Wednesday, July 31, 2019

Mandatory Drug Tests for Welfare Recipients

Should welfare recipients be drug tested? We have many different opinions about this subject. The problem is that people are receiving free money from the government and purchasing unnecessary or illegal products. Is that fair to people who work hard to earn their money and pay the taxes to support these addictions? No, it’s not fair. The money should go straight to support the individuals’ families until they can support themselves without the help of the government. People who can afford to buy drugs don’t need help from the government.Welfare should be used for its purpose only. Without drug testing people who receive the benefit, the government has no knowledge of how the money from welfare is being used. Drug tests would solve the misusing of the welfare money, and help keep recipients clean so they can keep a job and they can take care of their family with their own earned money. Why is there welfare? Some people run into difficulties in their lives where t hey may need some time of assistance; in these cases, welfare comes into place.Welfare is meant to help people who really need it. As the saying goes, â€Å"Bad things happen to good people,† and when people can’t afford to put food on their table or can’t afford a home to live in, welfare takes action and helps them. Welfare exists to make sure people can get back on their feet, and that’s what welfare checks should be used for and only for. People on welfare should be using that money effectively and meanwhile they should be looking for a job so they can afford their home and food and at one point get out of the welfare system.People are not supposed to lay back and pretend that their welfare check is their salary and use these funds for whatever they want (Welfare Information). But it happens. Unfortunately, welfare has become a way of life for a lot of people in the US. They sit around waiting for their next check with no intention of looking for a jo b or to improve their lives in anyway (Krannebitter). Therefore welfare is creating dependable people who don’t care to get out of their couch to make a better living for themselves.The worst part is that a lot of the people on welfare also use the money that come from the pocket of people who get up early in the morning to work almost every day, to buy drugs. If people are struggling to pay rent or to get food for their family, how are they having enough to buy drugs? What happens is that a lot of the times adults take the money that they are supposed to buy clothing, food, school materials for their kids and instead use it to buy drugs. That is not air to people in the work force because we are basically funding their drug addictions, and it’s definitely not fair to their kids, because that money is supposed to help them live a better childhood (â€Å"Welfare Misuse and Drugs†). So what can we do to prevent welfare money going to drugs? We should consider drug testing welfare recipients. By doing so, we would make sure that every person who receives the help from the government is clean and are using the money efficiently.Also it would make sure they are not losing jobs because of their addictions. People who are against drug testing welfare recipients always say that the 4th amendment make the drug testing unconstitutional. People who don’t know what the 4th amendment is all about, it basically states that the U. S. constitution protects people from unreasonable search (Fourth Amendment). So how come the 4th amendment doesn’t protect me from being drug tested for a job?I’m willing to work and earn my money and to do so I undergo through a drug test every so often, so how come the people who are in the welfare system, who by the way receives the money from the taxes I pay from my paycheck, for free, should not be tested? It’s just common sense. The drug testing would encourage people to stop using drugs and us e the money in a more productive way, and as a result of that, improving their lives. Welfare money is not always used for its purpose.With that in mind, the government should come up with a solution to solve this problem who is taking money away from people who really need the system. That solution is called drug testing. Drug tests should be a part of the application for welfare and it should happen also during the period when the person is getting help from the government, as people get tested to keep their job. Drug test would not only make sure that the welfare money is used properly, it would also make sure the recipients are clean and therefore can be more productive for their families and our society.

Intensive Mothering

Other writers, like Sharon Hays, mount descriptions of American mothering that implicitly criticize some of the facets of attachment parenting. After reading these authors' pieces alongside the work of attachment parenting proponents Like Lauren Lindsey Porter, William and Martha Sears, and Katie Allison Grange, do you believe that the critics' condemnation of attachment parenting Is fair? Does AP place undue demands on women? Why or why not? Questions to Ponder: Is attachment parenting synonymous with â€Å"intensive mothering? † Why or why not?Do you think attachment parenting always entails the type of parenting the authors criticize, or might aspects of attachment parenting in fact work against â€Å"intensive mothering? Is the rise of attachment parenting to blame for the stressful nature of motherhood in contemporary American society, or are other social structures at fault (e. G. Lack of maternity/family leave, lack of subsidized public childcare options, etc. )? Are t he practices AP promotes (co-sleeping, breastfeeding, and barreling, for example) problematic? Are they Incompatible with paid work?How does social class Influence the practice of attachment parenting, and do the authors myopically focus on the middle/upper-middle classes? Why do you think attachment parenting has been targeted as an object of criticism? Note that I do not expect you to answer all of these questions; I'm including them merely to give you a sense of some of the directions you might take with your Format and Specifications: In an approximately 4-5 page (1200-1500 word) paper, make a claim about whether or not you believe the critique of AP levied by the critics Is a fair and reasonable one, and why.The why Is as Important If not more Important than the stance Itself, and should play a part in your actual claim, so that your claim is not merely â€Å"the critique Your claim should be clear yet robust, and contestable, and you should draw on at east 2-3 of our in-class readings (note that you may use the Accredited and Blades and Rowe-Finickier readings on paid work and mothering as well) to support it. You should also cite at least one source that we have not read together as a class (more on that later), for a minimum of 3-4 sources.All of the papers you write for this class should adhere to MEAL guidelines both for citations (which will be parenthetical) and for the works cited page. You need not include works Vive given you to read for this course in your works cited page, but you should always put any outside sources that you cite on your works cited page. Please refer to your syllabus for specifications on margins, font, font size, and word count! Outside Sources: The following links might prove to be useful in learning more about the theory and practice of attachment parenting, and may lead you to other sources as well.I will generally accept any of the information on these sites as credible sources on attachment parenting as it is perceiv ed by its adherents. Www. Disenfranchisements. Org (official website of Attachment Parenting International Group) www. Wisped. Org (note that I don't normally encourage the use of Wisped for academic research, but TTS entry on AP is actually quite accurate and helpful; also contains links to other sites) www. Saddlers. Com (more from William Sears) www. Gastrointestinal]u. Com (this is Grange's blob; you can also link too list of her essays and articles from here) www. Naturalistic. Mom (the site on which the Porter reading appears; explores AP from a â€Å"Natural Family Living† perspective) www. Mothering. Com (website for â€Å"Mothering† magazine, an AP/NFG publication; contains numerous articles and hosts the largest discussion board on the web regarding attachment parenting issues) If you have questions or concerns about a source you intend to use, and whether it is reliable, feel free to ask me my opinion. You will have more time and opportunity to refine your u se of outside sources during the revision stage, but you should make a reasonable attempt to flesh out your evidence in this draft.Rhea Shawnee English Paper I-Draft Parenthood can often be extremely overwhelming and demanding. Putting aside your entire life and giving up everything to satisfy the needs of your baby is not an easy or poses a huge responsibility on parents. In my opinion, the critiques condemnation of attachment parenting is not fair. I believe that the concept of attachment is reasonable and infant necessary for infants to develop into skilled, independent and mature individuals who share a strong emotional bond with their parents.First and foremost, it is essential to know what Attachment parenting is all about? It is ‘an approach of raising children who are well connected to their parents rather than a strict set of rules. ‘A common misconception that people have is considering intensive mothering to be a synonym for attachment parenting. Intensive mot hering is based on the idea of completely sacrificing your needs and desires and devoting our life to your child or in other words letting your child dictate your life.Most of the articles such as DRP. Laurel's neighborhood focuses on the extreme extent people go to in order to raise their child in the â€Å"perfect† way. The author in a rather sarcastic tone aims to make the readers realize that even in the sass's and ass's parents raised babies who turned out to be Just fine without the concern that they aren't spending enough time with their kids and needing to demonstrate in countless ways each and everyday that you really, really love your child'.It lays emphasis on the fact that if you re unable to provide technologically advanced gadgets like ‘Baby-Be-Safe Crib sheet or video surveillance cameras to keep a check on the nanny looking after your baby or electronic monitors to check the babies heart rate even before he is born' you are considered an incompetent pare nt.Attachment parenting on the other hand means ‘opening your mind and heart to the individual needs of your baby and letting your knowledge of your child be your guide to making on the spot decisions about what works best for both the mother and child, that is learning read the cues of your baby and responding appropriately to those uses. ‘ It encourages parents to find out which parenting style fits their lifestyle in the best way and modify what does not work for them. As sears says, â€Å"Like any Journey, parenting requires adjustments along the way. Attachment parenting does not pose undue demands on women in the sense that it is not compelling you to do all the seven Baby Bi's and being practical and realistic, if not impossible it is extremely difficult to do everything that is recommended. It mainly advises you to incorporate whatever makes the connection between you and your child stronger in your day to ay routine. Attachment parenting does not expect parents to spend 24 hours of a day Just attending to your child, instead it's the quality of time during which you are able to develop a feeling of trust and make your baby feel that he/she can rely on you for his needs.A frequently asked question that people have is won't the constant nursing and attention giving to your child be problematic? People feel tied down with the seven Bi's of attachment parenting and might consider them to be challenging. However, many attachment parents after being interviewed stated, â€Å"l feel so connected with y baby. † â€Å"l feel right when with her, not right when we're apart. † â€Å"l feel fulfilled. † The seven Bi's of baby wearing include, ‘breastfeeding, balance, beware of baby wearing and birth bonding. Attachment parenting is a very typical way of parenting and all these practices have been practiced all over the world for hundreds of years only recently these practices have been termed together as attachment parentin g. Though some people may consider the seven Baby Bi's to be highly problematic if they are working mothers but as stated earlier, it is not mandatory to follow all seven of them. For instance, I feel breastfeeding is essential for the health of the baby, moreover, ‘Current studies show that babies who are breast fed tend to be healthier, more secure and even score higher on IQ tests!In addition the bond between breastfeeding mom and baby tends to help form a secure attachment for the baby as he or she grows. Breastfeeding also tends to be an economical choice for many families. ‘ ‘A British study of 36 middle-class mothers and their three-year-olds found that securely-attached children scored 12 points higher on the Stanford-Bines intelligence test than did insecurely attached children (Crandall and Hobnobs 1999). Since research has proven that breastfeeding is vital for healthier growth of babies I think it would be unfair for those babies who are not breast-fed. Another topic that is highly debated over is whether a baby should co-sleep or not? Research has come to a conclusion that co sleeping reduces stress and anxiety levels among babies as they sleep in a safe and sound environment close to their parents. Co-sleeping may be a stress-reducer as well. A British study reports that children (aged 3-8) who slept in their parents' rooms showed lower daily levels of the stress hormone cortical (Wentworth 2007).Its is argued upon by people who say that it may be dangerous for the baby to sleep on the same bed as the parent and co sleeping may be spoiling the baby as it would not make him independent and the baby needs to learn how to sleep alone at some point. However, co-sleeping does not mean that the baby has to sleep on the same bed as the parent. The baby can sleep anywhere in the same room as the parents or in a crib right next to the parents bed it would still be considered co sleeping.The main idea is for the baby to be close to the par ents so that the parents can easily tend to the baby if needed. If pondered upon, intensive mothering is much more problematic in comparison to attachment parenting. Intensive mothering is Judging your capability as a mother on the basis of your ability to afford expensive and luxurious products. In that sense it can be said that attachment parenting is reasonable, as at least it is not expecting parents to go over the top to raise their child.All Attachment parenting is asking parents to do is treating your child with love and affection and to getting to know your child better. Which part of that is unreasonable or unfair for mothers? A child is not a machine; it is not inbuilt with functions neither goes it come into this wide world prepared to react to all the situations it is faced with. Parents need to understand what is going on the babies mind and respond accordingly. This can only be possible if the parent spends enough time with their baby. If parents are unable to find som e time out they should not to have a baby.As critiques put it, attachment parenting may pose undue demands on women, as she is the sole person who can provide the kind of care, love and attention that the baby is unable to devote herself to her babies needs when he/she needs it the most she is not ready for the challenges of motherhood. In western cultures, it is not an obligation for a married couple to have children. If both parents are professionals and have chosen their career over their family, it would be a wiser option not to have babies, as there is no point raising a child who is going to be neglected.In several parts of the world such as India, it is almost mandatory for a married couple to have children or else the family members along with the society raise questions and the mother is expected to leave everything aside and raise the baby. This is very customary in India, as my own grandfather did not let my mother continue with her equines, as he wanted her sole attentio n to be on raising her children. Therefore, a majority of the Indian babies are attachment parented. However, in countries like America, no one is putting a gun to your head to have a baby.It is entirely the couple's choice. Therefore, in conclusion, the fact remains that every individual is unique and one parenting style cannot fit everyone. I feel that a majority of the critiques â€Å"who tend to criticize attachment parenting don't really understand what attachment parenting is all about,† â€Å"So many studies show that if you meet the needs of a child when she's nouns, she will grow into becoming more independent. † Attachment parenting is a broad parenting style that promotes seven ways to get connected with your baby.Moreover, attachment parenting is exactly what has been practiced all over the world for years only now its been given a name; the only change that has occurred is that there has been a significant increase in the number of working mothers. Attachm ent parenting is criticized because it is thought to pose strenuous demands on working mothers but it is always possible to try to mix and match parenting style and figure out what works for them. It is not setting out a strict set of rules to raise a baby and above all it is because of its flexibility why I feel attachment parenting is fair and reasonable.

Tuesday, July 30, 2019

The Nature of Romantic Love in Shakespeare

The Nature of Romantic Love in Shakespeare's As You Like It The Shakespearean comedy As You Like It, discusses the nature of love through the stories of four couples that demonstrate a variety of love situations. All of the couples in As You Like It exhibit some elements of ridiculous Infatuation as well as elements of genuine connection in their relationships. This makes it possible to view love on all accounts as either genuine or ridiculous. The reader Is able to decide how they would Ilke to view the love stories In the play.In particular, the relationship between Silvius and Phoebe demonstrates the options that the reader has in viewing the nature of love in As You Like It. Silvius goes through a transformation of character, subtle as It may be. In the beginning, he is pining over Phoebe and seems to believe that his enduring the pain of her rejection Is a reality of love. He acts desperately to try to win her over and forgets to respect himself in the process, When Phoebe has p rofessed her love for Ganymede over him, he expresses that love is made of â€Å"sighs and tears† (V, ‘i, 88).Proving his foolish confusion of angst and infatuation with genuine love. But In his next sentence he says love is about â€Å"faith and service† (V, it, 93). So while Silvius has some very misguided thoughts about love, he seems to have some real understanding of what it Is. His true dedication and understanding of his emotions seems to suggest that he may be able to have a successful relationship, but he is certainly toeing the line of belief and delusion by refusing to let Phoebe go. Phoebe presents a slightly more interesting transition than her partner.Phoebe adamantly efuses a well-suited prospect for no apparent reason. Silvius Is clearly passionate about Phoebe. He is persistent and unrelenting; he does not doubt his own love. However, Phoebe loves Ganymede and has to deal with the disappointment of not being able to marry him. Through this, she m ay be able to relate to Silvius, whom had to accept the constant disappointments she gave him. When the truth about Ganymede becomes apparent to her, she tells Silvius â€Å"thy faith my fancy to thee doth combine† (V, iv, 155).She seems to change her perspective and begin to view Silvius' ersistence as commitment rather than desperation. The main problem with their relationship is that Phoebe would not have him, but In the end she does (even if she was tricked into D. So with that challenge surpassed, maybe they can begin to develop a healthy relationship. Although Silvius begins as a desperate character who cannot make a rational decision of self-preservation to stop loving the girl who will not have him. Phoebe has no reason to refuse Silvius, but one may speculate that she does it to feel more powerful.She emotionally abuses Silvius, but is it possible that she changes when she realizes how foolish she was to fall for Ganymede. This caused her to change her views on love and accept Silvius's commitment. Ridiculousness is not difficult to find in Silvius and Phoebe's relationship. On the other hand, it can be argued the couple has something genuine at the foundation of their connection, so they may be able to have a successful marriage. Silvius and Phoebe's relationship is a great example of a t Of2 situation In wnlcn tne reader or aualence.

Monday, July 29, 2019

Technology of Management in Organization Assignment

Technology of Management in Organization - Assignment Example The researcher of this essay analyzes and presents the importance of technology, that has risen in such leaps and bounds that organizations develop various management procedures and guidelines for the best implementation of the technology and to gain the utmost benefit of it. Change in organization today is evident. On the context of the technological change mainly there are two primary sources associated with such changes, the internal sources and the external sources. Owing to the amount of change in organizations, it is necessary for the organizations to possess a good mentor who can effectively guide the employees. Any good mentor in an organization should posses various characteristics like their willingness to share the skills, their knowledge and their expertise. The growing importance of technology in an organization has resulted in providing much importance to the technical workers. As the functioning of any organizations is almost impossible without the presence of technica l workers much emphasis is being given by the management in devising strategies to motivate and reward them. Motivation affects the morale of the employees and has a huge contribution in creating a positive work environment and it indulges an added responsibility on the employees to be concerned about the success of the organization. Knowledge management has evolved as one of the efficient tools for the increase of productivity in an organization and helps to develop the intellectual capital within an organization.

Sunday, July 28, 2019

Framework for the Development of Transboundary Offshore Oil and Gas Essay

Framework for the Development of Transboundary Offshore Oil and Gas Resources in Neighbouring States - Essay Example The paper tells that discoveries of deposits of gas and oil that exist on the boundary between two sovereign states present a complex challenge that must be approached with caution. Both sides have different interests and consequently decisions must be made that resolve conflicts and balance the competing interests of the different parties. Transboundary deposits of gas and oil do not conform to the standard laws in relation to political boundaries or property lines. This is because the resource can be exploited from one side of the boundary without the line needing to be crossed. There are several international conventions and guidelines that focus on how to resolve such disputes, however, not all countries have ratified to these, and they have little to no legal power. One important aspect of the development of offshore oil and gas resources is the economic perspective. These resources represent significant means for economic development for the countries in which they are present. However, this is not the only consideration. Other relevant factors are the social, political and environmental factors . These differ between states and two states attempting to reach an agreement over a transboundary resource may differ in how their priorities which may affect the types of technology they are prepared to use or the processes that they want to be involved in. The ideal situation for a transboundary deposit is for the states whose boundary the deposit is on to work collectively. However, the situation becomes more complex as each of the states have different laws, principals and procedures by which they work with the various parts of the oil and gas cycle, such as the discovery of the deposit, exploitation, transportation and eventual decommissioning5. This report aims to examine the current framework for how transboundary offshore oil and gas resources are managed, what the benefits and limitations are, and what appears likely for the future. Legislation Legislati on concerning transboundary offshore resources is not simple, as there is no international legal system that has the authority to create legislation that is legally binding. International law arises from international custom, conventions and general law that is recognized by civilised nations6. However, some countries do not recognise all international law. One important aspect of any state is territory and boundaries. Usually, the states boundaries are well mapped and represent a specific point, which marks the difference between one state and another. Within its boundaries, a state has sovereignty and has the power to exploit any and all natural resources that are present. Oceanic boundaries are more complex. Prior to the 1940s, territorial see was viewed as three miles from the coast of the state and this was not accepted in all cases. In 1945, President Truman declared that the natural resources under the high seas that neighboured the United States were part of its territory an d thus under its control. He did however state that if the continental shelf extended to another state, then ‘equitable principles’ would be used to determine who had the right to the resources7. The 1958 Geneva Convention on the Continental Shelf defined the continental shelf as being the deep-sea areas that were next to the coast of a territory but were not part of the territorial sea. The coastal state has the right to exploration of the continental shelf and exploitation of any natural resources that are present. In the case of a shelf that is next to two or more costal states, the Convention states that the boundary should be decided by agreement, and if none is made, then the boundary will be the median line between the territories. An important piece of legislation concerning the rights of states and the sea in general is the United Nations Convention on the Law of the Sea (UNCLOS)8. This article is a comprehensive document with 320 articles, involved more than

Saturday, July 27, 2019

Newborn Thermoregulation at birth Essay Example | Topics and Well Written Essays - 1750 words

Newborn Thermoregulation at birth - Essay Example The temperature of the baby is dependent not only on the thermoregulation of the baby, but also on the environment and the clinical condition of the baby. It is a very interesting fact that, an unattended baby loses heat very fast and the temperature can decrease by several degrees (British Columbia Reproductive Care Program Policy Manual, 2003). Nurses and midwives who attend to deliveries have a major role to play in helping newborn babies maintain temperature. They are the first people to come in contact with the little ones and they have a major responsibility to ensure that the baby is able to maintain appropriate temperature. They also need to make sure that the environment of the baby, including the towels, resuscitation equipment and the room are pre-warmed much before the baby is delivered. Attending to the needs of temperature in babies is very important because thermal disparities can lead to devastating metabolic consequences and can contribute to increased morbidity and mortality in the newborn. In this essay, thermal regulation in a newborn will be discussed. In this context, the role of a midwife in promoting the health of the newborn will also be reviewed. The capacity of the body to maintain equilibrium between production of heat and loss of heat for sustenance of temperature of the body within a normal range is known as thermoregulation. Neutral thermal environment is that environment in which the infant uses only minimal oxygen and expends minimal energy for maintenance of temperature. Thermoregulation of newborn is a much studied and important topic because; disruptions in thermal regulation can lead to hyperthermia and cold stress, both of which can lead to devastating metabolic consequences in the newborn. The normal core body temperature of the newborn is 36.5- 37.2 degree C. Severe hypothermia is when the temperature is

Friday, July 26, 2019

Economics of small and medium enterprises Essay

Economics of small and medium enterprises - Essay Example This essay offers a comprehensive review of the current economic policy of the UK government towards small and medium-sized enterprises. The efficiency of such policy is also analysed. The smaller firms are less fortunate to obtain significant financial aid to combat their insolvency problems. The successive governments in UK have been witnessing comprehensive policy initiatives for uplifting the small enterprises. The very existence of SMEs is vital for the overall economic growth of the developing nation of UK. For preserving the economic opulence of the country, the existing small enterprises must be rescued from all hindrances of sustainability. The threat to these business units resulting into critical problems such as severe unemployment and decline in the economic growth has made the Government to identify the urgency to rescue such SMEs from collapsing. Various action plans and schemes have been taken up by the government for protecting these enterprises. However, the government itself, along with others, admits that a lot of work is yet to be done for achieving the success of reviving small enterprises. There lies a wide gap between preparation of plans and measures, and putting them into appropriate actions thereby ensuring viable results. Impeccable efforts are still missing in order to bridge up this gap. In spite of the endeavours for complete eradication of the barriers faced by the struggling small business firms, a viable implementation of actions for the revitalisation of the SMEs is still lagging far behind.

Thursday, July 25, 2019

An investigation of the risk and protective factors associated with Research Proposal

An investigation of the risk and protective factors associated with high school graduation in the United States - Research Proposal Example Experts have estimated between 3.5 million and 6 million American students between ages 16 and 24 dropped out of schools for the last two years (Haskins, 2010). About 50 percent of minors fail to graduate with their class. African Americans tend to drop out higher than other minorities, which creates significant problems for them (Kogan et.al, 2005). For the class of 2013 84.1% of African Americans graduated, American Indian graduated 85.8%, Asian graduated at 93.8%, Hispanic at 85.1% and white at 93% according to Texas Education Agency 2012-2013. African Americans had the highest longitudinal dropout rate across racial/ethnic groups (9.9%), followed by Hispanics (8.2%). Asians had the lowest longitudinal dropout rate (3.0%), followed by White (3.5%) and multiracial students (4.4%). In the class of 2013, a total of 21,634 students dropped out in Texas. Females had a higher graduation rate of 90.3% compared to males with 85.9% (Texas Education Agency, 2013). Each state is experiencing the same trouble with a large percentage of students not graduating, so as a nation we are losing. In Texas, a total of 3,187 students dropped out of Grades 7-8, and 31,509 dropped out of Grades 9-12. The Grade 7-8 and Grade 9-12 dropout rates were 0.4 percent and 2.2 percent, respectively. The Grade 7-8 rate increased 0.1 percentage points from the 2011-12 school year, and the Grade 9-12 decreased 0.2 percentage points (TEA, 2013). In the school district that I work in which is Klein ISD, in 2010 Klein saw an increase in graduation rate. In May of 2010, 84.3% of the students statewide graduated while Klein ISD had a 92.6% completion rate. The student dropout rate has been an area of concern for many years in the United States. Programs are being implemented to help improve our nation’s battle with graduation. In 1984 House Bill 72 was passed to implement a system for collecting data on student dropouts. In 2009 House Bill 3 was passed to add postsecondary

Response paper Essay Example | Topics and Well Written Essays - 500 words - 2

Response paper - Essay Example Although the demise of the Aztec empire opened up the New World for European settlers, it is a tragic event when seen from the viewpoint of the natives. Their millennia long indigenous culture and civilization was abruptly and most violently cut short by the foreign conquest. In my opinion, rather than merely being a historical fact, this tragic facet to this historical episode should serve as a warning for contemporary politicians and policymakers, and make them realize that greedy ventures lead to humanitarian losses. I would like them to understand that while Spain and later European contingencies benefited from this conquest, from broader perspective humanity was the loser. Another aspect of the book I was most impressed with is its objectivity. Although author Miguel Leon-Portilla was trained in western scholarly tradition, his analysis and presentation does not betray this fact. At the same time, the empathy shown toward the disadvantaged Aztecs is matter of fact and not melodramatic. In this regard I like the subaltern approach adopted by the author in constructing history. I appreciate this book for features such as these. The extensive research conducted by the author is also quite impressive. Not only did he peruse primary sources for gathering evidence (which are in indigenous Aztec language), he also gives numerous cross references for further study, which is useful for college students like me. The detailed list of bibliographical entries at the end of the book is another handy feature. As I read through the book, I was able to appreciate the effort that went into researching this book. For example, previous to this work there was scarce scholarship on pre-Columbian culture in Mexico and the Americas. This book fills that void that its value cannot be overstated. The author also succeeds in bringing lots

Wednesday, July 24, 2019

Albert Chinalmg Achebe Essay Example | Topics and Well Written Essays - 750 words

Albert Chinalmg Achebe - Essay Example Born in 1930 in Ogidi, Nigeria, this 78 year old writer is widely known for his work, 'Things fall Apart', the first novel he wrote way back in 1958. This novel is in fact considered an unsentimental novel, depicting the life and ambitions of Okonkwo, a powerful leader of the Igbo community. Chinua Achebe too comes from this very community, therefore in a way he wrote about what he experienced and felt during the childhood and youth days. The main character of 'Things fall Apart, Mr. Okonkwo is the 'big man' of a traditional village, but the manner in which this man started moving towards fulfilling his ambitions led to prosecution and punishment for him. He was signalled out and targeted for fighting against colonialism. The western effect on values and institutions of traditional Africa, led to isolation of Okonkwo. Such incidents coupled with his approach towards circumstances led to his bad days and ultimately to his downfall. 'Things Fall Apart' narrated the adverse impacts of t he influence of western world on the traditional Ibo African society. Without glamorising his community i.e. the Ibo society, Achebe described how 'things' started 'falling apart' after the Europeans set foot on the African land2. The title of the book, 'Things fall Apart' has been taken from William Butler Yates's The Second Coming - 'Things fall apart; the centre cannot hold'.3 This novel proved to be hugely popular and subsequently translated into some 50 languages. About 10 million copies of this book have been sold around the world. In fact this book also formed the basis of a film 'Bullfrog in the Sun' directed by Hans Jrgen Pohland in 1972. While trying his hand at novels in 1958, Achebe is stated to have said, 'I was quite certain that I was going to try my hand at writing, and one of the things that set me thinking was Joyce Cary's novel set in Nigeria, Mister Johnson, which was praised so much, and it was clear to me that this was a most superficial picture.and so I thought if this was famous, then someone perhaps ought to try and look at this from the inside' (Gikandi, 1996). Chinua Achebe never looked back thereafter and came out with many popular novels with subjects ranging from satire on corruption to the plight of people in the ethnic violence and civil war. Some of the notable works of Chinua Achebe include Arrow of God (1964), A Man of the People (1966), Beware, Soul Brother (1971), Christmas in Biafra and Other Poems (1973), Anthills of the Savanna (1987) etc. Achebe started his working days from the Nigerian Broadcasting Co. in Lagos in 1954. He also studied broadcasting from the British Broadcasting Corp. in London, but destiny had something else in store for him and instead of becoming a broadcaster, he went on to become a successful writer. Presently teaching his students as a professor at Bard College, New York, Achebe has also travelled around the world for delivering lectures on subjects dear to his heart, at different universities. He became the Editor of Okike, a reputed and most influential African literary magazine in 1971, and he continued to edit it after having accepted the post of Professor of English at the University of Massachusetts at Amherst in 1971. Married with four children, Achebe met with a serious car accident in the year 1990, and subsequently the lower part of his body was paralyzed. But the manner in which

Tuesday, July 23, 2019

Human Rights Act Essay Example | Topics and Well Written Essays - 1500 words

Human Rights Act - Essay Example The act came into place in 1998 and before that a person who had his right infringed had to go all the way to the European Court of Human Rights to file such a complaint whereby a commission had to consider everyone’s petition in order to determine whether the case is admissible. Most cases failed to go through at this stage. The commission upon admission of a petition would then ascertain the facts and consider whether a friendly statement would suffice and if a friendly statement did not work, the court would come up with a report that illustrated its findings. Individual applicants could also not demand a hearing (Woodhouse, 2001). The act has placed powers on courts to defend the rights of individuals. These rights are important because they form part of our everyday lives. The United Kingdom has now been bound by case law from the European court of Human Rights rather than precedent. The act has created an obligation on the British courts to take case law from the Europea n court of human rights into account and to interpret legislation in a way that is compatible with the convention on human rights. Initially there had been a conflict between the common law courts and the convention court. The courts have always upheld the common law principles and in doing so the courts came up with statutory interpretations (Rt Hon Lord Justice Elias, 2009). The European Convention on Human Rights is an international document and the European Courts of Human rights also applied their own principles in determining a case. This is whereby the convention courts made different interpretations from the British courts, An example of such a conflict is seen in the case of R (on the application of Marper) .vs. Chief Constable of Yorkshire [2004] 1 WLR 2196. Issue was whether the retention of DNA samples of people who had been arrested amounted to an infringement of rights under Article 8 read together with article 14 of the convention or not. The House of Lords ruled that there was no human rights infringement and the convention court held that there was an infringement of rights. The United Kingdom courts now have the power to undermine parliament. The act has influenced the process of policy formulation of the government firstly, through the process of making sure that there is compatibility with the convention rights. Secondly, through litigation whereby a particular policy may be changed or the method in which the policy is delivered could also be changed. Finally, there is the change that is made in behavior whereby the act requires that the behavior of public authorities should conform to convention rights (Department for Constitutional Affairs, 2008). The Human Rights Act provides a way of enforcing compatibility with convention rights. To begin the courts under Section 3 of the Human Rights Act provides that courts will construe legislation in a way that is compatible with the convention rights. A case that illustrates the effect which the a ct has had in the circumstances is that of A and others .vs. Home Secretary [2005] 2 AC 68, whereby the house of lords held that the Anti- Terrorism Act of 2001 was incompatible with article 14 of the Convention of Human Rights by requiring that foreign nationals be detained without trial and thereby it discriminated on ones nationality and even racial status.

Monday, July 22, 2019

School Prayer Essay Example for Free

School Prayer Essay In simple terms, prayer is talking to God or a god. During that conversation, the person praying may use his or her own words or, â€Å"a set order of words,† such as the Lord’s Prayer to speak to God, may â€Å"request or wish† something from a God. The conversation may be vocal or silent. Questions involving school prayer are among the most argumentative questions posed to the courts. This has been the case decades ago and still occurring today. The history of prayer in the public education system is a story of legal rendering. The relationship between religion and government in the United States is governed by the First Amendment of the Constitution, which both prevents the government from establishing religion and protects privately initiated religious expression and activities from government discrimination. The First Amendment establishes certain limits on the conduct of public school officials as it relates to religious activity, including prayer. The First Amendment says, â€Å"Congress shall make no law respecting an establishment of religion, [known as the Establishment Clause], or prohibiting the free exercise thereof [known as the Free Exercise Clause],† (U.  S. Constitution) When deciding a case, the court has to balance between favoring a religion and prohibiting it. Landmark Case: Engle vs. Vitale The Supreme Court has many times held that the First Amendment requires public school leaders to be neutral in their treatment of religion. This means not showing favoritism toward any religion but yet not showing any hostile expression towards any religious doings, such as prayer. One of the most famous court cases involving religion and public schools happened in a New York City school district in the 1950s. Each morning before classes started, students would say a twenty-two word prayer that was created by the school board. Almighty God, we acknowledge our dependence upon Thee, and we beg Thy blessings upon us, our parents, our teachers and our Country. A few parents objected, saying that this school promoted prayer violated the First Amendment. The New York Supreme Court ruled against the parents, who was represented by Stephen Engle. After taking their claim to a higher court numerous times, the court case Engle v. Vitale (1962), finally made it to the Supreme Court. In 1962 the Supreme Court Judges voted, the vote was 6 to 1, deciding that the twenty-two word prayer was unconstitutional. It was decided that the prayer, â€Å"singled out a particular religious practice contradicting the Establishment Clause of the First Amendement. † (Haas 48) This landmark case is one of the significant case laws used in order to determine neutrality in questions of school prayer. It was decided that teachers and other public school officials may not lead their classes in prayer, devotional readings from the Bible, or other religious activities. Engel v. Vitale, 370 U. S. 421 (1962) Violation of the Establishment Clause: Sante Fe v. Doe While school leaders may not lead their students in prayer, according to 105 ILCS 20/5, Students do have the right to pray at school. They must respect the schools policies, regulations, and rules that are in place regarding any disruption to the educational system. This being said, â€Å"students may read their Bibles during study hall or other non-structured time, may say grace, and may discuss religion with their peers during non-directed free time, such as time spent on the playground, on a school bus, in the hallways, or in the cafeteria. † (Braun 184) This student right and Illinois compiled statute was tested in the case of Sante Fe Independent School District v. Doe. Santa Fe v. Doe centered on the Santa Fe Independent School District policy allowing student-led prayer before football games. Santa Fe Independent School District had a history of student-led prayer. The students were elected by their peers to lead prayer at a school event. An Appellate Court ruling found that the district’s policy was unconstitutional in accordance with the Establishment Clause. The Court stated that the policy was not only an actual endorsement of prayer, but also a perceived endorsement, and, therefore, sent a message to nonbelievers that they were outsiders and that believers were the favored group in the community If the prayer is student lead, driven, and initiated it does not go against the constitution. The Supreme Court ruled saying, â€Å"The delivery of such a message, over the schools public address system, by a speaker representing the student body, under the supervision of the school faculty, and pursuant to a school policy that explicitly and implicitly encourages public prayer is not properly characterized as private speech† (Santa Fe v. Doe, 2000). Moment of Silence for Prayer: Wallace v. Jaffrey? So far a few things have been decided. The first is that any school-sponsored religious practice is prohibited because it is in violation of the Establishment Clause. The second thing is that students do have a right to freely exercise their personal religious practices as long as they do it during non-structured times; but where does the law stand on moments of silence that schools use for personal prayer times? After court cases such as Engle vs. Vitale it was obvious that religion in schools was diminishing. To counter back at these Supreme Court rulings many states started establishing moments of silence at the beginning of each school day as a substitute for the vocal prayer that had been taken away. These moments of silence are permissible as long as they are done for a secular purpose. Wallace v. Jaffrey is the only case that the Supreme Court has heard on a moment of silence in schools. The case contested an Alabama law that established a moment of silence for the purpose of â€Å"meditation or voluntary prayer† (Wallace v. Jaffrey, 1985). The court found that the statue was unconstitutional because it was enacted solely for the purpose of promoting religion in schools. The majority opinion found that any statute establishing a moment of silence that included the word â€Å"prayer† was unconstitutional. 1985 the Supreme Court concluded that Alabama’s silent meditation and prayer statute violated the Establishment Clause. Alexander 217) Explaining how this ruling came to be, an understanding of how our courts can make such a decision is needed first. The Establishment Clause Tests: The Supreme Court uses three tests to determine violations of the Establishment Clause. The tests may be considered singularly or together to determine constitutionality. The court has repeatedly stressed that the Constitution prohibits public schools from teaching children in religion. But it is not always easy to determine exactly what constitutes teaching or school sponsorship of religious acts. To help explain the establishment clause, which is often a question in issues of school prayer, the court uses several tests. The three main tests include the Lemon, coercion, and endorsement test. Lemon Test: The Lemon test gets its name from the 1973 decision in Lemon v. Kurtzman, in which the Court struck down a state program that was giving aid to religious elementary and secondary schools. The Lemon test is a three prong test, each part being just as important as the other two. Using the Lemon test, a court must first determine whether the law or government action in question has a secular purpose. This prong is based on the idea that government should only concern itself in civil matters, leaving religion to the conscience of the individual. Second, a court would ask whether the state action has the primary effect of advancing or inhibiting religion. Finally, the court would consider whether the action excessively entangles religion and government. While religion and government must interact at some points while co-existing in society, the concern here is that they do not so overlap and intertwine that people have difficulty differentiating between the two. Although this test has come under fire from certain Supreme Court Justices, it has never been over turned, and it is still used to guide decisions in courts today. Coercion Test: Some justices propose allowing more government support for religion than the Lemon test allows, their support stands with the coercion test. Justice Kennedy created the coercion test in Lee v. Weisman. The coercion test is used to determine whether or not the government coerced participation in the religious activity. In regard to public schools, it is used to determine whether or not students experienced a coercive effect. Based on the 1992 case of Lee v. Weisman, 505 U. S. 577 the religious practice is examined to see to what extent, if any, pressure is applied to force or â€Å"coerce† individuals to participate. The Court has defined that the government does not violate the establishment clause unless it, (1) provides direct aid to religion in a way that would tend to establish a state church, or (2) coerces people to support or participate in religion against their will. Even the coercion test is subject to varying interpretations. This was evident and illustrated in Lee v.  Weisman. Endorsement Test: The third test that was proposed by Justice Sandra Day OConnor is the endorsement test. It was used in the 1984 case of Lynch v. Donnelly, asking whether a particular government action amounts to an endorsement of religion, thus violating the Establishment Clause of the First Amendment. Its with this test that a government action is invalid if it creates a perception in the mind of a reasonable observer that a religion is being endorsed or disapproved. The endorsement test has been included into the Lemon test. While the endorsement test has been applied in many cases, it has not produced a conclusive answer to the question of constitutionality in all cases. There is a forth test that is sometimes used in establishment-clause decisions, it is the neutrality test. While the Lemon, coercion, and endorsement test are used in matters of expression the neutrality test is mainly used in issues dealing with funding. Making sure the government is giving neutral aid to public and religious schools with no religious promotion. Because of its dealings and ruling in funding matters, the neutrality test is not often used in issues of prayer in public schools. The Wallace case is legally significant for representing the value of neutrality underlying the Establishment Clause. It also showed the significance for the Lemon test as the main test for evaluating the constitutionality of public school involvement in religion. The Court in Wallace showed its position that the Establishment Clause â€Å"‘requires the state to be a neutral in its relations with groups of religious believers and non-believers. ’† (Lofaso 30) The Court then concluded that Alabama’s moment-of-silence statute violated the Establishment Clause because it failed the purpose prong of the Lemon test: â€Å"The legislature enacted . . for the sole purpose of expressing the State’s endorsement of prayer activities for one minute at the beginning of each school day. Does Location of the Prayer Matter? It was almost a half-century ago that the Supreme Court in Engle v. Vitale established that daily prayer in the classroom is unconstitutional. Since then, this thought has grown due to cases where location of the prayer have been put into question. Now the Supreme Court extends their thinking to include, â€Å"any particular form of prayer which is to be used as an official prayer in carrying on any program of governmentally sponsored religious activity. The Supreme Court continued to keep watch even when school prayer moved outside the classroom to a graduation ceremony. In Lee v. Weisman, principals at public schools in Providence, Rhode Island invited clergy to speak at graduations. The principals provided the clergy with guidelines, which essentially boiled down to keeping the prayers nonsectarian. When Principal Lee invited a rabbi to give a prayer at Nathan Bishop Middle School’s graduation, Deborah Weisman and her parents objected. When the Weismans alleged a violation of the Establishment Clause, the school board argued that an event as significant as graduation warranted prayer. The lower courts agreed with the Weismans and the Supreme Court affirmed. The school board argued that graduation was a voluntary event. The Court dismissed this argument, finding graduation to be an important event in a student’s life that must not be forfeited due to different religious beliefs and that the government must not get involved. In 1992 the Court decided that it was unconstitutional for a member of the clergy to deliver an invocation or benediction at a public school graduation, and that in doing so, the school endorsed religion and required students who were non-believers to accept the religious practices. Conclusion: Supreme Court decisions provide insight into the debate against school prayer. Because of the various Court rulings on the school prayer issue, we do have a foundation to base other decisions off of when issues arise with mixing church and state in the public educational system. Students today can not be forced to recite any prayer that has been endorsed by the school, but they may practice a moment of silence during the school day as long as they are not required to use that time for prayer. Students are also free to exercise their religious beliefs. They may read their Bibles during non structured time and pray as long as they are following the rules and regulations regarding school disruption. If at any time the state gets involved, or the activities become school-sponsored then the religious acts are unconstitutional and violate the First Amendment. It is important to remember that the United States exists today because the founders sought to live in a country free from government interference, especially concerning religion. Individuals are free to exercise their beliefs as long as they are not forcing those beliefs unto others.

Sunday, July 21, 2019

Defining And Analysing Heroism

Defining And Analysing Heroism Heroism consists of actions that must help others, even if it is a possibility and risk of the helper s injury or even death. Some people consider heroism to be very close to altruism, but it is different. Where altruism emphasizes self-denying acts that help others, heroism means a personal sacrifice. The kernel of heroism rotates around of the obligation of the person to a noble goal and readiness to accept a consequence of fighting for this goal. Heroism is old as humanity itself. The human bent fort commemorating heroes is a universal quality of human culture. Heroes are honored in ancient paintings, folklore and myth. Societies dispatched such stories in oral traditions and legends, and myths into epic poems and eddas. Modern societies uphold the tradition of honoring heroes not only in literally masterpieces but also in movies and journalism. Some of heroic ideas are becoming lost or changed by general culture. Being a hero is not just being an outstanding figure. We believe it has become needful to revise the historical senses of the word, and to force it to arrive in modern timeframes. Historically, heroism has been closely connected with military service, although social heroism also deserves close research. For instance, Achilles is the archetypal war hero, whose values were so strong, that Socrates willingness to die for it was also a heroic exploit. Heroism that consist a notable idea is usually not so dramatic like heroism that entails direct physical risk. These different ways of exhorting with the heroic ideal mean a deeper, more tangled definition of heroism. Actions considered as heroic are ordinarily made voluntarily in the sense that they are not compelled by external pressures or at least go out the bounds of the behavior ordinarily prompted by external pressures. By understanding of heroism as a universal characteristic of human nature, not as an unusual feature, heroism becomes something that stands in the line of possibilities for everyon e, possibly inspiring us to answer that call. The thought about the banality of heroism disrobes the myth of the heroic elect . It is a myth that strengthens two fundamental human tendencies: to attribute very rare personal feature to special people who do special feats to see them as superhuman, comparing to the rest of us and the trap of inertial some people call it as the bystander effect . Investigation has shown that this effect is often motivated by scattering of responsibility. In their article The Banality of Heroism , Zeno Franco and Philip Zimbardo tell that heroism is made up of four autonomous measurements at least (based on authors analysis of many acts that they consider heroic). First, heroism involves some type of quest, which may range from the preservation of life to the preservation of an ideal (Franco, Zimbardo). Second, heroism should have some form of sacrifice (risk). This can be some form of physical danger or a strong social sacrifice. The physical risks in this case are clearly heroic in nature. For instance, Tom Cahill, a researcher from the University of California, called a press conference where defined the EPA s findings that in the after-grass of the September 11 events the air nearby Ground Zero was safe for breathing. With this action he risked his confidence as a scientist. Third, the heroic feat may be active or passive. Often we think of heroism as a courageous activity, something that is clearly perceptible. But some forms of heroism involve passive opposition or reluctance to be moved. And finally, heroism may be an unexpected, one time action, or something that continues over a longer time period. This may have a meaning that heroism may be a nearly immediate reaction to a situation. Or it may be a well considered series of actions endure over days, months, or a lifetime. Franco and Zimbardo give such an example: in 1940, a Japanese consul official in Lithuania, Chiune Sugihara, signed more than 2,000 visas for Jews hoping to escape the Nazi invasion, despite his government s direct orders not to do so. Every morning when Sugihara got up and made the same decision to help, every time he signed a visa, he acted heroically and increased the likelihood of dire consequences for himself and his family. At the end of the war he was unceremoniously fired from the Japanese civil service (Franco and Zimbardo). The scientists stress that even people who have led less than remarkable lives can be heroic in a sing le moment. For instance, during Hurricane Katrina, a man whose name is Jabar Gibson, who was previously arrested in the past, took a bus, freighted it with citizens of his poor New Orleans environs, and delivered them to safety Houston. This feat people of Louisiana considered as heroism, because is that concrete situation Jabar helped desperate people simply to survive. The really interesting investigation which called The heroism of women and men was done by Selwyn W. Becker (University of Chicago) and Alice H. Eagly (Northwestern University). They research heroism of both sexes in dangerous settings. Their study allows examining the ideas that heroism is performed by women as well as men. It is well-known that mostly men were portrayed as heroes in legends, poems and eddas. It is understandable, because of their strength, greater size and physical skills. It is also well-known that since pristine times men considered to be hunters. But we should not forget that women in their tur n always considered to be clever, somewhat cunning and undoubtedly, very skilful. The women may find the right decision more often because of their well-known sixth sense, so it is quite probably that they may take a risk with the same responsibility as men. Moreover, the women more often trust their feelings and inner senses, their intuition and sometimes it helps in those situations when it needs to sacrifice. Then, who says that women are more afraid of sacrificing? There are a lot of examples in the world literature when they made such really brave decisions showing in such a way their true feelings. Becker and Eagly write: Women s risk taking is assumed to derive at least in part from their traditional family role as main nurturer (Becker and Eagly). The authors are sure that nonetheless, it is possible that women s psychological answers to stress prime their helpful acts. Besides, many of women s heroic actions are hidden. But we forgot about another important question: What m akes a hero? Franco and Zimbardo convinced that actually, the first answer of many people who are called heroes is to disown their originality. They say: I just did what I had to do or I am not a hero! Anyone in the same position would have done what I did (Franco and Zimbardo). Sudden life and death situations are distinct examples of situations that excite people into heroic act. The investigators were convinced that these positions create a bright-line ethical inspection that drives some individuals to act in an attempt to stop the evil. Many people in common positions identify the ethical problems connected with the situation and are deeply upset, but decide to ignore it. Franco and Zimbardo believe that a significant factor that may cheer heroic act is the incentive of heroic kind of imagination. It is the capacity to imagine facing risky situations, to fight the hypothetical problems these situations cause, and to consider one s actions and the results. By this, the individual becomes more prepared to act if a moment that calls for heroism comes. Seeing oneself capable of heroism may be the first step towards a heroic consequence. There are several steps we can take to nurture the heroic type of imagination. We can start by remaining aware; critically evaluating each situation we meet so that we do not gloss over an emergency demanding our action. We must withstand the impulse to improve inaction and to develop exculpations that recast evil acts. Also we must try to exceed anticipating negative result connected with some forms of heroism, being socially ostracized as an example. We must trust that others will identify the value of our heroic feats. We should try to develop a capacity of things that do not fit, or do not make sense in a current situation. This means that we must ask questions to get the proper information for us to take action. Besides, it is important not to fear conflict, and to develop the personal courage necessary to stand firm for p rinciples we value. Actually, we should not think of hard conflicts but rather as attempts to force the other people to support their own ideology and principles. We should be engaged in the current position, to imagine alternative future scenarios. But outside of these fundamental points, our society needs to encourage heroic imagination in all of its citizens, especially in young ones. The ancient Greeks and Anglo Saxon tribes revered their poem heroes in Beowulf and Iliad . These stories are antiquated, but their descriptions of the hero still make sense. In these tales, the protagonist often meets a mystical figure who attempts to tempt the hero away from his track. We must also avoid the temptation of evil in our life, and we must recognize that perhaps the temptation will be quite ordinary: for example, an unethical friend, neighbor or coworker. By passing a series of smaller examinations of our stamina, we can refine a personal habit of heroism. Very often epic poems tell about the hero visiting the underworld. This metaphorical facing death depicts transcendence an acceptance of mortality. Arthur Margon in his work Urbanization in fiction. Changing models of heroism in popular American novels 1880-1920 writes that in a w ide line of popular literature works written between the end of Reconstruction and The First World War, prominent American novelists depicted the decline of usual heroism in an urbanized society. In an urban society, goodness and social responsibility could be guaranteed only through the institutions peculiarity of that society. Individualism did not lead to heroism in the materialistic cities. Urban writers dismissed the individualistic hero to either boundary of the junk heap. Some of the authors replaced him with an institutional structure which nurtured self-identification in the community. But American novelists increasingly reflected, through the demise of the hero, the understanding that in the urban age individualism was incompatible with public welfare (Margon) underlines Margon. Till this day, some types of heroism demand paying the final price. But we can also realize this as a hero s desire to face any of the results of heroic action whether the sacrifices are social of physical. The hero often follows a set of rules. It is obviously, that if we will stop imagining ourselves as real heroes, and to realize the real sense of heroism, our society will be more indignant. But if we can rejoin these ancient ideals, refresh them again; we can create a union with the hero in our souls. It is this urgent, internal connection between the modern world and the ancient world that can show to a simple person how to become an everyday hero. As about my opinion. It seems to me, that we often afraid to make such actions, because we live in a world where everyone cares about himself. But if each of us will make one good feat everyday, our life may change completely. Now to my mind comes a movie that is called Pay it forward where the teacher gave pupils the task to think h ow to change this world. The slogan was Think of an idea how to change this world and put it into action! . And one boy named Trevor found the way: each person should make three good actions and then those people whom he helped must do the same in their turn. Well, is not is a heroism I would like to ask? In such a special and very remarkable way this boy forced us to believe in goodness. Exactly such kind of actions may teach everyone to become a hero. We just have to learn how to be more patient, kinder, thankful, attentively, and more helpful but what is most important to help others not by words but by real actions. I think everyone must watch this film and think about his actions and thoughts. It would be great if we will find a possibility and place for good feats in our life. And it does not matter what it will be saving a cat from the transport movement or helping our friend with his tasks. All these details draw one colorful portrait of the modern hero! Work citied Becker W, Selwyn, Eagly H, Alice The Heroizm of Women and Men . Zero, Franco, Zimbardo, Philip The Banality of Heroism . Greater Good Megazine. 2006-2007. Margon, Artur Changing models of heroism in popular American novels 1880-1920 .

Physiotherapy Management of Lower Limb Tendonopathies

Physiotherapy Management of Lower Limb Tendonopathies A Systematic Review of the physiotherapy management of lower limb tendonopathies Tendonitis is a condition which is comparatively commonly seen in various clinics. The largest cohort of patients tend to have developed their condition as a result of various sports-related activities but it is acknowledged that there is a substantial cohort of RSI sufferers and occupation-related forms of tendonitis. (Kader et al 2002) In this piece we aim to review the various treatment modalities and to concentrate primarily on the eccentric muscle strengthening modalities of treatment, the rationale behind them and any evidence that they actually work. Before we can consider the direct question of eccentric loading as treatment for tendonopathies we must examine the rationale for its uses well as the basic science and theory behind the actual practice. We will do this largely by the mechanism of a literature review. Methodology In this review we shall be examining the literature for not only the methods that are currently employed in treating the various lower limb tendonopathies but also for justification for these methods and the quality of the science behind them. We shall therefore critically review the literature available and present it in a rational form. In addition to this we intend to present an overview of various factors in a wider picture that are relevant to our considerations. We shall consider the current views on the pathophysiology of tendonitis and the experimental evidence on the response of the tendon to exercise in general terms. Although it is accepted that the majority of patients currently seen in clinical practice with various forms of lower limb tendonitis are suffering from a sports related injury, we shall also look at the effects of ageing on tendon physiology as it is acknowledged that the elderly are another highly represented group with tendonitis. We conclude the preamble with a number of clinical considerations, most prominently the difficulties posed by the differences in nomenclature and terminology which renders both assessments and comparisons between clinical trials difficult. We conclude the dissertation with a review of various currently employed treatment modalities and the rationale behind them. We focus specifically on the use and place of eccentric muscle strengthening exercises in the spectrum of rational treatments.. Pathophysiology of tendonitis At the macro-anatomical level, the tendon is usually easily defined as a semi-rigid white or grey structure, generally found in close proximity to synovial joints. One of its prime functions is to transmit forces generated by muscles to the skeletal system, often inducing movement. (Huxley HE 1979). At the micro-anatomical level, it’s structure is very much more complex and requires a detailed examination before we can realistically and meaningfully consider the issues relating to the therapy of tendonitis. Tendons form part of the anatomical structures that are functionally grouped together as the extracellular matrix (ECM). The rate of turnover – both synthesis and degradation – is influenced by a number of different factors including metabolic and disease related factors, but the strongest influence on the turnover rate is mechanical stress, usually as a result of various degrees of physical activity. (Agar Pet al 2000) Tendon (and intramuscular) collagen, turns over at a rate which is about half as fast as myofibrillar protein turnover. The main physiological stimulus to turnover appears to be the multiple stimuli arising from mechanical or contractile activity.(Cuthbertson D et al2005) At the cellular level, degradation of collagen is mediated largely byte metalloprotease group of enzymes and synthesis is most strongly influenced by a number of different trophic factors which are released at the cellular level. (Algren MS. 1999) These growth factors are mainly responsible for both the transcriptional changes as well as the post-translational modifications that take place as a result of either physiological changes or disease processes. (Sand Meier et al 1997) Until comparatively recently, tendon tissue was thought to be fairly inert. Recent research work has given good supportive evidence that the internal metabolic processes, the internal vascular responses (Alstom et al 1994) and the actual catabolic turnover of the collagen protein in response to physical activity, is considerably greater than originally thought. The converse is also true, as inactivity appears to have the same inhibitory effect on tendon tissue as the better known effect of wasting in muscle tissue. (Abrahamson SO et al 1996). This effect is of particular importance in our considerations (later) when we consider that some authorities suggest that outright rest is inappropriate initial treatment for tendonitis. Collagen is a large polymer-type protein made up of many repeating subunits, (triple helices of polypeptides with a high proportion of proline and hydroxyproline). It is made by fibroblasts. In the muscle, it forms a basket-like network around the muscle fibres but then forms progressively more coherent and solid structure as it forms discrete tendon. In this way it allows the efficient transmission of forces generated by the myofibrils to the tendon – and hence to the bone. (Kjaer M 2004). Training, in the form of physical work, exercise or repetitive movements, will have a trophic effect on the tendon as a whole. Collagen turnover can be increased and there can be an overall increase in the amount of collagen protein in the tendon. (Herzog W et al 2002) Collagen, in the form in which it is found in a tendon, has enormous on-elastic tensile strength and a modest degree of ability to bend under lateral stress. As the amount of collagen in a tendon increases, the tendon’s mechanical (or more accurately, viscoelastic,) properties change. It decreases it’s stress levels for a given load, and thereby renders it more load resistant.(Fowls JL et al. 2000). Again this facts of great relevance to our clinical considerations later in this piece. The stiffness, or resistance to lateral stress, is a function of the cross-linking of sulphur bonds across the parallel bands of protein. In general terms, the more cross-links, the stiffer the tendon. The degree of cross-linking is a result of a complex interaction between a number of enzyme systems in the matrix of the tendon. (Hamill OP et al.2001) Polyglycans are an important feature of this enzyme cascade and become an increasingly important functional component as age increases. Older or ageing collagen will tend to exhibit glycolated cross links in addition to the sulphur links of youth. This is part of the reason why older tendons are less flexible (and possibly more prone to injury). (Inglemark BE 1948). The functional significance of these links is that they render the tendon even stiffer and less able to bend.(Davidson PF 1989).Understanding these processes is fundamental to the prescribing of a rational treatment regime for tendon injuries and other pathologies. It is also important to have a complete understanding of both the vascular and neurologically mediated adaptation processes that are present in the my-tendon complex. These work on a far more rapid and immediate time frame than the processes that we have just described, and are primarily responses to rapid changes in the mechanical loading stresses. As muscle tissue develops physiologically, there is a symbiotic relationship between the muscle and the extracellular matrix. The various physiological mechanisms that stimulate muscle growth and hypertrophy appear to have a similar effect on the extracellular matrix. (MacLean et al 1991) But in the latter case, they are less well understood. We know that that significant and repeated mechanical loading will trigger off, or initiate a process, which starts with the activation of trophic gene in a cellular nucleus, (Banes AJ et al.1999), it progresses through the complex processes of protein synthesis and functionally ends with the deposition of collagen in the tendon tissue.(Yasuda et al 2000) Responses of the tendon to exercise There would appear to be some form of integration between the muscular and the extracellular matrix signalling pathways, which optimises the co-ordinated activity of the trophic processes in response to the stimuli (which can be both loading and tensile in nature), which produce the response in the first place. (Viidik A.1993). This co-ordination mechanism must exist, as it is a well-recognised phenomenon that a tendon hypertrophies to accommodate the increased mechanical stress that its associated hypertrophied muscle produces. (Derwin et al 1999) Considerable research effort has been expended in trying to delineate the mechanism, but to date, the results have not increased our understanding of the situation significantly. (Vierck J et al 2000) Specific studies in this area have been able to show a clear correlation between collagen response and an increase in physical training. (Langberg et al 2001). The response was detectable after a 4week training programme and was maximal at 11 weeks. When we consider the pathophysiology of RSI (repetitive strain injury) or even chronic overload syndrome, the stimuli that can produce muscle hypertrophy or increase muscle fibrosis can also produce fundamental changes in the tendon structure. (Birk DE et al 1990) These changes can include changes in both the chemistry and the functionality of cross bonding of the collagen fibres, (Barnard K et al1987), changes in the size of the collagen fibrils, areas of locally increased blood flow (known as hyper vascularisation zones), and an increase in the catabolic processes which can result in either (or both) collagen being synthesised and laid down, or increase in fibroblastic activity which increases the fibrous component of the tendon. (Greenfield EM et al 1999) It is a fundamental recognition of the fact that these processes require â€Å"adjusted loading† rather than an enforced absence of loading(immobilisation) to reverse the physiological processes, that underpins most of the thrust of this review.( Howell JN et al 1993), (Jà ¤rvinenTAH et al 2002) The experimental evidence to support this view comes from the classic set of investigations by Gibson (et al 1987) who compared the rate of collagen synthesis and turnover in an immobilising long-cast leg with the rate of turnover in the unaffected leg. The rate of collagen synthesis dropped by half over a seven week period in the immobilised leg. The investigators also found an adaptive (and compensatory)reduction in the rate of collagen degradation which had the overall effect of reducing the protein loss in the tendons. In the overall context of our investigation it is also important to note that the authors also found that minimal electrical stimulation of the muscle (5% of maximum voluntary contraction for 1 hr. per day),increased protein synthesis to such an extent that there was no net protein loss over the same seven week period of the trial. (Gibson etal 1989) In a study that was remarkable for its invasiveness (the authors took repeated biopsies of human patella tendon after periods of exercise), Miller (et al 2004) demonstrated that tendon collagen synthesis showed a 30% rise within 6hrs of exercise and up to a 50%rise within a 24 hr. period. This was found to exactly follow the pattern of protein synthesis in skeletal muscle. This finding is strongly supportive of the assertions made earlier in this essay, that there would appear to be a mechanical or humeral mechanism that links the trophic effects that are apparent in both tendon and skeletal muscle. Various authors have postulated different mechanisms (it has to be said with scant evidence), including integrin’s, (Levenhagen et al2002), growth factors including transforming growth factor beta (TGFB) (Moore et al.2005), or mechano growth factor (MGF) (Rennie et al 2004),which they suggest may be responsible for the co-ordination of the trophic effects of perimysium collagen, tendon collagen and the myofibrils. More concrete evidence exists (and is arguably of greater relevance to our investigation here), for the fact that dietary protein alone can produce a trophic stimulus for tendon collagen. (Jefferson Kimball 2001). It is postulated that there is some form of amino acid sensor that is responsive to the availability of amino acids. This haste effect of changing the availability of various protein kinases in the extracellular matrix generally and a subsequent enzymatic cascade which results in an increase in various anabolic signalling molecules which are, in turn, responsible for the activation of mRNA. This is then responsible for the increased synthesis of collagen (and other related proteins), in tendon and other extracellular matrix tissues. This series of very elegant experiments was done in carefully controlled conditions which removed the possibility of other anabolic factors being relevant as the only variable was the availability of amino acids. (Cuthbertson et al 2005) There is further evidence of the effect of exercise on tendon structure in the form of the set of experiments by Rennie and disco-workers. Looking specifically at the metabolism of collagen Rennie found that after strenuous exercise, the rate of incorporation of a marker into tendon collagen followed a specific pattern (Rennie Tipton 2000). There was a latent period of about 90 mines after exercise where there was no change in metabolic rate. It was then noticed that there was a dramatic increase to about 5 times normal rates of synthesis, which peaked at about 12 hrs., was maintained for about 12hrs, and then declined over the next 48 hrs. In line with the findings of Cuthbertson (above) the investigators noted that the rise in levels of synthesis is greatest if associated with an amino acid load just pre- or post-exercise, and this effect can be further enhanced by the administration of insulin secretagogues(such as glucose). There is therefore little doubt that feeding helps the post exercise response. (Atherton P et al 2005) The effects of ageing on tendon pathophysiology We have already commented, in passing, on the physiological effects of ageing in relation to the polyglycan cross bonding in tendons. There are a number of other changes which will naturally occur in relation to advancing years, which are of direct relevance to our considerations here. It is clearly a matter of observation that muscles, bones and tendons deteriorate as age increases. This deterioration leads to physical symptoms such as loss of strength, mobility and suppleness together with an increase in fatigability and a general reduction in proprioception. This condition is sometimes called â€Å"sarcopenia†.(Forbes 1987) Epidemiological studies (Dorrens et al 2003), provide good evidence to support the popularly held view that an active lifestyle into old age is more likely to support a higher level of bone density, muscle bulk and tendon flexibility, than a sedentary one. One can postulate that the trophic mechanisms referred to above, stay active for longer when constantly stimulated by mechanical activity. One effect of ageing that has been experimentally demonstrated, is that the trophic effects of available amino acids in the bloodstream are not as great in the elderly as in the young. The elderly appear to have an ability to develop resistance to the trophic effects of amino acids, which was not present when they were younger. (Cuthbertson et al 2005) Another physiological change that can be demonstrated in the elderly, is a reduced RNA : DNA ratio in tendon tissue, which is a marker of a reduced ability to manufacture protein. This, together with reduction in the amount of detectable anabolic signalling proteins, seems to be central in the failure of the muscle and tendon synthesising mechanisms. (Smack et al.2001). If we add these findings to other work of Smack (et al 2001) and Leverhagen (et al 2002) which shows that the elderly can show responsiveness in terms of trophic changes in the collagen content of tendons by manipulation of the diet. Both studies showed that maximising the protein : energy ratio of ingested food is a reasonable strategy. It should also be noted that they also demonstrated that one has to be careful to keep the energy content of the food low in order to minimise unwanted weight gain. The elderly could reasonably be assisted to maximise the benefit they get from training (resistance training in these particular studies), by integrating it with feeding concentrated in the immediate pre- or post-exercise period. This appears to have the effect of increasing the positive synergistic relationship between exercise and amino acid delivery.( Williams et al. 2002) Clinical considerations Differential diagnosis The first and possibly most fundamental issue that we have to consider when looking at the issues of the treatment of tendonitis, is the issue of correct diagnosis. This, sadly, is compounded by the fact that there appear to be several different terminology vocabularies in common clinical use. It therefore can be difficult to directly compare treatment studies of â€Å"tendonitis â€Å" unless one has direct and clear diagnostic criteria. (Saxena 1995) Tendonitis may be taken in some medical circles to include all those conditions which come under the broad heading of â€Å"painful overuse tendon conditions† (Khan et al 1999). This is generally accepted by the uncritical, as meaning that this equates with a painful inflammatory reaction in the tendon tissue. Histological investigation of the typical chronically painful tendon, generally shows an absence of the polymorphonuclear and other associated inflammatory cells. In some literature we can see the emergence and replacement of the term tendonitis with tendinitis. This latter term tends to be defined as pertaining to areas of collagen degeneration, increased ground substance and neo-vascularisation. (Purdue et al 1996) To both illustrate and clarify the point, let us consider thevarious clinical entities that may either present like, or may be diagnosed as, â€Å"tendonitis†. For ease of classification and clarity, in this section we shall consider the term â€Å"tendonitis† in specific relation to the Achilles tendon. Williams (1986) produced the (arguably) most commonly currently accepted definitions of Achilles tendon pathologies. He classified them into:- Rupture, Focal degeneration, Tendinitis, Per tendonitis (peritendonosis), Mixed lesions, Origin/insertion lesions, Other cases such as metabolic/rheumatic causes. In common clinical parlance, any of them can be referred to, with reasonable accuracy, as â€Å"tendonitis†. (Galloway et al 1999) The aetiologies can vary (and this may well have a bearing on treatment), from trauma, reduced flexibility, abnormal or changed biomechanical considerations (such as excessive pronation, supination or limb length inequalities) to name but a few. (Saxena, A 1998) It should be noted that the anatomy of the Achilles tendon is unusual and certainly different from any other in the lower limb. It does not have a true synovial sheath but a petition which extends from its origin in the muscle to its insertion in the calcaneus. Peritendonosisis therefore a commonly misdiagnosed as Achilles tendonitis. It is also clinically significant that there is a region of decreased vascularity in the tendon, which is typically about 6 comes above its insertion (Hume 1994). The clinical difference between these two conditions is that true Achilles tendonitis may, if chronic, be characterised by fucoid, or fatty focal degenerative, changes in the tendon itself, where asperitendonitis will not involve the Achilles tendon at all. (Kvist1994). These degenerative changes may be extremely resistant to non-surgical forms of treatment. In practice, the two conditions may well be presenting the same individual. (Killer et al 1998) The differentiating signs are, however, fairly easy to detect and the two conditions can be separately distinguished in most cases. Per tendonitis is the inflammation of the petition and can usually be clinically distinguished by the presence of clinical crepitus as the Achilles tendon tries to glide back and forth along the inflamed petition. This sign together with pain, generally tends to increase with activity and the tenderness is normally felt along the whole length of the tendon. Achilles tendonitis on the other hand classically gets better with movement and is at its worst after a period of rest. The discomfort tends to be more localised into discrete areas and is more commonly found in cases where there has been either a partial or even a complete rupture in the past. (Clement et al 1994) Other pathologies can arise associated with the Achilles tendon, and for the sake of completeness we should briefly consider them as they could be potentially confounding factors in any trial which aims to consider tendonitis. Tendocalcinosis is an inflammatory process which involves the Achilles tendon but only at the point of insertion to the calcaneal bone. It typically will result in calcification and therefore should be considered a different entity to Achilles tendonitis as such. It is characterised by localised pain, and prominence of the calcaneal insertion of the tendon which may well be associated with a retro-tendon bursitis. (Williams 1986) If we apply the same rationale to the patella tendon, we are again faced with a bewildering array of terminology and conditions which tend to get lumped together as â€Å"tendonitis† and may also therefore be confounding factors in any study. We shall therefore spend a few paragraphs delineating them. Some authors point to the fact that conditions that had been previously referred to as tendonitis, when examined at a histological level, are found to be the result of collagen breakdown rather than inflammation (Khan et al 1996), and therefore suggest the title oftendinosis is more appropriate. (Cook et al 2000) (I) The whole issue of the role of the inflammatory process in the tendonopathies appears to be far from clear. An examination of the literature can point to work (such as that by Khan – above), who demonstrated that the prime histological changes were non-inflammatory and were more typical of fucoid, hyaline or fibrous degeneration with occasional calcific processes being identified. Other investigators however, point to the clinical picture which commonly includes the classic inflammatory triad of dolour, rub our and tumour (pain, redness and swelling)(Almekinders et al 1998). This, associated with the evidence of the relieving effect of NSAIA’s or corticosteroids(Friedberg 1997) leads to an ambiguous picture. The pathophysiology of this condition is most commonly thought tube related to jumping and landing activity which is the mechanism which appears to cause the rupture of the collagen filaments and hence the histological appearances. The characteristics of this type of condition are that it tends to be focal, and often in the region of the lower pole of the patella. Initially it tends to be self healing but as the chronicity increases, the pain levels can increase to the point where pain is experienced even at rest (Cook et al 2000) (II) This type of condition must clearly be differentiated from there-patella bursitis (Housemaid’s knee) which is often mistakenly diagnosed as a patella tendonitis. (Halaby et al 1999) Factors which appear to predispose to tendonopathy Many authors identify chronic overuse as being one of the major factors in tendonopathy generally. (Kist 1994) (King et al 2000). This applies equally to the occupational tendonopathy as much as the sports-related conditions. (Jon stone 2000) (Kraushaar et al 1999). We should acknowledge that the term overuse can refer equally to overuse in terms of repetitive action just as much as it can refer to overloading. The two factors being independent (but often related). Some of the current literature points to the fact that there can be differentiation in the spectrum of overuse injuries between those conditions that arise from some form of biochemical change in the structure of the tendon itself (Joss et al 1997), those that are associated with biomechanical changes (such as change in function or previous injury) (Alstom 1998) and those that arise as a result of ageing or other degenerative changes (Alstom et al 1995). These factors can arise as a result of, or independently from, other factors such as the fact that the anatomical path of a tendon can take it over (or in close proximity to) friction-inducing structures such as a bony prominence – as in the case of the tibias posterior tendon, (Benjamin et al 1998) or factors relating to the site of insertion of the tendon into the bone – as in the case of theAchilles-calcaneum interface.(Benjamin et al 1995) We can point to evidence that extraneous factors can also predispose to tendonopathy. There are genetic factors (Singer et al 1986), and a relationship to blood type (Joss et al 1989). The presence of certain concomitant chronic or debilitating illnesses can certainly be associated with tendonopathies (Kannur et al 1991) as can the chronic use of certain medications – most notably the fluoroquinolone group.(Huston 1994)(Ribard et al 1992). The mechanism in the latter case appears to be associated with an increase in the amount of MMP and its associated activity which seems to be associated with an increase in the rate of degradation of protein (especially collagen) in certain tissues. (Williams et al 2000). Other authors have identified biomechanical factors as being significant (rather than necessarily causal), in the development oftendonopathies, but we shall discuss this in specific relation to treatment, and so will not discuss it further here The spectrum of currently available treatment Before beginning any rational consideration of the various forms of treatment available, one must appreciate a common truth in medicine, and that is that different treatments and different patients will respond differently to a specific treatment modality, and one of the factors that will influence this phenomenon is the skill and experience of the practitioner concerned. For example, a surgeon may well find that he gets good results from tenotomise but poor results from eccentric exercises and therefore will recommend surgery. Physiotherapist may find the converse. It is therefore important to be critical of such factors in any appreciation and appraisal of different techniques for the treatment of the lower-limb tendonopathies. In this section we shall examine the available literature to try to obtain an overview of the various treatment modalities that are currently being prescribed and examine the rationale behind their use and efficacy Most authors seem to agree that, before considering the specific conditions, a general approach of conservative measures (such as load reduction, strengthening exercises, and massage) should be tried before other modalities such as medication and physical interventions(ultrasound etc.), and that surgery should only realistically be considered as a last resort. The only obvious exception to that approach would be when complete (or sometimes perhaps partial ) rupture of the tendon has occurred, and then surgery may well be considered the prime intervention. (Cook et al 2000) (I) Let us consider the various options in turn. In this section we will begin (again, for the sake of clarity), by specifically considering the options available for patella tendonitis. We accept that there will, of course, be overlap between the treatments for the various tendonopathies, but it makes for a rational approach to consider each in turn. The first comment that we must make is that, after examination of the literature it is noticeable that there are only a comparatively few well constructed, placebo controlled randomised trials in this area.(Almekinders et al 1998). Those that we can examine appear to suggest that the traditional treatments aimed at minimising the inflammatory processes in the condition are largely ineffective. The authors (Cooked al 2000) (II) suggest that this may well be because of the findings we have quoted earlier (Khan et al 1996) that histologically, the prime pathology is not inflammatory. Relative Rest Cook (et al 2000) (I) points to the fact that many strategies can rationally involve load reduction and the (now outmoded) instruction to â€Å"Stop everything and rest† is positively contraindicated. The rationale for this relates to the mechanisms that we have examined earlier in this piece. Immobilisation of a tendon is actually harmful as we can point to evidence (above) that shows that tensile stress and mechanical action not only stimulates collagen production, it also is vital in tendon to ensure it’s optimal fibre alignment. Rational treatment suggests that a programme of â€Å"Relative rest† may be beneficial. By that, the authors (Cook et al 2000)(I) suggest that activity should continue as long as the prime traumas of jumping, landing or sprinting can be avoided and reintroduced in a carefully graded fashion. Biomechanical Correction Because patella tendonitis is primarily related to jumping and sprinting sports ( in numbers that present clinically), we will consider treatment in relation to them. The forces that are generated in the patella tendon on landing after a jump are considerably greater than those that produced the jump in the first place. (Richards et al1996). It logically follows that if biomechanical methods can be employed to more efficiently minimise the forces, they would be best employed on landing strategies than jumping ones. One should appreciate that the energy-absorbing capacity of the limbs dependant, not only on the patella tendon, but factors at the hip and ankle as well. Studies show that the ankle and calf are the prime sites of absorbing the initial landing load (Richards et al 1996) and, if these structures are not biomechanically sound, then this will increase the forces transmitted to the knee. Prilutskii and his co-workers (et al 1993) completed a series of studies which showed that up to 40% of the energy absorbed on landing is transmitted proximally from the ankle/calf mechanism. It follows that it must be biomechanically sound if it is to absorb the 60% bulk of the load which otherwise would be transmitted upwards to the knee mechanism. Another set of studies (Prapavessis et al 1999) concluded that when flat-foot and fore-foot landings were compared, the latter generated less forces throughout the lower limb and that the forces could be reduced further (up to another 25%) by increasing the range of both hip and knee flexion on landing. There are a number of other potential biomechanical deficiencies that can be amenable to correction and should therefore be sought outspans planes may be an obvious anatomical problem detectable at an initial examination (Kaufman et al 1999), but there are other types of functional abnormality (such as excessively rapid pronation on landing) (McCrery et al 1999), that may require far more sophisticated evaluation. Outhouses inside shoes may go a long way to help these problems Some authors, (McCrery et al 1999), regard a reduced range of movement in the sub-taller joints as an aggravating factor which places and undue stress on the Achilles tendon and that manual mobilisation of the joint is indicated in these cases. Cry therapy In the light of the histological findings mentioned earlier,cryotherapy has a rational place in treatment. It is thought th Physiotherapy Management of Lower Limb Tendonopathies Physiotherapy Management of Lower Limb Tendonopathies A Systematic Review of the physiotherapy management of lower limb tendonopathies Tendonitis is a condition which is comparatively commonly seen in various clinics. The largest cohort of patients tend to have developed their condition as a result of various sports-related activities but it is acknowledged that there is a substantial cohort of RSI sufferers and occupation-related forms of tendonitis. (Kader et al 2002) In this piece we aim to review the various treatment modalities and to concentrate primarily on the eccentric muscle strengthening modalities of treatment, the rationale behind them and any evidence that they actually work. Before we can consider the direct question of eccentric loading as treatment for tendonopathies we must examine the rationale for its uses well as the basic science and theory behind the actual practice. We will do this largely by the mechanism of a literature review. Methodology In this review we shall be examining the literature for not only the methods that are currently employed in treating the various lower limb tendonopathies but also for justification for these methods and the quality of the science behind them. We shall therefore critically review the literature available and present it in a rational form. In addition to this we intend to present an overview of various factors in a wider picture that are relevant to our considerations. We shall consider the current views on the pathophysiology of tendonitis and the experimental evidence on the response of the tendon to exercise in general terms. Although it is accepted that the majority of patients currently seen in clinical practice with various forms of lower limb tendonitis are suffering from a sports related injury, we shall also look at the effects of ageing on tendon physiology as it is acknowledged that the elderly are another highly represented group with tendonitis. We conclude the preamble with a number of clinical considerations, most prominently the difficulties posed by the differences in nomenclature and terminology which renders both assessments and comparisons between clinical trials difficult. We conclude the dissertation with a review of various currently employed treatment modalities and the rationale behind them. We focus specifically on the use and place of eccentric muscle strengthening exercises in the spectrum of rational treatments.. Pathophysiology of tendonitis At the macro-anatomical level, the tendon is usually easily defined as a semi-rigid white or grey structure, generally found in close proximity to synovial joints. One of its prime functions is to transmit forces generated by muscles to the skeletal system, often inducing movement. (Huxley HE 1979). At the micro-anatomical level, it’s structure is very much more complex and requires a detailed examination before we can realistically and meaningfully consider the issues relating to the therapy of tendonitis. Tendons form part of the anatomical structures that are functionally grouped together as the extracellular matrix (ECM). The rate of turnover – both synthesis and degradation – is influenced by a number of different factors including metabolic and disease related factors, but the strongest influence on the turnover rate is mechanical stress, usually as a result of various degrees of physical activity. (Agar Pet al 2000) Tendon (and intramuscular) collagen, turns over at a rate which is about half as fast as myofibrillar protein turnover. The main physiological stimulus to turnover appears to be the multiple stimuli arising from mechanical or contractile activity.(Cuthbertson D et al2005) At the cellular level, degradation of collagen is mediated largely byte metalloprotease group of enzymes and synthesis is most strongly influenced by a number of different trophic factors which are released at the cellular level. (Algren MS. 1999) These growth factors are mainly responsible for both the transcriptional changes as well as the post-translational modifications that take place as a result of either physiological changes or disease processes. (Sand Meier et al 1997) Until comparatively recently, tendon tissue was thought to be fairly inert. Recent research work has given good supportive evidence that the internal metabolic processes, the internal vascular responses (Alstom et al 1994) and the actual catabolic turnover of the collagen protein in response to physical activity, is considerably greater than originally thought. The converse is also true, as inactivity appears to have the same inhibitory effect on tendon tissue as the better known effect of wasting in muscle tissue. (Abrahamson SO et al 1996). This effect is of particular importance in our considerations (later) when we consider that some authorities suggest that outright rest is inappropriate initial treatment for tendonitis. Collagen is a large polymer-type protein made up of many repeating subunits, (triple helices of polypeptides with a high proportion of proline and hydroxyproline). It is made by fibroblasts. In the muscle, it forms a basket-like network around the muscle fibres but then forms progressively more coherent and solid structure as it forms discrete tendon. In this way it allows the efficient transmission of forces generated by the myofibrils to the tendon – and hence to the bone. (Kjaer M 2004). Training, in the form of physical work, exercise or repetitive movements, will have a trophic effect on the tendon as a whole. Collagen turnover can be increased and there can be an overall increase in the amount of collagen protein in the tendon. (Herzog W et al 2002) Collagen, in the form in which it is found in a tendon, has enormous on-elastic tensile strength and a modest degree of ability to bend under lateral stress. As the amount of collagen in a tendon increases, the tendon’s mechanical (or more accurately, viscoelastic,) properties change. It decreases it’s stress levels for a given load, and thereby renders it more load resistant.(Fowls JL et al. 2000). Again this facts of great relevance to our clinical considerations later in this piece. The stiffness, or resistance to lateral stress, is a function of the cross-linking of sulphur bonds across the parallel bands of protein. In general terms, the more cross-links, the stiffer the tendon. The degree of cross-linking is a result of a complex interaction between a number of enzyme systems in the matrix of the tendon. (Hamill OP et al.2001) Polyglycans are an important feature of this enzyme cascade and become an increasingly important functional component as age increases. Older or ageing collagen will tend to exhibit glycolated cross links in addition to the sulphur links of youth. This is part of the reason why older tendons are less flexible (and possibly more prone to injury). (Inglemark BE 1948). The functional significance of these links is that they render the tendon even stiffer and less able to bend.(Davidson PF 1989).Understanding these processes is fundamental to the prescribing of a rational treatment regime for tendon injuries and other pathologies. It is also important to have a complete understanding of both the vascular and neurologically mediated adaptation processes that are present in the my-tendon complex. These work on a far more rapid and immediate time frame than the processes that we have just described, and are primarily responses to rapid changes in the mechanical loading stresses. As muscle tissue develops physiologically, there is a symbiotic relationship between the muscle and the extracellular matrix. The various physiological mechanisms that stimulate muscle growth and hypertrophy appear to have a similar effect on the extracellular matrix. (MacLean et al 1991) But in the latter case, they are less well understood. We know that that significant and repeated mechanical loading will trigger off, or initiate a process, which starts with the activation of trophic gene in a cellular nucleus, (Banes AJ et al.1999), it progresses through the complex processes of protein synthesis and functionally ends with the deposition of collagen in the tendon tissue.(Yasuda et al 2000) Responses of the tendon to exercise There would appear to be some form of integration between the muscular and the extracellular matrix signalling pathways, which optimises the co-ordinated activity of the trophic processes in response to the stimuli (which can be both loading and tensile in nature), which produce the response in the first place. (Viidik A.1993). This co-ordination mechanism must exist, as it is a well-recognised phenomenon that a tendon hypertrophies to accommodate the increased mechanical stress that its associated hypertrophied muscle produces. (Derwin et al 1999) Considerable research effort has been expended in trying to delineate the mechanism, but to date, the results have not increased our understanding of the situation significantly. (Vierck J et al 2000) Specific studies in this area have been able to show a clear correlation between collagen response and an increase in physical training. (Langberg et al 2001). The response was detectable after a 4week training programme and was maximal at 11 weeks. When we consider the pathophysiology of RSI (repetitive strain injury) or even chronic overload syndrome, the stimuli that can produce muscle hypertrophy or increase muscle fibrosis can also produce fundamental changes in the tendon structure. (Birk DE et al 1990) These changes can include changes in both the chemistry and the functionality of cross bonding of the collagen fibres, (Barnard K et al1987), changes in the size of the collagen fibrils, areas of locally increased blood flow (known as hyper vascularisation zones), and an increase in the catabolic processes which can result in either (or both) collagen being synthesised and laid down, or increase in fibroblastic activity which increases the fibrous component of the tendon. (Greenfield EM et al 1999) It is a fundamental recognition of the fact that these processes require â€Å"adjusted loading† rather than an enforced absence of loading(immobilisation) to reverse the physiological processes, that underpins most of the thrust of this review.( Howell JN et al 1993), (Jà ¤rvinenTAH et al 2002) The experimental evidence to support this view comes from the classic set of investigations by Gibson (et al 1987) who compared the rate of collagen synthesis and turnover in an immobilising long-cast leg with the rate of turnover in the unaffected leg. The rate of collagen synthesis dropped by half over a seven week period in the immobilised leg. The investigators also found an adaptive (and compensatory)reduction in the rate of collagen degradation which had the overall effect of reducing the protein loss in the tendons. In the overall context of our investigation it is also important to note that the authors also found that minimal electrical stimulation of the muscle (5% of maximum voluntary contraction for 1 hr. per day),increased protein synthesis to such an extent that there was no net protein loss over the same seven week period of the trial. (Gibson etal 1989) In a study that was remarkable for its invasiveness (the authors took repeated biopsies of human patella tendon after periods of exercise), Miller (et al 2004) demonstrated that tendon collagen synthesis showed a 30% rise within 6hrs of exercise and up to a 50%rise within a 24 hr. period. This was found to exactly follow the pattern of protein synthesis in skeletal muscle. This finding is strongly supportive of the assertions made earlier in this essay, that there would appear to be a mechanical or humeral mechanism that links the trophic effects that are apparent in both tendon and skeletal muscle. Various authors have postulated different mechanisms (it has to be said with scant evidence), including integrin’s, (Levenhagen et al2002), growth factors including transforming growth factor beta (TGFB) (Moore et al.2005), or mechano growth factor (MGF) (Rennie et al 2004),which they suggest may be responsible for the co-ordination of the trophic effects of perimysium collagen, tendon collagen and the myofibrils. More concrete evidence exists (and is arguably of greater relevance to our investigation here), for the fact that dietary protein alone can produce a trophic stimulus for tendon collagen. (Jefferson Kimball 2001). It is postulated that there is some form of amino acid sensor that is responsive to the availability of amino acids. This haste effect of changing the availability of various protein kinases in the extracellular matrix generally and a subsequent enzymatic cascade which results in an increase in various anabolic signalling molecules which are, in turn, responsible for the activation of mRNA. This is then responsible for the increased synthesis of collagen (and other related proteins), in tendon and other extracellular matrix tissues. This series of very elegant experiments was done in carefully controlled conditions which removed the possibility of other anabolic factors being relevant as the only variable was the availability of amino acids. (Cuthbertson et al 2005) There is further evidence of the effect of exercise on tendon structure in the form of the set of experiments by Rennie and disco-workers. Looking specifically at the metabolism of collagen Rennie found that after strenuous exercise, the rate of incorporation of a marker into tendon collagen followed a specific pattern (Rennie Tipton 2000). There was a latent period of about 90 mines after exercise where there was no change in metabolic rate. It was then noticed that there was a dramatic increase to about 5 times normal rates of synthesis, which peaked at about 12 hrs., was maintained for about 12hrs, and then declined over the next 48 hrs. In line with the findings of Cuthbertson (above) the investigators noted that the rise in levels of synthesis is greatest if associated with an amino acid load just pre- or post-exercise, and this effect can be further enhanced by the administration of insulin secretagogues(such as glucose). There is therefore little doubt that feeding helps the post exercise response. (Atherton P et al 2005) The effects of ageing on tendon pathophysiology We have already commented, in passing, on the physiological effects of ageing in relation to the polyglycan cross bonding in tendons. There are a number of other changes which will naturally occur in relation to advancing years, which are of direct relevance to our considerations here. It is clearly a matter of observation that muscles, bones and tendons deteriorate as age increases. This deterioration leads to physical symptoms such as loss of strength, mobility and suppleness together with an increase in fatigability and a general reduction in proprioception. This condition is sometimes called â€Å"sarcopenia†.(Forbes 1987) Epidemiological studies (Dorrens et al 2003), provide good evidence to support the popularly held view that an active lifestyle into old age is more likely to support a higher level of bone density, muscle bulk and tendon flexibility, than a sedentary one. One can postulate that the trophic mechanisms referred to above, stay active for longer when constantly stimulated by mechanical activity. One effect of ageing that has been experimentally demonstrated, is that the trophic effects of available amino acids in the bloodstream are not as great in the elderly as in the young. The elderly appear to have an ability to develop resistance to the trophic effects of amino acids, which was not present when they were younger. (Cuthbertson et al 2005) Another physiological change that can be demonstrated in the elderly, is a reduced RNA : DNA ratio in tendon tissue, which is a marker of a reduced ability to manufacture protein. This, together with reduction in the amount of detectable anabolic signalling proteins, seems to be central in the failure of the muscle and tendon synthesising mechanisms. (Smack et al.2001). If we add these findings to other work of Smack (et al 2001) and Leverhagen (et al 2002) which shows that the elderly can show responsiveness in terms of trophic changes in the collagen content of tendons by manipulation of the diet. Both studies showed that maximising the protein : energy ratio of ingested food is a reasonable strategy. It should also be noted that they also demonstrated that one has to be careful to keep the energy content of the food low in order to minimise unwanted weight gain. The elderly could reasonably be assisted to maximise the benefit they get from training (resistance training in these particular studies), by integrating it with feeding concentrated in the immediate pre- or post-exercise period. This appears to have the effect of increasing the positive synergistic relationship between exercise and amino acid delivery.( Williams et al. 2002) Clinical considerations Differential diagnosis The first and possibly most fundamental issue that we have to consider when looking at the issues of the treatment of tendonitis, is the issue of correct diagnosis. This, sadly, is compounded by the fact that there appear to be several different terminology vocabularies in common clinical use. It therefore can be difficult to directly compare treatment studies of â€Å"tendonitis â€Å" unless one has direct and clear diagnostic criteria. (Saxena 1995) Tendonitis may be taken in some medical circles to include all those conditions which come under the broad heading of â€Å"painful overuse tendon conditions† (Khan et al 1999). This is generally accepted by the uncritical, as meaning that this equates with a painful inflammatory reaction in the tendon tissue. Histological investigation of the typical chronically painful tendon, generally shows an absence of the polymorphonuclear and other associated inflammatory cells. In some literature we can see the emergence and replacement of the term tendonitis with tendinitis. This latter term tends to be defined as pertaining to areas of collagen degeneration, increased ground substance and neo-vascularisation. (Purdue et al 1996) To both illustrate and clarify the point, let us consider thevarious clinical entities that may either present like, or may be diagnosed as, â€Å"tendonitis†. For ease of classification and clarity, in this section we shall consider the term â€Å"tendonitis† in specific relation to the Achilles tendon. Williams (1986) produced the (arguably) most commonly currently accepted definitions of Achilles tendon pathologies. He classified them into:- Rupture, Focal degeneration, Tendinitis, Per tendonitis (peritendonosis), Mixed lesions, Origin/insertion lesions, Other cases such as metabolic/rheumatic causes. In common clinical parlance, any of them can be referred to, with reasonable accuracy, as â€Å"tendonitis†. (Galloway et al 1999) The aetiologies can vary (and this may well have a bearing on treatment), from trauma, reduced flexibility, abnormal or changed biomechanical considerations (such as excessive pronation, supination or limb length inequalities) to name but a few. (Saxena, A 1998) It should be noted that the anatomy of the Achilles tendon is unusual and certainly different from any other in the lower limb. It does not have a true synovial sheath but a petition which extends from its origin in the muscle to its insertion in the calcaneus. Peritendonosisis therefore a commonly misdiagnosed as Achilles tendonitis. It is also clinically significant that there is a region of decreased vascularity in the tendon, which is typically about 6 comes above its insertion (Hume 1994). The clinical difference between these two conditions is that true Achilles tendonitis may, if chronic, be characterised by fucoid, or fatty focal degenerative, changes in the tendon itself, where asperitendonitis will not involve the Achilles tendon at all. (Kvist1994). These degenerative changes may be extremely resistant to non-surgical forms of treatment. In practice, the two conditions may well be presenting the same individual. (Killer et al 1998) The differentiating signs are, however, fairly easy to detect and the two conditions can be separately distinguished in most cases. Per tendonitis is the inflammation of the petition and can usually be clinically distinguished by the presence of clinical crepitus as the Achilles tendon tries to glide back and forth along the inflamed petition. This sign together with pain, generally tends to increase with activity and the tenderness is normally felt along the whole length of the tendon. Achilles tendonitis on the other hand classically gets better with movement and is at its worst after a period of rest. The discomfort tends to be more localised into discrete areas and is more commonly found in cases where there has been either a partial or even a complete rupture in the past. (Clement et al 1994) Other pathologies can arise associated with the Achilles tendon, and for the sake of completeness we should briefly consider them as they could be potentially confounding factors in any trial which aims to consider tendonitis. Tendocalcinosis is an inflammatory process which involves the Achilles tendon but only at the point of insertion to the calcaneal bone. It typically will result in calcification and therefore should be considered a different entity to Achilles tendonitis as such. It is characterised by localised pain, and prominence of the calcaneal insertion of the tendon which may well be associated with a retro-tendon bursitis. (Williams 1986) If we apply the same rationale to the patella tendon, we are again faced with a bewildering array of terminology and conditions which tend to get lumped together as â€Å"tendonitis† and may also therefore be confounding factors in any study. We shall therefore spend a few paragraphs delineating them. Some authors point to the fact that conditions that had been previously referred to as tendonitis, when examined at a histological level, are found to be the result of collagen breakdown rather than inflammation (Khan et al 1996), and therefore suggest the title oftendinosis is more appropriate. (Cook et al 2000) (I) The whole issue of the role of the inflammatory process in the tendonopathies appears to be far from clear. An examination of the literature can point to work (such as that by Khan – above), who demonstrated that the prime histological changes were non-inflammatory and were more typical of fucoid, hyaline or fibrous degeneration with occasional calcific processes being identified. Other investigators however, point to the clinical picture which commonly includes the classic inflammatory triad of dolour, rub our and tumour (pain, redness and swelling)(Almekinders et al 1998). This, associated with the evidence of the relieving effect of NSAIA’s or corticosteroids(Friedberg 1997) leads to an ambiguous picture. The pathophysiology of this condition is most commonly thought tube related to jumping and landing activity which is the mechanism which appears to cause the rupture of the collagen filaments and hence the histological appearances. The characteristics of this type of condition are that it tends to be focal, and often in the region of the lower pole of the patella. Initially it tends to be self healing but as the chronicity increases, the pain levels can increase to the point where pain is experienced even at rest (Cook et al 2000) (II) This type of condition must clearly be differentiated from there-patella bursitis (Housemaid’s knee) which is often mistakenly diagnosed as a patella tendonitis. (Halaby et al 1999) Factors which appear to predispose to tendonopathy Many authors identify chronic overuse as being one of the major factors in tendonopathy generally. (Kist 1994) (King et al 2000). This applies equally to the occupational tendonopathy as much as the sports-related conditions. (Jon stone 2000) (Kraushaar et al 1999). We should acknowledge that the term overuse can refer equally to overuse in terms of repetitive action just as much as it can refer to overloading. The two factors being independent (but often related). Some of the current literature points to the fact that there can be differentiation in the spectrum of overuse injuries between those conditions that arise from some form of biochemical change in the structure of the tendon itself (Joss et al 1997), those that are associated with biomechanical changes (such as change in function or previous injury) (Alstom 1998) and those that arise as a result of ageing or other degenerative changes (Alstom et al 1995). These factors can arise as a result of, or independently from, other factors such as the fact that the anatomical path of a tendon can take it over (or in close proximity to) friction-inducing structures such as a bony prominence – as in the case of the tibias posterior tendon, (Benjamin et al 1998) or factors relating to the site of insertion of the tendon into the bone – as in the case of theAchilles-calcaneum interface.(Benjamin et al 1995) We can point to evidence that extraneous factors can also predispose to tendonopathy. There are genetic factors (Singer et al 1986), and a relationship to blood type (Joss et al 1989). The presence of certain concomitant chronic or debilitating illnesses can certainly be associated with tendonopathies (Kannur et al 1991) as can the chronic use of certain medications – most notably the fluoroquinolone group.(Huston 1994)(Ribard et al 1992). The mechanism in the latter case appears to be associated with an increase in the amount of MMP and its associated activity which seems to be associated with an increase in the rate of degradation of protein (especially collagen) in certain tissues. (Williams et al 2000). Other authors have identified biomechanical factors as being significant (rather than necessarily causal), in the development oftendonopathies, but we shall discuss this in specific relation to treatment, and so will not discuss it further here The spectrum of currently available treatment Before beginning any rational consideration of the various forms of treatment available, one must appreciate a common truth in medicine, and that is that different treatments and different patients will respond differently to a specific treatment modality, and one of the factors that will influence this phenomenon is the skill and experience of the practitioner concerned. For example, a surgeon may well find that he gets good results from tenotomise but poor results from eccentric exercises and therefore will recommend surgery. Physiotherapist may find the converse. It is therefore important to be critical of such factors in any appreciation and appraisal of different techniques for the treatment of the lower-limb tendonopathies. In this section we shall examine the available literature to try to obtain an overview of the various treatment modalities that are currently being prescribed and examine the rationale behind their use and efficacy Most authors seem to agree that, before considering the specific conditions, a general approach of conservative measures (such as load reduction, strengthening exercises, and massage) should be tried before other modalities such as medication and physical interventions(ultrasound etc.), and that surgery should only realistically be considered as a last resort. The only obvious exception to that approach would be when complete (or sometimes perhaps partial ) rupture of the tendon has occurred, and then surgery may well be considered the prime intervention. (Cook et al 2000) (I) Let us consider the various options in turn. In this section we will begin (again, for the sake of clarity), by specifically considering the options available for patella tendonitis. We accept that there will, of course, be overlap between the treatments for the various tendonopathies, but it makes for a rational approach to consider each in turn. The first comment that we must make is that, after examination of the literature it is noticeable that there are only a comparatively few well constructed, placebo controlled randomised trials in this area.(Almekinders et al 1998). Those that we can examine appear to suggest that the traditional treatments aimed at minimising the inflammatory processes in the condition are largely ineffective. The authors (Cooked al 2000) (II) suggest that this may well be because of the findings we have quoted earlier (Khan et al 1996) that histologically, the prime pathology is not inflammatory. Relative Rest Cook (et al 2000) (I) points to the fact that many strategies can rationally involve load reduction and the (now outmoded) instruction to â€Å"Stop everything and rest† is positively contraindicated. The rationale for this relates to the mechanisms that we have examined earlier in this piece. Immobilisation of a tendon is actually harmful as we can point to evidence (above) that shows that tensile stress and mechanical action not only stimulates collagen production, it also is vital in tendon to ensure it’s optimal fibre alignment. Rational treatment suggests that a programme of â€Å"Relative rest† may be beneficial. By that, the authors (Cook et al 2000)(I) suggest that activity should continue as long as the prime traumas of jumping, landing or sprinting can be avoided and reintroduced in a carefully graded fashion. Biomechanical Correction Because patella tendonitis is primarily related to jumping and sprinting sports ( in numbers that present clinically), we will consider treatment in relation to them. The forces that are generated in the patella tendon on landing after a jump are considerably greater than those that produced the jump in the first place. (Richards et al1996). It logically follows that if biomechanical methods can be employed to more efficiently minimise the forces, they would be best employed on landing strategies than jumping ones. One should appreciate that the energy-absorbing capacity of the limbs dependant, not only on the patella tendon, but factors at the hip and ankle as well. Studies show that the ankle and calf are the prime sites of absorbing the initial landing load (Richards et al 1996) and, if these structures are not biomechanically sound, then this will increase the forces transmitted to the knee. Prilutskii and his co-workers (et al 1993) completed a series of studies which showed that up to 40% of the energy absorbed on landing is transmitted proximally from the ankle/calf mechanism. It follows that it must be biomechanically sound if it is to absorb the 60% bulk of the load which otherwise would be transmitted upwards to the knee mechanism. Another set of studies (Prapavessis et al 1999) concluded that when flat-foot and fore-foot landings were compared, the latter generated less forces throughout the lower limb and that the forces could be reduced further (up to another 25%) by increasing the range of both hip and knee flexion on landing. There are a number of other potential biomechanical deficiencies that can be amenable to correction and should therefore be sought outspans planes may be an obvious anatomical problem detectable at an initial examination (Kaufman et al 1999), but there are other types of functional abnormality (such as excessively rapid pronation on landing) (McCrery et al 1999), that may require far more sophisticated evaluation. Outhouses inside shoes may go a long way to help these problems Some authors, (McCrery et al 1999), regard a reduced range of movement in the sub-taller joints as an aggravating factor which places and undue stress on the Achilles tendon and that manual mobilisation of the joint is indicated in these cases. Cry therapy In the light of the histological findings mentioned earlier,cryotherapy has a rational place in treatment. It is thought th