Nerve And Tendon Gliding Exercises Health And Social Care Essay

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

Ernest Hemmingway Research Paper

Steven Glansberg English Comp II Research Paper 3/28/12 Every writer has his or her own unique style of writing. Writing is such a personal matter that authors have no choice but to get creative. One of the most famous, classic American writers and journalists was Ernest Hemmingway. Ernest Hemmingway had one of the most unique writing styles of all time. His distinctive writing style, characterized by economy and understatement, influenced 20th-century fiction, as did his life of adventure and public image.Ernest Hemingway's fictional style of writing was successful due to the fact that the characters he presented exhibited authenticity that resonated with his audience. He created characters that would directly relate and grow upon the audience of his work. Ernest Miller Hemmingway was born on July 21st, 1899. He was born and raised in Oak Park, Illinois. Hemmingway led a normal life and after his high school graduation he worked as a reporter for the Kansas City Star. After that job he left for the Italian front where he became an ambulance driver during World War I.Unfortunately Hemmingway was seriously injured during his duty and returned home to the states in less than a year. This over-seas experience during war would later be the basis for his novel â€Å"A Farewell to Arms. † Ernest Hemmingway did most of his literary work between the mid-1920s and the mid-1950s. His career in writing ended shortly after he won the Nobel Prize in Literature in 1954. In his career Hemmingway published seven novels, six short story collections, and two non-fiction work.An additional three novels, four collections of short stories, and three non-fiction works were published posthumously. Hemmingway’s first novel was â€Å"The Sun Also Rises†. The New York Times wrote on this novel saying, â€Å"It was a truly gripping story, told in a lean, hard, athletic narrative prose that puts most literary English to shame and also no amount of analysis can convey the quality of this novel. † This novel was written in a spare, tightly written prose, which Hemmingway was notorious for. Hemmingway had one of the most distinct styles of writing in all of iterature. Many literature analysts believe that his writing style was influenced by his time spent in World War I. It is also thought that while at war Hemmingway lost his faith in the central institutions of Western civilization. Hemmingway created his own style of writing that reacted against the â€Å"elaborate style† of 19th century writers. By creating a style in which meaning is established through dialogue, through action, and silence he was able to create a fiction in which nothing crucial is stated explicitly. He said everything while keeping â€Å"under the radar† per say.That is how the Iceberg Theory came into place with Hemmingway’s writing style. The Iceberg Theory, also know as the Theory of Omission, was a theory that was all about how Hemmingway kept the he facts floating above the â€Å"water† but keeps the supporting structure and symbolism operate out-of-sight just like the structural view of an iceberg. In other words the meaning of a piece is not immediately evident, because the crux of the story lies below the surface, just as most of the mass of a real iceberg similarly lies beneath the surface.In Hemmingway’s novel â€Å"The Art of the Short Story,† he explains, â€Å"A few things I have found to be true. If you leave out important things or events that you know about, the story is strengthened. If you leave or skip something because you do not know it, the story will be worthless. The test of any story is how very good the stuff that you, not your editors, omit. † Hemmingway clearly states that by leaving out obvious facts, you unintentionally strengthen your writing by making your audience think and ask questions about certain topics that you wanted to focus on in the first place.A famous p iece of writing by Hemmingway that clearly supports the Iceberg Theory was â€Å"The Old Man and the Sea. † This novel centers upon Santiago, an aging Cuban fisherman who struggles with a giant marlin far out in the Gulf Stream. The plot of this story consists of the aging fisherman Santiago that sails out to see, catches a great white marlin, but then struggles all the way back to shore fighting off sharks to the point where he ends up with nothing but the carcass of the marlin.This story doesn’t seem like it has any literary significance on the surface but if you read between the lines you find out that this novel is a meditation upon youth and age. Even though the protagonist, Santiago, spends little or no time thinking of those terms you can see that the details point towards a struggle between ages. Another story that also has an underlying reflection upon the struggle between ages is â€Å"A Clean Well Lighted Place. † In this novel there is an internal st ruggle between the young and the older waiter in a restaurant.The struggle between characters in this novel is that the younger waiter thinks that he know more about life and love than the older waiter. Hemmingway doesn’t have the younger waiter come out and directly say he knows more than the older waiter for a specific reason. By not making the younger waiter say that he strengthens that topic because then his audience is now asking themselves questions about the young and old waiter’s feud. In this story Hemmingway used a large portion of dialogue.The reason for this is to create a constant back and forth motion between the two waiters. With this constant back and forth it is much easier to make a comparison between the two waiters. Hemmingway also did something very unique in this story. He used Spanish language in this story to even further the excellence of his language use. Ernest Hemmingway’s writing style can never be recreated or copied by anyone. He k new how to get the most from the least in his writing. He mastered the art of pruning language. Getting ever last drop of language genius out.No one knew how to multiply intensities as well as he did or knew how to tell nothing but the truth in a way that allowed for telling more than the truth. Unfortunately Ernest Hemmingway committed suicide in the summer of 1961. Even though he is gone his literary legacy lives on through his works still being read and used all around the world. His unique style of writing and his very interesting way of leaving out a topic that was important in order to strengthen his argument will be a great example for other writers even as the years pass.

Hamlet Research Essay Topics Fundamentals Explained

Hamlet Research Essay Topics Fundamentals Explained Choosing Hamlet Research Essay Topics There are several intriguing questions that you can pose about doing it. It is an impossible task to compose an abstract research paper since this kind of article always touches on a particular topic and supplies a true search for optimal methods of solving a specific issue. It is quite easy to come across such a topic and also write this kind of essay as long as you abide by a few essential rules. Locate the solution within this essay. This essay attempts to answer... Nowadays, there's no lack of television or print ads using the theme of Global warming. Fun research topics might even turn into a means for them to discover that writing is a skill they are in fact very good at. Country music is just one of the most well-known genres of music in the usa, with a substantial audience that encompasses all age ranges. You need to go for a theme that provides you room for fresh thoughts and bright perspectives. Easy expository essays are essays where you're predicted to work on facts as opposed to opinions. If you've decided on a particular keyword for example consumer behaviour, you can search for similar research papers on the web. In the procedure for writing research articles, it's required to adhere to a particular topic. What follows is an extensive collection of the most intriguing research topics to have you started. These art essay topics aren't that easy. You also need to constantly work to boost your writing style and create your essay attractive to read and simple to navigate. You have to understand completely that you're not writing a descriptive essay. An argumentative essay is a certain sort of academic writing. The success of your essay is in the ideal selection of the topic. Pick an intriguing essay topic, and you're going to start enjoying it. There are instances when you're assigned the topic by your university professor, but more frequ ently, you might have to to create a topic on your own. Ruthless Hamlet Research Essay Topics Strategies Exploited Naturally, you won't always have an actual situation to discuss for every single topic sometimes you must borrow ideas from different people or merely apply your imagination. You might think that interesting essay titles do all of the work, permitting you to add obvious examples and share ordinary ideas. At any time you catch yourself feeling captivated by an individu essay or article, take a better look at it. Remember that you could make funny argumentative essays if you do a few things. The Foolproof Hamlet Research Essay Topics Strategy Research writing will continue being part of their typical learning curriculum, and it's something they must succeed. Research papers are trying, but in addition they have the capacity to be somewhat rewarding. Students lead busy lives and frequently forget about an approaching deadline. The students will delight in making their research besides dreading it. Rumors, Lies and Hamlet Research Essay Topics Consequently, morality is a topic that may lead to argumentative statements that need to be defended by the student. Hamlet gives us the opportunity to pose many questions regarding the morality and personality that every character displays. Hamlet might be a masterpiece of literature, but that doesn't mean your students can't question its content too. As an example, Hamlet displays all the themes mentioned previously. Your essay may revolve around gender issues from different portions of the world such as women rights in the Middle East and so forth. The aim of research paper in this discipline is to cover current public problems, reveal important aspects of various difficulties, and, if at all possible, offer optimal solutions. If you're writing about social problems, you will usually be writing about the way the topic affects larger groups of people, including how poverty affects a whole ge neration. Researching any issue about government or laws may get overwhelming because of the intricacy of the issues and even due to the wording of some laws. Hamlet Research Essay Topics and Hamlet Research Essay Topics - The Perfect Combination Given below are numerous fashion topics to write about that are guaranteed to assist you get the maximum grade! Fantastic research topics are not difficult to discover, but there are tons of things you need to consider when making this decision. When you're planning to write a style essay, it's critical to be certain that you're referring to the arrival of the fashion industry in addition to its general development over recent years. Essays on fashion papers also play a vital part on the market for giving information on the most recent trends and style. Take a while to find out more about the net for information before you select research paper topics and you might even realize that fun research paper topics are likely to be more int eresting to write on. When you search for a superb research paper topic, you may easily grow to be the severest critic of any proposed idea. At times, great research paper topics are just the easiest ones. When selecting your research paper topic, you should make certain it is neither boring nor worn out. The more you comprehend the simpler it's for you to compose a thriving research paper. Perhaps a number of the ideal college research topics nowadays are IT research paper topics. When you have that narrowed down, you can concentrate your research and compose a remarkable paper. The entire research should be constructed around or from the subject. In the event if you're new to write fashion essay papers and don't have any knowledge of it, we will be able to help you. You'll also understand what fashion is truly about when writing fashion essay papers. Understanding Hamlet Research Essay Topics When you're taking the aid of our experts, they will offer you comprehensive info on the sort of essay you are getting involved in. It is possible to also acquire different discounts on our site which will help you to save some more money for future orders or anything you want to spend them on. When it has to do with choosing topics for a research paper there are many choices to selec t from and you need something that's unique while having the ability to compose well-defined info. In order to be successful, you will have to devote sufficient quantity of time to research. You can both utilize personal experience and cover new nuances for you, depending on the research of different authors and drawing your own personal conclusions. Think about seeing how long and research is necessary for each topic and if you're limited with time, look at narrowing down to research paper topics ideas that you may finish in the allotted time you've got. This essay discusses in detail how economic aspects like recession and inflation affect the fashion business and trends. In addition, it may be an essay that provides the reader an understanding of a difference between fashion in the right time of financial crisis and well-timed. The Advantages of Hamlet Research Essay Topics Before one can write, they have to be conscious of the content. You want to get a topic that has a lot of available material for you to use. Without a suitable content, great research paper topics are not going to make sense. This video guides you through the procedure for deciding on a topic.

The Impact Of Tajikistan On The United States Of The...

Tajikistan gained its independence from the Soviet Union in 1991 and in its short life has already seen considerable amounts of turmoil. When it was first declared a sovereign nation it was plunged very quickly in to civil war. The war led to a quick decline in the nation’s economy. This war crippled the nation leaving Tajikistan very weak in the June of 1997 when the war finally drew to a close. This civil war weakened Tajikistan’s legitimate economy and left many people to â€Å"rely on the revenues of illicit opiate trade†. Tajikistan is slowly recovering from the effects of becoming a new nation, plagued with war and drug problems early in its life, and this requires the government to find a way to end the drug usage and distribution problem that grips the country along with the corruption of the state in an attempt to improve the economy and living conditions of Tajikistan. There are many contributing factors to the perfect storm of sorts that lead to the r apid increase in Tajikistan’s status as a drug state. One of the most important of these is the proximity of Tajikistan to Afghanistan. This proximity allowed for Afghanistan to take advantage of Tajikistan in the midst of civil unrest giving the people of the poverty stricken economy an easy way to make quick money. This was made easier for Afghanistan by Tajikistan’s lack of border regulations, allowing drugs to easily be transferred between the two countries. Afghanistan shares a 1,200 km border with Afghanistan andShow MoreRelatedThe Economic Crisis And The Arms Race1165 Words   |  5 Pagesmajor reasons of the collapse of the Soviet Union and the fall had a big impact on today’s politics. The Soviet Union was formed in 1922. 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