The Effect Of Savings And Consumption On The National...

Economy January 1 2014 [Type the abstract of the document here. The abstract is typically a short summary of the contents of the document. Type the abstract of the document here. The abstract is typically a short summary of the contents of the document.] [Type the document subtitle] Table of Contents Answer 1 3 Answer 2 4 Answer 3 6 Answer 4 7 Answer 5 9 Answer 6 11 Answer 7 12 Answer 8 14 Answer 9 16 Bibliography 18 Answer 1 The multiplier is actually the method of measuring the effects of savings and consumption on the national income of an economy and it also shows the relationship between change in income and change in investment. The multiplier effect occurs when an input causes a bigger final increase in national income, for example, if the spending by the government increases by $550 billion, there would be an initial increase in aggregate demand of $550 billion. Every time there is an input of new demand into the circular flow of money there is most probably to be a multiplier effect. This is because an input of extra income leads to more spending, that creates more income, and so on. The multiplier effect refers to the rise in final income arising from any new input or spending by the government or any financial body. The size of the multiplier depends upon household’s marginal decision to spend, called the marginal propensity to consume (MPC), or to save, marginal propensity to save (MPS) . So the effect of increase in savings on the multiplierShow MoreRelatedHousehold Expenditure and Savings1090 Words   |  5 Pagesthe response of personal savings and expenditure to changes in the interest rates is a central to many issues in the economic policy. If personal savings decline as a result, the overall increase in the national savings would be less than the reduction in the budget deficit. Alternatively, contractionary monetary policy generally causes interest rates to rise. It personal saving increase as a result, the corresponding fall in consumer expenditure helps to slow the economy. Household behaviour isRead MoreAn Interview Of Mr. Connor s The Real Estate Market And Its Effects On The Elder Canadians881 Words   |  4 PagesThe report is based on an interview of Mr. Dean Connor, CEO, Sun Life Financial, which addresses a major potential issue in the real estate market. The report shows the concern of Mr. Connor regarding the dynamic real estate market and its effects on the elder Canadians. According to Mr. Connor, the debts on the mortgage should be closed before retirement. The interest rates are apparently increasing and this would decrease the value of real estate business soon. And he is afraid that majority ofRead MoreOutline and Explain the Ricardian Equivalence Theorem and Assess the Evidence Bearing on It.1515 Words   |  7 PagesBarrow in the 19th century, suggests that taking into account the government budget constraint a budget deficit will have no effect on national saving- the sum of private and public saving, in an economy. In this essay I am going to explain the reasoning behind this, assess its likelihood and finally review evidence either supporting or opposing the theorem. In an economy, if government spending exceeds government revenues, borrowing money (for example by issuing government bonds or increasing taxation)Read MoreDissertation Proposal1339 Words   |  6 PagesDevelopment of an individual economy passes through different economic phases. Sometimes it is booming and sometimes it suffers from recession. This phenomenon can be viewed as projection of consumption and investment strategies of the individuals and the government of the country. Interest rate, being a major factor of economics, plays a great role in economic activities carried out by nation and the nationalities. A change in interest rates may affect other factors of the economy. For instance, investmentRead MoreChina s Consumption And Its Consumption768 Words   |  4 PagesChina’s consumption, it is important to figure out feasible policies that the Chinese government could implement to stimulate its consumption efficiently. Anderson (2007) points out China’s firm s’ expropriate market share and profits from other countries cause China’s excess savings. Therefore, China’s imbalance economy does not result from low consumptions, but results from Chinese companies’ high profits and their rising savings. 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Change in expectations can shift the aggregate demand (AD) curve; expectations of inflation can cause inflation. For this reason expectations are central to all policy discussions, and what people believe policy will be significantly influences the effectiveness of the policy. Expectations complicate models and policymakingRead MoreEconomics and National Income1160 Words   |  5 PagesAn economy is currently in equilibrium. The following figures refer to elements in its national income accounts. | | £ billions | |Consumption (total) |60 | |Investment |5 | |Government expenditure |8 | |Imports |10 | |Exports |7 | (a) What is the current equilibrium level of national incomeRead MoreEcon984 Words   |  4 Pagesthat country. A5-3. In Saudi Arabia, gross domestic product (GDP) is less than gross national product (GNP). This means that the nation produces domestically more than it is able to consume domestically. A5-4. If aggregate household saving is negative, the marginal propensity to save from disposable income must be negative. A5-5. If desired aggregate expenditure is greater than actual national output, national output will increase. A5-6. If the domestic price level decreases, the price of domesticRead MoreEconomics1000 Words   |  4 PagesAssume a consumption function that takes on the following algebraic form: C = $100 + .8Y. Assume that Y = $1000 what is the level of consumption at this income level. C = $100 + .8($1000) = $100 + $800 = $900. 1. Using the above figure calculate the marginal propensity to consume between the aggregate income levels of $80 and $100. Also explain why this consumption function is linear. The marginal propensity to consume is equal to $15/$20 = .75. The consumption function

Introduction Of Feminism Throughout A Doll s House

Ryan Curry Mrs. Sherry Keown English 200-632 27 March 2016 The Introduction of Feminism through Female Roles in A Doll’s House According to Merriam-Webster dictionary, feminism is defined as â€Å"the theory of the political, economic, and social equality of the sexes† and viewed as â€Å"organized activity on behalf of women’s rights and interests†. During the early 1960s, many women began to advocate for feminist rights and social equality. In 1962, Marilyn Monroe passed away, and the following year journalist Gloria Steinem auditioned undercover to become a Playboy Bunny, through which she exploited the dirty, male-run system (Cochrane, 2013). Pre-feminism, men were often in control of the actions and decisions women made, and they usually had to approve and oversee any legal matters the women were involved in. The men in the household were considered the workers and the breadwinners, and women were viewed as the homemakers and caregivers. Feminism argues that the roles can actually be reversed. Feminism was al so marked by the literature of Sylvia Plath, who passed away in 1963. Speaking of feminism and literature, Henrik Ibsen, Norwegian playwright, is credited with having written perhaps the first feminist play: A Doll’s House. Through the independent decisions made by the female characters Mrs. Nora Helmer, Mrs. Kristine Linde, and Anne Marie, Ibsen revolutionized the role of women in society, as well as their rights to take control of their own lives. Anne Marie, also knowsShow MoreRelatedA Feminist Criticism A Doll s House1372 Words   |  6 Pages102 A1W November 11,2014 A Feminist Criticism A Doll House A Doll’s House, written by Henrik Ibsen examines the controversial point of persuasion of love and marriage that emphasis marital vows and women’s roles, during the nineteenth century. Where feminism lurks throughout the entire play. Through this play, I shall show you what I perceived what the writer Ibsen presumption of the equivalence among men and woman, and the idea of feminism. Where Women have a specific purpose, to hold upRead MoreGlaspell s Trifles And The Invisibility Of Women1490 Words   |  6 PagesGlaspell’s Trifles and the Invisibility of Women Susan Glaspell’s play Trifles and Henrik Ibsen s A Doll s House are plays that explore a number of important features of femininity and life as a woman. Trifles explores a number of thematic ideas surrounding a woman’s place and her propensity for violence. The Author explores a thematic idea that centers on the proper dispensation of justice: Glaspell critically investigates the question of whether an individual can truly receive justice fromRead MoreNora Helmer s A Doll s House2548 Words   |  11 PagesWhen the door slams at the end of â€Å"A Doll’s House† by Henry Ibsen, No one would not believe the woman walking out of her house is the same one who appeared at the beginning of the play. The main character in this play is Nora. Nora goes through a complete transformation, changing from a child like and dependant woman to a self strong woman pushing to become independent. Ibsen portrays the roles of society in the Victorian times in this play. Throu ghout her whole life, Nora’s husband and father haveRead More A Comparison of Gender-Roles in A Dolls House and A Streetcar named Desire1400 Words   |  6 PagesGender-Roles in A Dolls House and A Streetcar named Desire   Ã‚   The roles of males and females in our society are subjects that entail great criticism, and have been under scrutiny for as long as a `society has existed. In analyzing A Dolls House by Henrick Ibsen and A Streetcar named Desire by Tennessee Williams, the effects that gender-roles have on relationships is an evident aspect in both of the plays. The choice of words used by the authors strongly underscores the themes of supremacyRead MoreA Doll s House : Dolls2775 Words   |  12 Pages A Doll’s House: Dolls in Real Life Introduction Today, the accepted roles of both women and men judged by society’s expectations is an extremely controversial topic. Feminism is a battle that many women are fighting, because even though today’s women can be and accomplish almost anything, men often play the more superior role in many relationships. The role of women has been viewed differently throughout different points in history and in different areas. However, many people don t realize thatRead MoreA Doll s House : Dolls2775 Words   |  12 Pages A Doll’s House: Dolls in Real Life Introduction Today, the accepted roles of both women and men judged by society’s expectations is an extremely controversial topic. Feminism is a battle that many women are fighting, because even though today’s women can be and accomplish almost anything, men often play the more superior role in many relationships. The role of women has been viewed differently throughout different points in history and in different areas. However, many people don t realizeRead MoreA Doll s House By Henrik Ibsen2768 Words   |  12 PagesIntroduction Today, the accepted roles of both women and men judged by society’s expectations is an extremely controversial topic. Feminism is a battle that many women are fighting, because even though today’s women can be and accomplish almost anything, men often play the more superior role in many relationships. The role of women has been viewed differently throughout different points in history and in different areas. However, many people don t realize that the slight lack of power women seemRead MoreA Doll s House By Henrik Ibsen1784 Words   |  8 Pagesstated, â€Å"Feminism is the radical notion that women are human beings.† This statement is relevant to A Doll’s House and is relatable to the female audience. Not only does A Doll’s House incorporate relevant matters, it includes great character development in the protagonist, Nora. Her display of bravery moved many readers. Unlike A Doll’s House, Frankenstein, which is quite fictitious, may appea r to not be relatable. From the summer readings assigned for Sophomore World Literature, A Doll’s House, a playRead MoreNora – a Classical Hero in Henrik Ibsens a Doll`S House2683 Words   |  11 PagesNora – A Classical Hero in Henrik Ibsen’s A Doll`s House Nora Helmer makes the right decision to free herself from the social and traditional commitments and obligations and come and become an independent individual. Nora Helmer in Isbens A Dolls House lived in the world of predetermined social and societal constraints that made her deprived her of her freedom and happiness. The society in which she lived wanted people to live according to the rigidly set norms and standards of the societyRead MoreAntigone, By Susan Glaspell And The Doll House1812 Words   |  8 Pagesdegradation towards women of society. Over the course of time the role of women has changed dramatically, and the plays Antigone by Sophocles, Trifles by Susan Glaspell and The Doll House by Henrik Ibsen are great works that show how women can challenge the boundaries that were put on them by a society that was not very accepting of feminism. In â€Å"Antigone†, it does not take long for our main character (Antigone) to step outside of the boundaries set against women in society. Antigone’s brothers died in battle

Social Determinants of Health WHO

Question: Write about theSocial Determinants of Healthfor WHO. Answer: Obesity is the public health issue as per World Health Organisation or WHO. It is one of the leading causes of death in both developing and developed countries (World Health Organization, 2014). Worldwide, the prevalence of obesity has increased two fold over the past two decades among children, teenagers, and adults. Therefore, the rising burden of obesity has created a moral panic. Obesity is a multifactorial disease. It is known to be caused by genetics, over-eating and inappropriate diet, over-weight, hormones, environmental factors and lack of physical activity (Mitchell et al., 2014). The health impact of obesity includes diabetes, eating disorder, cancer, comorbidities such as renal failure, heart failure and death (Buchmueller Johar, 2015). Consequently, the disease has increased the health care cost. The exact cause of obesity must be known to prevent the global pandemic of obesity. The essay aims to identify if obesity is caused by broader social determinants of health or individual lifestyle choices. The essay highlights the determinants of obesity and discuss its relationship with individual lifestyle choices. The risk factors of obesity and its implications are also explored in essay. Obesity is characterised by excess fat accumulation in body which is found to reduce life expectancy. It is also measured in terms of body mass index or BMI. A BMI over 30kg/m2 represents obesity and is calculated as a ratio of individuals weight in Kg and square of height. It an important tool to asses obesity in all age groups at population level (Tanamas et al., 2014). Different BMI scores can determine the health risks due to obesity. For instance, if an individuals BMI is between 25-29 the condition can be referred as overweight. There are three classes of obesity and the first class is identified by BMI range of 30 and 34.9. Obesity of class 2 is recognised by BMI between 35 and 39. If the BMI is 40 or more then it is an alarm for high risk obesity and adverse consequences (Swinburn Wood, 2013). Worldwide, the prevalence of obesity has increased two fold over the past two decades among children, teenagers, and adults. According to WHO, in 2014, there were 1.9 billion obese adults and of these more than 600 million adults were marked obese. As per these reports 13% of the worlds adult population in 2014 were obese. It includes 15% of women and 11% of men. These reports highlighted that 39% of the population (18 years and above) were overweight in 2014 (World Health Organization, 2014). The rate of obesity is climbing faster in Australia than any other place in world. Australia is considered as one of the fattest developed nation due to rising trend of obesity (Kendall et al., 2015). According to the reports of Swinburn Wood, (2013) the obesity is estimated to rise to 38% by 2025 from current per cent of 28. In Australia, higher numbers of young adults are representive of obesity than the adults, which indicates individual lifestyle factors as underlying cause of the disease. The cause of obesity is debateable as there are multiple factors responsible for rising trend of obesity in children, adolescents, and adults. Diet is primary factor responsible for obesity. The weight of an individual is determined by the energy expenditure and the intake of calorie. The imbalance between the two parameters leads to overweight or underweight. Obesity is identified to be primarily associated with intake of high calories food and lack of physical activity (Teixeira et al., 2015). Overweight can result from genetic predisposition, defect in metabolism, individual behaviour, environmental and cultural factors. For instance, fat regulation is impaired by leptin deficiency and this problem is hereditary in nature. Similarly, intake of diet rich in carbohydrates, and saturated fatty acids leads to overweight individuals. Weight gain results from spike in insulin level which occurs due to consumption of large meals. The insulin level remains stable when small meals are take n frequently. Sedentary life style, results in weight gain due to low amount of calories burnt and is one of the major contributing factor of obesity. Hypothyroidism is the endocrine disorder which also contributes to obesity (Suglia et al., 2013). According to WHO, the risk factors of obesity are unhealthy lifestyle choices such as having fat and calorie rich diet, lack of physical activity, stress, and lack of sleep. Socioeconomic factors are also a risk for obesity development. Low social connectedness or unhealthy social environment, low socioeconomic statuses are found to be factors contributing to obesity (Roberto et al., 2015). Social determinants of health on a broad aspect are recognised to cause obesity. In order to develop effective interventions, it is necessary to know the relationship between social determinants and obesity. Educational status, Gender, age, employment status ethnicity, behavioural factors like smoking, alcohol abuse, lack of exercises and socioeconomic factors are the determinants of obesity. Among all the determinants, the socioeconomic factor is highest concern for obesity (Flores et al., 2015). People belonging to low socioeconomic class are prone to eating unhealthy diet and malnutrition due to low cost of living. They depend on fast foods and other food that do not met the bodys requirements of fats, protein and carbohydrates. Thus, people with obesity are highly represented from low socioeconomic status (Bhurosy Jeewon, 2014). On the other hand, people belonging to upper class society or having high socioeconomic status adopt healthy lifestyle. They have good housing facilitie s, healthy diet, and people participate in health promoting activities (Kennedy, 2015). However, it was also found that people with high socioeconomic status highly engage in sedentary lifestyle. The working population of high socioeconomic group due to busy schedule depend on ready to eat food of fast food centres, do not participate in physical activities, and are vulnerable to obesity. Children of working parents engage in watching television, eating junk food at schools and other sedentary behaviours that are not monitored on time and contribute to high BMI and obesity (Popkin Slining, 2013). The high socioeconomic group of people have been found to regularly visit fast food chain restaurants such as McDonalds. These groups of people mostly purchase large sizes of burger and consume beverages that increase calorie and fat level in body. However, due to lack of physical activities these fats and calories are accumulated leading to weight gain and obesity. Residents in close proximity of fast food centres are highest consumers of fat and calories then residents staying far apart. This behaviour indicates influence of individual lifestyle choices on obesity. Obesity is reco gnised to be an extension of advancing economy and technology (Bhurosy Jeewon, 2014). With the availability of smart phones and increasing popularity and use of e-commerce, accessing fast food has become easy for people living in distant part of cities or remote areas. These labour saving devices have increased consumption of fast food due to home delivery of food in maximum 30 minutes of time. It saves cooking time and people are more attracted to fast food. In addition, smoking and alcohol consumption add to the sedentary choices. Consequently, this group of people are found with low energy expenditure (Witten, 2016). Another most important factor determining obesity is gender. For instance, in America, more women than men are obese as women have higher body fat percentage. However, the scenario is not same in different countries (Flores et al., 2015). Cultural factors also play great role in obesity. In some countries, cultural factors favour larger body size (fat acceptance). It is regarded as sign of healthfulness, fertility, and prosperity (Robinson Christiansen, 2014). Age is another risk factor of obesity. In Australia, the number of overweight and obese males over 18 years was more than females. Obesity has been identified to increase with age. In Australia, rate of obesity is found to increase between 45 and 74 years for males and between 55 and 74 years of age for females. After 75 years of age the rate of obesity declines by 69% in males (Rahman Harding, 2013). Environmental factors influence eating behaviour. For instance, remote regions and rural areas lack accessibility to variety of food items therefore, people choose from limited options that may not meet adequate nutritional requirements of body (Flores et al., 2015). Psychological factors such as depression and anxiety also determine eating behaviours. Problematic eating such as snacking high calorie food items mindlessly or night eating leads to binge eating disorder in adolescents and children (Suglia et al., 2013). Education and health literacy is related to rising trend of obesity. People with high educational attainment tend to easily understand health and illness. The awareness of healthy and unhealthy lifestyle activities assist in making effective health decisions. People with poor educational attainment lack awareness about consequences of overeating and obesity. Health literacy help people participate actively in health promoting activities such as exercises, maintaing norm al vital signs, making lifestyle modifications and seeking counselling services for psychological issues. On the people with low health literacy, remain unaware of risk factors of chronic illnesses and initiatives that can prevent the adverse consequences (Witten, 2016). The cumulative effect of cultural, social, environmental and individual lifestyle factors causing obesity has several implications (Flores et al., 2015). The health implications of obesity include insulin resistance diabetes mellitus, hypertension, high cholesterol, and cardiovascular diseases. More men that are obese are dying due to colorectal cancer and women that are obese are dying due to endometrial cancer. Severe obesity leads to sleep apnoea, hypercapnia,and degenerative joint disease. These health risks are due to distribution of body fat. Obesity has significant impact on economy due to rising health care costs related to mortality and morbidity (Specchia et al., 2015). Since, it is evident that obesity is a complex mesh of multifactorial interactions, there is a need to address the dominant determinants of obesity such as individual choices and social factors causing obesogenic behaviour (Buchmueller Johar, 2015). Understanding the risk factors and raising awareness may d ecrease the vulnerability to the illness. More interventions are needed at societal and individual level then at medical level. Healthy lifestyle modification is vital which may be possible through stringent government policies on fast food restaurants, and initiate compulsory health education in every country (through campaigns and mass awareness) (Malik et al., 2013). More interventions are needed at psychological level to change compulsive eating behaviour, promote uptake of physical activities, and omit fat acceptance. In conclusion, obesity is the outcome of complex interactions of individual lifestyle choices and social determinants of health. Social factors and individual lifestyle choices are primary contributing factors of obesity out of various cultural, psychological and environmental factors. It implies the need of health education to address obesity and its adverse health activities. People need to be educated about healthy lifestyle choices. There is a need of more research in the area of gender disparities in overweight and obesity and cultural influences to understand the pandemic and develop preventive strategies. References Bhurosy, T., Jeewon, R. (2014). Overweight and obesity epidemic in developing countries: a problem with diet, physical activity, or socioeconomic status?.The Scientific World Journal,2014. https://www.hindawi.com/journals/tswj/2014/964236/abs/ Buchmueller, T. C., Johar, M. (2015). Obesity and health expenditures: evidence from Australia.Economics Human Biology,17, 42-58. https://www.sciencedirect.com/science/article/pii/S1570677X1500012X Flores, M. R., Velazquez, V. V., Mejia, G. T., Fuentes, V. S., Peniche, L. P., Maciel, R., ... Garcia, E. G. (2015). Association of Socioeconomic Factors with Success in the Treatment of Obesity.Canadian Journal of Diabetes,39, S72. https://www.canadianjournalofdiabetes.com/article/S1499-2671(15)00303-2/abstract Kendall, B. J., Wilson, L. F., Olsen, C. M., Webb, P. M., Neale, R. E., Bain, C. J., Whiteman, D. C. (2015). Cancers in Australia in 2010 attributable to overweight and obesity.Australian and New Zealand journal of public health,39(5), 452-457. https://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12458/full Kennedy, K. (2015). Increased Patient Health Literacy and Healthcare Provider Structural Competence: Public and Private Strategies for Improving Patient Health Outcomes. https://digitalcommons.tacoma.uw.edu/tactalks/2015/spring/6/ Malik, V. S., Willett, W. C., Hu, F. B. (2013). Global obesity: trends, risk factors and policy implications.Nature Reviews Endocrinology,9(1), 13-27. https://www.nature.com/nrendo/journal/v9/n1/abs/nrendo.2012.199.html Mitchell, R. J., Lord, S. R., Harvey, L. A., Close, J. C. (2014). Associations between obesity and overweight and fall risk, health status and quality of life in older people.Australian and New Zealand journal of public health,38(1), 13-18. https://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12152/full Popkin, B. M., Slining, M. M. (2013). New dynamics in global obesity facing low?and middle?income countries.Obesity Reviews,14(S2), 11-20. https://onlinelibrary.wiley.com/doi/10.1111/obr.12102/full Rahman, A., Harding, A. (2013). Prevalence of overweight and obesity epidemic in Australia: some causes and consequences.JP Journal of Biostatistics,10(1), 31. https://search.proquest.com/openview/83c4e06e520973d6bd8ac2a3fff46085/1?pq-origsite=gscholarcbl=1816344 Roberto, C. A., Swinburn, B., Hawkes, C., Huang, T. T., Costa, S. A., Ashe, M., ... Brownell, K. D. (2015). Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking.The Lancet,385(9985), 2400-2409. https://www.sciencedirect.com/science/article/pii/S014067361461744X Robinson, E., Christiansen, P. (2014). The changing face of obesity: exposure to and acceptance of obesity.Obesity,22(5), 1380-1386. https://onlinelibrary.wiley.com/doi/10.1002/oby.20699/full Specchia, M. L., Veneziano, M. A., Cadeddu, C., Ferriero, A. M., Mancuso, A., Ianuale, C., ... Ricciardi, W. (2015). Economic impact of adult obesity on health systems: a systematic review.The European Journal of Public Health,25(2), 255-262. https://academic.oup.com/eurpub/article/25/2/255/2837324/Economic-impact-of-adult-obesity-on-health-systems Suglia, S. F., Duarte, C. S., Chambers, E. C., Boynton-Jarrett, R. (2013). Social and behavioral risk factors for obesity in early childhood.Journal of developmental and behavioral pediatrics: JDBP,34(8), 549. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3960979/ Swinburn, B., Wood, A. (2013). Progress on obesity prevention over 20 years in Australia and New Zealand.Obesity Reviews,14(S2), 60-68 . https://onlinelibrary.wiley.com/doi/10.1111/obr.12103/full Tanamas, S. K., Shaw, J. E., Backholer, K., Magliano, D. J., Peeters, A. (2014). Twelve?year weight change, waist circumference change and incident obesity: The Australian diabetes, obesity and lifestyle study.Obesity,22(6), 1538-1545. https://onlinelibrary.wiley.com/doi/10.1002/oby.20704/full Teixeira, P. J., Carraa, E. V., Marques, M. M., Rutter, H., Oppert, J. M., De Bourdeaudhuij, I., ... Brug, J. (2015). Successful behavior change in obesity interventions in adults: a systematic review of self-regulation mediators.BMC medicine,13(1), 84. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0323-6 Witten, K. (2016).Geographies of obesity: environmental understandings of the obesity epidemic. Routledge. https://books.google.co.in/books?hl=enlr=id=0O4GDAAAQBAJoi=fndpg=PP1dq=Geographies+of+obesity:+environmental+understandings+of+the+obesity+epidemicots=D74S9aG_Onsig=ZKaQyxj2799KcvqRR5KmfAc5ut8#v=onepageq=Geographies%20of%20obesity%3A%20environmental%20understandings%20of%20the%20obesity%20epidemicf=false World Health Organization. (2014).Global status report on noncommunicable diseases 2014. World Health Organization. https://www.cabdirect.org/cabdirect/abstract/20153093363

Inclusive Pedagogy

Question: Describe about the Inclusive Pedagogy of Politics? Answer: Introduction The methods of the training which incorporates the learning styles and the dynamic practices, varied resources of the assessment and also the content which are multicultural with the basic goals of doing the promotion of the student academic success as well as the cultural, physical and the social well being. In this module it will examine the range of the context in which the learning of the research takes place. It also introduces the concept and the principles which are provided with the opportunity how the teacher can helps the students so that they can overcome the problem which they are facing in doing the reading, listening, writing etc. In this context it also gives the suggestion and the solution which the teacher needs to follow to solve the problem what the students are facing (Arden and Kecht, 1993). Critical Discussion In this part it critically discusses the some of the points which are related to students and also give some of the solution which will help the students to overcome the mentioned problems. Some of the problems are listed below: Reading Writing Listening Following directions Taking tests Moving about the classroom Talking support the arguments with the examples from the own practices Reading Reading mainly is a cognitive process which is complex in nature of decoding the symbols so that it can construct and also derive the meaning. In the todays society reading becomes one of the fundamental of the function. It also becomes more important for the success of the children. Reading cannot be controlled by one or more than one interpretations. Reading cannot follow any of the concrete laws. It promotes the exploration of the texts during the interpretation. Reader uses many of the strategies so that it can assist with the help of decoding of the symbols into the sound and also the visual representations of the speech and the comprehension. There is other type of the reading which is not on the speech basis. It is mainly based on the writing system such as representation or the notation (Bacon and Handley, 2014). The importances of the reading for the children are listed below: Excellence on the basis of the academic Basic skills of the speech The basic way to read the book Developing the better communication skills Developing the thinking of the logical skills To enhance the more discipline and the concentration Helps in the acclamation of the new experiences The problem what the student face in doing the reading is known as dyslexia. Dyslexia is mainly a complex language problem. It is mainly deals with the way how the brain works without the vision. It also involves of not being able to break the word down with the sound that makes it up and also the children not being able to write and also thinks about the sound to make it up. They also face the problem in translating the language to the thought and also thought to the language. Commonly dyslexia is one of the most common disabilities of the learning. Some of the symptoms of the dyslexia are: Poor ability of the drawing. Getting difficult of putting the thoughts on the paper. Reversal of the letter or word when writing Understanding or the remembering difficulty The children mainly face this problem due to the immaturity in the development of the brain and due to this the children get the spatial confusion and also get confuses between the pairs of the letters. The roles of the teacher in preventing the problem of the dyslexia are given below (Barry et al., 2012): Providing the knowledge and skills It is very serious that the teachers have the better understanding of the complexities in the reading process and also the skill which needs to implement all the components of the instruction of the effective learning. To help the children in this type of the problem the teacher needs to do some of the basic task which includes in improving the encouragement of the children so that they can use their knowledge and also helps them by providing the needed information which they are lack age of the context which helps in understanding the text. Dong the help of the children in such a way that they can ask and also answer the question which helps them to improve the clarification and also confirm the ideas so that it can helps in exploring the new ideas. Teacher also provides some of the direct instruction so that it can promote the comprehension, fluency and the decoding of the information in the mind of the student. The teacher sometimes needs to answer the childrens queries and also p roperly monitoring of the performance. The teacher also needs to make the proper link between the writing and the reading instruction so that it helps the students in recognizing the interconnected processes so that it makes the improvement in the other. Motivate the children to read Teacher plays the one of the important role in doing the help of the children so that it can develop and also they can also maintain the positive attitude in improving the literacy and also the learning. Teacher also uses some of the complex cognitive policy so that they can improve the demonstration of the passion for doing the reading, they also acts as the best model readers in the case of the students. Teachers also have the knowledge how the children perceive their own ability as the reader and also give them support so that the children can develop the positive self attitude by providing the enough time to perceive the reading task. Teacher also needs to provide some of the opportunities so that the children can take part for the teamwork, social interaction and also the discussion. Teacher also needs to improve the focus of the children so that they can increase the level of the personal satisfaction and also achieving the goals which is different in the individual child. Teac her also makes the student learning some of the meaning things by taking the account the interest, needs of the children and also the age. Assessing and Observing Teacher needs to do some of the basic observation and also the assessment which varies from the children to the children. To do this type of the assessment the teacher use varieties of the assessment tools which includes running records, doing the self reflection, informal reading and also doing the special conference. They also use some of the assessment data so that the teacher can determine both the current strength and the weakness of the students. The teacher also needs to do the continually updating of the teaching strategies so that it can match the students growth. They also needs to give the proper attention to the very single students who are risking the reading failure and also needs to seek the support of the timely intervention when it becomes clear the classroom instruction. To improve the students mind satisfaction the teacher needs to provide some of the meaningful feedback of the children improvement by providing the marks and also doing the celebration of the childr en success and also let them to know where and also the what type of the improvement is needed (Bonifacci et al., 2013). Writing There are enormous numbers of the children who are intelligent and only have the capabilities of listening the conversation but they are basically unable to transfer their thoughts on the paper. The writing difficulties are getting more common among the children and also can stalk out from the varieties of the attention and the learning issues. This type of the problem who the students are facing is known as dysgraphia. Dysgraphia is mainly the condition which impacts the causes of the trouble facing by the written expression. Some of the children facing the problem with dysgraphia are just of holding the pencil and also the organizing of the letters which seems very difficult to them. Some of the symptoms which state the problem of the dysgraphia includes the poor structure of the words, habit of the mixing of the upper and the lower case of the letters, the improper way of holding the pencil and also showing some of the disinterest in doing the drawing and the writing, etc. To improve the problem of the dysgraphia the teacher also needs to take some of the drastic steps which are listed below: Creation of the positive environment Children facing with the problem of the dysgraphia are getting easily distracted by the sounds of the environment. So the noisy room creates the unfavorable effects in to the writing experiences of the students. So to improve the writing skill of the students the creation of the positive environment is the basic key. If the environment is quite it makes the students feels more ease and also the students can give more focus to improve the writing problems of the students. The teacher also needs to take some of the special treatment of these types of the children they needs to sit with the children specially when they writing and also required to provide the positive feedback about the improvement of the work and the teacher also needs to do one of the important things which is comparing the one child with the others. Adoption of the positive approach The children who have this type of problem in writing also tried to avoid the practicing of the writing so the teacher encourage the students by adopting the positive approach and also encourage them so that they enjoy the writing. In this approach it includes planning, writing of the draft, checking of the errors and also the rewriting. The teacher also can encourage the students by drawing etc so that it can make the whole session more interactive (Weekes, 2012). Encouragement of the various writing activities The teacher needs to make the students feel that the writing is not the difficult task and also needs to engage the children in the various activities of the writing. To encourage the children in writing the parents also needs to play some of the important role by suggesting the children to write the experience of the travelling of the holiday so that they can document their whole trip. This is also acts an important opportunity for the children to get the encouragement of the writing. Use of the assistive technologies The children who are facing the difficulty in the writing also can benefited by using the modern technology specially computers. Now days there are the availability of the some of the software tools which are specially designed for the students who are facing the problem of the dysgraphia. This interactive software includes some of the approach of the games and the fun activities. Scheduling the practice session of the writing To improve the writing of the children the teacher can schedule some of the time so that the students can practice of doing the writing and if the students do get agree of doing the practice of the writing the teacher also sometimes needs to improve the process of convincing the children so that the children can easily get ready for doing the writing. Listening The common cause of the listening problem of the students which they are facing more commonly is the auditory processing disorder. Some of the signs of the issues what the children are facing includes that the children constantly misses the given direction and also needs to repeat the direction. Sometimes it also seems that the children having this problem does not hear at the first time and also get distracted very easily and also its becomes hard for paying attention when anybody talk to them. To improve this type of the problem of the students the teacher also pays some of the vital role which is given below (Srader, 2014): Improve the acoustic nature To improve the acoustic nature of the classroom the teacher needs to make the environment of the classroom more free from the background noise and also needs to prevent the outside sound comes to the room so that the class room remain more free from the sound. The teacher also needs to look after the distance of the sound from the children so that they get the proper sound. Because if the distance of the sound gets more the students cannot get the clear sound which also can lead to the listening issues of the children. The teacher also needs to keep notice that the sound does not occur the reverberation of the sound. If the sound gets echoed the students get more puzzled by the occurrence of the different types of the sound (Weekes, 2012). Make the proper arrangement of seating of the students in the classroom Teacher also keeps remaining the constant notice with the children who are facing this type of the problem. Teacher also needs to make the children mostly on the first row of the class so that the children cannot get easily influences by the other children. This seating arrangement of the children also enhance the children to improve the ability of the children so that the children can give the full acknowledge to the sound and also improve the paying of the attention. This also helps the children so that they can make the sense of the sound which they are listening. The teacher also needs to improve that much quality among the students so that they can have that much ability to do the filtration of the sound which is important and which is not. The teacher also helps the students in doing the figure out of the languages and the speech (Wolvin, 2012). Teacher to face the children and also needs to speak slowly To this type of the children its not get easy to get the sentence if anybody speak in more speed so the teacher needs to speak slowly so that the students gets that much time to get the meaning of the sentence. This also improves the listening skills of the children because if the children get the meaning of the sentence they can get attracted to the listening. The teacher also needs to provide some of the written instructions so that the children can easily get what they are listening and also gets easy to capture the given information which are being educated in the classroom study (Zhou et al., 2012). To make the interactive session To improve the listening skills of the children along with the teacher the parents also needs to take part actively in which that the parents needs to talk with the children all the time so that in having the conversation they also gets the habit of talking and also gets the habit of listening. Teacher as well as the parents also needs to arrange the interactive session of storytelling in such a way that anybody only tells the half of the story and the other needs to conclude the story in this process the listening, thinking ability also gets improved. Make the whole session more interactive with the availability of both the visual and the audio so that the children can get more interest. Teacher also needs to make the session of the storytelling interactive with the basic interactive question and answer session in which after the whole story the teacher ask the children some of the question regarding the story and who will able to give the answer are rewarded. Teacher always needs t o try to gain the eye contact with the children and sometimes needs to ask the children to repeat the exact sentence what they are telling (Fedesco, 2014). Following direction In this problem the children are facing the problem in focusing and the sustaining of the attention. In this it seems that the children are getting the complete understanding of the things and also even the write down of the directions but it all turns out in the wrong assignment which is executed incorrectly. In this the children only hear the one of the four parts of the things which may cause the problem (Chang, Choi and Chung, 2014). To improve this type of the problem the teacher needs to take some of the important measures which are given below: Establishment of the eye contact It is very needed to establish the eye contact with the students for the teacher so that they cannot get diverted from understanding and the following of the direction. Sometimes it is needed to pause in delivering the sentence so that the students get the proper meaning of the sentences and if necessary the teacher needs breaks up the sentence and also discuss the proper meaning of the sentence (Thibaut et al., 2014). Use of the visuals While giving the direction to the children the teacher needs to make some of the interactive by using some of the visual interactive methods so that the students seeks the attention without diverting to the other things and the teacher also needs to impress the students so that they can make the assignment of the different things which are related to the study (Chang, Choi and Chung, 2014). Taking tests In the taking of the tests the students also face some of the basic problems which are given below (Zilberberg et al., 2014): Identification of the problem areas In this the teacher helps the students doing the proper identification of the problem areas and also how to improve that area by enhancing the skills of the students and also reduce the level of the examination stress. This also acts as the first step to do the determination of the difficulty areas of the students. Proper ideas of the areas of the study Children in most of the cases are unaware of the whole idea of the study and also that which part they needs to prepare for the tests. So to determine this level of the awareness of the childs level the teacher needs to check some of the major issues which are to arrange the review session for the children so that they can identify the problem areas and also get the proper solution in that areas and the teacher also needs to look after the proper planning of the study to get in a systematic way. Next, the teacher also needs to do the proper assessment of all the attention, focus and the listening skills. Grading system of the test Grading system of the test have the both the positive and the negative side. In analyzing the positive side of the grading it creates the whole feedback of the knowledge of the students through which the teacher can do the analyze about the merit level of the students. By considering the negative side of the feedback sometimes this grading system causes the negative impacts on the children mind if the grade of the two students is compared with each others (Weekes, 2012). Moving about the classroom In doing the constant motion in the class room some of the students may face the problem of the attention deficit order. The children facing this type of the problem make the movement in the class room more than the eight times which are excessive in nature. This is also known as the hyper active behavior which is mainly caused by the brain based biological disorder (Classroom Discourse, 2014). Distinguish the breaking point If there is the time provided for doing the distinguish between the some of the lessons but the children who are facing that type of the problem can still find the time is short for doing the assessment. So the teacher needs to help the students to make some of the measures so that they can get the proper ideas about the thing in the given time (Gurkaynak, n.d.). To built of the movement throughout the whole school day The teacher needs to make the student understand and also needs to make the habit of seating in the one particular place so that the environment of the class and also the attention of the other students not get towards the another things (Grkan and Iandoli, 2014). To provide some of the alternatives in the standard classroom There are some of the students who do the work in a good way if they are allowed to do the movement in the whole class room. Children are not having the focus if they are not allowed to do the movement in the class room. Teacher needs to do give the proper attention so that the children can get the habit of seating in the one place and do the whole assessment (Imani and Habil, 2012). Give the encouragement in the physical activity Parents and the teacher both needs to play some of the important role to improve the condition of the children. They also needs to help the children in such a way that the children can grow the habit of seating or standing in the one place for some time on their own which is not be by force (Cohen, 1984). Talking support the arguments with the examples from the own practices In some of the arguments the teacher gives some of the lectures which are regarding the matters of the discussion by using the good premises which are both relevant and true in regarding the study. The teacher also makes to ensure that after the lecture it also gives the good support of the whole conclusion and also needs to do the whole check of the full things and the students also needs to do some of the jot down of the main points regarding the main topics and also the relevant aspects (Zhou et al., 2012). So that the whole lecture is stored and also use in the future if it is needed for the future studies. The teacher also needs to make sure that the students are jotting the all about the argument, conclusion and the deduction of the study. Teacher also notice that the students are avoiding the logical types of the fallacies which are both irrelevant and the illegitimate in nature comparing the study in which there is the lack age of the evidence for giving the support of the cl aim. Teacher also needs to notice that the students who are jotting down the important points of the study have the proper and the meaningful logic (Gurkaynak, n.d.). Conclusion In this part by concluding the above study it gives the proper and the full knowledge and also critical analysis in which the teacher helps the students so that they can overcome the problems which leads in the reading, learning, writing, following direction, taking tests, moving about the classroom and also the taking the support of the arguments also by citing the problem. It also includes how the teacher also takes some of the drastic measure so that the children who are facing these types of the problem can get freed and can get the proper cure from the problem. References Arden, E. and Kecht, M. (1993). Peadagogy Is Politics: Literary Theory and Critical Teaching. Academe, 79(3), p.85. Bacon, A. and Handley, S. (2014). Reasoning and Dyslexia: is Visual Memory a Compensatory Resource?. Dyslexia, 20(4), pp.330-345. Barry, J., Harbodt, S., Cantiani, C., Sabisch, B. and Zobay, O. (2012). Sensitivity to Lexical Stress in Dyslexia: a Case of Cognitive not Perceptual Stress. Dyslexia, 18(3), pp.139-165. Bonifacci, P., Montuschi, M., Lami, L. and Snowling, M. (2013). Parents of Children with Dyslexia: Cognitive, Emotional and Behavioural Profile. Dyslexia, 20(2), pp.175-190. Chang, Y., Choi, J. and Chung, W. (2014). Persistent Direction-Fixed Nystagmus Following Canalith Repositioning Maneuver for Horizontal Canal BPPV: A Case of Canalith Jam. Clinical and Experimental Otorhinolaryngology, 7(2), p.138. Chang, Y., Choi, J. and Chung, W. (2014). Persistent Direction-Fixed Nystagmus Following Canalith Repositioning Maneuver for Horizontal Canal BPPV: A Case of Canalith Jam. Clinical and Experimental Otorhinolaryngology, 7(2), p.138. Classroom Discourse. (2014). Classroom Discourse, 5(2), pp.215-215. Cohen, A. (1984). On taking language tests: what the students report. Language Testing, 1(1), pp.70-81. Fedesco, H. (2014). The Impact of (In)effective Listening on Interpersonal Interactions. International Journal of Listening, pp.1-4. Grkan, A. and Iandoli, L. (2014). Argument Mapping and Content Fusion to Support the Analysis and Synthesis of Information in Online Discussions. International Journal of Decision Support System Technology, 6(1), pp.14-33. Gurkaynak, R. (n.d.). Econometric Tests of Asset Price Bubbles: Taking Stock. SSRN Journal. Imani, A. and Habil, H. (2012). NNS Postgraduate Students Academic Writing: Problem-solving Strategies and Grammatical Features. Procedia - Social and Behavioral Sciences, 66, pp.460-471. Introne, J. and Iandoli, L. (2014). Improving decision-making performance through argumentation: An argument-based decision support system to compute with evidence. Decision Support Systems, 64, pp.79-89. Jakobsen, L., Ratcliffe, J. and Surlykke, A. (2012). Convergent acoustic field of view in echolocating bats. Nature, 493(7430), pp.93-96. Jenkins, H. (2012). Reading critically and reading creatively. Matrizes, 6(1-2), p.11. Lee, I. (2014). Feedback in writing: Issues and challenges. Assessing Writing, 19, pp.1-5. Leventhal, P. (2014). Non-clinical health writing. Medical Writing, 23(3), pp.171-171. Loughlin, R. (1965). An Open Letter to Students on Taking Tests. NASSP Bulletin, 49(302), pp.31-32. Milton, A. (n.d.). Do Standardized Reading Tests Assess Reading, or Test-Taking?. SSRN Journal. Morley, G. (2012). Regulatory writing. Medical Writing, 21(3), pp.243-244. Morris, P. (2012). Listening and Legos. International Journal of Listening, 26(2), pp.94-97. Pino, M. and Mortari, L. (2014). The Inclusion of Students with Dyslexia in Higher Education: A Systematic Review Using Narrative Synthesis. Dyslexia, 20(4), pp.346-369. Rangamani, G. (2012). Acquired Dyslexia/Dysgraphia in Kannada-English Bilingual Stroke-Survivors. Procedia - Social and Behavioral Sciences, 61, pp.309-310. Rangamani, G. (2012). Acquired Dyslexia/Dysgraphia in Kannada-English Bilingual Stroke-Survivors. Procedia - Social and Behavioral Sciences, 61, pp.309-310. Srader, D. (2014). Performative Listening. International Journal of Listening, pp.1-8. Srader, D. (2014). Performative Listening. International Journal of Listening, pp.1-8. Thibaut, P., Curwood, J., Carvalho, L. and Simpson, A. (2014). Moving across physical and online spaces: a case study in a blended primary classroom. Learning, Media and Technology, pp.1-22. Weekes, B. (2012). Acquired Dyslexia and Dysgraphia across Scripts. Behavioural Neurology, 25(3), pp.159-163. Weekes, B. (2012). Acquired Dyslexia and Dysgraphia across Scripts. Behavioural Neurology, 25(3), pp.159-163. Wolvin, A. (2012). Listening in the General Education Curriculum. International Journal of Listening, 26(2), pp.122-128. Zhou, P., Cheng, S., Yang, R., Wang, B. and Liu, J. (2012). Combination chemoprevention. European Journal of Cancer Prevention, 21(3), pp.231-240. Zilberberg, A., Finney, S., Marsh, K. and Anderson, R. (2014). The Role of Students Attitudes and Test-Taking Motivation on the Validity of College Institutional Accountability Tests: A Path Analytic Model. International Journal of Testing, 14(4), pp.360-384.

Symbiosis Mini Essay free essay sample

Parasitism is a relationship, usually between two organisms in which one organism benefits greatly (the parasite) and the other is negatively affected (the host). Commensalism: A relationship existing between two organisms which results in one organism benefitting while the other is unaffected. Mutualism General Example: The Hermit Crab and Sea Anemone. Hermit Crabs have been shown to remove sea anemones and attach them to their shells. Both organisms benefit because the crabs drop food particles in the water when feeding, these food particles are then eaten by the anemones. The crab benefits because if any predator tries to attack, not only can it retract into its shell but the anemone can sting the predator which usually scares it away. Caribbean Example: Ants and Aphids. Aphids when feeding on plants secrete a sweet substance called honeydew, this honeydew is loved by ants and as a result they consume it. In exchange for the honeydew, the ants provide protection for the aphids from predators such as Ladybugs. We will write a custom essay sample on Symbiosis Mini Essay or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Both organisms benefit equally from this relationship (2). Parasitism General Example: Tapeworm and Humans. Tapeworms are parasitic worms from the Class Platyhelminthes. This organism reaches maturity in the gut in which the tapeworm feeds on nutrient rich food which the human has eaten. Mature proglottids of the tapeworm separate from the adult and are expelled in the feces. These feces may be eaten by herbivorous animals such as sheep or cattle which then become infected and pass the tapeworms along if their meat is improperly prepared. Tapeworms can also pass on a variety of illnesses e. . blindness, pain and inflammation. Caribbean example: Parasitic Dodder Vines and Golden apple tree: Dodder vines can attach themselves to a wide variety of plants and use its parasitic connections called haustoria to gain access to the plants vascular system. This essentially robs the host plant of food it has produced and in many cases can lead to the death of the host. Commensalism General Example: Shark and Remora. Remoras are small fish which can att ach themselves to a shark’s skin via a disc on its head. When the shark hunts the remora would detach itself and eat scraps which float by, by this method the remora benefits because it is allowed to feed but the shark is unaffected by the remora’s attachment. Caribbean Example: Human beings and Egrets: Usually before planting a crop the field must be ploughed and this is done in more recent times using heavy machinery, namely a tractor. As a result of the soil being turned over many insects and worms can be exposed and the Egret takes advantage of this. Usually wherever there is soil being ploughed many egrets can be found feeding, sometimes even an entire flock of them.

The Lost Chinatown

The Lost Chinatown Free Online Research Papers â€Å"Welcome! Please come in!† piped the recorded voice as we went in a store. Those were the first few words I heard when I went to Chinatown, (Manila) a few days ago with my friends. As we strolled along the streets of the bustling little Chinese town, I was filled with mixed emotions. On one hand, I was feeling a bit nostalgic. The sight of the old buildings and restaurants, the distinct smell of incense and Chinese medicine, the old and revered Binondo church, the noisy street vendors and the colorful calesas, brought back memories of my first home. On the other hand, I was feeling uneasy seeing all the changes that had taken place in the past ten years. I felt that the addition of foreign shops, construction of new and modern buildings, the commercialization of restaurants and stores have changed more than just the appearance of Chinatown. Something was missing in today’s Chinatown. In the past, Chinatown was the core of the Chinese business enterprises. It used to be a landmark, the main source of China’s best goods. Anyone strolling around the streets of Chinatown would undoubtedly have a genuine Chinese experience. Everything was practically Chinese- the people, the food, the traditions, the architecture, the music, and the festivities. The Chinese have long strove to keep the richness of their culture intact. Since then, Chinatown has constantly changed. Through the years, it has continually kept pace with the waves of technology. In fact, the Chinatown I lived in was already a far cry from what it used to be. Yet, visiting my hometown ten years later, well- indeed a lot has changed. Perhaps if you would compare a sketch of Chinatown ten years ago and one of today, you would notice that the main difference would be the addition of electronic stores, beauty shops, spas, foreign restaurants and cafes. In fact, my friends and I agreed to meet in Starbucks for this trip! I tell you, years before; there was little chance of finding a restaurant serving a different cuisine other than Chinese in Chinatown, much less a foreign cafà ©! The additions of the foreign stores are not the only things that have changed the solely Chinese territory at Chinatown, but also several structural and technological improvements. A day’s activities in Chinatown ten years ago would be characterized by a ride in a calesa, a trip to the wet Aranque Market, a visit to the Chinese medicine stores and a taste of their exotic medicines, lunch in a quaint Chinese restaurant with the owner’s family themselves serving you, a stroll along the bridges across the dirty Pasig River, a stop to buy fruits from the street vendors, a sip of the yummy sugarcane juice, a friendly chat with familiar faces you would meet along the road, and perhaps for a young lass like me, a day full of games that would include the jump rope and the jackstones with my neighbors in the wide hallways of our buildings. A day in today’s Chinatown could start with coffee at Starbucks, a stroll along the newly renovated Plaza San Lorenzo Ruiz, a stop at the Eng Bee Tin store which sells the uniquely flavored hopias in nice, printed packages for pasalubong (gifts) for your workmates, perhaps lunch with your friends at a well-known, commercialized restaurant with Filipino waitresses dressed with traditional Chinese outfits serving you, a sip of one of those modern Chinese energy drinks, a ride in your BMW to the nearby supermarket to buy fruits and food for your family who live in a fancy new condominium with narrow hallways and unknown neighbors, a stop in the Globe Business Center, and perhaps, for the youth of today, a day full of computer games in the internet stations scattered throughout Chinatown. I have also noticed that because of modernization movement, some things are becoming obsolete- or should I say, â€Å"antique†. Such as, the calesa. I vividly remember my childhood years when my only means of transportation to school was the calesa: thewooden, colorful and sometimes rickety, carriage-pulled-by-the-horse. My yaya (Nanny)would bargain with the kutsero (driver)for the fare to be lowered. She would shout, â€Å"Bente nalang po (Could we pay twenty pesos instead?)† Some kutseros would stubbornly refuse the twenty peso fare. My yaya would persist. He would refuse. My yaya would persist. He would refuse. And the cycle would go on and on, every day of my school life. And I just smiled when I saw my friend Sheena persisting for a ride in a calesa. Today, only the wowed tourists ride them. With fares set at a very high price, and designated roads where the calesas cannot pass, people have opted to use cars and other â€Å"practical† means of transportation . Even so, calesas have contributed to the unique identity of Chinatown and therefore should not be simply put aside. Globalization has also brought a revolution in this part of the Manila. I remember years ago people from all over Metro Manila and perhaps other parts of the country would go and visit Chinatown to buy Chinese goods. Chinatown used to be the best source for Chinese goods - the best hopia, the best dimsum, the best congee- you name it, they have it, and they have the best in town. Also, Chinatown was the only source for authentic Chinese paraphernalia: costumes, luck charms, medicine, etc. But today, due to the increase in demand for Chinese goods, shops had to open branches in different parts of the city and the country. In short, there was. But, as a result of this expansion, Chinese shops are no longer unique to Chinatown. Those delectable goods can be bought anywhere now, and sometimes, even at a cheaper price. I recall the â€Å"dragonfruit expedition† that my friends and I had in our visit to Chinatown. It was the first time for some of my friends to see that fruit, and everybody wanted to taste something â€Å"unique† to Chinatown. But after bargaining with several fruit vendors, we still found it expensive, and concluded that it can be bought nowadays in supermarkets, so why bother? My friend Sheena asked me a while later, â€Å"So what else is here? What’s the specialty of Chinatown? Something that’s really different that we could experience?† I found that question difficult to answer. Practically nothing is completely unique to Chinatown anymore, including food. Chinese restaurants are scattered all around the city and I cannot deny that I have appreciated a lot of them. Authentic Chinese furniture, clothes and other imported products can be found everywhere. I could point out some distinct characteristics that Chinatown possess, but I cannot really name a unique quality anymore. I cannot deny that the commercialization, modernization and globalization of Chinatown have brought good. The improvements have been and are serving their purposes. In fact, the enhancements in this town have increased its charm to lure more tourists, and perhaps, have made the lives of the people living there easier. Chinese goods are now easily accessed by people living outside Chinatown. However, I sincerely regret that, for the sake of keeping up with the times, the changes have led to the dilution of the authenticity and the uniqueness of Chinatown. The essence of Chinatown, that special C-factor which keeps Chinatown authentic and unique, is now lost. What has kept the Chinatown authentic and unique throughout the years is its constant and strict following of its traditions. In today’s Chinatown, a great deal of these traditions have either been disregarded or compromised to give way to modern technology. It has long been the practice of the Chinese to keep themselves exclusively Chinese. With the influx of foreign restaurants and cafà ©s, the essence of keeping Chinatown solely Chinese as its name suggests, is slowly diminished. The commercialization of buildings and other structures in Chinatown has changed the atmosphere in the relationships of the people living there. The narrow hallways and stiff, condo-type designs give an air of professionalism and discourage familiarity among neighbors. Thus the Chinese ideology of close ties has been disregarded. Chinese businessmen nowadays have adopted Western ways of doing business; thus, losing the traditional, personal way of the Chinese. It has long been a tradition among th e Chinese that the whole family would contribute in the family business. In a restaurant, the father cooks, the mother serves the customers, the children wash the dishes, etc. Nowadays, children are exposed to several Western ideas and do not see the significance of this anymore. And, in the age of expansion and commercialization, hired help replace the family in service. â€Å"Thank you! Please come again!† piped the electronic recorded voice as we left Eng Bee Tin store, after buying some pasalubongs (gifts)for our families. Again, these technological improvements are not wrong. They serve their purpose and make people’s lives easier. But, let us not disregard the values of the past generations because they are essential in keeping the identity of Chinatown unique from any other place in the country. Instead, let us use technology to our advantage. That way, we could have both, technology and the preservation of the culture. Let’s keep that special C-Factor, so Chinatown would stay authentic and unique, the way it was before, the way it was known to be. So that anyone in the future, strolling along the streets of the little Chinese town, would have the benefit of a true Chinese experience. Research Papers on The Lost ChinatownWhere Wild and West MeetTwilight of the UAWThe Spring and Autumn19 Century Society: A Deeply Divided EraThe Effects of Illegal ImmigrationDefinition of Export QuotasMarketing of Lifeboy Soap A Unilever ProductPersonal Experience with Teen PregnancyBringing Democracy to AfricaHip-Hop is Art

Interview with an immigrant 4 pages single spaced Essay

Interview with an immigrant 4 pages single spaced - Essay Example Nabeeb: Learning English was really hard, especially considering that I had spoken a different language for 20 years. In Tanzania, I was accustomed to speaking the national language which is Kiswahili, in addition to my local Chagga dialect. It is very rare to find people speaking in English in Tanzania, and in fact, most people perceive English as a foreign language. Considering that I spoke very little English by the time I came to the United States, the language barrier was so much of an issue that most of the time, I did not make sense in my broken English, and people would laugh at me. Interviewer: It must have been really hard to get laughed at. How did you handle it? Nabeeb: At first, it was so humiliating. Imagine having kids as young as 6 years old laughing at you because they speak better English than you. It became so bad that I opted not to talk to people and this made me very lonely and homesick. Interviewer: So how did you overcome the language barrier issue and speakin g of home sickness, how bad was it? Nabeeb: After secluding myself for around two months, I realized that life would not get any easier if I did not take up the responsibility of fighting of the language barrier problem. I, therefore, enrolled at a local grammar school where I took up English lessons, started interacting with people and actually urged them to correct me whenever I spoke bad English. But I must say that for an immigrant, having to distinguish between formal English and American slang is an uphill task. The homesickness? No words can fully describe what it feels like to be in an alien land, away from friends and family, and forced to adapt to new life. I would get so home sick that I would spend my free time trying to find other Tanzanians who help me manage the homesickness. Communicating with my family back in Tanzania via telephone also helped ease the homesickness. However, the international calls were very expensive at the time for a student, meaning that communi cation was very rare. Interviewer: Apart from the language barrier and homesickness, what other challenges have you faced as an immigrant in the United States? Nabeeb: Once I set foot in the United States, everything was totally different. It is like waking up to a new world; the weather, the food, the modes of dressing, the accents, and more so the system of education, all gave me a culture shock. In class especially, I found the teaching methods so strange that I used to be the quietest student in class. I could not dare ask questions or even answer them. It really took me time to get adjusted to the American classroom. In addition, there are too many laws controlling the lives of immigrants that one almost feels suffocated. Obtaining a driving license, getting a work permit, travelling out of the country, getting social security, among many other regulations almost make one feel like a suspect. I must also add that it took me quite a while to get used to eating burgers and pizzas . I used to crave for Tanzanian food so much that I would try the recipes only to end up disappointed because the ingredients I found here are not the same as those used in Tanzania. Anyway, after months of complaining, I finally adjusted and I got used to the food here. Interviewer: But the experiences could not have been all bad. Is there anything positive about being an immigrant in the United States? Nabeeb: Everyone wants to live the American dream. That is what I came chasing for and that is the best decision I ever

Why we should have a Black President Essay Example | Topics and Well Written Essays - 1250 words

Why we should have a Black President - Essay Example The United States should have an African, or Black President, because it's the only way to demonstrate principles of equal human rights in actual fact. All the history of the United States has never been anything but a chain of white male presidents. Oddly, little has been said about this embarrassing subject. Of course, America probably has to break a few more social barriers before a black president could be elected. To be frank, a lot of people are not ready to have a black man or woman as President. On the other hand, there are a lot of progressive people, black and white, concerned that democratic principles should be implemented in the real life indeed.Electing of African President in 2008 will help to attract an attention of publicity to the problems of black community, such as educational, health, social, political and other issues. According to the recent Gallup Survey on "Black-White Relations" cited in Cronc, seven out of ten whites believe that blacks are treated equally in their communities: an optimism with which only 40 percent of blacks agree. Eight in ten whites say blacks receive equal educational opportunities, and 83 percent say blacks receive equal housing opportunities in their communities. Only a third of whites believe blacks face racial bias from police in their areas. If a Black President is elected in the United States in 2008, these problems will more likely to be solved. (1999)I think that the main benefit of Black President is providing the United States with the real equality in all areas of life. Also it will show to every black person that there is nothing impossible for him or her in self-development. Self-confidence of colored people will serve as a powerful tool for further development of democracy in the United States. Also, Black President will stimulate black people to get involved in the political process. If we have a black woman as a President, feminist's movement will also become more politically active and more significant. The idea of America having its first Black president has resonated with many African-Americans over the years, especially with the emergence of Illinois Senator Barack Obama. Obama is the third African American since the Reconstruction Era to serve in the United States Senate. He is also the only African American currently serving in the Senate. Obama showed he had national appeal last year, when he delivered the keynote address at the Democratic National Convention. Though he was not even elected into office yet, dreams of a black President popped into the heads of many African Americans who watched as Obama electrified an audience of all races. Obama is not the first African American to show national appeal as a potential presidential candidate. The Rev. Jesse Jackson ran twice in the 1980s, and though he did not win the White House Jackson showed that he had enormous appeal outside of the African-American community. Jackson managed to attract 6.9 million votes from Urban Blacks, Hispanics, poor rural whites, farmers, factory workers, feminists, homosexuals and white progressives. One more step to an African President is Bill Clinton, who often is referred to as the "black president" because he was so receptive to the needs of African Americans and because he worked to include them in the political process more than any other president. Reasons cited here for Clinton's popularity among blacks include his poor Southern upbringing and underdog status, the fact that he appointed more blacks to his cabinet and other federal posts than any other president, and good timing (he came into office after three consecutive Republican administrations). But perhaps the biggest factor discussed is the genuine ease with which Clinton relates to black Americans. Blacks trust him to consider their perspective and do not view him as just another white politician who appears only during election years. This is not to say that Clinton always did their bidding; he often disappointed them. But they also shared common enemies and a common outlook that brought

Workplace related issues Research Paper Example | Topics and Well Written Essays - 2250 words

Workplace related issues - Research Paper Example Many factors affect workers at the work place. With the growing business world, more opportunities are presented for employees to venture into; hence, the management is left with no choice but to find means of making sure that the employees are satisfied with the working conditions. These issues at a glance appear minor, but in the actual projection, they determine a great deal the motivation and efficiency of the worker (Hancock & Szalma, 2008). These issues range from the office design, office layout, the furniture in the office and the lighting systems. The services provided to the employees, such as refreshments, recreation facilities, health care plans and the rules and regulations as well as the policies of the organization (Hancock & Szalma, 2008). The level of interaction with the management and the influence of technology on the employees are also major issues. The employers are thus in the run to provide quality environment and services to the employees in order to be able to keep them for tomorrow. The ego of the employees determines a lot their motivation, and since the worker spends most of his or her lifetime at work, it is true that the quality of the place of work will affect the employee’s ego. A well-designed office, well built, partitioned and painted is a key motivator to a person’s attitude towards the work (Hancock & Szalma, 2008). For instance, if the work designated requires privacy for the employee, and the office does not provide such, the worker may feel an easy while executing their duty hence underperforming. A good design of building attracts and motivates the employee to stay around and provides essential factor for enhancing the creativity and innovative skills of an employee. The human mind is such that it makes preferences over color, and this generally affects the attitude of an individual towards a place. If the office is painted in such colors that the worker does not like, this will cause them to be de-motivat ed to stay in the office. Thus, it is important for the office to be painted in standard colors. The lighting system also matters a lot. A dimly lit room will cause low mood and negative attitude to the worker, toward the work. A moderately brightly lit office provides a serene working atmosphere hence motivating the employee to work. The arrangement of the office equipment and furniture is another key determinant factor to the attitude of the employee towards the office (Burke & Witt, 2002). A shabbily organized office will represent a job that is not taken seriously. The workers will tend to dislike the office hence this will affect his or her concentration in work, resulting to poor results. The furnishing of the office also affects the attitude of the worker towards their job. An office with old and shaggy looking office furniture will discourage the worker. For instance if the furniture is old and rugged, the employee who is expected to sit on them for most of the hours of his day will definitely not look forward to a new day at work. They as a result will just come to work for the pay but not to give quality work as is expected of them (Hancock & Szalma, 2008). The worker will do a job that is as good as the environment allows him or her to do. However, if the furniture is of quality, every worker will enjoy being at their workstation. In addition, they will be motivated to put in their best efforts and skills to work, since the setting is comfortable. A healthy health is essential for an individual to deliver quality service in all areas of life. An ailing person is not in a good state of mind

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