Creole Men In The Awakening Essay Example For Students

Creole Men In The Awakening Essay In Kate Chopins epic, The Awakening the characters of the Creole men are assorted and distinctive as the character Edna. The greater part of Kate Chopins stories revolve around a Woman unsatisfied with her situation throughout everyday life, while living in a man overwhelmed society. The three fundamental characters are average men of that period. Chopin shows the decent variety in every one of those three characters. Roberts arousing, and the battle to do what is the best thing. Alcee and how he is joyful and not worried about societys desires for him, thus has a notoriety. Mr. Pontiller, a representative most importantly, with minimal left for spouse and family. Robert did the privilege and honorable thing by leaving to go to Mexico in order to not need to see the object of his illegal love. Alcee sees Edna as another of his victory, and doesn't quit any pretense of, seeking after her at all expense. Alcee has not worry of what society considers him so he can do however he sees fit. Mr. Pontieller, while he trusts himself to be a caring spouse, is a run of the mill specialist of the time. He needs his better half to obey him. He needs the ideal Creole spouse, one who can assist him with exceeding expectations in the business world he adores to such an extent. In investigating these three men in Kate Chopins The Awakening, there are sure parts of each, while unique, the equivalent. All live during the 1800s were assurance notoriety was viewed as the most extreme significance to the specialist, yet, Alcee appears to be uninterested with any resolve or business obligation. In investigating the character of Robert who is by all accounts at a junction in his life. Quest for his fortune, discover a spouse, succeed and be decent, or, do the inconceivable and follow his heart. Mr. Pontellier is the run of the mill Creole spouse and specialist. Leonce is persuaded that satisfying fiscal needs pardons the lack of time he goes through with the youngsters, never assuming that a few needs can't be financially fulfilled: He has his hands full with his financier business getting by for his family on the street(885)} Even to himself, Leonces thought smack about the self indulgence of the enabled. Maybe on the grounds that he knows about his own disregard, Leonce ventures his blame onto Edna, expecting immaculate well evolved creature execution on her part to cure his residential nonattendance. (Patrsn, Out Of A Convention of Awakening, np)Patterson portrays Leonce has having self indulgence because of his empowererment. With the benefits of riches and social standing comes self-degradation. Leonce is so up to speed in his own beliefs that he neglects to see his response to his significant other, and youngsters. He is trapped in unrest among society and having no other way out. At that point Mr. Pontellier got up, saying he had a l arge portion of a brain to head toward Kliens lodging and play a round of billiards. (Chopin, 174) Leonce doesn't invest energy with his family while at the mid year cabin, having never developed closeness with his youngsters and spouse, Leonce would prefer to be with the young men, having some good times, doing whatever him might want to do, leaving all the regular obligations to his better half, or recruited help. Leonce is out of sorts when not working together. While at home Leonce anticipates that his better half should be mindful to all his words, rewarding him more like a forthcoming colleague than her significant other. Leonce doesn't acknowledge Ednas absence of consideration, and gets at her the main way he can, through her youngsters. Leonce gets an opportunity to vent his debilitation toward his better half. He thought it extremely debilitating that his significant other, the sole object of his reality, envinviced so little enthusiasm for things which concerned him and e steemed so little his discussion. (177) He reprimanded his better half with negligences (178) It is evident that Ednas negligences where of Leonce and not the youngsters. Leonce needed to get at his significant other from her absence of enthusiasm for his time at Kliens. This conduct is to some degree characteristic of an egotistical individual, looking to his own needs, or somebody who hasn't the foggiest about closeness. After he censures Edna he heads outside and smokes a stogie like it was the most normal thing on the planet to do. (178) The genuine occasion is that Leonce has settled the score with his significant other, for her absentmindedness to him. Later the following day Leonce feels to some degree regretful for his upheaval towards his significant other He had recovered which appeared to have been to some degree debilitated the prior night. (179) Leonce realizes that he acted sincerely as being unwell portrays. Leonce doesn't tell his wifeanything, yet later sends her a blessing bundle as though to make up to her what had occurred. Leonce was in disturbance, in regards to his activities, in spite of the fact that Leonce is as yet deciding to stay reserved towards Edna. How conventional, sending a blessing with out an expression of conciliatory sentiment. Leonce has no clue about how severely he has carried on in sending a blessing without an expression of conciliatory sentiment; it is just as he were attempting to repair a business connection. Leonces entire character is that of a man who has no closeness with spouse or youngsters. An effective business is the thing that he adores, what has become as long as he can remember. Leonces just purpose behind wedding was to help him in his business, stable wedded man, father, and lovely faithful spouse. Leonce has another sweetheart, his business. Leonce is stressed to such an extent that his business will endure if Edna goes out, he composed writes to reveal to him she is going out. Leonce quickly compos es a letter of unfit objection and denunciation. (316) Leonce isn't contemplating what this activity will do to his notoriety. No Leonce is pondering his money related respectability (316) Leonce shows again the absence of closeness for his significant other, were his business is concerned. Leonce is apprehensive if this gets out that his business will endure. Leonce deliberately makes an arrangement to hide any hint of failure and gives Edna minute guidelines to a notable engineer concerning the redesigning of his home, changes which he had since a long time ago mulled over, and which he wanted conveyed forward during his brief nonattendance (316) Leonce is a self-assimilated specialist. Leonce accepts, that he worships his better half and kids. What he loves is their specialty for him in his business. A decent notoriety went far during the 1800s in which he lived. Leonce rushes to cure any hindrance that will hinder his business. Leonce is a man of the 1800s totally. Chopin has gi ven a brief look at the Alcee a solitary man who lives however he sees fit. Alcee has decided to turn into a rebel of society, not sticking to the accepted practice that most men in that timeframe followed to.On one finish of the socio-political range is the unmarried Creole man who imparts a personal second to a wedded lady, an encounter that motivates a physco-sexual arousing in both. Presented as an uncommon agitator, this Creole lone ranger has made for himself a flighty open picture, which isolates him from the more traditional Creole men. Truth be told, his unpredictability fills in as an improvement for the enlivening in the lady he experiences. (Earthy colored, Awakened Men In Kate Chopins Creole Stories, np) Alcee needs the opportunity to do what he needs. He is by all accounts a rich person thus doesn't need to work so as to have material belongings. On the contrary,and asked in the event that he were identified with the noble man of that name who shaped one of the firm of Laitner and Arobin, legal advisors. The youngster conceded that Laitner was a warm close companion, who allowed Arboins name to enrich the organizations letterheads and to show up upon a shingle that graced Perdido Street (307-308) Alcee had pay from a law office for which he didn't work. Alcee was a nineteenth century playboy, while living in an eighteenth century society. Alcee had a notoriety among the Creoles. Presently on the off chance that I resembled Arobin you recollect Alcee Arobin and that account of the emissaries spouse at Biloxi (201) Alcee appears to concentrated his considerations on Edna and afterward seeks after her, with no respect for her notoriety Alcee naturally knows when a lady isn't content with her place throughout everyday life. Alcee utilizes his appeal and understanding fellowship to pick up the trust of these ladies. Alcee takes them out each night to the races, the club, or only for a drive. Alcee gives them his considerations with out requesting rest itution. This conduct isn't unprecedented with men who view themselves as a Ladys Man. His hand had wandered to her delightful shoulders, and he could feel the reaction of her tissue to his touch he situated himself next to her and her daintily upon the shoulder. I thought you were leaving, she stated, in a lopsided voice. I am, after I have said goodnight. Goodnight, she mumbled. He didn't reply, but to keep on touching her. He didn't state great night until she had gotten flexible to his delicate, alluring supplications. (315-316)Alcee had gained notoriety for being with hitched ladies. Alcee picks ladies who are hitched, leaving him with no obligation regarding their government assistance when he was done with them. Alcee is worried about victory. It is as though Alcee needs to satisfy his notoriety, to show that he can. Alcee was an energizing man to be with, leaning toward the round of enchantment to the genuine enticement itself. Robert Lebrun is a most intricate person. He sp ends summers on Grande Island with his mom and sibling. Robert is charmed by the wedded ladies at the cabins. Robert..had established himself the dedicated orderly of some reasonable lady or maid. At times it was a little youngster, again a widow; yet frequently as not it was some intriguing wedded lady. (185) Robert is an old buddy to these ladies. Robert is never paid attention to by the wedded ladies however. It was comprehended that he had regularly expressed uplifting statements and commitment to Madame Ratignolle, with no idea of being paid attention to. (186) Robert needs to be paid attention to, comprehending what it would intend to the lady. Robert is attempting to satisfy a mystery want, what to become in this life. Robert realizes his goals go on hard of hearing ears, until the day that Madame Ratignolle chats with him about Edna. His confronted flushed with irritation and removing his delicate cap he started to beat it impat

The Roaring 20's Essay Example | Topics and Well Written Essays - 750 words

The Roaring 20's - Essay Example The US senate likewise dismissed to concur the Treaty of Versailles which officially finished WW1 and accommodated the formation of the Group of Nations. The Senate chose to dismiss the Treaty from the dread it might prompt the commitment of the US in future European clashes. Americans only don't have to adapt to, nor endure the issues of Europe and abroad. (Pietrusza 5-10) As soon Americans place war simply behind their psyches that helped them to disregard the issues of European issues, and focus on the country, their zone, and themselves. American residents distinguished themselves in a period of progress, both the socially and socially. A few imagine that qualities had disintegrated completely. Preceding The First World War, females wore their hair protracted, had dresses contacting their lower legs, and exceptionally long silk cotton stockings. During the 20s, they put on shorter, tight garments, and collapsed their silk tights directly down to their knees. They wore extravagant lip sparkle and different cosmetics items. At last, women were even permitted the privilege to votein nineteenth Amendment. Ladies were never considered as a significant piece of the general public up to that period, in American culture. When the ladies had the power to cast a ballot, they didn't simply sit back once more. The women of 20's worked for equivalent rights for the two guys and females in network (Pietrusza 10-15) On other hand there were various issues spinning out of control in the entire nation after consequences of World war. Above all else Red Scare issue had all the earmarks of being the best issue raised. Red Scare that was seen as an outside socialist intrigue which was considered liable for various dissent activities and association practices in the long stretches of 1919 and 1920. A ton of Americas also watched out for the developing activities of the Klu Klux Klan who were associated with threatening individuals from different nations including blacks, Jews j ust as Roman Catholics. (Pietrusza 25-35) Books, compelling artwork, and new music likewise reflected the countries adjusting values. There were a great deal of notable scholars, writers, music specialists and entertainers which left their tag during the 20s. Sinclair Lewis distributed Main Street (1920), which reflects what he thought to be the exhausting lives and restricted arranged practices of people in a little town. One of the absolute best American creators to come up from the 20s was Ernest Hemingway. The most noted acknowledged works of Hemingway incorporates In to the trees and Over the trees .A great deal of Hemingway's best works conveyed the lead and experiences of the period's so named last age. During the 20's, Jazz was getting exceptionally well known. At whatever point the turntable was turned on, Americans essentially simply hosted to gathering. It was a new encounter of happiness, and fulfillment which showed up along with the beginnings of jazz tracks in USA. Wi th jazz getting major, Americans move a long way from great music and moving and started finding different sorts of new music for instance jazz. The charming, light, straightforward sensation related with jazz tunes was only an expansion of American feelings through the 20's; wondrous and absolutely free energetic. (Pietrusza 40-43) Radio likewise popped the entryways for creative pleasure for instance evening programs for watchers to hear to. Moms and fathers and their children would stay near the radio checking out such daily entertaining shows as Amos

Eating Disorders and Borderline Personality

Eating Disorders and Borderline Personality BPD Related Conditions Print Eating Disorders and Borderline Personality By Kristalyn Salters-Pedneault, PhD Kristalyn Salters-Pedneault, PhD, is a clinical psychologist and associate professor of psychology at Eastern Connecticut State University. Learn about our editorial policy Kristalyn Salters-Pedneault, PhD Medically reviewed by Medically reviewed by Rachel Goldman, PhD, FTOS on January 28, 2020 Rachel Goldman, PhD FTOS is a licensed psychologist, clinical assistant professor, speaker, wellness expert specializing in weight management and eating behaviors.   Learn about our Medical Review Board Rachel Goldman, PhD, FTOS Updated on February 23, 2020  FollowTheFlow/Getty Images More in BPD Related Conditions Diagnosis Treatment Living With BPD Eating disorders and borderline personality disorder (BPD) frequently occur together, but until recently, very little was known about the relationship between the two. Recent research is revealing how often BPD and eating disorders co-occur, why they may be related and how to treat these two types of disorders when they do co-occur.?? What Are Eating Disorders? Eating disorders are psychiatric disorders characterized by severe problems with eating behavior and related thoughts and emotions. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the official guidebook to the diagnosis of psychiatric disorders used by mental health providers, recognizes eight types of eating disorders. Eating disorders included in the DSM-5 include: Anorexia nervosaBulimia nervosaBinge-eating disorderRumination disorderPicaAvoidant/restrictive food intake disorder (ARFID)Other specified feeding or eating disorder (OSFED)Unspecified feeding or eating disorder (UFED) Anorexia and Bulimia Anorexia is marked by restrictive food consumption, a preoccupation with gaining weight, and significantly low body weight. In contrast, the central feature of bulimia nervosa is the presence of ?binge eating, followed by behaviors that attempt to compensate for the binge eating, such as self-induced vomiting, overuse of laxatives, excessive exercise, and others. There can be some overlap in symptoms between these two disorders. For example, someone may engage in binge eating and purging, but also be unwilling to maintain normal body weight. Binge-Eating Disorder Binge-eating disorder was officially added to the DSM as a diagnosis in 2013.?? The condition is characterized by binge-eating episodes where people feel that their eating is out of control. These episodes are also often accompanied by feelings of embarrassment or guilt. Unlike bulimia, there are no accompanying compensatory behaviors. Other Eating Disorders Pica and rumination disorder were moved from the now-eliminated DSM-IV section of disorders usually diagnosed in infancy, childhood, and adolescence into the feeding and eating disorders section of the DSM-5.?? Pica involves the craving and consumption of non-food substances. Rumination disorder involves regurgitating previously eaten food in order to spit or re-swallow it. Avoidant/restrictive food intake disorder is a new addition to the DSM, known previously as selective eating disorder. This disorder is characterized by restrictive food intake, but it not marked by distress over body size or weight gain.   The DSM-5 also contains umbrella diagnosis options of other specified and unspecified for conditions that do not meet the criteria of other eating disorders such as anorexia nervosa or binge-eating disorder.?? 9 Essential Facts About Eating Disorders Prevalence People with borderline personality disorder have a greater prevalence of eating disorders than people in the general population.?? For example, a widely cited study by Dr. Mary Zanarini and her colleagues at McLean Hospital found that 53.8% of patients with BPD also met criteria for an eating disorder (compared to 24.6% of patients with other personality disorders).?? In this study, 21.7% of patients with BPD met criteria for anorexia nervosa and 24.1% for bulimia nervosa. Of course, this is not to say that people with eating disorders necessarily have borderline personality disorder. In fact, the overwhelming majority of people with eating disorders do not have BPD.  It appears that the rate of BPD in people with eating disorders is somewhat elevated when compared to the general population (about 6 to 11%, compared to 2 to 4% in the general population).  ?? Some eating disorders, though, are associated with having a higher risk of BPD than others. One study found that people with bulimia nervosa, purging type may be at a greater risk for BPD (with about 11% meeting BPD criteria) than people with anorexia nervosa, binge-eating/purging type (with about 4% meeting BPD criteria).?? How Are They Related? Why do people with BPD seem to have eating disorders at a greater rate than people in the general population? Experts have noted that one possible explanation is that BPD and eating disorders (particularly bulimia nervosa) share a common risk factor: Both are associated with histories of childhood trauma, such as physical, sexual and emotional abuse.?? It could be that having a history of childhood trauma puts one at greater risk for both BPD and eating disorders. In addition, some experts have suggested that it may be that the symptoms of BPD put one at risk for developing an eating disorder. For example, chronic impulsivity and urges to self-harm may lead one to engage in problematic eating behavior, which may over time rise to the level of an eating disorder.?? Conversely, engaging in eating disordered behavior may lead to experiences of stress (e.g., intense shame, hospitalization, family disruption) that may trigger BPD in someone with a genetic vulnerability for the disorder. Treatments What can be done about BPD and co-occurring eating disorders? The good news is that there are effective treatments available for both types of conditions. While some studies have indicated that people with BPD do not respond as well to eating disorder treatment, other studies have found no differences in treatment response between people with eating disorders with or without BPD. Which problem should be treated first? It may be that both the eating disorder and the BPD symptoms can be treated at the same time, but this may be decided on a case-by-case basis. For example, some people have eating disorder symptoms that are so severe they are immediately life-threatening. In this case, hospitalization for the eating disorder symptoms may be necessary before treatment for the BPD symptoms can begin. Alternatively, in someone with very severe BPD symptoms that are either life-threatening or threaten to reduce their ability to engage in the treatment, the BPD symptoms may be treated first. Find Hep With the 9 Best Online Therapy Programs Finding Help If you think you (or a loved one) may have BPD and/or an eating disorder, the first step is to find a mental health provider who can make the right diagnosis and give you the right treatment.

The Cold War And The Soviet Union - 1173 Words

Along the course of American history, this nation has seen many conflicts in its brief timeline. However, as the alliance between America and the USSR dissolved after the second World War, the relationship between both superpowers began to fluctuate as they competed to spread their varying ideologies. This unique time period became known as the Cold War, a conflict unique as it was not fought with normal methods of warfare. In fact, it was not fought with weapons at all. To fully understand this unconventional war, it is important to understand the background to the hostile relationship between the United States and the Soviet Union. It is also important to study its methods of warfare and the conflicts that arose. The Cold War began as a†¦show more content†¦After seeing this, Russia created its own form of alliance to protect itself from an attack as well, showing how tension quickly arose between both countries as a result of distrust. To add on, the introduction of the T ruman Doctrine and efforts of Containment in Greece and Turkey further broadened the ideas of distrust among nations. America wanted to stop the spread of communism in Europe by providing financial aid to weaker countries and was vocal about its intentions of containment (Doc. 2). These actions and ideologies between America and Russia created the foundation of suspicion and tension during the Cold War. Although it is described as a war, The Cold War is unique as no physical fighting ensued between Russia and America. Instead, it was a battle using weapons of passive-aggressiveness between nations. One of weapons used during the Cold War is propaganda. An example of this propaganda can be seen in Khrushchev’s 1956 speech in which he introduces and defends the idea that America is attempting world domination (Doc. 6). Khrushchev said this to the Russian citizens to influence their feelings of negativity toward America and to justify his feelings of distrust towards them. Anoth er weapon of The Cold War was military and financial aid. Although this seems ineffective, this greatly helped Europe as ideas like the Marshall plan helped to prevent â€Å"...heavy economic, social, and political damage,† (Doc. 3). With a stronger Europe, itShow MoreRelatedThe Cold War And The Soviet Union973 Words   |  4 PagesThe Cold War was a state of economic, diplomatic, and ideological discord among nations without armed conflict. The Cold War was between the United States and the USSR because these were the two major powers after WWII. Basically, the Cold War was a series of proxy wars that had taken place back in time involving surrounding countries. One of the main causes for Cold War was that the Soviet Union was spreading communism and the United States didn’t like that so they were trying to contain communismRead MoreThe Cold War And The Soviet Union1233 Words   |  5 PagesThe Cold War is unique among war’s to be not a war between states, b ut a war between ideologies. The United States and other allies defend social democracy capitalism, as the pinnacle of freedom and equality; and the Soviet Union though communism was the pinnacle of equality. These ideologies manifested themselves through the superpowers, which caused the conflict between them. Both the United States, and the Soviet Union are to blame for the outbreak of the Cold War. The United State’s missionRead MoreThe Cold War And The Soviet Union1697 Words   |  7 PagesThe Cold War, in fact didn’t take place in the winter season, but was just as dangerously cold and unwelcoming, as it focused on two contrasting powers: the U.S. and the Soviet Union. 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(Viewpoints Article: the Soviet Union Start the Cold War) I believe The Cold War was triggered by the theory of two superpower countries in a race for dominance in the worldRead MoreCold War And The Soviet Union859 Words   |  4 PagesAMS2270 Cold War This essay will discuss about cold war, including the background, beginning, progress and ending. As we know, cold war is a struggle between U.S. with NATO and Soviet Union with WTO from 1947 to 1991. It is a significant event in history, and it influence the almost all of world, it directly lead to the radical change of eastern Europe and the breakup of the USSR. In 1946 February, George.F.Kennan wrote a â€Å"Long Telegram†, it clearly said the strategy of containing Soviets and itRead MoreThe Cold War On The Soviet Union1230 Words   |  5 PagesThe Cold War’s effect on the Soviet Union Shortly after the World War 2 ended, the United States and its North Atlantic Treaty Organization allies entered the cold war with the Soviet Union. Germany was divided in half and later, the Berlin Wall was constructed as a physical boundary between the Soviet controlled East Germany and NATO controlled West Germany. This standoff continued until the Soviet Union dissolved in 1991. The cold war had a huge influence on the world stage, but also had a majorRead MoreThe Cold War And The Soviet Union1391 Words   |  6 Pageswake of World War II as the decades-long force of Germany’s reign came to its conclusion, an extensive repositioning of authority among the world’s top powers began. The war wielded devastating consequences for most countries involved and effectively diminished the dominance Britain and France once employed across the globe. Out of this devastation rose the two new dominating forces of the world who were triumphant in the aftermath of the war: the U nited States and the Soviet Union. The United StatesRead MoreThe Cold War And The Soviet Union Essay965 Words   |  4 PagesThe Cold War was a period in world history marked with increased tensions primarily between the United States and the Soviet Union. Both countries desired to expand their ideologies across the globe, the U.S. urging capitalism and democratic elections and the Soviets promoting communism. After the allies had obtained victory in World War II, the Yalta Conference was held. Joseph Stalin, the leader of the Soviet Union, wanted to expand his sphere of influence into Eastern Europe and demanded thatRead MoreThe Cold War And The Soviet Union1343 Words   |  6 PagesAbstract: As one of the most important events in 20th century, the Cold War had a very deep influence for the human-being civilization and it changed the world structure . The United States and the Soviet Union ,the two poles, became enemies from friends after the World War II. They adopt hostile attitude towards each other and criticized the the opponents’ social systems. To find out who provoked the Cold War, the US, the Soviet Union, the United Kingdoms ,Roosevelt, Truman ,Stalin, and ChurchillRead MoreThe Soviet Union Of The Cold War1745 Words   |  7 Pages During the era of the Cold War, starting in 1947 and definitively ending in 1991, the United States and the Soviet Union faced off in conflicts with each other through smaller states. The United States and Soviet Union faced off to see who could spread their ideology the most in Europe. The Soviet Union used force and supported coups to spread communism while the United States installed democratic governments as a way to counter communism in Eastern Europe. These small conflicts that the two superpowers

Self Ananlysis Test - 1230 Words

Self Analysis Report Behaviour in Organizations Submitted by: Ajitha Katakam (PGP25249) I. WHAT ABOUT ME? A. Personality Insights 1. What’s My Basic Personality? Extraversion Agreeableness Conscientiousness Emotional Stability Openness to Experience 2. What my Jungian 16-type personality? (ISTJ etc.) 3. Am I type — A? 4. How well do I handle Ambiguity? 5. How creative am I ? 7 11 8 10 10 INTP 105 (A-) 28 -5 Attach Value Filled Questionnaire 34 55 -3 B. Values and Attitude Insights 1. What do I value? 2. How involved am I in my job? 3. How satisfied am I with my job? 4. What are my attitudes towards workplace diversity? C. Motivation Insights 1. What motivates me? Growth needs Relatedness needs Existence needs 2. What are my†¦show more content†¦: PGP25249 What do I Value? What Rewards I value most? How do my ethics rate? How good am I at personal Planning? Personality: My Big Five scores indicate moderate scores on all the five factors. The Jungian type is INTP which suggests that I am socially cautious, enjoy problem solving and highly conceptual. My score of 105 on the type- A test shows that I am A- suggesting I have a few traits of type- A personality. I can tolerate ambiguity but I am not creative. My most important terminal values are Pride in accomplishment, lasting friendships and Happiness where as my most important Instrumental values are Truthfulness (honesty), Assertiveness and Education intellectual pursuits. I have moderate job involvement, low job satisfaction and am pessimistic to work place diversity. My motivation for growth, relatedness and existence are high and on the same level. My dominant need is for achievement and the least is for affiliation. I am flexible in my perception of others, have strong course performance goals and strong self-efficacy. I have a very low job motivating potential and moderate response to job enri chment. My score on procrastination is towards the lower side suggesting I do not postpone or delay often. Though my ethics in some areas are concurrent with the majority they differ in most areas. I have EQ close to strongShow MoreRelatedQualitative Research Essay1628 Words   |  7 Pagesquantitative approach is one in which the investigator primarily uses post-positivist claims for developing knowledge (i.e. cause and effect thinking, reduction to specific variables and hypotheses and questions, use of measurement and observation, and the test of theories). (Creswell, 2003) †¢ Qualitative research is used to gain insight into peoples attitudes, behaviours, value systems, concerns, motivations, aspirations, culture or lifestyles. †¢ Qualitative researchers aim to gather an in-depth understandingRead MoreTechnical Analysis17695 Words   |  71 PagesHindalco 68 2. Bharat Heavy Electricals 70 3. LIC Housing Finance 72 CONCLUSION amp; RECOMMENDATION 74 Conclusion 74 Recommendations 74 BIBLIOGRAPHY 75 A. LIST OF CHARTS amp; TABLES Figure 1: Different Phases of Market 14 Figure 2: Market Ananlysis - Types 16 Figure 3: Types of Trends 23 Figure 4: Trend Lengths 24 Figure 5: Trend Lines 24 Figure 6: Channels 25 Figure 7: Support amp; Resistance 26 Figure 8: Support amp; Resistance - Role reversal 27 Figure 9: Volume 28 Figure 10: PriceRead MoreFundamental Analysis of Pharmaceutical Stocks12364 Words   |  50 Pagesthe pharmaceutical industry, industrial licensing for most of the drugs and pharmaceutical products has been done away with. Manufacturers are free to produce any drug duly approved by the Drug Control Authority. Technologically strong and totally self-reliant, the pharmaceutical industry in India has low costs of production, low RD costs, innovative scientific manpower, strength of national laboratories and an increasing balance of trade. The Pharmaceutical Industry, with its rich scientific talentsRead MoreFinal Account and Analysis48288 Words   |  194 Pagesstatements, major tools and techniques as explained, including                         Horizontal and vertical analysis Common-size statements Ratio analysis Liquidity and activity ratios Profitability ratios Capital structure and solvency ratios Market test ratios Cash flow ratios The significance of interim financial statements and segment reporting is explored, as are analysis of annual reports and management discussion and analysis (MDA). The analytical techniques discussed in this course are well

Gems, Jewelry and Diamonds Free Essays

The history says that India is known for the birthplace for the one of the strongest metals i.e.Diamonds. We will write a custom essay sample on Gems, Jewelry and Diamonds or any similar topic only for you Order Now Initially diamonds were only mined in India and were exported around the globe and were used as a medium of exchange for the commodities until the people knew its actual worth and how much materialist things that they can buy from it. Currently, India produces 33000 carats of rough diamond and more than 800 million of rough and polished cut diamonds. Few of the Major hubs and producers of diamonds in India.Surat is known for largest market of manufacturing of diamonds in India.Mumbai is known for the wholesaler’s market and where most of the trading takes place at BKC.Delhi is known for its silver jewelry and its manufacturing. There are many other states like Jaipur, Kolkata, Trichur where we can find the precious metals, synthetic diamond and light weighted jewelry respectively around the states in India. Indian Gems, Jewelry and Diamond IndustryOver the years India has been the greatest manufacturing of cut and polished diamond. The sector contributes to around 16% of the export of the country and 93% around the globe. To add more to it Gems and Jewelry has become the second largest industry in earning foreign currency and Gujarat is one of the largest manufacturers of diamonds around the globe. The Diamond Jewelry market has acquired the growth rate of 6% in India and the size of the industry is approximately Rs.6000 crore. Indian has been successful in achieving these goals in cutting and polishing business is all because of the competitive price and ready to work at a low margin. Moreover, India has developed a specialized skill in polishing large and magnificent stones with fancy cuts which again increase the chances of success. Not only this this but most of the small-scale business have introduced high end machinery from which now they can get the best product from a raw or a polish diamond. The Gold demand that the Indian market has rose from 9.13 % to 726.9 tones in 2017. As per the recent records it suggested that India has imported approximately $29 billion during the previous year. To Conclude, India has grown to become such a successful market that countries and companies are now insisting their diamonds to be manufactured in India.Industry Structure in IndiaGems ; JewelryDiamond Jewelry Precious StoneCut ; Polished Gold PearlRough Precious Metal Color Gem Stone Costume/ Fashion Synthetic Stone Market Segment The diamond market has three segments:1. Industrial Diamond: Under this there are all the natural and synthetic diamonds that are manufactured in the industry. It comprises of 25% of the total. Jewelry Diamond: All the assembled products such as the ready-made jewelry and gemstones are categorized under this section. It comprises of 15% of the total.3. Investment Diamond: it comprises of both the rough stones which are very expensive. It comprises of 60% of the total. Market Overview Every year 124 million carats of rough diamonds are being mined by Alrosa, BHP Billiton, De Beers, etc. The market value of these diamond is around $15 billion. Moreover, there has been a significant improvement in the growth by 31%.India has considered to be the largest exporter in gems and jewelry and to our knowledge the industry has played a very important role in Indian economy as it contributes a large part in the foreign reserves of the country. Other then, India, USA, Russia, China, Belgium, Hong Kong are few of the world’s biggest dealers in the diamonds.Export of Gems and Jewelry IndustryIf we see analysis the data we can see that, the net export of the industries gems and jewelry has shown rise of 7.06 % in the annual growth rate. During the previous year the overall net exports were $35.51 billion and has reduced slightly in the current and will surely rise. Notes: * – Data from April-February 2018, CAGR – Compound Annual Growth Rate till FY 2017.Source: GJEPC, Media sources.Import of Gems and JewelryIndia is also of the largest importer of gems and jewelry as well. If we see in the figures the India’s total rose from $11.63 billion to $42.72 billion from the years 2005 to 2012 respectively and since then it has shown a gradual set back during the next year. Again, the market has also gained strength after the fall from $42.72 million to $24 million and now covering back by $28.78 million during the previous years. Notes: * – Data from April-February 2018, CAGR – Compound Annual Growth Rate till FY 2017.  Source: GJEPC  Government Incentives and Strategies Developed by CompaniesThe Government has introduced the Pradhan Mantri Kaushal Kendras which will help create skill and provide labor. Moreover, it will provide vocational training to the engaged peoples who are getting training in it. The Make in India initiative will boost the exports and it will provide critical regulatory framework for the proposal Special Notified Zone(SNZs). However, it will also benefit the small-scale businesses (SMEs) that are involved with the industry. The government has proposed to cut down the tax to 25% for the micro and small-scale enterprises which was announced in the recent Union Budget. The government has permitted 100% FDI. After the booming of the ecommerce, many companies have started selling their jewelry online. Not only this but, many companies have tied up with the Amazon to sell their product online at discount. Companies also have provided buy-back option to the customer if they dislike the product but I think there are still terms and conditions to be stringent so that it will ease the procedure.Few of the Key Players in the Indian market are Tanishq, Malabar Gold ; Diamond, Gitanjali, Nirav Modi, PCJ, TBZ, Kalyan, Venus Jewels. How to cite Gems, Jewelry and Diamonds, Papers

Vincent van Gogh Example For Students

Vincent van Gogh Biography Vincent van Gogh (1853–1890). Dutch painter, born in Zundert. Son of a Calvinist preacher in Holland, after he left school he tried several occupations without success, including working for an art dealer’s firm in Amsterdam and London, teaching, and as an evangelist on the Belgian coalfields, before turning finally to art (1880). His  early pictures, e.g. The Potato Eaters, are sombre in tone and subject, a change coming in 1886, when in Paris he came to know the work of Millet and the Impressionists. But,  though he painted some 200 pictures at this time, the Impressionist techniques did not satisfy him and he did not reach his full maturity until he went (1888) to Arles in Provence. Here in the blaze of southern sunshine, he expressed the hidden turbulence of his nature in pictures vibrant with power and cascading with colour. Primary colours, reds, yellows, blues, were squeezed straight from tube to canvas and spread with broad curving brushstrokes. We will write a custom essay on Vincent van Gogh specifically for you for only $16.38 $13.9/page Order now Landscapes, interiors, sunflowers, cafe scenes, self-portraits – the subjects were repeated over and over again during this last period of astonishing productivity. But, though this is seldom discernible in his pictures, his mind was already giving way. In December 1888, as an act of desperation (aggravated by tinnitus), he cut off part of his left ear with the razor he used to threaten *Gauguin. (The celebrated Self-portrait with bandaged ear is a mirror image.) In  1889 he went to a local asylum and in May 1890 put himself under the care of Dr Paul Gachet at Ouvers-sur-Oise, near Paris, and at his house he shot himself, dying two days later. Only four or five of Van Gogh’s paintings were sold in his lifetime, and only the understanding help of his brother Theo, to whom he wrote most movingly of his sufferings, saved him from complete destitution and enabled him to struggle on in poverty, and unceasing despair overtook him. His sister-in-law, Johanna van Gogh-Bonger, organised exhibitions and promoted his work, and fakes were circulating by 1900. Of   879 paintings in the 1970 catalogue, perhaps 100 are in doubt. His Irises (1890) was knocked down at auction in New York to the Australian Alan Bond for $US53.9 million in November 1987 and later sold at a lower price to the Getty Museum. The centenary of van Gogh’s death created international interest and in May 1990 his Portrait of Dr Gachet was sold for $US82.5 million to a Japanese collector, Ryoei Saito, who announced that he wanted the painting to be cremated with him on his death. A pen drawing, Garden of Flowers, was sold for $US8.36 million in  1990.

Critical Theory Essay Essays

Critical Theory Essay Essays Critical Theory Essay Essay Critical Theory Essay Essay Critical theory is a organic structure of thoughts by and large associated with the ‘Frankfurt School’ . It was during the early eightiess that a new signifier of theoretic enquiry which was extremely critical of tradional theories of IR. emerged. However the generation of the theory can be found in the plants of Kant and Marx with their accent on the ‘emancipatry intent of cognition and enquiry’ . In other words critical theory entails ‘enlightenment project’ which subjects cognition and instruction to the ideal intent of freedom and release. Jurgon Habermas gave a new life to the critical and emancipatory positions of Kant and Marx when he questioned the epistemic ( beginning of knoeledge ) and ontological ( nature of being ) foundations of bing societal order and said that all cognition is historically and politically based. Critical theory besides involves the review of modernness in the spheres of province capitalist economy. hi-tech reindustrialization and science-cum-computer oriented instruction system that have strengthened and perpetuated the hegemony and laterality of few. Among the outstanding critical theoreticians inclde Max Horkheimer. Theodor Adorno. Paulo Friere. John Forester. Herbert Mercuse. Andrew Linklater and Dieter Misgeld. etc. .Tendencies in Critical Theory:Following are of import tendencies in critical theory: a ) Critical Social Theory:The basic point of analysis in critical societal theory is society as a whole. It seldom focal points on province. It discusses all the societal constructions which are responsible for laterality. ignorance and development. Frankfurt Scool is the poineer of this tendency. B ) Critical International Theory:Critical international theory with its footing in emancipatory thoughts of Kant and Marx seeks to look for the possibilities of tronsforming international dealingss so that restraints of laterality are removed and univaresal freedom and equality achieved. It is really the extension of critical societal theory to the sphere of international dealingss. Key Aspects of Critical Theory: 1 ) Problem-Solving and Critical Theories:Problem-solving Theory: Accordinng to Robert Cox job work outing theory takes the universe as it finds it. It does non dispute the present order but legitimise and affects its smooth working by work outing the peculiar jobs that troubles it. Traditional theories of IR are considered to be working in febrility of bracing predominating constructions of universe order with their inequalities of power and wealth. 2 ) Critical International Theory: It argues that cognitive procedures themselves are capable to political involvements and. therefore. are to be critically evaluated. Theories of IR like any other cognition are conditioned by societal. cultural and ideological influence ; and the undertaking of critical theory is to measure such conditioning deductions. It non merely challenges the status-quo orientated theories but besides comes up with normative solutions in favour of emancipation.

Learn about Charles Messiers Catalog of Objects

Learn about Charles Messier's Catalog of Objects In the mid-18th century, astronomer Charles Messier began studying the sky under the direction of the French Navy and its astronomer Joseph Nicolas Delisle. Messier was taxed with recording the comets he saw in the sky. Not surprisingly, as he studied the heavens, Messier came across a large number of objects that werent comets. Key Takeaways: The Messier Objects The Messier Objects are named for astronomer Charles Messier who compiled his list in the mid 1700s while searching for comets.  Today, astronomers still refer to this catalog of objects as the M objects. Each is identified with the letter M and a number.The most distant Messier object that can be seen with the naked eye is the Andromeda Galaxy, or M31.The Messier Objects catalog contains information about 110 nebulae, star clusters, and galaxies. Messier decided to compile these objects into a list that other astronomers could use as they searched the sky. The idea was to make it easier for others to ignore these objects as they, too, looked for comets. This list eventually became known as the Messier Catalog, and contains all objects Messier viewed through his 100-mm telescope from his latitude in France. First published in 1871, the list has been updated as recently as 1966. What Are the Messier Objects? Messier cataloged an amazing array of objects that astronomers still refer to today as the M objects. Each is identified with the letter M and a number. M13 is the brightest of the globular clusters in Hercules. It is the 13th object in Messiers list of faint fuzzies.. Rawastrodata, via Creative Commons Attribution-Share-Alike 3.0.   Star Clusters First, there are the star clusters. With todays telescopes, its fairly easy to look at many of Messiers clusters and pick out individual stars. Yet, back in his day, these collections of stars probably looked fairly fuzzy through his telescope. Some, such as M2, a globular cluster in the constellation Aquarius, are just barely visible to the naked eye. Others are easy to see without a telescope. These include the globular cluster M13, visible in the constellation Hercules, also known as the Hercules Star Cluster, and M45, commonly known as the Pleiades. The Pleiades is a good example of an open cluster, which is a grouping of stars that travel together and are loosely bound together by gravity. Globulars contain hundreds of thousands of stars and are globe-shaped collections Nebulae Clouds of gas and dust are known as nebulae and exist throughout our galaxy. While nebulae are much dimmer than stars, some, such as the Orion Nebula or the Trifid Nebula in Sagittarius, can be seen with the naked eye under good conditions. The Orion Nebula is a starbirth region in the constellation Orion, while the Trifid is a cloud of hydrogen gas that glows (it is called an emission nebula for that reason), and has stars embedded in it as well.  Ã‚   The Orion Nebula as seen by the collection of instruments aboard Hubble Space Telescope. NASA/ESA/STScI The Messier list also contains information about supernova remnants and planetary nebulae. When a supernova explodes, it sends clouds of gas and other elements hurtling through space at high speed. These catastrophic explosions occur only when the most massive stars die, those that are at least eight to ten times the mass of the Sun. The best-known M object that is a supernova explosion remnant is called M1 and is more commonly known as the Crab Nebula. It is not visible to the naked eye but can be viewed through a small telescope. Look for it in the direction of the constellation Taurus.  Ã‚   Hubble Space Telescopes view of the Crab Nebula supernova remnant. NASA/ESA/STScI Planetary nebulae occur when smaller stars like the Sun die. Their outer layers dissipate while whats left of the star shrinks to become a white dwarf star. Messier charted a number of these, including the famous Ring Nebula, identified as M57 on his list. The Ring Nebula is not visible to the naked eye but can be found using binoculars or a small telescope in the constellation Lyra, the Harp.   You can see a white dwarf at the heart of the Ring Nebula. This is a Hubble Space Telescope image. The Ring Nebula consists of a white dwarf at the center of an expanding shell of gases expelled by the star. It is possible our star could end up like this. NASA/ESA/STScI. Messiers Galaxies There are 42 galaxies in the Messier Catalogue. They are classified by their shapes, including spirals, lenticulars, ellipticals, and irregulars. The most famous is the Andromeda Galaxy, which is called M31. Its the closest spiral galaxy to the Milky Way and can be seen with the naked eye from a good dark-sky site. Its also the most distant object that can be seen with the naked eye. It lies more than 2.5 million light-years away. All other galaxies in the Messier Catalogue are visible only through binoculars (for the brighter ones) and telescopes (for the dimmer ones).   At 2.5 million light-years, the Andromeda Galaxy is the closest spiral galaxy to the Milky Way. The term light-year was invented to handle the immense distances between objects in the universe. Later, parsec was developed for truly huge distances. Adam Evans/Wikimedia Commons. A Messier Marathon: Viewing all the Objects A Messier Marathon, wherein observers try to view all the Messier objects in one night, is only possible once a year, usually from mid-March to mid-April. Of course, the weather can be a factor. Observers typically begin their search for Messier objects as soon after sundown as possible. The search starts in the western part of the sky to catch a glimpse of any objects that are about to set.  Then, observers work their way east to try and see all 110 objects before the sky brightens near sunrise the next day.   A successful Messier Marathon can be quite challenging, particularly when an observer is trying to find those objects embedded in the vast star clouds of the Milky Way. Weather or clouds can obscure the view of some of the dimmer objects. People interested in doing a Messier Marathon usually do them in conjunction with an astronomy club. Special star parties are organized each year, and some clubs give out certificates to those who manage to capture them all. Most observers practice by observing Messier objects throughout the year, which gives them a better chance of finding them during a marathon. Its not really something a beginner can do, but it is something to strive for as one gets better at stargazing. The Messier Marathons website has helpful hints for observers wanting to pursue their own Messier chase.   Seeing Messier Objects Online For observers who dont have telescopes, or the ability to get out and observe Charles Messiers objects, there are a number of online image resources. The Hubble Space Telescope has observed most of the list, and you can see many of the stunning images in the Space Telescope Science Institutes Flickr catalog. Sources Astropixels.com, astropixels.com/messier/messiercat.html.â€Å"Charles Messier - Scientist of the Day.†Ã‚  Linda Hall Library, 23 June 2017, www.lindahall.org/charles-messier/.Garner, Rob. â€Å"Hubbles Messier Catalog.†Ã‚  NASA, NASA, 28 Aug. 2017, www.nasa.gov/content/goddard/hubble-s-messier-catalog.Torrance Barrens Dark-Sky Preserve | RASC, www.rasc.ca/messier-objects.

Article Review 2 Essay Example | Topics and Well Written Essays - 500 words

Article Review 2 - Essay Example Summary It is asserted that divorce in the later life would decrease parental attachment to adult children. The study conducted by the National Survey of Families and Household focuses on the quality of relationship each divorced parent has for their adult children and found out that the degrees vary according to sex and custody. Although the study may have been limited, and not stating the exact time of which the parents had divorce, there are still important implications to the psychological behavior of children in the later life and their relationship with both parents. However, the result of the study indicates that relationship gaps between parents and adult children are most likely to occur to father and child rather than mother and child. This is due to the custody of the mothers to their children, especially if financial support was not met by the father. On the other hand, widowhood does not impact much the children since they are concentrated with the grief of the other spo use, and would be busy giving emotional support. Analysis The article is about the impact of divorce in the later life into parents-children relationship. The topic somehow is widely vulnerable to varying cases since there is no exact pattern for parental relationships, with or without divorce; although experts say that the bond is more apparent with mothers to their children.

Company analysis Research Paper Example | Topics and Well Written Essays - 2500 words

Company analysis - Research Paper Example It is a holding company. The company is a supplier of communications, entertainment, and information services and products to customers, government agencies, and businesses. It functions in two most important segments: Wireline and Verizon Wireless. Verizon Wireless Communications services and products consist of data services, equipment sales, and wireless voice over all United States (Verizon). The services and products of Wireline include internet access, voice, long distance, broadband video and data, network access, Internet protocol network services, and various other services. The company gives these services and products to consumers of United States, as well as to businesses, carriers, and government consumers in both America and all its one fifty countries globally. Verizon Communications Inc. attained HUGHES Telematics Inc. as well. The long-term source of Verizon value is central role we usually play in industry fundamental to global economy and extremely embedded in cust omers’ lives. Even though it’s the iconic products that enhance people’s creative strategies, and lives that release new markets and develop technological access. The associations that endorse initiatives or innovation apply technology to imperative social issues. Verizon is standard-bearer for industry and organizer in giving advantages of our authorizing technology to the global (Verizon). Verizon Communications Inc. ranked number one in industry list of World Most Admired Companies in 2012 Fortune magazine. For Verizon Communications Inc, the philanthropic and technological resources to attend to world’s unmet environmental and social needs are the first priority. In this procedure, the social innovation that will release new markets, reinforce growth and grow Verizon’s important role in digital world. Verizon Wireless was founded in 2000 as a mutual venture of Verizon Communications and also Vodafone. It is an inventive wireless communications corporation that links businesses and people with innovative wireless technology and also available service (Verizon). Vodafone is also an innovation of Verizon Communications Inc. It is the biggest mobile telecommunications giver in Western hemisphere and accounts for 45% possession of the Verizon Wireless. Vodafone provides services in thirty countries and networks in more than fifty more. The mission statement of Verizon Inc is As follows: "As a leader in communications, Verizon's mission is to enable people and businesses to communicate with each other. We are also committed to providing full and open communication with our customers, employees and investors." (Verizon). â€Å"Vision statement of Verizon Communications Inc is, â€Å"Win customers by building wireless, broadband and global IP networks and delivering the innovative products, services, applications and content that transforms lives and empowers businesses and communities.† (Verizon). Strategic Imperatives A t Verizon Communications Inc, the power of technology is used to resolve the impediments any company may face. The Strategic Imperatives are to increase the revenue, customer retention and growth, give bundle services of Television, data, and voice and takes share from the competition. Verizon exploit the weaknesses of cable, outperforms cable on service of customers, give best customer service, and also provided flexibility of installation. Verizon believes in

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