Treatment Rehabilitation of Grade II Medial Collateral Ligament (MCL) Injury The WritePass Journal

Treatment Rehabilitation of Grade II Medial Collateral Ligament (MCL) Injury Introduction Treatment Rehabilitation of Grade II Medial Collateral Ligament (MCL) Injury IntroductionGeneral Knee AnatomySpecific   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‚   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.   Whilst in the 1970’s and 1980’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 ‘mechanical advantage’ 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 ‘extensors’ and ‘flexors’ 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). Specific   Medial Collateral Ligament Anatomy Medial knee stability is provided, for the most part, by its ‘medial static’ and its ‘dynamic’ 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 ‘slack’ 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 ‘slack’ during knee flexion (Peterson Renstrom, 2001). Biomechanics Biomechanical studies show that the MCL’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 5Ëš of knee flexion and up to 78% at 30Ëš knee flexion. The deep MCL accounted for 8% at 5Ëš and 4% at 30Ëš 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 ‘close down an opposing player’ and then described performing a ‘change of direction’ or ‘cutting’ 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 occurs   (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 test   (MCL test) was performed with the knee in 30Ëš of flexion (figure 1), and compared to the contralateral knee as a control. The examination was then repeated with the knee in 0Ëš of flexion to recruit the function of remaining posteromedial structures (figure 2). The valgus stress test proved positive in contralateral comparison in 30Ëš of flexion and negative in 0Ëš 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 30Ëš 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. Lachman’s test (figure 4) and the Pivot shift test (figure 5) were also performed to negate the existence of any ACL rupture whilst Murray’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 90 ° 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 30Ëš 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 30Ëš 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 0Ëš and 30Ëš of flexion, Grade II injuries as those with valgus laxity in 30Ëš of flexion but stable in 0Ëš of flexion, and Grade III as those with valgus laxity in both 0Ëš and 30Ëš 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.   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 (O’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 ‘knee bend and straighten’ exercises, with the patient lying in a supine position on an exercise mat the movement repeated 10-20 times,   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 30Ëš flexion with the lower leg partially rotated inwards (figure 1). A combination of ‘lower leg and thigh anchors’, ‘medial cross’ and ‘medial straight line’ taping techniques, using   zinc oxide tape and elastic adhesive dressing,   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 MCL’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: ââ€" Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Decrease effusion ââ€" Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Decrease pain ââ€" Ã‚  Ã‚  Ã‚  Ã‚   Restore full range of motion ââ€" Ã‚  Ã‚  Ã‚  Ã‚   Enhance joint strength ââ€" Ã‚  Ã‚  Ã‚  Ã‚   Introduce proprioceptive exercise ââ€" 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‚   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 repeated  4 times at a mild to moderate stretch (pain free). ii. Hamstring Stretch Patient’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.   Calf Stretch With patient’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 repeated  4 times at a mild to moderate stretch (pain-free). iv. ITB Stretch Patient’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 repeated  4 times at a mild to moderate stretch (pain-free). v. Adductor Stretch Standing tall, and with back straight, pateint’s feet were placed approximately twice shoulder width apart. Patient then gently lunged to  one side, keeping his  other knee straight, until he felt a stretch in the groin of his straight leg (figure 5). Held for 15 seconds and repeated  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 patient’s injured knee. The patient began with the basic  knee strengthening exercises, advanced to intermediate  knee strengthening exercises and eventually undertook the advanced knee strengthening exercises. A.  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 45Ëš (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 sets  and/or resistance of the exercises  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‚   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 sets  or resistance  of the exercises provided they  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 90Ëš and was in line with his middle toe. His knee didn’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 ‘The awareness of position, movement or balance of the body or any of its parts’ (Prentice, 1994). As observed in the ‘Strengthening’ 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: ââ€" Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Regain full strength ââ€" Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Ensure full pain free range of motion ââ€" Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Maintain overall conditioning ââ€" 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 ‘hands on work’ 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 8’s. Advanced cutting drills at 45Ëš and finally 90Ëš 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. Cardiovascular fitness would be assessed by repeating the baseline testing done in pre-season and comparing the results Rehabilitation does not stop at this stage and the patient was instructed to continue with his proprioception and specific strengthening exercises for several months to minimise the chances of injury recurrence. Conclusion/Summary When undertaking the treatment and rehabilitation of medial knee injuries it is vital to understand and comply with the underlying pathology during the stages of healing to ensure optimum results. The treatment goal for any competitive athlete is an early and effective return to sport, without any residual symptoms and minimal risk of recurrence. This is achieved by following an individually tailored treatment and rehabilitation program with a built in maintenance plan to be continued well beyond the initial return to activity. References Abbott, L.C., Saunders, J., Bost, J.C. (1944). Injuries to the ligaments of the knee joint.   J Bone Joint Surg, 26: 503. Almekinders, L.C. (1999). Anti-inflammatory treatment of muscular injuries in sport: an update of recent studies. Sports Medicine, 28(6): 383-388. Bachman, L.M., Kolb, E., Koller, M.T. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and midfoot. British Medical Journal, 326: 417-419. Bleakley, C., McDonough, S., MacAuley, D. (2004). The use of ice in the treatment of acute soft-tissue injury. The American Journal of Sports Medicine, 32: 251-261. Bradley, F., Giannotti, M.D., Rudy, T., Graziano, J. (2006). The Non-surgical Management of Isolated Medial Collateral Ligament Injuries of the Knee. Sports Med Arthrosc Rev, 14(2). Christenson, R. (2011). Ligaments of the Knee: ACL and MCL sprains and tears.   Pure Sports Medicine. Cohn, B.T., Draeger, R.I., Jackson D.W. (1989). The effects of cold therapy in postoperative management of pain in patients undergoing anterior cruciate ligament reconstruction. American Journal of Sports Medicine, 17: 344-349. Daniel, D.M., Pedowitz, R.A., O’Connor, J.J., Akeson, W.H. (2003) 2nd Edition. Daniel’s knee injuries: ligament and cartilage structure, function, injury, and repair. Philadelphia: Lippincott, Williams and Wilkins. Derscheid, G.L., Garrick, J.G. (1981). Medial collateral ligament injuries in football: non operative management of grade I and grade II sprains. Am J Sports Med, 9:365-368. Dixit, S., Difiori, J.P., Burton, M., Mines, B. (2007). Management of Patellofemoral Pain Syndrome. Am Fam Physician. 74: 194-202, 204. Ellsasser, J.C., Reynolds, F.C., Omohundro, J.R. (1974). The non-operative treatment of collateral ligament injuries of the knee in professional football players. J Bone Joint Surg, 56a: 1185-1190. Fetto, J.F., Marshall, J.L. (1978). Medial collateral ligament injuries of the knee: a rationale for treatment. Clin Orthop, 132: 206-218. Grood, E.S., Noyes, F.R., Butler, D.L., Suntay, W.J. (1981). Ligamentous and capsular restraints preventing straight medial and lateral laxity in intact human cadaver knees. J Bone Joint Surg Am, 63: 1257-69 Hamill, J., Knutzen, K.M. (1995). Biomechanical Basis of Human Movement. Philadelphia; Lippincott Williams Wilkins: 86-88, 227-233. Hawkins, R.D., Hulse, M.A., Wilkinson, C. (2000). The association football medical research programme: an audit of injuries in professional football. British Journal of Sports Medicine, 35: 43-47. Hawkins, W. (2009). The Will to Perform: A Female Athlete’s Epidemic. Hayes, C.W. (2000). Mechanism-based pattern approach to classification of complex injuries of the knee depicted at MR imaging. Radiographics, 20: S121–S134. Hughston, J.C. (1994). The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament. Results of long-term follow-up. J Bone Joint Surg Am, 76: 1328-44 Indelicato, P.A. (1983). Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg, 65a: 323-329. Indelicato, P., Linton, R. (2003). Medial ligament injuries in the adult. Philadelphia; Saunders: 1938-1949. Knight, K.L., Brucker, J.B., Stoneman, P.D. (2000). Muscle injury management with cryotherapy. Athletic Therapy Today,   5: 26-30 Moorman, C.T., Kukreti, U., Fenton, D.C. (1999). The early effect of ibuprofen on the mechanical properties of healing medial collateral ligament. Am J Sports Med, 27: 738-741. Norris, C.M. (1998) 2nd Edition. Sports Injuries Diagnosis and Management. Oxford; Butterworth-Heinemann. O’Donohue, D.H. (1976). Treatment of Injuries to Athletes. Philadelphia; Saunders: 698-746. Osborne, M.D., Rizzo, T.D. (2003). Prevention and treatment of ankle sprain in athletes. Sports Medicine, 33(15): 1145-1150. Perryman, J.R., Hershman, E.B. (2002). The acute management of soft tissue injuries of the knee. Orthop Clin North Am, 33(3): 575-585. Peterson, L., Junge, A., Chomiak, J., Graf-Baumann, T., Dvorak, J. (2000). Incidence of football injuries and complaints in different age groups and skill-level groups. Am J Sports Med, 28(5): 51-57 Peterson, L., Renstrom, P. (2001) 3rd Edition. Sports Injuries: Their Prevention and Treatment. London; Martin Dunitz. Phisitkul, P., James, S.L., Wolf, B.R., Amendola, A. (2006). MCL injuries of the knee: current concepts review. Iowa Orthop J, 26: 77-90 Prentice, W.E. (1994). 2nd Edition. Rehabilitation techniques in sports medicine. St. Louis; Mosby. Pressman, A., Johnson, D.H. (2003). 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. Operative Techniques in Sports Medicine, 4(3): 192-201.

Elizabeth Cady Stanton Quotes on Women, Equality Life

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. Â  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.

Solution Description Research Paper Example | Topics and Well Written Essays - 750 words

Solution Description - Research Paper Example Primary interventions address coronary artery disease risk factors whilst secondary intervention addresses the health adverse outcomes. Patient’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 men’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 patient’s quality of life via eliminating premature deaths and preventing further complications. To the patients’ 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 clinician’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

Team Reflection Paper Essay Example | Topics and Well Written Essays - 1250 words

Team Reflection Paper - Essay Example During the ACC 544, Internal Control System, I was a member of team C. The purpose of this paper is to describe the interaction and learning experience that occurred during this course through the team learning mechanism. I have taken over 15 courses at the University of Phoenix online at the graduate level. Each of these courses had team assignments to be performed by a small group of students of 3-6 members. I believe that the university is doing a great job in their teaching methods because it is preparing us for the workplace of the future. Virtual teams are a hot trend in the managerial field due to the globalization movement and the fact that there are thousands of global corporations worldwide. â€Å"Managing a virtual team means managing the whole spectrum of communication strategies and project management techniques as well as human and social processes in ways that support the team. During the last six weeks I had the privilege to work with an outstanding team. It was a pl easurable experience working with a great group of professionals. Starting in week 1 team C always had great communication among the members. Communication in the workplace is an important variable that must be managed well by the leaders of an organization. Communication problems can lead to misunderstanding and conflict. Team C did not experience any of these symptoms. Whenever anyone was called upon to deliver data or information everyone responded promptly. As I mentioned earlier I have been a part of several work teams at the University of Phoenix. I believe that this team has been the most functional and productive team I have ever been in. The academic results prove my premise. Team C received a perfect grade of 25/25 on five projects the team completed. I’m a good student, but I do not have a 4.0 G.PA. Team C achieved perfection due to its hard work, commitment to excellence, cooperation, outstanding communication, and concise writing. I wished I would have had these teammates with me in all my previous courses. One of the best things about Team C was the lack of an ego. In other team I have worked on somebody always wants to be the team leader without getting approval from the other members. Team C did not have that problem. I believe that the leadership responsibilities were shared equally among the members. I loved the fact that the team member willingly divided the work parts without having anyone tell them to do things they did not want to do. Another great aspect about the team was the punctuality of the deliverables. At the University of Phoenix online the members of study teams depend on each other. If one member fails to deliver their work on time it creates a chain reaction that affects the quality of the work of the team. Team C cared about each other and respected the academic well being of the other members. The perfect grade the team was able to achieve in the five assignments will increase the chances of all the team members obtai ning a passing grade at the end of the course. I enjoyed working with this team because there was mutual respect among all the players on the team. The team was very organized throughout the entire course. This help the communication process because everyone always knew what they were supposed to do. I took initiative prior to week four and week five projects of creating an outline a few weeks before of how to separate the work in the team. This strategy worked well as everyone knew

Religion, Poverty and Wealth Essay examples -- Poverty Essays

Religion, Poverty and Wealth Poverty is now a problem on a global scale, and Hinduism has needed, and will continue to need, to undertake an ongoing state of change and adaptation. Many of the beliefs Hindus held only a couple of centuries ago have been altered or even removed altogether. The globalisation of Hinduism, bringing it into contact with a wide range of other cultures and religions, has influenced this a lot. Hinduism, however, is full of variations itself, so what is said of Hinduism may be true for some Hindus, and false for others. Hinduism is less a religion, than a culture, and way of life. This way of life affects how they view poverty and wealth, and what there reactions to it are, as outlined below. Unlike many other societies, where the caste system is based on power or wealth, thus giving the poorest the least power, Hinduism has four set castes, which a member belongs to by birth. These groups are called varnas, and each has its own set of rules and duties to live by, known as dharma. Too much inter-varna mixing, especially intermarriage, is strongly disapproved of. The first, and highest varna is that of a Brahmin-priests, teachers, and wisemen. The next is Kshatriya-warriors, rulers, and leaders. The third is Vaishya-traders, merchants, agriculture, and other work involved with commerce. The final, and lowest varna is Sudra-manual labour and service. In many societies, the difference between the high and the low, in terms of social status, has caused great troubles, due to discontentment of the poor and weak to continue living like they are. In Hinduism, however, this problem is avoided, by the promise o... ... many Hindus to make a small donation to the poor, and will give old clothes or shoes away, rather than throwing them out. MK Gandhi changed many old Hindu beliefs with his teachings. He taught that it is wrong to think that a poor person is only getting what they deserve. He believed that everyone was a part of God, and people should recognise that they share the same world and should care for one another. He taught that service to others was the best way to find God and comprehend fully the human condition. This had a profound effect on the treatment of the poor in India today. There are many charities set up for helping the poor in India, such as the Hindu Mission Hospital and Prison Fellowship India. These receive many donations from many Hindus-even those overseas will often send back money to help the poor.

Pen Biography

The Pen Mortality is a fact of life for everyone and has been since Creation. As humans, we have the intelligence to realize and understand this because we possess the ability to reason and to learn. This ability, when combined with the presence of Life that keeps us in existence, beckons us to secure the future in some way and for some reason(s). We need not only the chance at life beyond our own which comes with the birth of our children, but also to leave our own names, our own ideas and beliefs secured onto something more solid than the spoken word yet not as heavy as stone tablets.In he arid, desert climates this came in the form of parchment . In locations with more water and vegetation, it came from the papyrus plant. But in either climate, something was needed to stain the language onto this new device. That something was the first pen. The Dawn of Pen-kind As early as 2,800 years before Christ, the pen was beginning to appear as a writing implement in the world. Its first fo rm was that of a dried reed, its tip cut at an angle so to create a line of ink instead off blot. To write with it, simply dip the cut tip of the reed into an ink supply, then gently press the dipped tip against the paper .This was a simple meaner of writing that required raw materials ample in the environment. The degree of technology it used can be seen as only slightly higher than the scientific concept of the sharpened wedge (blade) used to cut an angle on the reed tip. The small effort needed to build a pen was far less than that of the ink needed. Nature grew the reed, humans merely plucked it from the ground and sliced off its bottom tip. During this period of Antiquity, the Egyptians had also constructed the Great Pyramids and the Sphinx.By no meaner was the pen as physically large and omelet a creation as the wonders of the world, which were constructed with the sole purpose of being the final resting-place of the Pharaoh. However, the reed pen had a much more profound, a m uch greater effect on the world and the path our present-day history took. There are no records to indicate any one person or group as the inventors of the pen. Rather, it is was a creation made to assist in the posterity of an Empire, and on that would effect all empires the earth would ever see.Israel, people of the Great WHY, the Creator, God, and one of the fiercest fighting people of the contemporary world, Egan their ascendancy into History by two stone tablets, engraved with the Ten Commandments by the hand of God. God can use stone without any trouble at all. He's all-powerful. To us humans, however, stone can get both heavy and impractical. We have no omnipotent powers to create and create and create whole encyclopedias from stone by sheer thought. We have to sit down and chisel away for hours and ideal thing for humanity to use as a writing implement.Along the same lines of uselessness, Papyrus, though very much lighter and easier to store away, was really just some plant strips without the use of the pen. Thanks to the pen, however, the Israelites, as well as the rest of the writing world, have secured themselves with ink on the pages of History. This is evident in the nightstand drawer of Just about every motel room in America. The prime of life for the reed pen lasted until around the 6th century AD, where the earliest recorded reference to quill pens was made by Spanish theologian SST. Isadora of Seville . The quill is a flight feather off bird.It is made ready for writing by, like the reed pen, slicing of the tip at an angle so as to have a point for ink to bleed onto papyrus or parchment. Before the cutting, however, the quill must first be hardened y heating it or simply letting it dry. A special penknife was usually used in cutting the tip, but any sharp blade could do the Job. Writers using the quill often had to recur the tip so to maintain its edge. Though there is no rule depicting any species mandatory as the origin of the feather, goose , swan, crow, and (later) turkey were preferred because of both the size of the feathers and the abundance of birds to obtain them from.This new pen was the main writing utensil used in Europe for the next 1,300 years. Its affordability was great, and its use was limited only by the spread of literacy. (Incarnate 98) As writing increased, commerce began creating more documentation than the Church. Hence, so to save money and time, new, more durable writing tools were sought after. Horn, tortoiseshell, and even gemstones were tested, but steel was ultimately used as a replacement for the quill tip. (Incarnate 98) Such a precise steel structure as a pen was not easily manufactured.They did not become popular until about the 19th century when free public education for children became prevalent. (Incarnate 98) Through the years as civilization developed and education became noticed for the potential that it gives humanity. Writing, a prerequisite to any complex civilization, became emph asized in education, and the popularity of the skill of quill cutting began a speedy decline. In 1803, English engineer Bryan Domain became the first person to patent a steel pen. (Incarnate 98) This patenting marked the entry of the pen into commercialism as a product for sale.We, as materialistic beings, decided that it would be best for us to profit from the pen rather than from the education available with the use of it. In 1884, a New York insurance salesman, Lewis Waterman, patented the first fountain pen with its own internal reserve of ink. He fountain pen would gradually become the prominent writing instrument until it was replaced by the ballpoint pen Just after World War II. (Incarnate 98) In our unending human efforts to improve upon old ideas, the ballpoint pen was developed.This new device had several advantages over the other pens that had The ink was waterproof and almost unarguable; the pen could write on many more kinds of surfaces and could be held in almost any p osition for writing, and the pressure required to feed the ink was ideal for making carbon copies. The advent of this new device has had an incredible effect on the writing of history. When we look at what a rudimentary part of everyday life the pen plays in society, it's hard to imagine life without it. Think about how often you pick up a pen and write something.Or, if you only type, consider that without a pen, the inventor would not have been able to put his thoughts for a typewriter, word processor or computer into a drawn plan, and, therefore, none would exist today. The same can be said for Just about every invention since the industrial revolution! Even as far back as Leonardo Dad Vinci, the pen had been used as a tool to expand the mind as well as secure the past. Inventors and dreamers scribbled away at drawings of such preposterous ideas to their contemporaries that we could not know of their attempts were it not for the pen.Dad Vine's drawing of man, his helicopter, and o ther ideas of his could never have been know were it not for the pen. Likewise, computers today have their own version of the pen. The stylus and light pen have been used as interface systems to input information into computers for years. The pen is due thanks for that. If you want to say, â€Å"well, what about the pencil? † FORGET IT! The pencil wasn't invented until around 1795 AD . The pen had already been around for centuries.In fact, it's not unthinkable to imagine today's world using much the same stone tablets as The Flintiness. The bottom line is this: without a written language that could easily be used to transmit information across both space and time, our society, our world, being the complex civilization that it is, would not have developed. Cities, schools, and everything we take for granted in or society would not exist. At best, we would be engraving cave walls with pictures or some basic language. We would not be the ever-increasing global community we are t oday.

An Introduction to Sicilian The Language of Sicily

What is Sicilian? The real question is what isnt Sicilian? Sicilian is neither a dialect nor an accent. It’s not derived from Italian. It’s not spoken only  in Sicily. Sicilian (u sicilianu) in Sicilian and  siciliana  in Italian) is the oldest of the  Romance languages  derived from Latin, and it’s spoken  in Sicily and in parts of southern Italy  such as  Reggio di Calabria  and  southern Puglia. It’s derived from  Latin, with  Greek,  Arabic,  French, Provenà §al,  German, Catalan and  Spanish  influences. Sicilian is currently spoken by most of the 5,000,000 inhabitants of Sicily, plus another 2,000,000 Sicilians around the world. With the predominance of Italian in Italian schools and the media, Sicilian is no longer the first language of many Sicilians. In fact, in urban centers in particular, its more common to hear standard Italian spoken rather than Sicilian, especially among the younger generation. Sicilian as Art? But what most people don’t know is that Sicilian developed as a form of art many years before what we currently define as â€Å"Italian†! In fact, even  Dante, father of Italian culture and dialect, referred to Sicilian poets and writers from the â€Å"Sicilian School† as pioneers in literary works and production written in vernacular Italian. The sicilian spelling of words is, like Italian, essentially phonetic. The spoken language is riddled with words of Arabic origin:  tabutu  (coffin) from Arabic  tabut. And in place names: Marsala, the Sicilian port, is from Allahs port,  mars  port   ala, from Allah. We can divide Sicilian dialect variations into three main areas: Western Sicilian  - From the Palermo areas to Trapani and AgrigentoCentral Sicilian  - Through the Enna’s zonesEastern Sicilian  - Divided in Syracuse and Messina Nowadays, Sicilian is the principle way to communicate within the family  (with a capital F). Its  used as a convivial language and as a homey bond with those who live distantly. What’s Siculish? Did you know that Sicilian dialect spoken by Italian immigrants living in the USA is called â€Å"Siculish†? The Sicilian novelist Giovanni Vergas surname means twig† or â€Å"branch in Spanish. The Italian word is  virga. How Does it Sound? But let’s cut to the chase, how does this ancient language sound? Most of the words aren’t too far from the Italian language, but  how  they pronounce them changes the entire game. B  - a normal â€Å"b,† heard several times in â€Å"babbo, bosco, bambole†¦,† turns into a -V. So la botte ( the barrel) sounds  Ã¢â‚¬Ëœa vuttila barca ( the boat)  Ã¢â‚¬Ëœa varcail broccolo ( broccoli) becomes  u’ vrà ²cculu Double L  - Words like â€Å"bello† e â€Å"cavallo† become  beddu and cavaddu. G  - between vowels falls and leaves only a slight trace: gatto sounds like  attà ¹gettare (to throw) sounds like  ittari Not all the sounds are squeezed though. There are cases that where letters strengthen and are redoubled in their sound. â€Å"gi† becomes  valiggia  ( suitcase), and the Sicilian jacket,  a giacca, has to be read as  aggiacca. Whether you’re a foreigner or an Italian, Sicilian is a complicated language that you can  only hope to understand. We could spend hours listening to this wonderful and melodious language that hides  a magic world dating back almost a thousand years  inside its devious words.