Effects of Ultrasound Therapy on MCL Injuries

Effects of Ultrasound Therapy on MCL Injuries The medial collateral ligament (MCL) is one of the most frequently injured ligaments of the knee joint. Fortunately, most patients who sustain MCL injuries are able to achieve their previous level of activity without the need for surgical treatment. However, the most severe injuries, especially those involving multiple ligaments, may require operative repair. This study will explore the effectiveness of a conservative treatment, namely ultrasound therapy and exercise therapy, in the treatment of MCL injuries of the knee joint. In a review by Phisitkul, James, Wolf, and Amendola (2006), treatment with early range of motion (ROM) exercises and progressive strengthening has been shown to produce very good results. Ultrasound therapy has been a widely used and well-accepted physical therapy modality for musculoskeletal conditions for many years. Wong, Schumann, Townsend, and Phelps (2007) performed a survey about the use of ultrasound by physical therapists who are orthopaedic specialists, and found that ultrasound therapy is a popular adjunct in orthopaedic physical therapy and that it is perceived as important. However, the lack of studies confirming its benefits has led many to question this traditional view. Indeed, many studied which explored the effectiveness of ultrasound therapy failed in establishing a definite conclusion. Nevertheless, it cannot be assumed that this lack of evidence implies that ultrasound therapy is ineffective, and thus further research is needed to establish the adequacy of its use. This study aims at answering the following crucial questions: In patients with MCL injuries of the knee, can ultrasound improve pain, disability and general recovery? Is it more effective than exercise therapy in improving symptoms? An answer to these questions will help to better direct physiotherapy treatment for these patients, and thus optimize recovery. Subsequent chapters will discuss the current literature available on the subject, followed by the methodology used in this study. The results are then presented and analysed. The interpretation of results in the context of previous research will be discussed in the discussion chapter, including the strengths and limitation of the study. Literature Review Ultrasound therapy has become commonly used in soft tissue injuries (Speed, 2001). Research carried out in the past few decades regarding the effects of ultrasound on body tissues will be discussed below. My aim is to review the research available from the past years in attempt to find conclusive and consistent results regarding the effects of ultrasound, and thus to justify the use of ultrasound in the clinical setting, specifically to treatment of medial collateral ligament injuries. As will be discussed in this chapter, when ultrasound enters the body, it is thought to exert an effect on it through thermal and non-thermal mechanisms (Robertson, Ward, Low, Reed, 2006, p.266). Some of these effects may stimulate healing; however others may be dangerous and may cause damage. Thermal effects of ultrasound As ultrasound waves travel trough body tissues, they cause oscillation of particles, thus converting sonic energy into heat energy. The amount of heat produced will greatly depend upon the intensity given and the rate of energy absorption, but also on certain tissue properties, such as the heat capacity, efficiency of heat transfer, and the tissue distribution and space (Robertson, Ward, Low, Reed, 2006, p.266). Some authors have suggested pre-heating the area of treatment to achieve a greater increase in tissue temperature (Draper et al 1998a). Living tissue will be affected by an increase in temperature in various different ways. According to Speed (2001), the thermal effects of ultrasound include an increased extensibility in tissues, enhanced blood flow, pain modulation, decreased joint stiffness and muscle spasm, together with a mid inflammatory response. These could explain why a temporary increase in range of motion is observed after ultrasound treatment (Draper et al., 1998b; Knight et al., 2001). Hayes, Merrick, Sandrey and Cordova (2004) studied the extent of heating in tissue at 2.5cm depth and found that 3MHz ultrasound was more effective in heating the tissues at this depth than 1MHz, reaching a temperature of 40 degrees Celsius after 4 minutes. Unfortunately the production of heat may place the patient at risk of a skin burn if applied incorrectly (Robertson, Ward, Low, Reed, 2006, p.290). Physical effects of ultrasound Cavitation Cavitation is the formation of tiny gas bubbles in the tissues as a result of ultrasound vibration (Robertson, Ward, Low, Reed, 2006, p.267). Johns (2002) explains how as sound waves travel through the tissues, the characteristic compression and rarefaction causes microscopic gas bubbles present in the tissue fluid to contract and expand. Injury to the cell may occur when these gas bubbles expand and collapse rapidly. Nevertheless, cavitation has been found to occur only when using high intensities, and thus it is unlikely to occur in vivo with therapeutic levels (Nyborg, 2001). However according to a review by Baker, Robertson, and Duck (2001), there are a few studies which suggest the existence of in vivo cavitation. Baker and his colleagues argue that these studies were not replicated and that results obtained may have been due to difficulty with the analysis of B-scan imaging, which were used to measure cavitation. A recent study investigated the method by which cavitation is de tected. The wavelet approach was identified as a new tool for studying bubble cavitation (Zhou, 2008). Cavitation becomes clinically relevant during ultrasound applications in water, as bubbles that form between the skin and the treatment head may block transmission of ultrasonic waves (Ward Robertson, 1996). Acoustic streaming Acoustic streaming may be described as a flow of liquid caused by a generation of pressure along the axis of the beam of energy and on any other structures which reflect it (Robertson, Ward, Low, Reed, 2006, p.268). There are two types of acoustic streaming: microstreaming and bulk streaming (Duck, as cited in Baker, Robertson Duck, 2001). Bulk streaming occurs in any fluid and develops as the ultrasound beam is propagated, while microstreaming occurs at a microscopic level and is formed as eddies of flow flanking to an oscillating surface (Robertson, Ward, Low, Reed, 2006, p.268). Unfortunately bulk streaming is much less mechanically powerful, with microstreaming being the only type of acoustic streaming which is able to stimulate cell activity and change membrane permeability (Duck, as cited by Baker, Robertson, Duck, 2001). Microstreaming can produce stress on the cell membrane and wash away any molecules and ions which accumulate outside the cell membrane (Robertson, Ward, Low, Reed, 2006, p.268). According to Duck (as cited by Baker, Robertson, Duck, 2001), only bulk streaming occurs in vivo, because microstreaming only occurs secondary to cavitation. In vitro studies show increased growth factor production by macrophages (Young and Dyson, 1990a), increased calcium uptake (Mortimer and Dyson, 1988), increased secretion and degranulation of mast cell (Fyfe and Chahl, 1984) and increase cell membrane permeability (McCance and Huether, as cited by Baker, Robertson, Duck, 2001) by microstreaming. This however will have minimal relevance in the clinical se tting if one assumes that cavitation will not occur. Nevertheless, Manasseh, Tho, Ooi, Petkovic-Duran, and Zhu, (2010), suggest that microstreaming which occurs secondary to cavitation will play a role in the action of microbubbles in therapeutic ultrasound. Standing waves Standing waves are formed when reflected sound waves are superimposed with incident waves, and are characterized by high pressure peaks, the antinodes and zones of low pressure known as nodes (Robertson, Ward, Low, Reed, 2006, p.267-8). Ter Haar and Wyard (1978) put forward that blood cell stasis may occur with ultrasound, with cells forming at half wavelength intervals in the blood vessels at antinodes. These results match those by Dyson, Pond, Woodward, and Broadbent (1974). The latter studied the effect of a stationary wave on blood cell stasis and endothelial damage in blood vessels of chick embryos. The cells form bands half a wavelength apart inside blood vessels. They suggest that under optimum conditions, the minimum intensity of less than 0.5 Wcm-2 at 3 MHz with continuous irradiation is required for stasis to occur. Damage to some endothelial cells of vessels in which stasis has occurred was revealed by an electron microscope. Thus, it is suggested that the treatment head is continuously moved during the treatment to minimize the formation of standing waves (Robertson, Ward, Low, Reed, 2006, p.268). The effect of ultrasound on repair of body tissues According the following research, ultrasound therapy may have an effect on cells involved in repair of body tissues, including: Levels of prostaglandins and leukotrienes Leung, Ng, and Yip (2004) performed a randomized, case-control study to study the effect of ultrasound during the acute inflammation of soft-tissue injuries. They measured the levels of leukotriene B4 and prostaglandin E2 in the medial collateral ligament of rats and found that pulsed ultrasound (1:4) applied for five minutes at different durations and intensities may stimulate acute inflammation by increasing the levels of the above mentioned leukotriene and prostaglandin. Release of fibroblast from macrophages Young and Dyson (1990a) studied if ultrasound therapy can increase the release of fibroblast mitogenic factors from macrophages in vitro, and assessed fibroblast proliferation over five days. This study showed an increased secretion of already formed fibroblasts in macrophages at 0.75 MHz ultrasound, which may be caused by permeability changes. On the other hand, at 3 MHz frequency, ultrasound appeared to encourage both the synthesis and secretion of fibroblast mitogenic factors. The reason why these two frequencies cause different effects may be explained by the different physical mechanisms involved. Williams (as cited in Young, 2002, p. 217), argues that cavitation is more liable to occur at lower frequencies, while at a higher frequency heating is more likely. Platelets and ÃŽÂ ²-thromboglobulin Williams, Chater, Allen, Sherwood, and Sanderson (1978) investigated the effect of ultrasound on platelets and established that more ÃŽÂ ²-thromboglobulin, a platelet specific protein, was released by ultrasound therapy. They suggest that this protein is released both by the disruption of platelets by cavitation and by other aggregating agents liberated in parallel with it which cause a release reaction in the adjacent platelets. This however, has not been proved to happen in vivo. Histamine release from mast cells Fyfe and Chahl (1984) suggest that ultrasound applied in the therapeutic range causes a significant increase in degranulated mast cells and thus an increase in histamine release, in rats. They suggest the possibility that ultrasound increases the permeability of mast cells to calcium causing them to degranulate, resulting in an increase in local blood flow. On the other hand, when Hogan, Burke, and Franklin (1982) investigated the change in blood flow in rat muscle on insonation, they found that arterioles vasoconstrict transiently in response to insonation, but improve perfusion after long-term treatment. Increase membrane permeability to calcium Change in the permeability of membranes to calcium has been demonstrated when using therapeutic ultrasound. According to Al-Karmi, Dinno, Stoltz, Crum, and Matthews (1994), applying ultrasound for two minutes will cause a significant boost in ionic conductance in the presence of calcium ions, thus confirming that calcium ions influence the biological effects of ultrasound. Dinno et al. (1989) also used a frog skin model to study the effect of ultrasound on membranes. They argue that the increase in the concentration of calcium ions inside cells which occurs after the application of ultrasound, may decrease the permeability of gap junctions and uncouple cells in the way by which cells differentiate. Therefore, they concluded that ultrasound can affect cell differentiation and consequently histogenesis, and thus its use should be avoided over embryonic tissue. Growth factor secretion Ito, Azuma, Ohta, and Komoriva (2000) applied ultrasound to a co-culture system of human osteoblastic and endothelial cells and studied their effect on growth factor secretion. Their study showed that ultrasound increases the levels of platelet-derived growth factor. This may be the reason for improved fracture healing rate with ultrasound treatment, as discussed later. Fibroblasts and Collagen synthesis Ramirez, Schwane, McFarland, and Starcher (1997), conducted an investigation to determine the effect of ultrasound on the rate of cell proliferation and collagen synthesis by using cultured fibroblasts form the Achilles tendons of neonatal rats. They found an increase in collagen synthesis and rate of thymidine incorporation and DNA content after ultrasound treatment, suggesting that ultrasound stimulates the synthesis of collagen in tendon fibroblasts and cell division after injury. In a more recent study Chiu, Chen, Huang, and Wang (2009), studied the effect of ultrasound on the proliferation of human skin fibroblasts at different frequencies. They applied ultrasound for three minutes daily for three days and found an increase in fibroblast proliferation by both 1 and 3 MHz frequencies, with less stimulation when using 0.5 MHz frequency. Chiu et al., also took into account temperature changes and found a change of only one degree Celsius after insonation, thereby implying that the results observed where due to non-thermal effects. This can be explained by the increase in protein synthesis found to occur in fibroblasts after ultrasound treatment. Harvey, Dyson, Pond and Grahame (1975) suggest that therapeutic ultrasound at 3 MHz frequency and at an intensity of 0.5 2.0 Wcm-2, can directly stimulate protein synthesis in fibroblasts, without any other cells acting as mediators. In fact they attributed this to membrane-associated changes. Nevertheless, the increase in fibroblast proliferation may occur as a result of the effects of ultrasound on macrophages, which release fibroblasts mitogenic factors (Young Dyson, 1990a), as previously discussed. Ultrasound not only stimulates fibroblasts to produce more collagen (Ramirez et al. 1997), but the collagen produced also has a higher tensile strength and is better organized and aggregated. Okita et al. (2009) studied joint mobility and collagen fibril arrangement in the endomysium of immobilized rat soleus muscle, and showed that therapeutic ultrasound may prevent changes in joint mobility and collagen fibril movement which occur with immobility. In contrast, when Larsen, Kristensen, Thorlacius-Ussing and Oxlund (2005) studied the influence of pulsed ultrasound at 3 MHz frequency and different intensities, on the mechanical properties of healing tendons in rabbits, they found greater extensibility after insonation with higher intensities, however there was no significant change of the point of rupture when the tendons were loaded, suggesting that pulsed ultrasound did not improve the mechanical properties of the healing tendons. Angiogenesis Therapeutic ultrasound may also affect the rate of angiogenesis. Young and Dyson (1990b) considered the formation of new blood vessels in full-thickness lesions of flank skin in adult rats and found that by day 5 post-injury, ultrasound treated wounds had developed a greater number of blood vessels, and were thus at a more advanced stage in the repair process. However by the seventh day, there was no significant difference between the groups. Therapeutic mechanism On the basis of these conflicting results, two schools of thought were developed. The evidence-based or factual school considers heat as the only effect of ultrasound therapy and thus emphasise the use of high doses and give little value to low intensity and pulsed treatment. This view is found in most American writing about this subject. On the other hand, the other school of thought is largely European, and is more involved in the biological and mechanical effects of pulsed low-intensity treatments (Robertson, Ward, Low, Reed, 2006, p. 269). Robertson, Ward, Low, Reed, (2006, p. 269) suggest that clinical studies may be used to investigate which doses produce better outcomes. In vitro studies can provide a dose-response relationship which may provide information about the most effective dose. Nevertheless, effects demonstrated in vitro, such as cavitation and acoustic streaming have not yet been shown to occur in vivo, since it is difficult to produce doses in vivo which are comparable to dose in vitro. They argue that in vitro, ultrasound is applied to only a thin layer of cells, and thus the noted changes do not necessarily occur when applied to a much larger volume of tissue in vivo. Moreover, in vitro the energy is confined to a very small volume and thus the power density will be much higher than in vivo. Therapeutic effects of Ultrasound Ultrasound therapy has been claimed effective in a wide range of clinical conditions, however there are still difficulties in establishing the effectiveness of ultrasound with certainty and in identifying a dose-response relationship, if there is any. Some of the alleged effects of ultrasound include promotion of fracture healing, soft tissue healing, articular cartilage repair, pain relief, increase local blood flow, change the extensibility of scar tissue and for the diagnosis of a stress fracture, and will be discussed below. Fracture healing Ultrasound has been proposed to promote the processes involved in fracture healing and thus increase its rate. Sun et al., (2001) investigated the effects of low-intensity pulsed ultrasound on bone cells in vitro, and found a significant increase in osteoblast cell counts and a significant decrease in osteoclast cell count after stimulation, suggesting a positive effect on the bone-healing process. Nolte et al., (2001) also studied the in vitro effects of low intensity ultrasound. The latter used foetal mouse metatarsal rudiments and found an increase in length of the calcified diaphysis, which was significantly greater in the ultrasound treated groups compared to the untreated groups, after 7 days. Therefore they concluded that low-intensity ultrasound directly affects osteoblasts and ossifying cartilage, with consequential more active ossification. Cyclooxygenase-2 regulates the production of Prostaglandin E2 by osteoblasts, both of which are thought to be an essential part of fracture healing (Zhang et al., 2002). Ultrasound stimulation has been found to increase cyclooxygenase-2 expression and to promote bone formation in osteoblast via various signalling pathways (Tang et al., 2006). Together with prostaglandins, nitric oxide is a crucial mediator in early mechanically induced bone formation. Reher et al., (2002), investigated the effect of traditional (1MHz, pulsed 1:4) and a long-wave (45 kHz, continuous) ultrasound on nitric oxide induction and prostaglandin E2 production in vitro, on human mandibular osteoblasts. A control group was set which was treated with sham ultrasound. They found a significant increase in both induced nitrate and prostaglandin E2 production. Long wave ultrasound was found to be more effective than the traditional ultrasound. Other studies suggest that ultrasound may have an effect on the regulation of genes necessary for osteogenesis. Suzuki and his colleagues (2009) studied the typical osteoblastic cell line in the presence or absence of daily low intensity pulsed ultrasound stimulation at 1.5 MHz frequency, and 30 mW/cm2 intensity, for 20 minutes, for 2 weeks. They concluded that stimulation with these parameters directly affected osteogenic cells, leading to mineralized nodule formation, thus low intensity pulsed ultrasound therapy is likely to have an influence on the activities of osteoblasts in alveolar bone. Clinical studies gave controversial conclusions in this area. In a review, Busse et al., (2002) concluded that evidence form randomised controlled trials suggest that low intensity pulsed ultrasound therapy may significantly reduce the time of fracture healing for non-operatively treated fractures. Five years later, Walker, Denegar, and Preische, (2007) confirmed this finding through another review. Moreover, Della Rocca (2009) reviewed studies about the effects of low-intensity pulsed ultrasound treatment in fracture healing and found a large body of animal and cellular research which shows this to be beneficial in simulating faster normal fracture healing. However, from a review to of randomised controlled trials to determine the effectiveness of low intensity pulsed ultrasound in fracture healing, Busse et al., (2009), concluded that the evidence available has a moderate to very low quality and provides conflicting results. Pain relief There are a very small number of studies which investigate the effectiveness of ultrasound in pain relief. Nevertheless, assuming that ultrasound promotes healing and resolves inflammation, pain should consequently decrease. Levent, Ebru, and Gulis (2009), used a randomised controlled trial to study the effect of ultrasound therapy in knee osteoarthritis. They applied ten sessions of five minutes of continuous ultrasound at 1 MHz to the experimental group and sham ultrasound to the control group to act as a placebo. They assessed pain by a visual analogue scale (VAS) and found that the decrease in pain in the experimental group is statistically significantly more than the control group. Thus they concluded that therapeutic ultrasound can be used effectively as a pain relief modality in patient suffering from knee osteoarthritis. An earlier review by Brosseau et al., (2001), did not show ultrasound as clinically important for pain relief in people with patellofemoral pain syndrome. However, they were unable to draw a conclusion regarding its use due to methodological flaws and limitations in the studies included in this review. Soft tissue injuries Wilkin, Merrick, Kirby and Devor (2004) studied the effect of pulsed ultrasound applied once daily for a week, on the healing of skeletal muscle in eighty rats. The results suggest that pulsed ultrasound as administered did not accelerate or improve regeneration of skeletal muscle tissue after contusion. Similarly, Markert, Merrick, Kirby and Devor (2005), using a randomized controlled trial with rats, found no evidence that specific continuous ultrasound and exercises protocols enhance skeletal muscle tissue regeneration following contusion injury. Takakura et al. (2002) investigated the effect of low-intensity pulsed ultrasound on the rate of healing of injured medial collateral ligaments of rat knees and found a significant improvement in the mechanical properties on the twelfth day, which however was lost by the twenty-first day. Nevertheless they also observed a larger mean fibril diameter in the ligaments treated with ultrasound, concluding that low intensity pulsed ultrasound enhances the early healing of medial collateral ligament injuries. Ebenbichler et al., (1999) investigated the effect of ultrasound in the treatment of calcific tendinitis. This study suggests better outcomes with ultrasound treatment. Since only patients with calcific tendinitis diagnosed by diagnostic imaging were included in the study, results are more valid than if numerous shoulder pathologies with different cellular process were included. This study was included in the review by Alexander et al., (2010). The latter carried out a review from various electronic databases and identified eight randomised controlled trials out of a total of seven hundred and twenty seven, which met their inclusion criteria. All the studies reviewed focused on shoulder musculoskeletal disorders. They concluded that statistically significant improvements were observed generally in studies which used higher levels of total energy and those who used longer exposure times. They noted favourable outcomes when at least 2,250J per treatment session was applied. This is fur ther suggested by the frequency resonance hypothesis, which suggests that the mechanical energy produced by the ultrasound wave may be absorbed by proteins, altering the structure of individual proteins or changing the function of a multi-molecular complex. Thus it may affect enzymatic proteins, inducing temporary conformational shifts, and thus alter the enzyme activity and cell function. This hypothesis implies that different frequencies will cause unique resonant or shearing forces which will therefore have specific effects at cellular and molecular levels (Johns, 2002). Thus further reviews should address different parameters used in different studies, in attempt to establish effective doses. Blood flow Noble, Lee, and Griffith-Noble (2007) applied ultrasound at 3 MHz frequency and 1 Wcm-2 for 6 minutes to assess its effect upon cutaneous blood flow by laser Doppler flowmetry. They also measured skin temperature. They concluded that cutaneous blood flow increased significantly with ultrasound even though no significant changes in temperature had occurred. Nevertheless, blood flow changes in skeletal muscles have not yet been established. Robinson and Buono (1995), investigated the effect of continuous ultrasound on blood flow using 1.5 Wcm2 intensity for 5 minutes and found no significant change in skeletal muscle blood flow. Wound healing Other authors have studied the healing rates varicose ulcers by ultrasound and found more marked healing of insonated ulcers (Dyson, Franks, Suckling, 1976). However more recent studies suggest that ultrasound does not have an influence on the acceleration of healing or final stage of the wound healing (Dolibog, Franeki, Taradai, Blaszczak, Cierpka, 2008). Different findings may be attributed to the different nature of the injuries studied and the different way by which the effectiveness of ultrasound is assessed. Diagnosis of stress fractures Romani and his colleagues (2001), were some of the few people who investigated the effectiveness of ultrasound therapy in the diagnosis of stress fractures. They used 1 MHz of continuous ultrasound therapy in twenty-six subjects with pain in the tibia since less than 2 weeks. Each subject completes a visual analogue scale after each different intensity was applies to assess the pain response to ultrasound. An MRI was taken to ascertain the diagnosis. However none of those who were found to have a stress fracture by MRI were correctly diagnosed by ultrasound. Following this review of literature, it is suggested that there may be a specific therapeutic window for ultrasound therapy. Conflicting results were obtained, possibly due to the different doses and frequencies used in various studies, indicating the need for further future research to identify the most effective parameters. Fortunately, none of the studies reviewed mentioned any negative effects on patients, making ultrasound a relatively safe modality when precautions are taken, and thus would make an important physiotherapy modality if its use is justified.

Investment Property Essay

The objective of this Standard is to prescribe the accounting treatment for investment property and related disclosure requirements. Investment property is property (land or a building—or part of a building—or both) held (by the owner or by the lessee under a finance lease) to earn rentals or for capital appreciation or both, rather than for: (a) use in the production or supply of goods or services or for administrative purposes; or (b) sale in the ordinary course of business. A property interest that is held by a lessee under an operating lease may be classified and accounted for as investment property provided that: (a) the rest of the definition of investment property is met; (b) the operating lease is accounted for as if it were a finance lease in accordance with IAS 17 Leases; and (c) the lessee uses the fair value model set out in this Standard for the asset recognised. Investment property shall be recognised as an asset when, and only when: (a) it is probable that the future economic benefits that are associated with the investment property will flow to the entity; and (b) the cost of the investment property can be measured reliably. An investment property shall be measured initially at its cost. Transaction costs shall be included in the initial measurement. The initial cost of a property interest held under a lease and classified as an investment property shall be as prescribed for a finance lease by paragraph 20 of IAS 17, ie the asset shall be recognised at the lower of the fair value of the property and the present value of the minimum lease payments. An equivalent amount shall be recognised as a liability in accordance with that same paragraph. The Standard permits entities to choose either: (a) a fair value model, under which an investment property is measured, after initial measurement, at fair value with changes in fair value recognised in profit or loss; or (b) a cost model. The cost model is specified in IAS 16 and requires an investment property to be measured after initial measurement at depreciated cost (less any accumulated impairment losses). An entity that chooses the cost model discloses the fair value of its investment property. Fair value is the price that would be received to sell an asset or paid to transfer a liability in an orderly transaction between market participants at the measurement date. An investment property shall be derecognised (eliminated from the statement of financial position) on disposal or when the investment property is permanently withdrawn from use and no future economic benefits are expected from its disposal. Gains or losses arising from the retirement or disposal of investment property shall be determined as the difference between the net disposal proceeds and the carrying amount of the asset and shall be recognised in profit or loss (unless IAS 17 requires otherwise on a sale and leaseback) in the period of the retirement or disposal.

John Adams, Facts and Brief Biography

My Goals For My Internship - 844 Words

My goals for the start for my internship were simple, but quickly evolved. My goals were to gain experience and build my resume, while bringing the lessons I have learnt in college, and using my skills as an engineer to help the department of public works. Now my goals have become more specific; I would like to learn more about sewer operations, I would like to develop my computing and design skills using the tools available to the Hydraulic section and I would like to mature as an engineering professional. While at the hydraulics section, I have access to programs like MUNSYS, as well as ArcGIS. As an intern, I update and maintain sewer related features on these programs. I would like to learn everything I can to develop my skills as a designer to help me become a better engineer. I have learnt from professors as well as other professionals that the key to a successful employee or even a successful person is to have above average communication skills. As an engineering intern, I would like to develop effective communication skills to help better myself and the team I work with. I would like to develop my skills in nonverbal communication, an ability to communicate clearly and assertively, and to manage stress in the moment. On a recent investigation, I learnt the importance of researching thoroughly before communicating the results of your investigation. A big mistake would be to communicate with a property owner about their surrounding sewer lines without having all theShow MoreRelatedMy Experience At Wyomissing Home Depot Human Resources Department942 Words   |  4 PagesDuring this internship experience, I have learned many useful skills that have lead me to be the person I wan to be today. From college classes to work experience, I now have the ability t o transcend upon internship experiences that can shape my perspective of life. For my last internship, I chose to intern at The Wyomissing Home Depot Human Resources Department. The human resources associates are responsible to maintain a positive work environment among employees. For the most part, human resourcesRead MoreMy Internship And The Washington Center Program898 Words   |  4 Pages From the beginning of my internship to the end, my plans for the future have become even clearer as I have completed my internship and the program. I came into this internship with a general idea of what I wanted my future to look like, such as getting my masters, joining the military, and working for federal law enforcement. However, now after completing my internship and The Washington Center program I have a better idea of what I want my immediate future to look like after I graduate collegeRead MoreA Research Study On Clinical Research1476 Words   |  6 Pages1. Describe the type(s) of internship(s) you are seeking this summer. This summer, I have been seeking clinical research internships. These include any research that is conducted in a hospital setting and correlates to patients. I would be developing my research skills in a laboratory setting while also developing intrapersonal skills working with patients. The research that I have conducted at the University of Richmond has been invaluable; however, I plan on applying to an MD/PhD program andRead MoreInternship At Metropolitan State University Of Denver1521 Words   |  7 Pagessuch as clinicals, externships, internships, hands-on experience, and so forth, but these terms basically mean the same thing (Makely, 2013). Enrolled as a Health Care Management student at Metropolitan State University of Denver, one of the requirements is to complete a 150 hour internship that is related to health care management. The internship is an opportunity to apply knowledge and skills that I have acquired during the classroom and the online portion of my training, in an actual health careRead MoreBecoming A Counselor, Therapist, Or Psychiatrist886 Words   |  4 Pages As a sophomore in college, I have a good idea what my current career goal is, related to my major in psychology, and how I think an internship will help me reach this goal. My overall career goal, or dream, is to combine my love and passion for music with my desire to help people. My major in psychology is how I plan on reaching my goal of helping people by possibly becoming a counselor, therapist, or psychiatrist. The main group of people I am interesting in helping are kids and teenagers withRead MoreMy Plans For The Future885 Words   |  4 Pages From January to May my plans for the future have become more clear to me as I have completed my internship and the program. I came into this internship with a general idea of what I wanted my future to look like, such as getting my masters, joining the military, working for federal law enforcement. However, now after completing my internship and several LEAD classes I have a better idea of what I want my immediate future to look like after I graduate college. I plan to apply to as many agenciesRead MoreThe Food Service Position At Missouri State University ( Msu )937 Words   |  4 PagesBefore my undergraduate studies, my interest in dietetics began with the culinary side of food, and then grew to a fascination of how nutrition impacts health. This fascination evolved from collecting recipes and looking for peanut allergy alternatives, to transitioning into vegetarianism and experimenting in the kitchen to meet my nutrition needs, and finally watching changes in health impact the nutrition of my parents – my mother after having her gallbladder removed and my father with a diabetesRead MoreEvaluation Of Academic Performance Action Plan1298 Words   |  6 PagesPerformance Action Plan My academic performance goal for my Senior year is to maintain a GPA of 3.5. To achieve that, I have determined myself to achieve as minimum grades, two B+ and three A- for this semester and for Spring and Fall of 2017. So far, I have performed quite well on my exams and projects this semester. However, on one class I barely passed my first exam with a 70 even though I felt I was prepared to obtain a much better grade. Therefore, to achieve my goal of maintaining a GPA ofRead MoreWhat Do You Believe You Reached Your Goals? Essay1311 Words   |  6 PagesTo what extent do you believe you reached your goals? I strongly believe that I have made significant improvement regarding all of the established goals on the learning contract. Additionally, I believe that I have accomplished a majority of the goals that were established on the learning contract as I have demonstrated the behaviors, actions, and knowledge that the goals were established to improve on. At the same time, I feel that with more experience and time in the social work field I willRead MoreMy Goal Of Becoming An Accountant876 Words   |  4 Pageshelps companies make accurate decisions. Ever since I took my first accounting class, I knew I wanted to be an accountant. I enjoy working with numbers, reaching exact solutions, and the critical thinking that goes along with it. Since accounting is the basics to any business and organization, it can help launch different opportunities. I chose to be an accountant because of all the possibilities I have of succeeding. The steps to achieve my goal of becoming an accountant are to f irst apply to the Coles

Video Game Industry - 1949 Words

I - Introduction: Video games are teachers that involve players into the virtual world. Nowadays, many video games include violence in many of its aspects such as war, stealing, slaying and many more. According to Video Games ProCon, â€Å"10 of the top 20 best-selling video games in the US contained violence.†(ProCon, 2014), they also believe that violent video games have not only cons but also pros; they stated that â€Å"Violent juvenile crime in the United States has been declining as violent video game popularity has increased. The arrest rate for juvenile murders has fallen 71.9% between 1995 and 2008. The arrest rate for all juvenile violent crimes has declined 49.3%. In this same period, video game sales have more than quadrupled.† (ProCon, 2014). However, the RWJF Blog team stated that the California law describes Violent Video Games as a â€Å"video game in which the range of options available to a player includes killing, maiming, dismembering, or sexually assaulting an image of a human being.† (Fisk, 2010) meaning that when playing those games, the player is not left with any option to resolve the issue but the previous ones. Many people believe that Violent Video Games may have a negative impact on minors. According to the case, the legislature of the California state propagated a law that bans underage minors from buying or renting video games that include any form of violence, they believe that those games promotes the feelings of aggression among minor players. The law wasShow MoreRelatedVideo Games And The Video Game Industry1290 Words   |  6 Pagesthe gaming demographic, but the industry hasn’t done much to make them feel welcome. During the last decade, the mainstream video game industry has seemed to operate under the same apparent assumptions: girls don’t play big action games, boys like the sexualization of girls in video games and won’t play as a female character unless she is heavily sexualized, and that girls play video games for the attention of boys. These assumptions are what allows the gaming industry to continue to focus on theirRead MoreVideo Games And The Video Game Industry792 Words   |  4 Pages The video game industry has changed a lot since its inception, and a large part of that is due to the video game crash of 1983. Despite this, the market itself has remained roughly the same except for the actual devices in it. The quality of the video games has drastically improved over the years. Unfortunately, something that will never change are the greedy companies looking for a quick buck. While the video game industry has grown and improved since the crash, some similarities are starting toRead MoreVideo Games And The Video Game Industry1344 Words   |  6 Pages In the year 2016, the video game industry hit an important milestone. As seen in this 2015-2019 analysis, the industry hit a market value of over $100,000,000,000: (â€Å"THE GLOBAL GAMES MARKET REACHES $99.6 BILLIO N IN 2016, MOBILE GENERATING 37%†). Just like today, 1983 was looking great for the future of video games. However, unlike today, 1983 did not go great for the video game industry, it went awfully. In 1983, the video game industry crashed and has not fully recovered to the value of the marketRead MoreVideo Games : The Video Game Industry1574 Words   |  7 PagesThe video game industry is one that continues to grow exponentially with consumers spending over $22 billion dollars on the gaming industry in 2014 (association, 2015). This popularity brings the opportunity to produce a stream of games that continue to expand in their nature and impact on their audience. Video games are now artistic, social and collaborative, with many allowing massive numbers of people to participate simultaneously (htt). The collaboration of the video gaming industry doesn’t stopRead MoreVideo Games And The Video Game Industry2174 Words   |  9 PagesVideo Games and the Video Game Industry The video game Pong was introduced in 1972 and can be considered the beginning of the video gaming industry. Unlike the game Pong, the controversies surrounding video games today are not quite as simple. Certain media outlets often portray video games to be bad for individual’s health and behaviour. There are still some people in the world that believe video games are contributing to the decline of today’s generation. However, video games and their industryRead MoreThe Effects Of Video Games On The Video Game Industry791 Words   |  4 PagesAn Atmosphere Unknown This is the future of the video game industry. Imagine looking through the eyes of your favorite video game character but in reality, you are actual sitting on the couch. Look to the left and you see R2-D2 trying to communicate to you. To the right, you have rebel fighters shooting at storm troopers that are attacking your home planet. Virtual reality lets you do all of this from the comfort of your home. However, Augmented reality lets you do this as well, but it is less virtualRead MoreVideo Games And The Video Game Industry1258 Words   |  6 PagesVideo games are a part of our entertainment industry and are more accessible than they have ever been. The video game industry is one of the fastest growing sectors in the U.S. economy. According to Wallace (2014), the video game industry generated about $78.5 billion in revenue and only fell behind the film industry at $88.2 billion. As the industry continues to expand, so does the technology that gives the games more realism and imme rsion. Games depicting violence is becoming more graphic and detailedRead MoreCompetitive Positioning in the Video Game Industry639 Words   |  3 Pagesonline, PC, console, handheld and mobile game publisher with leading positions across every major category of the rapidly growing interactive entertainment software industry.†1 The video game industry of today looks vastly different than it did 10 years ago, with the stark contrast being that many firms are designing their games to be more family-friendly; the stereotypes of video games no longer being just in the realm of teenage boys. All in all, the industry is faring well with reported sales ofRead MoreThe Effects Of Video Games On The Video Game Industry Essay1238 Words   |  5 Pagesnetwork effects in the video game industry? The network effects in the video game industry are derived from the console system that is sold to consumers. If a company is able to increase penetration in this arena, though at-cost/ below-cost pricing or pull created through the development of desirable content, it can potentially lock in the added value of the video games sold for the system. Which is to say, the console locks-in the network effects in the industry and the games serve to reap the profitsRead MoreVideo Game Industry : The Revolution1117 Words   |  5 Pages10/06/16 Video Game Industry: The Uprising Video games are luxury items owned by consumers of all ages. A worldwide phenomenon, video games delivered an impact towards social and technological society. The industry is flourishing, and will continue to flourish for the upcoming years. The expansion of such said luxury items comes with its set of pros and cons. Video games are an example of controversy and benefits. As many as ninety-seven percent of US kids age 12-17 play video games, contributing

Frank Lloyd Wright Free Essays

She has written several other books on American architecture Including On Architecture: Collected Reflections on a Century of Change and The unreal America: Architecture and Illusion. Her biography on Frank Lloyd Wright is both informative and entertaining; she not only reveals the long and harrowing Journey and the victories and defeats of the rebellious and egotistical architect, but also gives a clear view at the times in which he was most active and the ways in which the country and the world were reacting to his architecture while adapting with everything from changing architectural tastes and styles to economic depressions and the World Wars. Beginning with his birth and childhood in Wisconsin all the way to his latter days of work and death in Arizona, Hustle details the journey and evolution of his legacy and the tragedies that failed to hinder his art in coherent chronological fashion. We will write a custom essay sample on Frank Lloyd Wright or any similar topic only for you Order Now Hustle begins the first chapters of the biography with the birth of Frank Lloyd Wright and his beginnings as a child in Wisconsin. Hustle also Introduces the fact that Wright manipulated some details of his personal information throughout life to suit his ego and create his own elegantly presented persona, beginning with his birthday. Born truly in 1867, Wright later changed his birth date to 1869 which â€Å"made a case for a precocious talent with an impressively youthful, early success in Chicago in the 1 sass,† and more Importantly to Wright it â€Å"kept him shy of the dreaded 90-mark during his brilliant late work in the asses† (Hustle 1). In these acts of self- benefit, Hustle revealed the aesthetically egotistical side of Wright that I most certainly never realized was an active force in his life. From his birth, Wright was pampered and directed by his mother, Anna, who believed him to be destined for greatness. On conception, she decided that Frank would be a great architect one day and she was going to do everything in her power to help and guide him in that path, not only for his own benefit but for hers as well. She thought particular crib all to influence the newly born Wright towards a path of architectural nirvana. â€Å"He would deliver her from the despair and hardship of her life, make up for her thwarted ambitions; they would have a golden future together† (Hustle 7). Hustle describes Wright’s childhood as a bittersweet mixture of hard labor on his uncles farm and alienation from his father mixed with glorious Sunday mornings at he Lloyd Jones family Unitarian chapel followed up by emotionally restorative nights spent singing songs while his father played piano. She illuminates how even though he was a small and weakly child, he learned to â€Å"pile tired on tired† (Hustle 14) working on his uncle’s farm and how that strength and stamina of mind and body stayed with Wright even up to the final days of his career which was alive and well until his death. Hustle then begins to describe the evolution of Wright’s Journey to becoming an apprentice architect. He was given his first opportunity at a youthful age to assist in he design and construction of a family chapel and even added a windmill of his own design later which stood the test of time and physical stress against the disbelief of some in his family. Through his early life in the rolling hills of the scenic Helena Valley, Wisconsin, Wright planted the seeds of his ideas and passion for â€Å"organic architecture† (Hustle 27) which would be the basis of his unique art in his future works. Organic architecture makes the lay of land, its environmental atmosphere, and the nature of the construction materials the combined generators of the design f the building. His 1935 masterpiece, Billingsgate, built for Edgar Kaufmann over a waterfall is a perfect example of the mix between nature and architecture that makes it uniquely organic and uniquely Wright. Hustle does an amazing Job at keeping all of Wright’s advancements in chronological order and in a way that is easy to understand how he built his way up to the famous architect that he is. Through his confidence given to him by his mother, Wright began to understand that he was destined for more than an ordinary mortal life because he had â€Å"God-given creativity’ (Hustle 33). When Wright was twenty years of age, he moved to the booming cultural epicenter that was Chicago of the asses. He applied to many different architectural firms but only to the prestigious ones which he believed worthy of his gifts and unique abilities; ultimately reputation and image would be the factors Wright would take into account when choosing a firm to work for. He began with Joseph Lyman Sessile, moved on to Beers, Clay, and Dutton, went back to Sessile, and then found his first nest egg of architectural growth and education with Louis Sullivan and Dammar Adler of the Adler and Sullivan firm. Hustle describes Wright as being able to absorb and retain every bit of useful information. He would act as a sponge to Louis Sullivan, soaking up every ounce of the architectural knowledge he found interesting or worthy and committing it to memory. Although you would think that Wright would credit Sullivan for his influence, Hustle defines Wright as notoriously self-centered and arrogant. He would never admit that his ideas or passions for architecture had been influenced by any other human or any culture. His ego made him believe that his forms of architecture were completely ewe and unheard of; it was truly Just a concoction of every bit of influence he had every received through both education and observation Just mixed and manifested biography, Hustle tells how Wright went from sponge-like apprentice to fully accredited and renowned architectural celebrity. As his experience and popularity grew, Wright was approached by clients seeking his work apart from Sullivan influence and he began â€Å"moonlighting† (Hustle 70). With a newly wedded wife and children on the way, Wright needed more money to support them and his notorious self-indulgence into Japanese prints and fine clothing. Moonlight work, which is working on secret drafts without company permission and reaping all the profit, was forbidden in his contract with Adler and Sullivan and he was eventually found out and immediately fired. The blow to Sullivan was disastrous and the master and apprentice lost touch for years. When he had established himself well enough in the Chicago architectural scene, Wright began taking on employees as draftsman in his home-studio in the Oak Park suburb of Chicago. His Prairie House design and the Larking Administration Building were two of his greatest creations during this period. Wright was Just setting himself up with a good starting out career when Hustle delivers arguably the most controversial and disliked decision that Wright ever made: with children disturbing his concentration and the stresses of marriage and bills weighed together, Wright went through a mental breakdown and â€Å"in the fall of 1909, he left, abruptly cutting all ties. He abandoned a wife and six children and closed his practice, leaving debts and unfinished projects behind† (Hustle 106). Hustle describes how the newspapers and tabloids had a field day with reproving Wright’s deplorable actions. He embarked on a two year Journey to Europe with his mistress Amah Cheney. While she worked as a translator in Germany, Wright worked in Florence with his son Lloyd and draftsman Taylor Woolly observing the Italian and Germanic architecture. Upon moving back to the United States, his mother Anna purchased the land in Wisconsin that would soon be the birthplace of his completely tailored and architecturally unique home, Totalities. â€Å"Wright would survive tragedy and disasters there, the murder of a lover and her children, desperate financial crises, and three destructive fires, rebuilding each time† (Hustle 34) from the ashes f the previous. Shortly after the first Totalities was built, Amah and her children from her previous marriage were brutally murdered and Totalities was burnt to the ground. Accounts given by survivors of the disaster, gardeners and other Totalities workman, explained that the cook had some dispute with Amah and went ballistic. It took Wright several years, a new and blessedly time-consuming project, a new female companion, and Totalities II to bring him back out from a depressed slump. Wright gained instant international success upon the completion of the Imperial Hotel in Tokyo, Japan. In 1923, the hotel was completed and was one of the only structures that survived the great Kant Earthquake that struck Japan that same year. How to cite Frank Lloyd Wright, Papers

Copper Taste in my Mouth free essay sample

It’s a story. Not a simple one. Not an attractive one. But, it’s my story. I think I should tell it. But with the story comes a problem. No matter the details I use, the expertise I put behind my words, there is a risk of making it just a story. It’s not just a story. It’s my story. It doesn’t involve just people, it involves real people. And it left me with a copper taste in my mouth. Sirens blaring added to the maze of chaos I was stuck in. The reality of it all left a surreal impression for years to come. I witnessed an event that some people will never fathom in their lives, I was only fifteen. I was looking out the front of our car when I heard screeching of breaks followed by a silver Cadillac soaring above the median and onto oncoming traffic, on the other side of the freeway. We will write a custom essay sample on Copper Taste in my Mouth or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Then it started again, the screeching of breaks and the car got hit a second time. With the second blow came the sound of shattering glass and people. Two people got ejected from the car, and landed like a bug on a windshield, to the side of the road. My dad immediately stopped the car and all 3 of us ran over to help the two people that lay like ragdolls on the side of the road. As we approached I knew that one was gone for sure, due to decapitation, but the other lay motionless. He screamed and yelled for his mom who lay next to him. That’s when I first noticed the bitter taste of copper on my tongue. To say I was in a state of shock would be an understatement. I persevered to stay calm; I had to swallow the taste. I didn’t know what to do. So I took orders from anyone and everyone. My job was to hold the live victims head up so he couldn’t drown in his own blood. Minutes went by and finally we heard the sound of sirens that we, or at least I, had been waiting for. We found afterwards that their lives could have been saved if the driver would have been driving more careful and if either of them had worn their seatbelt. Something so simple. Something life changing. My hands and fingertips were blood stained. The taste of copper froze in my mouth. A taste I could not get rid of. A taste that still remains. It reminds me of the crash. Everyday I pass the crash site; it reminds me of the taste. It serves to me a reminder: that anything can happen, for better or for worse. Life is what you make of it, even if it’s hard to swallow.