A COMPARATIVE STUDY TO ANALYSE THE EFFECT OF ISOMETRIC

STRENGTHENING EXERICISES WITH WAXBATH THERAPY ON GRIP

STRENGTH AND HAND FUNCTIONS IN PATIENTS WITH

RHEUMATOID ARTHRITIS OF HAND

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

SALVI SAGAR PRADEEP

NAVODAYA COLLEGE OF PHYSIOTHERAPY

P.B. NO. 26 MANTRALAYAM ROAD, RAICHUR

KARNATAKA

JULY 2013

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE - II

PROFORMA FOR THE REGISTRATION OF SUBJECT OF DISSERTATION

6. RESEARCH QUESTION:

Does isometric strengthening exercises and wax bath therapy has any effect on

improving grip strength and hand functions in patients with Rheumatoid arthritis of hand?

6.1 BRIEF RESUME OF THE INTENDED WORK:

Rheumatoid arthritis (RA) is an autoimmune inflammatory chronic systemic

disease, which is particularly manifested at the synovial membrane of diarthrodial joints

and can result in destruction of the involved joints, leading to severe disability and

premature mortality. It is present in 0.5% to 1% of the general population, twice as often in

women, and the age at disease onset is mainly between 45 and 65 years.1, 2

The etiology of RA is still unknown but complex genetic factors, as well as

lifestyle and exposure factors are of importance. Given the presence of auto antibodies,

such as rheumatoid factor (RF) and anti–citrullinated protein antibody (ACPA) (tested as

anti–cyclic citrullinated peptide [anti-CCP]), which can precede the clinical manifestation

of RA by many years; RA is considered an autoimmune disease. Autoimmunity and the

overall systemic and articular inflammatory load drive the destructive progression of the

disease.3

The pre-disposing factors are,2

Genetic influence-More than 75% patients have positive family history.

There is a strong association with HLA-DR4 immune response gene.

Infectious agents

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1. NAME OF THE CANDIDATE AND ADDRESS:

SALVI SAGAR PRADEEP

NAVODAYA COLLEGE OF

PHYSIOTHERAPY, MANTRALAYAM

ROAD, RAICHUR.

2. NAME OF THE INSTITUTION: NAVODAYA COLLEGE OF

PHYSIOTHERAPY,

MANTRALAYAM ROAD, RAICHUR.

3. COURSE OF STUDY AND SUBJECT:

MASTER OF PHYSIOTHERAPY (MPT)

PHYSIOTHERAPY IN MUSCULO-SKELETAL DISORDERS AND SPORTS

4. DATE OF ADMISSION TO COURSE:

05/7/2013

5. TITLE OF THE TOPIC:

“ A COMPARATIVE STUDY TO ANALYSE THE EFFECT OF ISOMETRIC

STRENGTHENING EXERICISES WITH WAXBATH THERAPY ON GRIP

STRENGTH AND HAND FUNCTIONS IN PATIENTS WITH RHEUMATOID

ARTHRITIS OF HAND”

Trauma, psychological factors

RA is a chronic polyarthritis. In approximately two-thirds of patients, the

infectious agents such as the mycoplasam, Epstein Barr virus (EBV), cytomegalo virus

(CMV), are situated locally. After the process of immune pathogenesis in response to the

antigen, The (HLA-DR) and (CD4 + T-cells) are activated to elaborate the cytokines

(TNF-α, INF-γ, IL-1) which activates the endothelial cell, B-lymphocytes and

macrophages and triggers the inflammation to damage the synovial membrane which leads

to damage of the small blood vessels and collagen fibers and damages the bone and

cartilage, leads to fibrosis and joint deformities. It begins insidiously with fatigue,

anorexia, generalized weakness, and vague musculoskeletal symptoms until the appearance

of synovitis becomes apparent. Specific symptoms usually appear gradually as several

joints, especially those of the hands (proximal interphalangeal and metacarpophalangeal

joints), wrists, knees, and feet, become affected in a symmetric fashion. 3

Pain, swelling, and tenderness may initially be poorly localized to the joints. Pain

in affected joints, aggravated by movement, is the most common manifestation of

established RA. Generalized stiffness is frequent and is usually greatest after periods of

inactivity. Morning stiffness of less than 1-hour duration is an almost invariable feature of

inflammatory arthritis. Clinically, synovial inflammation causes swelling, tenderness, and

limitation of motion. Initially, impairment in physical function is caused by pain and

inflammation, and disability owing to this is a frequent early feature of aggressive RA.

Initially, motion is limited by pain. The inflamed joint is usually held in flexion to

maximize joint volume and minimize distention of the capsule. Later, fibrous or bony

ankylosis or soft tissue contractures lead to fixed deformities. Synovitis of the wrist joints

is a nearly uniform feature of RA and may lead to limitation of motion, deformity, and

median nerve entrapment (carpal tunnel syndrome).2

Characteristic changes of the hand includes (1) radial deviation at the wrist with

ulnar deviation of the digits, often with palmar subluxation of the proximal phalanges (“Z”

deformity); (2) hyperextension of the proximal interphalangeal joints, with compensatory

flexion of the distal interphalangeal joints (swan-neck deformity); (3) flexion contracture

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of the proximal interphalangeal joints and extension of the distal interphalangeal joints

(boutonnière deformity); and (4) hyperextension of the first interphalangeal joint and

flexion of the first metacarpophalangeal joint with a consequent loss of thumb mobility and

pinch. Later in the disease, disability is more related to damage to articular structures.2

According to the revised classification criteria of American College of

Rheumatology (ACR) 4, 5 1987 have been used.

Criterion

1. Morning stiffness

2. Arthritis of three or more joint areas

3. Arthritis of hand joints

4. Symmetric arthritis

5. Rheumatoid nodules

6. Serum rheumatoid factor

7. Radiographic changes

* Criterion 1-4 must have been present for at least 6 weeks

According to the American college of Rheumatology the Revised Criteria for

classsification of functional status in RA.6

Class I - Complete able to perform usual activities of daily living ( self care,

vocational, avocational)

Class II – able to perform usual self care and vocational activities but limited

in avocational activities

Class III- able to perform usual self care activities but limited In vocational

and avocational activities

Class IV- limited in ability to perform usual self care, and avocational

activities

Self care activities include dressing, feeding , bathing, grooming and

toileting. Avocational (recreational and or leisure) and vocational ( work, school, home

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making) activites are pateint desired and age- and sex- specific.6

MANAGEMENT OF RA:

Medical management:

Medical management includes, disease modifying anti-rheumatic drugs

(DMARDs), Non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids and

immunosuppressant. Surgical treatment in early stage includes synovectomy and in later

stages reconstructive surgeries like arthrodesis and total joint replacement 7, 8, 9

Physiotherapy management:

Physiotherapy management includes, wax bath therapy, Interferential therapy,

transcutaneous electrical nerve stimulation, diathermy, and exercises. Exercises are

strengthening exercises, flexibility exercises, free exercises etc.2

Diathermy: It increases blood flow in local arterioles and capillaries by producing

sympathetic vasodilatation. It also accelerates the local metabolism. The increase in muscle

blood flow is also associated with the removal of substances related to fatigue and pain-

inducing substances within the muscle.8

Transcutaneous Electrical Nerve Stimulation (TENS) and Interferential therapy

(IFT): It produces effects by activation of opioid receptors in the central nervous system. It

reduces the excitation of central neurons that transmit the nociceptive information and

activates the muscarinic receptors centrally to produce analgesia (by temporarily blocking

the pain gate).10

Effects of wax bath therapy:

There is a marked increase in skin temperature in the 1st two minute, up to 12-13°c.

Stimulation of superficial capillaries and arterioles cause local hyperemia and reflex

vasodilatation.11 The hyperemia is due to response of the skin to its function of heat

regulation. The effects of vasodilatation in the muscle are negligible, but then may be some

reflex heating in the joints. Exercise after the wax is essential to increase the muscle

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6.2

circulation and sedative effect of heat to obtain more range of movement and muscle

strength. The most important effect of wax its marked sedative effect on the tissue.12 Wax

leaves the skin moist, soft and pliable which is useful for stretching scar and adhesion

before applying mobilization techniques. Overall, wax helps in reducing pain and stiffness

of joints.11, 13

Effect of isometric exercises of hand:

Isometrics exercise helps in increasing joint flexibility and muscle strength.14 It

helps to maintain bone and cartilage health, improves ability to perform daily tasks.

Isometric exercises can help maintain strength to prevent injury or facilitate fatigue.

According to Hettinger, daily isometric contractions of 10%-20% of maximum tension

held for 10 seconds can maintain isometric strength. In RA patients, it has been shown that

isometric strengthening can lead to ADL performance with reduced effort. Isometric

strengthening exercises significantly improved grip strength and hand function in patients

with RA.15, 16

HYPOTHESIS:

NULL HYPOTHESIS (H0):

There will be no significant effect on grip strength and hand functions

followed by isometric strengthening exercises and wax bath therapy in patients with

Rheumatoid arthritis of hand.

ALTERNATIVE HYPOTHESIS (H1):

There will be significant effect on grip strength and hand functions followed

by isometric strengthening exercises and wax bath therapy in patients with

Rheumatoid arthritis of hand.

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6.3 REVIEW OF LITERATURE:

1. Cima et al (2013)17 conducted study to evaluate the effects of an exercise program

in improving the hand strength in individuals with hand deformities resulting from

RA and to analyse the impact these exercises have on functionality.20 women of

Group 1 (n = 13) participating in the exercise program, Group 2 (n = 7) with RA

who received no treatment for their hands (control).The treatment program for hands

consisted of 20 sessions, twice a week and at-home exercises. Both groups were

submitted to Health Assessment Questionnaire (HAQ) and evaluation of HS and PS

by means of dynamometry. Group 1 and after 2 months in Group 2. After 20

sessions, Group 1 had a significant gain in HS and PS (p < 0.05) in addition to the

improvement of functionality as assessed by HAQ (p = 0.016). Group 2, no

difference was found between (p > 0.05).They concluded that the strengthening

exercises for individuals with RA hand deformity are beneficial to improve handgrip

and pinch strengths as well as functionality.

2. Dilek (2013)18 conducted RCT to evaluate the efficacy of paraffin wax bath therapy

on pain, function, and muscle strength in patients with hand osteoarthritis. Patients

were randomized into 2 groups- Group 1 (n=29) had paraffin bath therapy (5 times

per week, for 3-week duration) for both hands. Group 2 (n=27) was the control

group The primary outcome measure was pain (at last 48h) at rest and during

activities of daily living (ADL), assessed with a visual analog scale (0-10cm) at 12

weeks. The secondary outcome measure was the Australian Canadian Osteoarthritis

Hand Index (AUSCAN). At baseline, there were no significant differences between

groups in any of the parameters (P>.05) When the 2 groups were compared, pain at

rest, both at 3 and 12 weeks, decreased in the paraffin group (P<.05) Paraffin bath

therapy seemed to be effective both in reducing pain and tenderness and maintaining

muscle strength in hand osteoarthritis

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3. Dogu et la (2013)19 conducted a RCT to evaluate the effect of 6-week-long isotonic

and isometric hand exercises on pain, hand functions, dexterity and quality of life in

women’s (age 40-70 years) diagnosed as RA. All patients were applied wax therapy

in the first 2 weeks. The pain was assessed with visual analog scale (VAS), and their

hand functions with Duruo¨z Hand Index (DHI) and hand grip strengthening.(HS) .

VAS and DHI scores improved in both exercise groups (p = 0.002; p = 0.0001)

while isometrics showed a significant increase in dominant HS (p = 0.029). Authors

have concluded that isometric and isotonic hand exercises decrease pain and disease

activity and improve hand functions, dexterity and quality of life.

4. Brorsson et al (2009)20 conducted study to evaluate the effects of hand exercise in

patients with RA, and to compare the results with healthy controls. 40 women (20

patients with RA and 20 healthy controls) performed a hand exercise programme.

The results were evaluated after 6 and 12 weeks with hand force measurements.

Hand function was evaluated with the Grip Ability Test (GAT) and with patient

relevant questionnaires (DASH and SF-36). The extension and flexion force

improved in both groups after 6 weeks (p < 0.01). Hand function (GAT) also

improved in both groups (p < 0.01). The rheumatoid arthritis group showed

improvement in the results of the DASH questionnaire (p < 0.05). They have

concluded that hand exercise is an effective intervention for RA patients, leading to

better strength and function.

5. Bastiana et al (2008)21 conducted an experimental study to evaluate the effect of

range of motion (ROM) and muscle strengthening exercises for 6 weeks on grip

strength and hand function in RA patients. 17 patients with chronic RA were

randomly assigned to a treatment group A (n=8), muscle strengthening exercises and

paraffin baths 3 times a week and ROM exercises once a day at home for 6 weeks)

and a control group B (n=9), was treated paraffin baths 3 times a week). After 6

weeks, there were significant differences in hand function (p=0.003), and bilateral

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hand strength (p=0.000 and p=0.001). ROM and isometric strengthening exercises

significantly improved grip strength and hand function in patients with RA, while no

Impact was found when the patients were given paraffin baths only.

6. Ronningen et al (2008)22 conducted a RCT to test the effect of an intensive hand

exercise programme in patients with RA. The first 30 participants received a

conservative exercise programme (CEP), while the next 30 received an intensive

exercise programme (IEP). Outcomes were assessed at baseline, and after 2 and 14

weeks. Hand strength, measured as grip strength and pinch strength, was the primary

Outcome variable. Secondary outcomes were joint mobility, hand pain, and

functional ability. After two weeks, there were significant differences between the

groups in favor of the IEP in pinch strength in the dominant hand (p=0.01), as well

as grip and pinch strength in the non-dominant hand (p=0.04 and 0.05). Authors

have concluded that an intensive hand exercise programme is well tolerated and

more effective in improving hand function in patients with RA.

7. O’Brien et al (2006)23 conducted RCT to evaluate the effectiveness of three

different physiotherapeutic approaches in the management of the RA in 3 groups.

Group 1 participants received a set of additional hand- strengthening and mobilizing

home exercises, group 2 a different set of additional hand-stretching exercises and

group 3 the JP information alone. Analysis was by intention to treat group (1) n=21,

group (2) n=24 and group (3) n=22. A 78% follow-up was achieved at 6 months. In

groups 2 and 3 there was a mean increase in Arthritis Impact Measurement Scales

(AIMS) II scores of 0.18 (1.54) and 0.30 (1.22). The differences in AIMS change

scores between group 1 and groups 2 and 3 were statistically significant (P=0.007)

and remained so after adjustment for multiple testing (P=0.012).They have

concluded that the significant improvements in arm function have been demonstrated

following a program of home-strengthening hand exercises in RA patients.

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8. Brosseau et al (2002)12 conducted a systematic review to evaluate the effectiveness

of different thermotherapy applications in patients with RA. Comparative controlled

studies, such as randomized controlled trials, controlled clinical trials, cohort studies

or case/control studies, of thermotherapy compared to control or active interventions

in patients with RA were eligible. Two independent reviewers identified potential

articles from the literature search (VR, LB). These reviewers extracted data using

predefined extraction forms. Consensus was reached on all data extraction. Quality

was assessed by two reviewers using a 5 point scale that measured the quality of

randomization, double-blinding and description of withdrawal Seven studies (n=328

participants) met the inclusion criteria. Superficial moist heat and cryotherapy can be

used as palliative therapy. On basis of the results, they concluded that Paraffin wax

baths combined with exercises can be recommended for beneficial short-term effects

for rheumatic arthritic hands.

9. Bijur et al (2001)24 conducted a study to assess the reliability of the Visual analogue

scale (VAS) for measurement of acute pain in emergency department. Intra class

correlation coefficients (ICCs) with 95% confidence intervals (95% CIs) a Bland-

Altman analysis were used to assess reliability of paired VAS measurements

obtained 1 minute apart every 30 minutes over two hours. The summary ICC for all

paired VAS scores was 0.97 [95% CI = 0.96 to 0.98]. The Bland-Altman analysis

showed that 50% of the paired measurements were within 2 mm of one another, 90%

were within 9 mm and 95% were within 16 mm. Reliability of the VAS for acute

pain measurement as assessed by the ICC appears to be high. Ninety percent of the

pain ratings were reproducible within 9 mm. These data suggest that the VAS is

sufficiently reliable to be used to assess acute pain.

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10. Taljanovic et al (2001)25 conducted the study to evaluate the short-term effects of

physical therapy (ice massage or wax packs, thermal baths, and faradic hand baths)

and exercise therapy on the RA hand (38 women and 12 men). The control group

consisted of 50 randomly selected RA outpatients (37 women and 13 men). The

clinical indices used for evaluation of inflammation included erythrocyte

sedimentation rate (ESR), pain intensity, proximal interphalangeal (PIP) joint size,

Hand grip strength, ROM and palmar tip-to-tip and key pinch finger strength were

the parameters used to assess the functional hand status. There was an improvement

for most of the observed indices from baseline parameters that achieved statistical

significance (P < 0.01 and P < 0.005) after the 3-week study period. At least in the

short term, physical and, particularly, exercise therapy produce a favorable

improvement in the functional status of the RA hand.

11. Lefevre-Colau et al (2001)26 conducted the study to assess the Cochin functional

disability scale for the RA hand after surgery. Clinical outcome measures included

duration of morning stiffness, total score for tenderness, VAS score for pain in the

hands and wrists, a score for overall mobility of the wrist and the fingers, grip and

pinch strength, the Hand Functional Index (HFI) the Kapandji index and the Cochin

scale. 50 patients (42 women) were evaluated twice at an interval of 7.16±2.10

months (mean ± S.D.) (Range 6–15 months). The Cochin scale score was improved

at the second visit (P<0.0001), with mean and effect size values of 0.66 and 0.58

respectively. The correlation of the change in Cochin score with patient overall

satisfaction was rS=0.40. Authors have concluded that the Cochin scale is

responsive and appropriate for the assessment of the effects of surgical treatments on

disability in RA hands.

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12. Bellace et al (2000)27 conducted study to examine the concurrent validity of the

Dexter Evaluation System with Jamar dynamometer attachment (Dexter) compared

with the reference-based criterion of the Jamar adjustable hand dynamometer

(Jamar) for measurement of maximal hand grip strength among normal subjects.

Sixty-two subjects between the ages of 20 and 50 years, who had no history of hand,

arm, shoulder, or neck injuries, were tested with the Jamar in the second handle

Position and, during the same visit, with the Dexter in the identical position. This

study concluded that the Jamar was found to be highly reliable (ICC [3,1] = 0.98)

and valid (ICC (2,K) = 0.99) for measuring hand grip strength.

13. Dellhag et al (1992)28 conducted RCT to evaluate the effect of active hand exercise

and warm wax. Treatment was given in 52 RA patients randomized into four groups.

(1) Both exercise and wax bath, (2) exercise only, (3) wax bath only, and (4)

controls. Treatment was given three times a week for 4 weeks. Deficits in flexion

and extension in digits II–V bilaterally, grip function, grip strength, pain, and

stiffness were measured before and after the treatment period. The control group was

measured at corresponding times. Wax bath treatment followed by active hand

exercise resulted in significant improvements of ROM and grip function. active

exercise was found to Significantly reduce pain with no resisted motion (p <

0.01), stiffness (p < 0.05) and flexion deficits in both the dominant and the non-

dominant hands (p < 0.01 and p < 0.05) The study concluded that active hand

exercise alone reduced stiffness and pain with wax non-resisted motion and

increased ROM.

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6.4 OBJECTIVE OF THE STUDY:

To find out the effect of wax bath therapy with isometric strengthening exercises in

patients with Rheumatoid arthritis of hand

To find out the effect of wax bath therapy in patients with Rheumatoid arthritis of

hand

To compare the effect of wax bath therapy with isometric strengthening exercises

and wax bath therapy alone in patients with Rheumatoid arthritis of hand

7. MATERIALS:

Wax bath unit

Hand dynamometer

Therapeutic Putty

Visual analogue scale (VAS)

Cochin Rheumatoid hand disability scale( CRHDS)

7.1 SOURCES OF DATA:

The patients those who are diagnosed with Rheumatoid arthritis by the orthopedic

department of NAVODAYA MEDICAL COLLEGE HOSPITAL & RESEARCH

CENTER, RAICHUR referred to musculoskeletal physiotherapy department will be taken

into the study.

A. RESEARCH DESIGN:

The pre & post test control group study design which is true experimental in

nature.

B. SETTING OF STUDY:

Navodaya Medical College Hospital and Research Center, Raichur, which is 1200

bedded multi specialty hospital with fully equipped Musculoskeletal physiotherapy

department.

C. VARIABLES:

Independent Variables:

Wax bath therapy, Isometric strengthening exercises

Dependent Variables:

VAS, Grip strength, Hand functions, CRHDS

D. SAMPLE AND SAMPLING TECHNIQUES:

Since the study is true experimental in nature, randomized sampling technique will

be chosen to select the subjects.

Total sample consists of 30 subjects with Rheumatoid arthritis of hand.

Group - A

15 patients will be receiving wax bath therapy and isometric strengthening

exercises.

Group - B

15 patients will be receiving wax bath therapy alone.

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E. INCLUSION CRITERIA:

Age group 40-60 years

Both sexes

Any three factor positive according to American Rheumatism association criteria

1987

Patients who are falling in Class I, II, and III (functional status) according to revised

criteria of the American college of Rheumatology

Patients who do not have any deformity

F. EXCLUSION CRITERIA:

Deformity of hand (swan neck deformity, claw hand, boutonniere deformity,

Any other orthopedic involvement

Patients who are falling in Class IV (functional status) according to revised criteria of

the American college of Rheumatology.

Open wounds

Sensory abnormalities off hand

Any neurological problems

Patients who are not able to understand VAS and CRHDS

7.2 METHODS OF DATA COLLECTION:

Pain level will be assessed by visual analog scale (VAS)29, 30

Grip strengthening by hand dynamometer30, 31, 32

Hand functions by Cochin Rheumatoid hand disability scale34

A. STATISTICALTEST:

Descriptive statistics will be used such mean, standard deviation and proportion to

present the data.

Comparison between intra group will be done by paired “t” test and inter group

comparison will be done by unpaired “t” test.

7.3 PROCEDURE:

A brief explanation of the process shall be given to prepare the subjects.

Subjects who are falling under inclusion criteria will be randomized into two groups.

Group A - subjects will be receiving wax bath therapy and Isometric strengthening

exercises

Group B - subjects will be receiving wax bath therapy alone

Total study duration is 6 weeks.

Wax bath therapy:

Wax bath therapy will be given by Dipping and wrapping method on both hands

symmetrically with 4-5 repetitions per session for three days at 47o – 500 C for 6 weeks.28, 35

Isometric strengthening exercises:

Six isometric strengthening exercises will be given for three times per week for six

weeks. The resistance will be held with a maximum effort for 3-5 seconds with 10-15

repetitions per session with a rest period of 20 seconds between repetitions.21, 28

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Isometric strengthening exercises will be given by using therapeutic putty:20

(I) The hand will squeeze the putty. (II) The putty will be pressed by the finger tips

against the surface. (III) The wrist proper will be placed in the putty, and then the fingers

will be stretched (movement in the metacarpophalangeal joint) in the putty. (IV) The thumb

and other fingers will press the putty against each other. (V) The putty will be placed

between two fingers and patient will be asked to press the putty. (VI) Strengthening

exercises will be done by opposing the resistance by the therapist’s hand without

performing any movement of the joints.21

Subjects will be asked to retain from any type of anti-inflammatory or analgesics

drugs during the course of study of both the groups.

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7.4

A. Has the study required any investigation Or Interventions to be conducted on animals Or human beings?

No other investigations

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 SALVI SAGAR PRADEEP

SIGNATURE

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

NAME AND DESIGNATION

OF GUIDE

MR.B. KOWSHIK

ASSO. PROFESSOR

NAVODAYA COLLEGE OF

PHYSIOTHERAPY, RAICHUR.

SIGNATURE

PRINCIPAL MR.S.MANIVANNAN

NAVODAYA COLLEGE OF

PHYSIOTHERAPY,

RAICHUR.

REMARKS OF THE PRINCIPAL

RECOMMENDED FOR APPROVAL

SIGNATURE