Nerve And Tendon Gliding Exercises Health And Social Care Essay

Nerve And Tendon Gliding Exercises Health And Social Care Essay Carpal Tunnel Syndrome was first described by Sir James Paget in 1854 but the term was coined by Moeirisch. It is a syndrome of compression neuropathy of median nerve at the wrist. Carpal Tunnel Syndrome results in considerable discomfort and pain, limitation of activities of daily living, loss of sleep and work disability. (Levine et al., 1993). Twenty percent of symptomatic subjects with symptoms of pain, numbness, nocturnal parasthesia and tingling sensation in the hand would be expected to have Carpal tunnel syndrome based on the clinical examination and electro physiologic testing. CARPAL TUNNEL SYNDROME IN PREGNANCY Carpal tunnel Syndrome is more frequent in pregnancy because the systemic process increases the extra capsular fluid retention by the hormone Prolactin and produce soft tissue swelling in the later stages (third trimester) of their pregnancies. The Carpal Tunnel Syndrome can thus be produced by compression or swelling of the median nerve in its synovial sheath (Gelberman et al., 1981; Snell, 2000; Szabo, 1989; Primal Pictures, 2001; Rempel et al., 1999). Many therapies have been advocated for treating the carpal tunnel syndrome including Mobilizations, nerve gliding, tendon gliding, etc. Therefore the presence study was focused on the Effect of Nerve and Tendon gliding Exercises in the functional recovery of the carpal tunnel syndrome during pregnancy. Tendon gliding Exercises were mostly performed at the end range of motion at small amplitude are performed at the limit of available motion and stressed into the tissue resistance. These exercises are thought to relieve pressure on the median nerve and stretch the carpal ligaments, which also helps decrease pressure. They are also thought to help blood flow out of the carpal tunnel, which can help decrease fluid pressure. INCLUSIVE CRITERIA Pregnant Women with pain and swelling in the wrist for at least 1 month. Pregnant women with both unilateral and bilateral carpal tunnel syndrome. Pregnant women with age group between 25years and 32years. EXCLUSIVE CRITERIA Non-pregnant women with carpal tunnel syndrome. Pregnant women having other complications like hypothyroidism, diabetes that may lead to carpal tunnel syndrome. Any other trauma related injuries in hand. Males. MATERIALS AND METHODS Nerve and Tendon Gliding Exercises. Functional Status Scale for measuring functional activity. HYPOTHESIS Nerve and Tendon Gliding Exercise programme will be effective in the treatment of carpal tunnel syndrome during pregnancy. NULL HYPOTHESIS There may not be any significance between the nerve and tendon gliding exercise programme and carpal tunnel syndrome during pregnancy. OBJECTIVES The aim of this study is to determine from the available evidence the effectiveness of Nerve and Tendon gliding exercises programme in carpal tunnel syndrome during pregnancy using Functional Status Scale for performance and Symptom Severity Scale for wrist pain. STUDY DESIGN A total of 20 patients having carpal tunnel syndrome during pregnancy are selected to find out the effectiveness of nerve and tendon gliding exercises on them. The duration of study per patient 4 weeks Treatment session 10 minutes per session / 2settings Treatment per week 7 days DURATION OF STUDY: 6 months OUTCOME Relief of pain and swelling in hand. An improvement in the functional ability of hand. Awareness is created for the working pregnant women especially with computers, typewriters, cake decorators, postal workers, dentists, and dental technicians virtually, who use their hands and wrists repetitively. Avoiding the severity of median nerve injury, which may lead to claw hand if unnoticed. INTRODUCTION Sir James Paget first described carpal Tunnel Syndrome in 1854 but Moeirisch coined the term. It is a syndrome of compression neuropathy of median nerve at the wrist. INTRODUCTION: Carpal Tunnel Syndrome results in considerable discomfort and pain, limitation of activities of daily living, loss of sleep and work disability. (Levine et al., 1993). The Carpal Tunnels floor is made up of the 8 tiny wrist bones. Its roof is a thick ligament called the transverse carpal ligament. 9 tendons pass through this tunnel. 4 of the 9 tendons bend the tips of the finger, another 4 of the 9 tendons bend the middle joints of the finger, and the 9th tendon bends the thumb tip. The median nerve passes through this tunnel. When there is swelling or if there is thickening of the ligament the nerve gets pinched or compresses. With enough compression carpal tunnel symptoms occur. If the compression is severe or occurs over a longer period of time the nerve may change shape and flatten causing some permanent damage. Carpal Tunnel Syndrome occurs due to many causes like Wrist injury CARPAL TUNNEL SYNDROME IN PREGNANCY Carpal tunnel Syndrome (CTS) is more frequent in pregnancy because the systemic process increases the extra capsular fluid retention by the hormone Prolactin and produce soft tissue swelling in the later stages (third trimester) of their pregnancies. The Carpal Tunnel Syndrome can thus be produced by compression or swelling of the median nerve in its synovial sheath (Gelberman et al., 1981; Snell, 2000; Szabo, 1989; Primal Pictures, 2001; Rempel et al., 1999). CTS have been recognized as a common complication of pregnancy (HeckmanSassard, 1994). The pathophysiology of pregnancy related CTS (PRCTS) has been mostly attributed to redistribution of fluids (Ekman-Ordeberg et al., 1987; Wand, 1990; Pauda et al.,2001). Signs And Symptoms 1.Pain that shoots from the hand up the arm as far as the shoulder. 2.Tingling in the hands during the day or the night that disrupts sleep and limits the ability to grasp objects with the hands. 3.Weak feeling in the hands, and the inability to pick up small objects. 4. The feeling that the hands are swollen, even if they do not appear to be so. 5.Burning numbness and tingling sensation in the thumb and first three fingers. 6.Weakness in the muscle at the base of the thumb, near the palm. Motor weakness will be seen in abductor pollicis brevis, flexor polices brevis and opponens policis brevis. Passive flexion or hyperextension of the affected hand at the wrist for more than one minute may worsaen symptoms.(Phalen.G.S.,1966). Percussion of the median nerve at the wrist causes paresthesis of the digits (Steward.J.D.,1978). Early Treatment 1.Splinting the wrist in a neutral position. 2.Avoiding the activities which causes pain if possible 3.Tendon and nerve gliding exercises. 4.Massaging 5.Elevating the arm or flicking 6.Neural mobilization 7.Ultrasound, icing, as pain relieving modality etc. Non operative treatment s is more effective in early stageas such as NSAIDS and local corticosteroids injections.If the probl;em is severe surgery is made to release the carpal tunnel. Diagnostic criteria Harrington etal suggested surveillance criteria for carpal tunnel syndrome should be pain or parasthesia or sensory losss in the median nerve distribution and one of the following: Tinels sign positive Phalens test positive Nocturnal exacerbation of symptoms Motor loss with wasting of the abductor pollicis brevis Abnormal nerve conduction studies. Nocturnal and exertonal dyesthesias in the radial half of the palm occur in 10% to 25% of pregnant women. When the carpal tunnel syndrome occurs, the symptoms area more often bilateral. Onset of symptoms is typical during the third trimester. Because of itas trnsient nature carpal tunnel syndrome during pregnancy is best treated by using conservative measures, such as tendon and nerve gliding exercises. That subsequent pregnanciesaraae frequently associated with repeated episodes of carpal tunnel syndrome confirms the association of carpal tunnel syndrome and pregnancy. Gliding Exercises Tendon gliding and median nerve-gliding exercises are two types of exercises that may help with carpal tunnel syndrome. These exercises are thought to relieve pressure on the median nerve and stretch the carpal ligaments, which also helps decrease pressure. They are aolso thought to help blood fow out of the carpal tunnel, which can help decrease fluid pressure. Fist Flexion Exercises Fist Flexion Exercises(also known as tendon gliding exercises) move your fingers through five positions while your wrist stays in a neutral position(meaning it is not bend). To perform this exercise, do the following: 1.Start with your fingers straight. 2.Make a hook fist and then return to a straight hand. 3.Make a straight fist and then return to a straight hand. 4.Make a full fist andthen return to a straight hand. Hold each positons for seven seconds amd do 10 repetitions. Repeat three times to five timeas a day. Median Nerve Gliding Exercises For median nerve gliding exercises ou move yout thumb through 6 positi0nswhile your wrist stays a neutral position. To perform this exercise, do the following: 1.Begin by making a fist with your wrisat in the neutral position. 2.Straigthen your fingers anad thumb. 3.Bend your wrist back and move your thumb away from your palm 4.Turn your wrist palm up 5.Use your other hand to gently pull uyout thumb farther away from your palm. Hold each position for seven seconds, and do five repetitions. Repeat three ti five times a day. Effectiveness of the Tendon and nerve gliding exercises used as conservative treatment approachesd in relieving the symptoms of the carpal tunnel syndrome during pregnancy.(Lamia Pinar, Asgel Enhos et al.,) Definition Carpal tunnel syndrome is a condition caused by compression of median nerve within the carpal tunnel leads to sensory changesover the lateral side of the hand and muscle weakness in thenar eminence, results in pain, numbness and tingling of fingers. It usually occurs in the third trimester of pregnancy. Aim of Study A STUDY OF EFFECTIVENESS OF NERVE AND TENDON GLIDING EXERCISES AS TREATMENT APPROACH TO CARPAL TUNNEL SYNDROME DURING PREGNANCY. OBJECTIVES The aim of this study is to determine from the available evidence the effectiveness of Nerve and Tendon gliding exercises programme in carpal tunnel syndrome during pregnancy using Functional Status Scale for performance and Visual Analogue scale for wrist pain. HYPOTHESIS NULL HYPOTHESIS There may not be no significance between the nerve and tendon gliding exercise programme and carpal tunnel syndrome during pregnancy. Alternate Hypothesis Nerve and Tendon Gliding Exercise programme will be effective in the treatment of carpal tunnel syndrome during pregnancy. Review of literature 1.Lamia Pinar, Asgel Enhos et.al Conducted an experiment study on total of 26 patients with caroal tunnel syndrome were divided into two groups. In one group the volar splint were applied and trained to modify their functional activities in accordance witrh conservative treatment. In group two tendon gliding exercises were continued for 4 weeks with numeric rating scale and Gonuiometry. It comcluded that group two reported excellent results in pain reduction and functional improvement than gropup one. 2.Akaline.E.,et.al.,(2002) Conducted an experimental study on carpal tunnel syndrome with a total of 28 patients with 36 hands of CTS, which were divided into two groups, with 14 patients each. One group was treated with nerve and tendon gliding exercises along with custom made neutral volar splint, and another group was treataed with only neutral volar splint for 4 weeks continuously. Patientas satisfaction was invesatigated during the follow up ranging from 5-11 month, with a mean of 8 month. The study explained that, of those patients who performed nerve and tendon gliding exercise with wearing custom made neutral volar splint, 93% reported good results, and of those patients who have only wearing neutral volar splint, 72% reported good results. American Journal of Physical Medicine Rehabilitation, 2002, Feb;81(2), Pp:108-13). 3.Rosemaryn .L.M., et.al.,(1998) Conducted an experimental study on carpal tunnel syndrome with 240 hands, from 197 patients. They were divided into two groups. Patients in both groups were treated with standard conservative methods, and those in one group were also treated with a program of nerve and tendon gliding exercise of those who did not perform the nerve and tendon gliding exercise, 71.2% underwent surgery compared with only 43.0% of patients who did perform them. Patient in experimental group, who did not undergo surgery were interviewed at an average follow-up time of 23 months (range, 14-38 months), of these 53 patients, 47(89%) responded to this detailed interview of those 47, who responded, 70.2% reported good or excellent results, 19.2% remained symptomatic, and 10.6% were non-complaint.(Journal of Hand Therapy, 1998, Jul-Sep:11(3),171-9). 4.Dakowick.A.,(2005) the purpose of the study was to evaluate the usefulness in conservative treatment of carpal tunnel syndrome. 40 Patients aged 30-72 years, with unilateral CTS cofirmed by EMG examination were included. The patients were divided into 3 groups based on clinical symptoms according to Whitley. The character of pain, its frequency and intensity (VAS Scale) were determined using parameter. Decrease in pain was observed by the usae of VAS. (Rock Akad Med Bialmyst, 2005:50-suppi:196-8). 5.Bonebrake.A.R.,et.al.,(1990) the study was designed to assess the efficacy of a proposed new and unique programme relative to treatment. The patients diagnosed as CTS were compared to control to a control population showing no symptoms. Prior to undergoing treatment and following completion of the treatment programme. Results indicate that individuals with CTS had significantly lower values in strength, ROM, and slower task performance than did the control;ratings of pain anad distress were also significantly higher than the control groups. Analysis of the post treatmaent cases revealed statistically significant improvements in several measures of up to statistically significant improvements in several measure of up to 25% over post treatment values. Significant improvement was also shown to several ROM measures of upto 22%. Finally, a significant reduction of 15% pain and distress ratings was demonstrated in the post treatment cases. (Journal of Manipulative Physical Therapy, 1994 (May);17(4):246-249). 6.Scrimsha.S.R.,et.al.,(2001) Conducted a comparative study between the responsiveness of Visual analogue scale and McGill pain questionnaire. Measures in 75% patients and concluded that the VAS was a better tool than the McGill pain questionnaire for measuring pain in clinical practise. 7.O.Baysal, Z.Altay et.al Conducted a study in 28 female patient with clinical and electrophysiologic evidence of bilateral carapal tunnel syndrome. They were divided into two groups. Group 1 received tendon gliding exercise with splinting. Group 2 received splinting with ultrasound for a period of 4 weeks with Visual analogue scale and Functional status scale. 8.Bringer TL.,Roger IC et.al conducted a randomized trial in totoal of 61 patients with carpal tunnel syndrome. They were divided into four groups. Group 1 received neutral wrist and MCP exercise group. Group 2 received neutral wrist MCP exercise along with splint. Group 3 received wrist cock-up exercise and Group 4 received wrist cock-up exercise and tendon gliding exercise along with splintas perfoarmed 3 times a day. The tool used to asses the function is functional Status Scale and Symptom Severity Scale. There was significant effect in Group4. 9. Sonodyn, Sieman(2000) Conducted an experiment on study of 16 patients. They was treataed with Ultrasound for a period of 4 weeks and the pain was assessed. In this, 88% reported good reasult and reduction pain was assessed by using Visual Analogue Scale. 10. Davis.P.T.,et. al., (1998) Conducted an experimental study to compare the efficiency of conservative management care with chiropractic care in treatment of carpal tunnel syndrome. The group with 9 week of treatment and a 1 month follow-up interview. 96 eligible patients with symptoms were conformend by clinical exam and nerve conduction studies. Conservative treamtment included mobilization of carpal bone, soft tissues, joints (three treatment per week for 2 wee, two treatment per week for 3 week, and one treatment per week for 4 wek). Main outcomes measures were pre and post assessment of self reported physical and mental distress, nerve-conduction studies, results show that there was significant improvement in perceived function and comfort, neve conductuion and finger sensation. (Journal of Manipulative Physiotherapy, 1999 June;22(55);348-9) 11. FD Burke, J Ellis, H McKenna, M J Bradley(2003) Carpal Tunnel syndrome of mild to moderate severity can often be effectively treated in a primary care environment. Work space modifications wrist splints tendon and nerve gliding exercises are of benefit and useful for symptomatic women in the third trimester of pregnancy. 12.Shaafi Sh*, Naimain Sh*, Iromlou H*, Sayyah Melli M** A convenience sample of 90 pregnant women (30 women from each trimester) were referred from Al-Zahra Hospital of the electrodiagnostic ward of examined clinically and then by electroneurodiagnostic tests.There were suspected symptoms of CTS in 45 patients. The most frequent symptom and sign were hands paresthesia(34%) and positive tinel and phalen sign(each22%). CTS was definite diagnosis in 15 women(16.6%) by electroneurodiagnostic studies. Mild bilateral involvement was seen in 73.3% of patients. There was a meaningful relationship between CTAS and trimester that 26.6% of patients were at third trimester. Also there was a meaningful relation to age. The CTS was more frequent in ilder women. 13.BaumannF, Karlikaya G, Yuksel G, Citci B, Kose G, Tireli H(2007) Pregnant women in the third trimesater (n=69) and age-matched non-pregnant women (n=40) asymptomatic for CTS were included in the studyNerve conductn studies of themedian and the ulnar nerves across the carpal tunnel were bilaterally performed with the standard techniques. All the median sensory nerve conduction studies performed from the ring finger and palmar region to the wrist. Median sensory nerve latencies from palmar branches to wrist were significantly longer in the pregnant group.(p 14. OConner.D.,et.al.,(2002) Conducted an experimental study to evaluate the effectiveness of non surgical treatment for carpal tunnel syndrome versus a placebo or other non-surgical control interventions in improving clinical outcome. Twenty ine trials involving 884 people were included. In one trial involving 21 people carpal bone mobilization significantly improved symptoms after three weeks, (weighted mean difference is -1.43;95% confidence interval is 2.19 to -0.67), compared to no treamtment. Current evidence shows significant short term bebefit from carpal bone mobilization. (Cochrane Databasae syst Rev.2003;(1):CD003219). MATERIALS AND METHODOLOGY MATERIALS AND METHODOLOGY FULL PAGE MATERIALS AND METHODOLOGY MATERIALS USED Couch Chair Pillow Foot stool VAS SCALE FUNCTIONAL STATUS SCALE METHODOLOGY STUDY DESIGN Quasi experimental study with Pre Vs.Post test design. STUDY SAMPLING The 10 samplings were selected from Retna Global Hospital, Trichy and Thanthai Roever College of Physiotherapy, perambalur. A total number of 10 subjects were diagnosed as symptomatic Carpal Tunnel syndrome during pregnancy at age group of years was selected by Quasi-experimental purposive random sampling method after giving due consideration to inclusion and exclusion criteria. STUDY SETTING The study was conducted at Outpatient Physiotherapy Department in Thanthai Roever College of Phsiotherapy, Perambalur, Rathna Global Hospital, EMG Laboratory in PG Studies under the supervision of concerned authority. STUDY DURATION The study was conducted for a period of 4 weeks. INCLUSION CRITERIA Pregnant women with pain and swelling in the wrist for 1 month. Both unilateral and bilateral involvement. Age 25 years and 32 years. EXCLUSIVE CRITERIA Non pregnant women with carpal tunnel syndrome. Pregnant women having other complications like hypothyroidism, diabetes which may lead to carpal tunnel syndrome. Any other trauma related injuries. Abnormal X-Ray of the wrist. Males. Gained surgical of symptoms. History of steroid injection into the carpal tunnel. PARAMETER A.VISUAL ANALOGUE SCALE(VAS) The VAS Scale is the valid and reliable measurement tool for pain.It is used to measure the pain response that the patient experience before and after nerve and tendon gliding exercises of median nerve. VAS Scale consists of 10cm horizontal line with two ends labeled as no pain(0) and severe pain(10), the patient will mark a point on the line, which corresponds to the intensity of pain what theyexperience. B.FUNCTIONAL STATAUS SCALE(FSS) Functional Status Scale was used to measure the functional disability offhand. It consists of six items of questionnaire (writing, buttoning of clothes, holding a book while reading, household, carrying grocery bags, bathing and dressing). SCORING 06-12 -No difficulty 13-18 -Mild difficulty 19-24 -Moderate difficulty 25-29 -cannot do at all due to hand or wrist symptoms. PROCEDURE A total of 10 subjects with symptomatic carpal tunnel syndrome during pregnancy was selected randomly with due consideration to inclusion an exclusion criteria A brief demonstration was given about tendon and nerve gliding techniques for the patient. Pre test data and post taest data was collected with VAS and FSS Scale. The results were recorded. The subjects weare given nerve and tendon gliding exercises. The results of post test of the same parameter was recorded and compared. Statistical tools The statistical tool used in this study were paired t-test. PAIRED T-TEST à ¢Ã‹â€ Ã¢â‚¬Ëœt-test was used to find out the statistical significance between Pre and Post test values of tendon and nerve gliding exercises and VAS pain response and FSS Scale response before and after treatment. FORMULA: PAIRED T-TEST S= à ¢Ã‹â€ Ã¢â‚¬Ëœdà ¢Ã‚ Ã‚ ¿ d =Difference between the Pre Test Vs post Test _ d= Mean difference n=Total number of subjects S=Standard deviation DATA PRESENTATION DATA PRESENTATION TABLE-1 S.No Visual Analogue scale Pre Test Post Test Functional Status Scale Pre Test Post Test 1. 8 4 27 16 2. 7 3 27 12 3. 8 5 26 15 4. 9 4 29 13 5. 7 2 25 15 6. 8 4 25 12 7. 9 3 28 16 8. 7 4 28 16 9. 8 2 27 17 10. 8 3 28 14 DATA ANALYSIS AND INTERPRETATION DATA ANALYSIS AND INTERPRETATION This chapter deals with the analysis and interpretation of the Datas collected from 10 patients with carpal tunnel syndrome during pregnancy and the effect of nerve and tendon gliding exercises aas a treatment approach to carpal tunnel syndrome during pregnancy by comparing the VAS Scale for pain response and FSS for functional ability. TABLE II The table II shows the mean value, mean diference, standard deviation and paired t value between pre and post test value of Visual Analogue Scale for patientas whao have been subjected to tendon anad nerve gliding exercises. VAS Mean Mean difference Standard deviation Paired t value Pre test Post test 7.9 3.4 4.5 1.07 13.28 It explains the paired t value of pre and post test value was 13.28 at 0.05 level of significance which was greate than the tabulated t value 2.26. This showed that there was a statistical significant difference between pre versus post test. The pre test mean was 7.9 the post test mean waas3.4 and the difference was 4.5 which showed that there was a reduction in Visual Analogue Scale score in post test values in which the recovery of selected samples in response to intervention. THEREFORE THE STUDY IS REJECTING THE NULL HYPOTHESIS AND ACCEPTING THE ALTERNATE HYPOTHESIS. Graph Visual analogue scale: Pretest VS Post test Series1: Pretest Series2: Posttest Functional Status Scale: Pre test Vs Post Test Series1: Pretest Series2: Posttest TABLE III Table III representas the mean values,mean difference, standard deviation and paired t value of Functional Status Scale who have been subjected to tendon and nerve gliding exercises. FSS Score Mean Mean difference Standard deviation Paired t value Pre test Post test 27.1 14.6 12.5 2.22 17.7 It explains the paired t value of pre versus post sessions awas 17.7 at 0.05 level of significance which was greater than the tabulated t value 2.26. this showed that there was a statistical significant difference between the pre and post test resultas. The pr tesat ment was 27.1, the post test ment was 14.6,and the difference was 12.5 which showed that there was a reduction in functional status scale score in post test values in which recovery of the selected samples in response to intervention. Thrrefore the study is rejecting the null hypothesis and accepting the alternate hypothesis. Graph DISCUSSION DISCUSSION The aim of the study was to determine the effect of tendon and nerve gliding excercises in reducing the pain and improving the functional ability of hand in patient with carpal tunnel syndrome during pregnancy. Carpal tunnel syndrome is most common and significant of all nerve entrapment syndromes (Phalen.G.S. 1972). It causes 20% of all compression syndromes especially in the third trimester of pregnancies. A total number of 10 subjects of age group of 25-32 years were selected for the study. Visual Analogue Scale for pain and Functional Status Scale for functional ability were taken as parameters to measure the affliction of patients. Pre test data has collected for the subjects and computed. They were subjected to tendon and nerve gliding exercises for 4 weeks. The result of post teat of same parameter was recorded for comparison after 4 weeks of treatment. The paired t test was used to compare the pre VS post test results of subjects. Caarpal tunnel syndrome is a common condition among people who do repetitive wrk all day lke punching keys on computer or cash register or even pressing on the strings of a violin. Pregnant women are also susceptible to carpal tunnel syndrome even if they do not type or play msic all day. The studies have shown that one out of four pregnant women complains of the syndrome usually in the second or third trimester of pregnancy when fluid retention in the aarms and hands is more likely to put pressure on the nerve that leads to the hands anad fingers. The nervous system is normally under some pressure and tension. If the tension is breaked there results some movement(Millesi.et.al.1972). Dackowicz . A.,, conducted an study to evaluate the usefulness in conservative treatment of the carpal tunnel syndrome. According to Butler neural tissue requires movement to promote healing and restoration of optimum mechanical properties.Decreased neural mobility and adverse mechanical tension in nervous system can generate pain.(Butler and Elvey 1978). Mchellan and Swash in 1976 noted that wrist and fingers extensor wil move the median nerve at wrist 2 or 4 times more than the middle of the upper arm. According to Asgel Enhos tendon requires movement to promote functional ability. Rosmaryn and Asgel Enhos said that the decreased tendon gliding in nervous system can generate pain. Rosmaryn proposed that radicular pain might be mobilizing the involved nerve. The mechanical respose is tendon movement in the cross sectional shape and viscoelastic function. So the treatment of tendon Gliding Exercise mah normalize the pressure gradient around the nervous system and releases the tendon thus reducing pain improving functional ability. Summary Summary The objective of the study was to determine from the available evidence the effectiveness of tendon and nerve gliding exercises programmed in reducing pain and of increasing the functional ability in the carpal tunnel syndrome during pregnancy. To conduct the study, the total number of 10 carpal tunnel pataients during pregnancy with both unilateral and bilateral involvement at the age group 25 to 32 years, who were suitable for inclusive criteria was selected by Quasi experimental purposive random sampling technique and informed consents were obtained from subjects individually. The pre and post test of VAS and FSS were conducted and recorded before and after treatment programmed for 4 weeks of nerve and tendon gliding exercises inmcarpal tunnel syndrome during pregnancy. The paired t test is used to compare the pre and post test values of nerve anad tendon gliding exercises and the pain and functional ability are computed by the VAS and FSS Scale. In the analysis and interpretation of the data based on the Visual Analogue Scale for pain the paired t- test value (13.28), which was greater than the tabulated paired t test val

Reader-oriented Theories and Their Application to Ernest Hemingway’s Hi

Reader-oriented Theories and Their Application to Ernest Hemingway’s Hills like white elephants From the very beginning of the literature people tended to criticize the literary works according to some certain criteria. Some critics claimed that the text itself is important and some other said the author and his style is the thing that should be focused on. Form and content were the other significant elements in the history of the literary criticism. In addition, the social and political influences of the time that the work was written were also considered as important. However the reader who reads the work and his thoughts and his interpretations were not as valuable as the other criteria until late 19th and early 20th century. From then on we come up with a new approach, reader-response. The aim of the present paper is to give some basic tenets of the reader-oriented theories and their application to the work â€Å"Hills like white elephants† by Ernest Hemingway. We can say that Reader-oriented theories have no single or predominant philosophical starting point. There are quite different writers that commented on the reader response and they belong to different traditions of thought. They seriously challenge the predominance of the text-oriented theories of New Criticism and Formalism. As for them it is impossible to talk about the meaning of a text without considering the reader’s contribution to it. We see an interesting explanation about reader-response criticism by Tompkins. She claims that â€Å"reader response criticism is not a conceptually unified critical position, but a term that has come to be associated with the work of critics who use the words reader, the reading process, and response to mark out an area for investig... ...n and fertile part of the country was a symbol of the productive part of the woman and the barren part is the symbol of the man who did not want the baby. And the other readers stated that these two different parts of the land were a reflection of the inner part of the woman. The reason for the man not to want a baby was considered as an obstacle for him to travel. It was observed that the woman readers were supporting the woman in the story and the man readers were supporting the man’s part of the argument... Finally we can say that the discussion in the class and the differences in the interpretations showed us clearly the differences between the perceptions of the readers on the same work. In the lights of the reader-oriented theories one can claim that there is no single truth or meaning derived from the text, the responses will change as the readers change.

LEARNERS AND LEARNING ASSIGNMENT 4 Essay

INTRODUCTION Students learning English as a foreign language are often confronted with the challenge of learning and using English effectively. Some students seem to cope with the difficulties of language learning with great success and neither little effort, while for others the task is neither an enjoyable nor a successful one. What is it that makes learning a new language so easy for some and so difficult for others? One reason is that â€Å"each student has his/her own preferred way of learning that is determined by his/her cultural and educational background and personality† (Shoebottom, 2007). BRIEF LESSON OUTLINE In this assignment I evaluated differences in learners’ responses and considered ways in which the quality of their learning could be improved. The lesson was aimed to help the students understand and use the 2nd Conditional in the context of life survival. I designed a lesson of an escape survival plan at school which consisted in following rules of a fire exit plan in every room. It’s the kind of thing you always see on your hotel door, with a plan of all the exits, staircases, elevators and rooms. I gave them a fun and language rich way to use these plans in a zombie-infested building right here at school, of course, containing plenty of grammar-juice in it. STUDENT’S PROFILE There are 20 students in my class. The learners described are intermediate students whose ages varied from 16’s to 17’s.I have been teaching them for about 9 months. They show great interest in language learning and most of them like my teaching approaches and interact with me well in class. 2/3 of the students are of average level of the class. They like to communicate in class but are weak at the accuracy of language. DIFFERENCES IN LEARNERS’ RESPONSES AND ACHIEVEMENTS Having observed and taught the class, I can figure out that each student has his/her own way of following my teaching stages and activities during the lesson. These different ways seemed to influence how they responded to different teaching methods I applied in each activity and how successful they were in understanding and using the language focus. The differences discussed later include the learners’ age, motivation, personality, and social and cultural background. AGE Compared to motivation, personality, and social and cultural background, age seems to be easier to define and measure. Nevertheless, the relationship between learners’ age and their potential success in foreign or second language acquisition is still a subject of debate. â€Å"Linguists argue that many young learners are capable of communicating successfully in a foreign language, in terms of accent, word choice, or grammatical features because they begin learning a language when they are young† (Lightbown & Spada, 2003). I, therefore, planned and set up activities that helped them understand, practice, and produce the language form gradually in a relaxed atmosphere and a non-threatening way. My group stated that they preferred working in pairs to other options. They were shown to be well balanced in the primary senses; Visual, Auditory or Kinesthetic which people use principally in learning.  This information is in line with my observations of this group in class and I believe is also somewhat representative of their age. Being teenagers, they have still to fully develop their preferred learning styles and learners of this age group often feel self-conscious about being ‘criticized’ or corrected in front of others. Having said this, I found my group to be attentive and well-balanced learners. MOTIVATION My students were very motivated and excited planning their way out of a zombie-infested building. They started acting a little, and they could not wait to start the lesson. They did not mind following my instructions and were willing to do any activities set up in each teaching practice. In order to sustain the pupils’ motivation, I set up a variety of activities, i.e., guessing pictures, role play, listening tasks, team work, highlighting form and pronunciation, mingling speaking activity. By doing these various  activities, I could avoid boredom and increase their interest levels during the one hour lesson. Williams (1999) cites the work of Gardner (1985) and defines motivation as consisting of effort, plus desire to achieve the goal of learning, plus favorable attitudes towards learning the language. A distinction is made between integrative (or intrinsic) orientation, which occurs when the learner wishes to identify with the culture of the target language, and instrument al (extrinsic) orientation, which occurs when motivation arises from external goals, such as passing exams, financial rewards, or furthering a career. Lamb, M. (2012) adds a third category: success in the task, which is a combination of satisfaction and reward.  PERSONALITY One of the challenges I faced teaching this lesson (in the beginning) was the discipline. I made clear right from the start of the lesson what the rules of the classroom were and the consequences of not behaving well, this made the students’ behavior in my classroom much better The personality of the group as a whole was of outgoing teenagers. They were eager to participate and even the shy ones contributed willingly in this lesson. A few of them, the extroverts, were the ones who volunteered more. Usually, these are the most prominent students, and this helped in modeling correctly for their peers. They had no problem in following instructions and started work immediately. I was pleased to see they agreed to work without hesitation. They did prefer to work with a friend, as it often happens when they have been together for at least three years, but still they worked collaboratively. SOCIAL AND CULTURAL BACKGROUND The social background of the students in this Institution is of a well-off family with moral values. The majority of them go abroad for their holidays and own a house and one or two cars. Their parents either own a business or have an executive position in a company. They belong to a club and have lessons in the afternoon of martial arts or practice a sport. During this lesson I noticed an active participation, students also play active roles in developing the knowledge that was to be learned, this in my own way of seeing things is that a student that has a better social status tends to be more organized and more structured this also involves some shifting of roles and responsibilities; teachers become less directive and more facilitative, while students assume increasing responsibility. During this class my students took risks with the language in communicative tasks. They expressed their ideas orally without being afraid of making mistakes. They were more concerned with speaking fluently than speaking accurately. Altogether, I believe a good social and cultural background contributes for a better learning environment. (Shoebotton, 2007) âÅ"” IMPROVING THE QUALITY OF LEARNING FOR THE LEARNERS Having described my students above, I am determined to improve their learning quality through some teaching strategies I elaborate in the following paragraphs. The strategies will be in accordance with their age, motivation, personality, and social and cultural background. During the class I noticed that some students did their best to maintain communication with their peers, but their pronunciation and their structure was not very successful. I was very happy to see that the language was produced but I think it was not good enough for an activity of this magnitude. In the future I will conduct oral productive stages to cater the weak learners. Later, I will also monitor them and give feedback on their erroneous expressions so they will find the communicative activity more meaningful and almost at the same time they will pay more attention to form in a more interesting way. I will maintain highlighting form and pronunciation since they like to pay attention to details of language, es pecially grammar rules. I will set up activities related to language form so that they can be more motivated to show their grammar competence. Afterwards, I will ask them to practice the form in a guided speaking activity so that they will be more ready to enter a freer speaking activity. In relation to the students’ motivation, besides setting up activities that suit their learning characteristics, I will also keep setting up various activities ranging from initial to main activities and from receptive skill to productive skill stages. By doing so, I can avoid teaching patterns that potentially create boredom and gradually demotivate their learning spirit. Instead, I will conduct different activities in each stage that can optimally increase their motivation. CONCLUSION Having stated the learners and learning issues above, I believe that varying classroom activities, teachers will make sure to cater learners with different learning styles at least some of the time. If we balance the activities to suit the learning styles, it is quite probable that the outcome will be the result of a well-planned lesson. Timing also plays an important role in planning lessons. While some activities like completing a task in a limited time proves to set pressure upon the learners. This assignment makes me really reflect on my teaching experiences. I believe this assignment contributes a great deal towards my teaching skills and in turn potentially develop my understanding towards my students’ learning styles, responses, and achievements. References: Shoebottom, P. 2007. Language learning styles. Retrieved on November 23, 2007 from http://esl.fis.edu/parents/advice/styles.htm Lightbown, P.M. & Spada, N. 2003. How Languages Are Learned. UK: Oxford University Press Williams, M., & Burden, L. R. (1997). Psychology for language teachers. Cambridge: Cambridge University Press. Gardner, R. C. (2006). The socio-educational model of second language acquisition: A research paradigm. EUROSLA Yearbook, 6, 237-260. Lamb, M. (2012). A self-system perspective on young adolescents’ motivation to learn English in rural and urban settings. Language Learning, 62, 997-1023.

Free Essays on The Toaster

Toasters are part of most people’s everyday breakfast; you plug it in, pop the bread in, push the lever down and you’re away. But there’s more to toasters than just making good toast. In this report I’ll take you through the inside story of the toaster, how it works, history and the technology required. Crompton and Co. invented the first electric toaster in 1893, though it first appeared in 1909. It was a manual toaster made possible by electricity. Manual meaning it toasted one side at a time and when it was done as desired, you pulled the plug. It wasn’t until 1919 that the first automatic electric toaster was invented by Charles Strite. Today’s modernized toaster is much simpler for the person to use, yet much more complicated for the device itself. It was created using the technology of current-resisting elements from electric irons and heaters. The toaster works by converting electrical energy into heat energy. To do this, the current flows directly from the power point, through the contacts to most often, the nichrome wires. Different metals react differently to the flow of current. Nichrome wires are seen to be the best as they have a fairly high electrical resistance, meaning even a short length of it has enough resistance to get quite hot. Also nichrome alloy doesn’t rust at high temperatures seen in the toaster. The conversion from electrical energy to heat energy happens by infrared radiation. Electrons moving from atom to atom along the nichrome wire cause a vibration. As this vibration of metal atoms increases, the wire gets hotter radiating heat from the element. Now this is the process of the manual toaster. Today’s toaster, for your convenience, also consists of a spring-loaded tray and a timer. These follow basically the same process but a circuit had been added. This circuit acts as a timer and is made up of transistors (for its switching behaviour-A small current can turn a larger current ... Free Essays on The Toaster Free Essays on The Toaster Toasters are part of most people’s everyday breakfast; you plug it in, pop the bread in, push the lever down and you’re away. But there’s more to toasters than just making good toast. In this report I’ll take you through the inside story of the toaster, how it works, history and the technology required. Crompton and Co. invented the first electric toaster in 1893, though it first appeared in 1909. It was a manual toaster made possible by electricity. Manual meaning it toasted one side at a time and when it was done as desired, you pulled the plug. It wasn’t until 1919 that the first automatic electric toaster was invented by Charles Strite. Today’s modernized toaster is much simpler for the person to use, yet much more complicated for the device itself. It was created using the technology of current-resisting elements from electric irons and heaters. The toaster works by converting electrical energy into heat energy. To do this, the current flows directly from the power point, through the contacts to most often, the nichrome wires. Different metals react differently to the flow of current. Nichrome wires are seen to be the best as they have a fairly high electrical resistance, meaning even a short length of it has enough resistance to get quite hot. Also nichrome alloy doesn’t rust at high temperatures seen in the toaster. The conversion from electrical energy to heat energy happens by infrared radiation. Electrons moving from atom to atom along the nichrome wire cause a vibration. As this vibration of metal atoms increases, the wire gets hotter radiating heat from the element. Now this is the process of the manual toaster. Today’s toaster, for your convenience, also consists of a spring-loaded tray and a timer. These follow basically the same process but a circuit had been added. This circuit acts as a timer and is made up of transistors (for its switching behaviour-A small current can turn a larger current ...

Pre-College Summer Programs Should You Go

Pre-College Summer Programs Should You Go SAT / ACT Prep Online Guides and Tips If you're contemplating your summer plans, you may want to consider pre-college summer programs. These programs offerhigh school students the opportunity to live and learn on a college campus. In this article, I'll explain the different types of programs and let you know the benefits and drawbacks of attending them. Furthermore, I'll let you know if doing one of these programs can help you get into college. What Is a Pre-College Summer Program? A pre-college summer program offers high school students the opportunity to take classes at a college and experience college life during the summer. Many programs offer a residential and commuter option. Students can stay in dorms with their peers, or they can commute from home if they live close to the college. Typically, these programs range anywhere from one to eight weeks. During these programs, not only are students able to take classes from college professors or visiting scholars, but they’re also able to listen to lectures from alumni and participate in social activities. Many selective private colleges, including Stanford, Harvard, and Columbia, offer pre-college summer programs for high school students. Some of theseprograms are open enrollment (anyone can attend), and others require admission through an application process. The selective programs typically require teacher recommendations, application essays, and standardized test scores. Check a specific program’s website for its admissions requirements. Possible Benefits of Pre-College Summer Programs Spending part of your summer studying at college or a university may not sounds like the most fun, but it canoffer a number of potential benefits. Prepare for College Life For many students, adjusting to college life can be very difficult. A pre-college summer program enables you to spend time on a college campus and take classes from college professors. These programs can help ease the transition to college life when you go to college. You’ll be more familiar with the expectations of a college class, and you’ll be more comfortable navigating a college campus. Explore Your Academic Interests Pre-college programs allow you to take classes in subjects you’re interested in, or you can discover new interests. You can take courses in a wide variety of subjects like computer science, theater, economics, and philosophy. Enhance Your College Resume Colleges do like to see that you’re taking advantage of your summers to participate in meaningful activities. By attending a pre-college summer program, you can demonstrate your interest in academics and show that you’re motivated to do more than what’s required to pursue your academic passions. Exposure to a Specific College If you're strongly considering attending a certain college, going to its summer program can help you figure out if it's the right place for you. You'll get a feel for the campus and its location, and you may get the opportunity to interact with current students and professors. You'll come away with a better sense of whether you can see yourself thriving in that environment. Make New Friends You shouldn’t discount the social benefits of attending these programs. You can meet people from around the world and form meaningful relationships that will last beyond the program. Keep in mind that there are potential costs of attending these programs. Possible Drawbacksof Pre-College Summer Programs Though many students really enjoy attending these programs, there are some issues to consider. Cost Pre-college summer programs are expensive. For example, an 8-credit course at Harvard’s seven-week secondary school summer program costs $5,900 for tuition and $5,400 for housing. That doesn’t even include transportation costs if you don’t live near Harvard. However, Harvard does offer some financial aid that covers partof the tuition forstudents with outstanding academic records who demonstrate financial need. The all-inclusive cost for the three-week Stanford Pre-Collegiate Summer Institutes is $6,300. That includes room and board and transportation between Stanford and San Francisco International Airport. These Programs May Not Help You Get Into College Many college experts believe that going to a pre-college summer program may in fact hurt your chances of getting into a selective college. If you go to a summer program at Brown and you apply to Cornell, Cornell may assume that you’re more interested in Brown. Also, due to the cost of pre-college programs, some admissions counselors believe that these programs are basically summer camp for wealthy students. Many advise students tofind more creative and low-cost ways to explore their passions. For example, you can volunteer to do research with a local college professor or work at an art museum. However, there are summer programs that will undoubtedly impress college admissions officers. Free, highly selective summer programs like Research Science Institute and the Young Engineering and Science Scholars will greatly enhance your college application because they only admit a limited number of exceptional students. Perfect Zero/Flickr Is a Pre-College Summer Program Right for You? I won't advise you whether or not you should do a pre-college summer program. That's your decision. However, if you can afford to attend one of these programs and feel like it would be a good option for you, I recommend tailoring it to your interests. Take courses that are related to your intended college major, or go to a program at a college that you may want to attend. Also, I don't think that doing a costly program will substantially hurt or help your college applications. However, it can be helpful if you excel in the program and get an outstanding recommendation from a professor. Additionally, if the program stimulates an academic interest or prepares you to do well in school, it can indirectly help your chances of gaining admission to the most selective colleges. What Are Some Well-Known Pre-College Summer Programs? If you do decide attending one of these programs is a good choice for you, here are some popularoptions to check out: Duke TIP Duke TIP serves students as young as 4th grade. It's meant to provide opportunities for academically gifted students. We've written articles on Duke TIP 7th grade Talent Search and Duke TIP SAT requirements. Stanford Pre-Collegiate Summer Institutes and High School Summer College These are two different summer programs at Stanford. At the High School Summer College, you can take a quarter of Stanford classes with Stanford students. The Pre-Collegiate Summer Institutes offer a three-week residential program for students to live in Stanford housing and take a class not often given at the high school level. Summer Institute for the Gifted This program is conducted at colleges across the country. It is designed for gifted and talented students from 5-17 years of age. There are residential and commuter programs. Summer@Brown Summer@Brown offers nearly 200 courses that range from 1-4 weeks. They are designed to reflect Brown's liberal arts curriculum, and they're taughtat the level of first-year college courses. To find the right program for you, there are a number of factors to consider: your budget, the length of the program, the available courses and credit options (some programs offer courses for college credit), and the location of the program. If there's a college that really intrigues you, check the school's website to see if it offers a summer program. You can use the Summer Program Finder to identify a program that fits your needs and interests. You can spend your summer at the beach or college. Or both. Recap Pre-college summer programs provide you with an opportunity to experience college life, explore your academic interests, and make friends. Even though these programs can help prepare you for college, just going to one won’t significantly impact your chances of getting into a selective college. If you’re interested in a pre-college summer program, you can find one at colleges across the country. You’ll be able to take classes in many subjects that aren’t usually offered at the high school level. What's Next? Find out what you need to get into Ivy League schools and the most selective colleges. Are you still uncertain if a pre-college program is right for you? Get some more ideas onhow you can spend your summer. If you're going into your senior year of high school, maybe your summer plan should include preparing for the SAT/ACT. Want to improve your SAT score by 160 points or your ACT score by 4 points?We've written a guide for each test about the top 5 strategies you must be using to have a shot at improving your score. Download it for free now:

The Nursing Theory of Dorothea Orem Research Paper

The Nursing Theory of Dorothea Orem - Research Paper Example When she observed nurses in various hospitals, she found that while they generally were able to perform their job functions, they could not articulate the true purpose of nursing. Orem’s intention was to determine an appropriate focus for the profession that centered on individual patients. This theory was significant in the sense that it provided nurses with a clearer focus on what the profession entailed: helping those who were unable to help themselves due to their health conditions. This paper will give a biographical account of Dorothea Orem’s life and provide a complete description of the Orem Model of Nursing including the Self-Care Deficit Theory. The paper will include examples of how the theory can be applied in various medical settings. It will also discuss the contributions, value and relevancy of her theory. The Nursing Theory of Dorothea Orem Dorothea Orem was a nursing theorist who developed the Orem Model of Nursing also known as the Self-Care Nursing Theory. Orem's nursing theory states that caring for oneself is a basic human need. The duty of nurses is to design interventions to provide or manage self-care actions for individuals to recover or maintain health (Taylor, p. 74). Orem was one of the first theorists to realize that nursing is needed when humans are unable to care for themselves. She felt that â€Å"nursing is distinguished from other forms of care by the way it focuses on human beings† (Fawcett, 2001, p. 35). ... in 1934 and went on to the Catholic University of America to earn a Bachelor of Science in Nursing Education in 1939 and a Master of Science in Nursing Education in 1945 (â€Å"Dorothea Orem,† n.d.). Orem’s first jobs were at Providence Hospital, Washington, D.C. and St. John's Hospital in Lowell, Massachusetts. Some of the positions she held included operating room nurse, private nursing, hospital staff nursing in pediatric and adult medical –surgical units and evening emergency room supervisor. In 1945 she began to focus her career on nursing education. She worked as the director of Providence Hospital School of Nursing in Detroit and continued this phase of her career at the Catholic University of America where she worked as an Assistant Professor, Associate Professor, and Dean of Nursing. In 1949 she left Detroit and moved to Indiana where she found a position as a consultant in the Division of Hospital and Institutional Services of the Indiana State Board of Health. During her tenure there she intended to raise the standard of nursing in hospitals throughout the state (â€Å"Biography of Dorothea Orem,† n.d.). Between 1949 and 1957 Orem was able to closely observe nurses and their work as a result of her position with the Indiana State Board of Health. As a result of her observations she began to realize that nursing required a certain way of thinking as well as a certain way of communicating (Fawcett, 2001). In attempting to develop nursing as a meaningful profession, Orem asked herself three questions: â€Å"(1) What do nurses do and what should nurses do as practitioners of nursing? (2) Why do nurses do what they do? and (3) What results from what nurses do as practitioners of nursing?† (Fawcett, 2001, p. 34) She

Maintaining the Flow of Global E-Commerce Data (Case 2) Case Study

Maintaining the Flow of Global E-Commerce Data ( 2) - Case Study Example On the contrary, philosophy in the United States identifies a level of freedom. There is no government regulation on data privacy and the regulation responsibility relies on individual organization. Even though government agencies act as watchdogs for self-regulation, there is no formal framework for punishing non-compliance. The main difference, therefore, is that while the European Union has a regulated environment for data flow, the United States lacks such a regulated environment. E-commerce relies on technology such as the internet for transmission of data from parties to a commercial communication or transaction. The European Union regulations for data privacy restricts transfer of data to regions that lack a formal regulatory framework on data privacy buy the safe harbor eliminates this rule on the United States. The exemption applies to organizations that meets the Union’s requirements for data safety and allows free transfer of data. The implication of the safe harbor and data privacy is therefore a facilitated E-business because of free transfer of data from the European Union to the United States. Absence of free harbor would prohibit such data transfer and stop E-commerce between the United States and the EU and between organizations in the United States and their subsidiaries in the EU (Morgan and Boardman 217). Conventions such as the establishment of the directive by EU to establish standards for data privacy are legal regulations and binds member states. If the EU and the United States could not agree on the standards then the EU regulations would prohibit data flow to the United States. This would stop E-commerce between the United States and members of the EU because parties in the United States would not receive data from entities from the European Union. The communication barrier would paralyze E-commerce between people from the two regions. This would further have adverse effects on the two economies.