Comparing Making History and Death of a Salesman Essay

‘The tragic hero is a man of noble stature. He is not an ordinary man, but a man with outstanding quality and greatness about him. His own destruction is for a greater cause or principle.’ Aristotle How far is this statement true concerning Willy Loman and Hugh O’Neill? Compare and contrast how heroism is presented in Making History and Death of a Salesman. Willy Loman has no extensive amount of greatness as a character and socially he is a middle-class citizen, he is a very proud man, this personality flaw tends to obstruct his view of reality. Within the Loman household Willy controls his family, in return they look up to him as the man of the household and a symbol of dependence as he is shown to be the prime bread-winner and he constructs a cloudy image to his sons that he is a â€Å"well liked† man in order to inspire them to pursue the ‘American Dream’. Hugh O’Neill, on the other hand, is a much more renowned man within society and his role is great (dissimilar to Willy’s), due to the fact he has a vast amount of power as the Earle of Tyrone. He too has an image to present for his plans to ensue effectively. Willy Loman believes that the only people who achieve are the ones who â€Å"make an appearance in the business world, the man who creates a personal interest, is the man who gets ahead.† Something Willy said to Bernard, an inferior friend of Biff’s who is far less ‘attractive’ but more intelligent, ironically Bernard becomes more successful in further scens of the text. In addition, this illustrates how Willy’s ideals are becoming outdated and obsolete, as the society he is living in requires work to be efficient and the way a person is perceived has no impact on working effectively. Willy’s incapability to overlook aesthetic qualities is one of many flaws he possesses as a character, due to the fact his thoughts have been narrowed by past ideals. Willy hasn’t changed along with the format of the high demand-business world he inhabits; this contributes towards his depression and dissatisfaction with his son Biff, who has so much â€Å"personal attractiveness†. Although this segment of the play is a memory and seemingly light-hearted, the message is a lot deeper and symbolises how shrouded Willy’s views are, Bernard acting as a symbol of this. Arthur Miller uses several character’s to act as symbols or messages, for example it could be argued that Ben, Willy’s older, more successful brother is a metaphor for the ‘American Dream’ as he achieved what neither Willy nor any other Loman have managed. Ben talks of â€Å"diamonds† which are aesthetically attractive, and it could be argued that they are worth s o much due to their appearance, this is very reflective of Willy’s own pride induced views of success. During Act 2, Scene 2 when Hugh â€Å"shuts the book in fury† is symbolic as it represents change within Hugh, in earlier sections of the play Hugh questions Lombard’s intentions when writing said book, and asks â€Å"But you’ll tell the truth?†, and now in the second act he is infuriated by the book as Mabel is not a part of his history and Hugh disregards his usual behaviour to follow instructions. His duty would be to remain true to Lombard’s plan, but his anger towards ‘The History’ book demonstrates Hugh’s personal beliefs becoming a priority whereas beforehand his identity was dependant on his duty. The theme of history reoccurs throughout Friel’s play, the title alone reinforces the idea that Lombard wants to make a history for the Irish to remember, but Hugh wants reality. It could be argued that Hugh’s identity becomes less fragmented as the play ensues. The book Aristotle said that â€Å"A man doesn’t become a hero until he can see the root of his own downfall†. Similarly, Willy is aware of his flaws but fails to outwardly admit to doing so, instead he takes a defensive approach and orders his memories in a way to create a reality which does not exist, for example, during Act 2, Scene 5 Willy learns of Bernard’s success and naturally compares him to Biff, (as he always has) who is yet to achieve anywhere near as much as Bernard. When Bernard asks Willy about what happened to Biff, Willy answers â€Å"If a boy lays down is that my fault?† The reason for Willy’s aggressive behaviour in this scene is influenced by the fact he knows that he is the reason for Biff’s loss of ambition. His flaw being brought to the surface, as Willy fails to admit that he is to blame although the audience is shown via facial expressions and changes in vocal tone or physicality e.g. a nervous twitch, to show Willy’s anxiety towards Bernard.

Piaget’s Cognitive development theory Essay

Jean Piaget and his theory of the stages of cognitive development have made significant contributions to a wide cross-section of disciplines including educational psychology and applied developmental psychology. Though his original theory has undergone some amount of changes, the basic tenets are still applicable in understanding how humans develop progressively from birth to adulthood. Several theorists have criticized Piaget’s theory and have proposed alternative approaches to explaining human development. Other theorists have espoused Piaget’s theory with few modifications or additions to the original theory. Nevertheless his theory of cognitive development has had a tremendous impact on developmental psychology and will continue to represent a valid theory in helping to understand the nature and stages of human development. The field of applied developmental psychology has and will continue to benefit from the views put forward by Piaget. Biography of Jean Piaget Jean Piaget was born in Neuchatel, Switzerland on August 9, 1896 to what he described as a ‘tumultuous family environment. From an early age Piaget showed signs of having superior intelligence and acquired an interest in several fields of study including psychoanalytic theory, philosophy, mechanics and natural history. At the very young age of ten he published a study on mollusks (malacology). Several years later, in 1917 he published a philosophical novel. His intellectual and research accomplishments thereafter are numerous. In 1918, at only 21 years of age he obtained his doctoral degree in Biology from the University of Neuchatel continuing his study of mollusks in his thesis. His interest in philosophy and psychology led him to Zurich where he worked with mental patients while studying psychoanalytic theory. His interest in child developmental psychology began in Paris with his work in a laboratory at a grade school. Here he worked along with Alfred Binet, who headed the laboratory, in standardizing reasoning tests for Paris children. He became curious about the thought processes of children that influenced them producing either the correct or incorrect answers. Piaget published a number of articles discussing the research he conducted here. In 1921 Piaget was made director of studies at the Institut J. J. Rousseau in Geneva. In 1923 he married Valentine Chatenay with whom he had three children. He continued his study of child psychology and later published five books on the topic. His background in Biology had a significant amount of influence in his research (Slavin, 2000). These publications subsequently distinguished him in this field of study. His academic and administrative appointments saw him working at the University of Geneva, the Sorbonne, the Institut des Sciences de l’Education, and the Bureau International de l’Education. He is also noted to have founded and directed a center for philosophers and psychologists called the Centre d’Epistemologie Genetique. He worked along with several other researchers including Alina Szeminska, Barbel Inhelder, and Marcel Lambercier. Among the research topics that he conducted extensive studies on have been noted the notions of number, physical quantity, and space; manipulation of objects; and the development of perception. These areas collaboratively contributed to his theory of cognitive development. His platform of study was both at the professional and personal level. It is widely known that he conducted detailed observations of his three children Jacqueline, Lucienne and Laurent throughout their infant and language development years. His wife, herself a psychologist, also worked along with him during his observations, recording the behaviors of their children (Fischer & Hencke, 1996). Piaget’s contributions to the field of developmental psychological are indeed considerable and have been widely acknowledged. He was awarded the Distinguished Scientific Contribution Award in 1969 by the American Psychological Association for his contributions. At his death in Geneva on September 16, 1980, Piaget had written and published more than 40 books and over 100 articles or chapters dealing with the topic of child psychology. His earliest works include The Origins of Intelligence in Children (1936/1952), The Construction of Reality in the Child (1937/1954) and Play, Dreams, and Imitation in Childhood (1945/1951) (Fischer & Hencke, 1996). To date his research is believed to have made the single most important contribution to developmental psychology (Slavin, 2000; Beilin, 1992) and to a large extent the field of cognitive development psychology was founded primarily on his work (Goswami, 2001, p. 259). Piaget’s theory of cognitive development Piaget sought to describe how development occurs from the moment of birth unto adulthood and the cognitive changes that occur as physical development takes place. Using his background in Biology and his knowledge of the way organisms behave relative to their environment, Piaget sought to explain how children think along these lines. Piaget’s position that children construct knowledge based on these processes was in antithesis to behaviorist orientation which suggested that behavior was molded exclusively by external environmental forces. Piaget’s theory was more constructivist in nature proposing that each child is actively involved in constructing his own reality. Construction of knowledge, Piaget argued, was facilitated via the interaction of the processes of adaptation, accommodation, assimilation and equilibration. Piaget commenced by proposing that children are born with a natural inclination to interact with and a need to understand their environment (Slavin, 2000). From the earliest stage children develop mental patterns that guide their behavior, what Piaget calls schemes. Schemes are used to â€Å"find out about and act in the world† (Slavin, 2000, p. 30). The goal of intellectual development, according to Piaget, was towards adaptation where existing schemes are adjusted in response to modifications in the environment. As new situations arise children either incorporate new objects or events into existing schemes through assimilation or they adjust existing schemes when new objects and events do not fit into those existing schemes in the process of accommodation. When unfamiliar situations arise a state of disequilibrium ensues and the processes of accommodation and assimilation facilitate the return to equilibrium where balance is restored between existing understanding and new experiences – the process of equilibration (Slavin, 2000). The dimensions of the theory Piaget believed that children passed through four different stages of development that are defined by different characteristic features from birth to adulthood. Piaget proposed that each child moves progressively through each of the stages of cognitive development as they mature physically. The four distinct stages of cognitive development that Piaget has specified are the sensorimotor, preoperational, concrete operational and formal operational periods. He also gives an estimate as to the age at which each child will enter either stage. Wakefield (1996) points out, though, that â€Å"the age range for each stage is only an average† a child may enter a specific stage earlier or later than that estimated by Piaget. However, each child, Piaget argues, must pass through each of these stages of development in the specified order and no child can skip a particular stage. It must also be noted here that his theory is necessarily universal as it examines only how all children will progress and does not seek to analyze individual differences among children. The sensorimotor period represents a child zero (0) to two (2) years old. The main aspects of this stage Slavin (2000) summarizes as where â€Å"infants learn about their surroundings by using their senses and motor skills†. Piaget believes that each child is born with some built in mechanisms and tendencies and these he labels as reflexes. Because a newborn child has not yet developed a concept of his environment, his initial response to this environment up to one month old is instinctive. These reflexes, however, soon become the basis through which the child acquires new perspectives and behaviors (schemes) in an attempt to learn about and understand his environment. From birth to one month children begin to establish schemes as they commence the processing of interacting with and understanding their environment. Initially displaying behaviors by simple reflex children soon begin to modify these reflexes. From one to four months children attempt to reproduce recurring themes in their schemas. Children later begin to establish repetitive patterns in behavior and to associate different behaviors with different schemes. Examples include an infant crying when hungry and laughing when happy. The period two to four months Fischer and Silvern (1985) notes as when the child is developing the ability to intelligently adapt individual actions such as grasping a rattle (p. 634). Between four and eight months children are more object-oriented paying more attention to objects in their external environment, becoming more observant and less preoccupied with issues related to themselves such as hunger and sleep. Children begin to display more coordination in their schemes. From eight to 12 months children become aware of what they want and begin to construct their own schemas in order to achieve their goals. Behaviors are now more deliberate, carried out with a particular purpose in view. From 12 to 18 months children they are exploring new possibilities with objects in their environment. A child’s action at this stage is very experimental using trial and error to discover new schemas. From 18 to 24 months children begin to transition from this stage to the second preoperational stage. They are developing the ability to function using symbolic representations. Of course a child at the sensorimotor stage may not necessarily be able to fully understand every new thing that he perceives in his environment. Wakefield (1996) comments that, even though a child is unable to perform some amount of logical thinking at this stage, there is still some attempt to understand his environment through the use of his sense perceptions and motor skills. The preoperational stage is between ages two and seven years approximately. At this second stage children begin to be able to use symbols to represent things mentally by associating those new things with objects they are familiar with. While they are a little more developed cognitively than the earlier stage they still have a very narrow view of their environment. Within this stage, from age two to four years a child is relatively egocentric believing that everyone else sees things from their perspective. They also possess some amount of animism, believing that objects have characteristics similar to living things such as the ability to move. From age four to seven children further develop their reasoning capacities even though their thought processes are not completely logical. They have difficulty, however, with the concepts of centration and conservation. Slavin (2000) explains these concepts by illustrating that in this stage a child does not understand that the amount of milk in a tall glass is the same when it is poured into a shallower container nor are they able to realize that an object painted a different color is still the same object. The third stage of cognitive development is the concrete operational stage which covers children aged seven to eleven. At this stage children, while experiencing difficult thinking in abstract, are able to form concepts and solve problems. Of course they must be able to relate such operations to already familiar objects or situations in order for them to function properly. They are now able to understand and apply the principles of conservation and centration. Their reasoning is also considerably more logical and can show interrelations between different objects and classes of objects. They are still limited, however, in that they are unable to reason in abstract terms but need concrete circumstances and examples as guides. A child in the final formal operational stage, lasting from age eleven (11) to adulthood, is now able to reason in abstract and to conceptualize situations beyond what they can see and touch. They have now developed the capacity to perform reasoning about events, actions or objects that they cannot see or that are strictly hypothetical and they are also able to use deductive reasoning. They begin to devise plans to solve problems and test their hypothesis against a variety of options. Piaget’s stratification of cognitive development into different stages has considerable implications particularly for educational goals. Because children are able only after having moved through certain stages, to manipulate certain tasks and to be effective in certain cognitive activities, learning situations must be structured so that they match the developmental stages. Education must therefore be developmentally appropriate to the abilities of the child and attempts should be made to help children, as they progress from one stage to the next, to manipulate the operations inherent at each stage. Piaget’s view of cognitive development has been quite formidable and influential in helping researchers understand the processes at work at different stages and ages. There have, however, been several criticisms of the model. One of the major criticisms has focused on the presumed universality of the stages that Piaget describes. He supposes that every child, irrespective of situational context, will go through these stages at a prescribed time and that the principles are therefore applicable to all children everywhere. Some researchers have noted, however, that the rate and stage of development is not at all universal. The ages that Piaget initially suggested as delineating each stage are therefore thought of as rough estimates and children can enter and exit each stage either earlier or later than initially prescribed. Another concern that was raised with regards to Piaget’s theory was that it suggested that as the child progressed through the stages that the abilities at the lower stage no longer become useful or necessary. Piaget later clarified, however, that the concrete thinking and other abilities at the lower stage are not only essential before a child is able to progress to more complex thinking but they are also persistent over time and that a child never loses the lower abilities. He suggests that over time certain tasks become automatic, almost instinctive, but they are still essential even in the later stages of development. Further Piaget’s original theory had not considered the potential impact that the environment may have in impacting behavior. His initial argument much to anti-behaviorist and thus the power of environmental factors to shape behavior was almost ignored. Even though he accounted for these influences in his explanations of the process of adaptation and equilibration, he did not focus much on this aspect. Researchers have found that various social and environmental factors can have a considerable impact on a child’s development. They propose that a child can enter a stage earlier and progress through that stage much quicker than others based on the stimuli available in his environment. Similarly a child’s development may be significantly retarded if adequate stimuli are not provided in the environment. A child would therefore progress through stages later and at a slower pace. The behaviorist position that the environment matters is therefore not completely invalid and their view of the potential influence of the external environment in shaping behavior has some merit. Despite this failure to fully acknowledge and explain the relevance and impact of environmental factors in facilitating knowledge construction based on reality and even though the theory seems to emphasize universal stages of development, Fischer and Hencke (1996) believe that Piaget with his cognitive development theory is notably still the most influential researcher and theorist on developmental that the twentieth century has seen (Fischer & Hencke, 1996, p. 09). Current research Several theorists have arisen in more recent times to expand on Piaget’s original theory, to propose modifications on the areas of weakness or to suggest a complete new approach to understanding cognitive development. Among those worthy of mention are Robbie Case, Kurt Fischer, Michael Shayer and Juan Pascual-Leone. Robbie Case is a neo-Piagetian who agrees with Piaget’s general position that children go through developmental stages. Case also agrees with Piaget that each stage is delineated based on age and is representative of the changing ways that children are able to mentally represent reality and how they process information in their brains. Case also supports that cognitive development occurs in four stages commencing from when a child is around one month old until the period of adulthood. Within each stage he also recognizes substages of development postulating, like Piaget that each successive stage is a continuation or a building on to the former (Sternberg, 1987, p. 08). Beginning in the mid-nineteen seventies Case began to propose alternative interpretations of the stage development theory. He has developed some characteristics in his new theory that are not in complete alignment with original Piagetian thought. His first area of departure is with relation to the way that information is processed in the brain throughout the stages.

Economics of Sports Projects Assignment Example | Topics and Well Written Essays - 500 words

Economics of Sports Projects - Assignment Example streak since probability if making a hit after three misses is 83.3% which is higher than the probability of making a hit after three hits with a probability of 50%. The calculated correlation coefficient is negative. This therefore does not show evidence of the hot hand. Given a player has made one or two hits; their opponents will usually try to improve their defensive mechanism on the particular player and therefore take away the players successive shooting streaks. Defensive strategies can be the probable cause for the negative correlation between successive hits. The evidence suggests existence of hot hand. The Z statistic reported above test the significance of the variation between the expected and the observed number of runs. There is always a significant difference between the expected value and observed value for individual players. Run tests performed on each player within individual games reveal compelling results. Considering the 76ers and their opponents, data obtained of 727 basketball players show game records of more than two runs. When the observed number of runs and expected number of runs are compared there is no sufficient evidence to provide any basis for rejecting the hot hand hypothesis. Clearly 13.55% calculated is less than 13.6% tabulated therefore we accept the null

An investigation on Crystals belief that the language of texting Essay

An investigation on Crystals belief that the language of texting contain features which are not linguistically novel but contain antecedents in earlier language use - Essay Example ill also look at how adults have adapted to the use of the language, nullifying much of the advantages that adolescents believed they had gained from its use. In looking at the responses to a questionnaire on the topic of text messaging, a determination can be made on the level of infiltration that the language has made into current culture can be assessed. Finally, the study will make some recommendations on the development and legitimacy of the language, utilizing the research to create informed conclusions. In the past decade, the increase in the use of an abbreviated language to communicate in the form of the text message has become a significant addition to the number of ways in which information is passed. In using this method of communication, an adoption of a new language has created a controversy over the possible diminished depth of formal writing in favor of the simplistic version of language that is used in SMS (short message service). As a generational gap is created by the introduction of these technologies to the youth, the worry becomes more integrated into parental concerns over a form of language that cannot be easily deciphered. As the text messages in contemporary society become linguistically defined by standardized terms that are becoming recognizable on a universal level, a new language has emerged that requires identification, interpretation, and examination for its validity. The creation of convenient language that interprets current cultural needs is not a new phenomenon. Meaning that is developed contextually and contains relevance to popular culture has been the vernacular of language throughout history. The way in which intimates communicate has always been through language that is developed in such a way as to have an exclusionary effect. By creating a language for communicating through the technology of text messaging, society is continuing a tradition that is not new in history. Therefore, the creation of this language

Case Study Analysis Research Paper Example | Topics and Well Written Essays - 500 words

Case Study Analysis - Research Paper Example Even sites that were contaminated got their attention. They refused to give up. The Americans made few mistakes. The Mexicans made many mistakes. At times it seemed as though they were trying to obstruct justice. They contaminated scenes and slowed down the process. They refused to cooperate in the interests of getting to the bottom of the case. Indeed, they did little investigating on their own. Most of the time they followed the Americans around trying to prevent them from finding new evidence. There was a serious air of complicity in their actions. The Americans had a hard time because they werent in their own country and had to obey the Mexican law enforcement agents. That made their situation especially difficult. Under normal circumstances, the rule of law would have applied, and it would have been much easier to do their investigation in a timely and methodical fashion. In the United States those who obstruct the investigation of law enforcement agents face a criminal complaint. Unfortunately this case occurred before many modern methods of investigation were available. DNA profiling would have been useful. The best method of collecting a sample is through a â€Å"buccal swab.† Sometimes this requires a court order and police can’t get it. In these cases, other methods can be used including taking samples of blood, saliva, semen, or other fluid or tissue from personal items (for example, toothbrush, razor, etc) or stored samples. Sometimes, samples taken from blood relatives may be used to catch bad guys. So far these methods have proven to be very successful. These processes could have been done on the bodies and the residence and the

Small Firms in UK Essay Example | Topics and Well Written Essays - 3000 words

Small Firms in UK - Essay Example For these reasons, small business industry is critical to UK economic development and social cohesion. They provide a medium for retirees and other potential unemployed persons to have gainful employment and contribute fully and independently to wider society. Small businesses have been contributing to employment and manufacturing since the 1960s. The increasing rates of self-employment have been attributed to; a parallel rise in rates of unemployment (e.g., retirees, unspecialised graduates); reductions in levels of unemployment benefits and government incentives; and the increasing importance of technology in the information service industry. In the early 1970s there were changes to the industrial structure across the globe of industrialised nations. Initially, the value of the small business decreased, but by the 1970s the structure of manufacturing saw dramatic changes and small firms began to provide better quality of products and services than larger corporations, particularly in areas of rapid technological changes (e.g., electronics). Over time, small firms began again to add value to the UK economy, and among many small businesses their rates of employment increased. So that there has been a significant shift in industrial structure back to the small firm amongst industrialised nations (Landstrom, 2005).The shift brought within environmental opportunities to be exploited by entrepreneurs with their innovations and business developments. Political discourse began to focus upon entrepreneurship, receiving support from Margaret Thatcher in the mid 1980s and strong policy was introduced to support small businesses and entrepreneurship. The research interest in small business increased during this period, and social scientists began to contribute to research directions and understandings. This has led to a strong multi-disciplinary approach to small business research in the UK today. (Landstom, 2005). During the 1990s the interest become more about growth orientated established businesses. Tony Blair took a much more narrow and focused approach to reforms as compared to Thatcher, targeting technology-based firms and socially inclusive entrepreneurship as ways to bring 'life' back to weak regions of industry (Landstrom, 2005). The present government provides most of the funding for research into small business dynamics and the contributions of such entities to the growth and strength of the UK nation. However, this also biases the areas that research goes into, what interests the government and this could counter advances in knowledge and processes. However, funding from the government does require the use of empirical investigative techniques, ethical considerations and a policy focus to research endeavours. With the consolidation of small business research there was a great support for entrepreneurship.As industrialised nations shift manufacturing sectors to less developed natio ns to lower the costs of production, the likelihood of unemployment has increased. This global shift in industry structure has fostered employment opportunities for some through small businesses (AusIndustry, 2006). Current trends of redundancy for older workers, such as those in middle management positions have seen some retirees adapting self

Race, Ethnicity and Slavery in America Essay Example | Topics and Well Written Essays - 1250 words

Race, Ethnicity and Slavery in America - Essay Example Takaki argues that multicultural education ensures a comprehensive understanding of American History (Takaki, 34). This is crucial in situations involving Americans going to work in other countries as it helps them identify well and understand those cultures. It is of critical importance to highlight that both the two authors concur that ethnicity and racism bring about several conflicts. These may be in form of conflict of perception, opinions, and inclusion within the society. This may disrupt peace enjoyed within that society. James and Heather Olson Beal concur that the issue of racism leads to erosion of the culture of a nation and conflicts (Olson & Beal, 10). These authors also concur that the issue of ethnicity may cause unnecessary discrimination on people. This may make some people land jobs whereas preventing others from securing such jobs. James and Heather Olson Beal argue that the issue of ethnicity is a monster to national development as is associated with inequality a mongst individuals. As such, this may at times disrupt the peace of the society as it can cause several conflicts (Olson & Beal, 11). However, America being a culturally endowed nation has the moral responsibility to ensure that its entire people are considered one. It aims at unifying the different races and ethnic groups so that they can effectively coexist and share the different skills, expertise, talents, and capabilities towards a common goal. However, even though these authors perceive race and ethnicity in a negative perception, there are some advantages associated with different races and ethnic groups coming together (Takaki, 34). Circumstances involving coming together of different races and ethnic groups may ensure poor people from one race being encouraged by other prominent persons from other races, thus, promoting development. The spirit of inclusion through multicultural education also leads to a feeling of unity and promote peace (Takaki, 48). Being an American enta ils a lot. One must be able to understand that America is composed of several races and ethnic groups. Since these people have different cultural beliefs, traditions, and customs, there is a need to provide a harmonious ground that can suit all these people, with all their cultural diversities. This is crucial in ensuring development in several sectors on several perspectives in America. The issue of different races and ethnic communities residing in America is quite advantageous since it brings a sense of development with regard to diverse expertise, experiences, talents, and skills from the different ethnic groups. Therefore, promotion of unity and peace in America more so, through the American national anthem is core towards harvesting all these advantages associated with diverse cultures. It is of critical significance to note that race and ethnicity have played major roles in the history of America. In order to fully expound on this matter, it is crucial enough to understand th e meanings of these two terms; race and ethnicity. The term race refers to the biological differences that distinguish a group of people concerning their physiology. Race may apply to the distinction in skin color, color of hair and facial features. However, on the other hand, ethnicity refers to the distinction of individuals concerning their culture, beliefs, and traditions.  

Samsung Electronics Case Study Example | Topics and Well Written Essays - 500 words

Samsung Electronics - Case Study Example The memory industry is characterized by having few powerful suppliers. The consumers are extremely price conscious thus profit margins are low. In order to be able to get lower prices from suppliers companies have to buy in bulk. Suppliers give high volume buyers a 5% purchase discount. Memory represents about 4-12% of the cost of an OEM computer. The OEM computer industry is the primary buyers of DRAM. The OEM computer industry is fragmented and no single OEM manufacturer holds more than a 20% market share. Quality is a critical success factor for companies in the memory industry. Product quality allows companies to achieve customer retention (Kotler, 2002). Defective memory is high risk for a computer manufacturer because it could destroy product value. OEM companies are willing to pay an extra 1% price premium for reliable suppliers. Samsung which is a successful player in the memory industry developed new types of cutting edge memory chips that enable them to differentiate themselves from the competition. The use of innovation enabled the company to have a great product variety and penetrate niche markets within the industry were they could charge higher prices. In 2003 Samsung offered 1200 types of DRAM products. This gave the company an advantage because by 2005 the prices of the older memory technology started to depreciate in price. When this occur the best approach for companies that did not have the new innovative products like Samsung was to utilize a strategy to gain market share. Chinese manufacturers utilized the strategic approach of increasing market share. Another critical success factor in the industry is having organizational experience and tacit knowledge to master the design and production process. Testing chips for reliability during the production process was imperative. Successful companies designed process improvements to allow more

Performance Theory or Theorizing Performance Essay

Performance Theory or Theorizing Performance - Essay Example From this paper, it is clear that the scene is a mixture of all kinds of elements that make a script worthwhile and captivating to the audience. The script has the elements of love, hatred, anger, irritation, etc. that make it attention grabbing for the audience and make it interesting and challenging for the role player as well. The use of material objects at the scene was outstanding and made it easy for us as well as the audience to focus on the main plot of the script. For example, the starting scene when Will is sleeping on Skyler‘s bed shows a deep intimacy he shares with her and the closeness of their relationship. But at the same time, the scene portrays unpredictability to their relationship. The language of Will shows his aggression which is a reflection of the child abuse he went through in his early days with his father. He is continuously using abusive language which shows that he is not a follower of any culture and lives his life according to his own rules. The u se of abusive words adds up to the aggression in Will character. Moreover, the intensity of his anger is indicated with the deliverance of his dialogues. He doesn’t let Skyler complete the whole sentence and cuts her in between. And even if she says something Will doesn’t listen to her and says whatever comes to him. The performance displayed was an implication of the performance theories in theatrical performances. All the blocks of structured performance were connected with the use of right content, speech, objects, language, and actions.

INTRODUCTION TO NEGOTIATION Essay Example | Topics and Well Written Essays - 750 words

INTRODUCTION TO NEGOTIATION - Essay Example Individuals and groups use it to resolve conflicts that cannot find unilateral solution (Rana, 2009). Bilateral negotiation has the objective of ensuring there is a solution to issues that cannot get unilateral solutions. Bilateral negotiation ranks top in conflict resolution because it employs numerous tactics. Such tactics easily influence the hard-liner party to ease its position. The tactics employed by negotiator easily directs parties involved into an area of possible solution to the issue discussed (Rana, 2009). Consequently, parties making extreme offers find an atmosphere for falling back easily from their hard bargains. Bilateral negotiation offers time for preparation. Although people underrate this time, it remains a fundamental stage of the conflict resolution process. The preparation time has merit because upon finding a resolution, implementation follows instantly since at that time all parties involved are available (Ertel & Gordon, 2008). Preparation time gives those involved time to break down their direct and indirect strengths, aims and limits, argument, style and tactics and hidden agenda. The stage also provides parties involved an opportunity to examine their perceptions among other cross-cultural issues involved in the conflict. Preparation time in bilateral conflict enables businesses to gather relevant internal information for the task of conflict resolution. Consequently, each gathers all the facts, alternatives and other necessary options (Rana, 2009). In addition, this stage that ensures institution of negotiation team, with identification of its leader. Such procedures provide for direction to the negotiating team. Another stage that gives bilateral negotiation credit is the pre-negotiation stage. The stage, negotiators, and the teams involved find an opportunity to clear up conflicting interests. Moreover, negotiating team makes an establishment on whether there is a possibility and

Consequences of Exploration for Europeans and the Indigenous Peoples Essay Example for Free

Consequences of Exploration for Europeans and the Indigenous Peoples Essay In 1492, Christopher Columbus landed in the Caribbean bearing the name of the Spanish Crown in hopes that he had landed in the Indies of Asia using a direct sea route. Though that is not where he landed, his New World was a place of great wealth, new materials and crops, new source of labor, and new land for the European nations. The consequences for the native people of the Americas were much worse with devastating death tolls, enslavement, new diseases and racist attitudes towards them. Though it would not be fair to say that the Europeans did not share in negative consequences or that the indigenous people did not gain any advantages. The greatest negative consequences for the Europeans due to the European expansion are a devastating economic revolution, and the introduction of the venereal disease Syphilis. Once the Spanish began to mine the precious ores of America the wealth of Spain underwent a major transformation. Demanding one-fifth of all profit, the Crown became immensely rich and this showed in their influence on the rest of Europe, seeing that other countries now lacked the material wealth of Spain. Throughout this time of great wealth the population rose steadily in Spain. With population increase, came an increased demand for food and merchandise. Spain had expelled a large amount of their skilled farmers, workers, merchants and businessmen during the Inquisition when they cleansed their country of the Jewish and Muslim people. Along with the demand in Spain, the demand for Spanish and European products in the Americas also became hard to keep up with. With the ever-increasing influx of silver bullion the prices in Spain began to rise and the inflation quadrupled the prices of everything within thirty years. In 1556, Martin de Azpilcueta Navarro, a Spanish canon lawyer, writes about the influx of American silver as the cause of the inflation. We see by experience that in France, where money is scarcer than in Spain, bread, wine, cloth, and labour are worth much less. And even in Spain, in times when money was scarcer, saleable goods and labour were given for very much less than after the discovery of the Indies, which flooded the country with gold and silver. The reason for this is that money is worth more where and when it is scarce than where and when it is abundant. Along with this, the Spanish king Philip II spent more money on outside enterprises to worsen his countries debt. When needing to pay his debt to other countries, he also paid in silver bullion spreading the inflation to the rest of Europe. The discovery of the Americas led Europe to inflation and increased prices and Spain to almost complete debt by the seventeenth century. Besides silver and gold, the native people of the Americas passed Syphilis on to the Spanish who came to settle there. In five year time, Syphilis had spread to Russia from the European Atlantic coast. Though it could not be proven, Syphilis is thought to have originated in Espaniola because no evidence of Syphilis exists in Europe before 1493. These open sores, boils, and aches in the joints caused excruciating pains to many Europeans due to this quickly widespread venereal disease. The only proven effective way to treat Syphilis was from drinking the boiled bark of the guaiacum tree which only grew in Espaniola. Though no exact numbers were calculated for Syphilis it could not be compared to the death tolls that the European diseases left on the Indian populations. In a period of 130 years, something like 95 percent of all Native Americans died of disease. That number is far greater than experts (until recently) had ever suspected. The Native Americans who survived the plagues were, of course, completely demoralized and depressed by this tremendous loss of their loved ones, of their lifestyle, and of their ancient culture. (Bib 2. ) The 95 percent population loss of the Natives was staggering compared to probably one percent death caused by Syphilis. Thus though Syphilis was a negative consequence of European expansion it proved minor compare to the Indigenous peoples loss due to European disease. Besides new crops and animals the indigenous people were introduced to new religions, medicines and ways of life that helped better themselves. Christianity was introduced to the indigenous people thanks to very ardent Catholicism from the Spanish and Portuguese. These Christians taught of love, equality and a heaven after death for those who acted well on earth. For many indigenous people this religion called to them and they were converted. Those who did not convert voluntarily were either forced to convert or killed. The native people actually became very passionate about this religion and even followed religious doctrines more closely than the Spanish conquistadors. The natives began to spread peace and love as a bigger doctrine than territory fighting which shows how religion was a positive outcome from European expansion. New technology and medicine helped more effectively cure the local people and brought new light to the topic. In Pre-Colombian times the Indian populations would come to the ailing and stay by their side through illness thus probably catching the illness themselves, the Europeans taught to isolate the sick and better medicines to treat them. The lives that new medicines saved in the Americas is immeasurable but probably still do not compare to the lives lost from European diseases. New technologies such as guns, steel and sailing equipment helped build stronger weapons than the ones previously possessed by Indians, and a new material from which objects could be made. Very strong steel could be used to make protection from swords and swords themselves thus fortifying indigenous peoples ability to make weapons, protect themselves, and hunt. Many thousands of things brought from Europe helped make indigenous life better such as candles to light the night and paper so writing and language could be better developed. Though much understated there were many positive outcomes from European expansion to the indigenous people of the Americas and even a few negative outcomes for the Europeans themselves. More often than not, when talking about the European expansion into America, the Europeans seem to get much better rewards from their expansion. And they actually did. They reaped much higher rewards from their conquest of the Americas than the indigenous people, yet it cannot be forgotten that both peoples had multiple sides to their gains and losses due to European expansion. Bibliography Quotes: {draw:frame} 1. Why were Native Americans so vulnerable to European diseases? (article). Articles on how to feel good more often and get more done. Web. 10 Oct. 2009. http://www. youmeworks. com/why_native_americans. html. Galloway, J. H. The Sugar Cane Industry An Historical Geography from its Origins to 1914 (Cambridge Studies in Historical Geography). New York: Cambridge UP, 2005. Print. American Indian past and present. Norman: University of Oklahoma, 2008. Print. Other Info: Spanish colonization of the Americas -. Wikipedia, the free encyclopedia. Web. 11 Oct. 2009. http://en. wikipedia. org/wiki/Spanish_colonization_of_the_Americas. Native Americans in the United States European colonization. Spiritus-Temporis. com Historical Events, Latest News, News Archives. Web. 11 Oct. 2009. http://www. spiritus-temporis. com/native-americans-in-the-united-states/european-colonization. html.

Elasticity Of Demand And Economics Decision Making Economics Essay

Elasticity Of Demand And Economics Decision Making Economics Essay Extent or degree to which a demand or supply curve reacts to the change in price is called elasticity of that curve. This nature of curve varies with different nature of products means if a product is essential then change in price does not effect much on demand. On the other hand less essential product are quite sensitive to the price changes because opportunity cost of buying those product become too high. A good or service is said to be highly elastic if slight change in price leads to a sharp changes in quantity demanded or supplied. There are lots of products in the market which are not needed in our routine life. And a good or service is said to be highly inelastic if changes in price doesnt effect much on the quantity demanded or supplied. These are those product or services which are very much essential to our daily life. Price Elasticity of Demand It is defined as the percentage change in quantity demanded to the percentage change in price for a particular product or service. Demand is said to be elastic if change in price leads to a higher change in demand, in that case Price Elasticity of Demand (PED) would be more than one i.e PED > 1 P P D D Elastic demand PED>1 Q Perfectly Elastic Q Goods which comes under elastic category tend to have following characteristics They are luxury goods. They are very expensive like sports cars. Goods bought frequently. Goods with many substitutes in market. Price Inelasticity of Demand: Demand is said to be inelastic if the percentage change in price doesnt affect much on the demand of a product i.e. PED P P Inelastic demand PED Goods which come under inelastic category tend to have following characteristics: They are necessities. People are use to them means they are addictives like wine cigarettes. They have no or very few substitutes like petrol. They cost a small percentage of income and bought infrequently. In the short demand is usually more inelastic because it takes time to find alternatives. We can say if the price of chocolate increased demand would be inelastic as there is no alternatives, however if the price of mercury increased there are close substitutes in the form of other chocolates. Therefore demand would be more elastic. In broad there are three factors influencing the demands price elasticity: The availability of substitutes: This is the most important factor influencing the elasticity of a good or service. In general speaking more the substitutes the more elastic the demand will be. Income available to spend on goods: This factor affecting demand elasticity refers to the total a person can spend on a particular good or service. Now suppose price of orange juice goes up from $2 to $3 and the income remains the same. So the income that is available to spend on orange juice which is say $12 is enough for only 4 cans rather than 6. In other words consumer is forced to reduce his demand of orange juice. So if there is increase in price and at the same time no increase in available amount for that good or service then there will be elastic reaction in demand. Therefore demand will be sensitive to a change in price if there is no change in income. Time: Another important factor is time. If price of cigarettes goes up by 15%, a smoker with very few substitute start buying on daily basis instead of buying for a week or so. This suggests that tobacco is inelastic because change of price will not have a considerable influence on the quantity demanded. However if the smoker finds difficult to spend extra 15% and begins to get rid off smoking, the price elasticity of cigarettes for that consumer become elastic in long run. Market Structure: Every market has his own features on which it works or behaves. There are few features which we should consider while determining the market structure as First of all we should know the awareness of consumer about the market. We should know how knowledgeable our customers are. We should know how many firms are doing the same business; it tells us the extent of competition we are supposed to face. What type of product we are dealing with, whether it is coming in the category of necessary product or in the category of luxury product. Whether the entry in the market is easy or difficult and same is the case with leaving the market. Based upon these factors we decide whether the market is perfectly competitive or imperfectly competitive. In a perfectly competitive market there is no entry and exit barrier, we can enter or exit at any point of time from the market. Also in perfectly competitive market product is homogenous and there are large number of buyers and sellers. While in imperfectly competitive market there are very few buyers and sellers, very difficult to enter into and exit the market and at the same time there is monopoly of product. Market Structure of Airline Industry: Market structure which suits to Airline Industry is oligopoly market. In this type of market there are only 2-3 firms who dominate the market. Advertisement and marketing is very important in such type of markets. As there are very few firms, they know each other very well. They know strategies of each other. So they always consider their competitors, while making price strategies, because they just cant set the prices by themselves. They have to consider the pricing of their competitors as well. Although when one firm has a dominant position in the market the oligopoly may experience a price leadership. Firm having lower market share may forced to follow the pricing policy of dominant firm. As large amount of fixed cost is involved in this type of market so entry as well as exit is very difficult. There are basically three major theories about the oligopoly of pricing as under: These firms collaborate to charge the unique price and at the same time unique profit. These firms compete on price so that price as well as the profit will remain same as in competitive market. These firms had the price and profit in between of perfectly competitive and monopoly markets. Market Structure Seller Entry Barrier Buyer entry Barrier Number of Seller Number of Buyers Perfect competition No No Many many Oligopoly Yes No Very few many Monopoly Yes No Only one many Table for different market structure Yield Management: The basic concept of yield management is to provide right service to right person at the right price on right time. (Kimes, 1989: Weatherford and Bodily 1992). Now in case of Airline Industry we can define yield management as generating maximum revenue per seat by keeping customer satisfied. We can do this by applying different policies. As in every industry, customer is very important in this industry. Customer is paying quite an amount to get the services of this type of industry. So we have to take a very good care of customer as well. We have to provide good service right from the booking of ticket to leaving off the plane. The strategic points of yield management are four Cs namely, calendar, capacity, clock and cost and they all bound together with another C i.e. customer. Singapore Airlines is a great example of this. They take a great care of their customers. They keep data of each and every passenger travel with them. They not only provide excellent service but also maintain good and caring relations with customers. Firms compete for market share and demand from customers in many ways. We differentiate these ways into two major subheads i.e. Price Competition and Non-price Competition. We are considering New Zealand Airline Industry as an example Price Competition: Price competition involves increasing the demand by discounted the price. We increase our business in different ways as under: We can provide discounted tickets in the off seasons. We can provide ticket through some scheme like buy one ticket and get 50% discount on purchase of another ticket. This would definitely attract customers and at the same time would increase the revenue. Because there is no use of flying with vacant seat, its better to have customers with discounted tickets. We can also start pre booking scheme especially for our off season. We can launch scheme like discount on ticket booked 1-2 months before. This would enable us to know how much customer we have in our off season and we can make our further strategy according to that. If we still have very few bookings then we can offer some gifts, holiday package or so on booking to boom our sale. We can introduce new packages with our tickets. We can collaborate with few hotels to provide a complete holidays package to family, newly married couples teenagers. We can provide one way free travel, means a person can pay for one way and get the ticket for return as well. This will increase the revenue and at the same time enable us to get few loyal customers. Non- Price Competition: This is the focus on other strategies to increase the market share. There are various strategies which comes under this category as Advertisement and marketing is the major strategy which comes under this category. As there is huge investment involve in this type of industry so we want to get super normal profit out of this. Advertisement plays an important role in achieving this. We advertise and market our product or service in such a way that it put significant impact on customer. On line booking is another value added service. We can book our ticket from home and get our seat confirmed. This would help customer to make his plan well in advance and at the same time it is hassle free. This would enable them to get rid off agents as well as long queue. And apart from this it is 24 hours service. Locality card or points given to every customer, who keeps on adding and customer, will get a prize on reaching certain points. This enable customer to interest for his next trip from same airline.

Physiotherapy Management of Lower Limb Tendonopathies

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