DISSERTATION SYNOPSIS



DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BENGALURU

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

By

NIKAM MADHUMITA UDHAV

UNDER THE GUIDANCE OF

S NATARAJAN

VIKAS COLLEGE OF PHYSIOTHERAPY

MARYHILL, KONCHADY, MANGALORE-575006

2010-12

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BENGALURU

REGISTRATION OF SUBJECTS FOR DISSERTATION

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|1. |Name of the Candidate |NIKAM MADHUMITA UDHAV |

| |and Address |VIKAS COLLEGE OF PHYSIOTHERAPY |

| | |AIRPORT ROAD |

| | |MARYHILL, KONCHADY |

| | |MANGALORE – 575008 |

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|2. |Name of the Institution |VIKAS COLLEGE OF PHYSIOTHERAPY |

| | |Mangalore. |

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|3. |Course of study and subject |Master of Physiotherapy in Musculoskeletal disorders and Sports Injury |

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|4. |Date of admission to Course |26-03-2010 |

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|5. |Title of the Topic |

| |A COMPARITIVE STUDY OF EFFICACY OF CPM AND ACTIVE ROM EXERCISE WITH ONLY ACTIVE KNEE ROM EXERCISES IN IMPROVING KNEE JOINT |

| |FLEXION POST-IMMOBILIZATION OF TIBIAL PLATEAU FRACTURES. |

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| |BRIEF RESUME OF THE INTENDED WORK |

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| |6.1) Need for the study |

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| |Tibial plateau fractures account for 1% of all fractures. A wide spectrum of fracture patterns involves the medial tibial |

| |plateau (10-23%), the lateral tibial plateau (55-70%),or both (11-31%). These fractures occur through metaphyseal bone and |

| |usually result from axial loading, combined most often with some varus or valgus forces. The distribution for age and gender|

| |shows a bimodal pattern. The incidence peak in men occur during the 4th decade of life, caused by a high-energy trauma, |

| |while in women this occurs on the 7th decade of life, and are typically low-energy trauma on highly osteoporotic bones. |

| |Low-energy trauma usually cause unilateral fractures with plateau depression, while high-energy traumas cause communitive |

| |fractures with larger soft parts and neurovascular injuries. There are different treatment approaches: closed reduction with|

| |cast or traction; percutaneous fixation, with screws, wires or external fixator, under arthroscopic view or limited |

| |arthrotomy and open reduction by broad approach with plates and screws. Cast braces are often employed, a brace around the |

| |thigh and calf with a knee hinge, with the brace limiting any sideways forces on the knee which might worsen the fracture. |

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| |Knee stiffness or limited knee flexion is the most common complication seen after tibial plateau fractures as a result of |

| |immobilizing the knee with a brace. Knee pain after tibial plateau fractures is often due to arthrofibrosis, and the patient|

| |needs to be counseled that the time to achieve knee motion is now. Once the brace is removed the physiotherapist will work |

| |on flexion of the knee and strength of the quadriceps and hamstrings. Many interventions have been used for increasing knee |

| |flexion by physiotherapist. |

| |Continuous passive motion (CPM) is a rehabilitation technique designed to assist in recovery of joint range of motion (ROM).|

| |CPM provides progressive passive ROM to an extremity through an externally applied force. CPM use is based on the theory |

| |that recovery will be accelerated by decreasing soft tissue stiffness, increasing ROM, and promoting healing of joint |

| |surfaces in soft tissues, and preventing the development of adhesions. Motion and stress are important for the maintenance |

| |of normal connective tissue and the healing of injured connective tissue. Motion enhances blood flow and decreases pain. |

| |Passive motion involves movement of a joint without active contraction of muscle groups. It is used to maintain ROM and |

| |flexibility in joints in the early postoperative and rehabilitative period after surgery or injury when active movement |

| |might disrupt the repair process or is too painful to perform. |

| |ROM exercises is a precise set of actions to move joints through their range as |

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| |possible. They can be either passive, active assisted or active. ROM exercises are isotonic and are used to prevent muscle |

| |atrophy, to maintain muscle tone, strength and function, to forestall many problems that occur with reduced mobility. |

| |Gradual progress from active ranges of movement towards resisted movements is encouraged. |

| |Despite the recorded benefits of CPM on knee flexion, it is clear that consensus has not been attained about the long term |

| |efficacy of the procedure. Although controversial, CPM has been used by many physiotherapists as part of a standard |

| |postoperative management. Little information exists to enable the clinician to select optimal CPM parameters, such as the |

| |most appropriate number of degrees per day to advance the CPM device or the optimal daily treatment duration. |

| |Given the limited amount of information to guide the clinician in deciding how to increase ROM in knees that are stiff after|

| |immobilization, a need exists for more information about the various treatments. Due to above factors further studies are |

| |necessary to evaluate both the forms of treatment to determine the most effective and safest treatment for the management of|

| |knee stiffness due immobilization of tibial plateau fractures. |

| |The goal of the present study is to compare the outcomes of CPM and active ROM exercises with only active ROM exercises in |

| |improving knee joint flexion post-immobilization of tibial plateau fractures . |

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| |6.2) Review of Literature |

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| |Gaston et al. assessed the functional outcome following fracture of tibial plateau in 63 patients. 21% had a limited |

| |residual flexion at the end of 1 year which showed that there was significant impairment of joint movement after fracture of|

| |tibial plateu. |

| |Lindenfeld et al.(2000) assessed and stated the cause of compromised knee ROM to be intrarticular or extrarticular trauma, |

| |prolonged immobilization or surgery. They also observed that extension contracture of knee is far less common than flexion |

| |contracture. |

| |Brosseau et al. (2004) conducted a meta-analysis of randomized clinical trials, controlled clinical trials, case control and|

| |cohort studies published through 2003 to determine the effectiveness of CPM following knee arthroplasty. CPM in combination |

| |with standard PT was compared to standard PT alone. The outcome measures were active and passive knee ROM, length of |

| |hospital stay, pain, swelling, fixed flexion deformity and quadriceps strength at end of treatment and during follow- up. |

| |Fourteen studies 952 patients met the inclusion criteria. The results suggested that CPM combined with PT is effective at |

| |increasing active knee flexion compared to PT interventions alone. Patients who received CPM in addition to PT were |

| |discharged from the hospital earlier and required fewer postoperative knee manipulations than those who received PT alone. |

| |Lenssen et al. (2008) conducted a randomized controlled trial to evaluate the effectiveness of prolonged CPM use in the home|

| |following TKA .Subjects were randomly treated with CPM and physical therapy for 17 consecutive days. At the end of three |

| |months after surgery there was no significant difference in ROM was noted at any other assessment period. This study |

| |suggests that prolonged use of CPM may have short-term effects on ROM but this did not translate into improved function nor |

| |did the improvement continue into the long-term. |

| |Postel et al. (2007) performed a systematic review of the literature regarding the use of CPM after TKA in order to develop |

| |clinical practice guidelines. After analysis of 21 studies included in the review, the authors determined that CPM after TKA|

| |could have short-term beneficial influence on the speed of recovery of motion, early flexion, postoperative pain, knee |

| |swelling and length of hospital stay but found no long-term confirmation of the early benefit of CPM. The authors concluded |

| |that, although there is insufficient evidence to recommend substituting CPM for other modalities of rehabilitation following|

| |TKA, it can be used as an adjunctive option to accelerate short-term results. |

| |In a Cochrane review, Milne et al. (2003, updated 2008) evaluated 14 trials to determine the effectiveness of CPM following |

| |TKA. In the main comparison of CPM combined with physiotherapy (PT) versus PT alone, the results favored CPM. CPM combined |

| |with PT was found to increase active knee flexion and decrease length of stay to a statistically significant degree. The |

| |authors concluded that CPM combined with PT may offer beneficial results compared to PT alone in the short-term |

| |rehabilitation following TKA. |

| |Rosen et al. (1992) conducted a prospective study to examine the effects of CPM and supervised active ROM following ACL |

| |repair (n=75). Patients with ACL deficiencies treated with arthroscopic ACL autograft reconstruction were randomized into |

| |one of three groups. Group A (n=25), the active motion group, received PT three times a week. Group B (n=25) received PT and|

| |CPM. Group C (n=25) received CPM but no formal PT. Evaluations occurred at specific intervals for six months. The authors |

| |reported no statistically significant differences among the three groups in drain output, medication usage, hospital length |

| |of stay, or in any other outcome measures. The authors concluded that effects of CPM on ROM were similar to that of active |

| |motion and that neither protocol had deleterious effects on stability. |

| |Brosseau L, Balmes S, et al conducted a study on reliability and validity of goniometer. 60 subjects were examined for the |

| |study. Knee flexion and extension ranges were measured for the study purposes. Universal goniometer (UG) was found to have |

| |the intratester reliability of 0.997 in knee flexion and 0.985 in knee extension. Parallelogram goniometer (PG) was found to|

| |have the intratester reliability of 0.996 in knee flexion and 0.953-0.955 in knee extension. Thus, they concluded that UG is|

| |preferred for measuring ROM for knee joint rather that visual estimation. |

| |Yaikwawongs N, Limpaphayom et al conducted a study for reliability and validity of digital compass goniometer in measuring |

| |the knee ROM . Knee flexion and extension ranges were measured for the study purposes. Results were compared with the range |

| |of knee joint motion using the standard roentgenographic picture by interclass correlation coefficient. They concluded that |

| |the digital compass goniometer is a reliable tool for measuring the ROM of knee joint. |

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| |Objective of the study |

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| |The objective of the study is to investigate, in a randomized, prospective study the effect of isometric quadriceps |

| |exercises with active knee mobility exercises versus the effect of only active knee mobility exercises, in patients with |

| |knee stiffness, on pain and joint range of motion of the knee post-immobilization of proximal tibial fractures. |

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| |Specifically, to determine |

| |The study the effect of active knee ROM exercises on improvement of knee flexion range of motion. |

| |The effect of CPM on improvement of knee flexion range of motion. |

| |The effect of CPM combined with active knee ROM exercises. |

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|7. | |

| |Materials and methods |

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| |7.1 Source of data |

| |Data will be collected from patients, who are referred to the outpatient physiotherapy department of Vikas college of |

| |Physiotherapy, Mangalore, with knee stiffness post tibial proximal tibial fractures, after obtaining informed consent. |

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| |7.2 Method of collection of data |

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| |Hypothesis |

| |1. Null hypothesis (Ho) |

| |There is no significant difference between the effects of CPM combined with active knee mobility exercises and only active |

| |knee mobility exercises in improving knee flexion range of motion post-immobilizaton of tibial plateau fractures. |

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| |2 Alternative hypothesis (H1) |

| |There is significant difference between the effects CPM combined with active ROM exercises and only active knee mobility |

| |exercises in improving knee flexion range of motion post-immobilizaton of proximal tibial fractures. |

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| |Research Design |

| |Experimental design will be used for this study. |

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| |Sampling method |

| |Random sampling method |

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| |Methodology |

| |30 Patients who are diagnosed to have knee stiffness due to immobilizaton of tibial plateau fracture will be randomly |

| |assigned to one of the two groups. Each group will consist of 15 patients of both genders, within the age group of 25 to 45 |

| |years. Group I will be administered CPM and active knee ROM exercises and Group II will be administered only active knee ROM|

| |exercises. Both the groups will be administered the treatment for 6 sessions a week for 6 weeks. |

| |In both the groups the active knee mobility exercises will be repeated for 2 sets of 10 repetitions each with one minute |

| |rest after each set. |

| |In Group I CPM will be administered for 30 minutes with rest interval of 4 seconds. |

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| |Inclusion Criteria |

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| |Both male and female patients. |

| |Patients of age group between 25 to 45 years. |

| |Patients presenting history of trauma. |

| |Patients who have undergone open reduction and internal fixation for tibial plateau fractures. |

| |Fracture immobilisaton period of 4-6 weeks after surgery. |

| |X-ray investigations showing appropriate fracture healing. |

| |Patients with knee stiffness or limited flexion, due to fracture immobilisation. |

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| |Exclusion Criteria |

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| |Patients with multiple lower limb fractures. |

| |Patients with history of rheumatoid arthritis, osteoarthritis, septic arthritis, osteomyelitis. |

| |Presence of an unexpected traumatic episode in the affected knee during the course of the study. |

| |Any contradiction for x-ray or peripheral MRI study. |

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| |Interventions |

| |Group 1: |

| |This group will consist of 15 patients of both genders who will be administered CPM and active knee ROM exercises. |

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| |CPM will be administered in comfortable supine position for 30 minutes. Rest interval will be of 4 seconds. The flexion |

| |range will be increased every 5 minutes by 2-3 degrees. |

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| |Active knee ROM exercises administered will be heel slides, knee curls. |

| |Heel slides: Lie on your back with your hands at your sides. Slide the heel of the injured knee toward your buttocks as far |

| |as you can until you feel mild tension. Hold the bent knee in that position for 30 seconds and return the leg to a straight |

| |position. |

| |Repeat this exercise for 2 sets with 10 repetitions each. |

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| |Knee curls: lie on stomach with hands on sides. Bend knee inside towards buttock as far as possible. Hold bent knee in that |

| |position for 30 seconds and return leg to straight position. Repeat this exercise for 2 sets of 10 repetitions each. |

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| |Group 2: |

| |This will consist of 15 patients of both genders and they will be administered only active knee ROM exercises. |

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| |Outcome measures: |

| |Before the beginning of the rehabilitation protocol and after 4 weeks of treatment, |

| |All the patients will be evaluated in the following outcome measures. |

| |1. Range Of Motion: Goniometer |

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| |Statistical tests: |

| |The following statistical tests will be used to analyze the collected data |

| |1. Paired and unpaired t-tests |

| |2. Wilcoxon signed rank tests |

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| |7.3 The study requires non-invasive investigations and interventions to be conducted on patients. The investigations to be |

| |conducted include physical examination of knee joint like inspection, palpation, joint range of motion with the help of |

| |goniometer. |

| |Interventions in the treatment that are used for this study are is CPM and active knee ROM exercises. |

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| |7.4 Ethical clearance has been obtained from the ethical committee of our institutions to carry out the investigations and |

| |interventions on patients necessary for this study. |

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|8 |REFERENCES |

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| |1. Alfredson H, Lorentzon R. Superior results with continuous passive motion compared to active motion after periosteal |

| |transplantation: A retrospective study of human patella cartilage defect treatment. Knee Surg Sports Traumatol Arthrosc. |

| |1999;7(4):232-38. |

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| |2. Brosseau L, Milne S, Wells G, Tugwell P, Robinson V, Casimiro L, et al. Efficacy of continuous passive motion following |

| |total knee arthroplasty: a metaanalysis. J Rheumatol. 2004 Nov;31(11):2251-64. |

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| |3. Cosgarea A, DeHaven K, Lovelock J. The surgical treatment of arthrofibrosis of the knee. Am J Sports Med. |

| |1994;22(2):184-191. |

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| |4. DeLee: DeLee and Drez’s Orthopaedic Sports Medicine, 2nd ed. Saunders, an imprint of Elsevier; 2009. |

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| |5. Duke Orthopaedics. Wheeless' Textbook of Orthopedics. (Accessed 3/7/05). |

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| |6. ECRI Institute. Hotline Response [database online’. Plymouth Meeting (PA): ECRI Institute. Continuous passive motion |

| |devices following orthopedic surgery. 2009 Apr 2. Available at URL address: |

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| |7. Engstrom B, Sperber A, Wredmark T. Continuous passive motion in rehabilitation after anterior cruciate ligament |

| |reconstruction. Knee Surg Sports Traumatol Arthrosc. 1995;3(1):18-20. |

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| |8. Gates H, Sullivan F, Urbaniak J. Anterior capsulotomy and continuous passive motion in the treatment of post traumatic |

| |flexion contracture of the elbow. Bone Joint Surg Am. 1992 Sep;74(8):1229-39. |

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| |9. Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. |

| |Cochrane Database Syst Rev. 2010 Mar 17;3:CD004260 |

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| |10. Handoll HHG,Madhok R, Howe TE. Rehabilitation for distal radial fractures in adults. Cochrane Database of Systematic |

| |Reviews 2003, Issue 3. |

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| |11. Jerosch J, Aldawoudy AM. Arthroscopic treatment of patients with moderate arthrofibrosis after total knee replacement. |

| |Knee Surg Sports Traumatol Arthrosc. 2008 Jul;16(7):720-2; author reply 723. |

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| |12. Lastayo PC, Wright T, Jaffe R, Hartzel J. Continuous passive motion after repair of the rotator cuff. A prospective |

| |outcome study. J Bone Joint Surg Am. 1998 Jul;80(7):1002-11. |

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| |13. Lenssen TA, van Steyn MJ, Crijns YH, Waltje EM, Roox GM, Geesink RJ, et al. Effectiveness of prolonged use of continuous|

| |passive motion (CPM), as an adjunct to physiotherapy, after total knee arthroplasty. BMC Musculoskelet Disord. 2008 Apr |

| |29;9:60. |

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| |14. McCarthy MR, Yates CK, Anderson MA, Yates-McCarthy JL. The effects of immediate continuous passive motion on pain during|

| |the inflammatory phase of soft tissue healing following anterior cruciate ligament reconstruction. J Orthop Sports Phys |

| |Ther. 1993 Feb;17(2):96-101. |

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| |15. Milne S, Brosseau L, Robinson V, Noel MJ, Davis J, Drouin H, Wells G, Tugwell P. Continuous passive motion following |

| |total knee arthroplasty. Cochrane Database of Systematic Reviews 2003, Issue 2. |

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| |16. Postel JM, Thoumie P, Missaoui B, Biau D, Ribinik P, Revel M, et al. Continuous passive motion compared with |

| |intermittent mobilization after total knee arthroplasty. Elaboration of French clinical practice guidelines. Ann Readapt Med|

| |Phys. 2007 May;50(4):251-7. |

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| |17. Raab M, Rzeszutko D, O'Connor W, Greatting M. Early results of continuous passive motion after rotator cuff rehab: a |

| |prospective, randomized blinded controlled study. Am J Orthop. 1996 Mar;25(3):214-200. |

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| |18. Ring D, Simmons B, Hayes M. Continuous passive motion following hand metacarpophalangeal joint arthroplasty. J Hand |

| |Surg. 1998 May;23(3):505-511. |

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|9. | |

| |Signature of the candidate : |

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|10. |Remarks of the Guide |

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|11. |Name and Designation of |

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| |Guide : |

| |Assoc Professor |

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| |Signature : |

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| |Co-Guide : - |

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| |Signature : - |

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| |Head of the Department : Prof. S. NATARAJAN M.P.T. |

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| |Signature : |

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|12. |12.1 Remarks of the Chairman and Principal |

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| |12.2 Signature : |

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