Gate Control Theory Of Pain Health And Social Care Essay

Gate Control Theory Of Pain Health And Social Care Essay OA knee pain prevalence, cost to NHS etc. Physio treatment of neck painà ¢Ã¢â‚¬  Ã¢â‚¬â„¢ electro modalities, esp TENS Pain is something that everyone suffers with at one time or another. Pain can be a huge burden on employers due to absenteeism (White et al, 2005). There are many methods used to relive pain with TENS being one method. Having completed a review of current literature, it is clear that the application of tens has a significant effect on the pressure pain threshold of a subject, however no study to date has researched the effects the positioning of the TENS being applied has on the pressure pain threshold. Therefore this study has the aim of investigating whether the positioning of the electrodes at the nerve root level will affect the pressure pain threshold of the relevant dermatomal area giving rationale for the use of TENS as a pain reliving modality for injuries to the extremities. Literature Review 4k Literature Search This research is investigating the effect of transcutaneous electrical nerve stimulation at a nerve root has on the pressure pain threshold at the periphery in relation to osteoarthritis of the knee. A review of the current literature was conducted using the following databases: PubMed, ScienceDirect, MetaLib (Cardiff Universitys Electronic Resources) and Google Scholar for journals dated 1982-2012. The main key words used in the search included, transcutaneous electrical nerve stimulation, pain, osteoarthritis, knee, and periphery. Backchaining was also used to ensure all relevant literature was obtained. Introduction Osteoarthritis a very common joint disorder occurring in any joint but most commonly in the hip, knee, the joints of the hand and foot, and spine (Symmons et al. 2003). It mostly affects those aged 60 and over with approximately 40% of people over the age of 65 suffering symptoms associated with knee OA (Zhang et al., 2008) resulting in globally nearly 250 million people having osteoarthritis of the knee, 3.6% of the population (Vos et al. 2012). This resulted in osteoarthritis becoming the fourth leading cause of disability in the year 2000 (Symmons et al. 2003) and costing the NHS a total of 25 million pounds in 2008 (NICE 2008) Arthritis knee Osteoarthritis of the knee is a chronic degenerative disorder with a multifactorial aetiology (Felson, 2000). This includes general factors; such as age, sex and obesity, mechanical factors; such as alignment and trauma (cooper et al. 2000) and genetic factors (Reginato et al. 2002). Osteoarthritis of the knee is characterised by both loss of articular cartilage and by central and marginal new bone formation (subchondral sclerosis, osteophytes) (Woolf and Pfleger, 2003). There is also often thickening of the capsule and low grade synovitis resulting in alterations in biomechanics of the joint. Osteoarthritis affects the whole joint with secondary changes including ligament laxity due to articular cartilage loss and muscle weakness around the joint due to disuse respectively (Felson 2000). Osteoarthritis of the knee is associated with pain, joint stiffness and deformity, which in turn lead to limitations of daily activities for sufferers. Although there is currently no cure available, there are a number of treatment options open to sufferers to provide symptomatic relief, as well as joint function improvements. There are many non- pharmacological treatment options available such as education, rehabilitation exercises, manual therapies, acupuncture and electro-modalities such as TENS. There is also a wide range of pharmacological measures available, non-steroidal anti-inflammatory drugs, oral analgesia and topical treatments. Pharmacological treatments also include intra-articular modalities such as injections of corticosteroid and hyaluronic acid and tidal irrigation to reduce symptoms. In severe cases, where nonsurgical interventions have failed, more invasive approaches may be needed (Cooper et al 2000) including therapeutic arthroscopy and joint replacement. Models of Pain Pain something that the medical profession aims to alleviate in all patients suffering from it. In order to do this an understanding of the function of pain is needed as well as knowledge of the physiological processes the cause pain. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (Bonica 1979). It serves as a stimulus to motivate an individual to cease or withdraw form damaging or potential damaging situations, or to protect a damaged body part during the healing process (Winlow et al. 1984). There are three main models of pain, the cognitive-behavioral model of pain, the gate control theory of pain and the neuromatrix theory of pain. Gate control theory of pain The gate control theory suggests there is a neurological gate in the dorsal horn of the spinal cord (Melzack and Wall 1967). This gate either blocks pain signals or allows them to continue to the brain. This gate in the spinal cord differentiates between the types of fibers carrying pain signals. Pain signals travelling down the larger C nerve fibers are blocked whereas pain signals travelling done the smaller a-delta nerve fibers are allowed to pass through and therefore continue up to the brain where the pain can be perceived (cord (Melzack and Wall 1967). This gating mechanism is influenced by descending nerve impulses from the brain in response to ascending pain stimuli. Cognitive behavioral theory of pain The cognitive behavioural pain theory explores the perception of pain by relating it to more than just the physical and physiological attributes of the pain mechanism, and explores the predisposing and perpetuating factors as well as the psycho-social aspects involved in pain perception (Letham et al. 1983). This model explains why some individuals continue to experience pain after trauma has healed, or display a pain response disproportionate to the original condition. The theory states that the perception of pain is influenced by predisposing factors such as personality, coping style and previous history of illness, as well as perpetuating factors such as behaviour, emotions, and physical symptoms (Letham et al. 1983). This explains why some individuals suffer with continued pain after the original injury has resolved and are driven by fear of further pain leading to increasingly restricted activities despite the original injury being resolved, exhibit a maladaptive avoidance response. While other will experience very little pain in situations that would otherwise be excruciating, for example soldiers in battle (Letham et al. 1983) Neuromatrix theory of pain The pain neuromatrix theory is a development of the gate control theory of pain. A widespread distribution of neurons imprint a neurosignature upon nerve impulse patterns that pass through the sensory matrix (Melzack 2001). This neurosignature creates the experience of self and gives subsets of patterns that give unique experiences such as pain. The perception of pain in the brain would be as the end result of an activation of the pain neuromatrix with a characteristic pattern relating to the pain signature (Melzack 2001). This is part of a multi system response to a perceived threat. However there are many other inputs that can trigger the pain neuromatrix in the brain including movement, touch, fear and visual stimuli (Melzack 2001). This is due to the fact that the widespread neurons which make up the neuromatrix for pain perception are involved in many other activities so the pattern for pain perception can be triggered by other groups of neuromatirx being active during other activities not purely the pain neuromatrix Pain and pathways There are four basic processes involved in nociception(processing of pain), Transduction, transmission, perception and modulation (McCaffery and Pasero, 1999). Transduction begins when nociceptors (free nerve endings) of either the A-delta fibres or C fibres of the primary afferent neurones respond to noxious stimuli. A noxious stimulai occurs when tissue is damaged and inflation occurs. The nociceptors are found in the somatic structures (skin, muscles, and joints) as well as the visceral structures (organs such as gastro-intestinal tract or the liver). (Wood 2008) Although both the C fibre and A-delta fibres are Primary afferent fibres they have different cell structures and are associated with different pain qualities (table 1). Table 1: Characteristics and functions of C fibres and A-delta fibres (Farquhar-Smith 2007) C fibres A-delta fibres Characteristics: Small diameter Unmyelinated Slow conducting Receptor type: Polymodal: respond to more than one type of noxious stimuli: Mechanical Thermal Chemical Pain quality: Diffuse Dull Burning Aching Referred to as slow or second pain Characteristics: Large diameter Myelinated Fast conducting Receptor type: High-threshold mechanoreceptors: respond to mechanical stimuli over a certain intensity. Pain quality: Well-localised Sharp Stinging Pricking Referred to as fast or first pain There are three stages to the transmission of pain; first the impulse is transmitted from the site of transduction along the nociceptor fibres (first order neurons) to the dorsal horn, in the spinal cord, where both C fibre and A delta fibres terminate. In the dorsal horn they synapse with the second order neurons and which then cross the spinal cord via the anterior white commissure and ascend to the thalamus via the two main nociceptive ascending pathways. These are the spinoparabrachial pathway and the spinothalamic pathway. The thalamus then directs the nervous impulse to multiple areas of the cortex and higher brain for processing as there is not a discrete pain centre (Wood 2008). The end result of the pain transmission is the perception of pain. This is where pain becomes a conscious and multidimensional experience with affective-motivational, sensory-discriminative, emotional and behavioural components. When painful stimuli are transmitted to the brain stem and thalamus, three main cortical areas are activated, the reticular system, the somatosensory cortex, and the limbic system, each one is responsible for a different response to the pain stimuli. (McCaffery and Pasero, 1999) The reticular system is responsible for the autonomic and motor response to pain, for example, automatically withdrawing from a painful stimulus. It also plays a role in the affective-motivational response to pain, such as assessing an injury after pain has occurred. The somatosensory cortex is involved with the interpretation and perception of sensations. It identifies the location, type and intensity of the pain sensation and relates this sensation to past experiences before triggering a response. The limbic system is responsible for the behavioural and emotional response to pain as well as past experiences of pain. The modulation of pain involves altering or inhibiting the transmission of pain impulses in the dorsal horn of the spinal cord. The complex pathways involved in the modulation of pain are called the descending modulatory pain pathways (Ossipov et al. 2010). These pathways can lead to either an excitatory response (an increase in the transmission of pain impulses) or an inhibitory response (a decrease in transmission of pain impulses). Descending inhibition produces an analgesic effect by causing the release of inhibitory neurotransmitters which partially or completely block the transmission of pain impulses in the spinal cord (Ossipov et al. 2010). Endogenous pain modulation helps to explain the wide variations in the perception of pain in different people as individuals produce different amounts of inhibitory neurotransmitters. Endogenous opioids are found throughout the central nervous system (CNS) and prevent the release of some excitatory neurotransmitters, for example, substance P, therefore, inhibiting the transmission of pain impulses. Physiotherapy and treatment of Pain Transcutaneous electrical nerve stimulation (TENS) papers on TENS and Pain (critical review of the literature) Transcutaneous electrical nerve stimulation (TENS) is an electro therapy procedure the aim of which is pain relief. During treatment a low amplitude and frequency alternating electric current is passed between two electrodes placed on the body resulting in stimulation of the nervous system. Research will be reviewed examining the theory that TENS is an effective pain reliving modality. Previous studies by Chesterton et al (2002, 2003) Vance et al (2012) and Chen et al (2010) have all shown TENS to be an effective form of pain relief against blunt pressure pain with. All however have used different parameters for both the TENS settings and application sites. All of the previous studies looked at found TENS to be an effective method of pain relief based on pressure pain threshold measurement. Both of Chestertons and Vances studies found a statistically significant increase in pressure pain threshold after a twenty minute application of TENS (p=0.005, p=0.01, and p=0.002 respectively). Chen also found a significant difference in post TENS of p= Vance was the only study to look at other forms of pain measurement s outcome measures, as well as the use of a pressure pin threshold measure similar to the other studies a cutaneous mechanical pain threshold measure using Von Frey filaments and heat pain threshold measure were also used. Although using these additional outcome measures to assess the effectiveness of TEN as a pain reliving modality it was only the pressure pain threshold measure that yielded a significantly change. Therefore the results of the study can still only be extrapolated to the pressure pain reliving abilities of TENS and no other forms of pain. Both Vance and Chen explored the differences between the frequencies TENS applied. Chen uses 3Hz for low frequency and 80Hz for high frequency. Vance does not specify the actual frequency used and only states high and low frequency Tens was used with the definition of High frequency TENS >50Hz and Low frequency TENS In Chestertons 2002 also explored the differences between the frequencies of TENS applied using 4Hz as the low frequency and 110Hz as the high frequency. The results were similar to Chen with the high frequency TENS proving a more affective pain reliving modality of TENS. All three studies have good internal reliability, the same experimenter was used for every measurement, and standardised testing procedures were used. The rate of application of the algometer was kept constant when measuring the pressure pain threshold and the same point was used on each subject for the measurement. Chen and Vance, however, relied sole on the skill and consistence of the experimenter to ensure the pressure pin threshold reading was taken in the same manner for every subject. Chestertons studies used a special mounting frame for the algometer to ensure that it was perpendicular to the skin and that the rate of application was constant. This improved the internal reliability of the study as each subject will have had the reading taken in exactly the same way. Chesterton and Chen both use healthy volunteers as the subjects in their studies. Both studies have a good sample size with an equal distribution of males and females. Chen subjects have a small age range (mean  ± SD, age 26.7  ± 2.9 years) which is not representative of the population. Chestertons sample has a much larger are range (mean  ± SD, age 30 ± 7 years, range 18-57 years) which is a far closer representation of the general population and makes the extrapolation and application of the results more reliable. However both of these studies, due to only using healthy subjects, cannot be reliable extrapolated to apply to people who are not healthy. Therefore it cannot reliably be said that anyone suffering with a painful condition, be it degenerative, trauma, or surgical, will benefit from the application of high frequency TENS or that it will reduce their pain. It can only reliable be said that it will reduce the pain perceived in healthy individuals. This however is add ressed by Vance, although using smaller sample size than Chesterton all of the subjects used in the study all had a diagnosis of medial compartment osteoarthritis of the knee. Unlike the other studies Vance did not have an equal split of male to female subjects (29 male 46 female), however by using a stratified randomisation process it was ensure that each experimental group had the same ratio of male to female subjects. Therefore unlike the other studies Vances results can be reliably extrapolated to apply to a population with a diagnosis of medial compartment osteoarthritis of the knee, and high frequency TENS can be reliably used as a pain reliving modality. Random allocation of groups Not all subjects tens naive Blinding All have good baseline comparability between groups. Chen Good base line A paired t-test on this data found no significant differences (mean + SD = -1.50  ± 5.65N,  P  = .143) Chesterton 2002 Good basleine similar This was confirmed by a one-way analysis of variance (ANOVA) for pre-treatment mean MPT (P 0:19 Chesterton 2003 Good One-way analysis of variance (ANOVA) showed no significant differences in PPT, between the groups at baseline (p 0:142) Vance Bad not equal gender split 29 male 46 femle. But good that same ration in each group. Good There were no significant differences between groups in demographic characteristics, with the exception of body mass indexes (P.027). Algomiter reliability Aim(s) Hypothesis (hypotheses) Does High-TENS affect pressure pain threshold (PPT) at the periphery? Null Hypothesis: There will be no difference in the pressure pain threshold between the control group and experimental group. Methods Design This study was an experimental repeated measures clinical trial. The independent variable being assessed was transcutaneous electrical nerve stimulation. The dependent variable was Pressure pain threshold. The study included 20 people who had no previous history of knee pain and had not previously experienced TENS. Subjects attended two sessions with a 48 hour interval. In the first session subjects were given a placebo TENS and in the second a single high frequency TENS treatment. Outcome measurements were obtained before and during each treatment. Ethical approval for the study was granted by the University Ethics Committee (Cardiff University, 2012). Participants A convenience sample of 20 subjects from Cardiff University School of Healthcare was used. The inclusion criteria consisted of being a healthy subject. Subjects were screened for relevant contraindications and exclusion criteria including: pacemakers, heart disease or arrhythmias, undiagnosed pain, epilepsy, peripheral neuropathy (Fox and Sharp, 2007), history of trauma or surgery to the dominant leg in the last 6 months, medication, history of pregnancy or knowledge or use of TENS treatment (Chesterton et al., 2002). No subjects were excluded. The experimental procedure was explained to each subject who then signed a consent form witnessed by an independent person (Appendix 4). At the first session, subjects were assessed for bilateral recognition of sharp versus dull pressure at the L3 dermatome to rule out loss of sensation. Ethics Ethical approval was obtained from The School of Healthcare Studies Ethics committee Cardiff University and a single blind experiment using repeated measures was used. A risk assessment was carried out for the pilot and data collection assess risk to the subjects and the investigator using the standard risk assessment method of the cardiff university Physiotherapy department. The risk is quantified by the Risk Rating Number which is calculated by multiplying the probable frequency by the potential severity. For this research the probable frequency is unlikley scoring two and the potential severity is negligible scoring one (appendix 1). The Risk Rating number is two which requires no further action (Cardiff Univeirsity 2012). Individuals with a history of knee pain were excluded, reducing the likelihood of physical injury to the subjects during the PPT measurement process. In the event of an injury subjects would be withdrawn from the study and appropriate medical advice would be sought. The privacy and dignity of the subjects during electrode placement was ensured by using screens, and gaining informed consent before exposing the skin on the back. The information sheet given to the subjects (Appendix 3) informed them of what the study involved, and that the results would be analysed as part of this research project. Subjects were informed they were free to withdraw from the study at any time. All data was confidential and anonymous. All data stored on a computer was and password protected and anonymous. Pilot study A pilot study was conducted on 3 subjects not included in the main study prior to data collection. This was to ensure that the method to be used was satisfactory and to allow researcher to familiarize themselves with the equipment. It also allowed the researcher to estimate the time required, allowing appropriate time slots to be set. Another reason for the pilot study to be carried out was to expose any unforeseen errors or limitations in the design protocol allowing modification as necessary (Jenkins et al, 1998). The pilot study highlighted variations in subject foot placement in sitting, in turn effecting the knee positioning needed for a PPT reading to be taken. It was therefore decided to give subjects the following verbal command on how to sit, sit with your feet flat on the floor and your knees at ninety degrees, to minimize variance in knee position. The rest of the method was deemed sufficient and no further changes were made. Apparatus The pressure pain threshold was assessed using a handheld pressure algometer (Algometer commander, Jtech medical, United States) with a flat circular metal tip measuring 1.1 cm in diameter. The force was displayed digital in increments of 0.1N and applied at a rate of at 5N/s (Chesterton et al 2002). The subjects were instructed to say stop when the sensation first became painful. A practice test was first performed on the non-dominant knee to familiarize subjects with the procedure. The use of a pressure algometer for measuring pressure pain threshold has excellent test-retest reliability (r.70-94) (Fischer, 1987), and is a valid measure for deep-tissue hyperalgesia as discussed by Staud et al. (2007) Electrical stimulation was generated via a commercially available a dual channel, TENS unit (200 plus, TPN), the unit uses an asymmetrical, biphasic waveform. The pulse width was set at 50 microseconds and the frequency 150Hz, and the intensity was increased to the subjects verbal report of when the feeling became strong but still comfortable. Procedure. Before taking part in the study, all subjects were given an information sheet (appendix 3) explaining research study and what would be expected from them if they participate and completed a consent form (Appendix 4). Subjects came in on two separate occasions 48 hours apart; once for the control trial (sham TENS) and once for the application of TENS. In the first session demographic data was obtained, which included age and gender. A standard sharp/blunt discrimination test was performed, using neurotip at each stimulation site, to ensure intact skin sensation. The skin was then cleaned using an alcohol wipe before the application of electrodes (Chesterton et al., 2003). Two TENS electrodes were then placed over the L3 spinal level. Each electrode was placed over the L3 Spinal nerve root the location of which was found by palpating to the L3 spinal level (Rhoades et al. 2009). The first electrode was positioned 10mm to the left of the L3 spinal process with the second positioned 10mm to the right. The center of each the electrode was placed level with the inferior aspect of the L3 spinal process (figure 1). Experimenter 1 was responible soley for the electrode psoiting nd TENS application to ensure internal reliability. Figure 1 Subjects were seated in a comfortable upright position with feet flat on the floor. The position of the pressure pain reading was then marked bilaterally. This was done by measuring 30mm superior to the central aspect of the superior border of the patella in flexion (figure 2). Experimenter 2 was responsible solely for the positioning of the pressure pain reading and the algometer application to ensure internal reliability. Figure 2 A practice pressure pain measurement was then performed on the subjects non dominant side with subjects instructed to say stop when the sensation first became painful. At this point the experimenter immediately retracted the algometer. (Chesterton et al. 2003) This process was then repeat three times at 30 second intervals on the dominant side to establish a base line figure (Vance et al 2012). The Tens machine was then turned on and the intensity increased to the subjects verbal report of when the feeling became strong but still comfortable. For the sham TENS subjects were told that some forms of TENS were imperceptible and, they might not feel any sensation. The battery in the TENS unit was inserted the wrong way round. The unit was still visibly switched on and the intensity turned up, but no current was flowing (Chesterton et al 2003). A 30 minute timer was started as soon as the intensity was correctly adjusted. When the 30 minute time period had elapsed three further pressure pain threshold readings were taken again at 30 second intervals on the dominant side to a post treatment figure. Once these reading were taken the TENS machine was turned off and the electrodes removed. Subjects were monitored for a further 30 min after the end of the stimulation period (Chesterton et al 2002). Subjects returned for the second session 48 hours later. Data Analysis All data was entered into Windows Excel version 2010 Descriptive analysis was carried out using means, standard deviations this was presented as tables and graphs. The data was then entered into SPSS (Statistical Package for Social Sciences version 20.0). The data was interval ratio and the study investigated one group of subjects. A paired t-test was conducted to compare the percentage change in pressure pain threshold between the control and high TENS conditions. A statistical significance level of 95% (p Results The demographic data can be seen in Table 1. The following tables and graphs present both descriptive and statistical analysis of the pressure pain threshold data. All SPSS outputs can be seen in appendix 5 and raw algometer data can be seen in Appendix 6. Table 1: Demographic Characteristics of Sample N minimum maximum mean S.D Age 20 19 23 19.95 1.09904 Key: N = Number of subjects S.D = Standard Deviation A small standard deviation is seen for the age of subjects in Table 1. The male to female ratio was 1:1 with 10 female subjects and 10 male subjects. All subjects met the inclusion and exclusion criteria, and all were able to complete the study. Discussion There are two primary and related theories for explaining the efficacy of TENS in chronic or acute pain relief. The gate theory (Wall, 1965 (Melzack R, Wall P. Pain mechanisms: a new theory. Science. 150(699):971-979,1965)) proposes that pain transmission relies on a gate to the thalamus and cortex for nocireceptive information to be interpreted as pain. This theory postulates that inhibition of nocireceptors can be caused by rapid impulse activation of myelinated nerve fibers. The second related theory postulates that neurotransmitter exhaustion can be caused by rapid nerve activation outside of its refractory period, and that the temporary exhaustion of neurotransmitters would provide pain relief until such time as neurotransmitter synthesis had refilled the synaptic junctions (Kaye, 2007(Transcutaneous Electrical Nerve Stimulation: WebMD eMedicine. http://www.emedicine.com/pmr/topic206.htm January 26, 2007)). Limitations Clinical Implications Further research Conclusion

Oregon Oxford Debate Essay

OREGON OXFORD DEBATE †¢. Rules and Guidelines On Debate Prepared by:Ma. Martha Manette A. Madrid, Ed.D. Professor marztmonette@yahoo.com †¢2. Proposition:Resolved: â€Å"That Parliamentary Form of Government Be Adopted† †¢3. Format of Debate:Oxford-Oregon Type †¢4. Three Speakers fromeach sideFirst Affirmative -Constructive SpeechFirst Negative -Interpellation of the first affirmative SpeakerFirst Negative -Constructive SpeechFirst Affirmative -Interpellation of the first negative speakerSecond Affirmative -Constructive SpeechSecond Negative -Interpellation of the second affirmativeSecond Negative -ConstructiveSecond Affirmative -Interpellation of the second negativeThird Affirmative -Constructive SpeechThird Negative -Interpellation of the third affirmativeThird Negative -Constructive SpeechThird Affirmative -Interpellation of the third negative †¢5. Three Speakers fromeach sideRebuttal of the Team Captainof the Affirmative SideSUR- Rebuttal of the Team Captainof the Negative Side †¢6. Duration Constructive Speech: Minimum of five (5) and maximum of seven (7) minutesInterpellation: Five (5) minutesRebuttal Speech: Three (3) minutesSUR- Rebuttal: Three (3) minutes †¢7. Issues for Debate A. Whether or not it is Necessary?(Necessity)B. Whether or not it is beneficial?(Beneficial)C. Whether or not it is practical?(Practicability) †¢8. Criteria for JudgingA. Evidence – 25%B. Delivery – 30%C. Interpellation – 30%D. Rebuttal &SUR-Rebuttal – 15% †¢9. Criteria for Judging- The judges, based on theirdiscretion, shall have the authority todetermine who will be the BestSpeaker and Best Debater. Thewinning team shall be determined bythe majority decision of the Board ofJudges. †¢10. Guides for Constructive SpeechSpeech types of Constructive Speech maybe:Reading MethodMemory MethodExtemporaneousMix method of memory andconversational or dramatic †¢11. Guides for Constructive SpeechPoise, gestures, audience contact and voice projection are highlyrecommended. †¢12. Rules on Interpellation1. Questions should primarily focused on argumentsdeveloped in the speech of your opponent. However,matters relevant and material to the proposition areadmissible.2. Questioner and opponent should treat each other withcourtesy.3. Both speakers stand and face the audience during thequestion or Interpellation period.4. Once the questioning  has begun, neither the questionernor his opponent may consult a colleague. Consultationshould be done before but as quietly as possible . †¢13. Rules on Interpellation5. Questioners should ask brief and easily understandablequestion. Answers should equally be brief. Categorical questionsanswerable by yes or no is allowed, however, opponent if hechoose, may qualify his answer why yes or why no.6. Questioner may not cut off a reasonable and qualifyinganswer, but he may cut off a nervous response with a statementsuch as a â€Å"thank you† â€Å"that is enough information† or â€Å"yourpoint is quite clear† or â€Å"I’m satisfied.†7. Questioner should not comment on the response of hisopponent.8. Your opponent may refuse to answer ambiguous, irrelevant orloaded questions by asking the questioner to rephrase or reformhis question. †¢14. Rules on Rebuttal SpeechA. Rebuttal speaker should point out clearlythe fallacies committed by his opponentstating clearly what particularly statement orargument constitute said fallac y.B. If not familiar with the fallacies of logic,the debater may counter arguments directlyby stating what arguments or statement isincorrect or false. †¢15. Role of the ModeratorThe moderator of the debate has the followingduties:1. To reveal the issue involve the debate;2. To rule on points of clarification about theissues or questions and answers made during theInterpellation; and3. To see to it that the debate is orderly andfollows the rules of parliamentary procedures. †¢16. Role of the Timer1. To time the speakers and debatersaccurately;2. To give the speakers a one-minutewarning with the ringing of the bell oncebefore his/her time is up.3. To prevent the debaters from exceedingthe time allotted to them by ringing thebell twice. †¢17. Tips on Interpellationand RebuttalCROSS EXAMINATIONA. The cross-examination period of a debate is a time when the person who is not going to speak next in the constructive questions the person who has just finished speaking.B. Consider cross examination an information exchange period – it is not the time to role play lawyer. †¢18. CROSS EXAMINATION C. Cross examination may serve six objectives: 1. To clarify points 2. To expose errors 3. To obtain admissions 4. To setup arguments 5. To save prep time 6. To show the judge how cool you are so they WANT to vote †¢19. CROSS EXAMINATION D. Most debaters tend to ignore the value of good cross- examination. Remember, 30% of the entire debate is spent in cross-examination — it should be a meaningful and essential part of the debate. If nothing else, debaters tend  to underestimate the importance that cross-examination may have on the judge. E. Cross-examination will indicate to the judge just how sharp and spontaneous the debaters are. Invisible bias will always occur in a debate round and judges would always like the sharpest team to win. Good, effective cross- examination of the opponents can play an important psychological role in winning the ballot of the judge. †¢20. CROSS EXAMINATION F. Be dynamic. Have questions and be ready to go, answer questions actively and with confidence whenever you can. The image you project will be very important to the audience/judge. This is the one opportunity the audience/judge has to compare you with opponent’s side-by-side. †¢21. GUIDELINES FOR ASKINGQUESTIONS:1. Ask a short Q designed to get a short A2. Indicate the object of your Q3. Dont telegraph your argument, dontmake it too obvious.4. Dont ask Q they wont answerproperly.†So, we win, right?† †¢22. GUIDELINES FOR ASKINGQUESTIONS:5. Make Q seem important, even if it isjust an attempt to clarify.6. Politeness is a must — emphasize thedifference if they are rude.7. Approach things from a non-obviousdirection. Then trap them.8. Mark your flow/notes as to what youwant to question them about. †¢23. GUIDELINES FOR ASKINGQUESTIONS:9. Avoid open ended Qs unless you aresure they are clueless.10. Face the judge/audience, not youropponent.11. CX answers must be integrated intoyour arguments made during a speech. †¢24. GUIDELINES FOR ANSWERINGQUESTIONS:1. Concise A.2. Refer to something you have alreadysaid whenever possible. This is safe.3. Answer based on your position in thedebate so far. Keep options open.4. Dont make promises of what you oryour partner will do later. †¢25. GUIDELINES FOR ANSWERINGQUESTIONS:5. Qualify your answers.6. Be willing to exchange documentsread into the debate.7. Answer only relevant questions.8. Address the judge. †¢26. GUIDELINES FOR ANSWERINGQUESTIONS:9. Try and not answer hypothetical Q. Ifthey demand, say you will give ahypothetical A.10. Signal each other, dont tag-team.11. Dont say†I dont know,†say†I am notsure at this time†¦.† †¢27. REBUTTALSA. Most debaters, coaches, and judges would agr ee that rebuttals are the most difficult and yet the most important parts of the debate.B. Not only is there less time within each speech, but each debater has to sort through all of the issues to determine which ones are the most important ones!C. What a debater does or does not do in rebuttals will decide who wins the debate. Very few debaters (especially beginners) can hope to extend everything that  happened in the constructive speeches. †¢28. REBUTTALSD. Debaters dont have to do that and just because a team may have dropped a point or an argument is not an automatic reason to vote against that team.E. What matters is the type of argument that is extended or dropped in rebuttals-this will determine the winner of the round. †¢29. REBUTTALSThink about these four issues when rebuttalshappen:1. Which arguments have more weight at theend of the round?2. Which outcomes (disads, counter plans)are more likely given lots of internal links?3. What about time frame-what happensfirst?4. What about the quality of evidence? †¢30. REBUTTALSHere are some other helpful hints:1. Avoid repetition. Dont just repeat yourconstructive arguments. Beat the other teamsarguments and tell the judge why your argumentsare better.2. Avoid passing ships. Dont avoid what theother team said. You must clash directly withtheir responses.3. Avoid reading evidence only. You must beexplaining and telling the judge why these issueswin the de bate. †¢31. REBUTTALS4. Avoid rereading evidence that has alreadybeen read in constructive. You can makereference to it by referring to it, but dont re-read it.5. Avoid â€Å"lumping and dumping.†Dont try togo for everything. You cant make 12responses to each argument in a few minutes.6. Be organized. Dont jump from issue toissue at random. Be specific and logical aboutwinning issues. †¢32. REBUTTALS7. Dont be a blabbering motor mouth. Speakquickly but not beyond your ability. If you speaktoo fast, you will stumble and not get through asmuch.8. Dont whine to the judge about fairness or whatthe other team might have done that you think isunethical. Make responses and beat them.9. Dont make new arguments. You can read newevidence but you cant run new disadvantages ortopicality responses. You are limiting to extendingthe positions laid out in the constructive speeches. †¢33. REBUTTALS10. Use signposting. Make sure the judge knowswhere you are on the flow sheet. This is not the timeto lose the judge on the flow.11. Use issue packages. Organize your argumentsinto issue packages. Choose arguments which youwant to win. Dont go for everything. Extend thosearguments that you need to win.12. Cross-apply arguments. If you dropped anargument in a prior speech that you think wasimportant dont act like your losing. Cross-applyarguments you made somewhere else in the d ebate toanswer it.

Outside Forces Creating Change in Characters Love in the...

Authors are often well known for their use of outside forces to initiate change within the relationships of their main characters. The works Love in the Time of Cholera and The Metamorphosis are exemplary in this respect. The author’s choice, in both works, to use an outside force helps develop the storyline in each and brings out an underlying irony. Marquez chose to use Dr. Juvenal Urbino, a highly esteemed and prosperous doctor, as an outside force that initiated change in the relationship between Florentino Ariza and Fermina Daza. Kafka chose to use three boarders to initiate the rapid decay of Gregor and Grete’s brother-sister relationship. Both consistencies and inconsistencies exist between the ways in which each author uses the†¦show more content†¦She cleaned up his room and ensured that he was well fed. Even though the relationships among the main characters were different, a consistency is found within the seemingly â€Å"perfect† classificati ons of both relationships. Both authors chose to use picture perfect relationships with virtually â€Å"unbreakable† bonds. They possibly did this to demonstrate how powerful and important the outside forces were. This is where the irony can be seen in both works. The outside forces managed to break the bonds shared between this brother and sister and soon to be husband and wife quite easily. In each work, the outside forces caused different changes to take place. In Love in the Time of Cholera, Dr. Urbino was brought on by Fermina’s father, Lorenzo Daza, who wanted his daughter to marry into money and be well taken care of. Dr. Urbino was able to change the relationship between Fermina and Florentino by causing it to cease. Once Lorenzo Daza decided he wanted his daughter to marry Dr. Urbino and Dr. Urbino â€Å"†¦ had been struck by the lightning of his love for Fermina Daza† (Marquez 115), that ended what had been between Fermina and Florentino. This cha nge caused by Dr. Urbino and Lorenzo Daza lead Florentino to make â€Å"†¦a fierce decision to win fame and fortune in order to deserve her.† (Marquez 165). He decided that he would remain a virgin for Fermina until the day Dr. Urbino died and hoped that she would still love him.Show MoreRelatedFundamentals of Hrm263904 Words   |  1056 Pagesresources With WileyPLUS: Students achieve concept mastery in a rich, structured environment that’s available 24/7 Instructors personalize and manage their course more effectively with assessment, assignments, grade tracking, and more manage time better study smarter save money From multiple study paths, to self-assessment, to a wealth of interactive visual and audio resources, WileyPLUS gives you everything you need to personalize the teaching and learning experience.  » F i n d o u t

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