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text: Rehabilitation Postfacial Reanimation Surgery After Removal of Acoustic Neuroma: A Case StudyWilson, Christopher M. PT, DPT, GCS; Ronan, Susan L. PT, DPT, PCSJournal of Neurologic Physical Therapy: March 2010 - Volume 34 - Issue 1 - p 41-49 doi: 10.1097/NPT.0b013e3181cfc324 Case Study Abstract Author Information Article Outline Background and Purpose: Facial paralysis can have a significant negative impact on an individual's social, physical, and emotional well-being; however, little information has been reported on the efficacy of physical therapy interventions for this condition. The purpose of this case study was to describe the details of a physical therapy evaluation and intervention for a patient who underwent facial muscle transfer after resection of acoustic neuroma. Case Description: A 29-year-old woman underwent left-sided facial reanimation surgery, which included transplantation of the temporalis muscle and platysma muscle to the corner of the mouth. Intervention: The patient received 30 sessions of physical therapy that included electrical stimulation, biofeedback, lymphatic drainage, home exercises and facial stretching, and scar management. Outcomes: The patient exhibited an improvement in the Composite score of the Sunnybrook Facial Grading System from 17 to 41. She was able to regain function of the left side of her face with gains in expressions of smiling, frowning, and puckering, but symmetry was not completely restored. The patient had chronic difficulty with left-sided lymphedema, requiring frequent manual lymphatic drainage. Discussion: Data from this case study suggest that physical therapy management improves functional outcomes for individuals with postoperative changes in facial motor function from facial reanimation surgery. Further research is required to explore factors that influence the rate and extent of recovery derived from physical therapy interventions. Department of Physical and Occupational Therapy (C.M.W.), William Beaumont Hospital, Troy, Michigan; Department of Physical Therapy (C.M.W.), School of Health Sciences, Oakland University in Rochester, Michigan; and Department of Physical Therapy (S.R.), New York Medical College, School of Public Health, Valhalla, New York. Address correspondence to: Christopher M. Wilson, E-mail: firstname.lastname@example.com. Abstract INTRODUCTION METHODS Examination Initial Observation History and Interview Tests and Measures Pain Assessment Initial Observation Active Range of Motion Muscle Strength Testing Anthropometric Measurements Palpation Assessment Functional Assessment Evaluation Diagnosis Prognosis INTERVENTION RESULTS Patient Outcomes: Phase 1 Follow-Up and Continued Care DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES Back to Top | Article Outline INTRODUCTION Facial paralysis has been described as the loss of unilateral or bilateral motor function as a result of injury to the facial nerve. This leads to an inability to close the eye and paralysis of the muscles of facial expression.1 Facial nerve damage may also occur after acoustic neuroma resections, trauma, brain hemorrhage, birth trauma, and congenital causes, such as congenital bilateral facial paralysis (ie, Möbius syndrome).2,3 The incidence of acoustic neuroma (eg, vestibular schwannoma) is one to two per 100,000 persons, with the median age of diagnosis being 55 years.4,5 Tumor resections in the posterior fossa and at or near the distal branches of the facial nerve can result in the loss of facial nerve function secondary to surgical procedures to resect the tumor.6 Loss of facial motor function results in decreased facial muscle tone and paralysis.7 Other possible sequelae may also occur, such as temporomandibular joint (TMJ) dysfunction, decreased lacrimation, drooling, poor dentition (as a result of poor oral hygiene because of sensory loss), and lip or cheek trauma caused by malocclusion.8 Corneal damage may occur secondary to poor eyelid closure and impaired lubrication of the eye. The physical and functional complications associated with facial paralysis can also affect an individual's social, psychological, emotional, and physical well-being. Facial paralysis can result in the reduction and inability to express emotions.1 The social and psychological sequelae reported after facial paralysis include guilt, anger, depression, rejection, and paranoia.1,9 Individuals often feel ostracized, and their facial asymmetry serves as a point of social discomfort.8 These emotions may be coupled with the stress of other diagnoses and the resulting treatments. The treatment options for these individuals include surgical interventions and facial muscle rehabilitation. Surgical interventions, termed facial reanimation, are procedures used to improve cosmesis, resting facial symmetry, and functional recovery. The initial therapeutic approach used includes modalities of electrical stimulation and biofeedback. Oral motor stimulation and exercise are also incorporated.10 The goals of facial reanimation surgery are twofold: (1) to restore resting symmetry to the face and (2) to improve voluntary motor control for speaking and expression.11 The ideal candidate is someone with less than one year of facial paralysis. Facial reanimation surgery often consists of two stages. The first stage reinnervates the paralyzed side of the face by means of nerve grafting.12–14 In the second stage of the procedure, muscular connections are made to the grafted nerve. If the denervated muscles are not viable, it is possible to use a muscle transfer to restore movement to the face. The temporalis muscle is harvested and transferred to the zygomatic arch and temporal fascia. The muscle is also sutured to the dermis along the nasolabial crease. In cases of congenital paralysis or Möbius syndrome, split temporalis grafts have been used to restore movement to the upper lip and cheek area. The nerve supply to the temporalis muscle is from the fifth cranial nerve (trigeminal) and is usually not affected by trauma to the facial nerve. The temporalis transfer is performed without the nerve graft surgery.12,13 These patients will need to initiate some jaw clenching to accomplish any facial movement. Physical therapy for individuals with facial nerve injuries has included facial exercise, electrical stimulation, oral motor stimulation, and biofeedback.15–18 Treatment can begin six weeks after facial reanimation surgery, that is, the muscle transfer stage. Byrne et al10 described physical therapy beginning once a week, progressing to once a month when the patient was able to be independent with a home program and was able to dissociate certain facial motions. The initial presentation of the surgical site can be swollen, slightly discolored, and tender. Patients will report changes in their oral function secondary to the surgery and swelling. Their presurgical compensatory strategies for articulations, speech, and eating may not be as efficient with the improved nerve supply and muscular alignment. Patients may report biting on foods differently because there may be a new alignment of the teeth and facial structures.19 The new alignment of the musculature will change an individual's proprioceptive feedback for facial movement. Patients require a sensorimotor retraining program to improve their ability to control the transplanted muscle. Patients frequently have difficulty with bilabial sounds such as the "m" in "mother" and particularly in generating force behind phonations for plosive sounds such as the "b" in "boy." VanSwearingen and Brach20 described facial neuromuscular re-education exercise programs that target facial movement patterns used to improve facial movement and decrease synkinesis. Synkinesis is defined as the presence of inadvertent motion in one area of the face produced during intentional movement in another region of the face.21 Two commonly used grading systems for facial paralysis are the House-Brackmann Facial Nerve Grading Scale and Sunnybrook Facial Grading System. The House-Brackmann Scale was introduced in 1983 and is endorsed by the Facial Nerve Disorders Committee of the American Academy of Otolaryngology.22 Based on the degree of facial function, the patient is placed into one of the six categories (Table 1).23 Although accepted as a standard for clinical practice, the House-Brackmann Scale has not been shown to have strong interobserver reliability.23,24 It has been noted by Croxson et al25 that this is a gross scale not useful for determining small, incremental changes in facial function. TABLE 1 The Sunnybrook Facial Grading System has demonstrated sensitivity to changes in facial function with rehabilitation.26–28 This system grades facial Resting Symmetry on a zero to one- or two-point scale, with 0 representing normal symmetry. A five-point scale, where 1 is unable to initiate movement and 5 is a complete movement, is used to grade facial Voluntary Movements, such as forehead wrinkle, gentle eye closure, open mouth smile, snarl, and lip pucker. Synkinesis is graded on a scale of zero to three points, where 0 represents no synkinesis and 3 represents severe synkinesis. Once these category scores are determined, the Composite score is calculated by subtracting the weighted Resting Symmetry score and the Synkinesis score from the more heavily weighted Voluntary Movement score.29,30 The Sunnybrook System is frequently cited in the literature and has been considered to be reliable for this patient population, except for the grading of synkinesis, for which the reliability was rated as low by Coulson et al.30 Although the Sunnybrook System has been reported to be valid,29,31 no studies could be identified that have assessed the validity of the House-Brackmann Scale. The Sunnybrook System has been shown to have good to excellent repeatability, and the House-Brackmann Scale has fair to good repeatability.30,32 Balliet et al33 reported on patients after facial nerve anastomoses and noted functional progress made by the patients with feedback training, behavioral modification, and specific motor retraining, despite varying latencies of time to onset of rehabilitation after the surgical procedure. The authors attributed the progress to the improvement in sensory and motor awareness of the involved side. Mirror training was also used to improve motor control, increase facial awareness, and decrease synkinesis. Although the use of electrical stimulation for patients after facial reanimation has not been studied, electrical stimulation has been used as an intervention for facial paralysis with the intent to improve motor recovery. Daily use of subsensory stimulation for patients with chronic facial nerve paralysis has been reported to improve motor nerve action potential distal latencies and to be associated with the gain of one grade in the House-Brackmann Scale.34 The application of subsensory electrical stimulation to the hand of individuals with an intact nervous system has been shown to change cerebral blood supply to the associated representational area of the motor and somatosensory cortex, suggesting increased cortex activity.35 Daily use of subsensory stimulation and progression to functional electrical stimulation of the hand may improve muscle tone and increase motor control in individuals who have had a stroke.36 Electrical stimulation, therefore, may aid in the retraining of muscles by facilitating activity in the cortical region representing the face. This may facilitate an alternative mechanism of recovery with electrical stimulation beyond the traditional use of local nerve and muscular stimulation, but further study is necessary. A Cochrane review of the literature related to Bell's palsy showed no significant improvement with the use of electrical stimulation over control or no treatment groups.37 Biofeedback has been used for facial retraining to encourage muscle activity and decrease synkinesis.12 It is particularly helpful to retrain facial movements like lip closure, puckering, and smiling in facial reanimation recovery secondary to the grafted neural supply and muscle transfers. The patient requires training to use these newly grafted muscles and nerves for facial function. Biofeedback has been used to encourage movement and relaxation in muscles. Mirror training has also been used to reinforce muscular control and encourage symmetry of movement in patients after facial reanimation surgery.38 The purpose of this case study was to describe the physical therapy examination, evaluation, and intervention of a patient who received facial reanimation surgery that included muscle transfers to compensate for denervated muscles after acoustic neuroma removal. At the time of writing of this manuscript, no other articles could be located to describe detailed physical therapy interventions and outcomes after facial muscle transplantation for facial reanimation. The patient completed an informed consent before submission of this article. Approval for a retrospective medical record review was sought from the Beaumont Hospitals Human Investigation Committee (Royal Oak, MI). The Human Investigation Committee determined that the study was exempt from full review, and a written Waiver of Review was provided. Back to Top | Article Outline METHODS Examination Initial Observation The patient was a 29-year-old woman referred to physical therapy by her facial reconstruction surgeon five weeks after muscle transfer for facial paralysis. The patient presented with significant swelling and bruising around the left mandibular area and extensive loss of motor function of the muscles on the left side of her face. Back to Top | Article Outline History and Interview The patient's chief complaint was limited left-sided facial movement and edema, bruising, and pain after facial reanimation surgery. She stated that 11 years before the initial evaluation, she had a diagnosis of hydrocephalus and a large left-sided acoustic neuroma. There is an established relationship between hydrocephalus and acoustic neuroma, with the incidence of hydrocephalus being between 3.7% and 42% in those with acoustic neuroma.39 Excision of the tumor resulted in complete left-sided facial paralysis because the facial nerve was transected near the brainstem. She also experienced complete left-sided hearing loss, slurring of speech, and inability to close the left eye completely. After surgery, the patient received limited speech and physical therapy and had minimal to no recovery of left facial function. The patient described that five weeks before the current physical therapy initial evaluation, she underwent facial muscle grafting and tissue transplantation. Before facial reanimation surgery, the patient underwent electromyography testing and physical examination, which demonstrated "severe paralysis" of the facial nerve. The surgical report noted that surgery included lifting the left temporalis and platysma muscle origins and transposing the origins to the upper and lower left corners of the mouth, respectively, while attempting to preserve the muscles' innervation. The patient also had a portion of her left tensor fascia lata transplanted to provide an extension from the platysma to the inferior corner of the mouth. A segment of tensor fascia lata was grafted at her left nasolabial fold to improve symmetry of the nasolabial folds. A left hemilip elevation procedure and a left frontalis advancement procedure were performed to assist with restoring facial symmetry. Finally, a small gold weight was placed in the left eyelid to assist with eye closure. Her recovery from facial surgery was unremarkable; however, she was not instructed in any exercises or range of motion until starting formal physical therapy to allow for proper connective tissue healing. The patient stated that she was a bank manager for seven years, and her job involved a high degree of public interaction. Back to Top | Article Outline Tests and Measures Pain Assessment The patient reported postoperative pain in her left lateral thigh donor site and left facial region. Pain was assessed with a zero to 10 numerical pain rating scale for ease of administration. Pain was reported to be 3/10 and 5/10 for the left thigh and the left facial region, respectively. Numbness was detected in the left mandibular area as assessed subjectively by light moving touch. Back to Top | Article Outline Initial Observation On initial observation, the patient displayed healing incisions of ∼2.0 cm along the left nasolabial fold, one crescent-shaped incision along the scalp at the origin of the temporalis muscle, a 2.5-cm incision along the underside of the left chin, and a circumferential incision along the outside border of the left upper and lower lip. Back to Top | Article Outline Active Range of Motion The patient displayed 20 mm of jaw opening; left jaw lateral deviation was 10 mm and right jaw lateral deviation was limited to 4 mm (normal ranges have been cited as 35–55 mm and 10–15 mm, respectively).40 Jaw active range of motion measurements were taken using a retractable cloth tape measure. Cervical range of motion into forward bending and right rotation was within 80% of normal limits, and right side bending was more limited at 60% of normal limits. Pain was not increased with any of the limited motions in the neck or the jaw; however, stiffness was reported for all of the limited movements. The patient was able to incompletely close the left eye gently, with a 3.0 to 4.0 mm opening remaining. Back to Top | Article Outline Muscle Strength Testing Muscle strength testing was performed using a 0 to 5 grading scale as described by Hislop and Montgomery.41 Typically, when describing facial muscle strength, specific muscle names would be cited, but because of the extensive denervation and facial muscle grafting, it was determined that a description of the direction of motion would be more meaningful. Grades for the tested facial movement were as follows: Closing and protruding the left inferior lip: 2/5 Closing and protruding the left superior lip: 3/5 Elevating the left upper lip: 2−/5 Elevating and drawing the left commissure (corner of the mouth) laterally (smiling): 1+ to 2−/5 Depressing the left commissure (frowning): 0 to 1/5 Left forehead or eyebrow elevation: 0/5 Back to Top | Article Outline Anthropometric Measurements To monitor edema, the left side of the face was measured and compared with the right side using the same standard retractable cloth measuring tape and consistent landmarks. No standardized anthropometric facial measurements could be found in the literature; therefore, the therapist devised a method using stable facial landmarks not determined to be affected by this patient's swelling, such as the superior and inferior seams of the earlobe, the nasolabial fold, and the cleft of the chin. The distance from the anterior earlobe to the cleft of the chin was 13.5 cm on the right and 14.5 cm on the left. The distance from the anterior earlobe to the corresponding nasolabial fold was 11.0 cm on the right and 12.0 cm on the left. The distance from the superior ear seam to the cleft of the chin was 16.5 cm on the right and 17.0 cm on the left. Back to Top | Article Outline Palpation Assessment The patient's left-side perioral skin and subcutaneous tissue were stiff and hypomobile when compared with the right side and initially did not have sufficient flexibility to allow full excursion for a balanced smile as determined by subjective examiner assessment. Back to Top | Article Outline Functional Assessment The patient reported that her main functional limitations were difficulty with smiling, eye closure, and lack of overall facial symmetry, all of which affected her interpersonal interactions with the public and her co-workers. She stated that she was just beginning to eat solid foods but was having difficulty because of biting the inside of her mouth and pocketing food on the inside of the left cheek. She also noted increased periods of wakefulness when attempting to sleep on her left side because of increased pain in her face and left thigh. Two functional grading scales were used to assess function: the House-Brackmann Facial Nerve Grading Scale23 and the Sunnybrook Facial Grading System.29 According to the House-Brackmann Scale, the patient displayed a Grade V (severe) dysfunction, which is defined as only barely perceptible gross motion, asymmetry at rest, no forehead motion, incomplete eye closure, and slight mouth movement. The patient was also graded with the Sunnybrook Facial Grading System and was determined to have a Voluntary Movement score of 40 (normal = 100; range, 20–100), a Resting Symmetry score of 15 (normal = 0; range, 0–20), and a Synkinesis score of 8 (normal = 0; range, 0–15) for a Composite score of 17 (unimpaired facial movement = 100). Back to Top | Article Outline Evaluation Examination identified commonly expected postsurgical changes such as pain, edema, difficulty eliciting muscular contraction of the grafted muscles, and TMJ active motion limitations. The patient arrived in physical therapy with a prescribed home exercise program and recommendation for use of neuromuscular electrical stimulation (NMES) from the surgeon. To target the appropriate muscle groups and avoid synkinesis during exercise, facial exercise retraining augmented by biofeedback, including exercising in front of a mirror and surface electromyography (sEMG), was deemed to be an optimal approach. The patient had significant soft-tissue restriction to the left facial skin and subcutaneous tissue, which required restoration. Unless perioral tissue flexibility was restored, the patient's facial motion would be restricted despite underlying facial muscle strength. In addition, it was anticipated that the patient would have difficulty with chronic lymphedema because there are several lymphatic tracts around the mandible and anterior neck. It is likely that these tracts were disturbed during surgery, and the patient would possibly require manual lymphatic drainage (MLD) massage as described by Zuther.42 Back to Top | Article Outline Diagnosis Based on the American Physical Therapy Association's Guide to Physical Therapist Practice, the patient was assigned to the Practice Pattern 5F: impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury.43 Back to Top | Article Outline Prognosis It was anticipated that because of the short duration of TMJ immobilization postoperatively, joint mobility was likely to return during normal use without the need for joint manipulation. Because no facial nerve reconstruction was noted in the operative report, it was anticipated that there would be no further muscular recovery in the facial nerve innervation pattern (including the forehead and eyebrow region) beyond the patient's baseline status. Restoration of some left perioral motion and function was expected from the newly transplanted muscles around the left corner of the mouth. Back to Top | Article Outline INTERVENTION The patient received physical therapy for a total of 30 sessions spanning 14 weeks (labeled here as phase 1). Frequency was three times per week for sessions 1 to 18, decreased to two times per week for sessions 19 to 26, and finally decreased to once per week during the final four sessions, with increased emphasis on home treatment during these last sessions. Home treatment included self-MLD and home exercises previously introduced in the clinic. Re-evaluation was performed by the same physical therapist every six sessions to assess progress, including administration of the Sunnybrook Grading System. Each session lasted approximately one hour. A synopsis of the series of interventions is illustrated in Figure 1. FIGURE 1. During the first phase of physical therapy, the patient was instructed extensively in the home exercise program developed by her surgeon and one of the study authors (S.R.). The exercise protocol included word pronunciation and active range of motion exercises, including puckering lips, smiling, smirking, grimacing, eye closure, brow lifting, nostril flaring, wrinkling forehead, whistling, eyebrow elevation and lowering, wrinkling chin, mandibular protraction, winking, opening eyes wide, and platysma contraction for 10 to 20 repetitions performed three times daily. In addition to this home exercise instruction, the patient received MLD massage to the left facial region. Lymphatic fluid was guided in the direction of the thoracic duct to empty into the subclavian vein (Fig. 2). The patient performed active-assistive range of motion with the therapist's manual assistance in the direction of puckering, frowning, and smiling, which was continued for five sessions until the patient was independent in performing these movements. FIGURE 2. At the second session, the patient was provided an Empi 300 PV NMES unit (Empi, St. Paul, MN) and instructed on how to use the machine to electrically elicit muscle contraction with simultaneous volitional effort. Parameters for the NMES included a symmetric biphasic pulsatile current. Two 1.25-in self-adhering circular electrodes were used; one was placed under the left chin and the other over the left zygomatic arch. The placement of the electrodes was in accordance to the surgeon's specifications to stimulate the muscle that was both innervated and transferred for optimizing facial function (Fig. 2). The "on time" (time at peak current amplitude) was seven seconds and the "off time" was 45 seconds, with additional ramp-up and ramp-down times of three seconds each. The frequency was 50 pps and the pulse duration was 200 microseconds. The intensity of the stimulation was increased to the level at which a minimal muscle twitch was observed in the transposed temporalis muscle, which was able to contract because its original innervation was preserved. The patient was instructed to achieve an observable active contraction (1/5 on muscle strength testing) using electrical stimulation and volitionally attempt to smile during the "on" period of the stimulation. In this and subsequent NMES sessions, the stimulation intensity was adjusted to achieve motor activation. The patient was instructed to perform NMES for 20 minutes three times per day. The patient continued home NMES until she was able to elicit consistent volitional contractions of smiling without the assistance of NMES; this was achieved at session 17. At the third session, the patient's home program was modified to omit any eyebrow or forehead exercises because there was no further anticipation of forehead recovery. By the sixth session, the patient displayed full, pain-free cervical range of motion without need for specific intervention. The patient was able to move the left commissure 1.2 to 1.5 cm into the direction of smiling. Commissure excursion measurements were performed as described by Manktelow et al.44 Also, all previously assessed edema measurements for the left face were within 0.5 cm of the right; therefore, MLD in the clinic was transitioned to the home program. At this time, sEMG biofeedback (Chattanooga Vectra Genisys unit; Chattanooga Group, Hixson, TN) was initiated to better allow the patient to relearn the smiling motion more effectively and efficiently. Three self-adhering circular sensor electrodes (3.17 cm) were placed superior and anterior to the left mandible (Fig. 2). Maximum voluntary contraction level was set according to the manufacturer's instructions. The device was set to elicit an audio tone when the patient was able to achieve a contraction of >80% of a maximum voluntary isometric contraction of the transplanted temporalis muscle. The patient was instructed to hold this contraction for 10 seconds, attempting to elicit the audio tone for the entire time. Initially, a rest time of 30 to 40 seconds was provided between sEMG contractions, but as the treatment progressed, the patient was able to hold a full contraction with only a 20-second rest. The patient completed three sets of 20 repetitions of sEMG isometric contractions each session. The patient performed sEMG in front of a mirror to emphasize symmetry of the smile to avoid synkinesis. The patient's maximum voluntary contraction strength gradually increased over time, and, accordingly, the 80% threshold was readjusted at each treatment to the patient's new maximum. Once the patient was able to elicit a voluntary smile contraction, focus was placed on reducing the effort required to smile. Blocked practice "rapid fire" smiling was initiated with visual feedback from a mirror for a high number of repetitions (50+) to help facilitate decreasing the conscious thought related to learning the new skill of smiling. This blocked practice was performed for three sessions and was phased into random practice interspersed throughout treatment once the skill was acquired, as indicated by Schmidt.45 By session 12, the patient was able to elicit an excursion of the left commissure in a smiling motion to 1.5 cm with maximal effort (according to patient's subjective report) and a trace frowning motion. As a measurement of progress, isometric contraction duration was assessed, and the patient was able to hold her smile for 30 to 45 seconds before fatigue. She continued to have difficulty coordinating a natural bilateral smile; consequently, blocked practice of "rapid fire" smiling was resumed and incorporated in conjunction with random practice of smiling for six more sessions. The patient's edema measurements continued to be stabilized; however, the patient indicated that home treatments were taking considerable time and effort. Thus, MLD massage was reintegrated into the clinic treatment plan at session 14. At this time, increased flexibility was noted in the left facial musculature and subcutaneous tissue, and no pain was noted in the left facial region. At the session 18, treatment was decreased to twice per week. The patient reported stiffness and discomfort in the left shoulder with a loss of the last 20 degrees of flexion and abduction range of motion; therefore, gentle manual stretching was performed between sessions 20 and 24, at which point full, pain-free range of motion was restored. Glenohumeral stretching used both physiologic and accessory motions. Beginning at sessions 23 and 24, the patient began to report left-sided cervical discomfort and stiffness and occasional cervicogenic headaches for which soft-tissue massage and postural exercises (scapular retraction and cervical retraction) were performed during sessions 25 to 30. These exercises were also added to the home program. At the session 26, the patient's treatment was changed to once per week, with continued refinement and advancement of her home program. During sessions 29 and 30, the patient's facial mobility, function, and Sunnybrook score stabilized; the patient demonstrated independence in her home program, and it was, therefore, determined that she should be discharged from physical therapy. Throughout treatment, the patient cited strong adherence to the home exercises, NMES, self-stretching, and self-MLD; however, no formal tracking log or diary was kept. Back to Top | Article Outline RESULTS Patient Outcomes: Phase 1 On completion of 30 sessions of physical therapy, the patient reported no pain in any areas and no difficulty with speech, eating, sleeping, or drinking. She also displayed continued equalization of facial edema measurements concurrent with the MLD treatments and with soft-tissue healing and recovery after surgery. It was noted that if the patient missed an MLD home session, there was an associated increase in left facial edema, which reinforced the plan for continued daily MLD techniques. She was able to display a smiling motion of 1.5 to 1.7 cm excursion of the left corner of the mouth (normal range cited between 0.7 and 2.2 cm, average = 1.4 cm)46 and was able to do this motion easily without hesitation, but reported that it was not reflexive and spontaneous. In addition, she was able to display movements of puckering, which was a 1.0-cm medial excursion of the left commissure from its resting position, and a limited frowning motion of 0.3 to 0.5 cm on the left (no normative data available in the literature for these measurements). She reported continued difficulty with grimacing or showing her teeth, but she indicated that this did not frequently affect her daily life. She displayed full TMJ mobility, but continued to lack appreciable recovery of mobility in her left eyebrow or forehead region, which was anticipated, because there were no nerve or muscle transplants to this denervated area. Eyelid closure was described as "movement almost complete" on the Sunnybrook Grading System after this series of visits; however, the patient required eyedrops to prevent corneal dryness. Grades for the tested facial movement were as follows: Smiling, closing, and protruding the left side of the mouth: 3+/5 Frowning: 1+/5 Elevating the left upper lip: 2/5 On discharge evaluation for phase 1, the patient had a Sunnybrook Composite score of 41 compared with a score of 17 on initial evaluation, an improvement of 24 points. The Sunnybrook Voluntary Movement score improved from 40 to 52, Resting Symmetry score from 15 to 5, and Synkinesis score from 8 to 6. It should be noted that decreased scores in Resting Symmetry and Synkinesis indicate an improvement according to the Sunnybrook System (Fig. 3 and Table 2). FIGURE 3. TABLE 2 Finally, the patient's initial Grade V (severe) disability on the House-Brackmann Scale improved on discharge to Grade IV (moderately severe) dysfunction. The patient met all of the criteria for achieving Grade III (moderate function) except for "moderate to good forehead function." One of the criticisms of the House-Brackmann Scale is that low scores in one criterion can unduly restrict the score.30 Back to Top | Article Outline Follow-Up and Continued Care Four months after discharge, the patient returned to physical therapy (phase 2), which was initiated five weeks after undergoing a refinement surgery to her left facial region to enhance symmetry. The surgical procedure included tightening of a muscular sling at the left temple and zygomatic arch, liposuction to the left mandibular area, removal of some deep stitches near the left nasolabial fold, and microdermabrasion to the scars surrounding the left hemilip. The patient participated in physical therapy for nine sessions during one month, which included left perioral facial stretching, scar tissue mobilization, MLD, cervical stretching, and sEMG biofeedback. On phase 2 initial evaluation, the patient had a Sunnybrook Composite score of 27; on discharge, the score was 33, with most limitations in the Resting Symmetry category. Voluntary Movement scores improved from 36 to 52. It should be noted that the patient discharged herself early during this phase of intervention and did not fully return to values achieved at the end of phase 1 on the Sunnybrook scale because she was going on vacation and then having her next surgical revision. Two weeks after discharge from phase 2 of physical therapy, the patient underwent another revision surgery to remove more scar tissue at the left perioral region and to again tighten the temporal sling to enhance smile symmetry. She returned to physical therapy (phase 3) five weeks after this most recent surgery, which was 10 months after the initial physical therapy visit. During this latest phase of physical therapy, the patient reported setbacks, including edema, dysarthria, cervical spine stiffness, and drooling after her most recent surgery. This phase of physical therapy consisted of 12 sessions during two months. The focus was on cervical spine myofascial mobilization, including suboccipital release, resumption of MLD massage, NMES three times daily at home, scar mobilization, and sEMG biofeedback. On completion of phase 3, the patient returned to the status that was achieved at the end of phase 1, but with minimal further gains in function. Back to Top | Article Outline DISCUSSION A major focus of physical therapy for this patient was to address the adaptive shortening of the left perioral tissues caused by the long duration of facial paralysis before facial reanimation surgery. This adaptive shortening prevented the patient's newly transplanted postsurgical muscles from generating sufficient force to perform facial excursions against the resistance of tightened soft tissues. Another challenge for this patient was that the temporalis muscle that had been transplanted could only create its newly intended motion by having the patient contract in the motion of its original purpose. The patient had to "clench her jaw" to create a smiling motion on the left side, while coordinating the original facial muscles on the right to create a symmetrical smile. The patient noted that this smile was never quite reflexive and required concentration and volitional effort using the learned technique when the social situation called for a bilateral smile. The precision of motor control was aided by the use of sEMG biofeedback, mirror exercises, and functional exercise to reinforce the muscular control of smiling performance. The cervical branch of the facial nerve innervates the platysma muscle, and there was no evidence during initial evaluation to show that the platysma had retained innervation, which raised the question why the surgeon transplanted the muscle. An article authored by this surgeon clarified the rationale for platysma transfer: "In the [surgeon's] experience, however, even in cases of denervation of the cervical branch of the facial nerve, the "static" pull of the platysma/autogenous fascia lata extension will effectively evaginate the lower lip and improve lip symmetry and function in repose."19 Because it was unclear at the time of initial evaluation whether the platysma was innervated, it was determined that the patient's progress would not be hindered by working on the motion of frowning, which the newly transplanted platysma would perform, if only partially innervated. To some extent, the positive outcomes for this patient were likely related to her adherence to her home program. Achievement of adequate functional outcomes is impeded when a patient is not able to adhere to a home program that requires performance of complex tasks. Subjectively, the patient reported that she was pleased by the ability to elicit a bilateral smile and to achieve increased left-sided expressions, but she continued to pursue operations to improve with cosmesis. These further surgeries did not modify the functioning or esthetics of the face as much as had the initial facial reanimation surgery; each surgical procedure was also associated with some regression in outcomes, prompting the need for further physical therapy. However, with physical therapy, the gains were re-established and no long-term negative effects of the repeated surgical procedures were noted. After phase 3, the therapist discussed with the patient some of the potential adverse effects of multiple surgeries, including keloid scar formation, risk of infection, and regression of cosmesis. Limitations of this case study include its single-subject retrospective design, which lacks the rigors of a prospective study with a large sample and statistical significance to support treatment effectiveness. Other limitations could include incomplete recording of the details of relevant examination and treatment information and the inability to plan for reporting all information that might later be determined to be important. Another limitation is the lack of digital photographic documentation of progression of facial symmetry. Digital photography was used initially for clinical documentation, but these records were destroyed by a flood at the treating clinic. The use of digital photography for quantifying symmetry and facial excursions is recommended for future studies to provide a graphic record of progress. Back to Top | Article Outline CONCLUSIONS Facial reanimation surgery, after acoustic neuroma excision and facial nerve transaction, carries with it a number of opportunities and challenges for a patient with facial hemiparalysis. The patient in this case study was able to achieve limited facial motion on the left side in the direction of smiling, puckering, and frowning, where there was no such motion for 11 years. The patient struggled with chronic edema of left cheek and mandible region, which was managed with frequent MLD massage. Although functional recovery was incomplete (according to measurement instruments used) and there remained a marked difference in motion between sides, this residual difference did not have an impact on the patient's speech, eating, or drinking; the patient did, however, report continued perceived limitations in public interactions. The two subsequent surgeries temporarily reversed her functional gains, but additional sessions of physical therapy, concentrating on cervical spine myofascial mobilization, MLD, and daily home NMES, allowed her to recover to the functional levels achieved after the first intervention period. Implications of this case study include the need for further study of the detailed effects of physical therapy interventions on facial muscle paralysis in surgical and nonsurgical cases. In addition, outcomes of various surgical techniques and use of electrical stimulation for facial reanimation should be compared to determine which procedures are most effective and offer the shortest recovery time. Back to Top | Article Outline ACKNOWLEDGMENTS The authors thank Elliot Rose, MD, Lisa Galazka, PT, MPT, and Janet Seidell, PT, MPT, for clinical advice during physical therapy management of the patient. They also thank Jackie Drouin, PT, PhD, Ralph Garcia, PT, PhD, and Chris Stiller, PT, PhD, for their critical review of this manuscript.Back to Top | Article Outline REFERENCES1.Stuart RM, Byrne PJ. The importance of facial expression and the management of facial nerve injury. Neurosurg Quart. 2004;14:239–248. Cited Here... 2.Mitchell H. To smile again. Reanimation for unilateral facial palsy. Br J Perioper Nurs. 2000;10:16–21. Cited Here... 3.Stedman, TL. Stedman's Medical Dictionary. 27th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2000. Cited Here... 4.Tos M, Stangerup S, Caye-Thomasen P, et al. What is the real incidence of vestibular schwannoma? Arch Otolaryngol Head Neck Surg. 2004;130:216–220. Cited Here... 5.Stangerup S, Tos M, Caye-Thomasen P, et al. Increasing annual incidence of vestibular schwannoma and age at diagnosis. J Laryngol Otol. 2004;118:622–627. Cited Here... 6.Magliulo G, D'Amico R, Forino M. Results and complications of facial reanimation following cerebellopontine angle surgery. Eur Arch Otorhinolaryngol. 2001;258:45–48. Cited Here... 7.Gossman MR, Sahrmann SA, Rose SJ. Review of length-associated changes in muscle: experimental evidence and clinical implications. Phys Ther. 1982;62:1799–1808. Cited Here... 8.Diels HJ. Facial paralysis: is there a role for a therapist? Facial Plast Surg. 2001;16:361–364. Cited Here... 9.Twerski A, Twerski B. The emotional impact of facial paralysis. In: May M, ed. The Facial Nerve. New York, NY: Thieme; 1986:788–794. Cited Here... 10.Byrne PJ, Kim M, Boahene K, et al. Temporalis tendon transfer as part of a comprehensive approach to facial reanimation. Arch Facial Plast Surg. 2007;9:234–241. Cited Here... 11.Tomat LR, Manktelow RT. Evaluation of a new measurement tool for facial paralysis reconstruction. Plast Reconstr Surg. 2005;115:696–704. Cited Here... 12.Doud Galli SK, Valauri F, Komisar A. Facial reanimation by cross-facial nerve grafting: report of five cases. Ear Nose Throat J. 2002;81:25–29. Cited Here... 13.Rose EH. Aesthetic Facial Restoration. Philadelphia, PA: Lippincott-Raven; 1998. Cited Here... 14.VanSwearingen JM, Brach JS. The facial disability index: reliability and validity of a disability assessment instrument for disorders of the facial neuromuscular system. Phys Ther. 1996;76:1288–1300. Cited Here... 15.Ross B, Nedzelski JM, McLean JA. Efficacy of feedback training in long-standing facial nerve paresis. Laryngoscope. 1991;101:744–750. Cited Here... 16.Dalla Toffola E, Bossi D, Buonocore M, et al. Usefulness of BFB/EMG in facial palsy rehabilitation. Disabil Rehabil. 2005;27:809–815. Cited Here... 17.Targan RS, Alon G, Kay SL. Effect of long-term electrical stimulation on motor recovery and improvement of clinical residuals in patients with unresolved facial nerve palsy. Otolaryngol Head Neck Surg. 2000;122:246–252. Cited Here... 18.Coulson S, Croxon G. Facial nerve rehabilitation—the role of physiotherapy. Aus J Otolaryngol. 1994;1:418–421. Cited Here... 19.Rose EH. Autogenous fascia lata grafts: clinical applications in reanimation of the totally or partially paralyzed face. Plast Reconstr Surg. 2005;116:20–32. Cited Here... 20.VanSwearingen JM, Brach JS. Validation of a treatment-based classification system for individuals with facial neuromotor disorders. Phys Ther. 1998;78:678–689. Cited Here... 21.Crumley RL. Mechanisms of synkinesis. Laryngoscope. 1979;89:1847–1854. Cited Here... 22.Kang TS, Vrabec JT, Giddings N, et al. Facial nerve grading systems (1985–2002): beyond the House-Brackmann Scale. Otol Neurotol. 2002;23:767–771. Cited Here... 23.House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985;93:146–147. Cited Here... 24.Smith IM, Murray JA, et al. A comparison of facial grading systems. Clin Otolaryngol Allied Sci. 1992;17:303–307. Cited Here... 25.Croxson G, May M, Mester SJ. Grading facial nerve function: House-Brackmann vs Burres-Fisch methods. Am J Otol. 1990;11:240–246. Cited Here... 26.Berg T, Jonsson L, Engstrom M. Agreement between the Sunnybrook, House-Brackmann, and Yanagihara facial nerve grading systems in Bell's palsy. Otol Neurotol. 2004;25:1020–1026. Cited Here... 27.Coulson SE, O'Dwyer NJ, Adams RD, et al. Expression of emotion and quality of life after facial nerve paralysis. Otol Neurotol. 2004;25:1014–1019. Cited Here... 28.Hu W, Ross B, Nedzelski J. Reliability of the Sunnybrook Facial Grading System by novice users. J Otolaryngol. 2001;30:208–211. Cited Here... 29.Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otolaryngol Head Neck Surg. 1996;114:380–386. Cited Here... 30.Coulson SE, Croxson GR, Adams RD, et al. Reliability of the "Sydney," "Sunnybrook," and "House-Brackmann" facial grading systems to assess voluntary movement and synkinesis after facial nerve paralysis. Otolaryngol Head Neck Surg. 2005;132:543–549. Cited Here... 31.Yanagihara N, Muakami S. New Horizons in Facial Nerve Research and Facial Expression. The Hague, Netherlands: Kugler Publications; 1998. Cited Here... 32.Kanerva M, Poussa T, Pitkäranta A. Sunnybrook and House-Brackmann facial grading systems: intrarater repeatability and interrater agreement. Otolaryngol Head Neck Surg. 2006;135:865–871. Cited Here... 33.Balliet R, Shinn JB, Bacy-Y-Rita P. Facial paralysis rehabilitation: retraining selective muscle control. Int Rehabil Med. 1982;4:67–74. Cited Here... 34.Hyvärinen A, Tarkka I, Mervaala E, et al. Cutaneous electrical stimulation treatment in unresolved facial nerve paralysis: an exploratory study. Am J Phys Med Rehabil. 2008;87:992–997. Cited Here... 35.Golaszewski S, Kremser C, Wagner M, et al. Functional magnetic resonance imaging of the human motor cortex before and after whole-hand afferent electrical stimulation. Scand J Rehabil Med. 1999;31:165–173. Cited Here... 36.Dimitrijević MM, Stokić DS, Wawro AW, et al. Modification of motor control of wrist extension by mesh-glove electrical afferent stimulation in stroke patients. Arch Phys Med Rehabil. 1996;77:252–258. Cited Here... 37.Teixeira LJ, Soares BGdO, Vieira VP, et al. Physical therapy for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2008;3:CD006283. Cited Here... 38.Johnson PJ, Bajaj-Luthra A, Llull R, et al. Quantitative facial motion analysis after functional free muscle reanimation procedures. Plast Reconstr Surg. 1997;100:1710–1722. Cited Here... 39.Fukuda M, Oishi M, Kawaguchi T, et al. Etiopathological factors related to hydrocephalus associated with vestibular schwannoma. Neurosurgery. 2007;61:1186–1193. Cited Here... 40.Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia, PA: W.B. Saunders; 1997. Cited Here... 41.Hislop HJ, Montgomery J. Daniels and Worthington's Muscle Testing. 7th ed. Philadelphia, PA: W.B. Saunders; 2002. Cited Here... 42.Zuther JE. Lymphedema Management: The Comprehensive Guide for Practitioners. New York, NY: Thieme; 2005. Cited Here... 43.American Physical Therapy Association. Guide to physical therapist practice. 2nd ed. Phys Ther. 2001;81:s269–s286. Cited Here... 44.Manktelow RT, Zuker RM, Tomat LR. Facial paralysis measurement with a handheld ruler. Plast Reconstr Surg. 2008;121:435–442. Cited Here... 45.Schmidt, RA. Motor learning principles in physical therapy. In: Lister MJ, ed. Contemporary Management of Motor Control Problems: Proceedings of the II-STEP Conference. Alexandria, VA: Foundation for Physical Therapy; 1991:49–63. Cited Here... 46.Paletz JL, Manktelow RT, Chanban R. The shape of a normal smile: implications for facial paralysis reconstruction. Plast Reconstr Surg. 1994;93:784–791. Cited Here... © 2010 Neurology Section, APTA Article Outline Abstract INTRODUCTION METHODS Examination Initial Observation History and Interview Tests and Measures Pain Assessment Initial Observation Active Range of Motion Muscle Strength Testing Anthropometric Measurements Palpation Assessment Functional Assessment Evaluation Diagnosis Prognosis INTERVENTION RESULTS Patient Outcomes: Phase 1 Follow-Up and Continued Care DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES Source Rehabilitation Postfacial Reanimation Surgery After Removal of Acoustic Neuroma: A Case Study Journal of Neurologic Physical Therapy34(1):41-49, March 2010. Full-Size Email + Favorites Export View in Gallery Email to a Colleague Colleague's E-mail is Invalid Your Name: (optional) Your Email: Colleague's Email: Separate multiple e-mails with a (;). Message: Thought you might appreciate this item(s) I saw at Journal of Neurologic Physical Therapy. Send a copy to your email Your message has been successfully sent to your colleague. Some error has occurred while processing your request. Please try after some time. Email to a Colleague Colleague's E-mail is Invalid Your Name: (optional) Your Email: Colleague's Email: Separate multiple e-mails with a (;). Message: Thought you might appreciate this item(s) I saw at Journal of Neurologic Physical Therapy. Send a copy to your email Your message has been successfully sent to your colleague. Some error has occurred while processing your request. Please try after some time. Add Item(s) to: An Existing Folder A New Folder Folder Name: Description: The item(s) has been successfully added to "".


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High triglycerides are found in a medical condition where the body has abnormally elevated triglycerides. They have been linked as a risk factor to several diseases. The condition is also known as hypertriglyceridemia, which means high blood levels of triglycerides.
What exactly are triglycerides? Simply put, they are a type of glycerides, where the glycerol is formed in to esters with three fatty acids. Both animal fats and vegetable oils have triglycerides as their major component.
High triglycerides symptoms can vary in one case as compared to the next. In some cases where the elevated levels are only mild, no physical symptoms may be present. Some potential symptoms include the following:
Abdominal pain
Appetite loss
Itching (from xanthomas mentioned below)
Lipemia retinalis (retina veins having white, milky appearance)
Pancreatitis (inflammation of the pancreas)
Xanthomas (fatty deposits under the skin)
Other symptoms may also be present, including those from an underlying cause that may be involved.
High triglycerides causes range significantly in type. Some possible causes may include the following conditions:
Certain medications
Diabetes (especially diabetes mellitus); insulin resistance
Excessive alcohol consumption
Familial hypertriglyceridemia
Fatty liver, cirrhosis, or other liver disease
High sugar diet; poor diet; lack of exercise; obesity
Hypothyroidism (underactive thyroid)
Kidney disease or failure; nephrotic syndrome
Additional underlying causes may need to be considered. The condition can also be idiopathic (without known cause). Continue reading a more detailed list of potential causes.
Diagnosis of high triglycerides is conducted by a doctor or medical professional. A test, known as the triacylglycerol test, may be used to take a blood sample in order for check triglyceride levels.
High triglycerides treatment may be based upon factors such as the extent of the elevation, the patient, the underlying cause, and others. Limiting fat and carbohydrates in the patient's diet is a common treatment method. Fish oil, niacin, statins, and fibrates may each be options to be taken. The omega-3 fatty acids found in fish oil have been noted as effective in lowering triglycerides.
Several complications may arise through high triglycerides. Some conditions it may be a risk factor for include:
Blood clots in arteries
Heart attack
Inflammatory response


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In all video editing packages, it is important that you have the ability to rotate video. "Rotate video" is a very basic but helpful and useful feature. As a professional video editor, Apple iMovie of course owns the video rotating feature too. But the newbie probably don't know where to get it in iMovie. It doesn't matter. In this article, you'll learn how to rotate video in iMovie. Additionally, there are other applications recommended to you for video rotating use if you don't use iMovie.
Part I: Why Need to Rotate Video?
Part II: How to Rotate Video in iMovie?
Part III: Rotate Video Using iOrgSoft Video Editor for Mac
Part IV: Rotate Video with QuickTime
As mentioned above, there are various reasons why you may need to rotate video in iMovie.
Wrong orientation – You may have been taking a video on your camcorder, and then tilted the shot a little bit; perhaps you were glancing away at something and inadvertently tilted the video, and you do not want to cut this section away. When editing using iMovie, you can correct this tilt by rotating the video.
Adding Special Effects – When you watch an action movie, you may find that some of the scenes are tilted for greater impact. You may want to incorporate this in some sections of the video. Once again, iMovie will allow you to do this with ease.
1) In the project timeline, you select the video clip that you would like to rotate.
2) Once selected, go to the toolbar at the top and click on the Adjust button. In the viewer, an adjustment bar will appear just above the clip that you want to rotate.
3) Now look for the cropping controls in the adjustment bar, and then click on the Cropping tool.
4) You will see arrows which show rotations to the left and to the right; counterclockwise and clockwise. Click on these buttons until you get the desired orientation.
5) Once you are happy with the result, you can click on the apply button which is to the right of the cropping tools.
6) If you get second thoughts about the adjustment, you can use the Reset button and then try it all over again.
iOrgSoft Video Editor for Mac is one of the best alternatives to iMovie.
Mainly key features:
Step by step guide on rotating video:
1. Open the program and you'll see the "select files to Import" instruction. Follow it to load desired videos.
2. Drag the add file to the timeline for further editing. Click on the crop icon that appears on the bar above the video timeline after you drag the video to the timeline.
3. After clicking on the crop icon, a new window is open and you can crop, rotate, flip, and select aspect ratio there. Click on the Rotate Clockwise button and the Rotate Counterclockwise button to get the rotation that you require. The effect will be added and when you export the video, the part you selected will be rotated as desired.
Apple QuickTime Pro is a flexible and powerful video presentation and editing tool. It is primarily used for showing and streaming QuickTime movies, but it also allows you to make some minor adjustments to your videos. It lets you trim, split, combine or paste, rearrange, rotate or flip clips. So, if you just want to apply some basic video effects like video rotating to your video, QuickTime can just do it for you easily.
1. Open QuickTime Pro and then open the video clip that you would like to rotate.
2. Click Window and then go to the Show Properties tab
3. Go to the Visual Settings tab and then use the arrows to rotate or flip your video clockwise or anticlockwise.
4. After getting the right rotation, you should export the new video clip under a new name.
There is no reason why you should not have great videos to share, when you have the programs mentioned above. You can now let people view your videos in a correct orientation, and give the production more impact through professional editing applications such as those in this article.
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Products/Services for Hopper Rail Car Dimensions
Rail Car Thawers - (8 companies)Rail car thawers facilitate the unloading or transloading of railcars in cold climates by thawing loads of viscous liquids and frozen aggregate. Rail car thawers facilitate the unloading or transloading of railcars in cold climates by heating loads...Show MoreHeater TypeIndoorOutdoor
Industrial Vibrators - (155 companies)...turbine vibrators are designed to move fine, dry materials in bins, hoppers, chutes, screens, and feeders. Specialized railway vibrators are used to unload dry bulk material from bottom-dump rail cars. Industrial vibrators are also used to remove air...Show More
Hoppers - (436 companies)Hoppers are used for the temporary storage of materials. They are designed so that stored material can be dumped or fed to a process easily. Types. There are many different types of hoppers, dumpers, and tippers. Examples include: bottom hoppers...Show More
Rail Services - (167 companies)...these locomotives are diesel, electric, or diesel-electric. Railcars include boxcars, freight cars, and flat cars; gondolas and hoppers; coal cars and refrigerated cars; and tankers or tank cars. Freight management services for the rail industry provide...Show More
Steel Rail - (33 companies)Steel rail is a form of steel fixed stock with a tee shaped rail profile for construction of railway tracks, which support and guide transit or railcar wheels. Steel rails are the load bearing and guiding elements in a railway or tramway track...Show More
Scales and Balances - (967 companies)...capacity is often measured in tens of tons, and can have a weighing area of hundreds of square feet. Material Positioning. The load bearing platform of the scale must effectively support the dimensions of the object to be weighed. An object on the scale...Show More
DIN Rail - (78 companies)DIN rails and DIN rail clips and brackets are used on computer boards. DIN is an acronym for Deutsche Institute fuer Normung, a German standardization body and member of ISO. DIN rails are used on computer boards. DIN is an acronym for Deutsche...Show More
Forklifts - (635 companies)Forklifts are used to engage, lift and transfer palletized loads. They can be divided into eight numbered classes and categorized by drive type. This product area also includes fork trucks.Show More
Rolling Stock (locomotives and railcars) - (47 companies)Rolling stock and rail vehicles includes powered and unpowered rail vehicles such locomotives, railroad cars, railway vehicles, coaches or passengers vans, wagons or freight cars, ballast hoppers, switchers, baggage car or luggage vans, and cabooses...Show More
Platforms and Walkways - (401 companies)...and pathway dimensions, including available floor space for structural supports. Common examples include: Arena catwalks. Accessibility platforms for hand-picking in warehouses. Maintenance walkways under bridges. Product berths and oil storage tanks...Show More
Product News
Aitken Products, Inc.
Rail Car Thawing Components Aitken Rail Car Thawing Components. This equipment will fit the needs of both small and large plants. It is adaptable to most plant situations and thawing time requirements. Each installation is designed to meet the needs of the individual plants. Why is infrared electric the best way to thaw a car?. The old approach to car thawing was open flame right on the car's skin. This wasn't just inefficient, it was downright dangerous. Other companies have used convected air heated by gas or oil... (read more)Browse Industrial Heaters Datasheets for Aitken Products, Inc.
Aitken Products, Inc.
Rail Car Thawing Heaters Rail Car Thawing Heaters. This extremely rugged weatherproof thawer has a low initial cost, low maintenance cost and low operating costs. This equipment will fit the needs of both small and large plants. It is adaptable to most plant situations and thawing time requirements. Each installation is designed to meet the needs of the individual plants. Why is infrared electric the best way to thaw a car?. The old approach to car thawing was open flame right on the car's skin. This wasn't just... (read more)Browse Industrial Heaters Datasheets for Aitken Products, Inc.
Demag Cranes & Components
Excellent dimensions, low deadweight Suspension Cranes - Double Girder Suspension Crane. Double-girder suspension cranes from our KBK modular crane system enable goods to be easily transported. KBK double-girder suspension cranes provide fast, reliable and precise positioning for all loads, including heavy loads with large span dimensions. KBK double-girder suspension cranes feature: Cost-effective implementation. Modular system design. Smooth and reliable handling. Favorable installation dimensions. Rated for loads weighing up... (read more)Browse Overhead Trolleys Datasheets for Demag Cranes & Components
Wacker Chemical Corp.
New Dimensions for Adhesives and Sealants GENIOSIL (R) XM - New Dimensions for Adhesives and Sealants (PDF | 3.3 MB). GENIOSIL (R) XM. New Dimensions for Adhesives and Sealants. The novel silane-modified polymers (SMPs) GENIOSIL (R) XM 20 and GENIOSIL (R) XM 25 allow a new formulation strategy for the production of adhesives and sealants. Both grades enhance performance properties without disrupting the existing characertistics of an SMP formulation. Moreover, when incorporated into adhesive and sealant formulations, conventional... (read more)Browse Silicone Adhesives and Sealants Datasheets for Wacker Chemical Corp.
IEEE Membership
Car Rental Through this program, IEEE members can save up to 20% and enjoy additional offers.* Valid at participating locations in the US, Canada, Latin America, and the Caribbean. (read more)
ABB Electrification Products
High Breaking Capacity - Compact Dimensions frame sizes: XT1, XT2 up to 160A and XT3, XT4 up to 250A. High breaking capacity in compact dimensions. XTraordinary limiting characteristics allow savings in copper and footprint in switchboard, high selectivity values and very compact motor protection solutions. Ease of use and installation flexibility. A dedicated range of accessories and a renewed solution for electronic trip units to adapt Tmax XT to different applications scenarios. Customized protection and information availability. Specific... (read more)Browse Circuit Breakers Datasheets for ABB Electrification Products
Thermon Manufacturing Co.
Tank and Hopper Heating Systems Thermon offers a simple system for cost-effective heating of tanks and hoppers utilizing our RT and RTF for tank heating, HT Module for hopper heating and ThermaSeam for standing seam insulation systems. Thermon's extensive line of electric heating cables can also be utilized for tank heating applications. BSX and RSX self-regulating heating cables are recommended for freeze protecting at or below 150°F (65°C). HTSX and HPT cables are recommended for up to 300°F (149°C). (read more)Browse Electric Heaters Datasheets for Thermon Manufacturing Co.
National Bulk Equipment, Inc.
U-shaped Agitator Hopper Agitator Hoppers. In-Use Advantages. NBE agitator hopper units are designed to ensure consistent, reliable flow of non free-flowing material into downstream conveyance or processing equipment. NBE agitator hoppers use a combination of design features; such as a full-length discharge trough, and continuous sweep arms, to condition material discharged from bulk bags or containers. NBE agitator hopper systems prevent bridging or ratholing above the take-away inlet and provide free material flow... (read more)Browse Hoppers Datasheets for National Bulk Equipment, Inc.
Aitken Products, Inc.
Railroad Car Thawing Heaters Railroad Car Thawing Heaters. This extremely rugged weatherproof thawer has a low initial cost, low maintenance cost and low operating costs. This equipment will fit the needs of both small and large plants. It is adaptable to most plant situations and thawing time requirements. Each installation is designed to meet the needs of the individual plants. Why is infrared electric the best way to thaw a car?. The old approach to car thawing was open flame right on the car's skin. This wasn't just... (read more)Browse Industrial Heaters Datasheets for Aitken Products, Inc.
Smith Systems, Inc.
Bearing Temperature Monitoring - Rail, Railroad For monitoring bearing temperatures on passenger rail cars. The T260625 is used for bearing temperature monitoring on passenger rail cars. The sensor employs an innovative right angle cable exit design that can be oriented anywhere (360°) around the centerline of the sensor body after it is torqued in place. This feature eliminates large service loops in cabling under the car which greatly reduces the incidence of cables being fatigued, snagged or cut by ballast and debris. Products featured... (read more)Browse Temperature Probes Datasheets for Smith Systems, Inc.
Light rail transit: planning, design, and operating experience
…on level, clean ballasted track, 7 .5 m from car Dimensions Length over fenders (m … Height of floor over rail (m) Height of roof … type Motor rating, per car (kW) Motor voltage (V … Beclawat Design 14, with hopper vents None Fitted to…
Economic feasibility study of a wood gasification-based methanol plant: A subcontract report
Scalper Feed Conveyor Dryer Feed Conveyor Fines Conveyor Stored Fines Conveyor Dried Fines Conveyor Truck Scale Tractor Shovel Reclaim Hopper and Chain Conveyor Magnetic Separator Scalping Screen Primary … Dried Chips Storage Silo and Reclaimer Gravimetric Feeder Rail Car Weigh Scale (optional) Fines .... a Screen dimensions only, does not include discharge hopper.
Intelligent system for real-time prediction of railway vehicle response to the interaction with track geometry
One difficulty in using the coupled model is the specification of vehicle dimensions , Wand L. .... As described in the section on the roll and pitch models, the value of'W is distance between the rail surface inputs (chosen as 59.5 inches) and L … axle of the vehicle (which for the 100-ton hopper car is 278 inches).
Handbook of Coal Analysis
Therefore, if car-top sampling is a necessity, the increments must not be collected predominantly from any given location relative to the dimensions of the rail car . .... bottom sampling in which coal is sampled as it is discharged from the bottom of hopper cars.
Management of dry flue gas desulfurization by-products in underground mines. Technical progress report, 1 January--31 March 1994
The container is flexible enough to conform to the centersill and hopper bays of rail cars , and durableenough to withstand the rigors of use in the coal and railroadindustries. .... The CIC dimensions are 10 feet high and 9 feet 2 inches in diameter.
A comparison of North American and European railway systems – a critique and riposte
The term carload in the North American context applies to those movements undertaken in separate rail vehicles which can include box cars of varying dimen- sions which are used primarily for higher value merchandise traffic and can be moved in single units .... Other carload traffic can include hopper wagons for minerals, agricultural products, solid fuel (Iess common now), ores…
Vitrified waste option study report
…15 ft 2.4 in Shield Name Source Shield 1 Ak Gap Shields Dimension 2.94*07 .... Bottom-discharge rail hopper cars will' discharge glass frit into a sub-grade hopper oulside 1he VF.
Code of Federal Regulations > Title 49 - Transportation > Pipeline and Hazardous Materials Safety Administration > [49 CFR Part 174] Carriage by Rail
(3) Packed in boxes or crates of such dimensions as to prevent their overturning; or. .... (b) Specification DOT-4L (§178.57 of this subchapter) cylinders being transported in a rail car must be loaded in an upright position and be securely braced. .... However, they may not be transported in hopper bottom cars.
Railroads and Price Discrimination: The Roles of Competition, Information, and Regulation
There are strong seasonal fluctuations in the utilization of hopper cars for grain transport; without a pricing mechanism to allocate cars, there were signif- icant car shortages and wait times for shippers during peak shipping seasons. .... They serve as a way to identify shippers with a higher willingness to pay for timely service, and therefore provide a new dimension of price discrimination, but they also allow for a more efficient use of rail -car capacity.
Federal Register > Thursday, April 28, 2011 > [76 FR 23714] Railroad Safety Appliance Standards
Finally, in 1910 the third Safety Appliance Act was passed requiring that all rail vehicles be equipped … Appliance Act also directed the Interstate Commerce Commission (ICC) to designate the number, dimensions , locations, and manner .... This order, as amended, designated the number, dimensions, location, and manner of application for safety appliances on box cars , hopper cars, gondola cars, tank cars, flat cars, cabooses, and locomotives.


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Latest Updates...
Visiting Faculties
Rare Collection :
• Handwritten Letters of Lokmanya Tilak.
• Setu Madhavrao Pagdi Collection: Noted historican and poet of Urdu language.
• Pandit Babrekar Shastri Manuscripts Collection: Noted Sanskrit scholar
• Prof. C.G.Kashikar Collection: Noted Sanskrit Scholar
• Prof. A.R.Kulkarni Collection: Noted historican and former Vice Chancellor of
• Kesari Collection: Noted books of Lokmanya Tilak
• C. G. Kashikar Collection: Noted Sanskrit scholar and former Vice Chancellor of
Highlights of the library
• Manuscripts digitization completed.
• Shodhganga grants received for digitization of old thesis and dissertations.
• Anti-plagarism software purchased from ithenticate from Balani Infotech.
• Facilities to researchers of other institutions to access the library resources and thesis.
• Inter library loan.
Security of library materials
• CCTV surveillance in the library with backup.
• Grilled wire windows.
• Security guard at the entrance.
• Fire alarm.
• Kesari library tie up provides the following facilities to students of TMV.
The facility provides access to scanned newspapers of Kesari from 1881-1930.
Issues of Mahratta bounded from 1881-1930
Rare photos of Lokmanya Tilak, Tilak family, work done is accessible in hard disk
Record of letters of Lokmanya Tilak maintained in registers.
Rare books on Lokmanya Tilak, M. K. Gandhi, Agarkar, Savarkar, N. C. Kelkar and
other noted historians.
Institutional Membership
• British Library: The membership facility is availed by students and faculties of management, nursing, media, animation and law.
• MCCIA: Mahratta Chamber of Commerce industries and agriculture. The facility is useful for Management students as e-mails are received for programs organized and can be attended by the students and faculties.
Activities conducted
• EBSCO hands-on training: beginning of second semester in October
• J-Gate demonstration: beginning of second semester in October
click here
• Reference books display exhibition: August 2013
click here
• Saraswati Poojan 2017
click here
• One day JCCC-INFONET workshop
click here
• User orientation program: during July and August.
• Best user of library award: 26 January
Future Plans
• Creation of Institutional Repository.
• Digitization of rare books in the library.
• To increase membership of other resourceful libraries.
• Encourage resource sharing through inter library loan.


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Charges laid over Warragul murder
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A man faced court today charged with the murder of a disability pensioner in the eastern Victorian town last week.
Wayne Norris, 45, from Warragul, was also charged with trespassing with intent to assault and the theft of a car belonging to Lee Christopher Bridge, 35.
Mr Bridge was found dead in his home last Thursday.
Norris was not required to enter a plea and was remanded to reappear in Melbourne Magistrates' Court on June 8.
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Thanks to its position in Central Europe, Vienna (Austria) is often a good choice for a stop-over before you head to Eastern Europe or the Balkans. The city is absolutely amazing and is worth your time but when you decide to move on, you should know which choices are available to get to Athens .
Quick summary
If the budget is not too low and you don't exactly like to spend (a lot of ) time in trains and buses, then choose to fly between the two capitals. In about 2 ½ hours you'll be at the destinations.
However, if you like to watch the scenery passing by and don't mind spending about a day in the train and/or bus, then you can choose one of the slower means of transportation. The cheapest option is definitely by bus for the entire length of the trip.
Flights from Athens (airport code: ATH) to Vienna
Unfortunately, the route between the two capitals isn't served by low-cost carriers and you have to choose among Austrian Airlines, Aegean Airlines and Olympic Airways if you choose a direct flight. Starting with May 2012, expect to pay from €84 one way on Aegean Airlines (2h 20 min flight), but outside the travel season (for example March, the fares start at €160 one way on connecting flights via Serbia)
Do keep your eyes on the airlines' sales though as you can end up saving quite a lot on airfare.
>>book a flight to Athens
Trains from Athens to Vienna
During the tourist season you can travel by train from from Thessaloniki to Bucharest (Romania) and then continue to Budapest and then Vienna.
Getting from Athens to Vienna by train can be quite daunting and is not exactly an adventure recommended for those who lack patience or don't like trains.
The shortest route takes little over 19 hours (according to DB BAHN ) and you'll be making several stops along the way; more precisely in: Eboli, Napoli, Rome, Venice and Salzburg.
You can also create your own route, via Bucharest (Romania) and Budapest (Hungary). It is one of the busiest routes during summer and you need to book the tickets in advance. First, you need to get to Thessaloniki and from there get on the train to Bucharest. The journey takes 18 hours. From Bucharest, choose the direct train to Vienna and travel for another 18 hours. It is daunting and long but it's one of the most beautiful train rides in Europe.
You can buy a train pass which allows for city breaks. Of course, the total travel time will increase but you'll get to see more cities along the way and get to relax as well.
Read more about:
>> Getting from Athens to Thessaloniki
>> Getting around Eastern Europe
Buses from Athens to Vienna
Long haul bases connect the cities in Eastern and Central Europe but there aren't any direct links from Athens to Vienna. Here's a simple route:
Step 1: Athens to Thessaloniki
You can travel from Athens to Thessaloniki by plane, train, bus or ferry, depending on you spare time and budget.
Step 2: Thessaloniki to Bucharest (Romania) by bus
There are several bus companies serving the route, including Eurolines. One way tickets start at €16 (65 RON).
Step 3: Bucharest to Vienna
You can travel from Bucharest to Vienna by plane, train or bus, depending on your spare time and budget. The cheapest choice, however, is the bus. One way tickets start at €65 and there are several bus companies offering connections.
Driving from Athens to Vienna
You can rent a car in Athens and plan to drive all the way to Vienna. Since both countries are in the European Union you shouldn't have problems picking up in Athens and dropping it off in Vienna, especially if you plan to drive only through European Union countries (the route via Bucharest – Budapest).
According to Google Maps, the shortest route is via Thessaloniki – Belgrade (Serbia) – Szeged (Hungary) – Budapest (Hungary) – Vienna. It's a total of 1728 km which can be covered in about 18 ½ h. Plan to make stops along the way. Budapest is definitely worth a day of sightseeing.
Another option in order to drive only through European Union countries it to choose the following route: Athens – Thessaloniki – Sofia (Bulgaria) – Bucharest (Romania) – Arad (Romania) – Szeged (Hungary) – Budapest (Hungary) – Vienna (Austria). It's much longer (2269 km) but you can plan to stop several times along the way. Bucharest, Sibiu (along the road to Budapest) and Budapest are definitely worth a day of sightseeing.
Photo credits: Vienna St. Stephan Cathedral by Cristina Puscas, Austrian Airlines at Vienna Airport , Bucharest Train Station (Gara de Nord) , Eurolines Bus
Note: the article was first published on April 19th, 2010 and has been republished on February 1, 2012.


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Concept Sculpt Of Samsquanch: Work In Progress Part 1
New internal projects are in development at Vermont Digital Arts! We have been working on some original game designs and concept art for a variety of platforms including the Oculus Rift, Steam and a host of emergent mobile devices to be developed in Unity.
Above is a sneak peak at a character rather early on in the concept art phase for an upcoming IP we are developing. This sculpt of a hybrid yeti-ape creature is modeled in ZBrush and is currently a whopping 13 million polygons. Today we hope to refine the basic form a little more then retopologize the creature in 3D Coat before modeling fine details and painting textures. It'd be great to hand a low poly version of this creature to our partners on the rigging and animation team at Anzovin Studio ASAP. It's essential to identify problem areas in the geometry as early as possible and allow the animators time to work.
Check back to see a series of posts on the creative and technical processes that drive our development.


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Iowa Wesleyan University
Iowa Wesleyan University
Latest from NCAA.com
- BVBTwo-time defending champ USC starts No. 1
- MTENUnbeaten West Florida remains No. 1 in latest ITA poll
- WTENLynn maintains No. 1 spot
- BASEStanford off to hot start under Esquer
- WHKY10 finalists named for Kazmaier Award
- WRESQualifier allocations, RPI announced
- WRESOSU's McKenna is Wrestler of the Week
- WLAXWatch Lindenwood's Sami Smit dazzle with a back-handed goal
More from NCAA.com


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Matt Mitchell – Mission Performance: After a few hours toiling with our primary winch system the engineer and his team managed to get the problem solved, the biggest problem was getting the covers off to get access to the gear box in the first place. After that they reported that the fix was easy enough.
The first half of the evening last night was fairly lumpy with light winds as we were trying to claw our way to windward. Then, after a few hours of very light winds, the story has changed completely and we have a nice north easterly air flow blowing us along with our Spinnaker 1 flying.
Overnight more disaster struck as our navigation PC, which is due to be retired in Brest, kept freezing, and we inadvertently entered into the forbidden Dover TSS, which if the race office aren't obliging in redress for a known and pre-existing equipment failure, will result in a six hour time penalty at the end of the race.
So as enjoyable and amazing as the first 24 hours of the race has been, we have been plagued by small bouts of bad luck, though as they say, bad things happen in threes so I am pleased to have gotten our three out of the way early!
Today looks to be a promising day with the potential for a scorcher of a day, if a little light on breeze.
Vicky Ellis – Switzerland: What a day on Switzerland! After Sunday's truly memorable send-off we started bright and early in the River Medway yesterday morning to a stunning still sunrise over the moored fleet of 12 Clipper 70s, all rafted together. After slipping lines we headed out to the race start location, hoisting main sails on the way and contemplating the first choice of headsails, poled out Yankee 1. When the helicopter arrived, brandishing the letters TV on its underside, that sealed the deal, Switzerland kite it was! It was the first time up on the boat and the coast was free of shipping and the wind direction as good as it could be, so under the pressure of being luffed by Derry- Londonderry-Doire and overtaken by Henri Lloyd, we pulled out a mean hoist!
The first gybe wasn't as pretty though, having decided to go with it earlier than planned and do an inside gybe that had been accidentally set up rather than an outside, however after a successful, well-rehearsed letterbox style drop and re- hoist we held our ground, albeit towards the back of the fleet.
Overnight, a few buckets were in use as the wind increased and tuned to head us as we rounded Dover. Forecast was for it to lighten overnight which it did and the morning has seen us creeping back in with the middle of the fleet.
Dawn came with a spectacular Spinnaker hoist and a knot or two more boat speed so a welcome cheer on deck! That and a pot of fresh coffee will keep us stoked as we turn our thoughts to the comparatively wide open space of the English Channel ahead. The mood on board is excited, optimistic and full of banter; Nina Simone sums it up well, 'it's a new dawn, it's a new day, it's a new life...and I'm feeling good!'
Rich Gould – Invest Africa: So the first full day at sea and what a day it's been. Race start yesterday was amazing, but downwind line starts always are. The whole fleet jockeying for positions a fair distance back from the line as no one wanted to be on course side (OCS) on the very first race start of our epic adventure.
As the 10 minute signal was sounded the crew became focused on the task in hand, the clock was ticking for the start of the world's longest yacht race.
40,000 miles and a lap around the planet lie ahead of us. 'BANG' and the race had started. As soon as we were over the line the crew were working hard to prepare the Medium Weight Kite, halyard and sheets good to go and up it went. Not quite a perfect hoist but it was up and still in one piece. As we sheeted on and the kite filled we all felt Invest Africa (IVA) surge underneath us as she picked up speed. Instantly our boat speeds were in double figures, the race was on!
Making our way out of the Thames estuary was fantastic; as we ploughed through the murky brown waters we picked our first target, Derry~Londonderry~Doire. They were lying ahead of us also flying their Spinnaker 2. With the crew working hard on to trim the sails we gradually closed the gap from half a mile to a quarter and then foot by foot until we were right on their tale. With a bit of a cat and mouse game between the two of us we ended up alongside them as we fought to get passed. Time for a gybe and it went without a hitch, the result being some good gains made on our closest comrade.
As the day went on the wind dropped, shiftless, picked up shifted and then shifted some more. We have gained and lost and then gained a place again over night.
At sunrise the Spinnaker two went back into the sky, we are now making good speed once again. For now it looks like it's going to be another beautiful day on the water.
With around 250 miles left between us and Brest it's all still to play for so…Let's go get 'em!
Simon Talbot – Great Britain: The excitement of leading the fleet for the first hundred miles or so yesterday has given way to the frustration of playing catch up as most of the fleet sailed round us whilst we languished in a wind hole off Hastings.
The whole fleet has now been re-arranged in the order they came out of the light wind lottery and we are currently lying in around eight or tenth position depending on how you measure it. The race is still young and motivation to claw back the places is still high despite the frustrations that Mother Nature has dealt us.
Damian Parnham - Team Garmin
Chris Hollis – PSP Logistics
What a start to the Clipper 13-14 Race. There was only one way to top the parade and that was to win the start with the kite flying right next to the south end pier.
However there was one little hiccup in the fact that the firing bullet that releasing the bottom point of the sail called the tack snagged, resulting in the sailing flying of the side waving about like a flag! No worries on board PSP Logistics...quick drop, sort it out and a smart deck hoist and we were off again.
We lead all the way to Margate in some tricky conditions, which involved multiple kite gybes and shallow water. Alongside Great Britain we were leading the fleet until the wind dropped before us allowing the fleet to catch up.
Since then the wind has built to 25 knots, changed direct, and disappeared altogether. Multiple sail changes required and the crew has responded with valour. Mission now...bust some grooves and make some moves and regain that lead we tasted earlier.
Patrick van der Zijden- Old Pulteney
Sean McCarter - Derry~Londonderry~Doire
After the leading duo Great Britain and PSP Logistics sailed into a wind hole, both us and Henri Lloyd were able to open up a substantial lead that we've been swapping through the night. I went for a quick power kip and the guys woke me up three hours late to explain we had overhauled Henri Lloyd...great stuff!
Currently under Spinnaker one and full main heading at Ushant. Hopefully the breeze holds to get us through the next few hours of unfavourable tide before we step on the elevator to Alderney and beyond!
Pete Stirling - Jamaica Get All Right: Race start yesterday was very exciting and only being the second time all 12 boats have started a race together. Normally race starts are upwind but yesterday was down wind and quite strong making it harder to judge the distance and time required to get to the start line without crossing it too early. We kept out of trouble and crossed the line in what looked like fourth place. Crew spirits were high and everyone was looking forward to some close racing at the head of the pack. However, due to a number of mistakes and equipment failures, by the end of the day we were at the back of the fleet and well out of contention. Fortunately for us the wind has gone light and Jamaica Get All Right is slowly making its way back through the fleet. We are now in tenth place and team morale is significantly better than it was last night - get all Clipper Round the World


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Web Content Display
of the
September 5, 2013
3:00 pm – 5:00 pm
Archdale Building – Ground Floor Hearing Room, Raleigh, NC
1. Call to Order and Notice ofNCGS 138A-15 - Committee Chairperson
In accordance with the State Government Ethics Act, it is the duty of every member of the North
Carolina Mining and Energy Commission to avoid conflicts of interest and potential conflicts. If
any member knows of a conflict of interest or potential conflict with respect to matters coming
before the Committee today, please identify the conflict or potential conflict at this time.
2. Approval of Minutes from July 25,2013 Committee Chairperson
3. Revisions or Additions to Agenda Committee Chairperson
II. Action Items
1. Preparation of Baseline Testing Rules for Transmittal to MEC Committee Chairperson
2. Preparation of Wellhead Standards Rules forTransmittal to MEC Committee Chairperson
III. Information Items
1. Discussion of Terminology and Assigned Responsibilities for "Permittees" or "Actors"
Terminology for Permittees/Actors Committee Chairperson
2. Discussion of Compiled Definitions Section Committee Chairperson
IV. Public Comment
V. Concluding Remarks
VI. Adjournment
Reminder to All MEC Members: Members having a question about a conflict of interest or potential
conflict should consult with the Chairman or with legal counsel.
Reminderto MEC Members Appointed by the Governor: Executive Order 34 mandates that in
transacting Commission business each person appointed by the Governor shall act always in the best
interest of the public without regard for his or her financial interests. To this end, each appointee must
recuse himself or herself from voting on any matter on which the appointee has a financial mterest.


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Reviews: 2
Average Rating: 4.0
2 reviews
Posted April 25, 2011
Great buy
These jeans fit perfectly and stay in shape after a full day of wearing eventhough the fabric is super thin and soft. I normally wear size 26 in most brands and got these in 26 as well.
Sizing: True to Size / As Expected
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Posted April 25, 2011
Huge distressing
I was excited to get these in the mail but was disappointed to see that the distressing on the thigh area was way bigger than the picture shows, at least for the pair that I got. Since it would be showing too much of my thigh skin, I decided to return them. I normally wear a size 26, and got a size 25 as suggested by the other reviews, and these jeans were still a bit loose all over. The wash was excellent and fabric super soft.
Sizing: Larger than Expected
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Community leader and human rights defender assassinated in Antioquia
News from Colombia |
on: Monday, 13 February 2017
Luz Herminia Olarte, a community leader and human rights defender, was assassinated on 7 February. She was the president of the Community Action Committee in Yarumal, Antioquia Department.
The human rights observatory the Colombia-Europe-United States Coordination Group (CCEEU) in Antioquia denounced that 19 social leaders have been murdered so far this year, with 5 of those killings in Antioquia. Óscar Olarte, a member of the Coordination, said that "she was viciously murdered" and although the authorities had been alerted to previous threats against the leader "the authorities did nothing". The Coordination demanded guarantees from the government and investigations into all the murders of leaders.
Olarte also said there is a concern in the communities and human rights organizations about the paramilitary presence in the region and that the paramilitary organisation the Autodefensas Gaitanistas had been active in areas where the Colombian army is present without the authorities taking action.


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Do I still have a chanceVisitor's Question from a 13-15 year old Male
Let's see....There is this girl that I have had my eye on for some time now..I told one of her friends how I feel about her, so I'm pretty sure she knows that I like her..We talk on the internet occassionally (usually just small talk). The thing is I saw her the other day..I wanted to talk to her and I think she did to because she turned and looked at me as if she wanted to talk BUT I FROZE and talked to someone else...I'm really dissapointed in myself for not saying anything..So my question is...Did I blow it??..Do I still have a chance??......thanks.
RomanceClass.com Advice
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Fri, 10/05/2018 - 5:00pm to Sun, 10/07/2018 - 3:00pm
This rich weekend immersion is designed for those who have taken Council 1 and have had some experience facilitating council. We will explore working with challenging situations, conflict, and "the shadow."
In council, we allow ourselves to be moved, to get out of our comfort zone, and to navigate how best to be of service to the circle, while maintaining safety and containment. This advanced workshop delves into the varied forms and modalities of council that are best suited to different situations, as well as the joys and challenges of bringing council into different parts of our lives.
This workshop offers an opportunity for council practitioners to become more skilled with "reading the interactive field," recognizing our sharp edges and our own reactivity in council, and to explore "turning into the skid" and inviting the perspective of the witness.
Two veteran council trainers will lead this exciting exploration of activities, practices and tools for embracing wholeness, enriching community, and learning to "think like a circle."
Fee: $625 includes a council manual, 6 vegetarian meals from Friday evening through Sunday lunch, and two nights shared accommodations.
Training prerequisites:
A letter of intent that includes your prior experience in council or similar circles and prior reading of The Way of Council by Jack Zimmerman and Gigi Coyle.
A letter of intent that includes your prior experience in council or similar circles and prior reading of The Way of Council by Jack Zimmerman and Gigi Coyle.
Register here or call us at 805-646-8343 ext. 123. Questions? Email firstname.lastname@example.com.