History resoponse Essay Example | Topics and Well Written Essays - 1250 words

History resoponse - Essay Example Most people believed the idea that humans were capable of destroying themselves. This war as referred by some people was indeed a great war. It affected all the nations of the world, from Europe to Africa. Today its effects are still felt. It was mainly among Britain, Austria, United States, Germany, Russia and France. These nations mobilized masses in other countries to fight against their enemies. There was political reformation in the whole world. The war is believed to have been greatly fueled by religious differences. Most of the political reformation was on religious grounds. Serbia matched with Russia as they shared the same doctrines, Croatia joined forces with Austria. Bosnia supported the Ottoman Empire. The war was catalyzed when Germany declared its support for Austria against the Serbs. This angered Russia and awakened British and French. Treaties were formed and the result was Europe being divided into two blocs. France Britain and Russia came to fight against Germany, Italy and Austria. Diplomacy disappeared and it was all about war. The impact of the war was soon to leave a mark in history. The use of chemical weapons adversely affected the human race. Bombs and poisonous gases killed millions of people and the few who survived developed permanent health problems, both physical and mental. Families were shattered and weeping became the norm in the entire world since all nations were affected and its people were being killed. Some of the bombs had far reaching catastrophes as they affected future generations. Children would be born with various defects. The atomic gases affected lifespan of the human race. Those who had greatly inhaled the gases died at an early age. Freedom of speech and expression was lost. Soldiers could not freely give their opinions on various matters especially those that pertained to war. Civil societies lost their voice and they could demonstrate leave alone striking. This resulted to people living in fear

Understanding Ethics and Ethical Behaviors Essay Example for Free

Understanding Ethics and Ethical Behaviors Essay The roadmap of this brief essay is to present an overview of the importance of ethics and ethical behavior in the field of management and business enterprise. This paper hopes to enumerate certain ethical behaviors necessary for the proper conduct of professional affairs, as well as cite certain examples that can help situate the discussions being unraveled. This discussion is important insofar as our present generation spends most of their times in their workplaces. In a manner of speaking, it is within these professional contexts where, according to Delbecq, most people’s characters are forged (qtd. in Schminke ix). Ethics is a science that seeks to shed light on matters that are either right or wrong. Merriam-Webster defines it as the discipline which deals â€Å"with what is good and what is bad, and with what is moral duty and obligation† (Merriam-Webster 398). As such, ethics is both informative and formative. It is on the one hand informative because it concerns itself with knowledge about all things right or wrong. Yet it is on the other hand formative (or imperative) because it demands adherence to moral laws in the conduct of human affairs. Many ethical norms are deemed necessary in view of making ethical the conduct of affairs transpiring within professional workplaces. Among others, honesty, truthfulness and transparency are three of the most fundamental traits that need to be observed. Specifically, dealing honestly with colleagues, being truthful in transacting business with clients, and being transparent in completing database and/or records are conditions of no little importance to one’s professional career (Mary Guy 22). Still, fairness, justice and respect are intricately woven ethical benchmarks as well. Fairness and justice go hand in hand; they behoove equal treatment and distributed opportunities for and to all stakeholders. Just the same, respect for colleagues and the workplace itself are truly important so as to maintain smooth interpersonal interaction. Hardly over, personal integrity and the courage to rectify misgivings are essential aspects of ethical behavior in workplaces as well. These traits enhance ethical decision-making process which individual employees must see through successfully. The case of Sherron Watkins, the once-Vice President who turned her back at Enron Corporation, is a good instance to cite. According to the story, Ms. Watkins was made accessory to accounting frauds, even while she was nervous about being implicated in the process. After much deliberation, she decided to expose the irregularities even to the point of being made to testify to the Congress; all because she wanted to rectify the detestable errors committed by her company (Pellegrini). Taking cue from the example of Sheron Watkins, it seems therefore needless to point that professional workers must take upon themselves the burden of behaving ethically in their workplaces. Far more critical, they should be prepared to handle incidences involving not just accounting frauds but also bribery, racial discrimination, favoritism, unjust wage, unsafe working environment and practices, onerous and unstipulated demands, tax frauds, sexual solicitation and/or harassment, illegal termination and espionage of employees, among others. To briefly conclude, this paper ends with a thought that affirms the importance of the discipline which the science of ethics demands from professionals reporting to workplaces almost on a daily basis. The discussions herein developed emphasized the importance of knowing certain ethical behaviors and implementing them in workplaces. As indeed, the case of Sherron Watkins provides a framework for ethical decision-making process, as well as the basis to be vigilant in correcting instances of misdemeanor committed within professional workplaces. References Delbecq, A. â€Å"Foreword†. Marshal Schminke, Ed. Managerial Ethics: Moral Management of People and Processes. Mahwah, New Jersey: Lawrence Erlbaum Associates, 1998. Guy, M. Ethical Decision Making in Everyday Work Situations. Westport, Connecticut: Quorum Books, 1990. Merriam-Webster Collegiate Dictionary. Tenth Edition. Springfield, Massachusetts: Merriam- Webster, Incorporated, 1996. Pellegrini, F. â€Å"Person of the Week: â€Å"Enron Whistleblower† Sherron Watkins†. Time Magazine. 05 January 2009 http://www. time. com/time/pow/article/0,8599,194927,00. html.

Physiotherapy Management of Lower Limb Tendonopathies

Physiotherapy Management of Lower Limb Tendonopathies A Systematic Review of the physiotherapy management of lower limb tendonopathies Tendonitis is a condition which is comparatively commonly seen in various clinics. The largest cohort of patients tend to have developed their condition as a result of various sports-related activities but it is acknowledged that there is a substantial cohort of RSI sufferers and occupation-related forms of tendonitis. (Kader et al 2002) In this piece we aim to review the various treatment modalities and to concentrate primarily on the eccentric muscle strengthening modalities of treatment, the rationale behind them and any evidence that they actually work. Before we can consider the direct question of eccentric loading as treatment for tendonopathies we must examine the rationale for its uses well as the basic science and theory behind the actual practice. We will do this largely by the mechanism of a literature review. Methodology In this review we shall be examining the literature for not only the methods that are currently employed in treating the various lower limb tendonopathies but also for justification for these methods and the quality of the science behind them. We shall therefore critically review the literature available and present it in a rational form. In addition to this we intend to present an overview of various factors in a wider picture that are relevant to our considerations. We shall consider the current views on the pathophysiology of tendonitis and the experimental evidence on the response of the tendon to exercise in general terms. Although it is accepted that the majority of patients currently seen in clinical practice with various forms of lower limb tendonitis are suffering from a sports related injury, we shall also look at the effects of ageing on tendon physiology as it is acknowledged that the elderly are another highly represented group with tendonitis. We conclude the preamble with a number of clinical considerations, most prominently the difficulties posed by the differences in nomenclature and terminology which renders both assessments and comparisons between clinical trials difficult. We conclude the dissertation with a review of various currently employed treatment modalities and the rationale behind them. We focus specifically on the use and place of eccentric muscle strengthening exercises in the spectrum of rational treatments.. Pathophysiology of tendonitis At the macro-anatomical level, the tendon is usually easily defined as a semi-rigid white or grey structure, generally found in close proximity to synovial joints. One of its prime functions is to transmit forces generated by muscles to the skeletal system, often inducing movement. (Huxley HE 1979). At the micro-anatomical level, it’s structure is very much more complex and requires a detailed examination before we can realistically and meaningfully consider the issues relating to the therapy of tendonitis. Tendons form part of the anatomical structures that are functionally grouped together as the extracellular matrix (ECM). The rate of turnover – both synthesis and degradation – is influenced by a number of different factors including metabolic and disease related factors, but the strongest influence on the turnover rate is mechanical stress, usually as a result of various degrees of physical activity. (Agar Pet al 2000) Tendon (and intramuscular) collagen, turns over at a rate which is about half as fast as myofibrillar protein turnover. The main physiological stimulus to turnover appears to be the multiple stimuli arising from mechanical or contractile activity.(Cuthbertson D et al2005) At the cellular level, degradation of collagen is mediated largely byte metalloprotease group of enzymes and synthesis is most strongly influenced by a number of different trophic factors which are released at the cellular level. (Algren MS. 1999) These growth factors are mainly responsible for both the transcriptional changes as well as the post-translational modifications that take place as a result of either physiological changes or disease processes. (Sand Meier et al 1997) Until comparatively recently, tendon tissue was thought to be fairly inert. Recent research work has given good supportive evidence that the internal metabolic processes, the internal vascular responses (Alstom et al 1994) and the actual catabolic turnover of the collagen protein in response to physical activity, is considerably greater than originally thought. The converse is also true, as inactivity appears to have the same inhibitory effect on tendon tissue as the better known effect of wasting in muscle tissue. (Abrahamson SO et al 1996). This effect is of particular importance in our considerations (later) when we consider that some authorities suggest that outright rest is inappropriate initial treatment for tendonitis. Collagen is a large polymer-type protein made up of many repeating subunits, (triple helices of polypeptides with a high proportion of proline and hydroxyproline). It is made by fibroblasts. In the muscle, it forms a basket-like network around the muscle fibres but then forms progressively more coherent and solid structure as it forms discrete tendon. In this way it allows the efficient transmission of forces generated by the myofibrils to the tendon – and hence to the bone. (Kjaer M 2004). Training, in the form of physical work, exercise or repetitive movements, will have a trophic effect on the tendon as a whole. Collagen turnover can be increased and there can be an overall increase in the amount of collagen protein in the tendon. (Herzog W et al 2002) Collagen, in the form in which it is found in a tendon, has enormous on-elastic tensile strength and a modest degree of ability to bend under lateral stress. As the amount of collagen in a tendon increases, the tendon’s mechanical (or more accurately, viscoelastic,) properties change. It decreases it’s stress levels for a given load, and thereby renders it more load resistant.(Fowls JL et al. 2000). Again this facts of great relevance to our clinical considerations later in this piece. The stiffness, or resistance to lateral stress, is a function of the cross-linking of sulphur bonds across the parallel bands of protein. In general terms, the more cross-links, the stiffer the tendon. The degree of cross-linking is a result of a complex interaction between a number of enzyme systems in the matrix of the tendon. (Hamill OP et al.2001) Polyglycans are an important feature of this enzyme cascade and become an increasingly important functional component as age increases. Older or ageing collagen will tend to exhibit glycolated cross links in addition to the sulphur links of youth. This is part of the reason why older tendons are less flexible (and possibly more prone to injury). (Inglemark BE 1948). The functional significance of these links is that they render the tendon even stiffer and less able to bend.(Davidson PF 1989).Understanding these processes is fundamental to the prescribing of a rational treatment regime for tendon injuries and other pathologies. It is also important to have a complete understanding of both the vascular and neurologically mediated adaptation processes that are present in the my-tendon complex. These work on a far more rapid and immediate time frame than the processes that we have just described, and are primarily responses to rapid changes in the mechanical loading stresses. As muscle tissue develops physiologically, there is a symbiotic relationship between the muscle and the extracellular matrix. The various physiological mechanisms that stimulate muscle growth and hypertrophy appear to have a similar effect on the extracellular matrix. (MacLean et al 1991) But in the latter case, they are less well understood. We know that that significant and repeated mechanical loading will trigger off, or initiate a process, which starts with the activation of trophic gene in a cellular nucleus, (Banes AJ et al.1999), it progresses through the complex processes of protein synthesis and functionally ends with the deposition of collagen in the tendon tissue.(Yasuda et al 2000) Responses of the tendon to exercise There would appear to be some form of integration between the muscular and the extracellular matrix signalling pathways, which optimises the co-ordinated activity of the trophic processes in response to the stimuli (which can be both loading and tensile in nature), which produce the response in the first place. (Viidik A.1993). This co-ordination mechanism must exist, as it is a well-recognised phenomenon that a tendon hypertrophies to accommodate the increased mechanical stress that its associated hypertrophied muscle produces. (Derwin et al 1999) Considerable research effort has been expended in trying to delineate the mechanism, but to date, the results have not increased our understanding of the situation significantly. (Vierck J et al 2000) Specific studies in this area have been able to show a clear correlation between collagen response and an increase in physical training. (Langberg et al 2001). The response was detectable after a 4week training programme and was maximal at 11 weeks. When we consider the pathophysiology of RSI (repetitive strain injury) or even chronic overload syndrome, the stimuli that can produce muscle hypertrophy or increase muscle fibrosis can also produce fundamental changes in the tendon structure. (Birk DE et al 1990) These changes can include changes in both the chemistry and the functionality of cross bonding of the collagen fibres, (Barnard K et al1987), changes in the size of the collagen fibrils, areas of locally increased blood flow (known as hyper vascularisation zones), and an increase in the catabolic processes which can result in either (or both) collagen being synthesised and laid down, or increase in fibroblastic activity which increases the fibrous component of the tendon. (Greenfield EM et al 1999) It is a fundamental recognition of the fact that these processes require â€Å"adjusted loading† rather than an enforced absence of loading(immobilisation) to reverse the physiological processes, that underpins most of the thrust of this review.( Howell JN et al 1993), (Jà ¤rvinenTAH et al 2002) The experimental evidence to support this view comes from the classic set of investigations by Gibson (et al 1987) who compared the rate of collagen synthesis and turnover in an immobilising long-cast leg with the rate of turnover in the unaffected leg. The rate of collagen synthesis dropped by half over a seven week period in the immobilised leg. The investigators also found an adaptive (and compensatory)reduction in the rate of collagen degradation which had the overall effect of reducing the protein loss in the tendons. In the overall context of our investigation it is also important to note that the authors also found that minimal electrical stimulation of the muscle (5% of maximum voluntary contraction for 1 hr. per day),increased protein synthesis to such an extent that there was no net protein loss over the same seven week period of the trial. (Gibson etal 1989) In a study that was remarkable for its invasiveness (the authors took repeated biopsies of human patella tendon after periods of exercise), Miller (et al 2004) demonstrated that tendon collagen synthesis showed a 30% rise within 6hrs of exercise and up to a 50%rise within a 24 hr. period. This was found to exactly follow the pattern of protein synthesis in skeletal muscle. This finding is strongly supportive of the assertions made earlier in this essay, that there would appear to be a mechanical or humeral mechanism that links the trophic effects that are apparent in both tendon and skeletal muscle. Various authors have postulated different mechanisms (it has to be said with scant evidence), including integrin’s, (Levenhagen et al2002), growth factors including transforming growth factor beta (TGFB) (Moore et al.2005), or mechano growth factor (MGF) (Rennie et al 2004),which they suggest may be responsible for the co-ordination of the trophic effects of perimysium collagen, tendon collagen and the myofibrils. More concrete evidence exists (and is arguably of greater relevance to our investigation here), for the fact that dietary protein alone can produce a trophic stimulus for tendon collagen. (Jefferson Kimball 2001). It is postulated that there is some form of amino acid sensor that is responsive to the availability of amino acids. This haste effect of changing the availability of various protein kinases in the extracellular matrix generally and a subsequent enzymatic cascade which results in an increase in various anabolic signalling molecules which are, in turn, responsible for the activation of mRNA. This is then responsible for the increased synthesis of collagen (and other related proteins), in tendon and other extracellular matrix tissues. This series of very elegant experiments was done in carefully controlled conditions which removed the possibility of other anabolic factors being relevant as the only variable was the availability of amino acids. (Cuthbertson et al 2005) There is further evidence of the effect of exercise on tendon structure in the form of the set of experiments by Rennie and disco-workers. Looking specifically at the metabolism of collagen Rennie found that after strenuous exercise, the rate of incorporation of a marker into tendon collagen followed a specific pattern (Rennie Tipton 2000). There was a latent period of about 90 mines after exercise where there was no change in metabolic rate. It was then noticed that there was a dramatic increase to about 5 times normal rates of synthesis, which peaked at about 12 hrs., was maintained for about 12hrs, and then declined over the next 48 hrs. In line with the findings of Cuthbertson (above) the investigators noted that the rise in levels of synthesis is greatest if associated with an amino acid load just pre- or post-exercise, and this effect can be further enhanced by the administration of insulin secretagogues(such as glucose). There is therefore little doubt that feeding helps the post exercise response. (Atherton P et al 2005) The effects of ageing on tendon pathophysiology We have already commented, in passing, on the physiological effects of ageing in relation to the polyglycan cross bonding in tendons. There are a number of other changes which will naturally occur in relation to advancing years, which are of direct relevance to our considerations here. It is clearly a matter of observation that muscles, bones and tendons deteriorate as age increases. This deterioration leads to physical symptoms such as loss of strength, mobility and suppleness together with an increase in fatigability and a general reduction in proprioception. This condition is sometimes called â€Å"sarcopenia†.(Forbes 1987) Epidemiological studies (Dorrens et al 2003), provide good evidence to support the popularly held view that an active lifestyle into old age is more likely to support a higher level of bone density, muscle bulk and tendon flexibility, than a sedentary one. One can postulate that the trophic mechanisms referred to above, stay active for longer when constantly stimulated by mechanical activity. One effect of ageing that has been experimentally demonstrated, is that the trophic effects of available amino acids in the bloodstream are not as great in the elderly as in the young. The elderly appear to have an ability to develop resistance to the trophic effects of amino acids, which was not present when they were younger. (Cuthbertson et al 2005) Another physiological change that can be demonstrated in the elderly, is a reduced RNA : DNA ratio in tendon tissue, which is a marker of a reduced ability to manufacture protein. This, together with reduction in the amount of detectable anabolic signalling proteins, seems to be central in the failure of the muscle and tendon synthesising mechanisms. (Smack et al.2001). If we add these findings to other work of Smack (et al 2001) and Leverhagen (et al 2002) which shows that the elderly can show responsiveness in terms of trophic changes in the collagen content of tendons by manipulation of the diet. Both studies showed that maximising the protein : energy ratio of ingested food is a reasonable strategy. It should also be noted that they also demonstrated that one has to be careful to keep the energy content of the food low in order to minimise unwanted weight gain. The elderly could reasonably be assisted to maximise the benefit they get from training (resistance training in these particular studies), by integrating it with feeding concentrated in the immediate pre- or post-exercise period. This appears to have the effect of increasing the positive synergistic relationship between exercise and amino acid delivery.( Williams et al. 2002) Clinical considerations Differential diagnosis The first and possibly most fundamental issue that we have to consider when looking at the issues of the treatment of tendonitis, is the issue of correct diagnosis. This, sadly, is compounded by the fact that there appear to be several different terminology vocabularies in common clinical use. It therefore can be difficult to directly compare treatment studies of â€Å"tendonitis â€Å" unless one has direct and clear diagnostic criteria. (Saxena 1995) Tendonitis may be taken in some medical circles to include all those conditions which come under the broad heading of â€Å"painful overuse tendon conditions† (Khan et al 1999). This is generally accepted by the uncritical, as meaning that this equates with a painful inflammatory reaction in the tendon tissue. Histological investigation of the typical chronically painful tendon, generally shows an absence of the polymorphonuclear and other associated inflammatory cells. In some literature we can see the emergence and replacement of the term tendonitis with tendinitis. This latter term tends to be defined as pertaining to areas of collagen degeneration, increased ground substance and neo-vascularisation. (Purdue et al 1996) To both illustrate and clarify the point, let us consider thevarious clinical entities that may either present like, or may be diagnosed as, â€Å"tendonitis†. For ease of classification and clarity, in this section we shall consider the term â€Å"tendonitis† in specific relation to the Achilles tendon. Williams (1986) produced the (arguably) most commonly currently accepted definitions of Achilles tendon pathologies. He classified them into:- Rupture, Focal degeneration, Tendinitis, Per tendonitis (peritendonosis), Mixed lesions, Origin/insertion lesions, Other cases such as metabolic/rheumatic causes. In common clinical parlance, any of them can be referred to, with reasonable accuracy, as â€Å"tendonitis†. (Galloway et al 1999) The aetiologies can vary (and this may well have a bearing on treatment), from trauma, reduced flexibility, abnormal or changed biomechanical considerations (such as excessive pronation, supination or limb length inequalities) to name but a few. (Saxena, A 1998) It should be noted that the anatomy of the Achilles tendon is unusual and certainly different from any other in the lower limb. It does not have a true synovial sheath but a petition which extends from its origin in the muscle to its insertion in the calcaneus. Peritendonosisis therefore a commonly misdiagnosed as Achilles tendonitis. It is also clinically significant that there is a region of decreased vascularity in the tendon, which is typically about 6 comes above its insertion (Hume 1994). The clinical difference between these two conditions is that true Achilles tendonitis may, if chronic, be characterised by fucoid, or fatty focal degenerative, changes in the tendon itself, where asperitendonitis will not involve the Achilles tendon at all. (Kvist1994). These degenerative changes may be extremely resistant to non-surgical forms of treatment. In practice, the two conditions may well be presenting the same individual. (Killer et al 1998) The differentiating signs are, however, fairly easy to detect and the two conditions can be separately distinguished in most cases. Per tendonitis is the inflammation of the petition and can usually be clinically distinguished by the presence of clinical crepitus as the Achilles tendon tries to glide back and forth along the inflamed petition. This sign together with pain, generally tends to increase with activity and the tenderness is normally felt along the whole length of the tendon. Achilles tendonitis on the other hand classically gets better with movement and is at its worst after a period of rest. The discomfort tends to be more localised into discrete areas and is more commonly found in cases where there has been either a partial or even a complete rupture in the past. (Clement et al 1994) Other pathologies can arise associated with the Achilles tendon, and for the sake of completeness we should briefly consider them as they could be potentially confounding factors in any trial which aims to consider tendonitis. Tendocalcinosis is an inflammatory process which involves the Achilles tendon but only at the point of insertion to the calcaneal bone. It typically will result in calcification and therefore should be considered a different entity to Achilles tendonitis as such. It is characterised by localised pain, and prominence of the calcaneal insertion of the tendon which may well be associated with a retro-tendon bursitis. (Williams 1986) If we apply the same rationale to the patella tendon, we are again faced with a bewildering array of terminology and conditions which tend to get lumped together as â€Å"tendonitis† and may also therefore be confounding factors in any study. We shall therefore spend a few paragraphs delineating them. Some authors point to the fact that conditions that had been previously referred to as tendonitis, when examined at a histological level, are found to be the result of collagen breakdown rather than inflammation (Khan et al 1996), and therefore suggest the title oftendinosis is more appropriate. (Cook et al 2000) (I) The whole issue of the role of the inflammatory process in the tendonopathies appears to be far from clear. An examination of the literature can point to work (such as that by Khan – above), who demonstrated that the prime histological changes were non-inflammatory and were more typical of fucoid, hyaline or fibrous degeneration with occasional calcific processes being identified. Other investigators however, point to the clinical picture which commonly includes the classic inflammatory triad of dolour, rub our and tumour (pain, redness and swelling)(Almekinders et al 1998). This, associated with the evidence of the relieving effect of NSAIA’s or corticosteroids(Friedberg 1997) leads to an ambiguous picture. The pathophysiology of this condition is most commonly thought tube related to jumping and landing activity which is the mechanism which appears to cause the rupture of the collagen filaments and hence the histological appearances. The characteristics of this type of condition are that it tends to be focal, and often in the region of the lower pole of the patella. Initially it tends to be self healing but as the chronicity increases, the pain levels can increase to the point where pain is experienced even at rest (Cook et al 2000) (II) This type of condition must clearly be differentiated from there-patella bursitis (Housemaid’s knee) which is often mistakenly diagnosed as a patella tendonitis. (Halaby et al 1999) Factors which appear to predispose to tendonopathy Many authors identify chronic overuse as being one of the major factors in tendonopathy generally. (Kist 1994) (King et al 2000). This applies equally to the occupational tendonopathy as much as the sports-related conditions. (Jon stone 2000) (Kraushaar et al 1999). We should acknowledge that the term overuse can refer equally to overuse in terms of repetitive action just as much as it can refer to overloading. The two factors being independent (but often related). Some of the current literature points to the fact that there can be differentiation in the spectrum of overuse injuries between those conditions that arise from some form of biochemical change in the structure of the tendon itself (Joss et al 1997), those that are associated with biomechanical changes (such as change in function or previous injury) (Alstom 1998) and those that arise as a result of ageing or other degenerative changes (Alstom et al 1995). These factors can arise as a result of, or independently from, other factors such as the fact that the anatomical path of a tendon can take it over (or in close proximity to) friction-inducing structures such as a bony prominence – as in the case of the tibias posterior tendon, (Benjamin et al 1998) or factors relating to the site of insertion of the tendon into the bone – as in the case of theAchilles-calcaneum interface.(Benjamin et al 1995) We can point to evidence that extraneous factors can also predispose to tendonopathy. There are genetic factors (Singer et al 1986), and a relationship to blood type (Joss et al 1989). The presence of certain concomitant chronic or debilitating illnesses can certainly be associated with tendonopathies (Kannur et al 1991) as can the chronic use of certain medications – most notably the fluoroquinolone group.(Huston 1994)(Ribard et al 1992). The mechanism in the latter case appears to be associated with an increase in the amount of MMP and its associated activity which seems to be associated with an increase in the rate of degradation of protein (especially collagen) in certain tissues. (Williams et al 2000). Other authors have identified biomechanical factors as being significant (rather than necessarily causal), in the development oftendonopathies, but we shall discuss this in specific relation to treatment, and so will not discuss it further here The spectrum of currently available treatment Before beginning any rational consideration of the various forms of treatment available, one must appreciate a common truth in medicine, and that is that different treatments and different patients will respond differently to a specific treatment modality, and one of the factors that will influence this phenomenon is the skill and experience of the practitioner concerned. For example, a surgeon may well find that he gets good results from tenotomise but poor results from eccentric exercises and therefore will recommend surgery. Physiotherapist may find the converse. It is therefore important to be critical of such factors in any appreciation and appraisal of different techniques for the treatment of the lower-limb tendonopathies. In this section we shall examine the available literature to try to obtain an overview of the various treatment modalities that are currently being prescribed and examine the rationale behind their use and efficacy Most authors seem to agree that, before considering the specific conditions, a general approach of conservative measures (such as load reduction, strengthening exercises, and massage) should be tried before other modalities such as medication and physical interventions(ultrasound etc.), and that surgery should only realistically be considered as a last resort. The only obvious exception to that approach would be when complete (or sometimes perhaps partial ) rupture of the tendon has occurred, and then surgery may well be considered the prime intervention. (Cook et al 2000) (I) Let us consider the various options in turn. In this section we will begin (again, for the sake of clarity), by specifically considering the options available for patella tendonitis. We accept that there will, of course, be overlap between the treatments for the various tendonopathies, but it makes for a rational approach to consider each in turn. The first comment that we must make is that, after examination of the literature it is noticeable that there are only a comparatively few well constructed, placebo controlled randomised trials in this area.(Almekinders et al 1998). Those that we can examine appear to suggest that the traditional treatments aimed at minimising the inflammatory processes in the condition are largely ineffective. The authors (Cooked al 2000) (II) suggest that this may well be because of the findings we have quoted earlier (Khan et al 1996) that histologically, the prime pathology is not inflammatory. Relative Rest Cook (et al 2000) (I) points to the fact that many strategies can rationally involve load reduction and the (now outmoded) instruction to â€Å"Stop everything and rest† is positively contraindicated. The rationale for this relates to the mechanisms that we have examined earlier in this piece. Immobilisation of a tendon is actually harmful as we can point to evidence (above) that shows that tensile stress and mechanical action not only stimulates collagen production, it also is vital in tendon to ensure it’s optimal fibre alignment. Rational treatment suggests that a programme of â€Å"Relative rest† may be beneficial. By that, the authors (Cook et al 2000)(I) suggest that activity should continue as long as the prime traumas of jumping, landing or sprinting can be avoided and reintroduced in a carefully graded fashion. Biomechanical Correction Because patella tendonitis is primarily related to jumping and sprinting sports ( in numbers that present clinically), we will consider treatment in relation to them. The forces that are generated in the patella tendon on landing after a jump are considerably greater than those that produced the jump in the first place. (Richards et al1996). It logically follows that if biomechanical methods can be employed to more efficiently minimise the forces, they would be best employed on landing strategies than jumping ones. One should appreciate that the energy-absorbing capacity of the limbs dependant, not only on the patella tendon, but factors at the hip and ankle as well. Studies show that the ankle and calf are the prime sites of absorbing the initial landing load (Richards et al 1996) and, if these structures are not biomechanically sound, then this will increase the forces transmitted to the knee. Prilutskii and his co-workers (et al 1993) completed a series of studies which showed that up to 40% of the energy absorbed on landing is transmitted proximally from the ankle/calf mechanism. It follows that it must be biomechanically sound if it is to absorb the 60% bulk of the load which otherwise would be transmitted upwards to the knee mechanism. Another set of studies (Prapavessis et al 1999) concluded that when flat-foot and fore-foot landings were compared, the latter generated less forces throughout the lower limb and that the forces could be reduced further (up to another 25%) by increasing the range of both hip and knee flexion on landing. There are a number of other potential biomechanical deficiencies that can be amenable to correction and should therefore be sought outspans planes may be an obvious anatomical problem detectable at an initial examination (Kaufman et al 1999), but there are other types of functional abnormality (such as excessively rapid pronation on landing) (McCrery et al 1999), that may require far more sophisticated evaluation. Outhouses inside shoes may go a long way to help these problems Some authors, (McCrery et al 1999), regard a reduced range of movement in the sub-taller joints as an aggravating factor which places and undue stress on the Achilles tendon and that manual mobilisation of the joint is indicated in these cases. Cry therapy In the light of the histological findings mentioned earlier,cryotherapy has a rational place in treatment. It is thought th Physiotherapy Management of Lower Limb Tendonopathies Physiotherapy Management of Lower Limb Tendonopathies A Systematic Review of the physiotherapy management of lower limb tendonopathies Tendonitis is a condition which is comparatively commonly seen in various clinics. The largest cohort of patients tend to have developed their condition as a result of various sports-related activities but it is acknowledged that there is a substantial cohort of RSI sufferers and occupation-related forms of tendonitis. (Kader et al 2002) In this piece we aim to review the various treatment modalities and to concentrate primarily on the eccentric muscle strengthening modalities of treatment, the rationale behind them and any evidence that they actually work. Before we can consider the direct question of eccentric loading as treatment for tendonopathies we must examine the rationale for its uses well as the basic science and theory behind the actual practice. We will do this largely by the mechanism of a literature review. Methodology In this review we shall be examining the literature for not only the methods that are currently employed in treating the various lower limb tendonopathies but also for justification for these methods and the quality of the science behind them. We shall therefore critically review the literature available and present it in a rational form. In addition to this we intend to present an overview of various factors in a wider picture that are relevant to our considerations. We shall consider the current views on the pathophysiology of tendonitis and the experimental evidence on the response of the tendon to exercise in general terms. Although it is accepted that the majority of patients currently seen in clinical practice with various forms of lower limb tendonitis are suffering from a sports related injury, we shall also look at the effects of ageing on tendon physiology as it is acknowledged that the elderly are another highly represented group with tendonitis. We conclude the preamble with a number of clinical considerations, most prominently the difficulties posed by the differences in nomenclature and terminology which renders both assessments and comparisons between clinical trials difficult. We conclude the dissertation with a review of various currently employed treatment modalities and the rationale behind them. We focus specifically on the use and place of eccentric muscle strengthening exercises in the spectrum of rational treatments.. Pathophysiology of tendonitis At the macro-anatomical level, the tendon is usually easily defined as a semi-rigid white or grey structure, generally found in close proximity to synovial joints. One of its prime functions is to transmit forces generated by muscles to the skeletal system, often inducing movement. (Huxley HE 1979). At the micro-anatomical level, it’s structure is very much more complex and requires a detailed examination before we can realistically and meaningfully consider the issues relating to the therapy of tendonitis. Tendons form part of the anatomical structures that are functionally grouped together as the extracellular matrix (ECM). The rate of turnover – both synthesis and degradation – is influenced by a number of different factors including metabolic and disease related factors, but the strongest influence on the turnover rate is mechanical stress, usually as a result of various degrees of physical activity. (Agar Pet al 2000) Tendon (and intramuscular) collagen, turns over at a rate which is about half as fast as myofibrillar protein turnover. The main physiological stimulus to turnover appears to be the multiple stimuli arising from mechanical or contractile activity.(Cuthbertson D et al2005) At the cellular level, degradation of collagen is mediated largely byte metalloprotease group of enzymes and synthesis is most strongly influenced by a number of different trophic factors which are released at the cellular level. (Algren MS. 1999) These growth factors are mainly responsible for both the transcriptional changes as well as the post-translational modifications that take place as a result of either physiological changes or disease processes. (Sand Meier et al 1997) Until comparatively recently, tendon tissue was thought to be fairly inert. Recent research work has given good supportive evidence that the internal metabolic processes, the internal vascular responses (Alstom et al 1994) and the actual catabolic turnover of the collagen protein in response to physical activity, is considerably greater than originally thought. The converse is also true, as inactivity appears to have the same inhibitory effect on tendon tissue as the better known effect of wasting in muscle tissue. (Abrahamson SO et al 1996). This effect is of particular importance in our considerations (later) when we consider that some authorities suggest that outright rest is inappropriate initial treatment for tendonitis. Collagen is a large polymer-type protein made up of many repeating subunits, (triple helices of polypeptides with a high proportion of proline and hydroxyproline). It is made by fibroblasts. In the muscle, it forms a basket-like network around the muscle fibres but then forms progressively more coherent and solid structure as it forms discrete tendon. In this way it allows the efficient transmission of forces generated by the myofibrils to the tendon – and hence to the bone. (Kjaer M 2004). Training, in the form of physical work, exercise or repetitive movements, will have a trophic effect on the tendon as a whole. Collagen turnover can be increased and there can be an overall increase in the amount of collagen protein in the tendon. (Herzog W et al 2002) Collagen, in the form in which it is found in a tendon, has enormous on-elastic tensile strength and a modest degree of ability to bend under lateral stress. As the amount of collagen in a tendon increases, the tendon’s mechanical (or more accurately, viscoelastic,) properties change. It decreases it’s stress levels for a given load, and thereby renders it more load resistant.(Fowls JL et al. 2000). Again this facts of great relevance to our clinical considerations later in this piece. The stiffness, or resistance to lateral stress, is a function of the cross-linking of sulphur bonds across the parallel bands of protein. In general terms, the more cross-links, the stiffer the tendon. The degree of cross-linking is a result of a complex interaction between a number of enzyme systems in the matrix of the tendon. (Hamill OP et al.2001) Polyglycans are an important feature of this enzyme cascade and become an increasingly important functional component as age increases. Older or ageing collagen will tend to exhibit glycolated cross links in addition to the sulphur links of youth. This is part of the reason why older tendons are less flexible (and possibly more prone to injury). (Inglemark BE 1948). The functional significance of these links is that they render the tendon even stiffer and less able to bend.(Davidson PF 1989).Understanding these processes is fundamental to the prescribing of a rational treatment regime for tendon injuries and other pathologies. It is also important to have a complete understanding of both the vascular and neurologically mediated adaptation processes that are present in the my-tendon complex. These work on a far more rapid and immediate time frame than the processes that we have just described, and are primarily responses to rapid changes in the mechanical loading stresses. As muscle tissue develops physiologically, there is a symbiotic relationship between the muscle and the extracellular matrix. The various physiological mechanisms that stimulate muscle growth and hypertrophy appear to have a similar effect on the extracellular matrix. (MacLean et al 1991) But in the latter case, they are less well understood. We know that that significant and repeated mechanical loading will trigger off, or initiate a process, which starts with the activation of trophic gene in a cellular nucleus, (Banes AJ et al.1999), it progresses through the complex processes of protein synthesis and functionally ends with the deposition of collagen in the tendon tissue.(Yasuda et al 2000) Responses of the tendon to exercise There would appear to be some form of integration between the muscular and the extracellular matrix signalling pathways, which optimises the co-ordinated activity of the trophic processes in response to the stimuli (which can be both loading and tensile in nature), which produce the response in the first place. (Viidik A.1993). This co-ordination mechanism must exist, as it is a well-recognised phenomenon that a tendon hypertrophies to accommodate the increased mechanical stress that its associated hypertrophied muscle produces. (Derwin et al 1999) Considerable research effort has been expended in trying to delineate the mechanism, but to date, the results have not increased our understanding of the situation significantly. (Vierck J et al 2000) Specific studies in this area have been able to show a clear correlation between collagen response and an increase in physical training. (Langberg et al 2001). The response was detectable after a 4week training programme and was maximal at 11 weeks. When we consider the pathophysiology of RSI (repetitive strain injury) or even chronic overload syndrome, the stimuli that can produce muscle hypertrophy or increase muscle fibrosis can also produce fundamental changes in the tendon structure. (Birk DE et al 1990) These changes can include changes in both the chemistry and the functionality of cross bonding of the collagen fibres, (Barnard K et al1987), changes in the size of the collagen fibrils, areas of locally increased blood flow (known as hyper vascularisation zones), and an increase in the catabolic processes which can result in either (or both) collagen being synthesised and laid down, or increase in fibroblastic activity which increases the fibrous component of the tendon. (Greenfield EM et al 1999) It is a fundamental recognition of the fact that these processes require â€Å"adjusted loading† rather than an enforced absence of loading(immobilisation) to reverse the physiological processes, that underpins most of the thrust of this review.( Howell JN et al 1993), (Jà ¤rvinenTAH et al 2002) The experimental evidence to support this view comes from the classic set of investigations by Gibson (et al 1987) who compared the rate of collagen synthesis and turnover in an immobilising long-cast leg with the rate of turnover in the unaffected leg. The rate of collagen synthesis dropped by half over a seven week period in the immobilised leg. The investigators also found an adaptive (and compensatory)reduction in the rate of collagen degradation which had the overall effect of reducing the protein loss in the tendons. In the overall context of our investigation it is also important to note that the authors also found that minimal electrical stimulation of the muscle (5% of maximum voluntary contraction for 1 hr. per day),increased protein synthesis to such an extent that there was no net protein loss over the same seven week period of the trial. (Gibson etal 1989) In a study that was remarkable for its invasiveness (the authors took repeated biopsies of human patella tendon after periods of exercise), Miller (et al 2004) demonstrated that tendon collagen synthesis showed a 30% rise within 6hrs of exercise and up to a 50%rise within a 24 hr. period. This was found to exactly follow the pattern of protein synthesis in skeletal muscle. This finding is strongly supportive of the assertions made earlier in this essay, that there would appear to be a mechanical or humeral mechanism that links the trophic effects that are apparent in both tendon and skeletal muscle. Various authors have postulated different mechanisms (it has to be said with scant evidence), including integrin’s, (Levenhagen et al2002), growth factors including transforming growth factor beta (TGFB) (Moore et al.2005), or mechano growth factor (MGF) (Rennie et al 2004),which they suggest may be responsible for the co-ordination of the trophic effects of perimysium collagen, tendon collagen and the myofibrils. More concrete evidence exists (and is arguably of greater relevance to our investigation here), for the fact that dietary protein alone can produce a trophic stimulus for tendon collagen. (Jefferson Kimball 2001). It is postulated that there is some form of amino acid sensor that is responsive to the availability of amino acids. This haste effect of changing the availability of various protein kinases in the extracellular matrix generally and a subsequent enzymatic cascade which results in an increase in various anabolic signalling molecules which are, in turn, responsible for the activation of mRNA. This is then responsible for the increased synthesis of collagen (and other related proteins), in tendon and other extracellular matrix tissues. This series of very elegant experiments was done in carefully controlled conditions which removed the possibility of other anabolic factors being relevant as the only variable was the availability of amino acids. (Cuthbertson et al 2005) There is further evidence of the effect of exercise on tendon structure in the form of the set of experiments by Rennie and disco-workers. Looking specifically at the metabolism of collagen Rennie found that after strenuous exercise, the rate of incorporation of a marker into tendon collagen followed a specific pattern (Rennie Tipton 2000). There was a latent period of about 90 mines after exercise where there was no change in metabolic rate. It was then noticed that there was a dramatic increase to about 5 times normal rates of synthesis, which peaked at about 12 hrs., was maintained for about 12hrs, and then declined over the next 48 hrs. In line with the findings of Cuthbertson (above) the investigators noted that the rise in levels of synthesis is greatest if associated with an amino acid load just pre- or post-exercise, and this effect can be further enhanced by the administration of insulin secretagogues(such as glucose). There is therefore little doubt that feeding helps the post exercise response. (Atherton P et al 2005) The effects of ageing on tendon pathophysiology We have already commented, in passing, on the physiological effects of ageing in relation to the polyglycan cross bonding in tendons. There are a number of other changes which will naturally occur in relation to advancing years, which are of direct relevance to our considerations here. It is clearly a matter of observation that muscles, bones and tendons deteriorate as age increases. This deterioration leads to physical symptoms such as loss of strength, mobility and suppleness together with an increase in fatigability and a general reduction in proprioception. This condition is sometimes called â€Å"sarcopenia†.(Forbes 1987) Epidemiological studies (Dorrens et al 2003), provide good evidence to support the popularly held view that an active lifestyle into old age is more likely to support a higher level of bone density, muscle bulk and tendon flexibility, than a sedentary one. One can postulate that the trophic mechanisms referred to above, stay active for longer when constantly stimulated by mechanical activity. One effect of ageing that has been experimentally demonstrated, is that the trophic effects of available amino acids in the bloodstream are not as great in the elderly as in the young. The elderly appear to have an ability to develop resistance to the trophic effects of amino acids, which was not present when they were younger. (Cuthbertson et al 2005) Another physiological change that can be demonstrated in the elderly, is a reduced RNA : DNA ratio in tendon tissue, which is a marker of a reduced ability to manufacture protein. This, together with reduction in the amount of detectable anabolic signalling proteins, seems to be central in the failure of the muscle and tendon synthesising mechanisms. (Smack et al.2001). If we add these findings to other work of Smack (et al 2001) and Leverhagen (et al 2002) which shows that the elderly can show responsiveness in terms of trophic changes in the collagen content of tendons by manipulation of the diet. Both studies showed that maximising the protein : energy ratio of ingested food is a reasonable strategy. It should also be noted that they also demonstrated that one has to be careful to keep the energy content of the food low in order to minimise unwanted weight gain. The elderly could reasonably be assisted to maximise the benefit they get from training (resistance training in these particular studies), by integrating it with feeding concentrated in the immediate pre- or post-exercise period. This appears to have the effect of increasing the positive synergistic relationship between exercise and amino acid delivery.( Williams et al. 2002) Clinical considerations Differential diagnosis The first and possibly most fundamental issue that we have to consider when looking at the issues of the treatment of tendonitis, is the issue of correct diagnosis. This, sadly, is compounded by the fact that there appear to be several different terminology vocabularies in common clinical use. It therefore can be difficult to directly compare treatment studies of â€Å"tendonitis â€Å" unless one has direct and clear diagnostic criteria. (Saxena 1995) Tendonitis may be taken in some medical circles to include all those conditions which come under the broad heading of â€Å"painful overuse tendon conditions† (Khan et al 1999). This is generally accepted by the uncritical, as meaning that this equates with a painful inflammatory reaction in the tendon tissue. Histological investigation of the typical chronically painful tendon, generally shows an absence of the polymorphonuclear and other associated inflammatory cells. In some literature we can see the emergence and replacement of the term tendonitis with tendinitis. This latter term tends to be defined as pertaining to areas of collagen degeneration, increased ground substance and neo-vascularisation. (Purdue et al 1996) To both illustrate and clarify the point, let us consider thevarious clinical entities that may either present like, or may be diagnosed as, â€Å"tendonitis†. For ease of classification and clarity, in this section we shall consider the term â€Å"tendonitis† in specific relation to the Achilles tendon. Williams (1986) produced the (arguably) most commonly currently accepted definitions of Achilles tendon pathologies. He classified them into:- Rupture, Focal degeneration, Tendinitis, Per tendonitis (peritendonosis), Mixed lesions, Origin/insertion lesions, Other cases such as metabolic/rheumatic causes. In common clinical parlance, any of them can be referred to, with reasonable accuracy, as â€Å"tendonitis†. (Galloway et al 1999) The aetiologies can vary (and this may well have a bearing on treatment), from trauma, reduced flexibility, abnormal or changed biomechanical considerations (such as excessive pronation, supination or limb length inequalities) to name but a few. (Saxena, A 1998) It should be noted that the anatomy of the Achilles tendon is unusual and certainly different from any other in the lower limb. It does not have a true synovial sheath but a petition which extends from its origin in the muscle to its insertion in the calcaneus. Peritendonosisis therefore a commonly misdiagnosed as Achilles tendonitis. It is also clinically significant that there is a region of decreased vascularity in the tendon, which is typically about 6 comes above its insertion (Hume 1994). The clinical difference between these two conditions is that true Achilles tendonitis may, if chronic, be characterised by fucoid, or fatty focal degenerative, changes in the tendon itself, where asperitendonitis will not involve the Achilles tendon at all. (Kvist1994). These degenerative changes may be extremely resistant to non-surgical forms of treatment. In practice, the two conditions may well be presenting the same individual. (Killer et al 1998) The differentiating signs are, however, fairly easy to detect and the two conditions can be separately distinguished in most cases. Per tendonitis is the inflammation of the petition and can usually be clinically distinguished by the presence of clinical crepitus as the Achilles tendon tries to glide back and forth along the inflamed petition. This sign together with pain, generally tends to increase with activity and the tenderness is normally felt along the whole length of the tendon. Achilles tendonitis on the other hand classically gets better with movement and is at its worst after a period of rest. The discomfort tends to be more localised into discrete areas and is more commonly found in cases where there has been either a partial or even a complete rupture in the past. (Clement et al 1994) Other pathologies can arise associated with the Achilles tendon, and for the sake of completeness we should briefly consider them as they could be potentially confounding factors in any trial which aims to consider tendonitis. Tendocalcinosis is an inflammatory process which involves the Achilles tendon but only at the point of insertion to the calcaneal bone. It typically will result in calcification and therefore should be considered a different entity to Achilles tendonitis as such. It is characterised by localised pain, and prominence of the calcaneal insertion of the tendon which may well be associated with a retro-tendon bursitis. (Williams 1986) If we apply the same rationale to the patella tendon, we are again faced with a bewildering array of terminology and conditions which tend to get lumped together as â€Å"tendonitis† and may also therefore be confounding factors in any study. We shall therefore spend a few paragraphs delineating them. Some authors point to the fact that conditions that had been previously referred to as tendonitis, when examined at a histological level, are found to be the result of collagen breakdown rather than inflammation (Khan et al 1996), and therefore suggest the title oftendinosis is more appropriate. (Cook et al 2000) (I) The whole issue of the role of the inflammatory process in the tendonopathies appears to be far from clear. An examination of the literature can point to work (such as that by Khan – above), who demonstrated that the prime histological changes were non-inflammatory and were more typical of fucoid, hyaline or fibrous degeneration with occasional calcific processes being identified. Other investigators however, point to the clinical picture which commonly includes the classic inflammatory triad of dolour, rub our and tumour (pain, redness and swelling)(Almekinders et al 1998). This, associated with the evidence of the relieving effect of NSAIA’s or corticosteroids(Friedberg 1997) leads to an ambiguous picture. The pathophysiology of this condition is most commonly thought tube related to jumping and landing activity which is the mechanism which appears to cause the rupture of the collagen filaments and hence the histological appearances. The characteristics of this type of condition are that it tends to be focal, and often in the region of the lower pole of the patella. Initially it tends to be self healing but as the chronicity increases, the pain levels can increase to the point where pain is experienced even at rest (Cook et al 2000) (II) This type of condition must clearly be differentiated from there-patella bursitis (Housemaid’s knee) which is often mistakenly diagnosed as a patella tendonitis. (Halaby et al 1999) Factors which appear to predispose to tendonopathy Many authors identify chronic overuse as being one of the major factors in tendonopathy generally. (Kist 1994) (King et al 2000). This applies equally to the occupational tendonopathy as much as the sports-related conditions. (Jon stone 2000) (Kraushaar et al 1999). We should acknowledge that the term overuse can refer equally to overuse in terms of repetitive action just as much as it can refer to overloading. The two factors being independent (but often related). Some of the current literature points to the fact that there can be differentiation in the spectrum of overuse injuries between those conditions that arise from some form of biochemical change in the structure of the tendon itself (Joss et al 1997), those that are associated with biomechanical changes (such as change in function or previous injury) (Alstom 1998) and those that arise as a result of ageing or other degenerative changes (Alstom et al 1995). These factors can arise as a result of, or independently from, other factors such as the fact that the anatomical path of a tendon can take it over (or in close proximity to) friction-inducing structures such as a bony prominence – as in the case of the tibias posterior tendon, (Benjamin et al 1998) or factors relating to the site of insertion of the tendon into the bone – as in the case of theAchilles-calcaneum interface.(Benjamin et al 1995) We can point to evidence that extraneous factors can also predispose to tendonopathy. There are genetic factors (Singer et al 1986), and a relationship to blood type (Joss et al 1989). The presence of certain concomitant chronic or debilitating illnesses can certainly be associated with tendonopathies (Kannur et al 1991) as can the chronic use of certain medications – most notably the fluoroquinolone group.(Huston 1994)(Ribard et al 1992). The mechanism in the latter case appears to be associated with an increase in the amount of MMP and its associated activity which seems to be associated with an increase in the rate of degradation of protein (especially collagen) in certain tissues. (Williams et al 2000). Other authors have identified biomechanical factors as being significant (rather than necessarily causal), in the development oftendonopathies, but we shall discuss this in specific relation to treatment, and so will not discuss it further here The spectrum of currently available treatment Before beginning any rational consideration of the various forms of treatment available, one must appreciate a common truth in medicine, and that is that different treatments and different patients will respond differently to a specific treatment modality, and one of the factors that will influence this phenomenon is the skill and experience of the practitioner concerned. For example, a surgeon may well find that he gets good results from tenotomise but poor results from eccentric exercises and therefore will recommend surgery. Physiotherapist may find the converse. It is therefore important to be critical of such factors in any appreciation and appraisal of different techniques for the treatment of the lower-limb tendonopathies. In this section we shall examine the available literature to try to obtain an overview of the various treatment modalities that are currently being prescribed and examine the rationale behind their use and efficacy Most authors seem to agree that, before considering the specific conditions, a general approach of conservative measures (such as load reduction, strengthening exercises, and massage) should be tried before other modalities such as medication and physical interventions(ultrasound etc.), and that surgery should only realistically be considered as a last resort. The only obvious exception to that approach would be when complete (or sometimes perhaps partial ) rupture of the tendon has occurred, and then surgery may well be considered the prime intervention. (Cook et al 2000) (I) Let us consider the various options in turn. In this section we will begin (again, for the sake of clarity), by specifically considering the options available for patella tendonitis. We accept that there will, of course, be overlap between the treatments for the various tendonopathies, but it makes for a rational approach to consider each in turn. The first comment that we must make is that, after examination of the literature it is noticeable that there are only a comparatively few well constructed, placebo controlled randomised trials in this area.(Almekinders et al 1998). Those that we can examine appear to suggest that the traditional treatments aimed at minimising the inflammatory processes in the condition are largely ineffective. The authors (Cooked al 2000) (II) suggest that this may well be because of the findings we have quoted earlier (Khan et al 1996) that histologically, the prime pathology is not inflammatory. Relative Rest Cook (et al 2000) (I) points to the fact that many strategies can rationally involve load reduction and the (now outmoded) instruction to â€Å"Stop everything and rest† is positively contraindicated. The rationale for this relates to the mechanisms that we have examined earlier in this piece. Immobilisation of a tendon is actually harmful as we can point to evidence (above) that shows that tensile stress and mechanical action not only stimulates collagen production, it also is vital in tendon to ensure it’s optimal fibre alignment. Rational treatment suggests that a programme of â€Å"Relative rest† may be beneficial. By that, the authors (Cook et al 2000)(I) suggest that activity should continue as long as the prime traumas of jumping, landing or sprinting can be avoided and reintroduced in a carefully graded fashion. Biomechanical Correction Because patella tendonitis is primarily related to jumping and sprinting sports ( in numbers that present clinically), we will consider treatment in relation to them. The forces that are generated in the patella tendon on landing after a jump are considerably greater than those that produced the jump in the first place. (Richards et al1996). It logically follows that if biomechanical methods can be employed to more efficiently minimise the forces, they would be best employed on landing strategies than jumping ones. One should appreciate that the energy-absorbing capacity of the limbs dependant, not only on the patella tendon, but factors at the hip and ankle as well. Studies show that the ankle and calf are the prime sites of absorbing the initial landing load (Richards et al 1996) and, if these structures are not biomechanically sound, then this will increase the forces transmitted to the knee. Prilutskii and his co-workers (et al 1993) completed a series of studies which showed that up to 40% of the energy absorbed on landing is transmitted proximally from the ankle/calf mechanism. It follows that it must be biomechanically sound if it is to absorb the 60% bulk of the load which otherwise would be transmitted upwards to the knee mechanism. Another set of studies (Prapavessis et al 1999) concluded that when flat-foot and fore-foot landings were compared, the latter generated less forces throughout the lower limb and that the forces could be reduced further (up to another 25%) by increasing the range of both hip and knee flexion on landing. There are a number of other potential biomechanical deficiencies that can be amenable to correction and should therefore be sought outspans planes may be an obvious anatomical problem detectable at an initial examination (Kaufman et al 1999), but there are other types of functional abnormality (such as excessively rapid pronation on landing) (McCrery et al 1999), that may require far more sophisticated evaluation. Outhouses inside shoes may go a long way to help these problems Some authors, (McCrery et al 1999), regard a reduced range of movement in the sub-taller joints as an aggravating factor which places and undue stress on the Achilles tendon and that manual mobilisation of the joint is indicated in these cases. Cry therapy In the light of the histological findings mentioned earlier,cryotherapy has a rational place in treatment. It is thought th

Theatrical Sound Designer :: Essays Papers

Theatrical Sound Designer The sound designer is responsible for handling the audio requirements of a theatrical performance. This includes the creation of sound effect cues, sound reinforcement, mixing, and possibly Foley. â€Å"Sound designers develop the aural, or sound, cues crucial to play’s mood. Running water, traffic, the murmuring of a crowd or the strains of music are the kinds of sound effects used as an integral part of a production.† (Mauro p.96) Along with the creation of sound, the sound designer must work in concert with all members of the design team from the lighting designer to the set designer, in order to create a total package. One of the first jobs a sound designer has is to read the script and create an effects cue sheet. A cue sheet is a list of the sound effects needed during a performance as determined by stage direction or intuition, such as a telephone ring, thunder, or the sound of a passing train. These sound effects may be created live during the performance using Foley, but more often than not the sound designer will utilize a keyboard and sampler, a CD player, or even a cassette tape deck. Depending on the theater the sound designer may have to employ some sound reinforcement techniques, such as micing the actors with wireless microphones or placing microphone such as PZMs on or around the stage. All of these signals are then routed through a mixing broad, which the sound designer operates during the performance. Although no formal training is required, experience in audio engineering, music theory, and basic stagecraft would be very beneficial. â€Å"Working in radio or for a studio that dubs sound cues in music could provide excellent experience.† (Mauro p.102) Most literature recommends an apprenticeship for breaking into the business, tacking a position as a sound person for example. A sound person implements the requirements but forth by sound designers and might also be expected to place the microphones and speakers. A sound person can expect to make anywhere from $250 to $1250 a week. (Field p.271-273) Depending on the market and venue a sound designer can expect to make $300-$1000 a week, to $100,000 a show for a Broadway production.

Propaganda speech Essay

?Homework. Why should we spend our afternoons slaving away doing work that no one wants to do, including the teachers. Teachers spend hours writing out the homework they want us to finish, and when we hand it in, they spend even more hours marking work when they would rather be doing something else, don’t lie teachers, I’ve heard you complain about marking hundreds of pieces of paper about the same exact thing, wouldn’t you rather spend your spare time with your friends and family, no, instead you have to mark other kids repetitive and most likely badly done homework. Homework puts unwanted stress on students, we panic for hours about whether or not we did do enough research, we worry about whether or not we did the homework how the teacher wanted, we sit and hope that we got that good grade our parents were pushing for. We students are forced to spend our afternoons slaving away in front of computers and books doing work that would be much easier and quicker done in class, when work is done in class we are more motivated to finish it, the teachers can hold over our heads the promise of leaving early, the promise of the last five minutes of class being free time, when we are at home there are many distractions such as television, TVs are in almost every teenagers room, providing quick relief from homework, what about the internet, it can be accessed almost anywhere, there is no more tempting distraction than the internet . And what example is being set for children, you go to school and do your work, and when you get home the work doesn’t stop, we aren’t allowing a balance that will assist student when they go out to the workforce. Students have other commitments that don’t include homework, just like the teachers. Some of them have after school activities such as part time work, driving lessons, plans with their friends, and many of them do after school sports, all of which are affected by homework. They get homework at school and realise that their plans are gone. They can’t go to that movie they had been planning on going to for days with their friends, they don’t have time to rest and relax when they get home from netball or tennis or soccer they have to finish their homework. Homework prevents socialisation that is necessary for the proper development of kids and teenagers. Homework can also be blamed for students staying inside all the time, if we have homework, we rush home to finish it, burning the daylight trying to finish so we have time to do something outside, but by the time we finish the mountains of homework, the sun is gone and all that is left to do is stay inside and eat and watch television, leading to the high numbers of childhood obesity. Nelson Mandela once said ‘after climbing a great hill, one only finds that there are many more hills to climb’. I think this famous quote applies to this situation, no matter how much homework we do or how well done it is, there is always more homework the next day, the next week, it never ends. The topic has been debated and debated, is homework really beneficial for school students, schools are already trialling the no homework idea, and it’s working, so should we have to toil away doing homework while they spend their days having fun, and my answer is NO, it needs to be removed from the school system is what I say, will you agree?

Inclusion1 essays

Inclusion1 essays According to the Curry School of Education, approximately 80% of students with learning disabilities receive the majority of their instruction in the general classroom (Inclusion. http://curry.edschool.virginia.edu/curry/dept/cise/ose.html. 10 Oct. 1999). That number is expected to rise as teachers and parents become aware of the benefits of inclusion. Because there are so many disabled students in regular schools, it is important to look at whether or not mainstreaming is necessary for their education. For parents, having their disabled children mainstreamed into regular education can be a difficult choice. Although disabled childrens education can be more challenging in regular schools, the benefits of inclusion include enhanced self-esteem, development of social skills, and exposure to regular curriculum. Many people believe mainstreaming only helps disabled children, but there are many challenges that hurt their education rather than help. Both faculty and students can be cruel to disabled students. Because they are not used to interacting with disabled children, faculty and students may be uncomfortable with the situation and be insensitive to the disabled children. By ignoring the disabled children or treating them badly, the children will lose self-esteem and may disrupt the class in order to show their unhappiness. Some teachers are not familiar with teaching disabled children, so the education is lacking for the children. Teachers may continue to teach their classes at an accelerated level, forgetting about the slower students. The students will then fall behind and get frustrated with the situation. All these factors hurt disabled childrens education and will hurt their chances at succeeding in life. Being in a regular school can help disabled children feel better about themselves and their accomplishments. When disabled children complete a more challenging task, they may ...

Free Essays on Media Literacy

Despite numerous attempts to introduce a formal media education policy into all U.S. Public schools, is has not been officially accepted as a part of the general curriculum. Only handfuls of school across the country offer the option to choose courses in media literacy, and choosing the course in the first place is the students discretion. However, media education policies have been extremely effective in countries such as Norway, and our neighbors to the North, Canada. One fundamental difference as to why media literacy policies and education programs have been in effect in those countries and not the United States is because the United states has a decentralized education system; Norway and Canada both have centralized systems. Change of curricula comes about much easier in the centralized systems, while it is much more difficult in decentralized school systems. The policy in Canada requires that 30% of all high school students language arts credits be taken in the subject of Media Literacy and Education. However, New Mexico was one of the first states to implement a mandatory media literacy requirement. The New Mexico Media Literacy Project, or NMMLP, was created in 1993 as an outreach of Alberquerque Academy, one of the best private schools (grades 6-12) in the United States. The program that they have developed is used by thousands of schools across several states, with their main goal being â€Å"†¦ to make New Mexico the most media literate state in the United States, and to spread the NMMLP model of grassroots, action-oriented media literacy education to other states.† The NMMLP provides in-service training for public and private school teachers, counselors, principals and administrators. They also hold four-day workshops three to four times a year. The American Association of Pediatrics has also released its suggested policy on children and media literacy. Published in PEDIATRICS Vol. 108 No. 5, November 2001, pp. 1222-12... Free Essays on Media Literacy Free Essays on Media Literacy Despite numerous attempts to introduce a formal media education policy into all U.S. Public schools, is has not been officially accepted as a part of the general curriculum. Only handfuls of school across the country offer the option to choose courses in media literacy, and choosing the course in the first place is the students discretion. However, media education policies have been extremely effective in countries such as Norway, and our neighbors to the North, Canada. One fundamental difference as to why media literacy policies and education programs have been in effect in those countries and not the United States is because the United states has a decentralized education system; Norway and Canada both have centralized systems. Change of curricula comes about much easier in the centralized systems, while it is much more difficult in decentralized school systems. The policy in Canada requires that 30% of all high school students language arts credits be taken in the subject of Media Literacy and Education. However, New Mexico was one of the first states to implement a mandatory media literacy requirement. The New Mexico Media Literacy Project, or NMMLP, was created in 1993 as an outreach of Alberquerque Academy, one of the best private schools (grades 6-12) in the United States. The program that they have developed is used by thousands of schools across several states, with their main goal being â€Å"†¦ to make New Mexico the most media literate state in the United States, and to spread the NMMLP model of grassroots, action-oriented media literacy education to other states.† The NMMLP provides in-service training for public and private school teachers, counselors, principals and administrators. They also hold four-day workshops three to four times a year. The American Association of Pediatrics has also released its suggested policy on children and media literacy. Published in PEDIATRICS Vol. 108 No. 5, November 2001, pp. 1222-12...

Epic Heroes Gilgamesh and Rama Essay Example

Epic Heroes Gilgamesh and Rama Essay Example Epic Heroes Gilgamesh and Rama Essay Epic Heroes Gilgamesh and Rama Essay Essay Topic: The Epic of Gilgamesh An epic hero is a brave and noble character in an epic poem, admired for great achievements or affected by grand events(Dictonary.com). Two perfect examples of this definition are Rama and Gilgamesh from the ancient stories The Ramayana and The Epic of Gilgamesh. Both of these main characters share qualities that qualify them as the ideal epic hero. The first thing these two protagonists have in common they both go on long journeys and fight outward battles and discover internal amity, in the case of Gilgamesh. The second thing they have in common is they are both connected to the gods; Gilgamesh is made up of two-thirds god, and Rama is also perceived by many as the re-embody of Vishnu, a Hindu god. The last way these two characters are similar is the two represent their time era and culture which they are written. Even though Gilgamesh and Rama are similar in ways, some circumstances contrast between their stories. These contrasting characteristics include their journeys, what they are seeking, and the cultures values that they represent. In The Ramayana Rama was forced to go on his quest by his father and his wishes. His father banished Rama to the woods because his stepmother wanted to see her son rule and knew that Rama was to become king when his father retired from the throne. The king ultimately kept his word to grant her any wish she wanted and complied with her requests by banishing Rama to the woods for fourteen years. Rama accepted the ruling willingly with no question by saying to his stepmother after she told him the news, My realm and wealth, mine own dear life, Unasked I fain would yield them all: More gladly at my father’s call (â€Å"The Ramayana of Valmiki† 7).His willingness to obey is father and give up everything shows his respect to his family and authority. Ramas response reveals the reason why Rama is so influential to the Indian culture, and what makes him a hero, it was because he lived hi

Immigration and British Social Policy Dissertation

Immigration and British Social Policy - Dissertation Example Building social capital 43 4.2. Promoting social inclusion 44 4.3. Ensuring social equality 45 5. Conclusions 46 References 49 List of Tables Table 1. Social cohesion: a social capital perspective 43 Table 2. Social cohesion: a social inclusion perspective 44 Table 3. Social cohesion: a social equality perspective 46 List of Figures Figure 1. Total long-term international migration estimates, UK, 2000–2010. 8 Figure 2. Recent trends in migrants’ flows. 25 Figure 3. Inflows of top 10 nationalities into the UK 25 Figure 4. Overseas nationals allocated a NI number, 2002 to 2006. 25 Figure 5. The conceptual framework of the study. 42 Acknowledgement The author would like to thank †¦ 1. Introduction 1.1. Research background A process of migration of humans between countries and continents, either as a result of difficult circumstances in a homeland or in search of better life, has taken place for centuries. But nowadays, in the era of growing globalisation, this phenome non has become especially outstanding, remarkable by its complex and multifaceted nature. Voicu (2009) defines immigration as â€Å"the act of entering a country, other than one’s native country, with the intention of living there permanently† (p.71). ... According to the United Nation Population Division (2006), in 2005 there were about 191 million migrants (foreign-born persons) in the world: 34 per cent of them lived in European Union (EU) countries, 23 per cent in Northern America, and 28 percent in Asia. Although these figures show that only a relatively small proportion of global population migrate (account of migrants was nearly 2.9 per cent of the total 6.5 billions in 2005), but the current trend in migration is remarkable by its scale and rate of growth, as during last two decades â€Å"the stock of world’s migrants almost doubled† (Wickramasekara 2007: p.3). It is also notable that roughly about 170 million of mentioned above 191 million migrants in the world (in 2005) were migrant workers and their families, i.e. people who â€Å"migrates from one country to another with a view to being employed otherwise than on his own account and includes any person regularly admitted as a migrant for employment† (W ickramasekara 2007: p.4). A majority of European countries also experience an increase of inward and outward flows of migrants, which happens during last two decades as a consequence of significant political and social changes. According to Boswell (2005: p.1), in 2001 net immigration in Europe amounted 3 per 1,000 inhabitants, and the region hosted a population of 56.1 million migrants, in comparing to 40.8 million in North America. These figures, taken along with the UNPD data above, indicate clearly that today’s Europe is a desired point of destination for migrants from every corner of the world, and experts predict further increasing of migrants’ population in European high-income countries, because the labour and skills

Rhetorical Analysis Memo Essay Example | Topics and Well Written Essays - 250 words

Rhetorical Analysis Memo - Essay Example He attempts to prove that he is similar to whites by doing everything that the Americans do. He speaks perfect, unaccented English to show that he is no less than Americans discriminative against race and other immigrants.Liu appeals to the sympathetic emotions of the audience by admitting that he had never been a victim of discrimination (Liu 1). Liu proceeds to tell about the betrayal he earned from his hair. The hair betrayal instance shows how petty his discriminators were. Liu’s curse arose from his hair that failed to feather back. The hair remained straight, rigid, and wiry and continued to grow in the wrong way as he adds on. The nature of this discrimination was cruel as the discriminators blamed Liu’s natural being. It pushed him towards blaming his Chinese genes, a factor that he could neither moderate nor change. Liu lived a disgusting and complicated life trying every day to live other people’s lives. Liu’s text reveals seclusion that dominated relations between Whites and Asians in America. He views the blending and assimilation as cruel and fair giving justifying evidences. The reader can tell how Liu’s life at school was more complicated since the American tutors extended discrimination to

Christian ethics Essay Example | Topics and Well Written Essays - 1500 words

Christian ethics - Essay Example Since our culture and traditions changes through time and varies from different perspectives, the concept of moral relativism may be, in part, true and can really happen. For example, Christians believe in monogamy but Muslims’ marriage and family tradition is polygamous. The Christians belief is based upon what they believe is true and that is the Christian concept of a monogamous relationship or marriage. Christians believe that this is the correct partner and relationship practice because they believe in the teachings from the Bible. Muslims, on the other hand, also has different literature and context about marriage and family. What may be right for the Muslims, like in the example above, contradicts the beliefs of the Christians. And in this part of moral relativism, I agree. What may be wrong for me may be right for some individual with a contrasting cultural background that what I have. Within a certain culture, there are differing opinions and thoughts, also, about believing in tradition and cultural values. An example of this is the belief in traditional medicine. Though we have a science of medicine, many still believe in the healing capabilities of traditional medicine. This does not indicate, in any way, that traditional medicine is not right or not good for us. What it shows is that the preference of people vary from individual to individual because they believe in something that works for them, or works according to their own pragmatic reasons. The concept of morality is closely related to the concept of one’s own faith and belief. Once and existing belief of a person is shaken, he may look into the other side or his own argument to find a solution to his problem and to bring back the stability of his belief. This indicates that human beings believe in something they want to believe in because it serves their purposes. Going back to the example above, one may encounter a disease in which

Diffusion of innovation theory Essay Example | Topics and Well Written Essays - 750 words

Diffusion of innovation theory - Essay Example Complexity connotes the extent to which the usage and understanding the simplicity of an innovation appear difficult. Youths are picking up essential technological and social skills that they need to contribute fully to contemporary society (Clark, 2011). Erecting barriers to communication deprives the youths of access to these forms of learning. Youths could benefit from educators being more open to forms of experimentation and social exploration that are not characteristic of educational institutions. The content, way of relating and skills that youths value are highly variable dependent on what type of social groups they associate with (Boyd, 2007). This diversity in forms of literature means that it is problematic to develop a standardized set of benchmarks to measure new levels of media and technical literacy. Both Guttenberg and Martin Luther faced great opposition from the religious authorities of the time and took the bold step to use mass production as an effective tool for evangelization. Through the power of the press, religious leaders like Martin Luther managed to spread the Word amidst widespread opposition and condemnation from the mainstream church (Crosby, 2012). Through the use of the press, Martin Luther was able to lead the Reformation and evangelize to the masses. The Reformation was a time of dramatic religious dissent during which various church groups broke away from the dominating Catholic Church.

Human Resource Management And Why It Is Critical In Employment Law Essay

Human Resource Management And Why It Is Critical In Employment Law - Essay Example As such, the statute provides that an employee is entitled to a notice period, prior to dismissal. Such notice period is established on the basis of the length of service of the employee (National Employment Rights Authority, 2012). Application An employee has been defined at section 230(1) of the Employment Rights Act 1996, as an individual who works under a contract of employment. The Employment Act 2002 (Dispute Resolution) Regulations 2004 require employers to implement procedures for grievance and disciplinary actions. These statutory procedures have to be commenced in the first instance. This is essential for submitting employment issues before the employment tribunal. A dismissal will be deemed to be unfair, if the employer fails to adopt these procedures (Pothecary Witham Weld, 2012). Furthermore, the employer would be held liable by the court. Employees should have completed a one year of continuous service with the same company to avail the protection of dismissal rights. T his applies only to those employees who were appointed before 6 April 2012. The corresponding period is two years for employees appointed after this date. In our problem, Janice had worked for two years with the same company. Hence, she should have been provided with a dismissal notice, which was not done by the company. Consequently, the dismissal procedures conducted by the company cannot be deemed as fair. Furthermore, in instances, wherein the employer dismisses an employee via procedures that are unfair, the dismissal will be deemed to be unfair, regardless of the issues involved (emplaw, 2012). Although, Kelsey had not completed a year’s period of employment with the company, she can file a claim of wrongful dismissal against the company for not following fair procedures in her dismissal. In general, the circumstances of a particular case, will determine the action that is justified or reasonable, whenever there is a need for formal action. As such, the employment tribu nals will take into account, the size and resources of an employer, at the time of deciding on cases (Code of Practice 1 ACAS Disciplinary and Grievance Procedures, 2009). Under no circumstances, disciplinary or grievance issues should be dealt with in an unfair manner. Moreover, the ACAS has strongly recommended a thorough investigation of allegations by employers. Prior to a disciplinary hearing, particulars of the allegations have to be provided to the employee. In addition, the employee should be provided with an opportunity to explain what had transpired, and to draw attention to any extenuating circumstances (Birkinshaw & Fairclough, 2001). In our problem, Janice and Kelsey were suspected of having stolen a harddisk drive, since it was located in their jointly held locker. They were immediately suspended by the Warehouse Manager, and after two days a disciplinary meeting was conducted and they were dismissed. It is incumbent upon an employer to adhere to a fair process, while addressing a disciplinary or grievance issue. This holds good, even if the employee in question admits to the offense, as also to instances of gross misconduct. In general,

Forum Discussion - Coca-cola Company Essay Example | Topics and Well Written Essays - 250 words

Forum Discussion - Coca-cola Company - Essay Example riations.  So, before releasing any campaign in  the local  market, the national office of the company studies the future impact in country and modifies it per local culture before the release.   The company ensures that their marketing strategy includes local, national and regional traditions as well as customs. In Tunisia, the company sponsors the national football team, and engages the most popular singers to spread its message. As part of the CSR policy, the company sponsors students from this country for studying at Kelly School of Business at Indiana State University on  a regular  basis (Wagner).   Thanks for your response. As you know,  Coca-Cola is  a global corporation with appropriate company structure.   An essential part of company’s global business strategy, the sponsorship decisions are taken by integrated marketing department, located in headquarters of  Coca-Cola Company.   This department of the company is responsible for sponsorship, licensing and global media marketing strategies (Coca Cola). Since 1928, the company is sponsoring the Olympics, a global event handled solely by an integrated marketing department. Although, the company has been split in two parts -- Coco Cola Americas and Coca Cola International, the event will be promoted by both Coca Cola companies in their respective areas. Although  Coca-Cola is  a global company and uses  the global  approach for marketing its products,  the company policy regarding any ad campaign is to recognize the cultural and local variations and modify the campaign

Diffusion of innovation theory Essay Example | Topics and Well Written Essays - 750 words

Diffusion of innovation theory - Essay Example Complexity connotes the extent to which the usage and understanding the simplicity of an innovation appear difficult. Youths are picking up essential technological and social skills that they need to contribute fully to contemporary society (Clark, 2011). Erecting barriers to communication deprives the youths of access to these forms of learning. Youths could benefit from educators being more open to forms of experimentation and social exploration that are not characteristic of educational institutions. The content, way of relating and skills that youths value are highly variable dependent on what type of social groups they associate with (Boyd, 2007). This diversity in forms of literature means that it is problematic to develop a standardized set of benchmarks to measure new levels of media and technical literacy. Both Guttenberg and Martin Luther faced great opposition from the religious authorities of the time and took the bold step to use mass production as an effective tool for evangelization. Through the power of the press, religious leaders like Martin Luther managed to spread the Word amidst widespread opposition and condemnation from the mainstream church (Crosby, 2012). Through the use of the press, Martin Luther was able to lead the Reformation and evangelize to the masses. The Reformation was a time of dramatic religious dissent during which various church groups broke away from the dominating Catholic Church.

Forum Discussion - Coca-cola Company Essay Example | Topics and Well Written Essays - 250 words

Forum Discussion - Coca-cola Company - Essay Example riations.  So, before releasing any campaign in  the local  market, the national office of the company studies the future impact in country and modifies it per local culture before the release.   The company ensures that their marketing strategy includes local, national and regional traditions as well as customs. In Tunisia, the company sponsors the national football team, and engages the most popular singers to spread its message. As part of the CSR policy, the company sponsors students from this country for studying at Kelly School of Business at Indiana State University on  a regular  basis (Wagner).   Thanks for your response. As you know,  Coca-Cola is  a global corporation with appropriate company structure.   An essential part of company’s global business strategy, the sponsorship decisions are taken by integrated marketing department, located in headquarters of  Coca-Cola Company.   This department of the company is responsible for sponsorship, licensing and global media marketing strategies (Coca Cola). Since 1928, the company is sponsoring the Olympics, a global event handled solely by an integrated marketing department. Although, the company has been split in two parts -- Coco Cola Americas and Coca Cola International, the event will be promoted by both Coca Cola companies in their respective areas. Although  Coca-Cola is  a global company and uses  the global  approach for marketing its products,  the company policy regarding any ad campaign is to recognize the cultural and local variations and modify the campaign