Factors for the Development of Trigger Points

Factors for the Development of Trigger Points Introduction The primary mean of locomotion which enables human and other animals to move on their foot is running. There are some regular points the gait cycle during which both the feet are not on the ground in running. Running has aflightphase during which neither limb is in ground contact. Running gait can be divided into two phases in context to the lower extremity which is  absorption, propulsion, initial swing and terminal swing. As per electromyographic data suggests: as speed increases, ilio-psoas, gluteus maximus, gluteus medius, hamstring and rectus femoris all developed larger peak forces throughout the stride cycle. The peak force exerted by gastrocnemius increases as speed increased from 3.5 to 7m/sec but showed no significant changes thereafter. The peak force exerted by soleus also increased from 3.5 to7m/sec, but furthermore t decreases till 9m/sec. soleus, gastrocnemius and vastus provides approximately 75% of the total vertical support impulse needs to accelerate where soleus alone contributes 50% of all. The vertical ground reaction force increases for speeds up to 7 m/sec is almost entirely of soleus whereas vastus to the vertical ground reaction force does not affect with increase in running speed. The rate of ankle plantar flexors shortening increases with the running speed and solus and gastrocnemius contracts at37% and 23% of their maximum shortening velocities respectively.as a result, onl y 30 and 40% of their peak potentially developed by soleus and gastrocnemius respectively during sprinting.inspite of producing significant and large amount of forces whetreas they did not contribute in knee-hip joint accelerations during swing phase. if we compare sprinters with non sprinters;the previous one has greater thickness with longer fascicles of their gastrocnemius and vastus lateralis muscles on ultrasound imaging,than later one.(abe et al.,2001) The plantar flexion moment arms were 25% smaller of sprinters than those of non-sprinters and this difference was highly significant. garth and miller examined 17 athletes who presented for treatment of incapacitating pain and soreness located posteromedially along the middle two thirds of the Symptoms were aggravated by repetitive wt.bearing which was referred to as shin splints. Due to excessively pronation caused by hyper mobile midfoot flexible pes valgus, muscular imbalance etc, the flexor digitorumlongus and flexor hallucislongus can become overloaded and vulnerable to develop trigger points in these muscles. The lateral compartment syndrome is likely to develop in runners with excessive pronation and abnormally mobile subtalar joints can also be overloaded in high arched supinated foot with triceps surae weakness as well as can be suggestive of peroneus longus and brevis trigger points. Myofascial trigger points:-Travell and Simons defined it as a hyperirritable contraction knot usually present within muscles or its fascia which produces pain on compression and can give rise to specific referred pain ,motor dysfunction ,and autonomic phenomena in a specified referred zone which rarely coincides entirely with dermatomal segment. Trigger points are manually palpated with following characteristics including local twitch response, jump in sign, referred pain zones and autonomic phenomenal changes. As suggested by Travell and simons in 1999 in their trigger point manual book,the etiology of trigger points involves all three factors that includes biomechanical,CNS,and local myofascial tissues. As per microscopic and biopsy studies, which has been done of local myofascial tissue where there is presence of trigger points revealed and explained these contraction knots as round,large and,darkly staining fibers.presence of these knots causes significant increases in average diameter of muscles. spontaneous electrical activity (SEA) in TrPs have also seen and studied through electromyographic studies while adjacent muscle tissues were electrically silent which suggested and implicated neuromuscular junction and motor end plates interchangeable, nevertheless the motor end plates describes structure and the neuromuscular junction reflects function. Gunn and Milbrandt in 1977 was first explicated and find correlation between motor end plates and trigger points also known as myalgic spots . As stated by Travell and Simons in context to motor end plate dysfunction that due to  excessively release of Ach from presynaptic nerve terminal leads to rapid activation of the  nicotinic Ach receptors on the post synaptic terminal which results in muscle action potential and muscle contraction. Since this hypothesis of travell and simons was one way to interpret EMG results but EMG for post synaptic fibers ,there is increase in SEA in trigger points that could be a characteristics to the result of presynaptic,synaptic or post synaptic dysfunction and can be inherited or acquired. As a general rule, factors for the development of trigger points includes muscle overuse or direct/ indirect trauma which may be the results of sustained low level or repetitive muscle contractions,eccentric/concentric,submaximal/maximal muscle contractions. Although muscular damage is not necessary all the time for development of trigger points there may be injuries at the microlevel which includes damage of cell membrane ,sarcoplasmic reticulum with release of high amounts of ca2+ ions,and disruption of proteins like desmin,titin or dystrophin. Mechanical muscle contractions exceeding respective muscles capacity is defined as overuse.as we know that arterial capillary beds blood pressures approx 35mm hg at the beginning and venous capillary beds pressure at the end is 15mm Hg which used to be obstructed during muscle contractions and recovers with relaxation;known as muscular pump. However,Muscular metabolism is maintained by oxygen and glucose which faces crisis during sustained muscle contractions.Even contractions performed at only 10 % and 25 % of maximum voluntary contraction (MVC) may alter and produce impairment in blood circulation of muscles, As per Otten ;pain and trigger points may be developed by increased or alterations in the pressure gradients during low level exertions(personal communications 2005). During submaximal concentric contractions, ATP is utilized for 4-6 seconds initially from muscle’s storage and subsequentally it shifts to direct phosphorylation of ADP through creatinine phosphate. Stored ATP and CP provides enough energy and power for approx 14-16 sec but thereafter physiologically a short span of rest is needed to replenish the exhausted reserves of intracellular ATP and CP. As a general rule if ATP demands are within the capacity of the aerobic pathway muscles  can continue its activities for hours but as demand exceeds;anaerobic glycolysis will start contributing of the total generated ATP. This further leads to crisis of ATP and sustained sarcomere contractions starts the progression of trigger points. The Eccentric contractions are commonly used to control the rate of movement in our body. although there is no solid correlations between eccentric loading and development of trigger points. Itoh et al found in their study in which middle finger extensor muscle was being eccentrically loaded. After 3 sets of exercise ,one day and two days after exercises ,findings were similar encapsulating tender taut bands which were painful on compression;suggests that eccentric  loading may be correlated with development of trigger points. There are biopsy studies also who confirms and suggest the role of eccentric contractions in disruption of cytoskeletal structures especially desmin , and titin (largest in our body);a protein which interconnects the adjacent myofibrils and connects myosin filaments to the z-bands with a linkage to actin filaments ;respectively. Prolonged ecentric exercises enlarge the muscle fibers microscopically and all these enlarged fibers are exclusively fast glycolytic type(typeII) which considered as highly fatiguable and unable to regenerate ATP in early exercise period It results a high stiffness state of fibers which on stretch disrupts leading to cytoskeletal and myofibrillar damage. Apart from this in eccentric exercised muscles there is increase concentration of calcium due to sarcoplasmic reticulum disruption that keep actin and myosin molecules together an activates several mechanisms which may further damage cell membrane and cytoskeletal disruption and again the same results that is development of trigger points. Jump in sign is an response to pressure applied on a trigger point which may leads to wincing, crying, or withdrawing by patients. Local twitch response is a fleeting response or contraction of tense muscle fibers or group that traverse a trigger point on response to stimulation via snapping palpation or needling of trigger point or its surrounding area. Referred autonomic phenomena: vasoconstriction (blanching), coldness sweating, pilomotor response, ptosis, and/or, hyper secretion that occur in a same region or area where trigger points refers pain and its sensations. Referred pain zones: an area of pain which is entirely remote from its source. Generally  in case of trigger points ,specifically activated and central trigger points and sporadically  infrequently,conjoin entirely with the peripheral nerve distribution or dermatomal segments. The lower extremity functional scale (LEFS) is a functional status questionnaire that aims to investigate the degree of difficulty a patient experiences in performing everyday tasks, due to disorders of his/her lower extremity.The LEFS consists of twenty items, each of which is scored on a 5-point scale (0 to 4) (appendix 1). Beck depression inventory-ii is a depression measurement scale or an instrument to measure the emotional, motivational,somatic and cognitive symptoms observed in patients.this scale consist of 21 questions which is symptom related to quantify degree of depression in subjects usually it covers adolescents and adults and given in appendix 2. VAS is a psychometric response scale and a measurement instrument for subjective characteristics or attitudes that cannot be directly measured. Respondents specify their  level of agreement to a statement by indicating a position along a continuous line between  two end-points. Pressure algometer is force gauze with a rubber disk of 1 cm surface which is very helpful in clinical setup for diagnosing trigger points ,fibrositis,myalgic spots as well as it helps in quantification of pressure pain threshold and Pressure pain threshold for measurement of  normal and abnormal surfaces are given in appendix 3.

Valuing Wal-Mart

Assessment of Wal-Mart valuation using different methods To test the assumption of a discount rate of 7% as given in the outline of the case, we calculated the required rate of return for the Wal-Mart stock using CAPM . Using rWalMart = Rf + ? WalMart [E(RM) – RF], we find the required rate of return to be 7. 01% and in line with the information given in the case outline. Perpetual dividend growth model: The standard method of calculating a stock price using the perpetual dividend growth model is done by assessing a company’s dividend one year into the future adding the future expected growth rate.The Cardiovascular SystemThe formula is written as: P0 = D1/(Ke ? g), where Ke is the investor required return, D1 is next year’s dividend and g is the expected growth rate of the dividend. The standard method can however be rearranged if the company analyzed is consider in â€Å"steady state†. A steady state implies that the annual return on equity equals the co st of equity capital providing the rational that the dividend payout ratio is the sole determinant of the dividend growth. It requires some complexity to determine if a company has reached steady state.To investigate and analyze if Wal-Mart is in steady state, we would employ the following definition: Steady state value = free cash flow / discount rate . After careful consideration we have reached the conclusion that we find it fair and realistic to label Wal-Mart as such. This is further underlined by the maturity and stable performance of the company, which is illustrated in the stable revenue growth (exhibit 1), stable financial market stock data and relative stable dividend distribution (exhibit 3).Further, we are comfortable using the simplified steady state formula given the foreseeable forecasting period as we are only forecasting the stock price a few years in the future and not conduction long-term multiyear forecasting where the underlying assumptions of the model and the competitive landscape can dramatically change. We find evidence that the forecast period is essential in the selection of method in the INSEAD article â€Å"Selecting an accounting-based Valuation Model† of May 2011. If we were to forecast long-term price levels, we would opt for the conventional formula of P0 = D1/(Ke-g).Given the steady state nature of Wal-Mart we use the adjusted dividend growth model of: P0 = (E1 ? p)/ (Ke ? g), where g = (1-p)*Ke and where E1 is the earnings 1 year into the future and p is the payout ratio or the percentage of earnings paid in dividends. Using this method, P0 = (E1 ? p)/ (Ke – ((1-p)* Ke)), we estimate the stock price to be $58. 56 . For reference and to provide validation to our estimates, we have in addition estimated the stock price using the conventional dividend discount model of P0= (D1/(Ke-g). Using the conventional model we estimate the stock price to be $59. 8. We conclude that the estimated price of the stock is higher t han the current market price of $53. 48 , which means we believe there is unrealized intrinsic value, hence the stock is undervalued and should we be analyzing the stock on this basis only, our recommendation would therefore be buy. Forecasted Dividend for the next 3 years plus future sale of the stock: Instead of valuing the stock with infinite dividend approach, we use a set number of years (3) plus we included the value of selling the stock after the set number of years.The selling of the stock is represented in the model as a terminal value. The terminal value is the value of the company’s expected cash-flow beyond the forecast period. We estimate the terminal value by using the perpetuity method mentioned above and be employing the formula of Terminal Value (TV) = FCFt+1 / WACC . We used the approximation that WACC equals the required rate of return as found using CAPM (7. 01%, appendix 1). This also corresponds with the given discount rate of 7%.As we are asked to find to price by forecasting dividends for the next three years plus the selling of the stock after year three, we have extrapolate our findings from the perpetuity method using the earnings per share with the given earnings per share growth and the required rate of return. By calculating the dividend per share until D=3 and employing: P0 = D1/(1+Ke)^1 + D2/(1+Ke)^2 + D3/(1+Ke)^3+TV/(1+Ke)^3, where TV is the terminal value we calculate the present day intrinsic value of the Wal-Mart stock to be $62. 15 hence the market value is consider low compared to our forecasted value.This method replicates the basic foundation of the Discount Cash flow Model (DCF), which in our opinion is the preferred method in valuation studies. Three-Stage Approach: There are no questions about this approach in the outline of the assignment, so the following comments should be considered â€Å"back of an envelope† considerations. In general the three-stage approach allows us to add complexity to the stand ard dividend discount models by enabling changing growth scenarios throughout the forecasting period: an initial period of higher than normal growth, a transition/consolidation period of declining growth and final a period of stable growth.The main assumptions are that the company on which we conduct the calculation study currently is in extraordinary strong growth phase. The time period with the extraordinary strong growth must be strictly defined and eventually be replaced with the declining growth assumption. Lastly, Capital Expenditures and Depreciation are expected to grow at the same rate as revenues. . Analyzing exhibit 4 we see a theoretical stock price of $120. 37. Using the excel template and by entering the calculated discount rate and the data given in the case, we find the theoretic value to be $95. 68.We recognize the calculated theoretical value is considerable higher than the market value of the Wal-Mart stock, which could provide a strong indication for investing. H owever, we also recognize the weakness of the three-stage model thus we are careful to draw too decisive conclusion. We are especially concerned about the sensitivity and impact on the end theoretical price when making just marginal changes in the input factor. Valuation models in general are sensitive to the input factors, but we believe the extra complexity in the three-stage model amplifies even small forecast errors.We understand that the three-stage model can be very useful for companies approaching the transition phase between growth phase and consolidation, but Wal-Mart does in our opinion not fulfill this characteristic. Thus, leading us to conclude the three-stage model isn’t particularly applicable to valuation studies of Wal-Mart. Price/Earnings multiple approach: The debate on whether to use trailing or projected price/earnings multiple is ongoing. We have found evidence in literature that there is no clear preference on which method to use as both have advantages and disadvantages .We have no strong view or preference generally speaking, but in the case of Wal-Mart we believe there is a case for use trialing data rather than projected data. For reference we have calculated both using P0 = EPS * P/E . We see the range of estimates is very wide, which is due to the sensitivity of the input factors i. e. even small changes in the P/E-data will have significant influence on the estimated value at P0. We prefer to use the P/E multiple to assess how Wal-Mart is perceived and valuated against peers. In addition we use S&P500 as reference index and benchmark.Using the data in exhibit 6, we have identified Wal-mart, Target, The Gap and Costco to be peers. We have concluded this after examining key financial data of all the companies provided in the exhibit. We realize that Wal-Mart is not directly comparable with the peers mentioned given the much larger market capitalization and turn-over, but knowing this a comparability study still adds value in our opinion. Detailed data of the comparison is brought in appendix 5. Looking at the graphical representation we see a clear trend in the peer group of declining P/E-ratios.The trend is confirmed by further lower P/E-projections for the coming year. We are not overly concerned with the declining P/E ratios as it seems to be an industry wide trend and not isolated to Wal-Mart. Hence when assessing relative attractiveness of the grocery industry players, we do not see Wal-Mart having worse financial performance than the peers. As argued in the beginning of this paper in the section when discussing the steady state phase of Wal-Mart, we believe we can make a rough estimation of whether the P/E-ratio reflects a fair value of the stock or not. The method e employ is a rewritten method of the DDM. By arguing steady state we can also defend arguing Wal-Mart to be a zero growth company by assuming the company pays out all of its earnings in dividends. As we know from the data provided, thi s is not entirely reflecting the real scenario, however we still believe it adds value to the overall assessment of the value of the Wal-Mart stock. The rule of thumb argues that the P/E-ratio using the zero growth company assumption is fair when it equals the 1/r, where r is the discount rate meaning when Projected P/E = 1/r the P/E ratio is fair and reflects a fair value of the company.Based on the research in this section we have found no red flags in the financial performance or when analyzing with peers. The historical P/E-ratio of Wal-Mart has been higher than the industry average so the decline over the time period can at first glance look dramatic. However, we believe the declining P/E-ratio is an industry wide tendency and not isolated to Wal-Mart. Further, given the strong P/E-growth in the early part of the data sample the Wal-Mart P/E-ratio is also subject to a strong base effect.When applying the zero growth company fair value estimates, we see the projections made by t he analysts are lower than the 1/r which we for this purpose consider a fair P/E, which can be seen as a supportive factor for the overall valuation of the Wal-Mart stock. Conclusion and recommendation: As indicated in the text above we have the most confidence in the first two methods in the paper. Taking a simple average of our findings we estimate the Wal-Mart stock price – or fair value – to be $60. 16 (58. 56; 59. 78; 62. 5), which is higher than the current stock price of $53. 48 hence we believe the Wal-Mart stock is $6. 68 or 12. 49% undervalued. Further, we find our estimates to be in line with the general analyst consensus target price of $60. 50. Given our findings and research we will recommend Gupta to buy the Wal-Mart stock. However, we recommend Gupta to employ a margin of safety. We recognize that our calculated price estimates have considerable projection risk given the future value is calculated based on estimates.It is out of scope for this paper to evaluate the quality of the projections and forecasts, so we recommend Gupta to be conservative in communicating the price target. We suggest communicating the buy recommendation with an initial price target of $57. 75, which is +8% from the current market price. When the $57. 75 price is achieved we recommend running the models again to get validation on the $60. 16 price target. We recommend this step-by-step approach as margin of safety for projection inaccuracies. Given the time and year of the research done, we find further evidence that employing a margin of safety is a solid strategy.This is especially due to the distressed situation of the financial markets after the collapse of the financial system starting in 2008. Given the unusual market situation any investments in stock or other financial instruments are subject to considerable risk from external factors, hereunder risk appetite, liquidity and macroeconomic developments, which currently are not properly factored in our price estimates. However, we are encouraged to invest in Wal-Mart given the defensive characteristics of the stock compared to the S&P500 benchmark given ?

‘Looking for Alaska’ by John Green Essay

‘Looking for Alaska’, John Green’s Debut novel was published in 2005.The novel is about a group of lost, but additionally very intelligent teenagers, who attend Culver Creek Boarding School for their first junior year. They are on the contrary to shallow, more or less precise opposite; Alaska Young, Miles Halter and Chip Martin’s thought are as deep as the Mariana trench. Their complicated way of looking at life, thirst for an adventure, seeking simplicity and comprehension in an intricate world will eventually end up hurting them. â€Å"If people were rain, I was drizzle and she was a hurricane† was Miles imagery of Alaska after her tragic death. Even though the novel is written via Miles perspective the entire structure of the story revolves around Alaska’s death. This is from one hundred and thirty six days before, where we see Miles as a dull, anti-social geek; to one hundred and thirty six days after where we see Miles as ‘Pudgeâ₠¬â„¢, a well developed man with friends, who smoked cigarettes and drank wine. Even before the actual death occurs, death is a recurring theme, from Alaska’s mother’s death to Miles trying to find out what happens to oneself upon dying. Miles is obsessed with peoples last words; dying words. The very actual thought of last words completely fascinates him. Alaska is a character in this book who is completely associated with death. It has played an important role in her life and will play an important role in the lives of the characters lives after her life is brought to an abrupt end. It makes the characters rediscover so much more about about themselves. We become acquainted with the characters through their actions and conversations. Alaska Young behaves in a most reckless manner.is such an interesting, beautiful, enigmatic individual, nevertheless so self-destructive. Just two days before she is gone forever, the boys learn that they hardly knew the girl they love so fervently (during ‘Barn Night’). January 9th, 1997 was the turning point in Alaska’s life. She was barley eight years old but witnessed her mother’s death, sitting by her side and watching the life draining out of her. Alaska never called the ambulance or made an attempt to save her mother. This had ruined her. Eight year old Alaska drowned he rself in guilt. Her extreme unpredictalbililty and spontaneity was most likely an effect of ‘ failing her mother’. She had her moment and didn’t take it. This effected the way she handled spontaneous situations in the future. Alaska would never think twice about her actions or reflect the possible consequences. This  eventually gets her killed. In the final religion exam, the students have to pick what they think is the most important question human beings must answer, and examine how Buddhism, Islam and Christianity (three world religions) attempt to answer it. Miles chooses to examine the question ‘What will happen to us when we die?’. Miles will never find the answer until he experiences it, but chooses to settle with a fact from science class; energy is never created and never destroyed. In religion the soul flies to heaven and peoples beliefs give them answers to everything. Alaska on the other hand isn’t a believer; the question related to her mother’s death drives her crazy. Among a variety of metaphors, the imagery of the labyrinth is a main throughout the novel. â€Å"How will I ever get out of t he labyrinth of suffering?†. Alaska dwindles into the boundless depths of this question. Is the labyrinth living or dying-the world on the end of it? The labyrinth answers the endless anwerless questions life brings. In this novel, Alaska is the labyrinth; she traps herself in an evil circle of answerless questions that force her deeper into the depths of sufferings. She cannot free herself from herself. The novel’s message is philosophical. it is about looking past a list of answerless questions in life, and not fold yourself into self-destruct. If Alaska killed herself, it was out of hopelessness. People kill themselves because it seems the only way out of the labyrinth of suffering; the flame of hope they carry is extinguished. But it never is as Green concludes. Alaska Young was to deep in the enigma of frustration over her answerless questions and guilt. There are many instances where Miles tries to figure out how Alaska’s death occurred, why it happened, what really are about, and Alaska Young’s last words. Death plays an important part in life, although many people fail to see it. It is a subject most people avoid talking about, as the thought itself scares them, but it is important to face death and be aware that it can touch anyone in anyway close to you. The book uses death as an aspect to show the readers that death is something inevitable, but we can never become ready for it.

Fahrenheit 451 Essay On Knowledge - 1532 Words

â€Å"Knowledge is more than equivalent to force!† As understood by Dr. Samuel Johnson, knowledge has an immense power and vast potential. Something as seemingly simplistic as the understanding of the concept of knowledge is often underestimated, it not only has the ability to help individuals, but hurt them. Though it is not physical, it has the capacity to cause more pain than any weapon, but simultaneously heal the deepest of wounds. Knowledge is defined as the awareness of or familiarity with a concept, gained through experience, fact or situation. In the novel Fahrenheit 451 knowledge refers to being aware of the society you live in, it s flaws and it’s successes as well as the control media now has over the population. It is the†¦show more content†¦With technology is where Mildred finds herself feeling most at home. Through her family in the walls and her â€Å"Seashells† she is ignorant to the society around her. The first introduction of Mildre d is her being passed out, with the shells in her ears when Montag arrives home. For the first time, Montag is slightly more enlightened on the world around him, as ideas such as dew on the grass in the morning, the existence of a man in the moon, and his own happiness are introduced to him by a seventeen year old girl named Clarisse. These ideas are the first taste Guy has of true knowledge, and the effects of the information are seen through his relationship with Mildred. Towards the beginning of the novel, this separation is minor, and manageable. Guy attempts to discuss the events of the night prior, which included his wife’s overdose, and his concern for her. While he discussed his concerns â€Å"She was quite obviously waiting for him to go. â€Å"I didn t do that,† she said. â€Å"Never in a billion years.† (Bradbury 17) This, is the first instance where we Andersen 3 see Mildred’s frustration with Guy over his knowledge. She is angered by his ideas as she does not understand how she is being controlled by the media around her,and has no memory of the event happening. Her lack of interest in anything but media causes her to push Guy away further, insulting him and complaining about their lack of a fourth parlour wall, saying that It s only two thousand dollars, [and]Show MoreRelatedAnalysis Of Ray Bradbury s Fahrenheit 451 875 Words   |  4 PagesGiridhar Batra Ross-1 Aug 29. 2014 Fahrenheit 451 Essay The Role of Technology as a Theme in Ray Bradbury’s Fahrenheit 451 The average person in our society spends 7-8 hours a day(The Washington Post) using technology; that is stuff like television, video games, surfing the web, etc. Let that set in; that’s a long time. Our society procrastinates also is constantly distracted by technology like no other. 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