Thursday, May 21, 2020
Although humankind has always practiced a spectrum of diversified cultures and rituals throughout history, people will remain constant. They will hang on to their ancient learnings creating a transparent, barbaric-based environment. Shirley JacksonÃ¢â¬â¢s famous short story Ã¢â¬Å"The LotteryÃ¢â¬ has created controversy among her audience with regard to its purpose. The story describes a small New England village which practices an annual ritual known as Ã¢â¬Å"The LotteryÃ¢â¬ . In the beginning of Ã¢â¬Å"The LotteryÃ¢â¬ , townspeople gather in the villageÃ¢â¬â¢s town square, where everyone waits for the ritual to commence. One of the main characters, Mr. Summers, hosts the lottery and chooses a Ã¢â¬Å"luckyÃ¢â¬ winner from a black, broken-down box. After selecting a name from the box,Ã¢â¬ ¦show more contentÃ¢â¬ ¦The description of the rituals show that someone influences the people to chant and praise. This illustrates an otherworldly identification of the leader. Ja ckson further describes the victim of the lottery as someone who stood before the crowd resembling a divine being. Words such as Ã¢â¬Å"dulyÃ¢â¬ and Ã¢â¬Å"supposedÃ¢â¬ provides knowledge that the village practiced and followed the same procedure every year with no other alternatives or any other unrequired arrangements. Similarly, Old Man Warner, when talking about the dangers of discontinuing the lottery, continues, Ã¢â¬Å"Used to be a saying about Ã¢â¬ËLottery in June, corn be heavy soonÃ¢â¬â¢Ã¢â¬ (Jackson 4). Old Man WarnerÃ¢â¬â¢s words imply the worship of a higher being, who willingly. sacrifice their own people to a divine individual with the hope that the rest of the year will be successful. This proves that the villagers donÃ¢â¬â¢t necessarily understand the real reason for the lottery; they subside because they believe in a higher being who will reward them with a good year. Although Jackson does tie Ã¢â¬Å"The LotteryÃ¢â¬ to a Biblical theme, there lie s a greater reason for the twisted ending of her short story. Ã¢â¬Å"The LotteryÃ¢â¬ uses details to illustrate the traditional customs of patriarchy. The abundance of evidence in the text that suggests that males dominate this society. Ã¢â¬Å"The lottery was conducted--as were the square dances, the teen club, the Halloween program--by Mr. SummersÃ¢â¬ (Jackson 1).Show MoreRelatedAll About Peace Education13195 Words Ã |Ã 53 PagesRights Peace education is an elusive concept. Although peace always has been and continues to be the object of an unceasing quest in almost all communities and groups, the training of each new generation centers on divisive issues of in-group/out-group differentiations, intergroup conflict and ongoing preparation for defense and war against real and perceived enemies. The universal presence of conflict and war in human history has always necessitated that priority be given to education forRead MoreDeveloping Management Skills404131 Words Ã |Ã 1617 Pagestextbooks for introducing students to the leading theories about management while ignoring what is known about effective management practice. Sympathetic to MintzbergÃ¢â¬â¢s critique, we set out to identify the defining competencies of effective managers. Although no two management positions are exactly the same, the research summarized in the Introduction highlights ten personal, interpersonal, and group skills that form the cor e of effective management practice. Each chapter addresses one of these skills
Wednesday, May 6, 2020
Coming of Age in Mississippi is an eye-opening testimony to the racism that exemplified what it was like to be an African American living in the south before and after the civil rights movements in the 50s and 60s. African Americans had been given voting and citizen rights, but did not and to a certain degree, still can not enjoy these rights. The southern economy that Anne Moody was born into in the 40s was one that was governed and ruled by a bunch of whites, many of which who very prejudice. This caused for a very hard up bringing for a young African American girl. Coming of Age in Mississippi broadened horizon of what it was like for African Americans to live during the 40s, 50, and 60s. There are many traces ofÃ¢â¬ ¦show more contentÃ¢â¬ ¦Also, I think that since she was busy with everything else in her life that she could not really hang out with friends, church was a place for her to make some friends. Religion was not just a factor for Anne, but for many of the slaves during the Civil War. The slaves would use religion as a way to get away from the harsh realities of their lives. Also they viewed Jesus and Moses as heroes who lead their people to freedom. Their religion was aimed toward the real world rather than being in heaven when they died. Basically, their singing or praying was about being delivered from slavery. They also used hymns as special codes for meeting points while trying to escape. To me the song Swanee River has a different meaning to the song on page 129. To me Swanne River was talking about being at home and a child, being around the familiar faces; your family and friends. Also, I think that home refers to being back on the plantation where they know they have security. Not in the sense of being safe, but being where they know and somewhat have fun. The song on page 129 about gods hebben means to me that black and white people are the same, minus the color of their skin. It is saying that every one is the same in God s eyes, and when we get to heaven we are all going to look the same. To me the Swanee River song tells me that the black people miss being at home and as much as they hated being owned by whites they miss being on theShow MoreRelatedComing of Age in Mississippi2022 Words Ã |Ã 9 PagesComing of Age in Mississippi Anne Moody Questions: 1. What did the murder of Samuel OÃ¢â¬â¢Quinn do to Anne Moody? 2. What were the causes of Anne MoodyÃ¢â¬â¢s relationship with her mother changing when she went to college at Tougaloo? 3. During the movement, why was organizing in Canton, Mississippi so much more difficult than in Jackson, Mississippi? Introduction Coming of Age in Mississippi is an autobiographical book written by Anne Moody. The book entails the struggles throughout an AfricanRead MoreThe Monograph Coming of age in Mississippi1286 Words Ã |Ã 6 PagesÃ¯ » ¿ MONOGRAPH PAPER COMING OF AGE IN MISSISSIPPI Coming of Age in Mississippi by Anne Moody was published on 1968. This autobiography is memoires of Anne Moody about growing up poor and black in the rural Mississippi. The book was divided into four parts from childhood until her late 20s that described the experiences of Anne Moody in the Civil Rights Movement and her struggles againstÃ racism. Anne Moody was born in the 1940s which was the time after World War IIRead MoreComing of Age in Mississippi Essay806 Words Ã |Ã 4 Pages As if growing up wasnt turbulent enough, Anne Moody grew up during a crucial time in American History. It was during this time that race and civil rights took center stage in her home state of Mississippi. Young women face many physical and emotional changes during their teenage years, regardless of when and where they grew up. However, for Anne Moody, and other young black women, there was the instability in race relations to deal with as well. During her younger childhood years, Anne wasRead MoreComing Of Age Throughout Mississippi1342 Words Ã |Ã 6 PagesDeandra Green Professor Joshua Jeffers United States History II 3 November 2015 Coming of Age in Mississippi The book Coming of Age in Mississippi goes into detail about a very prominent time in United States history. The book takes us back to a time where the issue of civil rights began to rise eventually reaching its peak marking this an unforgettable time in history for that generation and for generations to come. During this time the south in general was already a tough place to be in, butRead MoreComing of Age in Mississippi and Segregation Essay1304 Words Ã |Ã 6 PagesComing of Age in Mississippi is an autobiography of the famous Anne Moody. Moody grew up in mist of a Civil Rights Movement as a poor African American woman in rural Mississippi. Her story comprises of her trials and tribulations from life in the South during the rise of the Civil Rights movement. Life during this time embraced segregation, which made life for African Americans rough. As an African American woman growing up during the Civil Rights movement, Moody has a unique story on themes likeRead MoreAnne Moody Coming Of Age In Mississippi1626 Words Ã |Ã 7 PagesAnne MoodyÃ¢â¬â¢s autobiography, Coming of Age in Mississippi, depicts the various stages of her life from childhood, to high school, then to college, and ends with her involvement in the Civil Rights Movement. In the novel, Anne tells the reader her story through events, conversations, and emotional struggles. The reader can interpret various elements of cultural knowledge that Anne Moody learned from her family and community as a child. Her understanding of the culture and race relations of the timeRead More Coming of Age in Mississippi Essay example639 Words Ã |Ã 3 Pagesactivist and NAACP member tried to organize a meeting, the Principle Willis, who is an Uncle Tom, tattled on him. Samuel was shot by a mob of white men. The first experience of a civil rights movement was when she was attending Natchez College in Mississippi. The lunch lady served food with maggots in it. The cook, Miss Harris, knew that the food was s poiled but didnÃ¢â¬â¢t care. Anne organized a protest and it was successful. This was a hint of what was yet to come from Anne. nbsp;nbsp;nbsp;nbsp;nbsp;BlacksRead MoreAnne Moodys Coming of Age in the Mississippi1268 Words Ã |Ã 6 Pageswas with her white skinned Ã¢â¬Å"blackÃ¢â¬ relatives. Ã¢â¬Å"If it wasnÃ¢â¬â¢t the straight hair and the white skin that made you white, then what was it?Ã¢â¬ 3 The racial hierarchy was not only comprised of blacks and whites, which Essie-Mae Moody discovered at a young age. In between white and black were all shades of people, some almost flaunted their white qualities and lighter skin, and even acted superior to those of darker shades even among relatives. However, Essie didnÃ¢â¬â¢t understand why Ã¢â¬Å"Ã¢â¬ ¦ they hated Mama andRead MoreComing of Age in Mississippi- Anne Moody797 Words Ã |Ã 4 Pagesbegins with Anne as a four-year-old child watching her parents work everyday for Mr. Carter, a white plantation owner. She witnessed several black farmers living in rotten, two-room wooden shacks. It was most likely evident to her, even at that early age, that Whites were the affluent, upper-class. She elucidates her recognition of the difference in living conditions in the following statements: It seemed as though we were always moving. Every time it was a house on some white man s place andRead MoreComing of Age in Mississippi vs. The Jungle Paper1039 Words Ã |Ã 5 PagesComing of Age in Mississippi vs. The Jungle Paper There is an argument that states that Anne Moodys tale in Coming of Age in Mississippi is a more optimistic tale then that of Jurgis Rutkis in The Jungle and vice versa. This is not the case. When you take the time to analyze both story, you come to find that both have the same pessimistic core. The only difference is the character Jurgis was optimist throughout most of the beginning despite his circumstances yet in the end he loses all hope
Although they have very different plots with vastly different different characters, a common theme is cleverly intertwined by the authors of the following stories. Ã¢â¬Å"The Interlopers,Ã¢â¬ by Saki narrates a duel between two neighbors, torn apart by their forefatherÃ¢â¬â¢s grudge. Ã¢â¬Å"Gimpel the Fool,Ã¢â¬ by Isaac Bashevis Singer, is told by a man thought of as a fool, and forgives all those who mistreat and abuse him. We will write a custom essay sample on Irony a Common Theme or any similar topic only for you Order Now The play Ã¢â¬Å"Pygmalion,Ã¢â¬ by Bernard Shaw shows the story of a normal flower girl becoming an upper class lady, and all the woes that come with it. The Interlopers,Ã¢â¬ Ã¢â¬Å"Gimpel the Fool,Ã¢â¬ and Ã¢â¬Å"PygmalionÃ¢â¬ all share the common theme of irony. Even in such different contexts, irony is seen in these tales. Ã¢â¬Å"The InterlopersÃ¢â¬ has an ironic ending that shocks the reader. Saki starts the short story with Ulrich von Gradwitz seeking his nemisis, Georg Znaeym in a vast forest he calls his own. The reason for such hate would be many generations before dispute over land and game, which was still existed. When they both face each other, they are both prepared to kill one another, until a tree falls on them. After endless bickering under the tree, Gradwitz tells Znaeym, Ã¢â¬Å"Neighbor, if you will help me to bury the old quarrel I- I will ask you to be my friend,Ã¢â¬ (4) who then agrees. After this, Ã¢â¬Å"The InterlopersÃ¢â¬ abruptly ends with the two men ironically being eaten alive by a pack of wolves. In Ã¢â¬Å"Gimpel the Fool,Ã¢â¬ the main character, Gimpel, is treated as a fool all his life in a village, and doesnÃ¢â¬â¢t let it bother him, which further convinces the townspeople of his ignorance. This is ironic since Gimpel is actually the smartest of the bunch by thinking to himself, Ã¢â¬Å"let it passÃ¢â¬ (1) even though he is labeled throughout the story as a fool. Till the end, the village makes a fool out of Gimpel, through forcing him to marry an outwardly unfaithful woman to acting to his face as if they donÃ¢â¬â¢t know that all children born from her have different fathers. Finally, after his wifeÃ¢â¬â¢s death, Gimpel leaves his sad little hometown. He then travels around the world, telling tales to many audiences, and enjoying pleasureful company. Indeed, Gimpel was not a fool. In Ã¢â¬Å"Pygmalion,Ã¢â¬ a phonetics professor, Mr. Higgins, takes the responsibility of training a lower class flower girl, to becoming an upper class woman, which has an ironic outcome due to the fact that her new lifestyle would seem be more comfortable, but in reality is not. Mr. Higgins is forced to teach Eliza the whole English language to her once again due to her own version containing words/sounds such as Ã¢â¬Å"Ah-ah-ah-ow-ow-ow-oo! Ã¢â¬ (1749) Eliza already being beautiful, it only takes washing up to look like a lady. Resulting from becoming a proper lady, ironically Eliza has to sell herself in order to find a husband, while when she was a flower girl she just had to sell flowers. Keeping up with the superficial world of appearances with everyone watching her every move proves to be too stressful, and Eliza eventually breaks. She then leaves Mr. Higgins to marry someone he considered a fool, Freddy, who was smitten with her. In all these stories,different types of irony is expressed. The InterlopersÃ¢â¬ has situational irony since the result of the truce of the two men did not result in their freedom, but contrary, their death. In Ã¢â¬Å"Gimpel the Fool,Ã¢â¬ there is verbal irony since Gimpel is purposely labeled as a fool by the author though the truth is the opposite. Ã¢â¬Å"PygmalionÃ¢â¬ has dramatic irony since Eliza believes her life will be better as an upper class woman, though we know that will not be the case, as she herself also finds out the next day. Using irony not only adds twists to these stories, but also contributes to character development and increases suspense. How to cite Irony a Common Theme, Papers
Sunday, April 26, 2020
Why Are We So Concerned With Our Image Essay Example Paper Why Are We So Concerned With Our Image Essay Introduction We are subsequently concerned with our image and the manner others, around us perceive us. We strive, everyday to shine within a multitude of stars and to be fully appreciated by our friends, family and associates. We put on a show, each day according to the way we aspire others to view us, as individual people, who stand out and deserve an encore on our own, personal stages.Our world is a stage, our life is a drama, perfectly played out in our roles, and we are the actors, performing. Each and every one of us, share similar aspirations in life and yearn for each one of our presentations to be ideal in order to achieve our goals. Our personal stage must be precisely set and the audiencesÃ¢â¬â¢ reaction or perception of our acting abilities will be demonstrated through their feedback.During oneÃ¢â¬â¢s lifetime, a presentation on stage is not always what we anticipate, an event in which Erving Goffman referred to as a Ã¢â¬Å"dramaturgical analysisÃ¢â¬ .Our social life allows for more than one role to played, for example, being a student, daughter, or lover, requires different presentations. As Goffman mentions in his book Ã¢â¬Å"The Presentation of Self in Everyday life: Selections.Ã¢â¬ In our show, we offer an impression to the audience through verbal and body language, and the interaction we communicate to others, relays how we perceive ourselves. Goffman views the world as micro sociology; social interactions, and according to Henslin, it is face to face interaction demonstrating how people react and behave when they come together and demonstrates how they get along and survive.First impressions are incredibly important since they may affect how others regard us as individuals, while they build our confidence and heighten our reputation as award winning. According to Henslin, Ã¢â¬Å"When you first meet someone, you cannot help but notice certain features, especially the personÃ¢â¬â¢s sex, race, age and clothingÃ¢â¬ . We develop other impressions t hrough vision and by listening to the character. You may possibly hear someoneÃ¢â¬â¢s name or all about their story before you actually meet them and perhaps you have already developed a pre-developed image of that person.When you are first introduced to a person, important factors furnish us with a cause to imagine and possess assumptions regarding that individual, therefore, regardless of their true character or personality, your assumptions have already shaped your first impression. This is an important explanation of why people are so concern in relation to their image, since all factors have persuasive influence on a personÃ¢â¬â¢s social life.The scene displayed when Mary Harron first met with Andy Warhol, is one demonstration of a first impression of an individual. (Harron, 1980) In the article Ã¢â¬Å"Pop Art/ Art Pop: The Warhol Connection,Ã¢â¬ before Harron actually met with Andy Warhol, she had previously heard numerous stories in relation to Warhol, and she had alre ady develop a vivid impression of Warhol, consequently, there was little shock about his overall appearance and personality and she was only surprised about WarholÃ¢â¬Ës age.Pop art was a subject that came to mind when one imagined Warhol, so his age was never a consideration.Henslin mentions in his book titled Ã¢â¬Å"Essential of SociologyÃ¢â¬ , (Henslin, 2004) that Ã¢â¬Å"We possess ideas on how we want others to judge us, and we use our character roles in everyday life to communicate these ideas. Goffman referred to these efforts which manage the impressions that others receive from us, as Ã¢â¬Å"impression managementÃ¢â¬ . Goffman also considered impression management as a way to control our performance as we perform in a certain manner; one that an audience expects from us so they may be guided against an unexpected and unfamiliar scene.I play the role of a daughter, for my parents and my attitude is always respectful and polite since this is how I want to present myself to them.According to lecture notes on micro sociology, Professor Steve discusses the GoffmanÃ¢â¬â¢s Theory where he explains that Ã¢â¬Å"We are all trying to present an idealized vision of ourselves while trying to hide our very real problems or shortcomingsÃ¢â¬ . We consistently want to offer a good impression by acting out what we think others want, so we continually perform our roles according to what the audience wants to see, and the advantage is that we will gain an excellent reputation if we do meet their expectations but if we fail to meet those expectations, we fail while performing that role.Goffman looks at our daily life as a performance played out on a big stage and as actors performing for our audience; we must remember that what we perform will be our major Ã¢â¬Å"appearance.Ã¢â¬ Goffman also articulates that Ã¢â¬Å"It is an appearance on the front stage,Ã¢â¬ which also implies that there is an aspect of our personalities that yet remains on the back stage b ut front stage is what Goffman is concerned with thus our performance for others will be routinely acknowledged by society. As Speakers in our school clubs and dinners, we are considered actors in a front stage performance.According to an article Ã¢â¬Å"The Presentation of Self in Everyday Life: SelectionsÃ¢â¬ by Goffman, he refers to our performances as Ã¢â¬Å"All the activity of an individual which occurs during a period, marked by continuous presence before a particular set of observers and has some influence on our observers.Ã¢â¬ He also mentions that there are various elements in our appearances. The stage setting includes our physical layout while the background supports our stage. The setting will allow the audience to follow our performance, while the appearance and our method basically describes our social status and the role we play will demonstrate to the audience the level of our educational background and enlighten them whether we are involved in social activities or if we are aggressive actors, displaying us as great leaders in our performance.In Ã¢â¬Å"The Presentation of Self in Everyday Life: SelectionÃ¢â¬ , Goffman divided the front stage into two parts; we Ã¢â¬Å"giveÃ¢â¬ and Ã¢â¬Å"give offÃ¢â¬ . The give involves verbal symbols which he utilized to convey the information in helping the performer and audience to engage in the performance, while the Ã¢â¬Å"give offÃ¢â¬ includes a wide range of action performances in which the audience may consider feeling sympathy for the actor.Since there is a front stage, there must also be a back stage, where we relax and showcase our full identities without being concerned with how others perceive us.According to the lecture notes by Professor Steve, most of our time is spent performing on front stage, which means wearing costumes and dressing up, however, our back stage performance is a place where we hide our true problems, since everyone does have a secret about themselves. A person ma y have a drinking problem, gambling or some illegal activity that they wish to keep private. They may try to hide pieces of their life and during their performance, they may give a different impression to others about who they really are. Goffman offers that we have to conceal the process in order to make our stage performance. If Goffman is correct in his theory, then we all are exceptional actors who deserve to win Oscars!As Goffman pointed out in his article (Goffman, 1959) Ã¢â¬Å"The Presentation of Self in Everyday Life: SelectionÃ¢â¬ , Ã¢â¬Å"In order to get the setting right for the performance, manner calculating is also important,Ã¢â¬ which means that good designs should be a big part of the setting and like Mary Harron, Goffman shares her ideas of first impressions, as in her online article Ã¢â¬Å"Pop Art/ Art PopÃ¢â¬ , she mentions that one of the reasons that Andy Warhol became a famous pop artist was due to the fact that he respectfully, knew how to calculate and manipulate the media.Warhol has displayed a man who had respect for money, fame and power. He is a famous artist, who within his social connections is incredibly large, therefore, Harron made the connection that it is not only Warhol who became famous but the people around him; his friends and coworkers became famous, as well. All famous people have one thing in common; they have more stages to perform on than an average individual, while one stage is for the media and the public, the other stages are held out for their friends and family.Ã¢â¬Å"Movies, radio and TV have changed the nature of fameÃ¢â¬ , Mary Harron explains that Andy Warhol used this type of communication to build the idea of Pop Art and today, in our society because Andy Warhol is a symbol of pop, and plays the achievement role in his performances and Pop Art is a standard that people and society determine on their own.Warhol built up an idealization of society as he heightened their expectations by expressing h is wealth and power. Goffman also agrees that material possessions are expressed as one of the most important parts of social class as a status symbol.According to our lecture notes, Goffman believes that each of us possess secrets and display our freakiness in some fashion and if we behave in an anticipated manner or perform differently than what others expect, they may feel that we are behaving irrationally, so there is the chance that you could be considered less desirable as a human being.The movie Ã¢â¬Å"BoyÃ¢â¬â¢s DonÃ¢â¬â¢t CryÃ¢â¬ was inspired by a true story by Brandon Teena who has a sexual identity crisis, since she was born with a femaleÃ¢â¬â¢s body but thinks like a male. She cut her hair and taped down her breasts which made her look like a man; her way of setting her stage for her own performance; one that began when she arrived in Nebraska. The new audience had no idea that she was a female. When Brandon Teena falls in love with Lana and becomes one of LanaÃ ¢â¬â¢s friends, performing as a young male, she offered a grand performance. Garfinkel offered that she Ã¢â¬Å"Engaged in activities that made her appear to be something she wasnÃ¢â¬Ët.Ã¢â¬ The movie is not only about BrandonÃ¢â¬â¢s performance but about the environment that supports her status. Garfinkel also believes that we have to manage our own identities through hard work, achievement and accomplishment.There was nothing wrong with Brandon Teena as a person but she was not accepted and marginalized by the society, so she failed in her performance and end up murdered by LanaÃ¢â¬â¢s friendsI do believe that our society is changing because bisexuals are becoming more common and people tend to treat bisexuality as normal and in the movie Ã¢â¬Å"BoyÃ¢â¬â¢s DonÃ¢â¬â¢t Cry,Ã¢â¬ (Peirce, 1999) we understand how important and effective a front stage and back stage performance can be as we all want to find a spot in society where we can belong.In a personal experience of my own, I was studying aboard in England. When I first arrived at the school, I behaved as a quiet and shy stranger because I didnÃ¢â¬â¢t know anything about the people, in England. I didnÃ¢â¬â¢t want to offer a performance, until I know more about them. When I was approached for conversation, I changed my performance by offering an outgoing person, who did want to talk and be socially interactive, in order to make friends.Sometimes, I am nice to people that I donÃ¢â¬â¢t like and I play that role. Goffman refers to this behavior as playing different roles, while others call it being two-faced, but the more I think about it, I understand that everyone might have more than two faces on their stage in life.There are many instances during my life performances, where I will be forced to make alterations but I will continue performing, offering an award winning performance! Why Are We So Concerned With Our Image Essay Thank you for reading this Sample!
Thursday, March 19, 2020
Treatment Rehabilitation of Grade II Medial Collateral Ligament (MCL) Injury Introduction Treatment Rehabilitation of Grade II Medial Collateral Ligament (MCL) Injury IntroductionGeneral Knee AnatomySpecificÃ Medial Collateral Ligament AnatomyBiomechanicsMechanism of InjuryPhysical Examination/Clinical AssessmentRadiographClassification of InjuryTreatment and Rehabilitation ObjectivesInflammatory Phase (up to 72 hours post injury)Proliferation Phase (3-21 days post injury)Increased range of motion was also enhanced by using a stationary bicycle (Wilk et al., 1996).A.Ã Ã Ã Ã Ã Basic ExercisesProprioceptionConclusion/SummaryReferencesRelated Introduction The superficial medial collateral ligament (MCL), and other medial knee stabilisers (most notably the deep medial collateral ligament and the posterior oblique ligament) are the most commonly injured ligamentous structures of the knee (Grood, et al., 1981; Hughston, 1981; Phisitkul, et al., 2006; van der Esch, et al., 2006). The majority of MCL tears are isolated and predominantly occur in young people participating in sports activities. Typically, the mechanism of injury involves valgus knee loading, external rotation or a combined force vector- particularly prevalent in sports such as football and skiing which involve these type of forces and repetitive knee flexion (Peterson, et al., 2000). In the United States, occurence of these types of injuries to the knee has been reported to be 0.24 per 1000 during any given 12 month cycle and to be twice as high in males 0.36 compared with 0.18 in females (Daniel, et al., 2003). In actual fact, the incidence of these types of injury is probably much higher than reported as many minor MCL injuries are never even assessed or treated by medical personnel. In terms of treatment, the approach to medial knee injuries has changed dramatically over recent years. As the understanding of the anatomy, biomechanics, and causes of medial knee injuries has evolved, as has the treatment. Ã Whilst in the 1970Ã¢â¬â¢s and 1980Ã¢â¬â¢s surgical treatment for MCL injuries was common place, today most MCL injuries are treated conservatively with early rehabilitation (Phisitkul, et al., 2006). In general, all isolated Grade I and II tears and even the majority of Grade III tears can be treated non-operatively with a supervised, functional, rehabilitation program. Excellent results can be expected with return to full pre-injury activity level being the norm (Bradley, et al., 2006). This paper will research and interpret some of the relevant literature that is available to us, with the aim of developing and implementing a functional rehabilitation plan (in keeping with the principles of soft tissue healing) that is suitable for the treatment of a Grade II MCL injury of a 33-year-old, male, semi-professional footballer (the patient). General Knee Anatomy The knee joint, is the largest and most complex synovial joint of the human body (Bradley, et al., 2006). Figure 1: Anterior view of the patellofemoral joint. Hawkins (2009) The patella, patella ligament and femur combine to form the patellofemoral joint (Saladin, 2001). The patella itself is a triangular-shaped sesamoid bone that is attached to the quadriceps tendon. This tendon inserts into the trochlear groove on the femur and primarily acts to increase the Ã¢â¬Ëmechanical advantageÃ¢â¬â¢ of the quadriceps muscle group (Hamill Knutzen, 1995). The lateral and posterior aspects of the knee joint are encapsulated by a joint capsule whilst the anterior section of the knee is protected by the patella ligament (and its retinacula). The quadriceps and the hamstrings are the prime movers of the knee joint knee Ã¢â¬ËextensorsÃ¢â¬â¢ and Ã¢â¬ËflexorsÃ¢â¬â¢ respectively. The quadricep group of muscles are located on the anterior part of the thigh and comprise of the rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius. They converge on the patella tendon, travel over the patella and insert onto the tibial tuberosity. In addition to knee extension, the quadriceps group of muscles (in combination with the iliopsoas) are also responsible for flexion of the hip (Saladin, 2001). The hamstring muscles are found on the posterior section of the thigh and comprise of the biceps femoris, semimembranosus, and semitendinosus. They are responsible for the flexion of the knee joint and (together with the gluteus maximus) the extension of the hip joint (Saladin, 2001). The main stabilisers of the knee are the quadriceps tendon (to front of the thigh) and the semimembranosus tendon (at the back of the thigh) (Saladin, 2001). The medial and lateral collateral ligaments are primarily responsible for preventing the knee from rotating during extension (Saladin, 2001). The anterior cruciate ligament and the posterior cruciate ligament stop anterior and posterior translation of the tibia relative to the femur (Saladin, 2001). SpecificÃ Medial Collateral Ligament Anatomy Medial knee stability is provided, for the most part, by its Ã¢â¬Ëmedial staticÃ¢â¬â¢ and its Ã¢â¬ËdynamicÃ¢â¬â¢ stabilisers. The medial static stabilisers, which work as an integrated unit, are the superficial MCL, the posterior oblique ligament and the middle third of the deep MCL. The dynamic stabilisers are the per anserinus tendons most notably the semimembranosus tendon (Peterson Renstrom, 2001). The superficial MCL is, on average, 11cm long and 0.5cm wide. It originates from the medial femoral condyle (anterior to the tubercle) and travels, distally, to insert 5-7cm below the joint line on the anteromedial tibia (just below the insertion of pes anserinus tendons). The anterior fibres of the superficial MCL tense during knee flexion whilst its posterior fibres slacken. The superficial MCL is tight during external rotation of the knee (Peterson Renstrom, 2001). The middle third of the deep MCL is a short structure about 2-3cm long and is attached to the meniscus underlying the MCL. This part of the ligament is relatively Ã¢â¬ËslackÃ¢â¬â¢ to facilitate knee motion whilst short enough to hold the meniscus firmly in position. In terms of injury, the deep MCL can be ruptured both proximally and distally to the meniscal attachment (regardless of the location of the tear of the superficial MCL). The posterior oblique ligament is a thick capsular ligament originating just behind the superficial MCL (at the condyle just below the joint line). The posterior oblique ligament becomes Ã¢â¬ËslackÃ¢â¬â¢ during knee flexion (Peterson Renstrom, 2001). Biomechanics Biomechanical studies show that the MCLÃ¢â¬â¢s main function is to resist valgus (outward side motion of the leg) and external rotation forces of the tibia in relation to the femur . The superficial MCL has been found to be responsible for 57% of medial stability at 5ÃÅ¡ of knee flexion and up to 78% at 30ÃÅ¡ knee flexion. The deep MCL accounted for 8% at 5ÃÅ¡ and 4% at 30ÃÅ¡ whilst the posterior oblique accounted for 18% and 4% respectively. Mechanism of Injury The player reported to the clinic approximately 24 hours after the injury occurred. The player was able to weight bear. When asked how the injury occurred the player stated that he was running at pace to Ã¢â¬Ëclose down an opposing playerÃ¢â¬â¢ and then described performing a Ã¢â¬Ëchange of directionÃ¢â¬â¢ or Ã¢â¬ËcuttingÃ¢â¬â¢ manoeuvre. He stated that as he planted and pushed off his right leg, he experienced a sudden excruciating localised pain and an immediate lack of stability in his right knee. This caused him to collapse. As stated, the primary mechanism of injury to the MCL is most commonly a valgus stress (Fetto, et al., 1978). However, due to the position of the knee and the force vectors involved, a combined flexion/valgus/external rotation injury is usually the end result (Hayes, et al., 2000). The vast majority of MCL injuries are from a lateral force to the distal femur with the foot being fixed to the ground, although non-contact valgus external rotation injuries are common the latter being particularly prevalent in sports such as football and skiing (Perryman, et al., 2002; Pressman, et al., 2003). Because of the complexities of knee injuries, it is important to perform a complete knee examination in order to rule out other potential problems such as fractures, cruciate ligament tears, menisci ruptures or chondral cartilage damage (Bradley, et al., 2006). Physical Examination/Clinical Assessment The best time for examination of the knee is immediately after the injury before muscle spasm occursÃ (Phisitkul, et al., 2006). Unfortunately, as in this case, that is not always feasible. However, a 24 hour period of rest and immobilisation (which the patient undertook) is usually sufficient for muscle spasm to subside and relaxation to occur (Hughston, et al., 1976). This allows an effective examination and assessment of the injury. The injury was examined and assessed through a combination of subjective and objective approaches. Important initial information obtained through speaking with the patient and preliminary observations included the location of pain, the ability to ambulate after the injury, time and onset of swelling, the presence of deformity, and the immediate site of tenderness (Indelicato Linton, 2003). The location of oedema and tenderness can accurately identify the injury site of the superficial collateral ligaments in 64% and 76% of cases respectively (Hughston, et al., 1976). The exact location of injuries of the deep MCL and the posterior oblique ligament are more difficult to palpate because of their deep-seated position, but pain and tenderness in this area can at least indicate the presence of injury to these posteromedial structures (Sims Jacobsen, 2004) On asking the patient to indicate the most painful spot, he pointed to the medial aspect of the right knee joint. The area indicated by the patient suggested injury to the MCL. Contralateral comparison of the knees was carried out in order to identify areas of oedema and/or deformity. Significant swelling and slight discolouration was observed on the medial aspect of the right knee joint. Upon palpation of both knee joints, a noticeable heat differential was felt in the affected area. While keeping the patient relaxed, a valgus stress testÃ (MCL test) was performed with the knee in 30ÃÅ¡ of flexion (figure 1), and compared to the contralateral knee as a control. The examination was then repeated with the knee in 0ÃÅ¡ of flexion to recruit the function of remaining posteromedial structures (figure 2). The valgus stress test proved positive in contralateral comparison in 30ÃÅ¡ of flexion and negative in 0ÃÅ¡ of flexion. The absence of laxity in the second test reduced suspicions of any associated injuries to the secondary restraints such as the cruciate ligaments and the posterior capsule. In addition, a number of other tests were carried out to assess whether any injuries, commonly associated with MCL injuries, were prevalent (bone bruises, ACL tears, lateral collateral ligament tears, medial meniscus tears, lateral meniscus tears, and posterior collateral ligament tears). Anteromedial rotatory instability (often present when there is evidence of anterior subluxation of the medial tibial plateau during a valgus stress test with the knee in 30ÃÅ¡ of flexion) was assessd by performing the anterior drawer test (figure 3) whilst holding the tibia in external rotation. This proved negative and therefore ruled out the possibility of a posterolateral knee injury rather than a medial knee injury. LachmanÃ¢â¬â¢s test (figure 4) and the Pivot shift test (figure 5) were also performed to negate the existence of any ACL rupture whilst MurrayÃ¢â¬â¢s test (figure 6) was carried out to assess the integrity of the Meniscus cartilage. All these tests also proved negative. The results of the assessment supported the initial belief that the patient was suffering a superficial MCL injury with the posterior oblique ligament still intact and no associated damage to either the cruciate ligaments or meniscus cartilage of the knee. Radiograph In accordance with the Ottawa knee rules (Stiell, et al., 1997) it was decided that radiographs were not required for this injury. More recent work has shown the Ottawa knee rules to be very successful in reducing unnecessary radiography, whilst ensuring a high level of recognition fractures (Bachman, 2003). The Ottawa knee rules state that a radiograph is required only in patients who have an acute knee injury with one or more of the following: Age 55 years or older Tenderness at head of fibula Isolated tenderness of patella Inability to flex to 90Ã ° Inability to bear weight both immediately and in the emergency department Classification of Injury In 1976 (revised in 1994) Hughston standardised MCL injury classification into two related systems the severity system (Grade I, II III) and the laxity system (grade 1+, 2+ 3+). Under this combined classification system, Grade I involves a few damaged fibres resulting in localised tenderness but no instability or laxity. A Grade II injury involves a disruption to substantially more fibres, with more generalised tenderness but still no instability (although it is not uncommon for a degree of laxity with the knee in 30ÃÅ¡ flexion). A Grade III injury is a complete tear of the ligament with resultant instability and laxity. Grade III injuries are then sub-classified according to the extent of laxity (determined by the amount of absolute joint separation from valgus stress with the knee in 30ÃÅ¡ of flexion). Grade 1+, 2+, and 3+ laxities indicate 3-5 mm, 6-10 mm, and more than 10 mm of absolute medial separation respectively. Fetto and Marshall (1978) defined Grade I injuries as those without valgus laxity in both 0ÃÅ¡ and 30ÃÅ¡ of flexion, Grade II injuries as those with valgus laxity in 30ÃÅ¡ of flexion but stable in 0ÃÅ¡ of flexion, and Grade III as those with valgus laxity in both 0ÃÅ¡ and 30ÃÅ¡ of flexion. The injury was subsequently classified as an isolated Grade II MCL injury in accordance with Hughston (1976 1994) and Fetto Marshall (1976). Using a full return to sport as an indicator of a successful end point, Ellsasser et al (1974) treated 74 professional football players with incomplete tears of the MCL using a functional rehabilitation program. In this study, a success rate of 98% was found compared with a 74% success rate for a separate group treated surgically. In the non-operative group, return to play occurred between 3 and 8 weeks. Return to play was even quicker in a study by Derscheid and Garrick (1981). They treated football players with Grade I and Grade II injuries with a specific rehabilitation programme. Players with Grade I MCL injuries returned to full play in an average of 10.6 days, whereas those with Grade II MCL injuries returned in an average of just 19.5 days, with neither group showing a propensity for injury reoccurrence. Based on this research, a consensus on the time it would take for the patient to return to full sporting activeity would be 3-8 weeks. Treatment and Rehabilitation Objectives An appropriate treatment and rehabilitation plan is required to restore normal function to the knee joint and the surrounding soft tissues with a view to enabling the patient to return to his sport as early and effectively as possible with no residual symptoms and a minimal risk of injury reoccurrence All soft tissue injuries, regardless of their nature and severity, undergo the same three stages of healing the inflammatory phase, proliferation phase and the remodelling phase. The time required to complete each healing stage is dependent up on the nature and severity of the injury. However, of note, numerous investigations comparing surgical and non-surgical treatment have reported no advantages of surgical intervention over non-surgical intervention (Quarles Hosey, 2004; Phisitkul et al., 2006). The following treatment and rehabilitation plan was designed and implemented to address the needs of the patient. Inflammatory Phase (up to 72 hours post injury) The inflammatory phase is characterised by heat, redness, swelling and pain generally leading to a loss of movement and function. The goals of treatment at this stage were: Protect injury Control oedema Prevent associated muscle atrophy Regain range of motion Increase weight bearing capacity Maintain general fitness/strength P.R.I.C.E (Protection, Rest, Ice, Compression and Elevation) The P.R.I.C.E. regimen is employed following injury with a view to controlling the haemorrhage, decreasing inflammation, reducing tissue metabolism and minimising secondary hypoxic injury, cell debris and oedema.Ã Research has suggested that the sooner after injury that cold therapy (cryotherapy) is started, then the more beneficial the reduction in metabolism will be (Knight et al., 2000). Elevation has been shown to have a significant effect on reducing effusion (OÃ¢â¬â¢Donohue, 1976). The patient reported that he had already applied ice intermittently during the 24 hour period between injury occurrence and assessment approximated to have fulfilled 4 x 20 minute applications of crushed ice at 2 hourly intervals with the knee in an elevated position in line with commonly agreed protocol. He also reprted that he had kept the injured limb elevated for sustained periods. Measurement On inspection the right knee was swollen over the lateral aspect with a small amount of visible bruising. At this time the patient was asked to indicate his level of pain using a visual analogue scale (VAS). Measurement of the girth of the knee was also taken using a tape measure whilst active flexion and was also assessed using a goniometer. These measurements would be continually reassessed throughout the rehabilitation process in order to assess progress and outcomes. Continued active flexion was also encouraged at this time. Simple Ã¢â¬Ëknee bend and straightenÃ¢â¬â¢ exercises, with the patient lying in a supine position on an exercise mat the movement repeated 10-20 times,Ã 3 times a day, with a view to increasing active range of movement (figure 1) . The patient was also instructed in different exercises to maintain cardiovascular fitness and upper body conditioning. The patient also received a massage to the upper and lower leg (particularly the quadriceps group of muscles) in an elevated position using effleurage techniques to aid removal of waste products via the lymphatic system reflexive muscular inhibition of the quadriceps has been thought to be the result of the pain associated with MCL injury (Dixit, et al., 2007). The knee was then strapped. Strapping The knee was strapped to assist healing and reduce the risk of aggravating the injury. The knee was strapped in a position of 30ÃÅ¡ flexion with the lower leg partially rotated inwards (figure 1). A combination of Ã¢â¬Ëlower leg and thigh anchorsÃ¢â¬â¢, Ã¢â¬Ëmedial crossÃ¢â¬â¢ and Ã¢â¬Ëmedial straight lineÃ¢â¬â¢ taping techniques, usingÃ zinc oxide tape and elastic adhesive dressing,Ã were employed to provide suitable support for the patient and reduce and valgus stress (figure 2). Experience has shown that this type of strapping is preferable to the use of a knee braces in Grade II MCL injuries as the strapping can be re-applied whenever required with the correct level of compression and support required. There is some concern that functional braces may expose athletes to additional risk by imparting a false sense of confidence. It is reported that lower extremity muscle strengthening, flexibility improvements, and technique refinement are more important than functional bracing in treating ligamentous knee injuries (Christenson, 2010). The patient was advised to continue elevating the limb, as much as possible, for the following 24 to 48 hours. Anti-inflammatory medication Non-steroidal anti-inflammatory medication (ibuprofen) was prescribed to the patient, via NHS Direct, two hours after injury. Whilst some studies have shown no early adverse affect of nonsteroidal anti-inflammatory drugs on the strength of healing torn MCLÃ¢â¬â¢s (Moorman, et al., 1999), it remains controversial as to whether inhibiting the inflammatory response is uniformly advantageous. Pain and disability following injury are in part due to the inflammatory response and, whist it is suggested that decreasing the inflammation decreases the symptoms (therefore allowing earlier rehabilitation) (Weiler, 1992), it is also important to consider that inflammatory cells are responsible for clearing away cell debris and necrotic fibres and without this phagocytic function regeneration may not be able to begin (Reynolds et al., 1995, Almekinders et al., 1986, Jones 1999). As the patient reported that the pain had subsided over the last 24 hours (measured using a visual analogue scale), he was advised to continue taking the non-steroidal anti-inflammatory medication only when necessary. Proliferation Phase (3-21 days post injury) The proliferation stage involves the repair and regeneration of the injured tissue (development of new blood vessels, fibrous tissue formation, re-epithelialisation and wound contraction) and begins approximately 72 hours after injury. The goals of this rehabilitation phase included: Ã¢â" Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Decrease effusion Ã¢â" Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Decrease pain Ã¢â" Ã Ã Ã Ã Restore full range of motion Ã¢â" Ã Ã Ã Ã Enhance joint strength Ã¢â" Ã Ã Ã Ã Introduce proprioceptive exercise Ã¢â" Ã Ã Ã Ã Ã Achieve full pain free weight bearing statu Maintain general fitness and strength levels It has been stated that ligaments heal with a stronger and more organised collagen fibril architecture when early mobilisation and exercise is employed during the healing process (Osborne and Rizzo, 2003). Therefore, in addition to continuing the treatments introduced during the inflammatory phase (ice, intermittent compression, and massage), manual joint mobilisation techniques were also employed at this stage. Comprehensive zinc oxide and elastic adhesive strapping, removed and re-applied by the patient whenever necessary (particularly during active flexion exercises), was also continued. Pain scale assessment, ankle girth measurement and goniometer measurements were continually monitored throughout the proliferation phase. As stated, n the proliferation phase, the goals are to continue re-establishing full range of motion, increase muscular strength/power/endurance, and adding in functional activities. Exercises include isotonic exercises to isolate and strengthen particular muscle groups, such as in the hip and thigh regions (knee extension, leg press, hamstring curls and hip exercises). In order to re-establish the dynamic stability of the knee joint, it is crucial to strengthen the hip and calf musculature, with an emphasis on progressive Closed Kinetic Chain exercises (such as wall squats, step-ups, lateral lunges and stair climbing) that foster proprioception (Wilk et al., 1996). Range of Movement (RoM) Range of movement exercises were significantly progressed from the inflammatory phase. Active and passive movements continued with the addition of manual mobilisation techniques for the knee joint. The following advanced knee stretches were utilised with a view to restoring movement to the joint and improve flexibility of muscles crossing the knee. The patient was advised to carry out each separate muscle group stretch 3 times daily (provided they do not cause or increase pain). i.Ã Ã Ã Quadriceps Stretch Treatment couch was used for balance. Heel taken towards your bottom, keeping knees together and back straight until patient felt a stretch in the front of their thigh (figure 1). Held for 15 seconds and repeatedÃ 4 times at a mild to moderate stretch (pain free). ii. Hamstring Stretch PatientÃ¢â¬â¢s foot was placed on chair. With knee and back straight, patient leant forward at hips until he felt a stretch in the back of his thigh/knee (figure 2). Held for 15 seconds and repeated 4 times at a mild to moderate stretch (pain-free). iii.Ã Calf Stretch With patientÃ¢â¬â¢s hands placed against the wall, his leg was stretched behind him as demonstrated in figure 3. Keeping his heel down, knee straight and feet pointing forwards, the patient gently lunged forwards until he felt a stretch in the back of his calf/knee. Held for 15 seconds and repeatedÃ 4 times at a mild to moderate stretch (pain-free). iv. ITB Stretch PatientÃ¢â¬â¢s leg was placed behind his other leg and taken as far away from him as was comfortably possible. Patient then pushed his hips to the side of his leg until he felt a stretch in the outer thigh/hip (figure 4). Back was kept straight throughout. Held for 15 seconds and repeatedÃ 4 times at a mild to moderate stretch (pain-free). v. Adductor Stretch Standing tall, and with back straight, pateintÃ¢â¬â¢s feet were placed approximately twice shoulder width apart. Patient then gently lunged toÃ one side, keeping hisÃ other knee straight, until he felt a stretch in the groin of his straight leg (figure 5). Held for 15 seconds and repeatedÃ 4 times at a mild to moderate stretch (pain-free). Increased range of motion was also enhanced by using a stationary bicycle (Wilk et al., 1996). Strengthening Strengthening work for the lower limb musculature continued in a progressive form (as pain allowed). The following knee strengthening exercises were designed and implemented with a view to improving the strength of the muscles surrounding the patientÃ¢â¬â¢s injured knee. The patient began with the basicÃ knee strengthening exercises, advanced to intermediateÃ knee strengthening exercises and eventually undertook the advanced knee strengthening exercises. A.Ã Ã Ã Ã Ã Basic Exercises To begin with, the following basic knee strengthening exercises were performed approximately 10 times each, 3 times a day, during the first week of rehabilitation. As knee strength improved, the exercises were progressed by gradually increasing the repetitions and strength of contraction. i. Static Inner Quadriceps Contraction Patient was instructed to tighten his quadriceps muscle group by pushing his knee down into a rolled towel (figure 1). Placing his fingers on his inner quadriceps (vastus medialis) allowed the patient to feel the muscle tighten during contraction. Held for 5 seconds and repeated 10 times as hard as possible pain free. ii. Quads Over Fulcrum Patient was instructed to lie on his back, with a rolled towel under his knee, and told to relax the knee (figure 2). Patient then slowly straightened his knee as far as possible tightening the front of his thigh (quadriceps). Held for 5 seconds and repeated 10 times as hard as possible pain free. iii. Static Hamstring Contraction Patient began this exercise by sitting with his knee bent to about 45ÃÅ¡ (figure 3). He then pressed hisr heel into the floor tightening the back of his thigh (hamstrings). Held for 5 seconds and repeated 10 times as hard as possible pain free. B. Intermediate Exercises The following intermediate knee strengthening exercises were generally performed 1-3 times per week (during weeks 2 and 3 of the rehabilitation programme). Ideally they were not performed on consecutive days, to allow muscle recovery. As the knee strength improved, the exercises were progressed by gradually increasing the repetitions, number of setsÃ and/or resistance of the exercisesÃ provided they did not cause or increase pain. iv. Knee Extension in Sitting vs. Resistance Band Patient sat with with his knee bent and a resistance band was tied around his ankle (figure 4). Keeping his back straight, patient slowly straightened his knee, tightening his quadriceps. He performed 3 sets of 10 repetitions on each occasion. v. Hamstring Curl vs. Resistance Band The patient was instructed to lie on his stomach with a resistance band tied around his ankle as shown (figure 5). He then slowly bent his knee whilst tightening his hamstrings (figure 6). He performed 3 sets of 10 repetitions on each occasion vi. Squat with Swiss Ball Patient stood with his feet shoulder width apart and facing forwards. A Swiss ball was placed between the wall and his lower back to add an element of proprioception (figure 7). Patient then slowly performed a squat, keeping his back straight. His knees were kept in line with his middle toes and did not move forward past his toes. Performed 3 sets of 10 repetitions on each occasion. vii. Lunges Patient stood with his back straight in the position shown (figure 8). He then slowly lowered his body until the front knee was at a right angle (figure 9). His knee was kept in line with his middle toe and his feet facing forward. Performed 3 sets of 10 repetitions on each occasion. viii. Heel Raises Patient used treatment couch for balance (figure 10). Whilst keeping his feet shoulder width apart and facing forwards, patient slowly move up onto his toes raising his heels as far as possible and comfortable without pain. Performed 3 sets of 10 repetitions on each occasion. C.Ã Ã Ã Ã Ã Advanced Exercises The following advanced knee strengthening exercises were generally performed 1 3 times per week (from week 4 of the rehabilitation programme onwards). Ideally they were not performed on consecutive days, to allow muscle recovery. As the knee strength improved, the exercises were progressed by gradually increasing the repetitions, number of setsÃ or resistanceÃ of the exercises provided theyÃ did not cause or increase pain. ix. Single Leg Squat with Swiss Ball Patient stood on one leg with his foot facing forwards. A Swiss ball was placed between the wall and his lower back to incorporate a proprioceptive element (figure 11). Patient slowly performed a squat, keeping his back straight. Patient ensured his knee did not bend beyond 90ÃÅ¡ and was in line with his middle toe. His knee didnÃ¢â¬â¢t move forward past his toes. Performed 3 sets of 10 repetitions on each occasion. x. Lunges with Weight Patient stood holding light weights, with his back straight in the position shown (figure 12). He slowly lowered his body until the front knee was at a right angle. Knee was kept in line with his middle toe with feet facing forward. Performed 3 sets of 10 repetitions on each occasion. xi. Single Leg Heel Raises Patient stood on one leg with treatment couch for balance (figure 13). Keeping his foot facing forwards, patient slowly moved up onto his toes, raising his heel as far as possible and comfortable without pain. Performed 3 sets of 10 repetitions on each occasion. xii. Hamstring Curl on Swiss Ball Exercise began with patient lying on his back with a Swiss ball under his legs as demonstrated (figure 14). Keeping his back straight, patient slowly bent his knees and tightened the hamstrings. Performed 3 sets of 10 repetitions on each occasion. Proprioception Ã¢â¬ËThe awareness of position, movement or balance of the body or any of its partsÃ¢â¬â¢ (Prentice, 1994). As observed in the Ã¢â¬ËStrengtheningÃ¢â¬â¢ section of the proliferation phase, early proprioception exercises are started at this point. Many of the more basic strengthening exercises identified were progressed by getting the patient to close his eyes closed and/or changing the surface that he was standing on e.g. mini trampoline, air filled cushion, sponge cushions, wobble and rocker boards. During the proliferation phase all proprioceptive work is undertaken with the injured joint strapped with zinc oxide strapping providing confidence to the patient by its perceived level of support. Other specific proprioception exercises used at this stage included: Balance on swiss ball (figure 1) Balance on trampette (figure 2) Balance during leg press (figure 3) Dips on uneven surface (figure 4) Balance on Bosu ball (figure 5) Balance while throwing ball to alternate hands (figure 5) The exercises were progressed by time and/or by increasing the repetitions. All exercises would be performed bilaterally. Variations for proprioceptive exercise were almost endless a vital element in avoiding patient and therapist boredom. It was also important to this rehabilitation programme that exercises could also be carried out at home (as patient also had a full time job). Cardiovascular fitness and general strengthening was also addressed at this time using circuit training, swimming and cycling. Remodelling Phase (21 days to 12 months post injury) The remodelling phase of healing is a long-term process often taking years to complete (Prentice, 1994). Factors that can impede the rate of healing are varied and include surgical repair, poor vascular supply, infection, disease, wound size, health, age and nutrition In terms of rehabilitation, during this phase more aggressive strengthening and mobilisation was required to ensure optimum tissue realignment and strength. The goals of treatment in the remodelling phase were: Ã¢â" Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Regain full strength Ã¢â" Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ensure full pain free range of motion Ã¢â" Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Maintain overall conditioning Ã¢â" Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Prepare for return to full participation Range of Motion (RoM) exercises continued with a greater emphasis being placed on Ã¢â¬Ëhands on workÃ¢â¬â¢ in the form of joint mobilisation to ensure full movement is achieved. The strengthening work that was started in the proliferation phase was continued and progressed (in terms of resistance, speed and repetitions) whilst further emphasis was placed on general fitness at this time introducing more sport specific activities. Running drills were progressed from linear to exercises involving change of direction at high pace with and without a ball. Specifically, when the patient was able to run at 75% of maximum speed, figure 8 drills were used beginning with 20m and then 10m figure 8Ã¢â¬â¢s. Advanced cutting drills at 45ÃÅ¡ and finally 90ÃÅ¡ were also added. Proprioception exercises will be progressed, with a more sport specific content. This involved hopping onto various unstable surfaces (figure 1), hopping on a mini trampoline whilst side foot volleying a ball (figure 2), hopping forwards, sideways and backwards over hurdles at varying pace (figure 3) and practising the kicking action whilst planting the foot on an unstable surface (figure 4). Throughout this phase and when returning to full function the patient continued to wear zinc oxide and elastic adhesive strapping to minimise the possibility of recurrence of injury. Ice was used predominantly after exercise to guard against recurrent pain and swelling. When an athlete achieves the goals of the remodelling phase, they are close to returning to full participation. As earlier identified, Derscheid and Garrick treated 23 Grade II MCL patients and all were returned to playing football within 19 days (4 to 19 day range, 10.6 day mean). However, many of these athletes did not feel they were 100% for several weeks. For this reason, further rehabilitation including strengthening, dynamic knee stabilisation, plyometrics, SAQ drills and proprioception exercises should be completed until the athlete feels 100% and is able to play without inhibition (Wilk et al., 1996). Maintenance exercises, even after return to sport, that promote continuation of strength, endurance, and function are also vitally important to consider (Wilk et al., 1996). Pre Discharge The pre-discharge stage is vital. It is the time for the therapist and patient to decide whether or not a return to full unrestricted activity can take place. Return to full activity was allowed once the following were achieved: Ligamentous examination is normal Quadriceps strength is 90% or greater than the contralateral limb Sport/activity specific agility testing causes no pain To achieve these requirements, the patient was asked to do everything that is expected of him when returning to their chosen sport, including replicating the conditions in which the injury was caused. In this case the patient was required to run, sprint, jump, tackle, pass the ball over varying distances, change direction at speed and be able to withstand full physical contact. 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A review of ski injuries resulting in combined injury to the anterior cruciate ligament and medial collateral ligaments. Arthroscopy, 19(2): 194-202. Quarles, J.D., Hosey, R.G. (2004). Medial and lateral collateral injuries: Prognosis and treatment. Prim Care Clin Offce Pract, 19: 957-975. Reider, B., Sathy, M.R., Talkington, J. (1993). Treatment of Isolated medial collateral ligament injuries in athletes with early functional rehabilitation. Am J Sports Med, 22: 470-476. Reynolds, J.F., Noakes, T.D., Schwellnus, M.P. (1995). Non-steroidal anti-inflammatory drugs fail to enhance the healing of acute hamstring injuries treated with physiotherapy. South African Medical Journal, 85(6): 517-522. Saladin, K.S. (2001) 2nd Edition. The Unity of Form and Function. New York; McGraw Hill Company: 327-338 Sims, W.F., Jacobson, K.E. (2004). The posteromedial corner of the knee: Medial-sided injury patterns revisited. Am J Sports Med, 32(2): 337-345. Stiell, I.G., Wells, G.A., Hoag, R.H., Sivilotti, M.L.A., Cacciotti, T.F., Verbeek, P.R., Greenway, K.T., McDowell, I., Cwinn, A.A., Greenberg, G.H., Nichol, G., Michael, J.A. (1997). Implementation of the Ottawa Knee Rule for the Use of Radiography in Acute Knee Injuries. Journal of the American Medical Association, 278: 2075-2079. van der Esch, M., Steultjens, M., Ostelo, R.W., Harlaar, J., Dekker, J. (2006). Reproducibility of instrumented knee joint laxity measurement in healthy subjects. Rheumatology (Oxford), 45: 595-599 Warren, L.F., Marshall, J.L. (1979). The supporting structures and layers on the medial side of the knee. J Bone Joint Surg, 61a: 56-62. Weiler, J.M. (1992). Medical modifiers of sports injury: the use of non-steroidal anti-inflammatory drugs in sports soft tissue injury. Clinical Sports Medicine, 11(3): 625-644. Wilk, K.E., Andrews, J.R., Clancy, W.G. (1996). Nonoperative and Postoperative Rehabilitation of the Collateral Ligaments of the Knee. 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Monday, March 2, 2020
Elizabeth Cady Stanton Quotes on Women, Equality Life One of the best-known of the mothers of woman suffrage, Elizabeth Cady Stanton helped organize the 1848 womans rights convention in Seneca Falls, where she insisted on leaving in a demand for the vote for women despite strong opposition, including from her own husband. Stanton worked closely with Susan B. Anthony, writing many of the speeches which Anthony traveled to deliver. Selected Elizabeth Cady Stanton Quotations We hold these truths to be self-evident: that all men and women are created equal.Truth is the only safe ground to stand upon.But when at last woman stands on an even platform with man, his acknowledged equal everywhere, with the same freedom to express herself in the religion and government of the country, then, and not until then, will he be able to legislate as wisely and generously for her as for himself.The moment we begin to fear the opinions of others and hesitate to tell the truth that is in us, and from motives of policy are silent when we should speak, the divine floods of light and life no longer flow into our souls.Self-development is a higher duty than self-sacrifice.The happiest people I have known have been those who gave themselves no concern about their own souls, but did their uttermost to mitigate the miseries of others.I am always busy, which is perhaps the chief reason why I am always well.Whatever the theories may be of womans dependence on man, in the supreme m oments of her life he can not bear her burdens. (from Solitude of Self) Nature never repeats herself, and the possibilities of one human soul will never be found in another. (from Solitude of Self)Because man and woman are the complement of one another, we need womans thought in national affairs to make a safe and stable government.Woman will always be dependent until she holds a purse of her own.A mind always in contact with children and servants, whose aspirations and ambitions rise no higher than the roof that shelters it, is necessarily dwarfed in its proportions.It requires philosophy and heroism to rise above the opinion of the wise men of all nations and races.Womanhood is the great fact in her life; wifehood and motherhood are but incidental relations.Women have crucified the Mary Wollstonecrafts, the Fanny Wrights, and the George Sands of all ages. Men mock us with the fact and say we are ever cruel to each other.Men say we are ever cruel to each other. Let us end this ignoble record and henceforth stand by womanhood. If Victoria Woodhull must b e crucified, let men drive the spikes and plait the crown of thorns. So long as women are slaves, men will be knaves.It would be ridiculous to talk of male and female atmospheres, male and female springs or rains, male and female sunshine . . . . how much more ridiculous is it in relation to mind, to soul, to thought, where there is as undeniably no such thing as sex, to talk of male and female education and of male and female schools. [written with Susan B. Anthony]To throw obstacles in the way of a complete education is like putting out the eyes.The prejudice against color, of which we hear so much, is no stronger than that against sex. It is produced by the same cause, and manifested very much in the same way. The negros skin and the womans sex are both prima facie evidence that they were intended to be in subjection to the white Saxon man.Women of all classes are awakening to the necessity of self-support, but few are willing to do the ordinary useful work for which they are fitted.The heyday of womans life is the shady side of fifty.I think if wo men would indulge more freely in vituperation, they would enjoy ten times the health they do. It seems to me they are suffering from repression. [at the 1893 Parliament of the Worlds Religions] The new religion will teach the dignity of human nature and its infinite possibilities for development. It will teach the solidarity of the race that all must rise and fall as one. Its creed will be justice, liberty, equality for all the children of earth.The Bible and the Church have been the greatest stumbling blocks in the way of womens emancipation.The memory of my own suffering has prevented me from ever shadowing one young soul with the superstitions of the Christian religion.Among the clergy we find our most violent enemies, those most opposed to any change in womans position.I asked them why one read in the synagogue service every week the I thank thee, O Lord, that I was not born a woman. It is not meant in an unfriendly spirit, and it is not intended to degrade or humiliate women. But it does, nevertheless. Suppose the service read, I think thee, O Lord, that I was not born a jackass. Could that be twisted in any way into a compliment to the jackass? More About Elizabeth Cady Stanton Elizabeth Cady Stanton BiographySolitude of SelfComments on Genesis: Excerpt from The Womans Bible, Stanton About These Quotes Quote collection assembled by Jone Johnson Lewis. Ã This is an informal collection assembled over many years. I regret that I am not be able to provide the original source if it is not listed with the quote.
Saturday, February 15, 2020
Solution Description - Research Paper Example Primary interventions address coronary artery disease risk factors whilst secondary intervention addresses the health adverse outcomes. PatientÃ¢â¬â¢s safety can only be improved through medical adherence. This depends on the patient self-management such as lifestyle modification. All these need support from the health care system. Proposed solution From the survey conducted, it is evident that among the young males newly diagnosed with coronary artery disease, 70% of them have diabetes mellitus and hypertension in their medical history. In addition to that, 60% of these people smoke. However, they regularly carry out some physical exercise and do not have any idea of what coronary artery disease means to their health. This, therefore, means that they do not understand what is expected of them in order to contain the disease with reference to dietary. Given the fact that this population has no idea on diet, they have to be taught on what is expected of them. According to Hermida (2 011), changes in dietary can help in reducing the young menÃ¢â¬â¢s systolic blood pressure due to diabetes mellitus and hypertension in their medical history. The dietary factors that need to be considered by this group are reduced amount of salt intake and saturated fat contents. Adherence to these controls helps in managing hypertension and diabetes mellitus. Besides dietary changes, these individuals need to be encouraged not to smoke and also shun environmental smoke (Mosca et al., 2007). Compliance with lifestyle modification improves the patientÃ¢â¬â¢s quality of life via eliminating premature deaths and preventing further complications. To the patientsÃ¢â¬â¢ immediate family, compliance relieves them of the negative psychological effects of losing their loved ones. Additionally, adherence conserves the resources of the family that would have been channeled in the obtaining of health care. Organizational culture: This section aims to illustrate how lifestyle modification , as the proposed solution, is consistent with the organization of resources and culture of the society. To the society at large, patient compliance with treatment is an effective measure of saving costs. This is because it decreases complications of incidents and the need for further medications. This is of great significance to the health care public financed systems. Compliance has a great impact on the health care system. For instance, it limits hospitalization needs and reduces workloads on the healthcare system staff. In addition, satisfactory outcomes of treatment boost the attending clinicianÃ¢â¬â¢s morale whilst failure in treatment frustrates them and impacts their work delivery. Expected Outcome of the Project The expected outcome of the project is to improve the adherence of the patients to enhance their safety. The main reason is that chronic conditions such as the coronary artery disease need a lot of care. In addition, most of this care focuses on the patient self-m anagement. As a result, it requires complex multi-therapies and medical technology use for monitoring patient lifestyle change. Therefore, if these patients are not supported adequately by the health care system, they may be prone to risks that are life-threatening. The outcome will be achieved by educating the patients on lifestyle modifications such as the amount of salt intake, significance of physical activity, avoiding smoking, reducing the