Operation and logistic management Assignment Example | Topics and Well Written Essays - 1500 words

Operation and logistic management - Assignment Example For better understanding the purpose of operations management and its relationship with organizational strategy, it is important to look at a case study. An operations and logistics management case study of Domino’s Pizza in India will clearly explain the relationship between strategy and operations management. As the tagline of Dominos explains, the vision of Dominos Pizza is to become the pizza delivery experts. Dominos Pizza was called Dominick’s Pizza in the initial years when it was owned and operated as a small pizza shop by Dominick De Varti. It was bought by Thomas S Monaghan and James S Monaghan in the year 1960. From 1961 onwards it was owned and operated by Thomas when James sold his entire share to Thomas. In was later on renamed as Dominos Pizza and adopted a mass expansion strategy ever since. â€Å"Dominos philosophy rested on two principles – limited menu and delivering hot and fresh pizzas within half-an-hour.† (ICMR, 2010) Dominos entered the Indian market in the late 90’s when the market was just beginning to adapt to the fast food culture. The management saw an immense potential in the Indian market and had formulated a mass expansion plans in the country. This case study will give a clear insight into the strategic choices used by Dominos fo r managing its Indian operation. â€Å"An operation is transforming process converting a set of resources (INPUTS) into services and goods (OUTPUTS).† (Jpcmedia, 2010) For Dominos, the operations begin from the stage when it orders the raw materials like wheat, vegetable and other ingredients. As Dominos is in the food industry it is of utmost importance that the quality of the product should be given higher attention from the very beginning. The next operational challenge for the company is distribution of the processed raw materials to the different stores. Next is the step where customers are involved. That is, taking orders from the customers. Customers order pizza over the

Music assignment Example | Topics and Well Written Essays - 250 words

Music - Assignment Example The Gypsy Laddie also evidences localization and changing beliefs with the reference to the lady running with the gypsies and leaving her Lord and child reflecting the changing status in the community at the time with Lords and gypsies. Balladic formulas involved the use of recurrent phrases, stanzas, and lines to express narrative ideas and underline the ballad narrative making it easy to remember the words of a ballad while common modifiers were used in changing pitches. The formulas allowed for the remembering of a shortened fashion of large narrative depicting its importance in remembering words in a ballad. Examples of formulas and common modifiers include the stock words, whole stanzas, incremental repetition, phrases. In songs, the Lily-White hand represented the imminent occurrence of dramatic action including rape or seduction as evident in Prince Heathen and Katherine Jaffray involving rape and torture and rescue respectively. Other formulas used in ballads include dressing in rich attire, where to get a bonny boy, and playing at the ball. Preserving the lyrics or keeping the â€Å"emotional core† intact was important because it represented â€Å"time honored expressions of recurrent ballad actsâ €  with formulas facilitating memorization (Harris, 22). Other than localization, other forces of change that affected ballad lyrics include consciousness of class differences, increased literacy levels/education, urbanization, religion, and different social values and practices (Buchan, 236). There is a possible connection between African American spirituals and the Underground Railroad, and most of the scholars believe that a connection exists between spirituality and the Underground Railroad network. Examples of words used in the Underground Railroad network that come from spiritual texts include â€Å"Drinking Gourd† referred to The Big Dipper who’s handle pointed to the North Star symbolizing the North Start in the Bible that let the

Develop and promote positive relationships Essay Example for Free

Develop and promote positive relationships Essay The importance of good working relationships in the setting. It’s very important to have a good working relationship within a setting because it reflects and promotes a positive environment, that is not only inviting for children but for the parents also. Staffs are also approachable and children will be relaxed and confident and will feel that they are able to trust you. Parents would also find it easier to form professional relationships with staff members, this helps to make separation and transitions easier for the child and parent. It also makes discussing important information about the Childs individual needs or concerns easier. Forming good relationships with other colleagues makes the setting run smoothly, information is easily passed on. The working environment is relaxed and more enjoyable. K2 Relevant legal requirements covering the way you relate to and interact with children and young people The relevant requirements covering the way we relate to and interact with children are The United Nations Convention On The Rights Of Children 1989, this legislation ensures that children are listened to, shown respect and have the right to make choices (within reason). They must be protected from discrimination and have the right to freedom of expression. The Children’s Act 1989 brings together various pieces of legislation; it covers child protection and the responsibilities a parent must adhere to, as well as ensuring that children’s welfare is of a paramount importance. K3 Relevant legal requirements and procedures covering confidentiality and the disclosure of information. The Data Protection Act 1998 requires anyone who handles personal information to comply with a number of important principles. It also gives individuals rights over their personal information. This act covers all information held on paper or computer systems and all organizations that store personal data must register with the Data Protection Commission. The eight enforceable principles that must comply with are: †¢Fairly and lawfully processed. †¢Processed for limited purposes. †¢Adequate, relevant and not excessive. †¢Accurate. †¢Not kept longer than necessary. †¢Processed in accordance with the data subjects rights. †¢Secure. †¢Not transferred to other countries without adequate protection. To comply with these principles every school processing personal data must notify under the Act. Data Protection within the school is also checked with auditors and ofsted. Any passing on of a child’s personal information to other professionals must have written consent from the parents or main carer, or the school would be in breach of the Data Protection Act. All admission details of children leaving the school are passed on to their new schools, but historical data is kept on the school’s IT Management system. This information is stored under a secure password protected application. The different types of personal data which is held in the school are: Name and address of the child. Gender. Contact details of parents/carer including emergency telephone numbers. Development records/profiles of each child. Observations including photographic evidence on each child. Medical information. Absence/attendance records. Unique pupil number. Within the school any general information such as doctor /dentist or other professional appointments should be shared between colleagues only. We also have a medical room within the main school which contains medical records and photographs of those children who have food allergies and other serious conditions such as diabetes. Again this confidential information is only accessible by members of staff. It is also essential and important when working with children not to discuss them or their family outside your setting. No information should be passed on without parental consent, unless requested by the police or social services. The only time that you are allowed to breach confidentiality is when you are safe guarding a child or in an emergency. K4 Relevant legal requirements covering the needs of disabled children and young people and those with special educational needs. Legislation and the special needs code of practice: SEN and Disability Act 2001: Providers should make reasonable adjustments to include children with SEN e. g. provide / attend training. A written SEN policy is needed. A SENCO should be identified. Education Act 1944: Children with special needs should be educated alongside their peers. The views of parents should be recognized. Children’s handicap should be diagnosed. Disability Discrimination Act 1995. Those who provide goods and services to the public must make sure that they do not discriminate against those who have a disability, including children who may have learning or physical difficulties or long term illness. Code of Practice 1994. A five stage process to assess a child’s special needs is identified. If needed a statement is written to say how those needs will be met. Code of Practice 2001. A staged system of assessment consisting of Action and Action plus is introduced to support children whose needs may not require a statement or to contribute to the process of statementing. Education Act 1989. Children with disabilities should be educated in mainstream schools wherever possible. Health, education and social services should work together to asses a child’s needs. Children’s Act 1989. Every local authority should provide services for children with special educational needs in their local area. Early identification of special needs is important. K5 The types of information that should be treated confidentially: who you can and cannot share this information with. Who should have access to any records? Head teacher, teacher, parents/carers, Ofsted, SENCO, Social services and other professionals. 2. Where should records be stored? Records are stored in secure cabinets. In a software package. These records are on the individual teacher’s laptops which are password protected and stored in a central storage room overnight. All back up discs are also stored in secure cabinets. 3. How can records be checked for accuracy? External moderators from the Local Educational Authority check the software for accuracy and EYFS profiling. Regular meetings with current examples of tracking and profiles take place between the school and the moderators. 4. Who should be allowed to carry out observations and assessments? Teacher, Key person, SENCO and assessors. 5. Who can give permission for observations and assessments to take place? Written permission forms are signed by parents/carers at the start of the academic year for all new children attending the school, this also covers photographic observations/evidence. K6 The meaning of anti-discriminatory practice and how to integrate this into your relationships with children and other adults. It is paramount that all children and families feel that the setting is welcoming, non-threatening and that they are respected and valued. These means that all practitioners should have excellent communication skills and have the ability to listen carefully, question, understand and respond in a positive manner. Developing and building a trusted two way relationship means that you will be able to support both the family and child throughout their time in your care. The school also promotes that all individual children are given equal access to the school’s curriculum, care, moral and spiritual input, sports, arts and play opportunities. This support also includes the children being healthy, safe, enjoying and achieving and; making positive contributions to the community and society. A SEN register is held in school of all children who have been identified as having special needs. Other registers record different circumstances which may affect children’s access to the curriculum such as English as an additional language, medical needs, gifted and talented. K7 How you adapt your behaviour and communication with children to meet the needs of children in your care of different ages, genders, ethnicities, needs and abilities. It is still essential with this age group of children and young people to build on good relationships; they will be experiencing many physical changes and may feel anxious about puberty. Adults need to able to listen and be sensitive to the changes they are going through. It is vital that they have positive adult relationships, with an adult who can listen carefully, are sensitive, non-judgmental and have empathy to their individual needs. Within this age group they face far more peer pressure, wanting to fit in with their peers, feeling concerned about their outward appearances, even facing issues such as sex and experimentation with alcohol and drugs. Having a good relationship away from a family member where the children or young people can feel that they can express their own views and opinions and be respected and spoken to as an equal over important issues in their lives is paramount. Therefore they still require an adult who can give them advice, reassurance, praise and encouragement and understand their needs. K8 Strategies you can adopt to help children to feel welcome and valued in the setting. I ensure that all children in my setting are given the opportunities to play with an activity of their choice and that their views and beliefs are listened to. All children must be praised and encouraged, valued and listened to. I make them feel welcome and valued by being a positive role model and by taking an interest in what they do and say. K9 What is meant by ‘appropriate’ and ‘inappropriate behaviour when interacting with children, the policies and procedures to follow and why these are important? The school’s policies and procedures all members of staff must have a full and active part to play in protecting all pupils from harm, and at all times the children’s welfare is of paramount concern. We should all be working together to provide a caring positive and stimulating environment that promotes the social, physical and moral development of all the individual children. All members of staff are expected to develop their performance portfolios and undertake annual performance management meetings to improve on their teaching standards. The importance of following the school’s policies and procedures in appropriate behaviour are that you are contributing to the overall ethos and aims of the school and safe guarding the children. Helping to promote inclusion and acceptance of all pupils and encouraging interaction with others. Appropriate behaviour helps to develop the children’s confidence, self esteem, resilience and independence giving them a feeling of being respected and valued. Inappropriate behaviour from members of staff could result in the children lacking in confidence and lowering their self esteem. The children we feel that their views and opinions are not respected or valued. The children will become less independent and it will promote bad behaviour resulting in an environment where they will not learn or feel safe. Using unprofessional behaviour when interacting with children could become a child protection issue. Therefore it is inappropriate to be too personal or give personal information to the children in your care. K10 The importance of encouraging children to make choices for themselves and strategies to support this. By encouraging children to act in this way you are helping them to develop and make them become aware of their own needs and areas of improvement. This can be done by allowing the child to try and solve problems or necessary decisions before advice is given. Options can be given to the child to help them choose a path to take K11 The importance of involving children in decision-making and strategies you can use to do this. Within the foundation stage, the overall area is split into specific activities such as role play, home corner, writing table, messy area, quiet area and the outside area. The children can make decisions on when, how and for how long they stay at an activity. With all of the activities, there will be under pinned planned learning intentions and outcomes, some of which will have adult led or adult engagement involved. By letting the children play independently and by not interfering or leading the play, the children will develop social and emotional skills and learn to play alongside others or co-operatively. It enhances their imagination and creativity, develops communication and language skills as they work through ideas and concepts, also enabling the children to take risks and make mistakes and learn through their experiences. In involving the children in decision-making it will build on their confidence and self esteem and they will feel that their views and feelings are valued. K12 How to negotiate with children according to their age and stage of development. The first step in negotiation is to ask what dont you want to do and why. Using age related language, experience of the situation, the child and or children will in general be able to come to or reach an outcome. All children need choices it is not age specific, it depends on what level they are at in their development and understanding, for the choices that you give them. For example under 3 year olds, Its tidy up time, ask them to tidy away three things, give them a choice of what three things they are going to pick up. With children 3 years of age and over they start to learn for themselves about negotiating through their play by figuring out what the rules are, who’s going to go first, sharing toys and activities. As children get older it is important for them to be involved in negotiating and decision-making as it develops their ability to become responsible, understand consequences and prevents them from feeling excluded and powerless. Giving children choices puts the responsibility and power back into their hands. Within a school there are several ways in which you can negotiate with the children, including rewards such as stickers for those children who can undress independently for PE. For example if a few children who refuse to get changed, rewarding them with a sticker encourages them to try to undress independently or with our support. Maybe reward house points for good behaviour in following our ‘rules’ or trying really hard and working at their best ability. In the outside area we time the use of the bikes, scooter and cars so that all the children have a turn. We ensure that all the children have a choice of independent or adult led activities. When negotiating we are consistent with our actions and give the children explanations and consequences and listen to their views and feelings. K13 Strategies you can use to show children that you respect their individuality Keys to good practice: Provide activities that encourage self-expression. Provide opportunities within the foundation stage in creative development for the children to express themselves in exploring different media such as painting, drawing and modelling. The children can develop their imagination and expression in songs, music and dance, imaginative play and role play. Celebrate diversity by learning about each other’s culture, religion and beliefs. Encourage the children to listen and talk to each other in our weekly show and tell activity where the children can share a special toy, achievement or a special outing with us and their peers. Provide open-ended activities that children can put their own ‘stamp’ on. Allow the children free flow play where they can make up their own rules and games by providing different areas for role play and activities. Have independent activities based around our themed topics in which the children can expand on such as ‘buildings’. The children make 3D and 2D â€Å"Three little pigs† houses which is an adult led activity. By allowing them different mediums the children independently made houses by chalking out a town in our outside area, making houses with constructions toys, junk modelling, tents, and building their own using building bricks and homemade cement. Avoid comments that single children out as being different. Ensure that we listen and talk to the children include them in choices and decision making, acknowledge their interests and abilities by respecting their backgrounds, experiences and culture. Acknowledge children’s particular strengths and talents. Ensure that you respond to the children in different ways depending on their personalities. We share achievements or talents in special assemblies where the children can show their certificates or their talents to the rest of their peers. Show interest in things that the children enjoy doing. By knowing the children really well you can encourage them to try a new way of completing an activity such as if you know a child likes painting try to persuade them to try a different medium like a collage or junk modeling to create a picture. K14 How to balance the needs of individual children with those of the group as a whole. Within the setting daily routines of which the children have to adhere to such as registration and weekly timetable to adhere to. The school’s planning process involves grouping the children together by learning ability, style, physical and social groups and the teaching resources and levels are matched and deployed to deliver different styles of teaching to these different groups. K15 The importance of clear communication with children and specific issues that may arise in bilingual and multilingual settings All communication is a two way process and it is paramount when working with children that you listen carefully, question, understand and respond in a positive manner to what is being communicated to you. This will give the children the fundamental skills to take part in family life, school, employment and social activities. Within the setting we provide opportunities for the children to development their communication and language skills by different activities: It is important to give children clear communication and sufficient time to express themselves. †¢Showing our understanding and respect. †¢Giving children confidence and self esteem. †¢Encouraging independence. †¢Children can express their feelings and views. †¢Encourages socialising skills. †¢Gives children choice. †¢Showing we understand their needs. †¢Develops their language and communication skills. Also within our setting we have several children who are bilingual and multilingual with two or more languages these children have extra weekly support from our EAL co-ordinator. With these children we also ensure that we give clear and understandable instructions and in some cases use hand gestures or picture clues to help with their understanding. K16 Why it is important for children to ask questions, offer ideas and suggestions and how you can help them do this †¢It makes them feel part of the school. †¢They can have their say. †¢Gives the children a sense of responsibility. †¢Encourages their independence and confidence. †¢They will have a sense of belonging and pride in their school. †¢The children’s views and opinions are being listened to. †¢They will look after the new area or equipment (respect it). †¢Gives the children choices. †¢Builds relationships. †¢Develops their communication and language skills †¢They feel respected and valued. †¢They will explore and experience different activities / environments. †¢Develops their knowledge and understanding of the world. I feel that this is important to include the children in decisions about their environment, activities and learning opportunities because it gives them a sense of responsibility, independence and they will feel respected and valued. We do this by ensuring that the children have time to ask questions in a relaxed and natural way throughout their school day. K17 Why it is important to listen to children? It is important to listen to children so they know that you are interested in what they say and that you care for them. You also get to learn about the child when they are talking to you, for example if you need to help them with their language development or help them in their learning. †¢The children will feel that you are not interested in them. †¢Demonstrates that you are a role model to the children. †¢It builds the children’s self esteem and confidence. †¢It builds on good relationships with the children and other adults. †¢The children feel respected and will be happy to share suggestions and decisions. †¢Develops the children’s communication and language. †¢Helps the children to learn socialising, negotiation skills and independence. †¢The children may need to disclose a safeguarding incident. †¢It shows that we understand the children’s needs. K18 How to respond to children in a way that shows you value what they have to say and the types of behaviour that could show that you do not value their ideas and feelings. All children respond well to positive reinforcement of expected behaviour boundaries. By just giving general statements such as â€Å"do not interrupt† or â€Å"well done† does not reinforce or teach good values. Also by asking open questions you can demonstrate that you are listening to the child and or children and giving them time to express their feelings, views and opinions. K19 The importance of being sensitive to communication difficulties with children and how to adapt the way you communicate to different situations. Communication difficulties with children: †¢Hearing difficulties or deaf. †¢Poor vision or blind. †¢Ill health. †¢Special educational needs. †¢Physical disability. †¢Poor language skills or English as an additional language. †¢Disruptive child. †¢Speech problems. Cultural Differences and English as an additional language 1. Smile and have friendly facial expressions. 2. Use hand gestures to gain understanding. 3. Use pictures. 4. Show warmth and encouragement. 5. Use culturally relevant learning materials. 6. Group EAL co-ordinator who shares the same home language. 7. Have some key words in their home language. 8. Use translator. 9. Always treat children with respect and as individuals. 10. Ensure that you take into account their cultural differences, their life experiences and the way they prefer to communicate. 11. Respond appropriately to their non-verbal communication. Hearing impairment 1. Ensure that you always speak clearly and listen carefully. 2. Remove all distractions. 3. Always check and ensure hearing aids are working. 4. Use written communication if age appropriate. 5. Use sign language if and when appropriate. 6. Use a trained interpreter if a high level of skill is required. 7. Explain things using short, clear sentences and draw or use pictures, as required, to illustrate what you mean. 8. Use physical objects when learning new words or concepts. 9. Ensure the child as your full attention and that you maintain eye contact. Visual impairment 1. Use methods of multi-sensory interactions such as touch, sounds and smell. 2. Use different tones of voice with lots of expression. 3. Do not rely on non-verbal communication. 4. Use environmental sounds. 5. Develop routines when interacting with the child, such as using their name and touch in a consistent manner. Have clear signals that show the beginning and the end of your exchanges. 6. When explaining an activity or object ensure all visual communication is clear and understandable. Physical and learning Disabilities 1. Use alternative and augmentative communication such as hand gestures and eye pointing. 2. Use visual aids such as communication boards or displays, photographs, drawings and symbols to represent words or activities. 3. Use chat books or photograph album containing photographs, pictures, symbols, words and messages. 4. Use speech generating devices such as communication boards or displays on a machine which speak a message when a particular button is pressed. 5. Use spelling, using an alphabet board or typing device to spell out words and messages. 6. Use formal signing or signing which is particular to an individual. 7. Use object symbols that include normally objects or small versions of objects which represent an activity, object or person. Such as a set of car keys can represent it is time to go in the car. 8. Use a multi-sensory approach when providing information and learning taking into account the five senses and present information and activities in a different way enhancing learning and involving the children by doing, touching and seeing. 9. Ensure that your surroundings are appropriate and accessible. 10. Judge correct level of understanding. 11. Respond at the correct level repeating information when necessary. 12. Be prepared to wait and listen carefully. These children can be supported by: †¢Senco. †¢Parents. †¢Children under two by the health visitor. †¢EAL co-ordinator. †¢Other professionals †¢Nurture assistant. In terms of our physical environment we have no children with visual or speech impairments or with physical disabilities within the current foundation stage. So therefore we have no need of changing our different areas to accommodate any of these children. I would ensure that we accommodated these children by ensuring that the environment was spacious and accessible, bringing activities to their level or the floor. I would also use more visual and tactile aids. K20 How you can help the children to understand the value and importance of positive relationships with others. Within our school we encourage the children to develop positive relationships with others by praising good behaviour and following our rules. We act as positive role models such as praising nice manners. I have a rule for example, that if you accidently kick a ball over the fence I will let the children retrieve it if they can ask me with lovely manners. If they don’t ask nicely I make them wait and think about what would be a polite way of asking to retrieve the ball, thus instilling positive and desired behaviour. K21 The importance of children valuing and respecting other people’s individuality and how you can encourage and support this. †¢Act as a role model showing that you respect others individuality, feelings, views, ideas and cultures. †¢Have positive images and toys, books and dolls within your setting. †¢Have activities that encourage negotiation, sharing and building on relationships. †¢Demonstrate positive behaviour. †¢Have activities which encourage the children to talk to, listen and find out about others. K22 Why it is important for children to understand and respect other people’s feelings and how you can encourage and support this. †¢Stops the children’s frustration. †¢The children will feel that their feelings are being viewed. †¢Encourages empathy and social skills. †¢Encourages and promotes positive and expected behaviour. †¢Builds relationships. †¢Develops the children’s communication and language. †¢Develops personal, social and emotional skills. †¢Develops the children’s knowledge and understanding of the world. K23 Why it is important to be consistent and fair in dealing with positive and negative behaviour. †¢Being consistent and fair the children will understand right and wrong. †¢The children will understand expected behaviour boundaries and rules. †¢The children will understand consequences. †¢The children will understand that you are not showing favouritism. †¢The children will understand what is acceptable and what is not. Within my setting we reward positive behaviour with praise and other recognition such as house points and stickers. This is done in the presence of the child’s peers to encourage and reinforce positive and desired behaviour. With negative behaviour, if safe to do so we give no attention as it is often a play by the child for your attention. However, some unsafe and disruptive behaviour must be addressed immediately in a consistent and fair manner. K24 Strategies you can use to encourage and reinforce positive behavior Children may have negative behaviour due to: 1. Lack of sleep. 2. Feeling unwell. 3. Problems at home. 4. Sibling rivalry. 5. Tension at home. 6. Some children do not know how to play with others. 7. Bored and frustrated. 8. Lack confidence in socialising with others. We acknowledge positive behaviour and give reasons behind any boundaries such as we walk in school because we might fall over and hurt ourselves or others. We are consistent and fair by rewarding praise, house points and stickers for following the rules. We control negative behaviour by reinforcing and reminding the children of our rules. K25 Strategies you can use to challenge and deal with different types of behaviour which are consistent with your organisation’s policies The school policy aims and expectations are that every member of the school community feels valued and respected and that each person is treated fairly and well. The school’s policy encourages and promotes good relationships and that we work together to help everyone learn. We also aim to help the children grow in a safe and secure environment and for them to become positive, responsible and increasingly independent members of the school community. The school’s main ethos is to reward good behaviour as it believes that this will develop an environment of kindness and co-operation. The school employs sanctions to negative behaviour which are appropriate to each individual child, taking into consideration each child’s needs and the issue. The role of members of staff are to ensure that the rules are enforced in their class, that each individual child is treated fairly and consistently, to monitor repeated incidents and to seek advice from appropriate leadership team if necessary. We also use behaviour observations to help us understand the needs of the individual child such as requiring extra support from key worker, SENCO, EAL Co-ordinator, Management or other professionals. We also use different strategies and resources such as SEAL (Social and Emotional Aspects of Learning) to help individual children with their behaviour. K27 Why it is important to encourage and support positive relationships between children and other adults in the setting and strategies you can use to do this †¢It demonstrates that you are showing respect and sensitively. †¢Promotes good and positive behaviour. †¢Act as a role model for the children. †¢Promotes good communication in a caring and clear way. †¢It promotes good manners. †¢The children feel that they are listened too and that you value what they have to say. †¢It creates a positive atmosphere and environment where the children feel welcome and valued. †¢Promotes a friendly, consistent environment where the children will feel their views are worthwhile. †¢Ensure that you always give reasons and take time to explain your thoughts and actions. The main strategies that we use in the school are we work very closely in a team in the Foundation Area; we have a consistent approach with dealing with the children’s behavioural issues. We encourage the children to interact and build on relationships with all of us by acting as role models and by reinforcing our key rules. We also spend time with all the children across both classrooms in teaching and delivering our planned activities each week including taking phonics sessions, guided reading sessions, show and tell, PE and music, key person story time and supervision of the outside area. We have effective communication across the team to enable us all to keep up to date with any issues such as medical conditions, negative behaviour incidents, records of ongoing assessments / observations, developmental progress and achievements of the children in our care. K28 Why positive relationships with other adults are important. As a practitioner it is important that you maintain and have positive relationships with all adults that you come in contact with to support and develop the children in your care to grow into secure, confident and happy people. Having collaboration and support from parents, colleagues and other professionals will enable you to develop strong relationships which will enhance and benefit the children by demonstrating positive and desired behaviour. The children will cope better with transitions from home to school, to new classroom, to new staff and or support from other professionals. K29 Why it is important to show respect for other adults’ individuality and how to do so ? It’s important to respect other

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