Effect of THNPs on Heroin OD Mortality | Methodology

Effect of THNPs on Heroin OD Mortality | Methodology Chapter 2. Methods 2.1 Introduction This chapter contains a precise description of the process used to search and appraise the evidence for this systematic literature review. The search was carried out during August and September 2014. An in-depth description of how evidence and research available related to the PICO question were generated, will be discussed. As mentioned in the previous chapter, the aim of this dissertation is to determine the effect of THNPs to heroin users, on heroin OD mortality. The analysing process of the PICO question, whether THNPs reduces the incidence of fatal heroin OD deaths, will be amplified through a description of the actual search strategy, and the methods used to appraise the retrieved studies. Through specific criteria, a systematic approach was applied in obtaining and selecting the relevant literature. Identified keywords used for the search syntaxes will be presented, together with the databases used for the retrieval of evidence, and the number of hits produced from each database. Search syntax is the relationship of a sequence of words used in a search strategy. A discussion of the inclusion and exclusion criteria set for this systematic review (SR) will follow, together with the methods of appraisal chosen to evaluate the studies. 2.2 Keywords and databases used PICO Element Description Keywords Population Heroin injection users in the community heroin users, injection drug users, drug users, opioid users Intervention Take-home naloxone program take-home naloxone program, naloxone distribution program, Comparison No comparison Outcome Reduced incidence of fatal heroin OD deaths OD reversal, OD prevention, opioid OD prevention, heroin OD prevention, harm reduction According to Timmins and McCabe (2005) the cornerstone of an effective search strategy is the use of proper keywords. A number of keywords were formulated from the PICO question elements, and from the preliminary search of the literature. These were mainly identified from titles and keywords used in articles found from the preliminary search. Table 2.1 below, shows the keywords used in relation to each PICO element. Table 2.1 Keywords developed to describe the PICO framework The main electronic systematic search with the search syntaxes explained further on in this chapter was carried out using different databases accessed from the Hybrid Discovery (HyDi) available from the online library at the University of Malta. Relevant databases were found on HyDi by choosing the category ‘Health Sciences’ and sub-category ‘Nursing’ since the other sub-category is ‘Midwifery’ which is unrelated. Six databases were used to conduct a search for the literature. These were Academic Search Complete, Cumulative Index to Nursing and Allied Health CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, and Cochrane Database of SRs; via EBSCO host search engine together with Medline via ProQuest search engine, and Science Direct. In addition to these databases Google Scholar was also utilised, but the search syntaxes combinations could not be used since the search engine does not have an advanced search strategy, a nd the search resulted in large thousands of articles. Therefore simple keywords alone were used to search for any other relevant studies, or to obtain full text versions which are not available in other databases. Strengths and limitations of each database are described below in table 2.2. Database Strength Limitation Academic Search Complete Daily updates Provides full text journals Available only from EBSCO host CINAHL Plus with Full Text Weekly updates Over 950 journals Covers references and abstracts from 1982 onwards Available only from EBSCO host English and American language bias Cochrane Library Cochrane Central Register of Controlled Trials Cochrane Database of SRs Research analyzed using trustworthy methods Large source of literature Up-to-date Complete text reviews Limited by restrictions Medline Records indexed with Medical Subject Heading (MeSHÂ ®) Provides a large source of life sciences evidence needed by health professionals Limited by restrictions Science Direct Provides full text from Elsevier Science journals Provides full text articles Limited by restrictions Google Scholar Free access web based search engine Large amount of results due to lack of an advanced search strategy Table 2.2 Databases strengths Limitations 2.3 Inclusion and Exclusion Criteria For readers to assess reliability and validity of a SR they have to be provided with a set of inclusion and exclusion criteria (Cronin, Ryan, Coughlan, 2007). Furthermore, Torgerson (2003) suggests that a set of inclusion and exclusion criteria are important so that throughout the search, only the articles that will answer the PICO question are extracted while others are eliminated. During the preliminary search it was noted that literature about the subject lacks randomized controlled trials (RCTs’), meta-analysis, and SRs. As shown in figure 2.1, these study designs are found at the top of the hierarchy of evidence as described by Aslam et.al (2012). Hence, all types of study designs were part of the inclusion criteria. Sibbald Roland (1998) said that clinical trials are known to be a gold standard to perform good evidence based practice and although they were in the inclusion criteria, the results were negative since up-to date no RCTs have taken place. Although this is a major limitation for this literature review, one must keep in mind that currently, the first and largest RCT is being carried out as described in chapter 1. Source type selected in all databases was ‘Academic Journals’ since books, newspaper articles, and magazines are not of strong evidence for evidence based healthcare because sometimes they do not have any type of study design, and may be narrative. Each search was limited to English language literature only. Studies that administered intranasal (IN) naloxone were excluded since this method is an off-label method (Doe-Simkins, Walley, Epstein, Moyer, 2009), and in an RCT by Kelly et al. (2005) it was found that IM naloxone was clinically more effective than IN naloxone (6 minutes vs 8 minutes). Table 2.3 and table 2.4 below describe further in detail the inclusion and exclusion criteria respectively. Figure 2.1 The Hierarchy of Evidence Pyramid (adapted from Aslam et al. 2012, p.3) Table 2.3 Inclusion Criteria Inclusion Criteria Rationale Literature had to be in English language Not possible to translate to English Studies published from 1980’s till September 2014 Studies about THN commenced in the 90’s, and so all studies are obtained (Darke Hall, 1997) Involving heroin injection drug users above 18 years of age Since the population are adults injecting heroin, and in all studies found, drug users were of 18 years and above Involving THNP Since this review concerns the outcome of THNP Experimental studies including RCTs’, reviews, observational studies including cohort studies and longitudinal studies To include all study designs and to not eliminate valuable literature Study needed to have an outcome of survival rates or OD reversals associated to THNP If outcomes were different, studies would not answer the PICO question Exclusion Criteria Rationale Studies researching attitudes, views and opinions of health care practitioners providing THN and other stakeholders such as police Outcome of studies unrelated to PICO question Studies about experiences of fatal OD victims where naloxone was not provided to heroin users as a preventive measure of fatal OD Studies had to have THNP studied as a preventive measure rather than other measures Development of instrument tools for THNP evaluation These instruments do not answer the PICO question Users of prescription opiates including methadone Since population is specifically heroin injection drug users Studies including HIV, AIDS, buprenorphine, methadone, and supervising injecting facilities as a main topic For the fact that THNP is the main subject and intervention of this SR Studies were intra nasal naloxone was used Naloxone nasal spray is not yet approved or licensed anywhere in the world Studies where naloxone was not administered by any of the participants The outcome was not attributed directly to naloxone administration Studies not published in English Not possible to translate to English Table 2.4 Exclusion Criteria 2.4 Search Strategy The keywords mentioned in table 2.1 were developed so that each PICO element has its own search syntax as identified by Bettany-Saltikov, (2012). The use of search syntaxes has assisted in narrowing the search to the most relevant studies to the PICO question. Table 2.5 below, shows the search syntax used for each PICO item. PICO element Search syntax number Search syntax Population Search syntax 1 heroin users OR injection drug users OR drug users OR opioid users Intervention Search syntax 2 take-home naloxone program OR naloxone distribution program Outcome Search syntax 3 overdose reversal OR overdose prevention OR opioid overdose prevention OR heroin overdose prevention OR harm reduction OR overdose mortality Table 2.5 Search syntaxes Search syntaxes were combined as described here: Population (syntax 1) AND Intervention (syntax 2) Population (syntax 1) AND Outcome (syntax 3) Intervention (syntax 2) AND Outcome (syntax 3) Boolean logic operator ‘OR’ was used to combine each keyword of each PICO element syntax, while the operator ‘AND’ was used to combine the PICO elements together as described above. In all search fields of the databases used except Google Scholar, ‘In All Text’ was selected for all searches. In Google Scholar the keywords searched independently were ‘take-home naloxone’ and ‘naloxone distribution’. These keywords were searched in titles only, since when searched for anywhere in the article the results were over 50,000 with most of them irrelevant to the dissertation. As shown in table 2.6 below, the defined search resulted in 2,260 articles. After the titles were evaluated whether they fit with the inclusion and exclusion criteria mentioned previously, and removing duplicate articles the search results were reduced to 160 articles by reading through the titles. The abstracts of these 160 articles were read and consequently 25 articles were noted to be directly related to the PICO question addressed in this dissertation, as they all met the inclusion criteria. One of the 25 articles which is a study by Lenton Hargreaves (2000) was not available online for free. The author, Professor Lenton was contacted via e-mail. Fortunately there was an immediate response, and the article was provided for free. However, after reading these 25 articles, 15 were eliminated because they had one or more of the exclusion criteria fit. The remaining 10 articles were identified and had fit all of the inclusion and exclusion criteria and were chosen for the critical a ppraisal of this systematic literature review. Furthermore the search was enhanced by looking up at all the reference lists of the final articles chosen for critical appraisal, but no new studies were found. Identified studies for critical appraisal are the following: Strang et al. (2008), Piper et al. (2008), Tobin, Sherman, Beilenson, Welsh, Latkin (2009), Enteen et al. (2010), Wagner et al. (2010), Bennett, Bell, Tomedi, Hulsey, Kral (2011), Bennett Holloway (2012), Lankenau et al. (2013), Banjo (2014), and Clark, Wilder, Winstanley (2014). In addition to the electronic search, a hand search was done within the University of Malta library which did not produce any results. Table 2.6 below presents the number of hits obtained from each of the databases above and the different search syntaxes combination. Database Keywords Number of hits Academic Search Complete search syntax 1 AND search syntax 2 274 search syntax 1 AND search syntax 3 272 search syntax 2 AND search syntax 3 55 CINAHL Plus with Full Text search syntax 1 AND search syntax 2 7 search syntax 1 AND search syntax 3 114 search syntax 2 AND search syntax 3 10 Cochrane Central Register of Controlled Trials search syntax 1 AND search syntax 2 0 search syntax 1 AND search syntax 3 0 search syntax 2 AND search syntax 3 0 Cochrane Database of SRs search syntax 1 AND search syntax 2 0 search syntax 1 AND search syntax 3 1 search syntax 2 AND search syntax 3 0 Medline search syntax 1 AND search syntax 2 31 search syntax 1 AND search syntax 3 228 search syntax 2 AND search syntax 3 28 Science Direct search syntax 1 AND search syntax 2 532 search syntax 1 AND search syntax 3 485 search syntax 2 AND search syntax 3 145 Google Scholar take-home naloxone, naloxone distribution 78 Total number of literature found = 2,260 Table 2.6 Number of articles found from each search 2.5 Refining of the research question After finding the relevant literature to the original PICO question, and considering properly the population being studied, the research question was duly refined since this systematic literature review will be based on the impact of THNP effect on heroin OD deaths amongst heroin injection drug users. Initial PICO question was: ‘Do naloxone take-home programs provided to drug users in the community reduce the incidence of fatal opioid OD?’ The question was refined to: Do naloxone take-home programs reduce the incidence of fatal heroin OD amongst heroin injection users? The refining of the PICO question was essential since some of the literature concerned prescription opioid users or general drug users, but the reviewer’s main interest is heroin injection users. 2.6 Methods of Appraisal After identifying the relevant studies and refining the PICO question, the next step for this dissertation was to critically appraise the literature. This will be covered in chapter 3. Critical appraisal is the evaluation of strength and quality of research studies in order to deliver evidence-based clinical decisions and after determining the worthiness of different studies through the use of different critical appraisal tools, multiple research findings can be synthesized together to develop evidence-based-practice (LoBiondo-Woods Haber, 2013). Furthermore, Burls (2009) argues that studies being biased can result in false outcomes and conclusions, because they are not composed of an acceptable quality. A bias is an orderly deviation of the results occurring from the way that a study is led, investigated or reported. In light of this, critical appraisal tools were developed to help researchers in identifying valid and reliable studies. Specific critical appraisal tools in the form of checklists are used to analyse different study designs. Commonly used appraisal tools are: Critical Appraisal Skills Programme (CASP) Scottish Intercollegiate Guidelines Network (SIGN) Centre for Evidence Based Mental Health (CEBMH) Critically Appraise Topic (CAT) After studying and considering all of the above methods of appraisal, together with other appraisal tools, it was decided that the CASP appraisal tools are to be used for critically appraising the identified studies relevant to the PICO question. The reason for choosing the CASP appraisal tools is because it is clear, concise, and easy to understand. CASP offers different checklists appropriate for different research designs where one can critically evaluate research through a set of questions and helps in determining the quality of the literature being appraised. At this phase, the studies were also rated and arranged according to the hierarchy of evidence adopted from Aslam (2012) as shown in figure 2.1. 2.7 Conclusion In conclusion, the study’s main objective is to determine whether THNPs reduces the mortality rate of heroin OD. Several keywords were identified from the PICO question elements, and from preliminary search results. These keywords were systematically searched in different databases using different search syntaxes combinations. A set of inclusion and exclusion criteria were then set up in order to get to the studies relevant to the PICO question. PICO question was then refined and then it was decided to use the CASP appraisal tools for evaluating the relevant studies which will be discussed in the next chapter. Words 1763

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

Essay on The Holy Bible - Genesis, Chapter One -- Holy Bible Genesis E

Genesis - Chapter One as an Executive Summary â€Å"In the beginning†¦Ã¢â‚¬  Genesis 1:1 Acknowledging a beginning in the first sentence of any text is in itself indicative of the nature of the text as a whole. It is an acknowledgement of a creation. It is an admission that what is has not always existed and that a higher power is at work. Genesis begins with this phrase as a reminder of the existence of God; it emphasizes the fact that man is not alone. Dually, the phrase also is indicative of the nature of the Book of Genesis, and as the first book of the Bible it sets the frame for the entire text. â€Å"In the beginning†¦Ã¢â‚¬  illustrates the importance of the themes introduced in Chapter One—they form the structural basis of Genesis and are consistently emphasized throughout the book. The Book of Genesis begins with the Creation account that offers a set of detailed instructions as to how humans are to live and view their lives. Genesis Chapter One is an introduction of every theme that is to be addressed in depth throughout the book and, although myt hological in its narrative style, it constructs the main point of Genesis while the remaining forty-nine chapters supplement and elaborate upon the first account of the Creation. The overall account of the Creation in Chapter One is notable for its order, especially its ordering according to spatial differentiation and different levels of detail. It begins with God organizing the universe by the separation of the heaven from the earth, the light from the dark, the sea from dry land. After all of the major divisions are completed, God begins to organize within the new spaces. He deals first with the earth and then with the sky. The whole earth is made to bring forth plants, then the heavenl... ... of what will occur in the remainder of Genesis. Not only does it provide an account of a beginning through creation, but it also offers a summary of the beginning of humanity in the full maturation of its blessing. Human beings are separated from beasts through this blessing because humans are the only creation that plays an active role in their own creation. It is not until the blessing is delivered and realized that human beings are fully formed, and they themselves must play an active role in its actualization. An understanding of the blessing is an understanding of what it is to be a human. The first creation account is not only a summary of the rest of the book, but a summation of how humanity can be achieved. NOTES 1 The Holy Bible, Authorized (King James) Version. 2 I am indebted to Mr. Rob Geis for this point given in his lecture on 11 May 2004.

Criticism of Religious Hypocrites in Molieres Tartuffe Essay -- Tartu

Criticism of Religious Hypocrites in Tartuffe      Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Moliere rocked the 17th century French world with his comedy "Tartuffe" in 1664. Although, religious factions kept the play banned from theatres from 1664-1669, "Tartuffe" emerged from the controversy as one of the all-time great comedies. Tartuffe is a convincing religious hypocrite. He is a parasite who is sucking Orgon, the rich trusting father, for all he is worth. Orgon does not realize that Tartuffe is a phony, and caters to his every whim. For instance, he reneges on his promise to let his daughter Mariane, marry Valere. Instead he demands that she wed Tartuffe, whom she despises. He also banishes his own son, Damis, from his house for speaking out against Tartuffe and all of his son's inheritance is promised to Tartuffe.    Tartuffe is nothing more than a traveling confidence man who veils his true wickedness with a mask of piety. Orgon and his mother Madame Pernelle are completely taken in by this charade. On the other hand, Cleante, Elmire, and Dorine see Tartuffe for the fake that he really is. Cleante is Orgon's wise brother who speaks elegantly about Tartuffe's hypocrisy. Through Cleante, Moliere most plainly reveals his theme.    Spare me your warnings, Brother; I have no fear Of speaking out, for you and Heaven to hear, Against affected zeal and pious knavery. There's true and false in piety, as in bravery, And just as those whose courage shines the most In battle, are least inclined to boast, So those whose hearts are truly pure and lowly Don't make a flashy show of being holy (Meyer 1466).    In speeches such as these, Moliere wanted to get across the fact that it was false piety he was condemni... ...rtuffe" historically it becomes clear the courage it took for Moliere to perform this play, knowing that he would be ostracized by the church for the rest of his life. At Moliere's death, Bishop Bossuet said, "God is showing his anger against Moliere" (Bishop X). However, by using the historical viewpoint, we can see that Moliere actually died a hero, knowing that he had always fought for what he believed.       Works Cited Bishop, Morris. Eight Plays By Moliere. New York: The Modern Library, 1957. Fernandez, Ramon. Moliere: The Man Seen Through the Plays. New York: Hill and Wang, 1958. Gassner, John. Comedies of Moliere. New York: The Book League of America, 1946. Meyer, Michael. The Bedford Introduction to Literature. Boston: Bedford Books of St. Martin's Press, 1989. Walker, Hallam. Moliere. Boston: Twayne Publishers, 1990.    Criticism of Religious Hypocrites in Moliere's Tartuffe Essay -- Tartu Criticism of Religious Hypocrites in Tartuffe      Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Moliere rocked the 17th century French world with his comedy "Tartuffe" in 1664. Although, religious factions kept the play banned from theatres from 1664-1669, "Tartuffe" emerged from the controversy as one of the all-time great comedies. Tartuffe is a convincing religious hypocrite. He is a parasite who is sucking Orgon, the rich trusting father, for all he is worth. Orgon does not realize that Tartuffe is a phony, and caters to his every whim. For instance, he reneges on his promise to let his daughter Mariane, marry Valere. Instead he demands that she wed Tartuffe, whom she despises. He also banishes his own son, Damis, from his house for speaking out against Tartuffe and all of his son's inheritance is promised to Tartuffe.    Tartuffe is nothing more than a traveling confidence man who veils his true wickedness with a mask of piety. Orgon and his mother Madame Pernelle are completely taken in by this charade. On the other hand, Cleante, Elmire, and Dorine see Tartuffe for the fake that he really is. Cleante is Orgon's wise brother who speaks elegantly about Tartuffe's hypocrisy. Through Cleante, Moliere most plainly reveals his theme.    Spare me your warnings, Brother; I have no fear Of speaking out, for you and Heaven to hear, Against affected zeal and pious knavery. There's true and false in piety, as in bravery, And just as those whose courage shines the most In battle, are least inclined to boast, So those whose hearts are truly pure and lowly Don't make a flashy show of being holy (Meyer 1466).    In speeches such as these, Moliere wanted to get across the fact that it was false piety he was condemni... ...rtuffe" historically it becomes clear the courage it took for Moliere to perform this play, knowing that he would be ostracized by the church for the rest of his life. At Moliere's death, Bishop Bossuet said, "God is showing his anger against Moliere" (Bishop X). However, by using the historical viewpoint, we can see that Moliere actually died a hero, knowing that he had always fought for what he believed.       Works Cited Bishop, Morris. Eight Plays By Moliere. New York: The Modern Library, 1957. Fernandez, Ramon. Moliere: The Man Seen Through the Plays. New York: Hill and Wang, 1958. Gassner, John. Comedies of Moliere. New York: The Book League of America, 1946. Meyer, Michael. The Bedford Introduction to Literature. Boston: Bedford Books of St. Martin's Press, 1989. Walker, Hallam. Moliere. Boston: Twayne Publishers, 1990.   

Changes in the twenty first century workplace Essay example -- Technol

It was once a common belief that if employees worked hard, showed up on time and followed the rules that they would be guaranteed a job for life. However, over the last decade there have been changes in the workplace. There are two main causes for this change. The changes in the work place in the twenty-first century are being caused by advancements in technology and expansions in globalization through the Internet. The advancement in technology across the world is a major cause of the changes in the workplace. For instance, the advancements in computers are astounding. Mainframe computers have given way to personal computers, then laptop computers, and now hand-held tablets. Findings of a study by IDC, a market research company, showed that by 2015 more people will be connecting to the Internet using tablets, smart phones, and other mobile gadgets compared to those who use the Internet through their desktop computers (Schroeder). Cell phones have also seen a revolution by becoming faster, more efficient and more feature-rich. It is even possible to check email on the way to work using a handheld device. A Nielson fact sheet outlining the usage of various devices in America shows that â€Å"there are 223 million cell phone users over the age of 13, and 25% of the mobile devices sold during Q3 of 2009 were smart phones. That is estimated to go up to between 40-50% during 2010† (Heimbuch). Individuals can text, status update, tweet, or reach other seamlessly by mobile devices that can fit in their pockets. Even the printed word may become obsolete according to Aaron Bradley, as outlined in his online article called â€Å"A Modest Proposal for Newspapers in the 21st Century.† In his article, he discusses how the printing of newspapers is be... ...in the new â€Å"flat world† individuals need to figure out how to become â€Å"untouchable.† He explains that â€Å"untouchables are people whose jobs cannot be outsourced, digitized, or automated† (184). He explains that in a â€Å"flat world† there is no longer a job based solely on geographic, but rather in most cases an available job â€Å"will go to the best, smartest, most productive or cheapest worker-wherever he or she resides† (183). He goes on to show that companies and individuals have to look at the global picture today in order to succeed (183). The work place has changed through the course of the centuries. Technology and globalization are the causes of the change in the workplace in the twenty-first century. Who does what work, when, and how will continue to evolve as technology becomes increasingly more advanced and communication across the globe becomes more seamless.

Ship Breaking Industries of Bangladesh

Shipbreaking Activities in Bangladesh and collision of Marine Biodiversity Prabal Barua Associate Program Officer YPSA The marine environment of the coastal water is vital to mankind on a global as well as on local basis concerning energy. Man is becoming a dominant part of the ecosystem in many regions, due to his various uses of the marine environment. So the health of marine ecosystem is an important factor in man own existence.The Bay of Bengal which is a potential bode of marine life as well as for it’s vast coastal communities is now continually polluted by different types of pollutant through influx of land base and other sources and put an alarming signal of awareness about pollution in the sea. The coastal areas of Chittagong Support a complex trophic organization sustain a high biodiversity including some endemic species and are highly susceptible to interference from activities. Coastal ecosystem makes a sustainable livelihood particularly to coastal fishing communi ties.Ship breaking yards along the coast of Chittagong (Faujdarhat to Kumira) has become a paramount importance in the macro-and micro-economic context of poverty- stricken Bangladesh. Shipbreaking activities present both challenge and opportunity for coastal zone management in holistic manner. The history of ship breaking is as nearly old as shipbuilding. As we know that a ship is relatively a large vessel capable of operating in the deep ocean. The term ‘vessels’ applies to the vessels of over 5000 tons and that can navigate in open seas.In Bangladesh ship breaking is popularly known as ‘Beaching’. Ship breaking started as a business in Bangladesh in 1972. Prior to that, 2/3 ships were scrapped during Pakistan period. It started automatically when a 20000 DWT vessel was drive ashore by the devastating tidal bore of 1965. That was the first ship scrapped on the 2 Chittagong sea beach. At present, ship breaking is conducted in an area of about 10 km by 32 o ut of 110 ship Breaking yards from Bhatiari, Sonaichhari, kumira under the Sitakunda upazilla of Chittagong.The Department of Environment (DoE) has categorized the Ship Breaking Industry (SBI) as ‘Red’ in 1995(EIA guidelines for the Industries, 1997). The Environmental Impact assessment (EIA) is not conducted before the establishment of SBI. As there is no monitoring cell, the Shipyard owners are operating their business overwhelmingly as well as indiscriminately. They are less conscious about hazards, toxicity and environmental pollution whereas more conscious about their benefit. Wastes of the scrapped ships are discharged directly into its adjacent areas which are ultimately draining into the Bay of Bengal.These wastes especially oil and oily substances, PCBs, TBTs, PAHs etc. and different types of trace and heavy metals (Cd, Pb, and Hg) are being accumulated into the marine biota. As a result, marine fisheries diversity of the Chittagong coast that supports highly d iversified marine water fishes, mollusks and benthic organisms etc. is at the stake right at this moment. Moreover the Coastal inhabitants/fisher folks lead not only their livelihoods but also solely depend on the coastal resources for their protein source.The CPUE (Catch Per Unit effort) has drastically been reduced to more than half comparatively of a few decades ago. As a consequence, the coastal fisher folks are at the stake of their existence. They are either leaving their hereditary profession or migrating to other places and becoming ‘environmental refugees’. That is why their socio-economic status is below the poverty level. There are few studies was done to find out the linkage between Ship breaking activity (SBA) and the marine pollution, impact on fisheries biodiversity and livelihoods of the fishermen community.In those researches, investigators considered Bhatiary to Kumira as affected area and Sandwip Island as control area from the shipbreaking activity. The eastern side of Sandwip has been considered as control site because these are diagonally opposite and off the SBYs and the water and soil qualities are apparently free from pollutants as revealed from the earlier studies. From the previous analysis we found that trace metals concentration in sediments at shipbreaking area are so much higher than recommendation by GESAMP (Joint Group of Experts on the Scientific Aspects of Marine Pollution).But the researchers found that Sandwip which is significantly very lower than that of sediments at affected area. The values of Lead (Pb), Cadmium(Cd) and Mercury(Hg) found six and half; eight and half and ninety four times higher than that of certified values respectively. These could be attributed to the combined effects of oil and oil spillage, petroleum hydrocarbons from ships, tankers, mechanized boats etc. During the investigation all the researcher found water qualities such as Hydrogen Ion H Concentration (p ), Dissolve Oxygen (D. O), Biochemical Oxygen Demand (B. O. D), Chemical Oxygen Demand (C. O.D), Total Suspended Solid (TSS), Total Dissolved Solid (TDS), Oil and Ammonia (NH3) were concentrated as a higher value in affected area than control area according to the standard value of water quality for the coastal water of Bangladesh (EQS, 1991). All the parameters observed such a higher that they exceeded the value of EQS. But the water parameters in Sandwip channel were optimum and near to the value of EQS standard. Water qualities in affected area exceeded the EQS standard which reveals that the water body of the adjacent area of ship breaking yards is not suitable for the existence of flora and fauna.The higher concentration was due to the discharge of various refuse oils and oily substances, dyes, chemicals, iron pieces, various types of metal rusts, solids, dyes, erosion of soil dust etc. from the ship breaking yards. Pollutants are also discharged from the Sitakunda industrial area into the run-off open t o the Bay. Impact of Marine Biodiversity: Biodiversity, which is sort for biological diversity, is the term used to describe the whole variety of life on earth. In popular usage, the word biodiversity is often used to describe all the species living in a particular area.Biodiversity can be summarized as â€Å"Life on earth. † It is defined as â€Å" The varieties of life on earth at all its levels, from genes to ecosystem, and the ecological and evolutionary processes that sustain it. † The total biodiversity of an area can be broken down into two hierarchical components: the number of functional types of organisms (animals and plants) or ecosystems (forest, prairie, tundra and marine intertidal) and the number of functionally equivalent organisms within each functional type.There are three types of aspects to biodiversity: species diversity, genetic diversity and ecosystem diversity. All three interact and change over time and from place to place. Phytoplankton is the primary food producers of the aquatic habitat and plays an important role in the food chain. Phytoplankton is the best index of the biological productivity. Analysis of phytoplankton showed that during monsoon, Aanabaena , Clostratrum(10. 98%) and Coscinodiscus(21. 97%), Euglena (9. 89%) and Zygnema (30. 76%) and during post monsoon Coscinodiscus (97. 5%) and Euglena (2. 5%) dominated in the affected site.In the control site of Sandwip, these were dominated as 30. 41%, 19. 46%; 17. 03%; 9. 73%; 23. 35% in the monsoon and 94. 73% and 5. 26% respectively in the post monsoon. Throughout the study period the abundance of phytoplankton at affected site was 91 cells/ l in monsoon season and 80 cells/ l in post monsoon season and in control site it was 411 cells/l in monsoon season and 190 cells / l in post monsoon season. Drifting small floating animals, in the water body are collectively known as zooplankton on which the whole aquatic life depends directly or indirectly.As zooplankton i s very sensitive to optimum condition, so the coastal pollution due to ship breaking activities may have profound affects on its survival and occurrence. Analysis of zooplankton showed that Calanoida, Cyclopedia, Sagitta, Lucifer etc in the monsoon and Calanoida; Acetes shrimp; Lucifer and Zoea in the post monsoon were dominated in the affected site as revealed during zooplankton analysis whereas in the control site the dominant zooplankton were found as Calanoida, Cylpclpedia, Sagitta and Zoea during the post monsoon and Calanoida; Acetes shrimp, Lucifer, Cladocera and Zoea in the post monsoon respectively.The bottom living organisms –the benthos play an important role in the food chain especially in the inter tidal zone and it is also well recognized that the richest fisheries of the world are closely related to the benthic communities. Among the macro benthos, Amphipods, Polychaetes, Nemertina and Fish egg in the monsoon and Nemertina, Cladocera, Cyclopoida and Calanoida w ere found to be dominated at the affected site.But at the control site, Amphipod, Polychaete, Nemertina, Fish egg during the monsoon and Cladocera, Nemertina , Calanoida and Polychaete in the post monsoon were dominated So, the abundance of macro benthos in affected site was 118. 46 ind. / m3 in monsoon season and 4186. 74 ind. / m3 in post monsoon season, while in in the control site 368. 28 ind. / m3 in monsoon season and 14204. 41 ind. / m3 in post monsoon season.The fishery resources of the area seems to be affected by the ship breaking activities as revealed by increased fishing efforts, reduced species diversity, increased amount of trash fish. Horizontal expansion of the ship breaking yards has posed threat not only to the diversified coastal resources but also on the adjacent coastal inhabitants specially the fisher folks. The fishing hamlets of this study were found backward in the field of primary education and health that are the basic needs for them.Communication and dri nking water supply were observed satisfactory but the sanitation status was found to be very poor. Participatory Rural Appraisal (PRA) study showed that about 90% of them were local and full time fishermen and 10% were migratory of different districts including Bhola, Barisal, Mymensingh and others. The fisher folks are dissatisfied with different NGO activities working in this area. No government aid was found to be available for the welfare of fishermen communities.The catch has declined in the tune of at least 50 to 60% of what was two decades ago. This incident has got serious implication in the context of survival of such a disgraced community. It was found that about 70% of the fishermen had either nets or boats or both of them. They use both mechanized and non-mechanized boats and some traditional fishing crafts (Dinghi) for fishing. Among the fishing nets Set Beg Net (Behundi Jal) and Gill Net (Ilish Jal) were found to be widely used.Though the gears are available for fishin g, they can catch a very little amount in every effort. They uniquely reported that the fish catch had been reduced more than half of the previous time. Analysis of catch composition indicates that some commercially important fishes like Indian salmon (Polynemus indicus) commonly known as Lakhua, grouper (Epinephelus lanceolatus) known as bole coral; Long jew fish (Otolithoides brunneus) locally known as lombu fish; spanish mackerel (Cybium guttatum) known as maitta and butter fish (Psenes indicus) etc are in endangered position.Some other commercially important fishes like River shad (Tenualusa ilisha) Jwelled shad (Ilisha filigera) locally known as choikka; mud skipper (Gobies); mango fish (Polynemus paradysius) known as ‘Hriska Machh’; silver pomfret (Stromateus chinensis); bombay duck (Herpodon nehereus); mullet ( Mugil cephalus); Sea bass (Lates calcarifer); Anchovy(Coilia dussumeri; Coilia ramkorati; Setipinna taty) etc are reduced in catch. Many coastal fishermen are leaving their hereditary profession and moving around everyday as ‘environmental refugees’ from a state of unemployed and poverty to underemployment and grim poverty.Due to the deterioration of the water body, fishes are moving away from this area into the deep sea. But the poor fishermen with small fishing boats can hardly fish at deep seas the creditors and swindlers are taking this chances and rush to lend money and thus make them run into debt. The fishermen also reported that while they catch fish at sea they face piracy. They also face the muscle man, middle man and swindlers when they return with fewer amounts of fish.. These criminals snatch away the fishes forcefully. The fishermen are exploited by the dealers in dadon (earnest money).It is made obligatory that the middleman determines the price of fish in the season of fish. They are to sell fish to the lenders at a nominal or throwaway price. The middlemen indulge in maintaining miscreants to exercise th eir authority over them. Before the season of fish they borrow 4/5 thousand Taka from the dadonders (Buyers cum earnest money lenders) to repair the boat which lead them run into debt. Generally the months of MarchApril-May (Falgoon-Chaitra-Baishakh) are the â€Å"season of scarcity† as reported by the fishermen during PRA survey.At this time they require at least Tk. 4000/5000 to repair their boats, nets and for other incidental expenses. Most of the fishermen opined that Ship Breaking Activity (SBA) creates problems to them and the rest did not respond. Besides, 90% of the villagers of the vicinity were anxious about their existence in future. Their nets for the catching fish become stuck with oil and impurities. They suffer from respiratory difficulties, sonic booms, explosions, lightning, fumes, toxic chemicals and skin diseases.It is clear from the sociological study that coastal fish species diversity has been reduced due to the ship breaking activities. The fishermenâ €™s hereditary profession is now at the vulnerable position due to the Ship Breaking Activity (SBA); less access to credit etc. But the most interesting thing is that they are not conscious about their rights and deprivation. The increasing SBA is depleting the fishery resources which simultaneously decreasing catch per unit effort (CPUE). So this trend is provoking the fisher folks to change their livelihoods for what they never feel comfort and safe.Land grabbing by the yard owners also occurs sometime. Expansion of the yard shrinks the area of the fishing villages. They have to leave their space with a very nominal price. They have rights over only 200 feet of the seashore where they dry nets and anchor boats. Erosion of the village by sea wave action threatened the fishing village’s decade after decade. It started in sixties and nearly half a kilometer of the village has disappeared into the sea. Now at least 20,000 people engaged in catching fish are at the stake of their existence.Bangladesh is a party to the Convention on Biological Diversity (CBD), 1992 and the Biosafety Protocol. Bangladesh is also a party to the Convention on international Trade in Endangered Species of Wild fauna and Flora (CITES). Bangladesh has a Marine Fisheries Ordinance 1983 (ordinance No XXXV) and under this ordinance government may declare any area of Bangladesh fisheries waters and any adjacent or surrounding land to be a marine reserve (Part VII). So, if government will declare Sandwip channel and its adjacent area as a marine reserve area for fisheries biodiversity it will be.Besides, there are many laws, rules and polices in Bangladesh to conserve marine biodiversity such as The territorial water and maritime zones act (1974) and rules (1977), The forest act (1917), Environment Conservation Act (1995), Protection and Conservation of Fish rules (1985), national fish policy (1996), the water policy (1999), the environment policy (1992). If we conserve our diversi fy marine biodiversity it will be urgent need to establish environment friendly Shipbreaking activity in Bangladesh. Related article: Padma Bridge

Student Exploration: Graphing Skills Gizmo

. Student Exploration: Graphing Skills Vocabulary: bar graph, line graph, negative relationship, pie chart, positive relationship, scale, scatter plot, variable Prior Knowledge Questions (Do these BEFORE using the Gizmo. ) 1. Four kinds of graphs are shown in this Gizmo. Circle the kinds you have seen before. [pic][pic] [pic][pic] Bar graph Line graph Pie chart Scatter plot 2. Where have you seen graphs used? Graphs are used everywhere. You can find them in textbooks, newspapers, meetings, schoolroom, everywhere.Basically anywhere someone needs to portray information, visualize data, display trends or patterns, compare two or more things, chart progression/digression, show relationships, etc. 3. Why do you think graphs are useful? Like stated above, graphs are useful to share information with others and put it in a picture-like form. Sometimes it is easier to understand a concept if you can visualize it, which is what a graph does. Gizmo Warm-up: Using the Graphing Skills Gizmo 1.The Graphing Skills Gizmoâ„ ¢ starts with a bar graph on the right and a data set on the left. Practice using the Gizmo by doing the following: †¢ Write a title. †¢ Label the vertical and horizontal axes. †¢ Change the scale of the vertical axis. †¢ Drag the bars up and down. 2. Use the Graph type dropdown list to select other kinds of graphs. Practice with each type of graph: †¢ On the Line graph drag the points up and down. †¢ On the Pie chart change the size of each slice by dragging the edges. †¢ On the Scatter plot drag points from the data table to the graph. Activity A: |Get the Gizmo ready: |[pic] | | | | | |Bar graphs |On the Challenge menu, select Create graph. | | | |On the Graph type menu, select Bar graph. | | | |If necessary, click New until Animal speed data appears. | Goal: Build a bar graph based on a data table. 1. Create graph: A bar graph is useful for comparing things, such as how fast animals can run. †¢ Write a title f or the graph. (Look at the title of the data table for a suggestion. ) †¢ Label the horizontal axis and the vertical axis. †¢ Pick what you think is the best choice for a vertical axis scale. †¢ Drag each bar to match the data in the table. Do your best to estimate heights. 2. Check your work: Click Check to see how well you did. A. What was your accuracy score? Over 90 is excellent. ) Accuracy score is 100. B. What vertical scale did you choose? (In other words, how much does each horizontal line on the graph represent? ) Each line on the graph represents 20 km/h. 3. Revise: Click Show value on mouseover. Move the cursor over each bar to see its value. Adjust each bar and click Check until the accuracy score is 100. To show your work, click the screenshot camera at upper left. Paste the screenshot into a blank document. 4. Interpret: Which of these animals is fastest? Cheetah Slowest? Human . Apply: Click New and make the next bar graph. Adjust the scale if needed an d don’t forget to make a title and label each axis. Click Check to see your accuracy. A. What country has the highest life expectancy? The lowest? Country with the highest life expectancy is Andorra. Country with the lowest is Zambia. B. Does anything about the graph surprise you? I hoped that the USA would have the highest life expectancy, but that was not the case. (Too many McDonald’s to blame. ) 6. Challenge yourself: Hold a contest with your classmates.Turn off the Show value on mouseover checkbox and click New. Who can create the most accurate bar graph? |Activity B: |Get the Gizmo ready: |[pic] | | | | | |Line graphs and pie charts |Under Graph type select Line graph. | | | |If necessary, click New until Temperature data appears. | Goal: Build a line graph and a pie chart. Line graphs 1. Create graph: Line graphs are often used to show how something changes over time. Write a title and label the axes. Adjust the vertical scale if needed. Create the line graph b y dragging the points up and down. 2. Check your work: Click Check. What was your accuracy score? Accuracy score is 100. 3. Revise: Turn on Show values on mouseover and adjust the graph until your score is 100. Take a screenshot of your graph and paste it into a document. 4.Interpret: Which day was hottest? Wednesday Which day was coolest? Sunday 5. Apply: Try additional line graphs until you are comfortable making this type of graph. Discuss the most interesting graphs with your teacher and classmates. Pie charts 6. Create graph: Pie charts are used to show proportional data. Under Graph type select Pie chart. Make sure that Show values and labels is checked. Write a title for the pie chart and drag the pie pieces to match the data table. 7. Check your work: Click Check. Revise your pie chart if necessary.When the pie chart is correct, paste a screenshot of the chart into your document. 8. Interpret: What were the most popular pies? Apple 9. Apply: Try additional pie charts until y ou are comfortable with this type of graph. For a real challenge, try to make a pie chart with the Show values and labels checkbox turned off. 10. Extend your thinking: The Gizmo also allows you to create a data table from a graph. Under Challenge select Create table. Write a title for the table and then fill in each empty box based on the graph. Click Check to check your accuracy. Activity C: |Get the Gizmo ready: |[pic] | | | | | |Scatter plots |Under Challenge select Create graph. | | | |Under Graph type select Scatter plot. | | | |If necessary, click New until Studying and score data appears. | Goal: Create a scatter plot. 1. Create graph: Scatter plots are used to see if one variable is related to another. Each point on a scatter plot has two values. For example, if Robert studied for 40 minutes and got a quiz score of 98, Robert’s point would be placed at (40, 98) on the graph. (You can think of that as â€Å"over 40, up 98. †) To make a scatter plot, do the fo llowing: †¢ Write a title for the graph. †¢ Label the horizontal axis based on the second column of the data table, and the vertical axis based on the third column of the data table.Include units in each label. †¢ Adjust the horizontal and vertical axis scales if needed. †¢ Drag each point to match the data. 2. Check your work: Click Check. What was your accuracy score? Accuracy score is 100. 3. Revise: Turn on Show values on mouseover and adjust the graph until your score is 100. Adjust the axis scales if necessary. Paste a screenshot of your graph into a document. 4. Interpret: Based on this graph, will studying help you do well on a test? Explain. Yes! The longer a student studied, the higher his/her test score was. 5. Extend your thinking: The â€Å"Studying vs.Score† scatter plot shows an example of a positive relationship—as one variable increases, so does the other. The points in this type of scatter plot tend to go â€Å"uphill† from left to right. A negative relationship is the opposite—as one variable increases, the other variable decreases. These types of scatter plots go â€Å"downhill† from left to right. A. Which graphs in the Gizmo show a positive relationship? In the â€Å"Income versus Education† graph, as one’s education improved and increased, the income they earned also increased. With the â€Å"Study and Score Evaluation†, when one’s study time increased, the score also correlated with an increase.With the â€Å"Growth Over Time† graph, there is a positive relationship since as one person increases in age, the height also increases. B. Which graphs in the Gizmo show a negative relationship? The only graph I could find which remotely represented this was the Temperature Data Graph. As progression increased through the week and it got closer to the weekend, the temperature decreased. Although not demonstrated in the Gizmo, a perfect example of a negativ e relationship would be as the elevation above sea level rises, the temperature decreases. ———————– [pic]