|Year : 2019 | Volume
| Issue : 2 | Page : 48-57
Effect of integrated complimentary therapies on physical and psychological variables of patients suffering from knee osteoarthritis: A pilot feasibility study
Arjan Singh1, Hemant Bhargav2, Praerna Hemant Bhargav2, Nagarathna Raghuram3
1 Division of Yoga and Life Sciences, S-VYASA Yoga University, Bengaluru, Karnataka, India
2 Department of Psychiatry, NIMHANS Integrated Centre of Yoga, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
3 Arogyadhama Health Center, S-VYASA Yoga University, Bengaluru, Karnataka, India
|Date of Submission||01-May-2019|
|Date of Acceptance||21-Aug-2019|
|Date of Web Publication||17-Oct-2019|
Dr. Praerna Hemant Bhargav
Department of Psychiatry, NIMHANS Integrated Centre of Yoga, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Recent studies have shown beneficial effects of complementary and alternative therapies such as Yoga, Ayurveda, and Naturopathy on osteoarthritis (OA), but combining these therapies will have any synergistic effect and will be feasible and safe or not is not known. Aim: This study aims to assess feasibility and compare the effect of Ayurveda and Naturopathy as an add-on to Yoga in individuals with knee OA. Materials and Methods: This study involves forty Seven individuals (21 males and 26 females) in the age range of 45.19 ± 3.39, suffering from knee OA since 3.37 years admitted in a residential holistic therapy hospital. They were allocated into one of the three treatment programs based on their preference and clinician's advice: (a) Yoga (n = 16), (b) Yoga + Ayurveda (n = 21), and (c) Yoga + Naturopathy (n = 10). Assessments were done at baseline and after 1 week of respective treatment program using knee injury and OA outcome score (KOOS), perceived stress scale, visual analog scale for pain intensity, and stiffness index. Furthermore, physiological and anthropometric measures were assessed. Data were analyzed using paired t-tests and one-way ANOVA for within and between groups comparison, respectively, using SPSS version 10.0. Results: No side effects were reported by the individuals in any of the groups. Within-group comparisons showed significant improvement in all the variables except blood pressure in all the three groups and body mass index, heart rate (HR), and respiratory rate in Yoga + Naturopathy group. Between-group comparison showed significant improvement in Yoga group as compared to Yoga + Naturopathy group for KOOS subscale - sports function (P = 0.049; F = 3.24) and for HR (P = 0.025, F = 4.014) in Yoga group as compared to Yoga + Ayurveda group.
Conclusion: Addition of Ayurveda and Naturopathy to Yoga therapy for short-term treatment was found to be safe and feasible. Seven days of Yoga therapy improved clinical symptoms, anthropometric measures, and psychological states of individuals with knee OA.
Keywords: Ayurveda, integrative therapies, knee osteoarthritis, naturopathy, yoga
|How to cite this article:|
Singh A, Bhargav H, Bhargav PH, Raghuram N. Effect of integrated complimentary therapies on physical and psychological variables of patients suffering from knee osteoarthritis: A pilot feasibility study. Int J Yoga - Philosop Psychol Parapsychol 2019;7:48-57
|How to cite this URL:|
Singh A, Bhargav H, Bhargav PH, Raghuram N. Effect of integrated complimentary therapies on physical and psychological variables of patients suffering from knee osteoarthritis: A pilot feasibility study. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2019 [cited 2020 Dec 3];7:48-57. Available from: https://www.ijoyppp.org/text.asp?2019/7/2/48/269478
| Introduction|| |
Osteoarthritis (OA) is one of the most commonly found joint disorders and is a major source of pain, disability, and socioeconomic burden worldwide. The epidemiology of the disorder is complex and multifactorial, with genetic, biological, and biomechanical components. Epidemiological studies have found OA to be a heterogeneous set of conditions, each with particular interaction of multiple risk factors and having strong correlation with age, variation in site-specific location for various ethnic groups, and gender-based pattern and distribution. However, still mechanical wear and tear is supported by most epidemiologic evidences to play major role in the development of OA. Pain, which is related to actual or potential tissue damage, is the main symptom of OA. Primary OA results from a combination of risk factors, with increasing age and obesity being the most prominent and commonly affecting the knee, hip and hand joints. It has been found that loss of five kilograms of body weight decreases symptoms of OA by 50%. Still, it is unclear whether muscle weakness causes OA or whether the condition itself leads to muscle weakness. However, long-term engagement in intense physical labor such as high-impact sports or occupations requiring kneeling or squatting increases the risk to develop OA of knee and hips.,
Modern medicine has no specific cure for this condition and the treatment is centered on analgesics with the target at control of pain and joint swelling and minimizing functional impairment. However, patient's dissatisfaction with such treatment due to concern regarding adverse effects and difficulties with prescribing analgesics to patients with common chronic conditions such as hypertension constitutes significant limitation of the modern medical treatment approach. Joint replacement is an effective treatment for symptomatic end-stage disease, although functional outcomes can be poor and the lifespan of prostheses is limited. Consequently, the focus is shifting to disease prevention and treatment at early stages. Not surprisingly, complementary and alternative medicine (CAM) is one of the most sought out practices in arthritis.
As per American College of Rheumatology (ACR) subcommittee on OA guidelines, exercise programs such as aerobic and strengthening exercises are essential elements of any treatment program for OA, and yoga practice appears to be one such excellent treatment modality for OA as per a recent review. In a randomized controlled trial (RCT), 250 participants with knee OA between the age of 35 and 80 years showed improvements in pain while walking, knee disability, range of knee flexion, joint tenderness, swelling, crepitus, and walking time in the yoga group compared to the control group which received therapeutic exercises. Similarly, Kolasinski et al. found that the practice of Iyengar Yoga postures during a 90-min class once a week for eight subsequent weeks lead to significant improvements in pain, physical functions, stiffness, and affect. The existing evidence (although limited) suggests that yoga programs can be feasibly given to adults with OA that they are safe and have beneficial short-term effects. The effects of yoga relative to other complementary treatments (e.g. tai chi, acupuncture) or to conventional therapies are yet unknown.
In addition to yoga, popularity of other CAM therapies among patients with OA is also on increase. As per a survey, 43% of patients with OA resort to use of ayurvedic medicines and other natural remedies with Ayurveda (28%) being the most sought CAM therapy followed by homeopathy (20%). In a study done by Yip and Tam, significant improvements were found in pain levels, stiffness, and function with six massage sessions given with ginger and olive oil to senior citizens with knee OA in comparison to no treatment group and the placebo group receiving massage with olive oil only. In another RCT on knee OA, Perlman et al. showed significant improvements in pain, stiffness, and functioning after receiving Swedish massage twice a week for 4 weeks and once a week for another 4 weeks. Moderate to high effects sizes were found (0.64–0.86). These evidences suggest short-term benefits of naturopathic treatment in knee OA.
The recent literature has shown that yoga has healing effects in OA. However, in CAM health care institutions, the practice of yoga is commonly prescribed along with other adjacent modalities such as ayurvedic treatment and naturopathic treatments. Till date, there is no study which has examined whether there is an additional effect of these treatments to yoga. Hence, the purpose of this study is to study the feasibility of administering different CAM treatments together in patients suffering from OA and if there is any additional effect of other CAM treatment modalities when given as an add on to yoga therapy.
| Materials and Methods|| |
The study involved total 47 adult participants (21 males and 26 females) hailing from India and diagnosed with OA as per ACR guidelines since 3.37 years on an average, within the mean age range of 45.19 ± 3.39. They were admitted in a residential holistic therapy hospital for a week-long treatment program and were allocated into one of the three treatment programs based on their preference and clinician's advice: (a) yoga therapy (n = 16), (b) yoga therapy + Ayurveda (n = 21), and (c) yoga therapy + naturopathy (n = 10). Eligibility to participate in the study required participant to be within the age range of 18–60 years, diagnosed with OA and possessing medical clearance to undergo different treatment modules. Those suffering from any neurological or psychiatric disorders or undergone a recent surgery or having any physical limitations such that they were deemed by the medical practitioner to preclude yoga practice were excluded from the study.
This study followed convenient sampling procedure and employed three groups pre - post design where participants were allocated to 1 week treatment in either one of the three groups – yoga therapy or yoga therapy + Ayurveda or yoga therapy + naturopathy. Assessments were done at baseline and subsequent to the last session, after 1 week of respective treatment program by a trained medical professional who was blind to the groups using knee injury and OA outcome score (KOOS), perceived stress scale (PSS), visual analogue scale for pain intensity (PI) and stiffness index (SI). Furthermore, physiological measures of blood pressure (BP), heart rate (HR), respiratory rate (RR), and anthropometric measures such as body weight and body mass index (BMI) were assessed.
Signed informed consent was obtained from the individuals to participate in the study after explaining the protocol of the study. The approval of the research protocol was taken from the Institutional ethical committee of S-VYASA University.
Knee injury and osteoarthritis outcome score
The KOOS is a questionnaire to examine a person's opinion regarding knee related problems and associated issues. The KOOS includes five subscales: pain (9 items), other symptoms (5 items), activities of daily living (ADL, 17 items), sport and recreational function (Sport/Rec, 5 item), and knee-related quality of life (QOL, 4 items). Items are rated on a 5-point Likert type scale ranging from 0 to 4, with higher scores representing greater symptom severity. Each subscale score is calculated separately. In studies of patients with knee OA, the internal consistencies (Cronbach's alpha) for pain was 0.65–0.94, for symptoms 0.56–0.83, for activities of ADL 0.78–0.97, for Sport/Rec 0.84–0.98 and for QOF 0.71–0.85 Test–retest reliability ranges from 0.8 to 0.97 for pain, for symptoms from 0.74 to 0.94, for ADL from 0.84 to 0.94, for Sport/Rec from 0.65 to 0.92 and for QOL from 0.6 to 0.91.
Perceived stress scale
The PSS assesses the degree to which situations in one's life are perceived as stressful. Psychological stress is defined as the extent to which a person appraises that their demands exceed their ability to cope. The items are designed to examine how unpredictable, uncontrollable, and overloaded respondents find their lives. The scale also includes direct questions about current levels of experienced stress. The scale consists of 10 items which are rated on a five-point scale ranging from 0 (never) to 4 (almost always). Higher scores indicate more perceived stress except for four positive items which are reverse scored. Internal consistency (Cronbach's alpha) ranges from 0.84 to 0.86. Test-retest reliability is r = 0.85. A 1-week version of the PSS-10 (instead of 1-month) is used for the current study.
Visual analog scale for pain intensity
The visual analog scales which are used and described below are developed for this study specifically. The PI measures magnitude of pain experienced in the knee. In the current study, PI is measured using a visual analog scale. A 100 mm long horizontal line is given with two opposing faces and verbal statements at each ending point. The far left end indicates “No pain” and the far-right end indicates “Worst pain ever.” Ratings can be made along the 100 mm line in a gradual manner. Two visual analogue scales are used to measure PI in the right knee and PI in the left knee.
Visual analog scale for stiffness index
The visual analogue scales which are used and described below are developed for this study specifically. The SI measures the experienced stiffness in the knee. In the current study SI is measured using a visual analogue scale. A 100 mm long horizontal line is given with two opposing faces and verbal statements at each ending point. The far-left end indicates “No stiffness” and the far-right end indicates “Worst stiffness ever.” Ratings can be made along the 100 mm line in a gradual manner. Two visual analog scales are used to measure SI in the right knee and SI in the left knee.
BP is the pressure exerted by circulating blood upon the walls of blood vessels expressed in terms of the systolic (maximum) pressure over diastolic (minimum) pressure and is measured in millimeters of mercury (mmHg). BP is measured through auscultatory method using a stethoscope and sphygmomanometer in seated position after making the patients rest for 5 min in seated position.
The HR is the speed of the heartbeat measured by the number of contractions of the heart per minute (bpm). The HR is measured by manual measurement by feeling the artery's pulsation at the wrist with the index and middle fingers. The counted number of beats per minute is indicating the HR.
The RR (breathing rate) is the number of movements of the chest indicative of inspiration and expiration per unit time. It is measured by counting the number of breaths for one minute by monitoring how many times the chest rise BMI.
The BMI is a value derived from the mass (weight) and height of an individual. The BMI is measured using the formula body mass divided by the square of the body height.
Intervention for the three groups includes the following.
- Yoga therapy group (Y)
- Yoga therapy combined with Ayurveda treatment group (Y + A)
- Yoga therapy combined with naturopathy treatment group (Y + N).
The practices constituting the special techniques for arthritis involve physical practices (loosening practices), breathing practices, and relaxation. One hour class 3 times per day was conducted which involved combination of the same techniques. In addition to the daily practices, Kriyas (cleansing practices) were given twice a week. Daily schedule followed by all three treatment groups is provided in [Table 1]. The list of the practices given under each yoga based practice is enlisted in [Table 2] and the list of adjacent treatment given to ayurveda and naturopathy group is been provided in [Table 3].
|Table 1: Daily schedule for all three treatment groups (yoga therapy group, yoga therapy combined with Ayurveda treatment group, yoga therapy combined with naturopathy treatment group)|
Click here to view
|Table 2: Yoga therapy for arthritis: List of special techniques (3x/day)|
Click here to view
|Table 3: Adjacent treatment list for Ayurveda and naturopathy (1 h, 2x/day, morning/evening)|
Click here to view
Participants who were allocated to either yoga therapy + ayurveda or yoga Therapy + naturopathy group receive ayurvedic or naturopathic treatment, respectively, in addition to yoga therapy.
Data extraction and analysis
The data were entered in Microsoft Excel and analyzed using the statistical software SPSS version 10.0. (IBM India Pvt. Ltd.) Kolmogorov–Smirnov test was used to assess normality of the data in each group. Data were found to be normally distributed, and hence, paired t-test was used for within group pre-post analysis, and one-way ANOVA was used for between-group comparisons at the baseline and after the interventions, respectively.
| Results|| |
[Table 4] shows the demographic profile of the sample. All three groups were not significantly different in their basic demographic profile. No individual in any of the groups reported side effects of the intervention. Within-group comparison [Table 5] showed significant improvement in all the variables (all P < 0.01) except BP in all the three groups. Furthermore, BMI, RR, and HR did not show significant changes before and after the treatment for yoga + naturopathy group. Between-group comparison [Table 6] showed significant improvement in yoga group as compared to yoga + naturopathy group for KOOS subscale - sports function and recreation (P = 0.049; F = 3.24) and for HR (P = 0.025, F = 4.014) in yoga group as compared to yoga + ayurveda group.
|Table 5: Comparison of baseline scores with post intervention scores within the yoga group, Yoga+ Ayurveda group and Yoga + Naturopathy group|
Click here to view
|Table 6: Comparison between yoga group, yoga + ayurveda group and yoga + naturopathy group for baseline scores and post intervention score|
Click here to view
| Discussion|| |
This study was planned as a pilot trial to assess feasibility and effects of adding ayurveda and naturopathy to yoga therapy on the treatment outcomes of knee OA. We observed that addition of Ayurveda and naturopathy to yoga therapy for short-term treatment was safe and feasible. Yoga therapy for 1 week improved clinical symptoms, anthropometric measures, and psychological states of individuals with knee OA, but adding naturopathy or ayurveda treatments to yoga did not bring any significant change on these variables.
Within-group comparison in yoga group showed significant improvements in most of the parameters assessed. These results are consistent with findings of Garfinkel et al. who found similar result in patients with hand OA, i.e. improvement in finger's range of motion and pain. The current study shows similar positive findings with yoga therapy as found by Ebnezar et al. and Kolasinski et al. and that too within 1-week duration of yoga therapy. The results of the current study strengthen the understanding that yoga has a beneficial effect on knee OA. From previous studies, the insight has been gained that yoga works through reduction in associated pain and stiffness by realigning the skeletal structure, strengthening muscles around the joints, and stretching tight joint structures. For example, the frequent joint motion when practicing yoga has physiologic effects at the cellular level. Becausein vitro production of pro-inflammatory interleukin-1 z and tumor necrosis factor decreases under low-level intermittent fluid pressure, yoga exercise may reduce fluid pressure, which, in turn, preserves cartilage that would allegedly be lost by immobilization.
The effects of yoga relative to other complementary treatments (e.g. tai chi, and acupuncture) or to conventional therapies are still rather unexposed in the previous researches. Hence, the aim of the current study was to find whether ayurvedic treatments and naturopathic treatments are having an adjunct effect to yoga therapy in patients with OA. It was assumed that there is a significant difference in mean of the parameter measurements after the 1-week intervention between the three treatment groups. The between-group analysis showed significant differences in KOOS sports function after the treatment with yoga + naturopathy group having higher scores. Participants of the group yoga + naturopathy reported about more severe symptoms regarding their knee-related problems in the area of recreational activities and sport than the group which received only yoga therapy after 1 week of treatment. This result could reflect that symptoms may aggravate initially during the treatment with naturopathic methods whereas the symptom easing effect sets in after a longer duration of naturopathy treatment. A future study could concentrate on respective investigations with longer treatment durations for all groups. It was also shown that pulse rate was higher in yoga + naturopathy group than yoga group after 1-week treatment. Participants receiving naturopathy treatment were allocated to specific diets and fasting. It may be that these participants responded to changes in food habits with more internal stress which may have manifested in higher pulse rates.
Previous studies,, have shown significant results with yoga therapy for OA but none of them have done a comparative study with ayurveda and naturopathy treatments. This study was a first attempt to compare between different treatment modalities and to find out whether complimentary alternative therapies have an additional treatment effect to yoga therapy in the treatment of knee OA. Though the tendencies suggest that yoga therapy as a single treatment appears as effective as yoga + naturopathy or yoga + Ayurveda in a short-term residential setup, still the study showed that it was feasible to add Ayurveda or naturopathy to yoga in the treatment of knee OA without causing much adverse effects.
The major strengths of the present study are as follows: (a) the present study is the first attempt to compare the efficacy of two CAM treatments given as an adjunct to yoga, i.e. Ayurveda and naturopathy in the treatment of knee OA, (b) first trial to decipher whether Ayurveda or naturopathy can have an additional effect to yoga therapy in treatment of knee OA, (c) an attempt to give a direction towards integrating different treatment facilities for OA by finding out the feasibility, safety, and efficacy of integrative therapies.
The sample sizes of the yoga therapy, yoga therapy + Ayurveda and yoga therapy + naturopathy group were relatively small (n = 16, n = 21, n = 10). Furthermore, the duration of treatment time given to the participants was small which might not be sufficient enough to bring significant changes in the yoga + Ayurveda group and yoga + naturopathy group. It is known that the benefits of ayurvedic and naturopathic treatment can be seen only after a prolonged and continuous application rather than having immediate effects on health. Similarly, Ayurveda treatments should be preceded by purification treatments (Shodhana or Panchakarma) procedures which were not followed in this study. Future studies should test the effect of full Panchakama procedures.
Future studies should focus on higher sample sizes for the add-on treatment groups. Further recommendations include extension of treatment duration to assess the effects of add-on treatments when given for a longer duration of time. Furthermore, follow-up studies could investigate possible long-term effects.
| Conclusion|| |
Although addition of Ayurveda and naturopathy to yoga therapy for short term did not yield significant results, it was found to be feasible and safe. The current study also suggests yoga as monotherapy to be as effective as other CAM therapies in the treatment of OA in a short-term residential setup. Seven days yoga therapy improved clinical symptoms, anthropometric measures, and psychological states of individuals with knee OA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Davis MA. Epidemiology of osteoarthritis. Clin Geriatr Med 1988;4:241-55.
Bonica JJ. The need of a taxonomy. Pain 1979;6:247-8.
Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatr Med 2010;26:355-69.
Arden N, Cooper C. Osteoarthritis: Epidemiology. Osteoarthritis Handbook. London: Taylor & Francis; 2006. p. 1-22.
Ruddy S, Harris ED, Sledge CB, Sergent JS, Budd RC. Kelley's Textbook of Rheumatology. 6th
ed. Philidelphia: Saunders; 2000.
Haq I, Murphy E, Dacre J. Osteoarthritis. Postgrad Med J 2003;79:377-83.
Nevitt M. Risk factors for knee, hip and hand osteoarthritis. In: Arden N, Cooper C. editors. Osteoarthritis Handbook. London: Taylor & Francis; 2006. p. 23-48.
Sarzi-Puttini P, Cimmino MA, Scarpa R, Caporali R, Parazzini F, Zaninelli A, et al.
Do physicians treat symptomatic osteoarthritis patients properly? Results of the AMICA experience. Semin Arthritis Rheum 2005;35:38-42.
Sale JE, Gignac M, Hawker G. How “bad” does the pain have to be? A qualitative study examining adherence to pain medication in older adults with osteoarthritis. Arthritis Rheum 2006;55:272-8.
Walker-Bone K, Javaid K, Arden N, Cooper C. Regular review: Medical management of osteoarthritis. BMJ 2000;321:936-40.
Khan MU, Jamshed SQ, Ahmad A, Bidin MA, Siddiqui MJ, Al-Shami AK, et al.
Use of complementary and alternative medicine among osteoarthritic patients: A review. J Clin Diagn Res 2016;10:JE01-6.
Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American college of rheumatology subcommittee on osteoarthritis guidelines. Arthritis Rheum 2000;43:1905-15.
Sharma M. Yoga as an alternative and complementary approach for arthritis: A systematic review. J Evid Based Complementary Altern Med 2014;19:51-8.
Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effects of an integrated approach of hatha yoga therapy on functional disability, pain, and flexibility in osteoarthritis of the knee joint: A randomized controlled study. J Altern Complement Med 2012;18:463-72.
Kolasinski SL, Garfinkel M, Tsai AG, Matz W, Van Dyke A, Schumacher HR. Iyengar yoga for treating symptoms of osteoarthritis of the knees: A pilot study. J Altern Complement Med 2005;11:689-93.
Chandrashekara S, Anilkumar T, Jamuna S. Complementary and alternative drug therapy in arthritis. J Assoc Physicians India 2002;50:225-7.
Zaman T, Agarwal S, Handa R. Complementary and alternative medicine use in rheumatoid arthritis: An audit of patients visiting a tertiary care centre. Natl Med J India 2007;20:236-9.
Yip YB, Tam AC. An experimental study on the effectiveness of massage with aromatic ginger and orange essential oil for moderate-to-severe knee pain among the elderly in Hong Kong. Complement Ther Med 2008;16:131-8.
Perlman AI, Ali A, Njike VY, Hom D, Davidi A, Gould-Fogerite S, et al.
Massage therapy for osteoarthritis of the knee: A randomized dose-finding trial. PLoS One 2012;7:e30248.
Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee injury and osteoarthritis outcome score (KOOS) – Development of a self-administered outcome measure. J Orthop Sports Phys Ther 1998;28:88-96.
Örtqvist M, Roos EM, Broström EW, Janarv PM, Iversen MD. Development of the knee injury and osteoarthritis outcome score for children (KOOS-child): Comprehensibility and content validity. Acta Orthop 2012;83:666-73.
Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of knee function: International knee documentation committee (IKDC) subjective knee evaluation form, knee injury and osteoarthritis outcome score (KOOS), knee injury and osteoarthritis outcome score physical function short form (KOOS-PS), knee outcome survey activities of daily living scale (KOS-ADL), lysholm knee scoring scale, oxford knee score (OKS), western Ontario and McMaster universities osteoarthritis index (WOMAC), activity rating scale (ARS), and tegner activity score (TAS). Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S208-28.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
Nagarathna R, Nagendra HR. Yoga for Arthritis. Bangalore: Swami Vivekananda Yogaprakshana; 2015.
Garfinkel MS, Schumacher HR Jr., Husain A, Levy M, Reshetar RA. Evaluation of a yoga based regimen for treatment of osteoarthritis of the hands. J Rheumatol 1994;21:2341-3.
Taylor M. Yoga therapeutics: An ancient, dynamic systems theory. Tech Orthop 2003;18:115-25.
Grober J, Thethi A. Osteoarthritis: when are alternative therapies a good alternative? Consultant 2003;43:197-202.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]