Sunday, January 26, 2020

Full Kinetic Chain Manipulative Therapy on the Knee

Full Kinetic Chain Manipulative Therapy on the Knee The relative effectiveness of full kinetic chain manipulative therapy and full kinetic chain rehabilitation in the treatment of osteoarthritis of the knee. Brief Synopsis of the Research Therefore in this study we aim to establish the effect of the KFC manipulative therapy alone, FKC rehabilitation alone and the combination of the two interventions on osteoarthritis of the knee. This will be done by means of a quantitative randomised comparative clinical trial. 60 patients will have been diagnosed with osteoarthritis of the knee according to the inclusion and exclusion criteria, and will be randomly divided into 3 groups. 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 rehabilitation. Subjective (Beck Depression Inventory, McMaster Overall Therapy Effectiveness Tool, Western Ontario and McMaster Universities Osteoarthritis Index and Berg Balance Scale) and objective (Inclinometer) measures will be taken at baseline, 1 week and 1 month follow up. These results will be recorded and the data analysed using SPSS statistical package at a 95% confidence interval. Section B: To be typed in Arial 12-point font in one and half line spacing (expand sections to fit contents, but keep within the specified maximum lengths) 1. Field of Research and Provisional Title The relative effectiveness of full kinetic chain manipulative therapy and rehabilitation in the treatment of osteoarthritis of the knee. 2. Context of the Research 1. Osteoarthritis 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, falls cause nearly two-thirds of all non-intentional injury related deaths in older adults (Hawk et al., 2006). One of the causative factors is loss of hip and knee proprioception secondary to increased joint degeneration, thus by addressing these problems with the rehabilitation and/or adjustment there may be a decreased risk 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 home rehabilitation alone (Deyle et al., 2005), however this combination of treatments has never been compared against full kinetic chain manipulative therapy alone. 4. KOA stiffness, pain and dysfunction was shown by Deyle et al., (2000) and Deyle et al., (2005) to improve better when adding manipulative therapy to a rehabilitation program as compared to placebo and exercise alone, respectively. 3. Research Problem and Aims Aim: The relative effectiveness of full kinetic chain manipulative therapy and rehabilitation in the treatment of osteoarthritis of the knee. Objectives: i) To determine whether manipulative therapy alone is effective in the short term treatment of KOA in terms of subjective and objective measurements. 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 of 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 risk 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 review Osteoarthritis 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 hypertrophy 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 can occur in any joint but is most common in the hip; knee; and the joints of the hand, foot, and spine (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 well as improvement of joint function. Amongst these are non-pharmacological in terventions, such as rehabilitation, manual therapies, acupuncture and electromodalities, as well as pharmacological measures such as oral medication and intra-articular injections. In severe cases, where nonsurgical interventions have failed, more invasive approaches may be needed (Scher and Pillinger, 2007). McCarthy (2004) compared the effectiveness of an at home exercise program on its own or when supplemented with a class-based exercise program. There was found to be a greater improvement in WOMAC score 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) identified 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 additional 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 demonstrated 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 soft tissue mobilisation and an impulse 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 lower 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 range 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 better 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 adjus ting the lumbopelvic spine will decrease knee pain (in patellofemoral pain syndrome) is if there is a side-to-side difference in hip internal rotation greater than 14 °. The presence of this variable increased the likelihood of a successful outcome from 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 indicated 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 required. 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) scores 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 placebo (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 supervised exercise, manual therapy to the F KC and a home exercise program, while a second group received at home exercise only. Significant improvements where seen in both 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 author attributed this difference between groups to the application of manual therapy to the full kinetic chain. However, the clinic group performed the exercises under supervision and where corrected where necessary while the home group were largely 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 Methodology Design type: Quantitative comparative clinical trial conducted at the Durban University of Technology Chiropractic Day Clinic (hereafter DUT CDC). Advertising: [Appendix A] Old 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 procedure: A sample size of 60 (n=60) will be selected by means of convenience sampling (Brink, 2006). Those individuals responding to the advertisements will be screened and accepted based on the inclusion and exclusion criteria. Telephonic interview: Patients are required to contact 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]; knee[Appendix G] and; ankle and foot [Appendix H] regional examinations. Inclusion Criteria: A. 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 required: 4. Knee pain of ≠¥ 1 year duration and able to stand and walk without severe varus/valgus deformity and/or severe instability (Kellgren and Lawrence, 1957). 5. Diagnosis of concurrent subluxation/or joint dysfunction (S/JD) complex: a. 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 included (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 Criteria: 1. Significant visual disorders, severe vestibular disorders, neurological and peripheral sensory disorders which may be a contra-indication to exercise 2. 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 disc injury with sequela, 4. Severe balance and proprioception problems (i.e. inability to stand with and/or without marked spinal or hip deformity) 5. Symptoms of moderate to severe osteoarthritis in both knees and/or hips: Note: 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 basis: I. 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 time 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 time when ambulating; severe cardiovascular disease; severe instability in the knee or other joints or possibly less 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 validated for measuring depression in clinical and nonclinical settings (Beck et al., 1961). Radiological analysis: Although diagnosis of KOA will be made primarily through clinical examination, knee x-rays will be taken on patients who qualify and consent to participate in the clinical trial. 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 outside 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). Procedure: Time Baseline 2 weeks 4 weeks 6 weeks 1 week F/U 1 month F/U # Rx 2 2 2 Outcome measurement WOMAC ROM BBS BDI WOMAC OTE ROM BBS BDI WOMAC OTE ROM BBS BDI Once accepted into the study, patients will be randomly allocated into 3 (three) groups using a randomised allocation chart (reference). Interventions: Group 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 I] FKC manipulative therapy (manipulative therapy to the knee, and any indicated 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 extension 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 outlined 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 as the subluxation complex or manipulable lesion will be chosen based upon findings in the regional examinations. Rehabilitation: [Appendix J] Rehabilitative 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 frequency: All patient will receive: 6 treatments in the first three (3) weeks (2x treatments/week). Training 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 readings taken. Measurement Tools: All 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 improved, 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 utilized 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 assessments Objective 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). Statistics: The latest version of SPSS will be used to analyse the data. 6. Plan of Research Activities Provide a summarised work plan for each year of the project giving information for each research activity per year, under the following headings: Activity Timeframes (target dates for the duration of the project) 7. Structure of Dissertation / Thesis Chapters 1. Introduction 2. Review of the related literature 3. Subjects and methods 4. Results 5. Discussion 6. Recommendations and conclusions 7. References 8. 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 References Brink, H. 2006. Fundamentals of research methodologies for health care professional. 2nd edition. Juta and co. Cape 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 Randomised 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: National 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., Ward, 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: URL: http://www3.who.int/whosis/menu.cfm?path=evidence,burden,burden_gbd2000docslanguage=english Tucker, 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 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., Dougados, 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, 16:137-162. Appendix L The McMaster Overall Therapy Effectiveness (OTE) Tool (for general improvement and patient satisfaction) Patient No.â‚ ¬Ã…’â‚ ¬Ã…’â‚ ¬Ã…’â‚ ¬Ã…’ Visit No. Page No. . Overall Treatment Evaluation KOA We 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 BETTER: WORSE: How much BETTER would you say How much WORSE would you say your ACTIVITY LIMITATION, your ACTIVITY LIMITATION, SYMPTOMS AND/OR FEELINGS SYMPTOMS AND/OR FEELINGS have been since treatment started? Have been since treatment started? Please choose ONE of the options Please choose ONE of the options below: below: Almost the same, hardly better at all Almost the same, hardly worse at all A little better A little worse Somewhat better Somewhat worse Moderately better Moderately worse A good deal better A good deal worse A great deal better A great deal worse A very great deal better A very great deal worse Patient No.â‚ ¬Ã…’â‚ ¬Ã…’â‚ ¬Ã…’â‚ ¬Ã…’ Visit No. Page No. . Overall Treatment Effect CHF, continued Answer 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 before 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 important Slightly important Somewhat important Moderately important Important Very important Extremely important THANKS FOR YOUR COOPERATION! Description 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 7 Later we will dichotomize the scores on page one between scores > 1 (improved) and Appendix M The WOMAC Western Ontario and McMaster Universities osteoarthritis index KNEE OSTEOARTHRITIS Name:_________________________________________________ Date:___/___/______DOB:___/___/_____ In Sections A, B and C questions will be asked in the following format and you should give your answers by putting a straight vertical (up-and-down) mark on the horizontal line. Note: 1. If make a straight vertical (up-and-down) mark on the line, at the left-hand end of the line, i.e. NO PAIN EXTREME PAIN Then you are indicating that you have no pain. Note: 2. If make a straight vertical (up-and-down) mark on the line, at the Right-hand end of the line, i.e. NO PAIN EXTREME PAIN Then you are indicating that you have extreme pain. 3. Please Note: a) that the further to the right-hand end you place your straight vertical (up-and-down) mark on the line, the more pain you are experiencing b) 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 experiencing c) 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

Friday, January 17, 2020

Ready to Eat Cereal Case Study Essay

The value chain, Appendix B, in the RTE cereal industry consists of branded manufactures and private labels that receive their raw materials from suppliers and then distribute their product to food stores, drug stores, and mass merchandisers where the end consumer can eventually purchase the cereal product. Private labels rely on wholesalers and third-party distributors to get their product on the store shelves where the end consumer can purchase these items. In the RTE cereal industry, there were three large manufacturers, General Mills, Kellogg and Philip Morris that had a strong presence in the market. They were extremely profitable with pricing power and dominated the whole market with great market share; all this made it unattractive for potential new companies entering the RTE cereal industry. According to Appendix 2, Kellogg was one of the Big Three companies in the RTE cereal industry with an average market share of 40.25 from 1950 to 1993 in the whole industry. The industry was concentrated and the market structure for the industry was an oligopoly. The production of RTE cereal requires dough as the raw materials. Due to the fact that dough is a very common material, the power of the suppliers is low. Buyer’s switching costs were low because customers can freely choose different brands and products. Companies, in order to increase their customer’s brand loyalty to certain products, are offering coupons and promotions, which subsequently increase the buyers’ switching cost and weaken buyer’s bargaining power. There is high competition existing among RTE cereal companies; the Big Three companies had strong position and market share in the industry and are continuously introducing new brands and products causing increased competition in the industry. The high entry barrier in the RTE cereal industry was another factor that contributed to its high profitability and made the industry even more concentrated over time. The cost to manufacture RTE cereal was high to achieve a minimum efficient scale. The high cost for building a cereal plant and labor requirement made the capital requirements enormous for a new entry, contributing to our argument that the entry barriers are high. Existing Big Three companies were believed to restrain competition and new entry among themselves. They owned strong distribution channels and focused on the proper stocking, display, and promotion with supermarket chains and food stores, leaving little room for new companies to enter the industry. They emphasized the prime shelf space location in supermarket chains and food stores because the wide brand selection for customers can decrease their companies’ competitive advantage with no name brands. By guaranteeing their products maintain at the most valued center-aisle positions, providing discounts and cash payments to retailers, major companies made new entry to the industry unprofitable. In addition, existing major companies promoted coupons and in-pack premiums such as free toys and gifts to increase product sales and build brand loyalty. They also offered discounts to retailers for special treatment and promotions. This combined effort increased major companies’ dominance in the market share and the whole industry. Existing major companies also introduced a majority of new products and brands, making potential companies unable to enter the industry. At this point it looks as if the Big Three’s dominance over the RTE Cereal Industry will be everlasting; however it is hard to guarantee that a company will have sustainable competitive advantage over the industry. The industry crisis began when consumers started buying natural cereals. The Big Three did not prepare for this consumer demand, allowing other competitors to gain part of the market share. The threat of a substitute product, natural cereals, was increasing rivalry among competing firms in the RTE Cereal Industry. Although it was hard to imitate the Big Three, competitors found a way around this and found substitutes that consumers were interested in. Once private label competitors entered the market they were able to be successful in the industry by averaging only $1.90 per pound, which is significantly less expensive than the Big Three, who were charging $3.20 per pound. Private labels also had a better relationship with the grocers because of the better margins they offered to them. This was a bargaining tool Private Labels used to their advantage. Now their product was being placed in more strategically placed locations throughout the grocery store, which increased their sales and decreased the Big Three’s sales. In addition to allowing competitors into the industry, the Big Three hurt themselves by spending millions of dollars on coupons and advertising. There was little to no results that proved these methods were effective in gaining market share. For example, the RTE cereal industry spent $800 million in advertisements and trade promotions, but did not see much reward other than non-loyal consumers switching their products based on current trade promotions. Another factor of the industry crisis was due to the fact that the Big Three stopped their united front of raising prices together. The Big Three no longer made strategic moves together and in return made it easier for others to enter the industry. At the start of the RTE Cereal Industry the Big Three offered value to their customers, however over time their capabilities were possessed by many competitors, not making their organizations rare. This hurt their competitive advantage among the market. In the end the Big Three were not able to compete on cost and the willingness to pay from the consumer was declining as more substitutes came into play. Private labels faced relatively few entry barriers to become a potential threat to the branded manufacturers within the industry. The lack of product differentiation between the products of branded cereal manufacturers and private labels and the ability of private labels to offer their product at a cheaper price contributed to much of their success, Private labels success can also be attributed to the declining brand loyalty of popular branded manufacturers. Branded manufacturers relied heavily upon the distribution of promotional coupons to their consumer base, but as a result this tactic forced many customers to become price switching and brand switching sensitive that ultimately worked to the private labels favor. Furthermore, private labels success really was impacted by the higher margins their products offered to retailers, which were higher by 3% in comparison to branded manufacturers. The cost structures of private labels and branded cereal manufacturers have distinct differences, which has given private labels a strong competitive advantage in the industry. Private labels’ advertising and R&D expenses were less than branded manufacturers, which allowed the private labels to offer their product at a cheaper price. A typical cost breakdown per pound of cereal product for the Big Three cereal firms shows that 23.43% of the retail price accounted towards their advertising expenses which is about 40% less than what private labels contributed towards advertising expenditures. Ralston’s advertising expenses, the firm that dominated the private label cereal market, totaled to $0.15 per pound which about half of what other is branded cereal manufacturers contributed towards advertising. Private labels also relied on third-party distributors to deliver their product to stores. This assisted in cutting expenses by not requiring capital to create an independent distribution channel. Many private labels reduced packaging costs by packaging their cereal product in large plastic bags that proved to be a more cost-effected solution than using cardboard boxes. There are a number of things that General Mills may have been trying to accomplish when they decided to reduce prices and trade promotions in 1994, with the main reason being to improve the overall profit performance of their cereal division, Big G. Big G was the most profitable division of General Mills representing 30% of the company’s total profit. By cutting $175 million out of trade promotions and reducing the prices of their biggest brands by an average of 11%, General Mills hoped to become a more efficient firm. General Mill’s president Stephan Sanger backed up his plan for trade promotions by claiming â€Å"the 50 cents that the consumer saves by clipping a coupon can cost manufacturers as much as 75 cents.† When General Mills announced this plan to cut pricing and promotion, they believed they would be the industry leader with all other firms following suit. However, Kellogg decided to stick with their price up and spend back line. The industry was split between the two marketing strategies and bound to follow whichever approach generated more profit. By cutting $175 million from their promotion and couponing budget and reducing the prices of their biggest brands by 11%, General Mills was taking incredible risk. Cutting the promotion and couponing budget is the greatest source of the risk. The most obvious aspect of that is the loss of visibility. Customers find out about products through promotions or coupons and if those promotions and coupons are not as readily available as those of the competitor, it is hard for General Mills’ product to be as visible. Competition within breakfast cereal brands is high. Several people, often times referred to as â€Å"savers†, shop primarily based on coupons available. If coupons for General Mills’ brands are no available, these people will purchase cereal brands where coupons are available. The benefit of this decision, however, is that coupons in this industry are actually costing the company money. That being said, it is also difficult to put a price on the visibility that the coupon provides. General Mills’ decision to reduce the price of their major brands comes at a risk as well. This could be perceived by competitors as price-cutting and could start a price battle, which would end up poor for both General Mills and their competitors. As a competitor of General Mills, our expectation would be for them to have an almost wait and see strategy. We would not rush into any decision. Instead, we would see how this works for General Mills and then make a decision. By cutting promotions and coupons, General Mills is losing visibility but by cutting their prices, they are more attractive to the consumer who is already in the store. It is difficult to judge the benefit of that trade off so waiting to see what happens with General Mills is the strategy that is most appropriate for competitors. On the other hand, as General Mills, this decision has been made and they should stick to it. It boils down to the tradeoff discussed above. This seems to be a risky business decision for several reasons however this strategy should be monitored closely and reevaluated after a several months to determine the effectiveness and a plan to move forward from there.

Thursday, January 9, 2020

Childhood Obesity A Epidemic Of Today s Youth - 1108 Words

Childhood Obesity Have you ever been told to clean your plate because there are starving kids in Africa? This is a phrase you probably heard from your mother during childhood. With the difference ,in portion control, on the go meals, and lack of exercise in today,s youth, this question can cause a child to be a statistic of childhood obesity. Childhood obesity is one of the United States most leading medical epidemic of today’s youth. According to the Center for Disease Control, seventeen percent of children or about twelve and a half million adolescents between the ages of two and nineteen years, suffer from this disease. (www.huffington post.com//childhoodobesityrates.) There are many factors as to what contributes to these extremely high statistical numbers. One factor is peer pressure. Peer pressure comes in all shapes and forms and is used in all kinds of different situations. When most people think of peer pressure they think of drugs and alcohol, or something that promotes bad behavior. This isn’t always the case, peer pressure can also be about food. For example, celebrations of any kind seems to revolve around food. A birthday party involves cake and ice cream, a Christmas party is full of candy and sweet treats, and Thanksgiving, seems to be all about food. During these celebrations if one does not partake in these delicious treats they are considered rude, even antisocial. People say things like, â€Å"Its okay we are celebrating, it wont hurt you †or â€Å"just one biteShow MoreRelatedObesity A Social Problem Or A Epidemic1671 Words   |  7 Pages I will be responding to Task 3: OBESITY A SOCIAL PROBLEM OR A EPIDEMIC. In the research that I performed on this topic, I learned many things, including that the problem of obesity is not one or the other it is both. Meaning that it is not just a social problem, or just an epidemic it is both of them depending on the environment or situation that the particular person or people are in at the time. It is also not just a problem in the United States, but it is a problem on a global scale. I plan toRead MoreObesity A Social Problem Or A Epidemic1670 Words   |  7 PagesThis proposal will be responding to Task 3: OBESITY A SOCIAL PROBLEM OR A EPIDEMIC. In the research that I performed on this topic, I learned many things, including that the problem of obesity is not one or the other it is both. Meaning that it is not just a social problem, or just an epidemic, it is both of them depend on the environment or situation that the particular person or people are in at the time. It is also n ot just a problem in the United States, but it is a problem on a global scaleRead MoreChildhood Obesity : A Developing Problem1197 Words   |  5 PagesObesity in America is a developing problem, and not just in adults. Today, one in three American children and teens are either overweight or obese; almost triple the rate previously in 1963. Child obesity has expeditiously become one of the most genuine health challenges of the 21st century (â€Å"10 Surprising Facts About Childhood Obesity†). Physical inactivity, race, junk food in schools, the mass media, and the child’s parents flaws are all factors that have resulted in the prevalence of childhoodRead MoreChildhood Obesity : The United States1202 Words   |  5 PagesChildhood obesity is becoming one of the top public health concerns in the United States. â€Å"Over the past three decades, childhood obesity rates have tripled in the U.S., and today, the country has some of the highest obesity rates in the world: one out of six children is obese, and one out of three children is overweight or obese† (World Health Organization, 2015). With the drastic increase in obese children over the last 30 years and the huge healthcare associated costs many programs and incentivesRead MoreDoes Counseling Help Children with Issues of Obesity? Obesity in children is an epidemic that700 Words   |  3 PagesDoes Counseling Help Children with Issues of Obesity? Obesity in children is an epidemic that continues to be a serious problem in our nation. Over the past thirty years, childhood obesity rates in the United States have tripled, and currently, approximately one in three children in the U.S. are overweight or obese. High body mass index (BMI) among children and adolescents is a public health concern in the United States (Ogden, Carroll, Curtin, Lamb Flegal, 2010). According to the CentersRead MoreChildhood Obesity : Factors, Perceptions And Proactive Methods1197 Words   |  5 Pages Childhood Obesity: Factors, Perceptions and Proactive Methods in the Classroom Tavia Freedman (11053726), Travis Lingenfelter (10180044), Echo Chase (11162785), and Nadine Mundy (11148842) University of Saskatchewan March 28, 2017 Childhood Obesity: Factors, Perceptions and Proactive Methods in the Classroom Childhood obesity is a growing concern among today s youth. As educators, we play a significant role in the progress of this epidemic along with parents, coaches, and otherRead MoreChildhood Obesity And Its Effects On The United States Today1479 Words   |  6 Pagespediatric obesity now represents one of the most pressing nutritional problems facing children in the United States today. International population studies report comparable rates of increase, so that if current trends remain unchecked, childhood obesity is likely to challenge worldwide public health. Substantial consequences to physical and mental health, both short and long term, must be anticipated. Unfortunately, there is no uniform definition of childhood obesity. Childhood obesity has beenRead MoreObesity : Becoming A Public Concern1654 Words   |  7 Pages Executive Summary Obesity has become an epidemic in American societies that has become a public concern. According to the American Obesity Association (AOA), overweight and obesity rates are higher than ever in America’s youth. Obesity is the fastest growing cause of disease in American society today. Some of the major health concerns for today’s youth with obesity include severe asthma, Diabetes, Hypertension, orthopedic complications and sleep apnea. Researchers have come up with manyRead MoreEssay on Executive Summary985 Words   |  4 PagesExecutive Summary It is a well-known fact that obesity continues to burden the healthcare industry. According to the reports made by Center for Disease Control and Prevention (CDC, 2012), medical costs associated with obesity were estimated at $147 billion in 2008. Presently in the United States, two-thirds of adult population and approximately one in three children are fighting issue of being overweight or obese (Troy, Capretta, O’Grady, 2012). Obesity leads to chronic health diseases such as diabetesRead MoreObesity And Obesity Related Diseases Essay1706 Words   |  7 PagesChildhood obesity has become staggering in the United States. Children are considered obese if they have thirty percent amount of body fat or more and is measured by body mass index (BMI). Body mass index conveys the correlation of body weight to height. If a child’s BMI is at or exceeding over the 95th percentile, meaning if their body mass index is greater than 95% of other children that are the same sex and ag e, they are obese. Doctor Jeffrey Levi, an executive director of the Trust for America’s

Wednesday, January 1, 2020

Thomas Hobbes And John Locke - 911 Words

Two of the most prominent figures in social contract theory, Thomas Hobbes and John Locke established many of the founding ideals that contemporary Liberalism is based on. While the shared many similar positions, there are some key distinctions to be made between the arguments Hobbes and Locke make in Leviathan and Second Treatise of Civil Government, respectively. In this paper I will argue the differences between how each of them viewed the right of the subjects to revolt from the sovereign. Thomas Hobbes published his most famous work, Leviathan, during the height of the English Civil War. This was possibly the most violent and chaotic time in all of British history, and is certainly reflected in Hobbes’ writing. He introduces his view on the state of nature, that is, society without government, as a state of war, in which the lives of men are â€Å"solitary, poor, nasty, brutish, and short.† (Hobbes 89) From this state of nature he describes natural laws, which help to form the purpose of government in his eyes. The first, and â€Å"Fundamental Law of Nature† is that men â€Å"seek peace, and follow it† (92) This fundamental law is also what he believes a sovereign is meant to uphold. He argues that the Sovereign must do everything in their power to preserve the commonwealth. Hobbes strongly advocates for an authoritarian form of government. John Locke’s Second Treatise of Government was published after Leviathan though still during the English Civil War. As a wealthy landowner, LockeShow MoreRelatedJohn Locke And Thomas Hobbes886 Words   |  4 Pagesdiscuss the differences in political theories expressed by both John Locke and Thomas Hobbes. In, Leviathan, by Thomas Hobbes, and in, The Second Treatise of Government, by John Locke different theories of political legitimacy and definitions of the state of nature are described. The following paragraphs analyze multiple different points that are imperative to understanding these political theories. In the reading, Leviathan, Thomas Hobbes discusses what human existence is in the state of nature andRead MoreThomas Hobbes And John Locke Essay1441 Words   |  6 PagesEifling-Question 4 Hobbes and Locke During and after the English Revolution, a few philosophers expressed different views on their philosophical outlook and life experiences. Some of the most outstanding thinkers include Thomas Hobbes and John Locke. They had opposing views on governance matters, but the two, also, had striking similarities. In addition, the two represented an increasingly modernized European population that despised absolute kingship. Both Hobbes and Locke proposed a conceptionRead MoreJohn Locke And Thomas Hobbes1287 Words   |  6 Pagesknow how to balance and consider the nature of humankind and their rights. John Locke and Thomas Hobbes were both political philosophers who developed theories about how the government should work. They set up their theories around The Natural Law and the Social Contract Theory. Although John Locke and Thomas Hobbes had a similar goal, their beliefs and opinions were definitely not the same. John Locke and Thomas Hobbes both believed in the Natural Law and the Social Contract Theory. They both developedRead MoreThomas Hobbes And John Locke1346 Words   |  6 PagesContracts Thomas Hobbes and John Locke were two English political philosophers, who have had a lasting impact on modern political science. Thomas Hobbes and John Locke both spent much of their lives attempting to identify the best form of government. Locke and Hobbes were among the most prominent of theorists when it came to social contract and human rights. A Social Contract is an agreement among the members of a society to cooperate for social benefits. Thomas Hobbes and John Locke, are the twoRead MoreThomas Hobbes And John Locke928 Words   |  4 Pagesthere is no formed society, government, laws, safety, etc. both Thomas Hobbes and John Locke take this into perspective while introducing a political view. As illustrated by Thomas Hobbes, John Locke, Karl Marx, and Friedrich Engels, they proposed political views on how human nature can prosper. Initially, Thomas Hobbes introduces a concept on the state of nature and its effects as well as how peace can be achieved. In Leviathan, Hobbes defines what living in a state of nature would be like and theRead MoreThomas Hobbes And John Locke888 Words   |  4 Pagesare very similar but diverge in the moments that solidify their stance on their opinion. Thomas Hobbes and John Locke is both political scientist who have made strides in the area of social contracts and share being natural law theorist also. Locke and all other natural law theorists assumed that man was by nature a social animal and there fore struck contracts with each other to secure safety among them. Hobbes assumed differently, thus his verdicts are very different from other natural law theoristsRead MoreThomas Hobbes And John Locke1494 Words   |  6 Pages1) Thomas Hobbes and John Locke share the basic assumption that a theory based off of abstract individualism, consent, sovereignty and reason will produce a peaceful and productive society. This theory is the liberal political theory, which is the philosophy of individual rights and a limited government. Both Hobbes and Locke both center the majority of their ideas off of how people’s lives should be based off of nature rights instead of natural law. This being said, people are also subject to theRead MoreThomas Hobbes And John Locke1426 Words   |  6 PagesBy the second half of the 17th Century, England would experience one of the bloodiest conflicts in its history, ultimately serving to influence some of the most phenomenal political philosophers in Europe --Thomas Hobbes, and John Locke. England was in constant unrest, choosing new forms of government almost on a whim in desperate attempts to restore order in the Country. The English Civil War in 1642 etched a legacy of drea d in the people of England, and the war only appeared more disastrous andRead MoreThomas Hobbes And John Locke1659 Words   |  7 Pagesmajority. The following pages show how modern social contract theory especially that of Thomas Hobbes and John Locke, grew into the divisive issue it is in contemporary political philosophy. Modern social contract theory can trace its roots to prominent thinkers Thomas Hobbes and John Locke. It is their thoughts on social contracts that lie at the center of the many spheres we are a part of. For Hobbes and Locke, social contract theory sought to analyze the relationship between rulers and the ruledRead MoreThomas Hobbes And John Locke1361 Words   |  6 PagesThomas Hobbes and John Locke were two English thinkers in the seventeenth-century who s ideas became a key to the Enlightenment. Baron de Montesquieu and Voltaire were philosophers who applied the methods of science to understand and improve society. Thomas Hobbes believed in a powerful gover nment. He believed people were naturally cruel, greedy, and selfish, and if they were not strictly controlled they would commit crimes and abuse one another. He believed that life with no government would be