exhalation as rapidly as possible for 12 seconds. |

| |For Six Minute Walk Test: |

| |The subjects will be asked to walk as much as possible within 6 minute. |

| | |

| |For Health Related Quality Of Life: |

| |The subjects Health Related Quality Of Life will be assessed by using the Chronic Respiratory Questionnaire ( CRQ).The |

| |Questionnaire consists of 20 items which is divided into four domains: dyspnea (five items), fatigue (four items), emotional |

| |function (seven items) and mastery (four items) which will be asking to the subjects. |

| | |

| |Physical Therapy Techniques will be given to the patients in the following ways: |

| |Exercise training in the form of treadmill for 30 minutes followed by 10 minutes of rest.8 According to AACVPR intensity for |

| |exercise training will be taken as 40 – 60% of THRR. |

| |Arm exercises for 10 minute. It improves performance and tolerance to dyspnea.22,30 |

| |Respiratory muscle training in the form of Incentive Spirometry for 20 minutes followed by 5 minutes of rest.45 |

| |Breathing retraining in the form of pursed lip breathing for 8 minutes followed by 5 minutes of rest. This technique modulates and |

| |creates a new type of breathing which enhances tidal volume and lowers respiratory frequency without affecting the duty cycle |

| |fraction of inspiration to total duration of breathing cycle.4,9 |

| |Chest clearance technique in the form of Postural Drainage and Forced Expiratory Technique for 30 minutes followed by 15 minutes of|

| |rest. Forced Expiratory Technique together with Postural Drainage is more effective.4,51 |

| |Education for 5 minutes which is of objective benefit. It is necessary in order to maintain a proper compliance to treatment.9,29 |

| |In order to maintain the flexibility and extensibility Warm up and Cool down period will be given for 10 minutes in the form of |

| |calisthenics and stretching. |

| |Before and after the Rehabilitation Programme Haemodynamic Variables will be assessed to evaluate the Exercise response. |

| |Therefore, the total duration of the rehabilitation programme is 2 hours and 30 minutes per day which will be given 3 times a week |

| |for 8 weeks. |

| |The Lung Function FEV1, FVC, FEV1/FVC%, MVV, the Functional Level of the patients and the Health Related Quality Of Life will be |

| |assessed by using the SpirowinR Spirometry, Six Minute Walk Test and Chronic Respiratory Questionairre (CRQ) respectively in |

| |baseline and at the end of 8 weeks. |

| | |

|7.4 | | |

| | | |

|A. |Has the study required any investigation Or Interventions|No other investigations |

| |to be conducted on animals Or human beings? | |

| | | |

|B. |Has ethical clearance obtained |(i) Yes, ethical clearance is obtained from the institutional ethical |

| | |committee of NAVODAYA COLLEGE OF PHYSIOTHERAPY |

| | | |

| | |(ii) Informed consent will be obtained from subject before the |

| | |treatment. |

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|NAME OF THE CANDIDATE |MOIRANGTHEM JAMES |

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|SIGNATURE | |

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|REMARKS OF THE GUIDE |PROJECT IS RECOMMENDED FOR APPROVAL BY THE UNIVERSITY |

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|NAME AND DESIGNATION OF GUIDE |Mrs. HEERA VIJAYAKUMAR |

| |ASSOCIATE PROFESSOR |

| |NAVODAYA COLLEGE OF PHYSIOTHERAPY, RAICHUR. |

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|SIGNATURE | |

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|PRINCIPAL |MR.P.VIJAYAKUMAR |

| |NAVODAYA COLLEGE OF PHYSIOTHERAPY, |

| |RAICHUR. |

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|REMARKS OF THE PRINCIPAL |RECOMMENDED FOR APPROVAL |

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|SIGNATURE | |

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