Types of Volleyball Practice Essay Example for Free

Types of Volleyball institutionalise Essay massed practice and distributed practice whole practice and part practice blockade practice and random practice varied and constant practice drill and problem solvingMassed institutionalize is a training routine in which a skill is practised continuously and consistently. E.g. 50 softball pitches, 25 basketball free throws, volleyball 40 serves. A barrier to massed practice includes fatigue and demand and is usually undesirable to beginners.Distributed Practice consists of short, frequent practice sessions with rest intervals. This type of practice is impressive for learning skills. E.g. 5 sets of 20 chest passes with 2 blink of an eye rests. Most evidence indicates that distributed practice is more effective in improving performance.Whole Practice is the learning of the skill in its entirety. This type of practice is effective in skills that are high in complexity and low in organisation such as jump shot or skating.Part Prac tice is the learning of each of the separate components of the skill. It is particularly effective when the skill being taught is complex and has clearly defined components e.g. golf swing. Both Part and Whole Practice can be used to teach the same skills e.g. breaststroke.Blocked Practice is where learners attempt the same skill repeatedly in order to refine and mitigate their performance. E.g. Tennis 15 forehands,15 backhands, 15 volleys. More effective for learners in the cognitive stage.Random Practice is when all components of the multi task skill are practiced in random order within each practice session.Constant Practice refers to the practice of only one skill without any variation e.g. kicking a ball to a betoken 10 away.Varied Practice refers to practicing a class of skills using variations within the one practice session. E.g. kicking to a target 10m away then 20m away and 30m.Drills Learning through repetition (eg. Dig, Set, spike drill we do in class)Problem Solving l earning through investigating and discovery. (if the teacher gave you a ball and said work out how to serve the ball with no instruction or feedback)

Why is the Walt Disney Company so successful Essay Example for Free

Why is the Walt Disney Company so successful EssayAs the process of globalization develops continuously, multinational corporations are much more super acid nowadays which means inter ethnic communication has become an important part of daily work in thousands of millions of cross-cultural offices. This thesis lead mainly concentrate on discussing and analyzing the Walt Disney Companys experience of intercultural communication and the useful information we can learn from it so that some misunderstandings and problems can be avoided in some course activities. This thesis will discuss and answer the following questions 1. What is the Walt Disney Company?2. What is a cross-cultural working environment want in the Walt Disney World Resort, Orlando, Florida? How do the coordinators portion with different employers from different cultures? 3. What happened when Disney first entered French market? What happened when it first entered Japan? What are the cultural reasons behind thes e different phenomena? 4. Comparing to different multinational corporations like Starbucks and Ikea, what is the advantage of Disney and what can we use for reference from its experience? Some researches have already been done on related subjects such as intercultural communication management, the wideness of cross-cultural communication in business, and the effectiveness of intercultural communication in Human Resource area, etc. Based on these researches, however, my view point as a cast member of the Walt Disney World Resort can be creative and objective.Chapter I What is the Walt Disney Company? In this session, a brief introduction of the Walt Disney Company will be given especially the history of its process of globalization when it tried to get into France, Japan and Hongkong China.Chapter College Exchange Program in the Walt Disney World Resort after(prenominal) providing some information of College Exchange Program, I will concentrate on analyzing Disneys methods of dea ling with foreign Cast Members culture shock, cultural conflicts, and coordinators different formulation ways according to their different cultural backgrounds. Besides, a survey will be made to collect CPs opinions on how to improve the program or how will their future application affect intercultural communication.Chapter How to Deal with the Frustration in France? In this part, I will introduce the history of Disney first entering France and the cultural crisis it came across there. I will illustrate both the efforts and mistakes made by Disney as well. Comparing to the process it first entering Japan, I will show to engage the different cultural backgrounds with these different phenomena.Chapter Useful References of Disneys Experience Comparison will be made in this part between Disney and other multinational corporations and some useful references we can get so as to use them to avoid misunderstandings, sometimes even serious problems in business field.

Hard and Soft System Methodology

Hard and demulcent organization MethodologyIntroductionThere atomic number 18 two systems thinking namely hard and soft which are used to solve the problems. Peter Checkland (1981) suggested that Hard system thinking which is identified in system engineering and system analysis has the starting point in structured problems and assumes that the objectives of the system are clear and stable. This system thinking has a formulated way to solve the real world problems. On the other hand, Soft system thinking which attempts to structure a debate or so actions in problem solving has the start point in unstructured problems within kindly activity systems. Fixitup Toys limited is a manufacturer of toys which produces outdoor and indoor games, self-assembly models and toy soldiers. There has been some concern about their rising cost of manufacture and love has been given to the outsourcing of some or part of the production. The vision of the Fixitup senior management team is to optimize manufacture processing to produce the highest flavour and closely forward-looking products by using E-business conforming to the lean manufacturing principles and incorporate into their established QAD Application.In order to achieve these goals, we need to apply the principles of lean manufacturing. There are several(prenominal) key lean manufacturing principles includingUnderstand value in the eyes of the customer.Achieve perfect first-time quality.Continue improvement.Respect for humanity.Create pull. (Asefeso, 2011)After Gathering development from altogether aspects of the company the following steps go forth be takenAs can be seen, the Rich Picture is an unstructured way of capturing nurture flows, confabulation and human activity to represent complex problems and identify possible routes through to their solution (Berg, 2013). Avison and Fitzgerald (2003) stated that the Rich Picture is helpful since1. Lack of space on the paper forces decisions on what is really im portant.2. It helps people to visualize and discuss their own role in the organization.3. It helps defining the aspects of the organization which are intended to be cover by the nurture system.4. It helps showing up the worries of individuals, potential conflicts, and political issues. (Avison Fitzgerald, 2003)With reference to the Rich Picture, in that location are following problems in Fixitup.Since about 74% of customers power saw the service and quality as moderate or worse, the issue of quality of products must be considered. Further, a powerful randomness system helps different level managements for planning, decision making, target setting and their implementations (Stephanou, 1982).Therefore, quality control system and information management system are important and they will be discussed. mental imagery Resource Investment RequirementComments VOC was not heard because there was no effective communication betwixt the company and its customers.Remarks By establishing a bod division and integrating this department with the marketing department the customer feedback can be incorporated into the design.Comments Lack of checklists caused the absence of the systematic process of QC hence, the materialises of defects being disregard is considerably high.Actions The design department and the quality team will be compound to prepare checklists according to the quality required.Comments Since there was no analysis of the defective products, the defects were being ignored therefore they were persistent.Actions Train a quality control team who will be responsible for doing analysis, recording data and providing feedback.Comments There was no coherence between the departments to respond to the quality issues.Actions Develop communication channels between the supervisors and the technical, procurement and design departments in order to create coherence towards quality improvement.Comments There was no system for controlling and monitoring the Quality C ontrol Process.Actions Train the factory manager on the QC process and how he should intervene in hurt of analysing quality data and controlling the system. He will seek technical advice from technical, procurement and design department for a better monitoring of the system.Comments Monitoring and evaluation of the information system are missing.Actions Helen who is responsible for Internal Affairs and George can be trained for the information system and perform monitoring the system.ConclusionThere are different problems in Fixitup which resulted in dissatisfaction of the customers. Due to having permanently relevance and also being expected to map on to an organizational boundary, the transformation from in high-octane manufacturing to efficient manufacturing which has marketable products is assumed as the primary task process (Wilson and Van Haperen, 2015). Although discrimination between primary task- based and issue-based is often debatable, it seems quality control and inform ation management systems are issue-based which help the primary task to be carried out (Waring, 1996).The current strategy of Fixitup is to optimize manufacture processing to produce the highest quality and most advanced products by using E-business conforming to the lean manufacturing principles and integrating into their established QAD Application. After drawing the rich picture the main problems of the organization were revealed. The strategic make water which was used was classification schemes of issues which helped to identify the differentiating characteristics necessary to improve quality control and information management systems (Verma and Boyer, 2000). Further, the system construct used for quality control was arousal and output modelling of such system involves modelling of each process separately considering the connection between them (Apolloni, Howlett and Jain, 2007). In addition, the system construct used for information management system was integrated elements in which different elements including communication, information and resources were integrated for the success of the system (Khan and Burn, 2013).Otley and Berry (1980) argued that four conditions must be satisfied sooner any process can be said to be controlled. In the existing situation there was no one responsible for monitoring the systems and consequently, there was no capacity to take corrective actions (Emmanuel, Otley and Merchant, 2013).However, in the proposed systems, George and Helen were nominated to monitor the systems. To sum up, the details of the two systems will be discussed in the following tables.System name and typeQuality Control Process The input and output system construct.Role of informationDue to lack of information about the requirements of customers and standard criteria set by the management, the products were just inspected for the appearance by the operators. Therefore, the application of information which was vital to improve the quality of product s was missing and consequently the reputation of the factory was being worsening.Information needed to developIn order to use the information to improve the quality of products we need to knowQuality Criteria After hearing the percentage of customers and considering the strategy of the company the criteria for quality of products such as weight, shape and material should be prepared in a simple format.Training of Workers There was no information about the training of operators and even management in terms of quality control.Historic quality data The historic quality data including glance reports, the number of different products produced, the number of return items should be available for better assessment of the quality of products.Coherence between QC and departments There was no information as any department is dealing with quality matters. Further, there was no information about communication between operators and departments, if any, in terms of quality of products.More infor mation is needed to evaluate the possibility of automating the QC department.InterventionIn order to solve the problem of quality of products the following actions are suggestedDevelop a design department and integrate this department with the marketing department so that the customer feedback can be incorporated into the design.The design department and the quality team should be integrated to prepare a checklist according to the quality required.The quality control team will be responsible for doing analysis, record data and providing feedback.Develop a communication channel between the supervisor and the relevant technical departments in order to create coherence towards quality improvement. milling machinery manager should intervene in terms of analysing quality data and control the system.RisksEven after the intervention, the following risk associated with quality of products existEven after the successful QC audit, there is a chance that the toys will break while transferring/ packing.The Technical and procurement departments might not react to the QC feedback.There might be a friction between the Factory manager and the design team in terms of accepting innovative designs.There might be dissatisfaction of factory workers due to job enrichment without a knuckle under increase.Cost Benefit AnalysisIn order to assign a monetary value to the benefits, we need more information to predict the revenue accurately as well as intangible benefits (Mindtools.com, 2016). Having good quality products will result in increasing the loyalty of existing customers and acquisition of new customers and consequently, it will increase the revenue.In contrast, the firm may incur some costs to apply the changes. In this case, we do not have enough information about the existing departments and the expertise of employees. Assuming that none of the employees

The Competitive Landscape In The Banking Industry Marketing Essay

The Competitive Landscape In The Banking Industry Marketing EssayWe are bread and butter in the 21st century, everything is revolving around the earnings and technology, and its all about embracing the convergence. This explosion of the meshwork and technology has impacted on everything, and its altering the situateing industry as well, from branch banks and papers to networked and digitized banking services, it has already made its way in, but over all, the banking industry is still struggling to find a solution for the rapidly changing environment. The root of this problem is that most banking executives are still not ready to see the real impact of the profit age and act accordingly, few impacts of the internet and technology are discussed below,Altering the Rules of CompetitionToday, beca practice session of the internet dissolving the difference of the size of the businesses, thus letting small business get to delimit the free-enterprise(a) agenda and get the emolument. Physical processes are being replaced by virtual(prenominal), and virtual environments are being holdd, so unrivaledr or later one has to enter this market, in order to keep up with the market trend. The only difference is whether youll go by your own rules or follow the ones created by others. Internet representation, and web found outlets, if executed correctly, can give the power to one, to set its own rules for the competition.From Capital Requirements to Knowledge RequirementsTraditionally, absence of funds, has served as a hurdle to access into some(prenominal) grumpy industry. This has been especially true in the banking sector. Today, improving financings of the company is perhaps the one of the least problems, a company struggles with. Investors know that economical techniques of variation are no all-night an organizations key asset, its aside track record, its brand or anything. Investors today anticipate and are interested in companys knowledge. A large network sy stem, monetary muscle and a huge work power may not seem to have as much magnificence, as beforehand.Brand BuildingThe last(a) two decades, saw a large way on the growth of manufacturers, and brand building as a differentiation means, thus allowing service go awayrs, banks for instance, to create brand awareness among the customers for their loyalty towards the brand (Czerniawska Potter, 1998). Consequently, multi-million dollars of investment were solely done on the development of the image of the brand. Already on the Internet, thither are organizations perform as informers or experts, who help prospective buyers go for the best option, thus making the customers independent, and not be misled by the image created by the brand, and make more(prenominal)(prenominal) conscious decisions when going for a purchase.Customer Segmentation and RelationshipWith the help of the Internet a bank is able to target specific market online and provide them product information, ainized web pages and services, and other data for any client, when they access the companys web page. In short, the battlefield has changed, today it is brand or product variation, and focusing on the most profitable clients, and to keep the customer relations and support the best, for the long term profitability.From Access In Distribution Channels to Amiss to CustomersIn the 1980s and early 90s, one of the key areas of competition was to have the best distribution networks to make sure that products/services offered by the bank could be delivered to customers (Czerniawska Potter, 1998). Banks utilize to invest heavily and it was one of the main concerns too, to have the best location of the outlet, and build up their network. However, with the advent of the Internet such resources have become little relevant. Today the customer feels more easy going online and access the their bank account rather than to visit a physical branch.From Regulated Government insurance Its Unregulated Glo bal MarketIt is believed that regulatory and legal restrictions, other types of hurdle to access determined by Portia, be decreased beca practise of the Internet. For example, in the United States, saucily opportunities for the banks were created, when the act of branching efficiency or the Rigles Neal Act of 1994 was passed. This Bill allows banks, to become the full service fiscal institutions and providers (Kalakota Whinston, 1997). Clearly, this change is both a risk and a chance since the limitations that have ceased some from coming into an industry have also restricted the regional development of others.Global competitionThe erosion of boundaries due to the Internet has accelerated the trend towards global competition. Citibank has entered the Japanese market successfully with its web- found solution. Similarly, The Royal bank of Canada made its way into the US market with the help of the internet, by virtual banks.In summary, the internet is globalizing the banking industr y, the battlefield is evolving around the internet, attracting bracing customers and coming up with unique services and products which werent possible before are needed of the time today. argufy 2 Provide an analysis of the resources and capabilities a typical bank needs to have to be able to compete in this environment dominated by the internet and online banking. (500 words)Customer service is the key to survival of any bank. Customer loyalty and commitment is directly proportional to client thingmabob, personalized services and innovational offers and products. In the 1970s and 1980s, banks were marketing to a generation raised on an old style of banking personal service at a bank. They were not satisfied with automated services, and were scared to use computers. So, to have a physical branch office nearby was convenience and relaxation. Today, in a banking relationship, individual assistance and convenience are still the crucial aspects, but they are described in a differen t way. Clients still want the bank to be a monetary institution who knows them, and bank the one, they know, but they do not actually want to go to the bank.Today, customers are not afraid of computer techniques and technology they accept them. drag is doing their banking whenever and wherever they want. They are now relaxed with computers and other gadgets. They anticipate quick, effective, and precise assistance. And the only way to be successful, is to provide the immediate, quality assistance that clients demand, and that the competitors provides, is through intensive use of the most innovative and advance technology and through good people qualified in the use of these technological innovations. For all these factors, the banks keep modifying its delivery systems.The youthful Delivery SystemsThe increasing price of building brick-and-mortar divisions, and decreasing price of personal computer systems, slow revenue growth and proud delivery cost crush a relook at the tradit ional delivery systems. Furthermore, growing comfort of technology usage by the client is quickly promoting use online banking for daily transactions.The radical focus of the banks today is, that the branch be a place of a wide range of solutions like customer assistance kiosks, telebanking, remote electronic banking and ATMs, not fairish a high cost transaction hub.New Marketing OpportunitiesThe mod technology and its products are expensive, therefore, banks need to utilize founder and do more with the new technology than to just provide information and solutions. Banks have to also market and sell financial commitment products, insurance coverage to get a better come back on this investment. Telebanking can bring financial solutions to the home, especially if they are cost-effective screen mobile phones. By realizing how much interest the client conveys, the bank can market stock and insurance quotations. Interactive clips are a new technology innovation that banks can market their products with, and to maintain personal contact with the client while still decreasing the cost of services. An expert worker is not required in each branch with the interactive video, devote brokerage accounts, complex life insurance products, personalized product causas can be accessible were required. The interactive video clips will be cost effective. For banks, the internet is an unique way to reach to customers outside the normal consumer base of a division. Banks need to stay conscious of the customers need for new solutions and strategies and make them uncommitted before others do. misgiving 3 The authors argue that certain theories and concepts used to key for competitive advantage in the traditional business environments are no long-range meaning(a) in this new era of internet dominant environment. Explain. (500 words).As a result of the advent of Internet technology, larger banks no longer gain an advantage based on the economics of get over that they were abl e to achieve in the past. Physical size and bureaucratic organizational structure can mean high operating costs. as well as inefficient and limited degrees of flexibility.Traditionally, lack of money has acted as a barrier to entry into any particular market (Porter, 1979). This has been especially true in the banking sector. Today, raising finance is perhaps the least difficult task facing an organization. Investors recognize that an organizations key asset is not its economies of scale, its past track record, its brand or any or the other trump cards. What investors are interested in and expect is the organizations knowledge. Financial muscle, a large wear down force, and a large branch network may seem to have become less important.With the internet banking, bricks, mortar and physical networks are no longer required. Such a shift has substantially lowered the traditional barrier to entry. Internet banking shifts the competitive rules by levelling the playing field of large and small banks and reduces importance of issues such as physical distance and location. In todays banking environment, the processing of large physical branch network is perhaps no longer a near competitive advantage or primary concern for customer selecting a bank.From gatekeeper to gateway. In the old gatekeeper model the bank functioned as an inhibiting supplier that restricted the customers product choices. Now in the new gateway model, the bank functions as a flexible intermediary that provides access to an entire spectrum of products and delivery channels. In other words, the bank acts as a gateway, and provides its customers with access to value added services with normal services anywhere in the world.Today, Internet increases the bargaining power of buyers. The more products that become standardized and undifferentiated, the lower the switching cost, and hence more power is yielded to buyers. As more new comers are entering the industry, banking customers are facing more al ternatives that increases their bargaining power. Following this most of the internet banking services are now free of charge.Internet Banking enable the emergence of new rules of competition. Therefore, the traditional economics of scale benefits are no longer applicable. The internet is fundamentally changing the way banks conduct business. The processing of a large branch network is no longer a sustainable advantage. The banking market is likely to see the emergence of new small banks that use the internet to compete on equal grounds with the financial giants.Over the past several decades one of the most common tactics that organizations have adopted to sustain competitive advantage has been to establish a set of proprietary standards that keeps their customers from their suppliers and competition. Unfortunately, proprietary standards and the internets open -system architecture are contradictory in nature. The investment that banks have made in developing their own proprietary p acket to manage user interface is perhaps turning from an asset to a liability as the internet becomes a universal channel for information access.Question 4 Select a bank in your home country and answer the following (800 words).Using Porters Five Forces model, discuss its competitive environment,Citibank is a U.S. based commercial bank, it was first incorporated in 1812 as the City Bank of New York. Citibank is headquartered in Las Vegas, Nevada, US. The bank offers mortgage lending, consumer finance, retail banking service and products, investment banking, cunning finance, cash management, commercial banking and e-commerce services and products, and private financing services and products. Citigroup, Inc is the parent company of Citibank. It provides credit cards, deposit accounts and loans to consumers and small companies, and uses its parent companys depth of financial solutions by also offering investment and insurance products. The bank mainly operates in America, UK, Asia, M iddle East, and Africa including the Japan, US, Hong Kong, China, India, Singapore and the PhilippinesPorters Five force ModelAvailability of SubstitutesReplacement of one product with another one increases the competition within an market. It is hard to find an ideal alternatives of banks, the most ideal substitute of banking services are not available but they have a choice to choose between making an investment and preserving their cash. The individual can save their cash at their home or in Nationwide saving centers. The individuals can also invest their cash in stock market.Rivalry among existing firmsThere are lots of opponents among miscellaneous banks. There are a wide range of public and personal banks which are offering products and service on competitive prices. Rak bank was granted as the best bank for the year. There are several other Islmic banks which are recommended by the people there. NBAD, HSBC, RAK Bank, Loyalds TSB bank, Dubai Bank, RBS etc are the few opponent s of Citibank. The lots of opponents among these banks gives rise to the difficulties which the opponent bank have to face. The opponents among various banks improves the changing of the clients from one bankss product to the other.Threat of new entrantsThe banking industry of any nation has always possibilities of growth and competition, so galore(postnominal) new banks get in and out of the market. Mostly banks step in the developing nations for growing their divisions. But as global economic recession recently, the risk of new newcomers is limited.Power of buyerBargaining power of a client is low where the products alternatives are not available and clients are more in number. In case of banks there are lots of other banking intermediaries and banks, having wide assortment, so power of buyer in banking industry is high. The bank can not force any client to buy the preferred product because this directly impacts its reputation, but can persuade its clients by providing them speci al rewards or discounts.Bargaining power of suppliersBanks have previously acted as suppliers. However, in this new internet banking World, the business model has changed dramatically. Banks are no longer need suppliers, but are the suppliers to the financial products. So there is no bargaining power of the suppliers. There are no suppliers in the banking industry.How the internet impacts it competitive position andThese are the effects of the internetThe tremendous challenge that all competitors are experiencing in the banking market.The different systems for the different customers such as International organizations, small-medium businesses and personal customers were challenging more innovative e-business alternatives according with the improving use of the internet.Different providers coming into with new alliances.The new marketplaces that are possibly Citibanks alliances.The alternative products such as local financial, heritage system and technology organizations.how it has continued to have-to doe with its competitive position.Citibank highlight on client care instead of the price, client satisfaction was targeted on the support, technological innovation and reaction time providing assurance to the customers in the form the business was done. The good client support and goods and services are the reasons why Citibank is able to keep its identification and commitment throughout the world. Citibank used many technological innovation to get more customers pleased such as ATMs, phone collections, and the digital system of expenses which is a secure business transaction from the client.another(prenominal) difference Citibank done was the affordable costs of its products or to match their competitors costs to give affordable costs for the different services and goods.Competitive advantagesLower costs for its solutions and productsMultiple ways to access the account for the customersSecure transaction and operations over the internet

Full Kinetic Chain Manipulative Therapy on the Knee

Full Kinetic Chain Manipulative Therapy on the human kneeThe carnal knowledge effectiveness of complete kinetic concatenation manipulative therapy and full kinetic image replacement in the treatment of degenerative arthritis of the articulatio genus. Brief Synopsis of the lookTherefore in this study we aim to establish the effect of the KFC manipulative therapy solo, FKC rehabilitation alone and the combination of the two interventions on osteoarthritis of the genu.This bequeath be done by means of a quantitative randomise comparative clinical trial. 60 long-sufferings will have been diagnosed with osteoarthritis of the knee according to the cellular inclusion and exclusion criteria, and will be randomly divided into 3 sorts. The first group will receive 6 treatments using FKC manipulative therapy alone, the second will receive 6 treatments using FKC rehabilitation alone, and the third group will receive 6 treatments using FKC manipulative therapy combined with FKC reha bilitation. Subjective (Beck Depression descent, McMaster boilers suit Therapy Effectiveness Tool, Western Ontario and McMaster Universities osteoarthritis Index and Berg relaxation Scale) and objective (Inclinometer) measures will be taken at baseline, 1 week and 1 cal turn backar calendar month fol impoverished up.These results will be recorded and the data analyzed using SPSS statistical package at a 95% confidence interval.Section BTo be typed in Arial 12-point font in one and half line spacing (expand sections to fit contents, but keep within the specified level best lengths)1. Field of look and Provisional TitleThe relative effectiveness of full kinetic chain manipulative therapy and rehabilitation in the treatment of osteoarthritis of the knee.2. Context of the Research1. degenerative fit disease is a very common condition, affects 9.6% of men and 18% of women aged 60 years worldwide (Woolf and Pfleger, 2003).2. Although multi-factorial, f solelys cause nearly two-thi rds of all non-intentional injury related deaths in older adults (Hawk et al., 2006). One of the causative factors is loss of renal pelvis and knee proprioception secondary to increased conjunction degeneration, thus by addressing these problems with the rehabilitation and/or ad howeverment thither may be a decreased danger of fall.3. There is research to suggest that applying manipulative therapy and rehabilitation to the full kinetic chain yields greater benefits for KOA patients than at sign rehabilitation alone (Deyle et al., 2005), however this combination of treatments has never been comp ard against full kinetic chain manipulative therapy alone.4. KOA stiffness, aggravator and dys flow was shown by Deyle et al., (2000) and Deyle et al., (2005) to improve damp when adding manipulative therapy to a rehabilitation curriculum as compared to placebo and forge alone, respectively.3. Research Problem and AimsAimThe relative effectiveness of full kinetic chain manipulative t herapy and rehabilitation in the treatment of osteoarthritis of the knee.Objectivesi) To de limitine whether manipulative therapy alone is effective in the short endpoint treatment of KOA in terms of infixed and objective meters.ii) To determine whether manipulative therapy alone is effective in the intermediate term treatment of KOA in terms of subjective and objective measurements.iii) To determine whether rehabilitation alone is effective in the short term treatment of KOA in terms of subjective and objective measurements.iv) To determine whether rehabilitation alone is effective in the intermediate term treatment of KOA in terms of subjective and objective measurements.v) To determine whether manipulative therapy combined with rehabilitation is effective in the short term treatment of KOA in terms of subjective and objective measurements.vi) To determine whether manipulative therapy combined with rehabilitation is effective in the intermediate term treatment of KOA in terms o f subjective and objective measurements.vii) To compare short term results and intermediate results, respectively.viii) To determine whether manipulative therapy combined with rehabilitation is effective in decreasing the fortune of fall according to the Berg Balance Scale.ix) To determine whether rehabilitation alone is effective in decreasing the risk of fall according to the Berg Balance Scale.x) To determine which treatment method is more effective in decreasing the risk of fall according to the Berg Balance Scale.4. Literature reviewosteoarthritis is a chronic degenerative disorder with a complex aetiology (Felson, 2000). It is characterized by focal loss of articular cartilage within synovial joints, associated with grow of bone (osteophytes and subchondral bone sclerosis) and thickening of the capsule, resulting in alterations in biomechanical properties (Woolf and Pfleger, 2003). It is a very common joint disorder, affecting mostly those above the age of 60 and faeces occ ur in any joint but is most common in the articulatio coxae knee and the joints of the hand, foot, and spurring (Symmons, Mathers and Pfleger, 2003). As many as 40% of people over the age of 65 suffering symptoms associated with knee or hip OA (Zhang et al., 2008), resulting in OA becoming the fourth leading cause of disability in the years 2000 (Symmons, Mathers and Pfleger, 2003). Although no cure exists, a number of treatment options exist to provide symptomatic relief as swell as improvement of joint function. Amongst these are non-pharmacological interventions, such as rehabilitation, manual therapies, acupuncture and electromodalities, as well as pharmacological measures such as oral medication and intra-articular injections. In unplayful cases, where nonsurgical interventions have failed, more invasive approaches may be needed (Scher and Pillinger, 2007).McCarthy (2004) compared the effectiveness of an at piazza exercise program on its own or when supplemented with a cla ss- base exercise program. There was found to be a greater improvement in WOMAC scar in the class-based exercise group (20.6%) than the at home group (8.8%). These relatively modest effects may be owed to inability of exercise to address a number of factors that prevent patients from maximising results from their exercise program. Fitzgerald (2005) determine quadriceps inhibition or activation failure, obesity, passive knee laxity, knee misalignment, fear or physical activity and self-efficacy as examples of such factors. The necessity for special interventions to address these factors therefore becomes apparent.Tucker et al. (2003) compared the relative effectiveness of knee joint manipulation versus a non-steroidal anti-inflammatory drug (NSAID), and found manipulation to be just as effective as NSAIDs in the treatment on KOA. Fish et al., (2008) had similar results when comparing the effectiveness of knee joint mobilisation against Topical Capsaicin Cream. Capsaicin has been previously demo superior to placebo in many painful disorders including knee and general osteoarthritis. Pollard, Ward, Hoskins and Hardy (2008) applied a manipulative therapy protocol, consisting of loose tissue mobilisation and an caprice thrust to the symptomatic knee joint complex. This was found to have a statistically significant improvement in knee pain, mobility, crepitus and function when compared to the control group (interferential current set at zero). Pollard et al. (2008) also noted that knee treatment had a significant improvement in hip movement of those in the intervention group compared to the control group. This may be owing to the effect that treatment to a single joint may have on the full kinetic chain (hereafter FKC).A number of studies have been conducted on various joints of the full kinetic chain of the cut extremity to determine their effect on the knee. Cliborne et al., (2004) aimed to determine the short-term effect of hip mobilization on pain and ra nge of motion (ROM) measurement in patient with knee osteoarthritis (OA). It was demonstrated that the presence of hip pain and pain on squatting, restricted hip flexion and/or a positive scouring test predicts a burst knee OA outcome. Currier et al., (2007) suggest that pain over the hip, groin or anterior thigh limitations in passive knee flexion and internal rotation of the hip as well as pain with hip distraction predicts a favourable short-term response to hip mobilizations. In fact it was found that, based on the presence of one variable, the probability of a successful response was 92% at 48-hour follow-up, which increased to 97% if 2 variables were present. Iverson et al., (2008) suggest that the strongest predictor of whether adjusting the lumbopelvic spine will decrease knee pain (in patellofemoral pain syndrome) is if there is a side-to-side leaving in hip internal rotation greater than 14. The presence of this variable increased the likelihood of a successful outcome f rom 45% to 80%. These studies collectively show that correcting the various dysfunctions within the kinetic chain will have a favourable effect on knee joint dysfunction. However, there has yet to be a study that seeks to improve knee osteoarthritis by treating all call ford joints in the full kinetic chain.Few studies have looked at what effect combining manipulation and rehabilitation would have in the treatment of KOA. Deyle et al., (2000) applied manual therapy to the knee as well as to the lumber spine, hip and ankle as take. Additionally patients where given to knee exercise program to perform in the clinic on treatment days and at home. WOMAC (Western Ontario and McMaster Universities osteoarthritis Index) tons are used to detect changes in the patients perception of function and quality of life, specifically related to the disease process. In this study, there was a 55.8% improvement in the treatment group as compared to a 14.6% improvement in those patients receiving pla cebo (subtherapeutic ultrasound), thus proving the effectiveness of combining manipulation and rehabilitation. Using similar methodologies, Deyle et al., (2005) compared an at home versus in clinic physical therapy program. Those being treated in clinic received superintend exercise, manual therapy to the FKC and a home exercise program, while a second group received at home exercise only. Significant improvements where seen in two(prenominal) groups, however the clinic treatment group had an improvement in WOMAC scores of 52% and only a 26% improvement was seen in the home exercise group. The originator attributed this difference between groups to the application of manual therapy to the full kinetic chain. However, the clinic group performed the exercises nether supervision and where corrected where necessary while the home group were monumentally unsupervised and may have performed the exercises incorrectly as a result, thus decreasing the benefit such exercises would have. One should therefore not consider the difference in group performance to be solely due to the addition of manual therapy.To date there is no study which compares the effect of manual therapy alone versus the above mentioned treatment combinations. Therefore there is a need for a study to determine whether FKC manual therapy combined with a standardised rehabilitation program is more effective than either intervention alone in the treatment of osteoarthritis of the knee.5. Research MethodologyDesign typeQuantitative comparative clinical trial conducted at the Durban University of Technology Chiropractic Day Clinic (hereafter DUT CDC).Advertising Appendix AOld age homes and retirement villages throughout the greater Durban region will be approached, as well as advertisements placed on notice boards of DUT, community halls, shopping centres and places of worship.Sampling procedureA sample size of 60 (n=60) will be selected by means of convenience sampling (Brink, 2006). Those individu als responding to the advertisements will be screened and accepted based on the inclusion and exclusion criteria.Telephonic interviewPatients are necessitate to come through the DUT CDC telephonically to determine whether they meet the requirements of the study. This will be determined by asking the patient the following questions* Are you between the ages of 38 and 80?* Have you had knee pain for longer than 1 year?* Do you have a history of trauma or surgery to the lumbar spine or lower limb?* Are you able to stand and walk on your own, with minimal need and/or without significant dependence on canes and walkers?* Do you suffer from a chronic medical condition that would require you to take regular medication?* Would you be prepared to have radiographs taken of your lower limb?If the patient meets the criteria for the study, a consultation will be made, at which they will be presented with a letter of information and informed consent form Appendix B, which they will be required to sign. The following inclusion and exclusion criteria will be assess using a case history Appendix C physical exam Appendix D lumbar and pelvis Appendix E hip Appendix F kneeAppendix G and ankle and foot Appendix H regional examinations.Inclusion CriteriaA. Criteria, as developed by Altman (1991), requires a minimum of one of the first three clinical criteria below (1, 2 or 3) for diagnosis of KOA (sensitivity 89 % and specificity 88%).1. Knee pain and crepitus with active motion and morning stiffness 30 min (with age 38 80 years of age).2. Knee pain and crepitus with active motion and morning stiffness 30 minutes and bony enlargement (with age 38 80 years of age).3. Knee pain and no crepitus and bony enlargement (with age 38 80 years of age).B. The following 4 criteria are all required4. Knee pain of 1 year duration and able to stand and walk without life-threatening varus/valgus deformity and/or severe instability (Kellgren and Lawrence, 1957).5. Diagnosis of concurrent sub luxation/or joint dysfunction (S/JD) complexa. Diagnosis of S/JD will be supported throughout using the PART(S) system.6. A patient must have a score of 720 mm (30%) on the WOMAC scale to be include (Tubach et al., 2005).7. No history of meniscal or other knee surgery in the past 6 months (Pollard et al., 2008).8. A diary will be kept to monitor whether medication consumption is increased, decreased or stays the same.Exclusion Criteria1. Significant visual disorders, severe vestibular disorders, neurological and peripheral sensory disorders which may be a contra-indication to exercise2. History of knee or hip joint replacement, severe varus or valgus deformity, instability, fracture and severe osteoporosis, Rheumatoid arthritis, or frank avascular necrosis with or without moderate or severe deformity,3. History of significant lumbar herniated record injury with sequela,4. Severe balance and proprioception problems (i.e. inability to stand with and/or without discolorationed spinal or hip deformity)5. Symptoms of moderate to severe osteoarthritis in both knees and/or hips line of reasoning both knees can be treated if there is KOA or joint dysfunction in the opposite knee and otherwise no other severe complications as noted above. However, only data collected from the worst knee will be used for the purpose of the study.6. Long term chronicity combined with multiple treatment failure especially multiple failure with previous physical treatment ( 3), with and/or long term severe pain, and/or a severely complicated or complex disorder (such as multiple co-morbidities combined with KOA such as a mix of knee, hip and lumbosacral OA, and/or cardiovascular and/or auto-immune disease), or a severely disabled and/or a patient with severe and decreased functional ability and/or a severe clinical depression, may lead on a case by case basis, to exclusion.A basic guide for 6 to be used on a case by case basisI. Pain The patient gives a history that can be interpreted as having stayed constantly or chronically at a high level of an estimated verbal analogue score (VAS) of 7 or WOMAC score of 1680-1920mm (70-80%) (out of a maximum worst score of 2400mm) for 3 to 5 years or longer.II. Complicated or complex 3 or more disorders at one cartridge clip in the same patient (with KOA) as listed from 1-5 above.III. Severely disabled dependent on a cane, brace or walker 75 to 100% of the eon when ambulating severe cardiovascular disease severe instability in the knee or other joints or possibly slight(prenominal) than, or markedly less than half the normal ROM.IV. Clinically depressed determined by history and use the Beck Depression Inventory (BDI). The BDI has been logicalated for measuring depression in clinical and nonclinical settings (Beck et al., 1961).Radiological analysisAlthough diagnosis of KOA will be made primarily through clinical examination, knee x-rays will be taken on patients who bound and consent to participate in the clinical tr ial. The purpose is to determine the grade of osteoarthritic change (according to the Kellgren-Lawrence scale (reference)), to confirm suspicions of contra-indications to treatment, or to rule out a pathology impertinent of OA. Additionally, the subjects history and physical examination may indicate the need for lumbosacral/pelvic, hip, ankle and/or foot x-rays (see exclusion criteria below).ProcedureTimeBaseline2 weeks4 weeks6 weeks1 week F/U1 month F/U Rx222Outcome measurementWOMACROMBBSBDIWOMACOTEROMBBSBDIWOMACOTEROMBBSBDIOnce accepted into the study, patients will be randomly allocated into 3 (three) groups using a randomised allocation chart (reference).InterventionsGroup A will be treated with only manipulative therapy of the FKC.Group B will be treated with only rehabilitation of the FKC.Group C will be treated with manipulative therapy combined with rehabilitation of the FKC.Manipulative therapy Appendix IFKC manipulative therapy (manipulative therapy to the knee, and any i ndicated axial or appendicular joint dysfunction, such as to the spine, hip, ankle, and foot) for KOA has been hypothesized as superior to localised manipulative therapy (Deyle et al., 2005). Treatment will focus on carefully restoring knee flexion and character reference by lesser grades of mobilization as recommended by Deyle et al., (2005) and Fish et al., (2008), and patellar mobilization as per Pollard et al., (2008), along with careful high velocity low amplitude axial elongation of the knee joint as per Fish et al., (2008).Additionally, manipulative therapy will be applied where needed to the full kinetic chain using other diversified techniques, such as HVLA manipulation or mobilization as defined in Shafer and Faye (1990), and/or Peterson and Bergman (2002). Also, the hip technique, as outlined by Hoeksma et al., (2004) and the use of HVLA knee manipulation methods from Tucker et al., (2005) will also be utilized when indicated.The particular joint dysfunction also known a s the subluxation complex or manipulable lesion will be chosen based upon findings in the regional examinations.Rehabilitation Appendix JRehabilitative therapy will include exercises, focused soft tissue treatment and stretch to the knee and elsewhere along the full kinetic chain where needed based upon functional assessment (Deyle et al., 2005). Also included in rehabilitation will be patient advice, education and home exercise recommendations for managing their KOA.The rehabilitation protocol will be standardised across groups B and C, with minor case by case variations.Intervention frequencyAll patient will receive 6 treatments in the first three (3) weeks (2x treatments/week). dressing in a rehabilitation program, to be completed daily. Regular telephonic communication (every 1-2 weeks) following the completion of the 6th treatment.All groups will be required to return to the clinic no more than one (1) week after the 6th treatment and at the one (1) month follow up to have rea dings taken. step ToolsAll data will be collected previsit 1, no more than 1 week after 6th treatment and at 1 month follow up, with the exception of OTE which will not be collected at previsit 1.Subjective data will b obtained by means of Beck Depression Inventory Appendix K The McMaster Overall Therapy Effectiveness (OTE) Tool Appendix L will be used to assess patient satisfaction and general improvement.o The OTE is a valid and reliable questionnaire that allows the patient to classify the change in their health status whether their KOA symptoms, or overall quality of life has better, remained the same, or worsened since the last visit (Chan et al., 2006) The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Appendix M detects change in function and quality of life in patients suffering from KOA using multiple questions with the visual analogy scale (VAS).o The WOMAC is valid and reliable for KOA, and has a long history of being broadly and frequently utiliz ed to assess knee and hip OA, thus allowing comparison to a large number of studies and trials (Bellamy et al., 1988). Berg Balance Scale (BBS) questionnaire Appendix N is a predictor of fall risk and will be delivered if the one legged standing test is failed (Hawk et al., 2006)). KOA patients who are +ve for the Berg Balance Scale (BBS) will be monitored as a subgroup (with a + OLST and BBS) at all clinic assessmentsObjective data will be obtained by means of Inclinometer Appendix O readings for knee flexion and extension only to evaluate the patients range of motion (ROM) (reference).StatisticsThe latest version of SPSS will be used to analyse the data.6. Plan of Research ActivitiesProvide a summarised work plan for each year of the project giving information for each research activity per year, under the following headingsActivityTimeframes (target dates for the duration of the project)7. Structure of Dissertation / Thesis Chapters1. Introduction2. Review of the related literatu re3. Subjects and methods4. Results5. Discussion6. Recommendations and conclusions7. References8. Potential Outputs Provide details on envisaged measurable outputs (e.g. publications, patents, students, etc.) Expected national and/or international acclaim for the research and contribution of research outputs to building the knowledge base Exploitability of outputs, e.g. applicability to community development, improved products, processes, services in SA, region and/or continent Expected effects of research results.9. Key ReferencesBrink, H. 2006. Fundamentals of research methodologies for health care professional. 2nd edition. Juta and co. pallium Town.Cliborne, A., Wainner, R., Rhon, D., Judd, C., Fee, T., Matekel, R., and Whiteman, J. 2004. Clinical hip tests and a functional squat test in patients with knee osteoarthritis reliability, prevalence of positive test findings, and short-term response to hip mobilization. Journal of Orthopaedic Sports Physical Therapy, November 34(11 ) 676-685.Currier, L., Froehlich, P., Carow, S., McAndrew, R., Cliborne, A, Boyles, R., Mansfield, L., and Wainner, R. 2007. Development of a clinical prediction rule to identify patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a favourable short-term response to hip mobilization. Physical Therapy, September 87(9) 1106-1119.Deyle, G., Allison, S., Matekel, R., Ryder, M., Stang, J., Gohdes,D., Hutton, J., Henderson, N., and Garber, M. 2005. Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee A randomize Comparison of Supervised Clinical Exercise and Manual Therapy Procedures versus a Home Exercise Program. Physical Therapy, 85(12) 1301-1317.Deyle, G., Henderson, N., Matekel, R., Ryder, M., Garber, M., and Allison, S. 2000. Effectiveness of Manual Physical Therapies and Exercise in Osteoarthritis of the Knee. Annals of Internal Medicine, 132(3) 173-181.Felson, D. 2000.Osteoarthritis New Insights Part 2 Treatment Approaches. In N ational Iinstitute of Health Conference, Annals of Internal Medicine 133 726-737.Hawk, C., Hyland, J.K., Rupert, R., Colonvega, M. and Hall, S. 2006. Assessment of balance and risk for falls in a sample of community-dwelling adults aged 65 and older. Chiropractic and Osteopathy, 14(3).Haynes, S. and Gemmell, H. 2007. Topical treatments for osteoarthritis of the knee. Clinical Chiropractic 10 126-138.Iverson. C., Sutlive, T., Crowell, M., Morrell, R., Perkins, M., Garber, M., Moore, J., and Wainner, R. 2008. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome development of a clinical prediction rule. Journal of Orthopaedic Sports Physical Therapy, June 38(6) 297-312.McCarthy, C., Mills, P., Pullen, R., Roberts, C., Silman, A., and Oldman, J. 2004. Supplementing a home exercise programme with a class-based exercise programme is more effective than home exercise alone in the treatment of knee osteoarthritis. Rheumatology 43 880-886.Pollard, H., Wa rd, G., Hoskins, W. and Hardy, K. 2008. The effect of a manual therapy knee protocol on osteoarthritic knee pain a randomised controlled trial. Journal of the Canadian Chiropractic Association, December 52(4) 229-242.Symmons D, Mathers C, Pfleger B. 2003. Global burden of osteoarthritis in the year 2000 online. Geneva World Health Organization. Available at uniform resource locator http//www3.who.int/whosis/menu.cfm?path=evidence,burden,burden_gbd2000docslanguage=englishTucker, M., Brantingham, J., Myburg, C. 2003. Relative effectiveness of a non-steroidal anti-inflammatory medication (Meloxicam) versus manipulation in the treatment of osteo-arthritis of the knee. European Journal of Chiropractic, 50 163-183.Woolf, A.D. and Pfleger, B. 2003. Burden of major(ip) musculoskeletal conditions. Bulletin of the World Health Organization, 81 (9).Zhang, W., Moskowitz, R. W., Nuki, G., Abramson, S., Altman, R. D., Arden, N., Bierma-Zeinstra, S., Brandt, K. D., Croft, P., Doherty, M., Dougado s, M., Hochberg, M., Hunter, D. J., Kwoh, K., Lohmander, L. S. and Tugwell, P. 2008. OARSI recommendations for the management of hip and knee osteoarthritis, Part II OARSI evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage, 16137-162.Appendix LThe McMaster Overall Therapy Effectiveness (OTE) Tool (for general improvement and patient satisfaction)Patient No. Visit No. summon No. .Overall Treatment valuation KOAWe would like to find out if there are any changes in the way you have been feeling since treatment started after 6 treatments, and also at the 1st week and 1st month follow ups.Since treatment started, has there been any change in your ACTIVITY LIMITATION, SYMPTOMS AND/OR FEELINGS related to your knee osteoarthritis?Please indicate if there has been any change by checking one of the three boxes below (Better/About the same/ worse)Better About the Same Worse If you have checked ABOUT THE SAME, Please stop here. If you have checked the box If you have checked the box bankrupt WORSEHow much BETTER would you say How much WORSE would you sayyour ACTIVITY LIMITATION, your ACTIVITY LIMITATION,SYMPTOMS AND/OR FEELINGS SYMPTOMS AND/OR FEELINGShave been since treatment started? Have been since treatment started?Please choose ONE of the options Please choose ONE of the optionsbelow belowAlmost the same, hardly better at all Almost the same, hardly worse at allA little better A little worseSomewhat better Somewhat worse evenhandedly better Moderately worseA good deal better A good deal worseA great deal better A great deal worseA very great deal better A very great deal worsePatient No. Visit No. scalawag No. .Overall Treatment Effect CHF, continuedAnswer the following question whether or not you answered BETTER or WORSE and what your response was. Note if you have improved, the change will be important since you likely will be able to carry out your responsibilities with greater ease and comfort compared to in the lead the study. If on the other hand you are worse, then you will have more difficulty carrying out your responsibilities this will also be important for you as you have more difficulty with your activities.Is this change (BETTER/WORSE) important to you in carrying out your daily activities?Not importantSlightly importantSomewhat importantModerately importantImportantVery importantExtremely importantTHANKS FOR YOUR COOPERATIONDescription of scales and how they will be assessed* Pages one and two are graded separately.* Page one is graded on a 15 point scale. Scored from +7 to -7* If the answer to the first question is Better then you have a + integer* If the answer to the first question is About the Same the score is 0* If the answer to the first question is Worse then you have a integer* With a + or integer, the answers below the better or worse response are numbered sequentially from top to bottom. Almost the same, hardly better is a 1 and A very great deal better is a 7.* Page two is graded on a 7 point scale. Scored from 1 to 7* The answers are numbered sequentially from top to bottom. Not important is a 1 and Extremely important is a 7Later we will dichotomize the scores on page one between scores 1 (improved) and Appendix MThe WOMAC Western Ontario and McMaster Universities osteoarthritis indexKNEE OSTEOARTHRITISName_________________________________________________ fancy___/___/______DOB___/___/_____In Sections A, B and C questions will be asked in the following format and you should give your answers by putting a great vertical (up-and-down) mark on the horizontal line.Note1. If make a straight vertical (up-and-down) mark on the line, at the left-hand end of the line, i.e.NO PAIN peakPAINThen you are indicating that you have no pain.Note2. If make a straight vertical (up-and-down) mark on the line, at the Right-hand end of the line, i.e.NO PAINEXTREMEPAINThen you are indicating that you have extreme pain.3. Please Notea) that the further to the right-hand end you pla ce your straight vertical (up-and-down) mark on the line, the more pain you are experiencingb) that the further to the left-hand end you place your straight vertical (up-and-down) mark on the line, the less pain you are experiencingc) Please do not place your straight vertical (up-and-down) mark on the line outside the markers.You will be asked to indicate on this type of scale the amount of pain, s

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