Service Adhesives Strategic Change

Organizations exist in an environment that is under constant change. Therefore, it is vital for organizations to undertake several strategic changes from regularly. The strategic changes help organizations to maintain a competitive edge and meet the current and future needs of the market. The changes should incorporate all stakeholders of the company.Advertising We will write a custom essay sample on Service Adhesives Strategic Change specifically for you for only $16.05 $11/page Learn More Employees of a company are the stakeholders who help in the implementation of strategic changes. It is vital for a company to have efficient change management strategies. Failure to have efficient change management strategies would make an organization fail to reap maximum benefits of the strategic changes. Service Adhesive Limited operates in a rapidly changing environment. The company’s implementation of Total Quality Management (TQM), Six Sigma, and lean man agement has not produced the desired results. This necessitates the company to determine problems that led to the ineffectiveness of the strategies. Proper implementation of team-based working structure would improve the competitiveness and efficiency of the operations of Service adhesives. Service Adhesives currently employs up to 20% of its workforce on short-term contracts. This enables the company to reduce its costs of production. However, the employment structure of Service Adhesives may have adverse effects on the efficiency of implementation of the team-based working structure. This is because successful implementation of the team-based working structure requires employees to have a high degree of cohesiveness (Gitman McDaniel, 2008). Employing a large number of employees on short-term contracts reduces the job security of permanent employees. This reduces the motivation of the employees. In addition, efficient implementation of team-based working structure requires employe es to have good working relations. Working together for a long time improves the working relations of employees. Therefore, the employee structure of Service Adhesives may lead to isolation of employees who are on temporary contracts. This is because they do not have good working relations with permanent employees. Service Adhesives uses the traditional hierarchical organizational structure. This organizational structure gives special emphasis to the role of leaders in the organization’s hierarchy. A shift to the team-based working structure necessitates the company to undertake various structural changes. The hierarchical organizational structure does not usually have efficient communication structures.Advertising Looking for essay on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More Efficient communication is one of the major factors that lead to successful implementation of a team-based working structure. The mana gement must communicate the roles of each employee in the outcome of the company’s activities. This would make employees feel that they are a vital component of the company. In addition, appreciation of the roles of each employee would help in improving the cohesiveness of employees (Graen Graen, 2006). However, the current management structure of the company does not facilitate efficient communication. Lack of efficient communication is one of the major factors that inhibit the cohesiveness of employees of the company. Efficient implementation of a team-based work structure would improve the efficiency and productivity of Service Adhesives. This necessitates the company to formulate strategies that would lead to successful implementation of the initiative. Implementation of the team-based work structure should overcome the problem of lack of cohesion among employees of the company. Lack of cohesion among employees is one of the major factors that limited the success of vari ous initiatives in the past. However, lack of cohesion is not the only problem that Service Adhesives faces. Service Adhesives does not have efficient change management strategies. Lack of efficient change management may have been the major factor that led to the failure of various initiatives in the past. The organizational culture of the company is not responsive to various changes. Therefore, it is vital for the company to formulate strategies that would lead to the development of a favorable organizational culture (Driskill Brenton, 2010).  Team-based working structure would ensure that employees set the own targets. Therefore, employee empowerment is a critical component of the team-based working structure. Employee empowerment shifts the decision making process from the top management of the company to low-level employees. Low-level employees may make better decisions since they are in direct contact with the customers. In addition, direct involvement in undertaking various processes enables employees to make better decisions (Potterfield, 1999). Therefore, it is vital for employees of the company to have good problem solving skills. However, employees from Eastern Europe may not possess the necessary skills that would enable them solve problems effectively. This is because the employees are unable to adhere to quality procedures. In addition, these employees cannot read materials that are in English.Advertising We will write a custom essay sample on Service Adhesives Strategic Change specifically for you for only $16.05 $11/page Learn More Therefore, Service Adhesives should ensure that that it hires employees who have skills that would enable them make sound decisions.  Service Adhesives faces various problems that necessitate it to undertake several strategic changes to safeguard its position in the market. The company should formulate strategies that would help in proper implementation of these changes. The company intends to use a team-based working structure to solve some of the problems that it faces. However, successful implementation of a team-based working structure requires the company to ensure that there is efficient communication between employees. In addition, employees should have skills that would enable them make sound decisions. References Driskill, G.W. Brenton, A.L. (2010). Organizational culture in action: A cultural analysis workbook. London: SAGE Publications. Gitman, L.J. McDaniel, C. (2008). The future of business: The essentials. Belmont, CA: Cengage Learning. Graen, G.B. Graen, J.A. (2006). Sharing network leadership. Charlotte, NC: Information Age Publishing. Potterfield, T.A. (1999). The business of employee empowerment: Democracy and ideology in the workplace. Westport, CT: Greenwood Publishing Group. This essay on Service Adhesives Strategic Change was written and submitted by user Duncan Mccall to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.

How to Cook Ramen Noodles Essays

How to Cook Ramen Noodles Essays How to Cook Ramen Noodles Paper How to Cook Ramen Noodles Paper Whether you plan on staying at North Lake or you plan on going away to college we know ALL college students Like wings that are easy, cheap, fast and delicious Ill. If you do like easy, cheap, fast and delicious then you need to listen while I show you how to make a delicious, cheap, easy and fast meal out of Ramee Noodles and bratwurst. V. This speech will show you Just how easy it is to whip up a cheap meal that taste great in under 7 minutes from start to finish. V. Today I will show you how to prepare the noodles and bratwurst, cook them and basically throw them together for a quick meal packed full of protein and carbohydrates, both essential to busy poor college kids. BODY The first step is to gather the materials you need to make the Ramee and ratters dinner. A. There are several supplies that are needed for making this meal. 1 . You will need a package of chicken flavored Ramee Noodles. A. You will also need a pair of scissors to open the packages. 2. You will also need a saucepan, a measuring cup and a timer. . You will need 2 cups of water. 3. You will need one bratwurst. A. You will need a knife to cut the bratwurst. 4 Humanly you need a Doll Ana an appetite. II. The second step is to start cooking your Ramee Noodles and Bratwurst. A. First you will need measure out two cups of water and pour the water into the saucepan. 1. Then you will need to turn the stove to high and wait for the water to boil. B. Second, while waiting for the water to boil, cut the Ramee Noodle package open with the scissors and pull out the seasoning package. . Cut open the seasoning package with the scissors and pour it into your bowl. While waiting for the water to boil, cut your Brat into h inch slices. D. When the water starts to boil pour the Ramee Noodles into the saucepan and add your slices of bratwurst. 1 . Set your timer for three minutes. C. Third, Ill. Lastly, after the timer goes off, turn off the stove and pour your noodles, brats and water into your bowl. A. Stir the noodles, brats and water around so that the seasoning is mixed in really well. B. Once the noodles and brats cools off (this usually takes a couple of minutes) dive in to youre delicious, cheap, easy and fast meal. CONCLUSION l. So there are three main steps in cooking your cheap, easy, fast and delicious college meal. A. Gather the materials. B. Cook the Ramee Noodles and Bratwurst. C. Throw everything together in a bowl. I hope I have inspired you to add this cheap, fast, easy and delicious meal to your college diet.

Theres and There are

Theres and There are Theres and There are Theres and There are By Maeve Maddox An odd-looking contraction Ive noticed recently is therere for there are. Haiti Airport Baggage Handlers, Therere Just Too Many! Therere too many kids Therere Just A Few Days Left If Therere Seasons(song title) Contractions are supposed to be easy to say. For example, theyre for they are is easy to utter, but adding another re to there to create therere produces a word difficult to pronounce. I wonder if this nearly unpronounceable contraction may have something to do with the proliferation of theres to begin sentences in defiance of the rules of agreement between subject and verb: Theres ten members on the council. Perhaps the speaker knows better, but is in contraction mode and at the last minute decides that ungrammatical theres is a better choice than unpronounceable therere. Besides being difficult to pronounce, therere looks peculiar. In writing intended to be read by others, its probably best to avoid such ungainly contractions as therere and wherere. Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Grammar category, check our popular posts, or choose a related post below:Writing Prompts 101Difference between "Pressing" and "Ironing"Honorary vs. Honourary

Managing the Economy Research Paper Example | Topics and Well Written Essays - 1500 words

Managing the Economy - Research Paper Example Basic Income Tax Rate (% points) 23.0 23.0 23.0 23.0 23.0 Real Income Tax Allows (Index, 1995=100) 100.0 100.0 100.0 100.0 100.0 VAT Rate (% points) 17.5 17.5 17.5 17.5 17.5 Employers NICs Rate (% points) 10.0 10.0 10.0 10.0 10.0 Interest Rates (% points) 6.2 6.0 6.0 5.4 4.1 Real Unemp. Benefits (Index 1995=100) 100.0 100.0 100.0 100.0 100.0 DM / Exchange Rate 2.67 2.63 2.58 2.55 2.55 SETTING OF MAIN POLICY INSTRUMENTS IN THE REVISED FORECAST 1999 2000 2001 2002 2003 Govt Capital Expdt ( bn,1995 prices) 10.1 11.2 12.7 14.4 15.0 Govt Current Expdt ( bn,1995 prices) 149.7 152.4 155.8 159.4 162.0 Basic Income Tax Rate (% points) 23.0 23.0 23.0 23.0 23.0 Real Income Tax Allows (Index, 1995=100) 100.0 100.0 100.0 100.0 100.0 VAT Rate (% points) 17.5 17.5 17.5 17.5 17.5 Employers NICs Rate (% points) 10.0 10.0 10.0 10.0 10.0 Interest Rates (% points) 6.2 6.0 6.0 5.4 4.1 Real Unemp. Benefits (Index 1995=100) 100.0 100.0 100.0 100.0 100.0 There is no change made in the Main policy instruments between the base forecast and the revised ones. This is the effect of the changes to the assumptions which has been made. 1999 2000 2001 2002 2003 GDP (growth, % pa) -1.1 -2.0 -1.1 -0.0...High growth rates and high inflation rates go together. All these are the result of the rise in Oil price which is almost three times in the first two years of reckoning and more than twice in the next three years. The effect of these interlinked parameters has an impact on the other economic performances. Analysis: The GDP growth shows a negative figure due to the steep increase in the world oil price and in the substantial decrease in the rate of growth of the World trade (0.8%) during 1999. The figures saw themselves stabilizing during the subsequent period in 2000 with a growth rate of 3% which made the GDP growth rate 0. With a lowered growth rate, during the 1999 and 2000 this can be seen as a period of recession and the rest of the period from 2000 to 2003, there is a slow regaining resulting in lowering of the unemployment by the end of 2003. Inflationary tendency in the market comes down over this regaining period beyond 2000 while the earnings go up as indicated by the earnings inflation figure which shows an increase towards the end of the period. Current account holding has come down while at the same time, the strengthening of the DM indicates an advantage trade situation for sterling towards export of commodities and services rather than import of these services. i) A negative GDP growth rate was noticed in the earlier cases.

Information Systems Auditing Assignment Example | Topics and Well Written Essays - 1500 words

Information Systems Auditing - Assignment Example ing management controls in computer systems within an IT infrastructure to determine the adequacy of the system controls and ensure compliance (Puja, 2004, p. 5). It is done through collecting and evaluating evidence to determine whether data integrity is maintained and assets are safeguarded. The use computer based information systems has been incorporated into many companies and the ability of these companies to survive entirely depends on well-structured information system audit process that points out shortcomings in the information systems usage. The human resource department of any organization or company contains more sensitive data. Human resource workers specifically the payroll employees should be able to establish the employment status of an active employee, without altering the status, while the personnel employees have the clearance from human resource administration or higher authority to activate new employees and alter their status from active to terminated service. The personnel employees have no permission in handling of timecards for employees. This clearly defined separation of tasks prevents any occurrence of fraudulent incident. In most common cases it has been reported that the payroll employees or the personnel employees process illegal paychecks to terminated employees or ghost workers either as a result of ignorance or fraud motives. Human resource management systems house databases that contain other linked company information that the payroll employees have no reason of seeing. Such information may include; data from performance evaluation, health records, and retirement benefit plan balances, and insurance cover. The central location of human resource data is subject to access monitoring enabling the capture of identity of the person logging or exiting as well as the timestamp. This ensures that company data is accessed by authorized personnel and that entry codes are changed periodically where locking mechanisms with keypads are

The Rise Of Secularization In 19th Century

The Rise Of Secularization In 19th Century The secularization of 19th century England was multicausal. Various factors contributed to this process. Among them were post-effects of The Enlightenment namely humanistic philosophy that manifested itself with the spread of deism and Enlightenment aesthetics. Other factors included science and natural theology. Natural theology was the attempt of the church to stave off secularization, but in fact hastened the process. Clearly science was more responsible for the secularization of nineteenth century England than Enlightenment humanistic philosophy. This essay will explore the watershed of natural theology and its demise in nineteenth century England. Recognizing the intellectual context and environment that existed at the turn of the 19th century helps illuminate why humanistic causes contributed to Englands secularization. There was, as Thomas Kuhn states, a paradigm shift in society. The industrial revolution led to massive urbanization that often occupied previously religious building for commerce and industry. Cathedrals, abbeys, and churches gradually became merely additional spots in a city and no longer the city centres or primary places of gathering. There was a shift from superstitions and spiritual explanations for different phenomena to physical and reason-based explanations especially between the 17th century before 1660 and the Enlightenment of the 18th century. (155) For example, before this paradigm shift people dealt with the insane via exorcism because their insanity was attributed to Satan. (Brook 1993, 155) Afterwards, new medical elites deemed these practices madness and attributed insanity to non-spiritual ca uses. Among these events specific groups formed, which were led by this appeal of rationality over conventional religion such as the aesthetes and deists. The aesthetes, such as Irish author Oscar Wilde, deists and other groups resented bourgeois society particularly the rigid conservatism, oppressive hypocrisy and suppression of intellectualism of the church. Historians of Victorian intellectual life such as David J. DeLaura have recognized that numerous Victorian atheists and agnostics left the Christian church because they believed Christianity was becoming immoral. The loss of religious faith in such representative early Victorian agnostics as F. W. Newman (John Henry Newmans brother), and J. A. Froude was not due to the usually suggested reasons of the rise of evolutionary theory in geology and biology. The dominant factor was a growing repugnance toward the ethical implications of what each had been taught to believe as essential Christianity the doctrines: Original Sin, Reprobation, Baptismal Regeneration, Vicarious Atonement, and Eternal Punishment. (DeLaura 1969, 13). Murphys journal article The Ethical Revolt Against Christian Orthodoxy in Early Victorian England (1955) in The American Historical Review explains how it was predominantly ethical rejections of Christian Doctrine that led to the secularization of 19th century England. He presents case studies of three individuals F. W. Newman (1805-97), J. A. Froude (1818-94), and Mary Anne Evans (1819-1880). Murphy explains that contrary to the popular views, that once Darwin and Lyell demonstrated that neither the origin of the earth nor the origin of man according to Genesis was congruent with scientific discovery that the majority of thinking people became agnostic or atheist, secularization occurred during the Victorian age predominantly due to conflicts between orthodox dogma and meliorist ethical bias of the times. (Murphy 1955, 801) Murphy argues that science did provide important ammunition once the attack on orthodoxy had begun, but it did not produce the attack. The records of these three people leave no trace of having read Lyell and they all had left the church 10-20 years before Origin of Species was published. Newman grows up in a Christian home but later writes a book Phases of Faith where he describes that he is disturbed by the dominant Christian doctrines believing them to be unethical. Newman finds through critical reasoning that the sacrifice of Christ serving as atonement was not logical because attacking the infinite strength of Christ was evading not satisfying justice as Christ was not really harmed. (Murphy 1955, 803) Murphy explains that Froude did not waste time on fine points of science or Biblical scholarship, but came straight to the main point: the intolerable ethical primitiveness of the vicari-ous-atonement principle (808) Froude states the atonement principles claim that the guilt of a mans sin be transferred, even voluntarily, to an innocent Christ is a perversion of justice. Furthermore to then state that a mans sin is a loss that God suffe rs by which He would need satisfaction that needed to be paid, without it mattering by whom, is an insult to Gods persona. Finally, Evans deviates from the faith because she believes that it is unethical and untrue that religious faith is a necessary prerequisite to attaining moral excellence. In an article entitled Evangelical Teaching: Dr. Cumming (Westminster Review, October 1855) she writes about Dr. Cumming, a self-righteous admired London preacher to be teaching Christian doctrine found to be subversive of true moral development and therefore positively noxious. (Evans 1855, 1) Thus, these case studies demonstrate how the secularization of 19th century England occurred due to meliorist rejections of ethical issues found in church doctrine. However, what even more greatly contributed to the secularization of nineteenth century England was the development of science. Science was viewed as a vehicle of social and intellectual liberation. (Brooke 1993, 155) Natural Theology attempted to make theological claims about the existence of God by observing nature and drawing conclusions via the design argument instead of making claims based on Gods own self-revelation via scripture. The design argument is proposed by Paley in his work Natural Theology (1802) There cannot be design without a designer; contrivance without a contriver; order without choice; arrangement, without anything capable of arranging. (12) Paley believes nature is a mechanism, and hence was intelligently designed. He made this connection because he was writing while England was experiencing the Industrial Revolution. American Philosopher Alston in Perceiving God defines natural theology as the enterprise of providing support for religious beliefs by starting from premises that neither are nor presuppose any religious beliefs (Alston, 1991b, p.289) Natural theology as defence of Christian theology proves fatal. Swiss theologian Barth rejects Natural Theology. He states that this belief causes a bifurcation of knowledge of God into natural knowledge of God and revealed knowledge of the triune God, which is scientifically theologically intolerable. Barth argues that unless rational structure [is] bound up with the actual content of the knowledge of God it [becomes] a distorting abstraction.(Torrance, 1970, 128). American philosopher Platinga views Natural Theology as an attempt to prove or demonstrate the existence of God. This is a problem because it supposes that belief in God rests upon evidential basis. Hence belief in God is not a basic belief and self-evident. Belief in God necessitates being grounded on a more basic belief, but doing this gives the more basic belief greater epistemic status than belief in God. Platinga argues that belief in God is itself basic and does not need justification with references to other beliefs. Natural theology provided deists and atheists new ammunition to establish their own arguments. If God could be explained exclusively with empirical evidence, then His non-existence could also be explained exclusively with empirical evidence if that evidence could be attributed to another origin. Lyell in his Principles of Geology (1830) argues for uniformitarianism stating that the same physical and geological forces observed in the present have been active over a colossal span of time in the past. Darwin in On the Origin of Species (1859) poses a similar argument along with counter-teleological arguments of natural selection, presenting directionality within nature without implying progression or purpose. (McGrath 2010, 36) Biologist Thomas Huxley and Physicist John Tyndall make significant contributions in delegitimizing natural theology and using science to secularize England. Huxley debates and rebukes Oxford bishop Wilberforce when Wilberforce denounces Darwins evolution theory in their debate of 1860 at the British Association meeting at Oxford. This was but one of many events concerning the clergys lost domination of intellectual life in Britain. When the British Association for the Advancement of Science was founded in 1830 clerics composed 30% of its total members. During the period 1831-1865 forty-one clergy were in association. Then in the period 1866-1900 only three remained. (Brooke 1993, 50) Between 1660 and 1793 the scientific world established more than 70 official scientific societies (and almost as many private ones) in urban centres as far removed as St. Petersburg and Philadelphia. (Brooke 1993, 152) Huxley and his colleagues use the conflict thesis of science vs. religion to attack t he Anglican and Roman Catholic churches. Drapers History of the Conflict Between Religion and Science (1874) and Whites History of the Warfare of Science and Theology in Christendom (1896) made the Conflict thesis well know arguing that it is the nature of science religion to be in opposition. Draper in his work states, The history of Science is not a mere record of isolated discoveries; it is a narrative of the conflict of two contending powers, the expansive force of the human intellect on one side, and the compression arising from [traditional] faith and human interests on the other. (Draper 1874, vi) Northwestern University History Professor Heyck argues that Victorian scientists wanted nothing less than to move science from the periphery to the centre of English life (Heyck 1982, 87) Tyndall in 1874 gave a speech in Belfast, a very religious city, before the annual meeting of the British Association for the Advancement of Science. He argues that science holds greater authority than religion or non-rationalist explanations. In his attack on religion Tyndall upholds rationalism, consistency and scepticism. Thus, at the close of the 19th century, the concept was cemented into the English psyche that science and religion were in grave conflict and that, as such, science needed to be divorced from religion or non-rationality. Natural theology had been warped into a new breed of naturalistic science where the observations of nature provided evidence for an evolutionary origin not needing a religious explanation. Although post-effects of the enlightenment clearly did contribute to the secularization of 19th century England, they were not as significant as the contributions of science. Secularization in England had to do with changing society so that it was no longer under the control or influence of religion. The argument that meliorist objections to the ethical components of Christian Doctrine were the driving force that disempowered the church does not hold. Issues regarding ethics did decrease the membership of churches, but it did not disempower the church like science did. Science through the rise and fall of natural theology gave birth to a whole new generation of figures such as Huxley and Darwin who undermined the role of the church in society. Ethical grievances marginalized specific groups of people such as the aesthetes from the church but it did not remove the churchs influence over society to the same degree that scientific development did. The demise of natural theology led to a series of publications and conferences that took away the churchs predominant role in the field of science and society. Post enlightenment effects such as questions on ethics acted as a catalyst for secularization, but it did not lead to significantly greater removal of church influence. The enlightenment and science are inextricably linked but the effects science and natural theology had on removing church influence and supremacy in Victorian England caused greater paradigm shifts in society than ethical conflicts as evinced by the sources. Thus, it is clear that science to a far greater extent led to the secularization of nineteenth century England. The evidence demonstrates that Natural Theology did not strengthen but instead weakened the church. By attempting to demonstrate Gods existence and presence by empirical analysis exclusively theologians provided a platform for a new emergence of deism and atheism. Lyell, Darwin, Huxley, and Tyndall acted as catalysts to this process as they used the premises of Natural Theology to draw new conclusions about the origins the earth and living organisms. Draper and White towards the end of the nineteenth century concluded that science and religion had become enemies in their conflict thesis undermining religious activity as non-rational. Post effects of the enlightenment, such as the meliorist objections to the ethics of church doctrine and the emergence of new anti-religious groups such as the aesthetes did contribute to Englands secularization but to a lesser extent. Hence, s cience was the predominant factor in the secularization of England in the 19th century. Word Count: 2054 The above essay is all my own work: the source of all material used in its compilation has been duly cited and all help received is acknowledged. The essay does not substantially duplicate material previously or simultaneously submitted to academic staff at any academic institution. Jesse Alvarez

Rheumatoid Arthritis Case Study Essay

Skeeter Buck has had 4 years of joint pain with some very severe occasions. He complains of stiffness in his wrists, hands, knees, and feet. The stiffness seems to last anywhere from 30 minutes to 2 hours in the morning. When his joints are sore he is very unstable and feels as though he has no balance. The joint pain does not occur on a regular basis but when it does, he tends to lose his appetite. Medication: Cortisone shot (every 3 months), Aleve, Tylenol Medical History: 4 years of joint pain. Recently symptoms worsened. Family History: Grandmother and mother have rheumatoid arthritis and have had surgery. Grandma had a hip replacement and his mother had a knee replacement. Most of his family is overweight but there is no history of diabetes or heart disease. Social Lifestyle: Married with 2 children and wife is pregnant with their third. Lives in North Bay where he is the manager at a bank. He walks with a cane when his ‘flare ups’ are bad. Lifestyle History: Enjoys playing with the kids. He is as active as he can be without being in pain. He helps coach the hockey team his oldest son plays on. Wife is a dietician and so he eats healthy meals on a regular basis. Risk Factors: He is a non-smoker, regular cholesterol levels, and normal blood glucose levels. Physical Examination General Appearance: Looks healthy, comfortable and has great colour in face. Vital Signs: Blood Pressure = 123/82 mmHg in both arms, Pulse = 72 beats per minute, Respiration= 17 breaths per minute, Mass= 82 kg, Height = 70 in. (175 cm), BMI= 27, Waist Circumference = 34in. Cardiovascular: No carotid bruits, no jugular venous distension, clear lungs, normal point of impulse, regular rate and rhythm, no extra heart sounds, no edema, normal peripheral vascular exam. Skin: no rashes, a bit red, swollen and warm around knuckles on hands and feet. Musculoskeletal: walks slow due to pain, joints on the hands and feet are a bit swollen, does not have a full range of motion in his joints. Neurologic: Normal cranial nerves, loss of fine motor skills in hand, normal sensory exam. Resting Electrocardiogram before Exercise Test: Sinus rhythm, rate= 72 beats per minute, no Q waves, ST or T wave abnormalities. Computer interpretation is normal electrocardiogram. Diagnosis: Rheumatoid arthritis in wrists, hands, knees, and feet causing stiffness in the morning and pain throughout the day especially after more than normal use of the joints. This causes exercise intolerance and fatigue. Plan Complete a standard cycle ergometer test and initiate a training program focussing on increasing exercise tolerance, muscle strength, and range of motion. ** Please refer to following pages for pre-screen and informed consent forms! ** PATHOPHYSIOLOGY Rheumatoid Arthritis Rheumatoid arthritis is a type of inflammatory arthritis and an autoimmune disease. An autoimmune disease is one where the body’s immune system becomes confused and begins to attack its own body. In rheumatoid arthritis the target of the immune attack is the lining of the joints (synovial) and sometimes other internal organs. This causes swelling, pain, inflammation, and joint destruction. Inflammatory cells release enzymes that can digest bone and cartilage causing limited bone motion. This inflammation of joints usually occurs in a symmetrical and bilateral pattern (what happens on one side of the body, happens on the other). Rheumatoid arthritis is also characterized by aggravations and remissions (periods of time with intensified symptoms followed by period of time with reduced symptoms). Rheumatoid arthritis usually begins slowly, starting with only a few joints and spreading to others over a period of a few weeks to a few months. People with rheumatoid arthritis have impaired exercise tolerance. The disease affects flexibility, biomechanical efficiency, muscle strength, endurance, and speed, which contributes to functional limitations. There are three levels of classifying rheumatoid arthritis disease stages: 1. Acute: reversible signs and symptoms in the joint related to synovitis 2. Chronic: stable but irreversible structural damage brought on by the disease process 3. Chronic with acute exacerbation of joint symptoms: increased pain and decreased range of motion and function often related to overuse or superimposed injury. (3) Figure:(12) Signs and Symptoms of Concern (13)You should see your doctor if you experience any of the following symptoms for more than two weeks: Feel unusual pain and stiffness in your joints Pain and stiffness in the morning lasting more than 30-60 minutes before you feel any relief Feel more fatigued than normal Lack of hunger leading to weight loss Importance of Exercise for Rheumatoid Arthritis Patients Although people with rheumatoid arthritis may be hesitant to exercise due to pain they experience within their joints, current evidence suggests that a significant amount of disability related to the condition occurs from lack of fitness. By not exercising, muscle strength and endurance begins to deteriorate. This weakens the joint and contributes to accelerating the speed or arthritis. By not exercising you are also putting yourself at risk for other chronic diseases such as coronary heart disease, diabetes mellitus, and osteoporosis. The American College of Sport Medicine outlines three goals for exercise and arthritis. The goals are: 1) preserve or restore range of motion and flexibility around the affected joints; 2) increase muscle strength and endurance to build joint stability; 3) increase aerobic capacity in order to enhance psychological state and decrease the risk of cardiovascular disease. (8) Although long term effects of dynamic weight bearing exercise on those with rheumatoid arthritis remains unclear, current data suggests that vigorous exercise may be used to improve joint mobility, muscle strength, and aerobic capacity without causing joint damage (except when there is an acute joint inflammation or uncontrolled systemic disease)(8). Those with rheumatoid arthritis should remember that post exercise discomfort should be expected, but activities causing increased joint pain enduring for greater than two hours post-exercise should be discontinued. As previously mentioned, people with rheumatoid arthritis often have little aerobic capacity due to inactivity, but it has been shown to be a safe and beneficial form of treatment for those who are not experiencing acute symptoms. The American College of Sports Medicine suggests that people with rheumatoid arthritis should participate in large muscle activities such as walking, cycling, rowing, swimming, and dance at 60-80% of their peak heart rate or 40-60% VO2max, a rate of perceived exertion (RPE) rating of 11-16, 3-5 days per week for five minute sessions building up to thirty minutes. When working with people with rheumatoid arthritis, it is important to emphasis duration is more important than intensity with goals of increasing VO2max, peak work, and endurance within 4-6 months. It is also important to have at least fifteen minutes of warm-up and cool-down. (8) MEDICATION Although there is no specific cure for rheumatoid arthritis at the present, there are a range of medications available to manage the symptoms to improve the condition. Rheumatoid medications can be classified into different classes such as NSAIDs, Corticosteroids, DMARDs, Biological Agents, Salicylates, and Pain Relief Medications. Your doctor will most likely use a combination of these drugs to alleviate pain and prevent further damage to the joints. NSAIDs NSAIDs or Non-steroidal Anti-inflammatory Drugs are effective in pain relief and inflammation reduction, but do not serve to protect the joints from further damage. NSAIDs prevent your body from producing a substance called prostaglandins, which is primarily responsible for inflammation and pain. When taken in extreme dosages for a long time, these drugs can produce severe side effects, such as stomach bleeding, gastric ulcers, as well as potential damage to the kidneys and liver. Corticosteroids Corticosteroids suppress the immune system, thus managing inflammation. Although these may be very effective in treating rheumatoid arthritis, they have been said to trigger adverse side effects if used in prolonged periods. Examples of these side effects include easy bruising, glaucoma, cataracts, diabetes, excessive weight gain, and thinning of the bones. DMARDs DMARDS or Disease Modifying Anti-Rheumatic Drugs are groups of medications that serve to inhibit the immune system from damaging the joints, thus slowing further joint damage. Rheumatoid arthritis causes permanent joint damage in the early stages and so it is very important to start these medications right away. The risks for severe side effects are high with these medications. Taking DMARDs for a long time may result in bone marrow and liver toxicity, vulnerability to infections, skin allergies, and autoimmunity. Biological Agents Biological agents or biological drugs function to alleviate inflammation via various methods. An example of how they work is by inhibiting tumour necrosis factors. They also can treat inflammation through eradicating Beta cells. Salicylates Salicylates reduce the body’s production of prostaglandins. The use of salicylates has been replaced with NSAIDs, mainly due to the fact that they caused adverse side effects. Pain Relief Medications While anti-pain drugs neither decrease inflammation nor suppress further joint damage, these medications allow the individual become more comfortable and eventually function better. (2) PHYSICAL ASSESSMENT PROTOCOL To determine baseline levels and the areas exercise is in need of improvement, exercise testing can be used to evaluate the different exercise parameters. Those with rheumatoid arthritis tolerate sub-maximal and subjective symptom-limited treadmill tests that require less than 3 miles per hour walking speed. Early-onset muscle fatigue may limit receiving accurate information. Since people with rheumatoid arthritis may have troubles performing maximal treadmill test, sub-maximal bicycle tests may provide more accurate information without over-stressing joints.