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definition of addiction

definition of addiction. Help me study for my Psychology class. I’m stuck and don’t understand.

You started this course eight weeks ago and provided your personal definition of addiction. Revisit your definition. Would you change your definition of addiction? Why or why not? If you would, state your new definition.
Visit the website of the Association for Addiction Professionals (NAADAC) and review the code of ethics and credentialing process for an addiction counselor. Choose one ethical area that you feel is especially important and one area that you think could be challenging for new or inexperienced addiction counselors. Comment on at least two peers’ definitions of addiction or ethical concerns.
definition of addiction

Relationship between dysfunction of the prefrontal cortex. The prefrontal cortex (PFC) is an essential aspect of the frontal lobes in the brain. Executive function is carried out by the prefrontal cortex: where abilities to differentiate among conflicting thoughts and to determine what is good or bad operate. The PFC is connected very compactly with the rest of the brain which allows the PFC to be responsible for guiding features such as memory, emotion, decision-making, planning actions, and attention. If the PFC is damaged and the activity in it is minimal then this affects many things. The PFC could be damaged by lesions or even due to the misuse of drugs or alcohol (Rogers et al., 2010). In turn the damage to the PFC can lead the brain to make irrational decisions; have loss of behavioural control or even have a complete personality change: all of which explain why people may perform antisocial behaviour (ASB). Lesions in the prefrontal cortex have massive effects on decision making. (Manes et al., 2001). ASB stems from the fact that a human being has taken the decision as to whether they should act in a way that is not seen as appropriate in society: therefore, the damage to the PFC may have led them to this decision. Manes (2001) carried out a study to examine this theory. Manes found that out of several different groups he had with lesions in different parts of the brain – the group with large frontal lesions was the only group to exhibit risky decision making. This contradicts most other studies: including studies by Benjamin Libet and colleagues which showed that brain activity associated with deliberate decisions can be detected shortly before we are conscious of making the decision. (Libet, 1983) Participants were asked to note when they first felt the intention of making a movement by noting the position of a dot on a computer screen. The participants were first aware of their intentions about 200 milliseconds before actually acting. This is much later than the onset of readiness potential: meaning that the decision to act in a particular way in this study was risky. This experiment was heavily criticised for its accuracy. However, recent research has proven that if anything the actual onset of conscious intention is later. (Lau, 2006). The PFC can not only change the way somebody makes decisions -many studies have proven that lesions in the PFC can cause a complete personality change, where a good mannered personality can be changed instantly to an unpleasant one. (Chow, 2000) This was substantially displayed in the accident of Phineas Gage, (Harlow, 1848) where he survived a horrific accident after a large iron rod went completely through his head, destroying much of his brain’s left frontal lobe. This accident resulted in a vast personality change of Gage, which raised one of the first discussions as to whether damage to the prefrontal cortex can change a person’s behaviour. This then led to even more studies into this issue which resulted in one of the largest studies of patients with brain damage. Grafman (1996) found that the patients that showed an increase in aggression were most strongly associated with PFC lesions in a sample of 279 veterans of the Vietnam War. However, the higher scores were mostly associated with verbal aggression rather than physical. This, yet again, supported Harlow’s observation of Gage. (Grafman, 1996) The PFC is essential for behavioural control; therefore, this is why PFC lesions lead to ASB. Anti-social behaviour can be described as behaviour that is “likely to cause harassment, alarm or distress to [others].” (Riley, 2007). Many studies have demonstrated the direct effect that the PFC has on determining ASB. Violent behaviour is connected with structural and functional shortages in the prefrontal cortex according to many brain imaging studies. A meta-analysis of these studies was carried out by Yang et al (2009), where 43 structural and functional imaging studies were looked at. Results showed an 11% reduction in PFC grey matter in patients with anti-social personality disorder (APD). From all of these studies it was concluded that there is reduced prefrontal structure and function in antisocial individuals. Anderson (1999) also investigated this – he examined the long term consequences of PFC lesions before 16 months in two adults. It resulted in the two adults having severely impaired social behaviour despite basic cognitive abilities and also insensitivity to consequences of decisions. The two patients suffered from defective social and moral reasoning; showing attainment of complex social and moral rules had been impaired. This study explained that early prefrontal damage syndrome leads to syndrome resembling psychopathy. A great deal of empirical research demonstrates that mental illness is higher in incarcerated populations and estimates that as many as 25% of defendants evaluated for capability are medically and legally incompetent to stand trial. (Golding, 1984). With this fact in mind, many people argue that “minds are simply what brains do” (Minsky, 1948) If this is the case then people are controlled by their brain, therefore have little personal choice as to how they behave. It is clear that the PFC has a huge effect on behaviour of human beings. It can have such an effect that it changes a person’s entire personality from positive to negative. Anything that minimises the activity in the PFC can lead to negative consequences. It can make somebody less effective at decision making; make people violent and entirely change somebody as a person. All of these things in turn lead to antisocial behaviour which raises huge debate as to whether people who are antisocial due to minimal activity in the PFC are criminals or are innocently mentally ill human beings. It is certain how important the PFC is to the brain and the research that has been carried out shows that we should not abuse the PFC (alcohol, drugs) as it is very significant to enable us to behaviour in a responsible manner. Relationship between dysfunction of the prefrontal cortex

Management Decision BMW Market Research Paper

Management Decision BMW Market Research Paper.

Objectives that need to be shown in the writing to have fall marksExamine the concept of value and the elements and role of the value chain.Understand the conditions required for successful marketing planning, that marketing planning is focused on the value proposition, and that marketing planning is a dynamic process.Identify various types of organizational strategies.Conduct a situation analysis.Use the framework provided for marketing planning, along with the content in future chapters, to build a marketing plan.Describe the difference between market information systems and market research systems.Identify how critical internal (inside the firm) information is collected and used in making marketing decisions.Explain essential external (outside the firm) information collection methods.Recognize the value of market research and its role in marketing.Define the market research process.Illustrate current research technologies and how they are used in market research.MANAGEMENT DECISION CASE BMW’s Road to Higher Customer Satisfaction: Just Tell Me What You Think! Page 111 – 112 MANAGEMENT DECISION CASE BMW’S ROAD TO HIGHER CUSTOMER SATISFACTION: JUST TELL ME WHAT YOU THINK! Customer satisfaction and loyalty are critical elements in any successful marketing strategy, but they are essential when the product is purchased only once every few years. It was, therefore, of great concern to luxury automakers like Acura, Audi, and BMW when in 2014 their customer satisfaction scores all dropped below the average for the entire automobile industry. 34 For years these companies had been gathering and using external primary data from their own surveys, and also relying on secondary data from sources like the American Consumer Satisfaction Index, yet satisfaction was falling. Assuming the luxury automakers were listening and responding to the data they received from existing research, it appeared the old modes of research were missing key insights. Management had a new research deliverable—learn how we can improve customer satisfaction—and a new research question—what specific product attributes or service components are not satisfying our customers? In situations like this, you don’t know what you don’t know. Were less-expensive competitors adding features that satisfied customers at a lower price? Were service amenities like free loaner cars not valued by the customers? What were the features or service components that were failing, missing, or just not valued? Finding a method to ask questions that exposed areas of dissatisfaction (or missed opportunities to satisfy), and ask these questions in a way that was representative of the target customers, became the market research problem. One of these companies—BMW—learned how to listen and greatly improved its customer satisfaction scores. It now ranks above the industry average for customer satisfaction and higher in satisfaction than its luxury automobile competitors. 35 BMW’s focus on understanding its customers has helped it reach the top of its market, but its path was only possible with an understanding of important trade-offs different types of marketing research require. Through a worldwide dealer network, BMW makes 10 promises to its customers and then measures how well the company (and dealers) keep those promises. Walk into (or visit on the web) nearly any BWM dealership, from Idaho Falls, Idaho, to Hastings, New Zealand, and you will see a display of the 10 promises of service quality. 36 What you don’t see is how difficult it is to measure and make sense of hundreds, thousands, or, at a country level, hundreds of thousands of opinions about customers’ satisfaction with activities such as response timeliness, explaining the bill, or offering a test drive. In an effort to gather better satisfaction information, BMW UK set about to solve two problems at once. Like most companies, it had a difficult time getting customers to respond to its surveys. 37 And, with 10 promises to measure, the surveys were fairly long and time-consuming to complete. This led to a falloff in customer response rates. The second problem was making sense of the incoming survey data. To make surveys easier for respondents and for later analysis, market researchers use closed-ended quantitative questions, typically with a one-to-five-or one-to-seven-point scale of very unsatisfied to very satisfied. Customers who responded answered by bubbling in the appropriate number on their survey. But, without context as to why they were very satisfied (or not), it was difficult for BMW to know exactly what to keep doing and what to fix. More context meant more questions, and more questions meant fewer responses. To address this problem and get deeper context, market researchers often seek to gather deeper, qualitative information through in-depth interviews, which are often one on one and quite expensive to administer, or by inviting a small number of customers (usually around a dozen) to a focus group, where a professional moderator asks open-ended qualitative questions, digging out nuances of why customers are expressing a given level of satisfaction. One downside of both in-depth interviews and focus groups is that they are not a statistically valid representation of the population of interest (for example, a target segment such as Lexus buyers). BMW recognized that focus groups enable the company to gain deeper context and actionable insights through qualitative data but do not allow for generalizing the findings to a large group, so they only provide guidance on what should be focused on in a broader, statistically valid study. BMW faced what is, for all market researchers, a series of trade-offs between different research methods. Qualitative methods, such as focus groups, brought deeper insights, but at the cost of being able to apply the findings to a more general customer target. Other methods, such as quantitative surveys, brought speed, generalizability, and a higher level of numerical precision and statistical validity, but lacked an ability to delve deeper and understand the heart of what customers value. And, in both cases, the more information BMW sought, the fewer customers responded. Realizing a need for richer and more representative information, BMW set out to find a way to analyze representative samples of large amounts of open-ended qualitative customer responses. Questions for Consideration Questions: Assuming BMW wanted to learn more about what customers value in their luxury driving experience and then make decisions from that research, what kind(s) of market research would you recommend that may improve their understanding?BMW is facing the classic quality-quantity-cost tradeoff; the higher information quality they seek (represented by more questions), the fewer responses they get or the higher their research costs. Since BMW’s executives each have 25-to-30 years’ experience in the automotive market, what would be the advantages and disadvantages of trusting their own experience vs. spending more on market research?Often when problems develop like BMW is experiencing in their research data gathering, a new (often technological) solution is developed to address the problem. What might be some innovative ways to approach gaining both statistical significance (through higher response rate) and deeper context (through open-ended qualitative data)?
Management Decision BMW Market Research Paper

Magic

write my term paper Magic. Paper details Q-1: First make sure, you read the following article “Performing Magical Capitalism” https://www.epicpeople.org/performing-magical-capitalism/ (Links to an external site.) Same Article in PDF: Performing Magical Capitalism.pdf The authors in the article argued that: “Magic is at work in all sorts of modern practices”. For Q-1, choose one advertisement that is similar to the one discussed in the article and analyze its similarities to magic. How does your chosen ad work as magic? (i.e., a beauty product, a cleaning product, car, food, or insurance ad) Q-2: Can you think of any examples of magical thinking from your own life/culture? Think about times where you cannot find a rational explanation on why you or others do certain things in a certain way or why you or others in your culture believe in certain things in certain ways. Be critical! Do not say you do not have any beliefs/rituals that are magical. Take an outsider’s perspective. (List 1 or 2) Q-3: By using one or two of the magical beliefs/practices/rituals (discussed in Q-2), create a story (a paragraph) where you discuss them from the perspective of an outsider (imagine that you are an anthropologist and examining a different culture, use words like magic, supernatural, sacred, manipulation, when describing the ritual/superstitious belief)—like Miner, remember Nacirema Article. See two examples below. Sample-1: On jewelry/diamond wedding ring “This is an interesting phenomenon that occurs in a certain society which prides itself on looking beyond materials and professes to focus as much as possible on the person as possible. Love is a very desired feeling in this society and is one that is almost seen as a commodity that can be bought with material goods. These goods are shiny small clear rocks, which are placed on a small circular metal material, which is then placed around the finger. This whole thing is given a very high value in the bonding and love of two individuals and is seen as the object that seals the two individuals together. This idea is perpetuated by visual stories that are told by still and moving images (in television, videos), by those making and selling these circular metal objects with shiny rocks on them. The gift of this object from the male to the female is usually the case, and the visual encouragement from those selling these objects can be seen as the manipulation to entice the buyers into their magic acts of making their desired ones fall in love.” Sample-2: Lucky socks “This act is one in which the user of the rite wears a particular piece of clothing that is seen as a magic object that will influence the outcome of the proceedings. The magic piece of clothing is placed at the feet and is seen as magical because of the outcome of previous results when this piece of clothing was worn. This piece of clothing is used sparingly, on days when the individual is going to be tested by way of assessing their knowledge by a series of written questions on a piece of paper. This superstition is a rite that is only used when the outcome of the situation is uncertain and is thought positively determine the outcome.” Magic

Childhood Obesity in Health Science Interview Case Study

Table of Contents Introduction Main body Conclusion Reference List Introduction The best approach of conveying a technical concept on childhood obesity to a class of students would be through a case study developed from interviewing the director of pediatric health and weight management center in Illinois. The objective of the case study would be to make the class of students understand how Illinois successfully addressed the problem of childhood obesity through improved nutrition, physical exercise, and screen time policies in certified child-care centers within the state. From the interview with the director, it was ascertained that the policy approach for the codification of obesity prevention strategies in child-care centers was established by the Department of Children and Family Services (DCFS) in Illinois in collaboration with the Illinois Early Learning Council. Main body Child-care centers across Illinois serve nearly 200,000 children from birth to around five years of age (Johnson

Degrees Of Carpal Tunnel Syndrome Health And Social Care Essay

Share this: Facebook Twitter Reddit LinkedIn WhatsApp 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. ­­­­­­­­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. (BUPA’S 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 patient’s 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 Deqeurain’s 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) Unpaired’t’ test: To compare the pre test, post test values of both groups independent’t’ 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 PAIRED’t’ TEST Mean values, mean differences, standard deviation and’t’ 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 PAIRED’t’ TEST Mean values, mean differences, standard deviation and’t’ 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 UNPAIRED’t’ TEST Mean, mean difference, standard deviation and unpaired’t’ test of pre test v Share this: Facebook Twitter Reddit LinkedIn WhatsApp