Degrees Of Carpal Tunnel Syndrome Health And Social Care Essay

Degrees Of Carpal Tunnel Syndrome Health And Social Care Essay Carpal tunnel syndrome is a most common compression neuropathy of the upper extremity. It is caused by compression of median nerve in the carpal tunnel. Women are more commonly affected than men. It is commonly seen in age group between 30 and 60 years. Carpal tunnel syndrome usually occurs due to excessive use of the hands and occupational exposure to repeated trauma. Average cross sectional area of the carpal tunnel is 1.7 cm2 with the wrist in neutral position. Passive flexion and extension of the wrist has been increased the carpal tunnel pressure. Wrist extension increases carpal tunnel pressure more than the wrist flexion. Any space occupying mass or swelling of the structures in the tunnel also causes pressure on the median nerve. Mostly, the cause of carpal tunnel syndrome is unknown. Any condition which causes pressure on median nerve at the wrist will result in carpal tunnel syndrome. Obesity, pregnancy, hypothyroidism, arthritis, diabetes and trauma are the common conditions that lead to carpal tunnel syndrome. Repetitive work such as uninterrupted typing which result in tendon inflammation can also cause carpal tunnel symptoms. Carpal tunnel syndrome due to repetitive activities has referred to one of the repetitive stress injuries. In some rare diseases such as amyloidosis, leukemia, multiple myeloma, and sarcoidosis, deposition of abnormal substances in and around the carpal tunnel leads to nerve irritation. Prolonged flexion or extension of the wrists under the patients head or pillow during sleep is believed to contribute to the prevalence of nocturnal symptoms. Usually patient complaints pain, numbness and tingling sensation in the hand and fingers. Symptoms worsening at night typically awakening the patient or occurring on bunching up the hand for tasks such as writing. Carpal tunnel syndrome is the most common cause of acroparaesthesiae often pain and paraesthesiae may be the only symptoms for many months or years. The syndrome is essentially a sensory one; the loss or impairment of superficial sensation affects the thumb, index and middle fingers and may be or may not split the ring finger. There may be wasting and weakness of the thenar muscles. Weakness and atrophy of the abductor pollicis brevis and other muscles supplied by median nerve occur in only the most advanced cases of compression. Degrees of carpal tunnel syndrome are classified as dynamic, mild, moderate and severe. The pathophysiology of carpal tunnel syndrome is typically demyelination. Secondary axon loss may present in more severe cases. With 20 to 30 mm hg compression, the initial insult is a reduction in epineural blood flow. With wrist extension, intracarpal pressures routinely measure atleast 33 mm hg and often upto 110 mm hg in patients with carpal tunnel syndrome. Edema in the epineurium and endoneurium is caused by continued or increased pressure. Carpal tunnel syndrome diagnosed by detailed history collection, phalen maneuver, percussion test, two point discrimination test, vibrometry, monofilament test, distal sensory latency and conduction velocity, distal motor latency conduction, upper limb tension tests. X-ray is taken to check for arthritis and fracture. If there is a suspected medical condition that is associated with carpal tunnel syndrome, laboratory tests may be done. This condition could be mistaken for a brachial neuritis due to cervical intervertebral disc prolapse at C5 C7 level. Nerve conduction tests on the median nerve help to localize the lesion in the tunnel. Both conservative and surgical management options are available in order to reduce pressure over median nerve. The current conservative treatments include non steroidal anti inflammatory drugs, sometimes rest, local injection of corticosteroids, activity modification, ultrasound therapy, carpal bone mobilization, magnetic therapy, night and/or daytime wrist splint positioned at 0 to 15 degrees of extension, nerve and tendon gliding exercises. Anyone of the measures alone or in combination can be effective in treating early carpal tunnel syndrome. Tendon gliding exercises are performed to lubricate and increase gliding of the flexor pollicis longus, flexor digitorum superficialis and flexor digitorum profundus tendons. They are best performed with the hand elevated to concurrently control local edema. Median nerve gliding exercises and the upper limb tension test with median nerve bias can be used as treatment techniques. Modality treatment can also control symptoms and enhance the therapeutic exercise program. Exercise intervention for carpal tunnel syndrome focuses on mobility and strengthening without producing an exacerbation. Stretches for the extrinsic and intrinsic muscles are prescribed for several times each day. If working, a patient should perform them before work. They should be performed slowly and gently; the patient feel only a gentle stretching sensation. In workplace, modification of the job site or complete ergonomic redesign is typically the most helpful approach. In addition yoga, chiropractics, laser treatment have been advocated. Surgery is indicated in advanced cases with objective sensory loss and /or weakness or atrophy of the abductor pollicis brevis. In severe cases surgical division of the transverse carpal ligament relieves the condition. Surgical management includes open carpal tunnel release and endoscopic release. It aims to decompress nerve, to improve excursion and to prevent flexor damage. Splinting is the most popular method of conservative management of carpal tunnel syndrome. Splints are recommended by the American Academy of Neurology for the Carpal tunnel syndrome with light and moderate pathology. Immobilization of the wrist joint in a neutral position with splint will increase the carpal tunnel volume and minimize the median nerve pressure. Wrist Splinting in a neutral position will help reduce and may even completely relieve Carpal tunnel syndrome (Slater RR et al 1999). Ultrasound therapy is more useful in the management of Carpal tunnel syndrome. It has the potential to accelerate normal resolution of inflammation. Ultrasound therapy elicit anti inflammatory and tissue stimulating effects. Ultrasound therapy accelerates the healing process in damaged tissues. Pulsed Ultrasound therapy with the intensity of 1.0 w/cm2, 1:4 for fifteen minutes per session has significantly improved subjective symptoms in patients with carpal tunnel syndrome (Ebenbichler GR et al). Nerve and tendon gliding exercises are used in conservative treatment of carpal tunnel syndrome to decrease adhesions and to regulate venous return in nerve bundles (Rozmaryn et al). Nerve and tendon gliding exercises may maximize the relative movement of the median nerve within the Carpal tunnel and the excursion of flexor tendon relative to one another (Rempel D, Manojlovic R et al). Wrist splint along with nerve and tendon gliding exercises showed significant improvement in reducing symptoms in Carpal tunnel syndrome. (Akalin et al) NEED FOR THE STUDY: Ultra sound therapy, splints, nerve and tendon gliding exercises are significantly effective in reducing symptoms in the treatment of Carpal tunnel syndrome. Combination of various treatments is also useful in reducing symptoms in Carpal tunnel syndrome. Ultrasound therapy helps to increase healing process in damaged tissue. This study aimed to find out the effect of Ultrasound therapy in reducing pain in patients with Carpal tunnel syndrome. STATEMENT OF THE PROBLEM Effect of Ultrasound Therapy in reducing pain in patients with Carpal tunnel syndrome. KEY WORDS: Carpal tunnel syndrome Ultrasound therapy Splint Exercises Pain Visual analogue scale (VAS) AIM: To find out the Effect of Ultrasound Therapy in reducing pain in patients with Carpal Tunnel Syndrome. OBJECTIVE: To study the Effect of Ultrasound Therapy in reducing pain in patients with Carpal Tunnel Syndrome. HYPOTHESIS: 1.6.1. NULL HYPOTHESIS There is no significant effect of Ultrasound Therapy, Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome. There is no significant effect of Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome. There is no significant difference between the effect of Ultrasound Therapy, Splint and Exercises and Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome. 1.6.2. ALTERNATE HYPOTHESIS There is significant effect of Ultrasound Therapy, Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome. There is significant effect of Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome. There is significant difference between the effect of Ultrasound Therapy, Splint and Exercises and Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome. II.REVIEW OF LITERATURE CARPAL TUNNEL SYNDROME DAVID A FULLER, MD, et al (2010) Stated that carpal tunnel syndrome is the most common entrapment neuropathy. The syndrome is characterised by pain, paraesthesia, and weakness in the median nerve distribution of the hand. The etiology of carpal tunnel syndrome is multifactorial which is contributed by various degrees of local and systemic factors. Symptoms of carpal tunnel syndrome are due to ischemia and impaired axonal transport of the median nerve which results from median nerve compression at the wrist. (Lunborg G, Dahlin LB 1992). Elevated pressure inside the carpal tunnel leads to compression. HARVEY SIMON, MD et al, (2009) Stated that carpal tunnel syndrome is considered as an inflammatory disorder caused by medical conditions, physical injury or repetitive stress. JEFFREY G NORVELL, MD et al (2009) Stated that carpal tunnel syndrome (CTS) is caused predominantly by median nerve compression at the wrist because of hypertrophy or oedema of the flexor synovium. Pain is thought to be secondary to nerve ischemia rather than direct physical damage of the nerve. S.BRENT BROTZMAN, MD (2003) Explained that degree of the carpal tunnel syndrome as dynamic, mild moderate and severe. In mild cases, patients has intermittent symptoms, decreased light touch, positive digital compression test and positive tinel sign or phalen test may or may not be present. In moderate cases, patients have frequent symptoms, decreased vibratory sense, muscle weakness, positive tinel sign, phalen test and digital compression test. GERRITSEN AA, DE KROM MC, STRUIJS MA, ET AL (2002) Stated that carpal tunnel syndrome (CTS) is caused by median nerve compression at the wrist and is considered to be the more common entrapment neuropathy. Symptoms of carpal tunnel syndrome include pain, numbness or tingling sensation, paraesthesia, involving the fingers innervated by the median nerve. (Bakhtiary AH, Rashidy Pour AR et al 2004) GELBERMAN RH, HERGENROEDER PT, HARGENS AR, RYDEVIK B, LUNDBORG G, BAGGE U (1981) Fracture callus, osteophytes, anomalous muscle bodies, tumours, hypertrophic synovium, and infection as well as gout and other inflammatory conditions can produce increased pressure within the carpal tunnel. Extremes of wrist flexion and extension also elevate pressure within the carpal tunnel. Intraneural blood flow is affected by compression on nerve. Venular blood flow in a nerve is reduced by pressure as low as twenty to thirty mm Hg. At level of thirty mm Hg, axonal transport is impaired. At forty mm Hg, neurophysiologic changes manifested as sensory and motor dysfunctions are present. Any further increase in pressure will produce sensory and motor block. At level of sixty to eighty mm Hg, complete cessation of intraneural blood flow is seen. In one study, the carpal tunnel pressure in patients with carpal tunnel syndrome averaged thirty two mm Hg, compared with only about two mm Hg in control subjects. RH GELBERMAN, AR HARGENS, GN LUNDBORG, PT HERGENROEDER et al, (1981) Measured intra carpal canal pressures with the wick catheter in 15 patients with carpal tunnel syndrome and in 12 control subjects. The average pressure in the carpal tunnel was raised significantly in the patients with carpal tunnel syndrome. When the wrist was in neutral position, the mean pressure was 32 millimeters of mercury. With ninety degrees of wrist flexion the pressure raised to 94 millimeters of mercury. While with ninety degrees of wrist extension the average pressure was 110 millimeters of mercury. The pressure of carpal canal in the control subjects with the neutral position of wrist was 2.5 millimeters of mercury; with wrist flexion the carpal canal pressure rise to 31 millimeters of mercury, and with wrist extension it increased to 30 millimeters of mercury.  ­Ã‚ ­Ã‚ ­Ã‚ ­Ã‚ ­Ã‚ ­Ã‚ ­Ã‚ ­GEORGE S. PHALEN M.D, et al (1966) Stated that diagnosed Carpal tunnel syndrome has been made in 654 hands of 439 patients during the last seventeen years. The typical patient with this syndrome is a middle-aged housewife with numbness and tingling in the thumb and index, long, and ring fingers, which is worse at night and worse after excessive activity of the hands. The sensory disturbances both objective and subjective must be directly related to the sensory distribution of the median nerve distal to the wrist but pain may be referred proximal to the wrist as high as the shoulder. There is usually a positive tinel sign over the median nerve at the wrist, and the wrist flexion test is also usually positive. About half of the patients also have some degree of thenar atrophy. In clinical practice, Carpal tunnel syndrome is the most commonly seen entrapment mononeuropathy which is caused by median nerve compression at the wrist (PHALEN 1966, GELBERMAN et al 1998). Usually patients show one or more symptoms of hand weakness, pain, numbness or tingling in the hand, especially in the thumb, index and middle fingers (SIMOVIC and WEINBERG 2000). Symptoms are worst during night time and often wakeup the patient. WILLIAM C. SHIEL JR., MD.FACP, FACR, et al Stated that the cause of the carpal tunnel syndrome is unknown. Any condition which causes pressure on the median nerve at the wrist will result in carpal tunnel syndrome. Common conditions such as obesity, pregnancy, hypothyroidism, arthritis, diabetes, and trauma can lead to carpal tunnel syndrome. Repetitive work such as uninterrupted typing result in tendon inflammation can also cause Carpal tunnel symptoms. In some rare diseases such as amyloidosis, leukemia, multiple myeloma, and sarcoidosis, deposition of abnormal substances in and around the carpal tunnel leads to nerve irritation. MEDIAN NERVE LUNDBORG G, DAHLIN LB, et al (1996) Stated that throughout the extremity movement, mobility of the peripheral nerve changes and longitudinal movement of the median nerve mostly occur in the carpal tunnel. In Carpal tunnel syndrome, this physiologic mobility of the median nerve disappears. REMPEL D, MANOJLOVIC R, LEVINSOHN DG, et al (1994) Stated that during the exercise there may be redistribution of the point of maximal compression on the median nerve. This milking effect would promote venous return from the median nerve, thus decreasing the pressure inside the perineurium. NAKAMICHI AND S. TACHIBANA et al Conducted a study the motion of median nerve in patients with carpal tunnel syndrome and normal subjects. Median nerve motion was assessed by axial ultrasonographic imaging the mid carpal tunnel. They concluded that wrist of patients with Carpal tunnel syndrome showed less sliding which indicates that physiological motion of the nerve is restricted. This decrease in nerve mobility may be of significance in the pathophysiology of carpal tunnel syndrome. ULTRASOUND THERAPY BAKHTIARY AH, RASHIDY-POUR A et al (2004) Conducted a study to compare the effect of Ultrasound and laser therapy in patients with mild to moderate idiopathic carpal tunnel syndrome. By electromyography findings, 90 hands in 50 consecutive patients with carpal tunnel syndrome were confirmed and allocated randomly in two groups. One group received low level laser therapy and the other group received ultrasound therapy. Ultrasound treatment (pulsed 1:4, 1.0 W/cm2, 1 MHz, 15 min/session) and low level laser therapy (infrared laser, 830nm, 9 Joules, at five points) were given to the carpal tunnel for fifteen daily treatment sessions. Ultrasound group showed more significant improvement than low level laser therapy group in motor latency, motor action potential amplitude, finger pinch strength, and pain reduction. Effects were also sustained in the follow-up period. They concluded that ultrasound therapy was more effective than laser therapy in the management of carpal tunnel syndrome. EBENBICHLER GR, RESCH KL et al (1998) Studied the efficacy of Ultrasound therapy in patients with mild to moderate idiopathic Carpal tunnel syndrome. Ultrasound with parameters 1MHZ, 1.0 W/cm2 pulsed mode 1:4, 15 minutes per session was applied over the carpal tunnel and compared with Sham Ultrasound. Actively treated ultrasound group showed significant improvement than sham treated wrists in both subjective symptoms and electroneurographic variables. To confirm the usefulness of ultrasound therapy for Carpal tunnel syndrome, more studies are needed. Additional randomized trials comparing conservative therapies for Carpal tunnel syndrome would be useful in selecting appropriate treatments for individual patients. EL HAG M, COGHLAN K, CHRISMAS P et al (1985) Stated that Ultrasound could elicit anti-inflammatory and tissue-stimulating effects as already shown in clinical trials and experimentally (Byl et al 1992, Young and Dyson 1990). In this way, Ultrasound has the potential to accelerate normal resolution of inflammation (Dyson 1989). The results of these studies confirm that Ultrasound may accelerate the healing process in damaged tissues. In mild to moderate carpal tunnel syndrome patients, these mechanisms may explain their findings including pain relief, increased grip and pinch strength, and changed electrophysiological parameters toward normal values better than Laser therapy. WRIST SPLINT Wrist splints help to keep the wrist straight and reduce pressure on the compressed nerve. Doctor may recommend the patients to wear wrist splints either at night, or both day and night, although patient may find that they get in the way when they are doing their daily activities. Some research indicates that ultrasound treatment may help to reduce the symptoms of carpal tunnel syndrome. (BUPAS health information team 2010) BRININGER TL, ROGERS JC et al (2007) Fabricated customized neutral splint and nerve and tendon gliding exercises is more effective than wrist cock up splint and nerve and tendon gliding exercises in reducing symptoms and improving functional status in the treatment of Carpal tunnel syndrome. GERRITSEN AA, DE KROM MC, STRUIJS MA, et al (2002) Immobilization of the wrist joint in a neutral position with a splint will maximizes carpal tunnel volume and minimize the pressure acting on median nerve. AKALIN E, EL O, SENOCAK O, et al (2002) Compared the effect of wrist splint alone to wrist splint with nerve and tendon gliding exercises in the treatment of carpal tunnel syndrome. In their study, both groups showed significant improvement in clinical parameters, functional status scale and symptom severity scale. They also reported significant improvement only in pinch strength in the group with wrist splint in combination with exercises compared with the wrist splint group. MANENTE G, TORRIERI F, et al (2001) Stated that wearing a specially designed wrist splint at night time for four weeks was more effective than no treatment in reducing the symptoms of Carpal tunnel syndrome. SLATER RR, et al (1999) Stated that splinting the wrist in a neutral position will help to reduce and may even completely relieve carpal tunnel syndrome symptoms. SAILER SM, et al (1996) Stated that the optimal splinting regimen depends on the patients symptoms and preferences. To prevent prolonged wrist flexion or extension, night splint use is recommended. BURKE DT, STEWRT GW, CAMBER A, et Al (1994) Stated that carpal tunnel syndrome is the commonest compression neuropathy in the upper limb. Several studies have demonstrated the effect of wrist splint in reducing the symptoms of carpal tunnel syndrome. But the chosen angle of immobilization has varied in the management of carpal tunnel syndrome. Wick catheter measurements of carpal tunnel pressures suggest that the neural position has less pressure and, therefore, greater potential to provide relief from symptoms. KRUGER VL, KRAFT GH, et al (1991) Stated that wrist splint at a neutral angle helps to decrease repetitive flexion and rotation, thereby relieving mild soft tissue swelling or tenosynovitis. Splinting is most effective when it is applied within three months of the onset of symptoms. NERVE AND TENDON GLIDING EXERCISES BAYSAL O, ERTEMK, YOLOGLUS, ALTAY Z, KAYHANA et al (2006) Stated that combination of ultrasound therapy, splinting and exercises is a preferable and an efficacious treatment for patients with carpal tunnel syndrome. ROZMARYN LM, et al (1998) Used nerve and tendon gliding exercises in conservative treatment models to decrease adhesions developed in the carpal tunnel and regulate venous return in the nerve bundles. They reviewed more than 200 hands under consideration for carpal tunnel decompression. Altogether 71% of the patients who were not offered gliding exercises went forward to surgery; only 43% of the gliding exercise group was felt to require surgery. SERADGE et al (1995) Stated that intermittent active wrist and finger flexion-extension exercises reduce the pressure in the carpal tunnel. SZABO et al (1994) Showed that the relationship between median nerve and flexor tendon excursion was consistently linear. They suggested active finger motion of the median nerve and flexor tendons in the vicinity of the wrist to prevent adhesion formation even if the wrist is immobilized. REMPEL D, MANOJLOVIC R, LEVINSOHN DG, et al (1994) Stated that the median nerve movement is increased by nerve and tendon gliding exercises in the carpal tunnel and the flexor tendons excursion is increased in relative to one another. TOTTEN AND HUNTER, et al (1991) Proposed a series of exercises enhancing the gliding of the median nerve and tendon at the carpal tunnel for management of postoperative Carpal tunnel syndrome. They also suggested these exercises for non-operative Carpal tunnel syndrome. LAMINA PINAR, SAIT ADA AND NEVIN GUNGOR ET AL Stated that nerve and tendon gliding exercises included in conservative therapy approaches showed more rapid pain reduction and greater functional improvement in grip strength. HANNAH RICE MYERS, et al Stated that carpal tunnel exercises reduce the tension on the tendons in the tunnel and strengthen the weakened muscles of wrist and forearms. Even though nerve and tendon gliding exercises are effective when used alone, they have a greater effect when used along with other intervention such as splint. For people who are involving jobs with keeping their hands in a fixed position throughout the day such as typing secretaries, these exercises may help to prevent carpal tunnel syndrome from developing. VISUAL ANALOGUE SCALE POLLY E. BIJUR PHD, WENDY SILVER MA, E. JOHN GALLAGHER MD et al (2008) Conducted to study to assess the reliability of the visual analogue scale (VAS) for acute pain measurement as assessed by the intraclass correlation coefficients (ICC) appears to be high. The results showed that the Visual analogue scale (VAS) is sufficiently reliable to be used to assess acute pain. PAUL S. MYLES, MBBS, MPH, MD, FFARCSI, et al (1999) Stated Visual analog scale (VAS) is a tool widely used to measure pain. A patient is asked to indicate his/her perceived pain intensity (most commonly) along a 100 mm horizontal line, and this rating is then measured from the left edge (VAS score). The visual analogue scale score correlates well with acute pain. JOYCE, et al Suggested that visual analogue scale and another scales have been compared in terms of sensitivity, distribution of responses and preferences. Results of these studies appear equal. The visual analogue scale has been described as superior in one study because it was more sensitivity than any other scale. III. METHODOLOGY 3.1 STUDY DESIGN: Pretest and Posttest Experimental group study design. 3.2 STUDY SETTING: The study was conducted at Department of Physiotherapy, K.G.Hospital, Coimbatore. 3.3 STUDY DURATION: 3 weeks for each individual subject and the total duration was one year. 3.4 STUDY POPULATION: Patients with Carpal tunnel syndrome referred to the Department of physiotherapy, K.G.Hospital, Coimbatore. 3.5 STUDY SAMPLE: All patients with carpal tunnel syndrome who referred to Department of Physiotherapy, K.G. Hospital were selected. Among all patients, 20 patients who satisfied inclusive and exclusive criteria were selected and assigned into two groups, 10 of each by using Purposive Sampling method. 3.6 CRITERIA FOR SELECTION: INCLUSIVE CRITERIA: Age group above 30 years. Both sexes. Patients with mild to moderate unilateral carpal tunnel syndrome. Patients with Positive Tinel sign, Phalens test and Digital compression test. EXCLUSIVE CRITERIA: Patients with severe carpal tunnel syndrome Patients having thenar atrophy or denervation on electromyographic findings Patients with a neuropathy other than carpal tunnel syndrome in the past year Patient with history of steroid injection in carpal tunnel in the past 3 months Patients had a prior carpal tunnel release Cervical disc prolapse Degenerative changes of cervical spine Acute upper limb fractures Wrist and fingers stiffness Recent hand surgeries Deqeurains disease Pregnancy Acute Infections of Wrist and Hand 3.7 Variables: Dependent variable Pain. Independent variable Visual analogue scale. 3.8 Orientation of subjects: Before treatment all the patients were explained about the study and procedure to be applied and were asked to inform if they feel any discomfort during the course of the treatment. All the willing patients were asked to sign the consent form before the treatment. 3.9 OUTCOME MEASURES: Pain. 3.10 OPERATIONAL TOOLS: Visual analogue scale 3.11 STUDY PROCEDURE: 20 Patients with carpal tunnel syndrome were selected for this study after due consideration of inclusive and exclusive criteria. 20 patients were divided into 2 groups of 10 each. Group A: 10 patients received ultrasound therapy, splint and exercises. Ultrasound therapy with parameters of 1 MHz pulsed mode, 1:4, 1 w/cm2 is given 15 minutes per day, five times per week. Custom made neutral volar splint is given at night and during day time. Exercises are nerve and tendon gliding exercises. During tendon-gliding exercises, the fingers are placed in five discrete positions. Those were straight, hook, fist, table top, and straight fist. During the median nerve-gliding exercise the median nerve was mobilized by putting the hand and wrist in six different positions. During these exercises the neck and the shoulder were in a neutral position and the elbow was in supination and 90 degrees of flexion. Each position was maintained for 5 seconds. Each exercise is repeated 10 times at each session, 5 sessions per day. The total treatment duration is 3 weeks. Group B: 10 patients received only Splint and Exercises. Custom made neutral volar splint is given at night and during day time. Exercises are nerve and tendon gliding exercises. During tendon-gliding exercises, the fingers are placed in five discrete positions. Those were straight, hook, fist, table top, and straight fist. During the median nerve-gliding exercise the median nerve was mobilized by putting the hand and wrist in six different positions. During these exercises the neck and the shoulder were in a neutral position and the elbow was in supination and 90 degrees of flexion. Each position was maintained for 5 seconds. Each exercise is repeated 10 times at each session, 5 sessions per day. The total treatment duration is 3 weeks. 3.12 STATISTICAL TOOLS: Statistical analysis was done using Student t-test. Paired t test Where, n = Total number of subjects SD = Standard deviation d = Difference between initial and final value = Mean difference between initial and final value. (ii) Unpairedt test: To compare the pre test, post test values of both groups independentt test is used. Where, n1 = Number of subjects in Group A. n2 = Number of subjects in Group B. = Mean of Group A = Mean of Group B s1 = Standard deviation of Group A. s2 = Standard deviation of Group B. S = Combined standard deviation IV.DATA ANALYSIS AND INTERPRETATION TABLE-1 VISUAL ANALOGUE SCALE FOR PAIN GROUP A PAIREDt TEST Mean values, mean differences, standard deviation andt values of Visual Analogue Scale for Group A who underwent Ultrasound therapy, Splint, Nerve and Tendon gliding exercises. S. NO VAS Improvement t value Mean Mean difference Standard deviation 1. Pre test 5.60 3.90 0.70 39.0 2. Post test 1.70 0.67 FIGURE-1 GRAPHICAL REPRESENTATION OF MEAN VISUAL ANALOGUE SCALE FOR GROUP A TABLE-2 VISUAL ANALOGUE SCALE FOR PAIN FOR GROUP B PAIREDt TEST Mean values, mean differences, standard deviation andt values of Visual Analogue Scale for Group B who underwent to Splint, Nerve and Tendon gliding exercises. S. NO VAS Improvement t value Mean Mean difference Standard deviation 1. Pre test 5.40 3.0 0.70 20.12 2. Post test 2.40 0.52 FIGURE-2 GRAPHICAL REPRESENTATION OF MEAN VISUAL ANALOGUE SCALE FOR GROUP B TABLE-3 VISUAL ANALOGUE SCALE FOR PAIN PRETEST VALUES OF GROUP A VERSUS GROUP B UNPAIREDt TEST Mean, mean difference, standard deviation and unpairedt test of pre test v

Letter home nurse

My dearest Mother, I am missing you dearly and I hope everything is well. I am getting very home sick, life here is different than over there. I can hear sounds of the battlefield and it's very frightening. We also get very little sleep and It is so cold here. The food is so plain; we rarely eat meat. We eat mostly beans, potatoes and soup. I'm getting so tired of it. Many of the things I see are very disturbing but it feels good to help these men.Some of them have talked to me about their families or what they plan to do after the war. like to hear them being positive. I've started keeping a diary and I've even started writing poems. This helps me take all my emotions out. It feels really good, but you know what doesn't? Feeling to dirty all the time. I feel Ilke I feel this way most of the time. We have to take sponge baths with cold water, which doesnt help at all. Many girls have not been able to handle all of this and have gone home but that ont happen to me.Everything here move s so fast and the men come and go or we have to move and some are left behind. I get very sad when I think about those men and if they had families or not. Maybe that's why some girls are leaving, I don't blame them. I hope to see you and Father and sister soon, I hope this Is all over really soon. I miss you all so much It hurts. I've made some friends but I wish I was at home in my own bed, or having dinner with all of you. Ill be home soon! Love, Leslie

American workforce

The American workforce is becoming diversified than ever.   The issue on workplace discrimination has been around since time immemorial. Discrimination is part of the process of three components, the cognitive, affective and behavioral. The behavioral component means the tendency to take negative actions against a particular group. The behavior stems form attitudes and feelings which constitute prejudice. Although prejudice is generally negative it is not as damaging as discrimination. The behavior component makes it possible to make the thoughts become real. Research has found that discrimination in any form is detrimental to the well being of the discriminated individual (Mathis & Jackson, 2004). The workplace is the place in which the employee comes to work on his tasks and to carry out his profession. If the workplace is non-discriminatory, the employee is more likely to work effectively and efficiently and to increase productivity and performance as well. The most common methods employed by organizations to ensure that their work environment is non-discriminatory are to conduct sensitivity trainings, to provide provisions for grievances and complaints of discriminatory behavior and to follow non-discriminatory guidelines in terms of hiring, selection and promotions. Sensitivity trainings are common in most organizations especially if the company is culturally diverse as well as sexual orientation, disability and religion. The advantages of using sensitivity trainings to make employees become aware of the prejudices and discrimination they may have for other people and teaches the employees how to change their thoughts about minority groups in an experiential manner. It also communicates to each employee that an individual is a person in his/her own right and should be respected as such, and not be accorded respect based on one’s race, religion or sex. The disadvantage in using this method is that if  employees do not have a positive attitude towards the training then this would surely limit their capacity to learn from the sessions. Moreover, sensitivity trainings are periodically given and is not reinforced thus limiting its effectiveness. The provisions for grievances and complaints communicate to the employees that discrimination will not be tolerated by the management. It is effective as a control mechanism to lessen discrimination in the workplace and make the employees become cautious of their behavior. This method does not really ensure that the workplace would be discrimination free since it does not teach the employees why discrimination is wrong. It only holds people accountable for their actions, although it gives the employees who belong to the minority group comfort. Besides, discrimination may come in subtle forms and not even many employees who are victims of discrimination will file a complaint for fear of repercussions in terms of inter-office politics. Hiring, selection and promotion of employees based on merit and performance is a non-discriminatory principle to ensure that people become part of the organization based on criteria that can be achieved by most people. The difficulty with this measure is that although it is an objective measure, subjectivity is still present. It is common knowledge that when it comes to promotions and even selecting candidates for the job a certain amount of subjectivity that cannot be monitored by a guideline. It also does not consider that mangers may have their own prejudices which may dictate their decisions on hiring and promotion. References Bohlander, G. & Snell, S. (2003). Managing Human Resources 13th ed., South-Western College Publication Fitzenz, J. (2001). How to Measure Human Resource Management 3rd. ed , New York; McGraw-Hill Mathis, R. & Jackson, J. (2004). Human Resource Management 11th ed., South-Western College Publication    American workforce The American workforce is becoming diversified than ever.   The issue on workplace discrimination has been around since time immemorial. Discrimination is part of the process of three components, the cognitive, affective and behavioral. The behavioral component means the tendency to take negative actions against a particular group. The behavior stems form attitudes and feelings which constitute prejudice. Although prejudice is generally negative it is not as damaging as discrimination. The behavior component makes it possible to make the thoughts become real. Research has found that discrimination in any form is detrimental to the well being of the discriminated individual (Mathis & Jackson, 2004). The workplace is the place in which the employee comes to work on his tasks and to carry out his profession. If the workplace is non-discriminatory, the employee is more likely to work effectively and efficiently and to increase productivity and performance as well. The most common methods employed by organizations to ensure that their work environment is non-discriminatory are to conduct sensitivity trainings, to provide provisions for grievances and complaints of discriminatory behavior and to follow non-discriminatory guidelines in terms of hiring, selection and promotions. Sensitivity trainings are common in most organizations especially if the company is culturally diverse as well as sexual orientation, disability and religion. The advantages of using sensitivity trainings to make employees become aware of the prejudices and discrimination they may have for other people and teaches the employees how to change their thoughts about minority groups in an experiential manner. It also communicates to each employee that an individual is a person in his/her own right and should be respected as such, and not be accorded respect based on one’s race, religion or sex. The disadvantage in using this method is that if  employees do not have a positive attitude towards the training then this would surely limit their capacity to learn from the sessions. Moreover, sensitivity trainings are periodically given and is not reinforced thus limiting its effectiveness. The provisions for grievances and complaints communicate to the employees that discrimination will not be tolerated by the management. It is effective as a control mechanism to lessen discrimination in the workplace and make the employees become cautious of their behavior. This method does not really ensure that the workplace would be discrimination free since it does not teach the employees why discrimination is wrong. It only holds people accountable for their actions, although it gives the employees who belong to the minority group comfort. Besides, discrimination may come in subtle forms and not even many employees who are victims of discrimination will file a complaint for fear of repercussions in terms of inter-office politics. Hiring, selection and promotion of employees based on merit and performance is a non-discriminatory principle to ensure that people become part of the organization based on criteria that can be achieved by most people. The difficulty with this measure is that although it is an objective measure, subjectivity is still present. It is common knowledge that when it comes to promotions and even selecting candidates for the job a certain amount of subjectivity that cannot be monitored by a guideline. It also does not consider that mangers may have their own prejudices which may dictate their decisions on hiring and promotion. References Bohlander, G. & Snell, S. (2003). Managing Human Resources 13th ed., South-Western College Publication Fitzenz, J. (2001). How to Measure Human Resource Management 3rd. ed , New York; McGraw-Hill Mathis, R. & Jackson, J. (2004). Human Resource Management 11th ed., South-Western College Publication   

Analysing Contemporary Curriculum Of The Early Childhood...

Analysing Contemporary Curriculum Critically analyse one aspect of / component of the early childhood curriculum studied in this paper, with particular relevance to Aotearoa/ New Zealand Introduction This essay aims to critically analyse the emergent curriculum which has become a characteristic or philosophy of many early childhood settings in this twenty first century. It further goes to demonstrates how an emergent curriculum is developed and the relevance of emergent curriculum in the context of Aotearoa, New Zealand. Curriculum in simple and its purest definition means everything that takes place/ happens during the day in an early childhood setting (Ministry of Education, 1996; Arthur, Beecher, Death, Dockett Farmer, 2015).It includes what is planned or intended to be part of the curriculum, but also includes the unplanned, spontaneous experiences or interactions that children have or go through in a day at an early childhood centre. 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