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A Randomized Controlled Trial of a Passive Accessory Joint Mobilization on Acute Ankle Inversion Sprains
Toni Green, Kathryn Refshauge, Jack Crosbie, Roger Adams
Toni Green
T Green, GradDipPhty, GradDipManipTher, MAppSc, is Senior Research Physiotherapist, Physiotherapy Department, Calvary Hospital, PO Box 254, Jamison, Australian Capital Territory 2614 Australia.
Kathryn Refshauge
K Refshauge, GradDipPhty, GradDipManipTher, PhD, is Senior Lecturer, School of Physiotherapy, University of Sydney, Sydney, New South Wales, Australia
Jack Crosbie
J Crosbie, GradDipPhys, PhD, is Associate Professor, School of Physiotherapy, University of Sydney
Roger Adams
R Adams, PhD, is Senior Lecturer, School of Physiotherapy, University of Sydney
Background and Purpose. Passive joint mobilization is commonly used by physical therapists as an intervention for acute ankle inversion sprains. A randomized controlled trial with blinded assessors was conducted to investigate the effect of a specific joint mobilization, the anteroposterior glide on the talus, on increasing pain-free dorsiflexion and 3 gait variables: stride speed (gait speed), step length, and single support time. Subjects. Forty-one subjects with acute ankle inversion sprains (<72 hours) and no other injury to the lower limb entered the trial. Methods. Subjects were randomly assigned to 1 of 2 treatment groups. The control group received a protocol of rest, ice, compression, and elevation (RICE). The experimental group received the anteroposterior mobilization, using a force that avoided incurring any increase in pain, in addition to the RICE protocol. Subjects in both groups were treated every second day for a maximum of 2 weeks or until the discharge criteria were met, and all subjects were given a home program of continued RICE application. Outcomes were measured before and after each treatment. Results. The results showed that the experimental group required fewer treatment sessions than the control group to achieve full pain-free dorsiflexion. The experimental group had greater improvement in range of movement before and after each of the first 3 treatment sessions. The experimental group also had greater increases in stride speed during the first and third treatment sessions. Discussion and Conclusion. Addition of a talocrural mobilization to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone. Improvement in step length symmetry and single support time was similar in both groups.
Gait
Passive mobilization
Ankle inversion sprains occur frequently in sports,1–3 predominantly in athletes participating in running and jumping sports.4,5 The acute injury consists of damage to the lateral ligament6,7 and results in pain, swelling, and limitation of movement. The inability to dorsiflex is thought to be indicative of a severe injury8 and is often a complication of these injuries on follow-up.9,10 Restriction of dorsiflexion would normally be expected to limit gait and other functional activities. At least 10 degrees of dorsiflexion is required for normal walking,11 descending stairs, and kneeling, whereas running requires 20 to 30 degrees of dorsiflexion.12 Gait limitations have been reported.13,14 People with acute ankle sprains walk slowly and take smaller steps.13 Furthermore, the available pain-free range of movement in dorsiflexion has been shown to determine walking speed, contralateral step length when the range of movement in dorsiflexion is less than 10 degrees, and single support time, with the relationships being nonlinear.14 Subjects were less symmetrical for single support time when less than 4 degrees of dorsiflexion was available than when more than this range of movement was available.14 Thus, it would be expected that a treatment resulting in reduced pain and improved dorsiflexion range of movement should also result in more rapid improvement of these gait variables. Walking speed has been shown to be a good predictor of recovery from injury or disease15; consequently, changes in walking speed between measurements made before and after treatment were considered to be functionally significant.
In the acute phase of an ankle injury, the treatment combination of rest, ice, compression, and elevation (RICE) is advocated for pain and swelling.16–21 In addition, physical therapists commonly use passive joint mobilization to reduce pain by modulation of nervous tissue22 and to increase range of movement,23–26 despite the lack of evidence for the efficacy of this treatment.27 A passive joint mobilization is a gentle oscillating movement of the articular surfaces that creates movement of mobile segments by a means other than by the muscles normally related to those particular segments' movement.28 Some people22,26,29–33 believe that joint mobilization can relieve pain and improve range of motion by neurophysiological and mechanical mechanisms or some combination of neurophysiological and mechanical mechanisms.
Because limited dorsiflexion can negatively influence gait, the mobilization we studied is aimed at moving the talus in an anteroposterior (AP) direction, a movement thought to improve dorsiflexion.23,26 Selection of the AP mobilization is based on the opinions of MacConaill and Basmajian,34 who hypothesized that the combination of spin, slide, and roll accessory movements that occur between joint surfaces is primarily determined by the shape of the surfaces. The concave/convex rule—which states that, when a convex surface moves on a concave one, the direction of the slide and roll should occur in opposite directions—was based on this view, although data are lacking to determine whether the rule actually describes what occurs. Some authors35 have even provided evidence to dispute the rule. Thus, when the ankle is moved into dorsiflexion, the convex talus should roll upward and slide posteriorly on the concave surface of the crus. We believe, therefore, that mobilization of the talus in a posterior direction (an AP mobilization) restores dorsiflexion. Although the concave/convex rule has been disputed,35 the AP mobilization continues to be widely used to restore dorsiflexion.
Our study was designed to determine whether an AP mobilization improved the outcome of therapy for acute ankle sprain compared with use of the conventional RICE protocol. We investigated whether the mobilization decreased pain during dorsiflexion, improved the range of movement in dorsiflexion, or improved the gait variables of speed, step length, and single support time.
A randomized controlled trial was conducted with assessors who were unaware of the subjects' group assignments to compare the effect of an AP glide on the talus in addition to the RICE protocol with the effect of the RICE protocol alone on the variables of pain on dorsiflexion motion, dorsiflexion range of movement, and gait.
Subjects were assigned to control and experimental groups by use of a random number system. Group assignment was concealed from the assessors. The control group received the RICE protocol alone. The experimental group received AP mobilization, using a force that avoided pain reproduction, in addition to the RICE protocol. Subjects consented to participate in the trial prior to being randomly assigned to groups.
Subjects were treated every second day, except over weekends or when subjects could not attend an appointment, for a maximum of 2 weeks. A maximum of 6 treatment sessions, therefore, was possible over the 14 days of the treatment period. The outcomes were measured by the assessors before and after each treatment session. One follow-up measurement was conducted one day after the final treatment session. One physical therapist (TG) with 15 years of experience in manual therapy and advanced training in manipulative physical therapy treated all subjects.
From patients diagnosed with acute ankle sprain and referred by medical practitioners in the hospital's emergency department, 41 subjects volunteered to participate in the trial. A radiograph of each subject's ankle was obtained to screen for fractures and other abnormalities prior to entry into the trial. The control and experimental groups, in our opinion, were similar when they began the study in terms of age, time since onset of ankle injury, severity of ankle injury (Tab. 1) (t test, P>.05), and available range of movement in dorsiflexion (Tab. 2) (t test, P>.05). The groups appeared, in our view, to differ for history of a previous sprain, with more subjects in the experimental group reporting a previous sprain (Tab. 1).
Demographic Data and Injury Profiles of Subjectsa
Dorsiflexion Range of Movement (in Degrees) Before and After Each Treatment Session
Inclusion criteria.
To be included in the study, subjects were required to enter the trial within 72 hours of injury. In addition, only subjects with a sprain of sufficient severity to require assisted ambulation were included. All subjects, however, could bear partial weight on entry to the trial. An initial examination was performed by the treating physical therapist to screen for inclusion and exclusion criteria. Bruising, swelling, and tenderness on palpation of the lateral ligament were noted. Tenderness on palpation of each portion of the lateral ligament was recorded as tenderness of the anterior talofibular ligament (ATFL) in isolation, of both the ATFL and the calcaneofibular ligament (CFL), or of all 3 portions of the lateral ligament. Only subjects with tenderness restricted to the lateral ligament were included to control for the presence of injury of other structures such as the deltoid ligament that may occur with severe sprains.
Exclusion criteria.
Subjects were excluded if known factors were present that may have affected treatment outcome. Exclusion criteria included a history of previous injury (eg, fracture, talipes equinovarus), a sprain sustained in the previous 12 months, compensation claimed for this or any other condition, presence of severe vascular disease, or use of anticoagulant or anti-inflammatory medications.
Dropouts.
Three experimental group subjects (7%) dropped out of the trial. One of these subjects failed to return for treatment (follow-up phone calls failed to identify the reason), one subject resprained the injured ankle, and one subject reported the use of anti-inflammatory medication after testing had commenced. No control group subject dropped out of the trial. Therefore, in this trial, 19 subjects were in each group.
The Lidcombe template was used to measure dorsiflexion because measurements obtained with the template have been shown to have high interrater agreement of 77% and intrarater reliability (intraclass correlation coefficient [ICC]=.97) in subjects without health problems, subjects with cerebrovascular accidents, and subjects with head injuries.36 The device was modified for our study in an effort to ensure that dorsiflexion occurred at the talocrural joint. The template consisted of 2 boards joined by an adjustable hinge; one board served as a footplate, and the other board was positioned under the subject's calf (Fig. 1). To accommodate individual foot size and center of ankle rotation, the template was adjustable in 2 ways. The hinge adjusted the axis of rotation of the template in the vertical plane, and wooden blocks inserted on the calf plate allowed for adjustment in the horizontal plane. A hydrogoniometer was attached to the footplate to measure the angle of dorsiflexion in degrees.
The Lidcombe template. The template enabled standardized measurement of dorsiflexion range of movement. The axis of rotation of the ankle was aligned with the adjustable axis of rotation of the template. The spring balance attached to the footplate measured force, which was applied in a standardized direction.
In an effort to standardize the measurement, both the force applied and the angle of dorsiflexion at which subjects first experienced onset of pain were recorded.37 The force applied during measurement of dorsiflexion was standardized throughout the trial by use of a spring balance attached at the distal end of the footplate. The spring balance measured the applied force, and a spirit level attached to the spring balance ensured application of the force in a standardized direction. Both the applied force and the angle of dorsiflexion were recorded at the point when the subject first experienced onset of pain.37
The reliability of measurements obtained with the modified Lidcombe template by the assessors was tested prior to commencement of the trial. The range of dorsiflexion was measured in 30 subjects whose ankles had no impairment on 2 occasions 1 week apart. The measurements were made by 2 assessors on each occasion. The assessors were hospital staff physical therapists who were normally assigned to work in different departments on a rotating basis and, therefore, did not consistently work in the outpatient department for the 2-year duration of the trial. In addition, some assessors resigned from the hospital during this period. Therefore, 5 assessors were involved in the trial. Sixty-five measurements were made, of which 29% were in exact agreement and 84.5% were within 2 degrees. These results yielded an ICC (1,1) of .94, which is consistent with previous reports of reliability of measurements obtained with the Lidcombe template, with ICCs (2,1) ranging from .9136 to .97.38 Because the researchers in these previous studies36,38 did not examine reliability on the type of subjects we studied (people with acute ankle injuries), we cannot be sure how reliable the measurements in our study were.
Gait was analyzed with a National Panasonic video camera and recorder system,* using the procedure described previously by Crosbie et al.14 The camera was located perpendicular to a level 7-m-long walkway. Subjects, who were dressed in shorts and wearing no shoes, were filmed at a shutter speed of 2 milliseconds as they walked along the walkway. The lateral and medial malleoli were located and marked with long-lasting dye during the initial visit, and subjects were instructed not to wash off these markings. Adhesive markers were attached over the dye markings to improve the clarity and, therefore, the location of markers.
The field of view of the camera was the central 2 m of the walkway, an arrangement that provided a resolution to approximately 1 mm and ensured that subjects were walking at "steady-state" speed when data were recorded. The camera image was calibrated against a rigid frame of known dimensions. Videotapes of the subjects' walking patterns were overdubbed with a time code with a resolution of 0.01 second. Thus, on field-by-field playback, sensitivity to 20 milliseconds was obtained. Initial videotape playback was used to derive temporal events.39,40 The times of initial foot-ground contact and loss of foot contact on each side were recorded for each trial in turn. From these events, double and single support times for the affected and unaffected sides and the total stride time were calculated. Double support time was defined as the period between the commencement of foot contact on one side and the loss of foot contact on the other side. In the case of these subjects, limitation of ankle motion meant that, in the early trials particularly, the foot contact was not necessarily represented by a clear heel-strike. Single support time was defined as the period between loss of foot contact on the contralateral side and commencement of the next contralateral foot contact. Stride time was the time from one foot contact to the next initiation of foot contact on the same side.
The spatial coordinates of the foot markers were recorded using a manual digitizing tablet and the videotape playback unit in a configuration similar to that described by Abraham.41 Images from the videotape recorder (National AG6200 freeze-frame recorder*) and from an overhead camera that captured the active area of a SummaSketch II Professional Plus digitizing tablet† were mixed (National WJ-SIN*) and displayed on a monitor. Prior to each test, a calibration frame of known dimensions (1 m2) was filmed in the center of the target zone. The videotape was advanced or rewound until foot location during each stance phase of the cycle could be clearly identified. The digitizing tablet that we used has a stated resolution of less than 0.1 mm. The coordinates were stored using SigmaScan software‡ and subsequently analyzed with a customized program developed in-house. This program computed stride variables according to conventional definitions.42 On completion of the process, data were derived for stride and left and right step lengths as well as the temporal variables described. In addition, stride speed (gait speed) was calculated using the formula:
Seven walks were filmed at each visit in an effort to ensure that each subject's typical gait was analyzed. Because the camera was positioned at the center of the walkway, approximately one gait cycle was in view of the camera. Therefore, it was necessary for subjects to repeat the walks to enable averaging of data to represent typical performance. This procedure has been shown to yield reliable measurements of gait variables.43
All subjects received a standardized protocol of RICE.23 During each treatment session, the subjects' affected foot was elevated above the heart for 20 minutes. Crushed ice was applied over the anterolateral aspect of the affected ankle during the period of elevation. In addition to an oral explanation of the protocol, all subjects were given written instructions on the application of RICE so that they could continue the treatment as a home program. Rest was defined as avoidance of pain-provoking activities. The ice application was recommended for a minimum of two 20-minute sessions each day. Subjects wore an elastic tubular bandage daily until completion of testing to apply compression to the ankle and calf. In addition, subjects were instructed to elevate the foot above the heart for at least 25% of the day.
During the third treatment session, all subjects were taught to tape their ankle and were told to do so on a daily basis in an effort to protect against exacerbation of current sprain and occurrence of a new sprain. They used a standard application of rigid sports tape.44,45 Subjects were also given a written description of the taping procedure. Subjects continued to wear the elastic tubular bandage over the tape. During treatment session 4, subjects demonstrated how they applied the tape to ensure that the application was being done correctly.
The experimental group received passive joint mobilization during every treatment session before the application of the RICE. The mobilization was directed over the anterior surface of the talus to mobilize the talocrural joint with the subject lying supine (Fig. 2). The affected foot was positioned at the end of the available pain-free range of movement in dorsiflexion, and a gentle oscillatory technique as described by Maitland30 was applied in an AP direction. In this trial, the gentle force used for the mobilization was a small-amplitude oscillation applied so that pain and spasm were not produced. Although the technique was performed as far as possible into range of the accessory glide movement without producing pain, the range actually used was the beginning of the range due to the presence of pain during the first few treatment sessions. Subjects were questioned frequently in an attempt to ensure that no pain was produced, and the magnitude of the force applied was based on this feedback. Throughout the trial, the technique was performed for 60 seconds and repeated 2 more times with a 10-second rest between repetitions. During this 60-second oscillatory period, approximately 60 oscillations were performed. When pain during dorsiflexion was reduced, treatment was progressed by increasing the amount of dorsiflexion in which the foot was positioned.
Anteroposterior mobilization of the talus. The mobilization was performed with the subject lying supine and the ankle positioned over the edge of the plinth. The proximal hand of the therapist (left hand with the ring) stabilized the distal tibia and fibula while the distal (right) hand mobilized the talus with posteriorly directed oscillations.
Adherence to Treatment
All subjects were given an activity diary to record daily adherence to the RICE protocol and to indicate their activity levels during the treatment period. The diary was a simple questionnaire designed to ascertain whether subjects had worn their bandage, applied ice, and elevated their foot each day. In addition, subjects responded to questions about when they returned to work and to their normal amount of walking. Because ankle inversion sprains are most commonly sustained during sporting activities, questions were also included about when subjects could run without pain and when they returned to sports.
Outcomes were measured before and after each treatment and one day after discharge from the trial. Subjects exited from the trial when they had attained full pain-free range of movement in dorsiflexion (ie, the available range of movement in dorsiflexion was the same in both ankles) with the application of 100 N of force (approximately 12 N·m of torque), because no further improvement in this variable was possible. The treatment period was limited to a maximum of 2 weeks.
The outcomes measured were dorsiflexion and the 3 gait variables of stride speed, step length, and single support time. The angle of pain-free dorsiflexion and the force applied to achieve this angle were recorded.
Subjects were all partial weight bearing using ambulation aids on entry to the trial, but walked without their aids for the gait analysis. The gait variables were measured before and after each treatment. Because it was likely that high intersubject variability with respect to the absolute step length and step time values would reduce the power of the analysis, the symmetry ratios for step length and single support time were used as indicators of functional status. Such ratios are largely independent of confounding variables such as walking speed and height and are most likely to be influenced by the pain on weight bearing and reduced ankle range of motion associated with the injury.46
The number of treatments received by subjects was analyzed using the chi-square test.47 Dorsiflexion range of movement was analyzed using planned contrasts within an analysis of variance for repeated measures.47 Gait was analyzed in 2 ways. Walking speed was expressed as a percentage of the initial speed. For the variables of single support time and step length, a symmetry index was calculated using the following formula48:
Perfect symmetry is expressed by an index of 0.5. Single support time should be most affected on the injured side because it tends to be shorter in duration due to the pain associated with weight bearing on that side. In contrast, step length should be most affected on the side of the uninjured limb because a subject would be reluctant to take long steps due to pain and limited range of motion on the weight-bearing, injured side. We used statistical analysis to determine whether differences existed between the experimental and control groups and between treatment sessions. An analysis of variance for repeated measures was used to investigate these factors.
Subjects were discharged from the trial when they had recovered dorsiflexion. We decided, therefore, to analyze our data when fewer than half of the subjects in either group remained in the trial. This occurred after 3 treatment sessions. By the fourth treatment session, fewer than half of the subjects in the experimental group (32%) remained in the trial. We believe that this method of analysis indicates rate of recovery in addition to differences in outcome measures.
Finally, diary entries relating to adherence to the home program and return to activity during the trial are described. At the end of the trial, not all subjects had returned to the activities listed in the diary. Therefore, for these subjects, return to the activity was assigned as 14 days (ie, the conclusion of the trial). Using this maximum is conservative and thereby underestimates the rate of return to these activities.
This randomized controlled trial was designed to evaluate the effect of a common manual therapy technique for acute ankle inversion sprain on outcomes relevant to the patient, in particular, pain-free range of movement in dorsiflexion and gait.
Subjects were discharged from the trial when the application of a 100-N force led to full pain-free range of movement in dorsiflexion, that is, when no further improvement was possible for this variable. Therefore, the number of subjects continuing in the trial declined progressively over the 2 weeks of treatment. At completion of the trial, 1 subject remained in the experimental group and 4 subjects remained in the control group (Tab. 2). By the fourth treatment session, the majority of subjects in the experimental group (13/19 subjects [68%]) had been discharged from the trial because they had attained full range of movement in dorsiflexion, although only 3 subjects in the control group had been discharged by the same time (χ2=10.80, P<.01). Because fewer than half of the subjects in the experimental group remained in the trial by the fourth treatment session, only data derived from the first 3 treatment sessions were analyzed further.
Dorsiflexion Range of Movement
Anteroposterior mobilization of the talus using a gentle force to avoid reproduction of pain in addition to the RICE protocol resulted in greater improvement in dorsiflexion range of movement than the application of RICE alone for measurements taken before (P <.02) and after (P<.01) each of the first 3 treatment sessions (Fig. 3). After the first treatment session, subjects in the experimental group improved 4.3 degrees, from a mean of 8.9 degrees (SEM=2.2°) to a mean of 13.2 degrees (SEM=2.2°), and subjects in the control group improved 0.9 degree, from a mean of 7.2 degrees (SEM=2.5°) to a mean of 8.1 degrees (SEM=1.9°). From entry to the trial (baseline measurement before the first treatment session) until the start of the second treatment session, the experimental group improved 10.9 degrees (SEM=1.9°) compared with an improvement of 5.8 degrees (SEM=1.1°) for the control group.
Pain-free ankle dorsiflexion range of movement. The effect of anteroposterior mobilization on ankle dorsiflexion range of movement was greater than the control treatment in the first treatment session. Although the rate of recovery of the ankle was similar between treatment sessions for both groups, there was a continued gain in the experimental group as a result of the extra range of movement achieved in the first treatment session. Treatment 1 led to greater results than treatments 2 or 3 in the experimental group. No changes were observed in the control group.
Characteristics of Gait
Stride speed increased over the duration of the trial for both groups (Fig. 4). Greater increases were found within the first and third treatment sessions in the experimental group (P <.05). After the first treatment session, subjects in the experimental group improved from a mean of 0.41 m·s−1 to a mean of 0.50 m·s−1, and subjects in the control group improved from a mean of 0.43 m·s−1 to a mean of 0.47 m·s−1 (Tab. 3).
Stride speed. Stride speed was measured before and after each of the first 3 treatments for the experimental and control groups. The control group is represented by the filled circles, and the experimental group is represented by the open squares. Improvement was greater in the experimental group than in the control group. Error bars represent SEM.
Gait Variables for the First Three Treatment Sessions
Step length symmetry improved in both groups, reaching values close to symmetrical (0.5) after 3 treatment sessions (Fig. 5). Measurements taken after the second treatment session showed greater gains in step length symmetry in the experimental group than in the control group (P <.05).
Ratio of step length of uninjured limb to total stride length (symmetry ratio). The control group is represented by the filled circles, and the experimental group is represented by the open squares. There was no difference between groups in improvement in step length. Error bars represent SEM.
The symmetry of single support time (time spent on one leg alone) also improved with both treatments (Fig. 6). The distributions of these data, however, are skewed and demonstrate considerable intersubject variability. Consequently, there were no differences, based on our statistical analysis.
Ratio of single support time on injured side to total time spent in single support. The median of the control group is represented by the filled circles, and the median of the experimental group is represented by the open squares. There was no difference between groups in improvement in step length. Error bars represent 25th and 75th percentiles.
Return to Normal Activity
Return to normal activity was monitored using the activity diary. Because not all questions were applicable to all subjects, the mean was calculated only for those subjects for whom a particular activity was relevant, and the number of subjects is indicated in parentheses. The subjects in the experimental group (n=17) returned to work 6 days after injury, and the subjects in the control group (n=18) returned to work 5.3 days after injury. Subjects in the experimental group returned to a normal amount of walking (n=19) after 7.7 days, were able to run (n=16) after 12.6 days, and returned to sports (n=13) after 12.2 days. Subjects in the control group returned to a normal amount of walking (n=19) after 9.2 days, were able to run (n=19) after 13.3 days, and returned to sports (n=16) after 13.4 days.
In our study, we showed that when acute ankle inversion sprains were treated with AP mobilization of the talocrural joint in addition to the conventional RICE protocol, fewer treatments were required for pain-free dorsiflexion range of movement and stride speed to improve than when RICE alone was administered. Although researchers in pilot studies have demonstrated that passive mobilization can improve pain-free ankle range of motion,24,49 our trial is the first randomized controlled trial to demonstrate an effect of passive joint mobilization on sprained ankles.
We noted an apparent continued improvement in pain-free dorsiflexion range of movement for both groups between treatment sessions (Fig. 3). The measurements taken after one treatment and before the next treatment showed that dorsiflexion improved 5 to 6 degrees between treatment sessions for both groups. We believe that this improvement is likely to represent the rate of natural recovery from acute ankle sprain.
The improvement conferred by the AP mobilization is unlikely to be accounted for by differences in the groups that existed before the study. The 2 groups were similar at entry to the trial for most variables except that more subjects in the experimental group previously had sprains (Tab. 1). Although previous sprains might have worsened the prognosis, the experimental group improved more quickly than the control group. This finding suggests to us that passive mobilization is an effective additional treatment for improving pain-free range of movement and some gait variables.
Both groups reported good adherence to the home program. All subjects in the control group returned their adherence diary, but 3 subjects in the experimental group failed to return the diary, resulting in a return rate of 93%. Adherence was calculated as the percentage of days enrolled in the trial in which subjects performed each aspect of the protocol as required, and not as a percentage of subjects. The 16 subjects in the experimental group who returned their diary reported adhering to the rest regimen 79% of the time, to the ice regimen 81% of the time, and to compression 64% of the time. The control group adhered to the rest regimen 81% of the time, to the ice regimen 67% of the time, and to compression 58% of the time. Different rates of adherence to the home program, therefore, are unlikely to explain the improvement with the passive mobilization treatment in the experimental group.
Pain-free Dorsiflexion Range of Movement
The reasons for the beneficial effects of mobilization are unclear, although several hypotheses have been advanced, including physiological modulation of pain and mechanical alteration of tissues.33,50,51 Most authors agree that the mobilization should be performed at the end of the joint's range of motion, perhaps in the plastic deformation part of the tissue response to force, to effect these mechanical alterations. In our study, however, the mobilization was performed near the beginning of the joint's range of motion and not at the end of the range of motion. In addition, there was an immediate reduction in pain, as evidenced by the improvement in pain-free dorsiflexion range of movement, an unlikely response from a mechanical event.
The continued improvement of stride speed between treatment sessions indicates to us that the injury was resolving, and some benefits may or may not have been attributable to a treatment effect from the mobilization in the experimental group. In both groups, there were measurable improvements in walking speed following each treatment. The magnitude of the improvement was relatively greater after the first treatment than subsequent treatments, irrespective of the intervention. This step speed gain is consistent with the finding of maximum effect on ankle dorsiflexion range of movement at the first treatment.
The use of a symmetry index to examine the effect of the treatments on step length and single support time, in our opinion, diminishes some of the problems of intersubject variability. It is clear that the symmetry index was not substantially influenced by the first treatment. The second experimental treatment, however, evoked an improvement in step length symmetry. Although there was a trend toward improvement in single support time symmetry in the experimental group, and an opposite trend in the control group, these data are not clearly distinct and no conclusion can be drawn concerning the effect of mobilization on the ability to spend a longer period bearing weight on the injured side.
Because the walking speed remained slow, the lack of a change in the first treatment may indicate that there was only a slight increase in the step length. Of more interest is the fact that, although walking speed changed only by about 10% after the second treatment session, the step length symmetry improved by 35%. This finding may reflect a pattern of improved range of movement and reduced pain on weight bearing, permitting a longer step on the uninjured side.
Our research demonstrated that treatment (which included AP mobilization) improved pain-free ankle range of movement in dorsiflexion, as well as the functional outcome of stride speed. The improvement occurred with fewer AP mobilization treatments than were required for the control group. Subjects in both groups improved in all variables tested, although the improvement was greater for the experimental group than for the control group. Because a nontreatment group was not included in this trial for ethical reasons, it is unclear whether the improvements in the control group were achieved by the RICE protocol or by natural recovery.
Ethical approval for the study was obtained from the human ethics committees of the University of Sydney and Calvary Hospital, Canberra.
↵* Panasonic Inc, 1 Panasonic Way, Secaucus, NJ 07094.
↵† Summagraphics Inc, 60 Silvermine Rd, Seymour, CT 06483.
↵‡ Jandel Scientific Inc, 65 Koch Rd, Corte Madera, CA 94925.
Accepted September 14, 2000.
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Andriacchi TP, Ogle JA, Galante JO. Walking speed as a basis for normal and abnormal gait measurements. J Biomech.1977 ;10:261–268.
Basur RL, Shephard E, Mouzas GL. A cooling method in the treatment of ankle sprains. Practitioner.1976 ;216:708–711.
Birrer RB, Cartwright TJ, Denton JR. Primary treatment of ankle trauma. The Physician and Sportsmedicine.1994 ;2211:33–42.
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Knight KL. Cryotherapy: Theory Technique and Physiology. Chattanooga, Tenn: Chattanooga Corp;1985 .
Slatyer MA, Hensley MJ, Lopert R. A randomized controlled trial of piroxicam in the management of acute ankle sprain in Australian Regular Army recruits. Am J Sports Med.1997 ;25:544–553.
Starkey JA. Treatment of ankle sprains by simultaneous use of intermittent compression and ice packs. Am J Sports Med.1976 ;4:142–144.
Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. J Manipulative Physiol Ther.1998 ;21:448–453.
Brukner P, Kahn K. Clinical Sports Medicine. Sydney, New South Wales, Australia: McGraw-Hill;1993 .
Clinch P. Passive mobilisation of ankle inversion injuries. In: Fifth Proceedings of the Manipulative Therapists Association of Australia.1987 :54–61.
Corrigan B, Maitland GD. Practical Orthopaedic Medicine. Sydney, New South Wales, Australia: Butterworths;1983 .
Maitland GD. Passive movement techniques for intra-articular and peri-articular disorders. Australian Journal of Physiotherapy.1985 ;313:3–8.
Di Fabio RP. Efficacy of manual therapy. Phys Ther.1992 ;72:853–864.
Maitland GD. Vertebral Manipulation. 5th ed. Sydney, New South Wales, Australia: Butterworths;1986 :ix.
Frank C, Akeson WH, Woo SL, et al. Physiology and therapeutic value of passive joint motion. Clin Orthop.1984 ;185:113–125.
Maitland GD. Peripheral Manipulation. 2nd ed. Sydney, New South Wales, Australia: Butterworths;1977 :282.
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Paris SV. Mobilization of the spine. Phys Ther.1979 ;59:988–995.
Zusman M. Spinal manipulative therapy: review of some proposed mechanisms and a new hypothesis. Australian Journal of Physiotherapy.1986 ;322:89–99.
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McClure P, Flowers KR. Treatment of limited shoulder motion: a case study based on biomechanical considerations. Phys Ther.1992 ;72:929–936.
Moseley A, Adams R. Measurement of passive ankle dorsiflexion: procedure and reliability. Australian Journal of Physiotherapy.1991 ;373:175–181.
Matyas T, Bach T. The reliability of selected techniques in clinical arthrometrics. Australian Journal of Physiotherapy.1985 ;31:175–199.
Nield S, Davis K, Latimer J, et al. The effect of manipulation on range of movement at the ankle joint. Scand J Rehabil Med.1993 ;25:161–166.
Gaudet G, Goodman R, Landry M, et al. Measurement of step length and step width: a comparison of videotape and direct measurements. Physiotherapy Canada.1990 ;421:12–15.
Wall J, Crosbie J. Accuracy and reliability of temporal gait measurement. Gait Posture.1996 ;4:293–296.
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Fay F, Egerod S. The effects of joint mobilisations on swelling in the acutely sprained ankle joint: a pilot study. Australian Journal of Physiotherapy.1985 ;314:168.
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Vol 96 Issue 12 Table of Contents
Musculoskeletal Impairments Are Often Unrecognized and Underappreciated Complications From Diabetes
Physical Therapist–Led Ambulatory Rehabilitation for Patients Receiving CentriMag Short-Term Ventricular Assist Device Support: Retrospective Case Series
Education Research in Physical Therapy: Visions of the Possible
Predictors of Reduced Frequency of Physical Activity 3 Months After Injury: Findings From the Prospective Outcomes of Injury Study
Use of Perturbation-Based Gait Training in a Virtual Environment to Address Mediolateral Instability in an Individual With Unilateral Transfemoral Amputation
Effect of Virtual Reality Training on Balance and Gait Ability in Patients With Stroke: Systematic Review and Meta-Analysis
Effects of Locomotor Exercise Intensity on Gait Performance in Individuals With Incomplete Spinal Cord Injury
Case Series of a Knowledge Translation Intervention to Increase Upper Limb Exercise in Stroke Rehabilitation
Effectiveness of Rehabilitation Interventions to Improve Gait Speed in Children With Cerebral Palsy: Systematic Review and Meta-analysis
Reliability and Validity of Force Platform Measures of Balance Impairment in Individuals With Parkinson Disease
Measurement Properties of Instruments for Measuring of Lymphedema: Systematic Review
myMoves Program: Feasibility and Acceptability Study of a Remotely Delivered Self-Management Program for Increasing Physical Activity Among Adults With Acquired Brain Injury Living in the Community
Application of Intervention Mapping to the Development of a Complex Physical Therapist Intervention
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An area to discuss any seasonal things e.g. things that only happen at Christmas.
Interesting tips or places to visit to celebrate Halloween? Post it here!
Going to Florida at Easter time. Here's where you'll find all the information you will need.
Tips on how to get the most out of your vacation during Christmas.


Chromatography is a technique for separating the components in a complex mixture. The mixture flows though a medium and the individual substances that make up the mixture are deposited at different distances from the point of inflow. In contemporary chemistry the resulting image is incidental and largely ignored. The emphasis there is on analysis of the types and amounts of the components.
In biodynamics the technique was originally named capillary dynamolysis and is used to create a picture of the substance that can be interpreted directly. Approached in this way it can reveal something of the inner nature of a substance - its vitality and dynamics.
Below are a number of chromatograms I have made of different substances. In making these images, I followed the procedure and recommendations of E.E. Pfeiffer described in "Chromatography Applied to Quality Testing" 1984, Bio-Dynamic Literature, Wyoming, USA.
Essentially, a circular filter paper (Whatman #1) with a cylindrical paper wick sitting in a 0.5% solution of silver nitrate is allowed to absorb the solution, which spreads by capillary action, to a certain diameter. The wick is removed and the paper is dried. Meanwhile, the substance to be tested is mixed with a 0.1 to 1% solution of sodium hydroxide and let stand for a period of time. The prepared filter paper is then allowed to absorb this solution and the substance spreads over the paper. When it has spread to a certain distance, the wick is removed and the paper dried. The paper is then exposed to indirect sunlight to let the image develop.
Click on an image below to view different groups of chromas.
If you'd like further information email me.


Antibody was affinity purified using an epitope specific to p70S6 immobilized on solid support. The epitope recognized by A300-510A maps to a region between residue 475 and the C-terminus (residue 525) of human Ribosomal Protein S6 Kinase, 70 kDa, polypeptide 1 using the numbering given in entry NP_003152.1 (GeneID 6198).Immunoglobulin concentration was determined by extinction coefficient: absorbance at 280 nm of 1.4 equals 1.0 mg of IgG.
Detection of human and mouse p70S6K by western blot. Samples: Whole cell lysate (50 µg) from HeLa and mouse NIH 3T3 cells prepared using NETN lysis buffer. Antibody: Affinity purified rabbit anti-p70S6K antibody A300-510A (lot A300-510A-2) used for WB at 0.05 µg/ml. Detection: Chemiluminescence with an exposure time of 3 minutes.


This family tree is not only the work of the compiler - special thanks must go to Freddy Burke, Yardfield, Clonlara, Co. Clare, Ireland (researching Burke family).
John Burke, 95 Walnut Rise, Griffiths Avenue, Dublin. Co Dublin, Ireland (researching Burke family).
Peggy Cockran 71 Manning Baptist Village, 8 Robinsons Road, Baxter, Victoria 3911 Australia (researching Burke and Shine family).
Paul Robert Herstein, USA <PHerstein@aol.com> (researching Burke family).
Linda Burke, 9011 Maritime Court, Springfield, Virginia 22153 USA <bigpaw@cox.net>. Linda has more information on this family and would pleased to be assist others with research (researching Burke family).
Marie Boyce (dec. 2007), 15 Fairy Street, Warrnambool, Victoria 3280. Australia (researching Sheehy and Shine family).
Michael Raleigh, 49 Willmington St. Newmarket. Qld. 4051 (Tel. 07 33564482) email <sirwal30@hotmail.com> (researching Shine family).
This tree was compiled by Kate Press, 71 Claremont Avenue, Malvern Victoria 3144 Australia. It is not complete and is an on going project. Notes and photos will be added as time permits. The author welcomes correspondence, corrections and comments.
Many birth dates had to be estimated and where this occurs ten years either side of the given date is assumed to be a probable date of birth. Prior to civil registration Christening/Baptism dates have been used. Christening/Baptism dates most usually occur within twelve months of the birth but not always. Sometimes a Christening/Baptism will occur many years after the birth.
The original family data was organised using The Master Genealogist program and the web site using the new TMG web page generator, Second Site. This program allows fast and simple fine tuning of many TMG (ver 4 and 5) features.
Names, dates, places, age and relationships, found on birth, death, and marriage certificates, census forms, wills and probate documents, gravestone inscriptions, shipping lists, naturalization records, school records, employment forms etc.
This occurs for a variety of reasons. Our ancestors were not interested in providing information to the authorities English or otherwise And they were not into providing information for future family historians. The cold hard facts are that they were trying to survive and make their way in very difficult times or, as emigrants, were cutting out and improving their future in a new homeland.
From the above it appears that the entries 9 and 10 were filled in after the event and the parties to the marriage were inadvertently mixed up.
Death records are the most notorious for errors as they are filled in by an informant who may or may not be related and even the relatives get the information incorrect, particularly elderly relative whose memories are clouded. Other errors occur because some people hide the truth or are ashamed of their humble beginnings.
Birth records also contain errors and omissions. Sometimes a date of marriage is altered to hide the date of conception or a place name spelt incorrectly. The most misleading error I have encountered was a birth certificate which included a spouse, his occupation, date of marriage and location when in fact, the marriage never occurred. That sent me off on a very wild goose chase.
Baptismal names were often Latinised e.g. Maria for Mary, Eugenius for Owen and Anna for Anne.
Naturalization Records: emigrants filled out these documents well if they could. If not, they probably had the clerk in the court house do it for them and if the clerk understood the accent, they might be correct..
Errors can occur when calculating an ancestors age from shipping records as some emigrants put their ages down to gain cheaper fares.
Another dilemma is caused by dates given in different records that do not agree. For example: the year of birth calculated from the age given on a shipping manifest differs from the year of birth calculated from age at death given on a death certificate.
Also difficulties can also occur because of the lack of precise information: for example: when an ancestor just stages his age to the nearest 5 or 10 years.
Locating a birthplace can be difficult; problems often occur because the emigrant and/or the authorities did not consider it important to provide the precise birthplace. For example, an ancestor from Co Limerick would just state Limerick as his/her birthplace but not identify if this was Limerick city or a village within Co Limerick.
"from the information available all the dates given are a true and accurate record as can be estimated".
In 1853 as the parents of Mary Barrett of Shanagolden, County Limerick had both died, she took advantage of sponsorship offered by local landlord, Lord Monteagle to travel to Victoria, Australia on the Monteagle. She soon was employed by Mrs Hollis of South Bourke Street, Melbourne for 25 a year plus rations.
Like many other Irish settlers, out of her wages Mary remitted 6 to Ireland to assist with the fares of her siblings Bridget, Ellen, Catherine, Michael and John. Other relatives, Catherine and Mary Corbett, also made the long journey. Lord Monteagle advanced the remaining sum needed for their deposits while Lady Monteagle used her influence to ensure that the family travelled together at a time when, due to the gold rushes, assisted immigration for single males into Victoria was not generally permitted. After arriving in Geelong on the Chandenagore on 21 June 1854, Mary's family went to Collingwood to join their sister.
Mary Barrett's story came to light in documents associated with the 'Monteagle emigrants'. These were Australian-Irish who had previously lived within the influence of a local parliamentary member for Limerick (and later, Cambridge), Thomas Spring Rice and his family around his estate at Mount Trenchard overlooking the Shannon Estuary. (This is the same man who during his term as Secretary of State for the Colonies applied for leave to bring in a bill to establish criminal courts on Norfolk Island in the 1830s.) The history of this migration between 1838 and 1858, was told in a 1994 book, Poverty to Promise, written by Limerick researcher, Dr Christopher O'Mahony and Australian social historian, Valerie Thompson.
Following the success of this volume which identified about 736 of the settlers, Valerie Thompson now has joined forces with Kate Press of Melbourne to broaden the study to include West Limerick people who left the area up to the end of the nineteenth century including those seeking homes in places other than the two largest Australian colonies. The new quarto sized book, West Limerick Families Abroad, is most comprehensive, offering ready identification of over 1,000 family names, showing not only their Irish origins but also their issue in the new countries of residence.
Quite apart from the 214 pages allocated to West Limerick families' biographies, several appendices supplement the text contributing prolific references for anyone researching this particular county. A chronology of Irish history is augmented by a time-line for appropriate records before a more detailed listing of local sources ranging from census, histories, journals and directories, to gravestone inscriptions and graveyard records. Valuable schedules including the Limerick newspapers with their dates of publication as well as parish structures -covering the Roman Catholic, civil, and Church of Ireland equivalents and dates - appear in alphabetical groupings under both civil and Roman Catholic headings. Further amplification is offered by the reproduction of the section dealing with the Monteagle property in the 1844 Enquiry into the Occupation of Land in Ireland in addition to the inclusion of numerous Limerick entries that appeared in The Search for Missing Friends: Irish immigrant advertisements placed in the Boston Pilot, published by the New England Historic Genealogical Society in Boston, Massachusetts. Following a section on faction fighters and a couple of entries on convicts, the List of Contributors provides contact details for genealogists eager to link families. This well illustrated volume, of which only 1,000 copies were printed, is an essential reference book for libraries and society collections. West Limerick Families Abroad, by Kate Press and Valerie Thompson, Melbourne, 2001 is available from Data Tree Publishing, contact Tony Press, 71 Claremont Avenue, Malvern, Victoria, 3144 for A$28.95 plus postage and packing (within Australia) of A$11.00.
Kate Press, C/O Tony Press, 71 Claremont Avenue, Malvern Victoria 3144 Australia.
Vote by visiting this site!


The picture on the left is all the tablets I take first thing in the morning when I get up. Other than the prednisilone the next smallest is the tablet pictured on the right. Its my Theophylline. At one point about 8 years ago I thought this was my wonder drug. I had a fairly stable patch when I first started taking it. As I started losing control I was in hospital more requiring IV aminophylline (an intravenous version of theophylline but all from the same family). It works great but has its problems, the biggest one is weaning off and back onto oral medication.
One of the other issues I am having with it just now is establishing a therapeutic dose. Over the last year my theophylline serum level has always been towards the lower end of the therapeutic range and sometimes dipping under. I have tried increasing the dose but then I end up with horrendous effects from toxicity because my serum level is way above therapeutic range. The feeling of nausea, vertigo, dizziness and uncontrollable thirst is torture and there is no quick fix to get rid of it. The tablets are MR (modified release) over 12 hours so your level will only drop very slowly over time. It takes about 2-3 weeks for theophylline to build up in your system to achieve a therapeutic dose so it is just as long to reverse it.
I would normally just chuck all my tablets in my mouth and wash them down with a glass of water or a vitamin C drink but recently I have found I fish out my theophylline and have to almost pluck up the courage to take it because of how it is making me feel sometimes. It works so well on my chest that it is worth taking it but when things are just not quite right and the side effects are bad it is hard to make yourself swallow it down.
You would not think such a small innocuous tablet could make you feel the way it does. It seems to be the smaller the tablet the more potent it and its side effects are. Between theophylline and prednisilone Im not sure what is worse but what I do know is that both of them do work wonders and do fantastic things to my chest.
I guess the point of this post is that no matter how hard it is to make medication as long as you get the benefits from it then its worth having the side effects. I know I would be much worse off if I didnt take it but somedays the side effects are just so strong you wonder if it is worth it.
The beauty with modern day medication is that there are other medications you can take to counter act the side effects. You can end up in a bit of a polypharmacy and taking so much medication you don't know what is for what, but as long as you remember or write down why you take each thing and check regularly with a GP or pharmacist to make sure you still need the extra meds then you won't be taking stuff you don't need to. By doing this I have recently managed to cut out a good few tablets which I didnt really know what they were for or what they were doing but the bulk of my medication I now what it is for and why I take it and how it effects me if I don't take it.
Its tough sometimes but for me I far prefer dealing with side effects and taking extra meds for it compared with fighting for breath all day everyday and being totally limited in what I can do. Theophylline gives me some more breath back and some control!!!


Profile designing has a major role in promoting your business as it is a sign of innovation. It is used for the advertisement of your precious company among the customers so it should be designed in a way that even a layman can understand it. It should be simple and attractive, which will have a fine impression and long lasting effects. We not only serve you by designing graphics for your company, but also giving suggestions and recommendations is our basic task. You can tell us whatever type of graphic designing you need, or just let us know the specifications of your business; our highly trained designers will design the best possible Profile Design for you.
Make sure that graphic designing is not an expense by your side, as some companies use to believe; rather you will get out of it much more than your investment. You can calculate your budget and can do a cost benefit analysis, and you will see the difference. It is a powerful tool of making a positive image of your business. Our rates are very affordable and normal; you can compare our price with the market price.


SARDi Jewellery is costume jewellery that is either 22 carat gold plated, pure silver plated, rhodium plated or another variant. SARDi Gifts are 22 carat gold plated, pure silver plated, rhodium plated or another look.
SARDi Accessories are 22 carat gold plated, pure silver plated, rhodium plated or another look.
All SARDi Jewellery carries a 14 day guarantee, subject to conditions. If you are not delighted with your purchase after 14 days, return it to us for a full refund or replacement.
All of our products are made at our premises. All products are made from a customised composite alloy. Plating is as far as we know "Nickel Safe" from our suppliers. Thickness of plating varies with tailored orders.
- handmade by skilled and dedicated craftspeople.
- hand finished by experienced craftspeople.
- uniquely different & quality hand crafted products.
- Always store jewellery separately to avoid items becoming scratched.
causes unnecessary wear and tear and stress on the items.
- Wash your jewellery from time to time in soapy water.
- Rinse thoroughly with cool water prior to drying with a clean cloth.


Apply today for the Ignite for Tech Program!
Five One Labs is pleased to announce IGNITE, our very first entrepreneurship program focusing on achieving product market fit. This program will help you better understand the market you are competing in and how you can create the most value for your customers.
We are now recruiting tech-entrepreneurs from diverse communities all around Iraq to participate in this month-long program. If you are passionate about a tech-focused startup idea and want to learn the skills to turn it into a business, this program is right for you!
We will be running this program three times over the course of the coming months. Please see below for more information.
The full application for the program can be found here. Applications are due by March 27th at 11:59pm.
What do you get from joining Ignite?
Five One Labs entrepreneurs are provided with a variety of support. Our vision is to develop an inclusive network of innovators that have the support, skills, and connections to positively change their communities and countries.
Join the growing Five One Labs community and get access to networking events and an entrepreneurial family to share the experience with!
Are able to be in Sulaimani for the entirety of the program (Please note that if you live outside of Sulaimani, we have a small number of scholarships available to help cover costs of housing and transportation).
We will hold three separate Ignite programs before the launch of our full time incubator program running from September-November, 2019. Please note that although this is a standalone program, completing the Ignite program is a requirement for applying to the the full time incubator program running in September 2019.
Our three-month incubator takes you through the steps necessary to turn your idea into a reality. By the end of the incubator, you will have developed a solution that fits your customers' needs, and you will have built a working version of it (a Minimum Viable Product). You will have developed a professional-looking pitch deck about your idea and will have the opportunity to present it to Five One Labs management, mentors, advisors, and potential investors. You will have defined your business model, built connections to an incredible network of mentors and advisors around the world, and will be significantly closer to launching your business.
Graduates from the Five One Labs Incubator program will have the opportunity to compete for seed funding of up to $15,000!
Finally, we are looking for candidates from very diverse communities, including locals, refugees, and internally displaced people in Iraq. If you are not sure you are eligible or have any other questions, please email us at applications@fiveonelabs.org or send us a message on our Facebook page!
Programming at The Lab:Suli is generously supported by GIZ.


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Driving related legal matters in British Columbia can carry significant penalties. Beyond the financial fines and possibility of imprisonment for criminal driving offences, sanctions can often include driving prohibitions. As well, convictions for driving offences can affect driving insurance premiums and future employment opportunities.
Appeals against driving-offence convictions or sentences.
Contact Peck and Company at 604-669-0208 or via email at reception@peckandcompany.ca.


text:
// Increase max listeners for event emitters
require('events').EventEmitter.defaultMaxListeners = 100;

const gulp = require('gulp');
const path = require('path');
const tsb = require('gulp-tsb');
const es = require('event-stream');
const filter = require('gulp-filter');
const rimraf = require('rimraf');
const util = require('./lib/util');
const watcher = require('./lib/watch');
const createReporter = require('./lib/reporter').createReporter;
const glob = require('glob');
const sourcemaps = require('gulp-sourcemaps');
const nlsDev = require('vscode-nls-dev');
const root = path.dirname(__dirname);
const commit = util.getVersion(root);
const plumber = require('gulp-plumber');
const _ = require('underscore');

const extensionsPath = path.join(path.dirname(__dirname), 'extensions');

const compilations = glob.sync('**/tsconfig.json', {
	cwd: extensionsPath,
	ignore: ['**/out/**', '**/node_modules/**']
});

const getBaseUrl = out => `https://ticino.blob.core.windows.net/sourcemaps/${commit}/${out}`;

const tasks = compilations.map(function (tsconfigFile) {
	const absolutePath = path.join(extensionsPath, tsconfigFile);
	const relativeDirname = path.dirname(tsconfigFile);

	const tsconfig = require(absolutePath);
	const tsOptions = _.assign({}, tsconfig.extends ? require(path.join(extensionsPath, relativeDirname, tsconfig.extends)).compilerOptions : {}, tsconfig.compilerOptions);
	tsOptions.verbose = false;
	tsOptions.sourceMap = true;

	const name = relativeDirname.replace(/\//g, '-');

	// Tasks
	const clean = 'clean-extension:' + name;
	const compile = 'compile-extension:' + name;
	const watch = 'watch-extension:' + name;

	// Build Tasks
	const cleanBuild = 'clean-extension-build:' + name;
	const compileBuild = 'compile-extension-build:' + name;
	const watchBuild = 'watch-extension-build:' + name;

	const root = path.join('extensions', relativeDirname);
	const srcBase = path.join(root, 'src');
	const src = path.join(srcBase, '**');
	const out = path.join(root, 'out');
	const baseUrl = getBaseUrl(out);

	let headerId, headerOut;
	let index = relativeDirname.indexOf('/');
	if (index < 0) {
		headerId = 'vscode.' + relativeDirname;
		headerOut = 'out';
	} else {
		headerId = 'vscode.' + relativeDirname.substr(0, index);
		headerOut = relativeDirname.substr(index + 1) + '/out';
	}

	function createPipeline(build, emitError) {
		const reporter = createReporter();

		tsOptions.inlineSources = !!build;
		tsOptions.base = path.dirname(absolutePath);

		const compilation = tsb.create(tsOptions, null, null, err => reporter(err.toString()));

		return function () {
			const input = es.through();
			const tsFilter = filter(['**/*.ts', '!**/lib/lib*.d.ts', '!**/node_modules/**'], { restore: true });
			const output = input
				.pipe(plumber({
					errorHandler: function (err) {
						if (err && !err.__reporter__) {
							reporter(err);
						}
					}
				}))
				.pipe(tsFilter)
				.pipe(util.loadSourcemaps())
				.pipe(compilation())
				.pipe(build ? nlsDev.rewriteLocalizeCalls() : es.through())
				.pipe(build ? util.stripSourceMappingURL() : es.through())
				.pipe(sourcemaps.write('.', {
					sourceMappingURL: !build ? null : f => `${baseUrl}/${f.relative}.map`,
					addComment: !!build,
					includeContent: !!build,
					sourceRoot: '../src'
				}))
				.pipe(tsFilter.restore)
				.pipe(build ? nlsDev.bundleMetaDataFiles(headerId, headerOut) : es.through())
				// Filter out *.nls.json file. We needed them only to bundle meta data file.
				.pipe(filter(['**', '!**/*.nls.json']))
				.pipe(reporter.end(emitError));

			return es.duplex(input, output);
		};
	}

	const srcOpts = { cwd: path.dirname(__dirname), base: srcBase };

	gulp.task(clean, cb => rimraf(out, cb));

	gulp.task(compile, [clean], () => {
		const pipeline = createPipeline(false, true);
		const input = gulp.src(src, srcOpts);

		return input
			.pipe(pipeline())
			.pipe(gulp.dest(out));
	});

	gulp.task(watch, [clean], () => {
		const pipeline = createPipeline(false);
		const input = gulp.src(src, srcOpts);
		const watchInput = watcher(src, srcOpts);

		return watchInput
			.pipe(util.incremental(pipeline, input))
			.pipe(gulp.dest(out));
	});

	gulp.task(cleanBuild, cb => rimraf(out, cb));

	gulp.task(compileBuild, [clean], () => {
		const pipeline = createPipeline(true, true);
		const input = gulp.src(src, srcOpts);

		return input
			.pipe(pipeline())
			.pipe(gulp.dest(out));
	});

	gulp.task(watchBuild, [clean], () => {
		const pipeline = createPipeline(true);
		const input = gulp.src(src, srcOpts);
		const watchInput = watcher(src, srcOpts);

		return watchInput
			.pipe(util.incremental(() => pipeline(), input))
			.pipe(gulp.dest(out));
	});

	return {
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redpajama_set_name: RedPajamaGithub


text:
Scandal premiere recap: 'Survival of the Fittest'
Scandal's premiere takes no prisoners as the fight for the White House turns deadly
By Justin Kirkland
Credit: ABC/Tony Rivetti
Knock me into the Potomac and call me Amanda Tanner! Scandal is back.
I'll be joining you as your aficionado this season, and together we'll make sure it's handled. Through the Christmas episode abortions, the hooch in the dresser drawer, and the botched elections, we're here at the end of the most absurd election since… well, let's just stick with fiction. We open with Quinn and Huck trekking through the woods together, talking about marriage and looking for an unnamed woman, but when they get to the cabin she would be staying in, the cabin blows up. Let's just say that it's probably fair to say Amanda and this lady have something in common.
But of course, we don't get answers immediately because we have to throw back to the night before… Election Night, as exit polls are coming in. Remember when exit polls were fun to watch? What a time. Surprisingly, it appears that the election is coming down to California, which seems to be leaning in Mellie's favor, but it all depends on San Benito County. Mellie's camp seems pretty excited, but suddenly, it falls into Frankie Vargas' court. Olivia downs a glass of liquor, and Mellie falls back on the hope that there was voter tampering going on in San Benito.
Meanwhile, Jake's wife/best new character Vanessa is getting toasted on the couch, which feels super relatable on TGIT, am I right? Jake is nowhere to be found, and Olivia is pushing Mellie in the direction of having her concede. Mellie's determined that 4,000 votes aren't enough to end it, but Olivia demands she make the call. Olivia coaches her through it with cues on notepads, and it's painful, because how much has Mellie earned this? Yes, Frankie is great and fun and charming, but he has Cyrus in tow, and Mellie really had earned it.
Fortunately, Mellie and Olivia retreat to a bathtub, fully clothed, to drink victory champagne, now being used to nurse their loss. As they mourn, they hear cries from the main room. Running in, they reporter on television announces that President-elect Vargas has been shot. It's too, too much. They find the shooter, and Fitz is immediately briefed. Strangely enough, Jake is immediately by his side, and you have to wonder if his quick absence makes more sense because of it.
Abby heads to the hospital to start calling the shots on who can be around as PEOTUS Vargas is being operated on. The lead agent attempts to put Abby in her place, but she shuts that down REAL quick because this is her house… at least for a few more months. Of course, in the aftermath, Olivia and staff are trying to pull the pieces together. As the rest of the staff waits at OPA, practically considering Vargas dead, Olivia is coaching Marcus through reporting the news on Frankie. He was hit three times: once in the arm, once in the stomach, and the third went into his brain. And with that last shot, Frankie Vargas, PEOTUS of Shondaland, dies.
Of course, in the sadness of the moment, we have to turn back to the politics of it all: Who will be President now? David Rosen explains that while it could very well be Cyrus, it could also be a number of other people. Speaking of a number of people… we still don't have much detail on who killed Frankie Vargas, which leads Olivia to Rowan's office. He admits he didn't kill Vargas, but when he sets into a lecture about why Olivia lost the election, he reveals that Cyrus likely paid off the assassin who took Vargas out. He also reveals that he offered Olivia San Benito County, and she turned it down because who needs a double Defiance on their hands? Olivia heads back to OPA with Huck and Quinn to review the tapes to see that Cyrus did step away from Frankie right before the gunshots, as if any of us are shocked that Cyrus would maim a man for the presidency.
NEXT: Does Mellie want the job?
Olivia takes the news to Mellie, who says, "These people." Raise a chicken leg to this girl, because we get it, Mellie. She immediately dismisses the notion that she'd go for the Oval in the face of Frankie's death. But Olivia is not done with it, because she's a professional business lady. You know who else is a professional business lady? Abby. That's why she blocks Frankie's wife from calling their children, because the White House has to decide how to move forward. When you work for the government, you don't get to be a human… or even a Tide to Go pen. Poor Mama Vargas. Fitz has to choose a president because Vargas is dead, but according to Fitz, he's not dead until he says he's dead… which is not how science works, but Olivia was also kept in that red dungeon for, like, five episodes, so who are we to start calling shots now?
Olivia shows up at the Oval, ready to convince Fitz to choose Mellie for the presidency, and that's when she drops the assassination-sized bomb that Cyrus hired out to kill Frankie. Without proof, though, Fitz isn't willing to make a move. Instead, he gives Olivia until morning to figure it out. Huck, Quinn, and Charlie hop on the case, investigating the man who shot Frankie. But on the White House terrace, Fitz finds Mellie, who apologizes for all the resentment she had for Fitz. In the way Bellamy Young shines best, she goes into a full-blown monologue that amounts to her admitting Fitz was never weak… he just wasn't power hungry.
That's when he reveals to Mellie that he has to choose, and the choice is impossible. Cyrus and Mellie both broke the law to get him there (well, arguably, Cyrus a little bit more because… assassinations), but he can only choose one. He tells Mellie that if she doesn't want it, she can tell him in secrecy, and no one will ever know. But Mellie confirms that she does want it: that rare air. And you deserve it, sister friend. Through the cereal and rogue-son-killings and the adultery. You deserve it.
The OPA staff can't find any evidence connecting Cyrus to the assassination, but Olivia is not convinced — so much so that she scream speeches at the whole room. So Olivia does what she does best: handles it herself. She meets up with Abby on her way to Cyrus, but when she gets there, she's shocked at what she finds: a blood-soaked Cyrus, absolutely stunned by everything that has transpired. It leads her back to the White House, where she apologizes to Fitz.
Fitz heads to the hospital to meet up with Cyrus and tells him that if he will uphold the legacy of Francisco Vargas and be better than either of them ever were before, he will allow Cyrus Beene to be president. Cyrus. Beene. Is president. Marcus meets Mellie the next morning to give her the news, and she's clearly heartbroken. At OPA, Charlie and Quinn are talking about taking off on vacation. That's when Huck steps in as professional police and announces that this isn't for personal matters, unless they're interested in getting married. That's when Charlie proposes to Quinn.
Of course, as that transpires, Huck discovers one deleted voicemail the team didn't go over. It's from a Vargas campaign staffer named Jennifer Fields, who lives in a cabin deep in the woods… remember that cabin? It's the same one that blew up, and when Quinn and Huck get back from the site, Quinn says yes to Charlie's proposal and that voicemail is revealed. Olivia goes to the White House to offer her condolences to Cyrus, but as she leans in, we hear that voicemail: Jennifer confirms that Cyrus is the one who killed Vargas. And Olivia vows to Cyrus that she'll prove it. Lord be.
How many times can one person audibly gasp during an episode? Enough to nearly hyperventilate, per my count. What did you think of the episode, and do you think Cyrus will ever be proven guilty in the killing of that hunk of a president, Francisco Vargas? Rest in peace, sweet prince. We'll honor your name every Thursday at 9 p.m. /8 p.m. Central when Scandal returns.
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