Full Kinetic Chain Manipulative Therapy on the Knee

Full Kinetic Chain Manipulative Therapy on the human kneeThe carnal knowledge effectiveness of complete kinetic concatenation manipulative therapy and full kinetic image replacement in the treatment of degenerative arthritis of the articulatio genus. Brief Synopsis of the lookTherefore in this study we aim to establish the effect of the KFC manipulative therapy solo, FKC rehabilitation alone and the combination of the two interventions on osteoarthritis of the genu.This bequeath be done by means of a quantitative randomise comparative clinical trial. 60 long-sufferings will have been diagnosed with osteoarthritis of the knee according to the cellular inclusion and exclusion criteria, and will be randomly divided into 3 sorts. The first group will receive 6 treatments using FKC manipulative therapy alone, the second will receive 6 treatments using FKC rehabilitation alone, and the third group will receive 6 treatments using FKC manipulative therapy combined with FKC reha bilitation. Subjective (Beck Depression descent, McMaster boilers suit Therapy Effectiveness Tool, Western Ontario and McMaster Universities osteoarthritis Index and Berg relaxation Scale) and objective (Inclinometer) measures will be taken at baseline, 1 week and 1 cal turn backar calendar month fol impoverished up.These results will be recorded and the data analyzed using SPSS statistical package 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 level best lengths)1. Field of look and Provisional TitleThe relative effectiveness of full kinetic chain manipulative therapy and rehabilitation in the treatment of osteoarthritis of the knee.2. Context of the Research1. degenerative fit disease is a very common condition, affects 9.6% of men and 18% of women aged 60 years worldwide (Woolf and Pfleger, 2003).2. Although multi-factorial, f solelys cause nearly two-thi rds of all non-intentional injury related deaths in older adults (Hawk et al., 2006). One of the causative factors is loss of renal pelvis and knee proprioception secondary to increased conjunction degeneration, thus by addressing these problems with the rehabilitation and/or ad howeverment thither may be a decreased danger of fall.3. There is research to suggest that applying manipulative therapy and rehabilitation to the full kinetic chain yields greater benefits for KOA patients than at sign rehabilitation alone (Deyle et al., 2005), however this combination of treatments has never been comp ard against full kinetic chain manipulative therapy alone.4. KOA stiffness, aggravator and dys flow was shown by Deyle et al., (2000) and Deyle et al., (2005) to improve damp when adding manipulative therapy to a rehabilitation curriculum as compared to placebo and forge alone, respectively.3. Research Problem and AimsAimThe relative effectiveness of full kinetic chain manipulative t herapy and rehabilitation in the treatment of osteoarthritis of the knee.Objectivesi) To de limitine whether manipulative therapy alone is effective in the short endpoint treatment of KOA in terms of infixed and objective meters.ii) To determine 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 effective in the intermediate term treatment of KOA in terms o f subjective and objective measurements.vii) To compare short term results and intermediate results, respectively.viii) To determine whether manipulative therapy combined with rehabilitation is effective in decreasing the fortune of fall according to the Berg Balance 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 more effective in decreasing the risk of fall according to the Berg Balance Scale.4. Literature reviewosteoarthritis is a chronic degenerative disorder with a complex aetiology (Felson, 2000). It is characterized by focal loss of articular cartilage within synovial joints, associated with grow of bone (osteophytes and subchondral bone sclerosis) and thickening of the capsule, resulting in alterations in biomechanical properties (Woolf and Pfleger, 2003). It is a very common joint disorder, affecting mostly those above the age of 60 and faeces occ ur in any joint but is most common in the articulatio coxae knee and the joints of the hand, foot, and spurring (Symmons, Mathers and Pfleger, 2003). As many as 40% of people over the age of 65 suffering symptoms associated with knee or hip OA (Zhang et al., 2008), resulting in OA becoming the fourth leading cause of disability in the years 2000 (Symmons, Mathers and Pfleger, 2003). Although no cure exists, a number of treatment options exist to provide symptomatic relief as swell 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 unplayful cases, where nonsurgical interventions have failed, more invasive approaches may be needed (Scher and Pillinger, 2007).McCarthy (2004) compared the effectiveness of an at piazza exercise program on its own or when supplemented with a cla ss- base exercise program. There was found to be a greater improvement in WOMAC scar in the class-based exercise group (20.6%) than the at home group (8.8%). These relatively modest effects 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) determine quadriceps inhibition or activation failure, obesity, passive knee laxity, knee misalignment, fear or physical activity and self-efficacy as examples of such factors. The necessity for special interventions to address these factors therefore becomes apparent.Tucker et al. (2003) compared the relative effectiveness of knee joint manipulation versus a non-steroidal anti-inflammatory drug (NSAID), and found manipulation to be just as effective as NSAIDs in the treatment on KOA. Fish et al., (2008) had similar results when comparing the effectiveness of knee joint mobilisation against Topical Capsaicin Cream. Capsaicin has been previously demo superior to placebo in many painful disorders including knee and general osteoarthritis. Pollard, Ward, Hoskins and Hardy (2008) applied a manipulative therapy protocol, consisting of loose tissue mobilisation and an caprice thrust to the symptomatic knee joint complex. This was found to have a statistically significant improvement in knee pain, mobility, crepitus and function when compared to the control group (interferential current set at zero). Pollard et al. (2008) also noted that knee treatment had a significant 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 have on the full kinetic chain (hereafter FKC).A number of studies have been conducted on various joints of the full kinetic chain of the cut extremity to determine their effect on the knee. Cliborne et al., (2004) aimed to determine the short-term effect of hip mobilization on pain and ra nge of motion (ROM) measurement in patient with knee osteoarthritis (OA). It was demonstrated that the presence of hip pain and pain on squatting, restricted hip flexion and/or a positive scouring test predicts a burst knee OA outcome. Currier et al., (2007) suggest that pain over the hip, groin or anterior thigh limitations in passive knee flexion and internal rotation of the hip as well as pain with hip distraction predicts a favourable short-term response to hip mobilizations. In fact it was found that, based on the presence of one variable, 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 patellofemoral pain syndrome) is if there is a side-to-side leaving in hip internal rotation greater than 14. The presence of this variable increased the likelihood of a successful outcome f rom 45% to 80%. These studies collectively show that correcting the various dysfunctions within the kinetic chain will have a favourable effect on knee joint dysfunction. However, there has yet to be a study that seeks to improve knee osteoarthritis by treating all call ford joints in the full kinetic chain.Few studies have 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 ankle as take. Additionally patients where given to knee exercise program to perform in the clinic on treatment days and at home. WOMAC (Western Ontario and McMaster Universities osteoarthritis Index) tons are used to detect changes in the patients perception of function and quality 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 pla cebo (subtherapeutic ultrasound), thus 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 being treated in clinic received superintend exercise, manual therapy to the FKC and a home exercise program, while a second group received at home exercise only. Significant improvements where seen in two(prenominal) groups, however the clinic treatment group had an improvement in WOMAC scores of 52% and only a 26% improvement was seen in the home exercise group. The originator attributed this difference between groups to the application of manual therapy to the full kinetic chain. However, the clinic group performed the exercises nether supervision and where corrected where necessary while the home group were monumentally unsupervised and may have performed the exercises incorrectly as a result, thus decreasing the benefit such exercises would have. One should therefore not consider the difference in group performance to be solely due 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 standardised rehabilitation program is more effective than either intervention alone in the treatment of osteoarthritis of the knee.5. Research MethodologyDesign typeQuantitative comparative clinical trial conducted at the Durban University of Technology Chiropractic Day Clinic (hereafter DUT CDC).Advertising Appendix AOld age homes and retirement villages throughout the greater Durban region will be approached, as well as advertisements placed 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 means of convenience sampling (Brink, 2006). Those individu als responding to the advertisements will be screened and accepted based on the inclusion and exclusion criteria.Telephonic interviewPatients are necessitate to come through the DUT CDC telephonically to determine whether they meet the requirements of the study. This will be determined by asking the patient the following questions* Are you between the ages of 38 and 80?* Have you had knee pain for longer than 1 year?* Do you have a history of trauma or surgery to the lumbar spine or lower limb?* Are you able to stand and walk 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 radiographs taken of your lower limb?If the patient meets the criteria for the study, a consultation will be made, at which they will be presented with a letter of information and informed consent form Appendix B, which they will be required to sign. The following inclusion and exclusion criteria will be assess using a case history 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 active motion and morning 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 life-threatening varus/valgus deformity and/or severe instability (Kellgren and Lawrence, 1957).5. Diagnosis of concurrent sub luxation/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 include (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 same.Exclusion Criteria1. Significant visual disorders, severe 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 frank avascular necrosis with or without moderate or severe deformity,3. History of significant lumbar herniated record injury with sequela,4. Severe balance and proprioception problems (i.e. inability to stand with and/or without discolorationed spinal or hip deformity)5. Symptoms of moderate to severe osteoarthritis in both knees and/or hips line of reasoning 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 purpose of the study.6. Long term chronicity combined with multiple treatment failure especially multiple 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 severe and decreased functional ability and/or a severe clinical depression, may lead on a case by case basis, to exclusion.A basic guide 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 cartridge clip 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 eon when ambulating severe cardiovascular disease severe instability in the knee or other joints or possibly slight(prenominal) than, or markedly less than half the normal ROM.IV. Clinically depressed determined by history and use the Beck Depression Inventory (BDI). The BDI has been logicalated 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 bound and consent to participate in the clinical tr ial. 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 rule out a pathology impertinent 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 measurementWOMACROMBBSBDIWOMACOTEROMBBSBDIWOMACOTEROMBBSBDIOnce accepted into the study, patients will be randomly allocated into 3 (three) groups using a randomised allocation chart (reference).InterventionsGroup A will be treated with only manipulative therapy of the FKC.Group 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 i ndicated axial or appendicular joint dysfunction, such as to the spine, hip, ankle, and foot) for KOA has been hypothesized as superior to localised manipulative therapy (Deyle et al., 2005). Treatment will focus on carefully restoring knee flexion and character reference 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 diversified techniques, such as HVLA manipulation or mobilization as defined in Shafer and Faye (1990), and/or Peterson and Bergman (2002). Also, 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 utilized when indicated.The particular joint dysfunction also known a s 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, education and home exercise recommendations for managing their KOA.The rehabilitation protocol will be standardised 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). dressing in a rehabilitation program, to be completed daily. Regular telephonic communication (every 1-2 weeks) following the completion of the 6th 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 rea dings taken. step ToolsAll data will be collected previsit 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 reliable questionnaire that allows the patient to classify the change in their health status whether their KOA symptoms, or overall quality of life has better, remained the same, or worsened since the last visit (Chan et al., 2006) The Western Ontario and McMaster Universities Osteoarthritis 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 utiliz ed 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 ActivitiesProvide a summarised work plan for each 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 literatu re3. 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 international 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. pallium 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. Journal of Orthopaedic 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 identify patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a favourable short-term response to hip mobilization. Physical Therapy, September 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 Treatment Effectiveness for Osteoarthritis of the Knee A randomize Comparison of Supervised Clinical Exercise and Manual Therapy Procedures versus a 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 N ational Iinstitute of Health Conference, Annals of Internal Medicine 133 726-737.Hawk, C., Hyland, J.K., Rupert, R., Colonvega, M. and Hall, S. 2006. Assessment 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 Orthopaedic 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., Wa rd, 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 uniform resource locator 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., Dougado s, 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. summon No. .Overall Treatment valuation 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 ACTIVITY LIMITATION, SYMPTOMS AND/OR FEELINGS related to your knee osteoarthritis?Please indicate if there has been any change by checking one of the three boxes below (Better/About the same/ worse)Better About the Same Worse If you have checked ABOUT THE SAME, Please stop here. If you have checked the box If you have checked the box bankrupt 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, hardly better at all Almost the same, hardly worse at allA little better A little worseSomewhat better Somewhat worse evenhandedly better Moderately worseA good 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. scalawag No. .Overall Treatment Effect CHF, continuedAnswer the following question whether or not you answered BETTER or WORSE and what your response was. Note if you have improved, the change will be important since you likely will be able to carry out your responsibilities with greater ease and comfort compared to in the lead the study. If on the other hand you are worse, then you will have more difficulty carrying out your responsibilities this will also be important 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 importantExtremely importantTHANKS FOR YOUR COOPERATIONDescription of scales and how they will be assessed* Pages one and two are graded 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 OSTEOARTHRITISName_________________________________________________ fancy___/___/______DOB___/___/_____In Sections A, B and C questions will be asked in the following format and you should give your answers by putting a great vertical (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 peakPAINThen 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 pla ce 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