Neurologic aspects of pain - Free Essay Example

Sample details Pages: 28 Words: 8358 Downloads: 9 Date added: 2017/06/26 Category Biology Essay Type Argumentative essay Did you like this example? 1. Neurologic Aspects of Pain 1.1. Functional Properties of Nerve Fibres 1.1.1. Properties of Peripheral Somatic Nerves Peripheral somatic nerves consists generally of somatic-motor, autonomic-motor and sensible fibres. 1.1.1.1. Somatic-motor fibres for the striated musculature The cell bodys of somatomotor fibres for the striated musculature are always lying in the brainstem (12 pare cerebral nerves) or the fore horn of the whole spinal medulla. The stimulus runs from central to peripheral (efferent). The lateral cutaneous femoral nerve consists of sensible fibres and no motor fibres. The shiatic nerve consists of 20% motor fibres, 30% sensible, and 50% sympathetic fibres. The gluteal nerves consist of pure motor fibres, sympathetic fibres and no sensible fibres. 1,2 Don’t waste time! Our writers will create an original "Neurologic aspects of pain" essay for you Create order 1.1.1.2. Autonomic-motor fibres for the smooth muscles of blood- and lymphatic vessels The autonomic-motor fibres for the smooth muscles of the blood and lymphatic vessels are of sympathetic origin. Venes are not innervated. They function by the musculare pump system and in some cases by valves. The cells bodies of the autonomic-motor fibres are situated in the lateral horn between C8-L2. They are termed: the centro-ganglionar neurons. All motor neurons, situated in the spinal medulla go via the fore horn to the peripheral nerve. It must be mentioned that all smooth muscles can contract without external innervation (for example: heart, gut). This is due to the intrinsic nerve system with is influenced by the sympathetic and parasympathetic nervous system. 3-5 1.1.1.3. Sensible fibres for somatic structures The sensible fibres for somatic structures originate from muscles, tendons, capsules, joints, ligaments and bones. Their cell bodies are lying in the spinal ganglions of the corresponding nerve (= afferent). 2,6 1.1.1.4. Sensible fibres for autonomic structures: blood- en lymphatic vessels The cell bodies of the sensible fibres for autonomic structures are situated in the spinal ganglions of the segments where the sympathetic neurons start (SI-joint: T11-L1). The peripheral autonomic nerve contains generally autonomic-motor and sensible fibres and serves for the innervation of organs. Glands are always dubble innervated (sympathetic and parasympathetic), except for the adrenals. 2 Examples: The femoral arterie contains sensible fibres which go to the spinal ganglions and arrive in the dorsal horn where connections exist, via intercalar neurons, with the origins of the sympathethic fibres of the levels T10-T11. Knee joint: is sensible innervated via the sciatic nerve (posterior side of the knee), but in the knee capsule, sensible fibres exist which connect via the femoral arterie the levels T10-T12. 1.1.2. Properties of Peripheral Autonomic Fibres Peripheral autonomic nerves consist of autonomic-motor and sensible fibres. They innervate organs and glands. 1.1.2.1. Viscero-sensible fibres The cell bodies of viscero-sensible nerve fibres are situated in the spinal ganglions of those segments from where the sympathetic and parasympathetic neurons start. Example: the pelvis organs: S2-S4 and/or TLJ (= thoracolumbar junction). The TLJ receives a lot of information. Some of those stimuli go via the nervous supply in the blood vessel wall. 2 1.1.2.2. Motor fibres for smooth muscles The parasympathetic primary cells are situated in the brain stem to the level of C2 and the lateral horn of S2-S4. The sympathetic origin is situated in the lateral horn of C8-L2. 2,7,8 1.1.3. Axoplasma Flow of the Axons Materials and substances are moved within the cytoplasm of all cells. In the axoplasm (= cytoplasm of neurons), structures such as the smooth endoplasmic reticulum, ribosomes, microtubules and neurofilaments likely take part of the axoplasmic transport mechanism. Perhaps the human movement plays a role in this intracellular motility 9. In the cytoplasm of nerve fibres nutrients and transmitters are moved. At the nerve ends vesicles are located, that continue the transport into the gap junction. The transport in the axoplasma is termed antidrome and orthodrome transport. Antidrome (antegrade) transport occurs from central to the periphery and orthodrome (retrograde) transport in the opposite direction.1,10,11 For the sciatic nerve the antidrome transport is rather fast (12 hours), the orthodrome transport is slower (48 hours). 1.1.3.1. Signal transfer of the peripheral nerve fibres Ion-channels and receptors play an important role in the signal transfer of the peripheral nerve fibres. The ion-channels are located on the extremities of the fibres. They make the transport for the neurotransmitters possible. Receptors are specified. Every cell has  ± 1 million receptors. The gates of the ion-channels (mostly proteins) can be inhibitory or excitatory. The Swann-cells are spread over the axon and form de myelin sheet. The myelin sheets are interrupted by the knots of Ranvier. In the CNS they are termed glial cells. The glial cells have several functions. The myelin sheets have a certain thickness. Unmyelinated axons have Schwann-cells as well. In myelinated axons the stimulus progresses salutatory and in unmyelinated axons the stimulus progresses slowly. The signal transfer of the peripheral nerve fibres has 3 kinds of stimulus progress being chemical transport, electric stimuli progression and axoplasm flow. Chemical transport occurs at the nerve ends, and consists of neurotransmitters. The transport depends of the kind of ion-channel, the neurotransmitter and the receptor. Electric stimuli progress over the axon and occur by opening of the ion-channels stimulation the own nerve ends due to production of the neurotransmitters. The speed of transmission depends of the presence of a myelin sheet and the diameter of the fibres. The axoplasm flow of the neurotransmitter in axoplasma (= chemical) occurs in 2 directions. Sometimes the pain can occur 24 hours after injury! It can also be very slow (up to 48 hours) and be resposible for the à ¢Ã¢â€š ¬Ã…“delayed onset of painà ¢Ã¢â€š ¬?. 1,11 1.1.3.2. Morphologic and functional classification of nerve fibres: Understanding pain phenomen the morphologic and functional properties of nerve fibres is important. In time several classification systems have been investigated and proposed. 1.1.3.3. Classifying axons according to their conduction velocity In the 1920s and 1930s, there was a virtual use of classifying axons according to their conduction velocity 13. Three main categories were discerned, called A, B and C fibres: C fibres are the smallest and slowest. Mechanoreceptors generally fall in category A. The A group is further broken down into subgroups designated: the a fibres: the fastest the b fibres the d fibres: the slowest The muscle afferents axons are usually classified into four additional groups: I: the fastest II, III and IV: the slowest, with subgroups designated by lower case roman letters. 1.1.3.4. Properties of the A-d, A-b sensors or type I en II fibres The A-a and A-b fibres have low threshold properties. They are low threshold afferents/efferents, they have a quick adaptation, are bi- or monosynaptic and unimodal (= mechanosensors: only sensible for mechanical stimuli). They cross the midline in the spinal medulla. The A-b provides information about normal pressure or strain tension and the A-a provides information about position changes of joints in space. They give information about the smooth touch and kinesaesthesis in the skin. 1.1.3.5. Properties of the A-d and C sensors or type III en IV fibres 1.1.3.5.1. The A-d sensors or type III fibres The A-d or type III fibres are selective and have a slightly higher threshold than the A-a and the A-b sensors. They have a longer adaptation time. After a pin prick the pain keeps going on for a time which is a specific property of the A-d sensors. They are multisynaptic and cross the midline in the spinal medulla. A-d sensors are polymodal. They provide information about mechanical stretch and pressure forces from normal to noxious. They give information about temperature from normal to noxious stimuli. From 36,5 °C tot 42 °C especially C-fibres are involved. From 36,5 °C tot 38 °C the A-d fibres are responsible. A quantity of those fibres is noxious. They are termed: à ¢Ã¢â€š ¬Ã…“nocisensorsà ¢Ã¢â€š ¬? but not all. Some measure only normal temperatures and they become nocisensors in case of tissue injury. 11 1.1.3.5.2. The C sensors or type IV fibres The C or type IV fibres are selective and have a high till very high threshold. They are slow to very slow with a long adaptation time. They have tonic and continuous activity properties. They cross the midline in the medulla medulla and are polymodal. The C fibres measure the chemical consistence of tissues from normal to noxious. They measure temperature from normal till abnormal (= noxious). Some of those fibres are nocisensors but not all of them. Example: the sensibility of the knee consists of 80% normal sensibility sensors and 20% nocisensors. 11 1.1.3.5.3. Difference between à ¢Ã¢â€š ¬Ã…“nocisensorà ¢Ã¢â€š ¬?- stimulation and à ¢Ã¢â€š ¬Ã…“painà ¢Ã¢â€š ¬? A nocisensor measures the damage of injured tissue. A nocisensor can but must not necessarily provoke pain. A part of the A-d and C-fibres are nocisensors. They measure the damage or the almost-damage (mechanic, temperature, chemical). Their noxious stimulation does not always lead to pain perception. Here fore the stimulus must attain the thalamus and cerebral cortex, otherwise there is no pain sensation. Not all nociceptory stimuli rise so high to the midbrain or cortex. A lot of stimuli à ¢Ã¢â€š ¬Ã…“extinguishà ¢Ã¢â€š ¬? in the spinal medulla, the ascending pathways or in the brainstem. The stimulus attains the à ¢Ã¢â€š ¬Ã…“pain centresà ¢Ã¢â€š ¬? when the intensity of one stimulus is sufficient or when summation occurs of several stimuli in parts of the dorsal horn. As well reflectory (unconscious) as cognitive (conscious) reactions occur and the nocisensors will provoke à ¢Ã¢â€š ¬Ã…“painà ¢Ã¢â€š ¬?, in case of severe damage. Thus, not all nocisensors provoke pain but they can be considered as normal pain fibres. It is logic that if a nocisensor is sufficiently stimulated it will provoke the sensation of pain. A-d en C fibres can give pain thatà ¢Ã¢â€š ¬Ã¢â€ž ¢s not only caused by the damage itself, but as a result of the damage as well. A pain feelin which is more intense than normally expected is termed hyperalgesia. For example, when ice is applied on the skin it à ¢Ã¢â€š ¬Ã…“hurtsà ¢Ã¢â€š ¬? but ice applied on a burned skin does hurt even more. When punctuated stimuli are applied on the course of the sciatic nerve it à ¢Ã¢â€š ¬Ã…“normallyà ¢Ã¢â€š ¬? hurts but in case of sciatica it hurts even more (= hyperalgesia). Hyperalgesia is hypersensitivity on a stimulus that normally hurts, due to over stimulation of the nocisensors. The A-a and A-b fibres normally do not give pain, because they are not nocisensors. They register only à ¢Ã¢â€š ¬Ã…“normalà ¢Ã¢â€š ¬? values. Under certain circumstances they provoke pain. This happens in ca se of injured tissues or nerves or when the nocisensors become active. When nocisensors already give pain as a result of a decreased threshold, then the A-a and A-b fibres become sensitive as well. A light pressure on the pain area will also be painful. A low pressure- or strain force on the skin, tendons or muscles normally provoke no pain, but in case of damage it will well provoke pain. This is termed allodynia. Allodynia is pain that is caused by a stimulus that normally doesnà ¢Ã¢â€š ¬Ã¢â€ž ¢t hurt due to an increased sensitivity of the the A-a and A-b fibres. This phenomon gives an opportunity to test the pain perception of the nervous system by use of pricking or brushing tests on the painfull area. There is a difference between nocisensor stimulation and the pain interpretation. 11 Table 5: Difference between nocicensor stimulation and pain. By use of selective stimulation the A-a and A-b fibres can be stimulated without that the A-d and C-fibres become active. This is caused by the low threshold of the A-a and A-ÃÆ'Ã… ¸ fibres compared with the A-d and C-fibres. A-d en C-fibres canà ¢Ã¢â€š ¬Ã¢â€ž ¢t be stimulated selectively by use of mechanical stimuli because at the moment those fibres are stimulated; already the A-a and A-ÃÆ'Ã… ¸ fibres are active. When those become active, all fibres were stimulated. Also in case of nociception all those fibres are active. Selective stimulation can be used during TENS application or during active en passive mobilisations applied under the pain threshold level. 11 1.1.4. Hierarchy of the Nervous System The information processing in the nervous system happens on 4 levels. As well as the peripheral nerve ends, the dorsal horn, the brainstem and sub cortical and cortical levels are involvend. 1,7,11 1.1.4.1. The peripheral nerve ends The peripheral nerve ends are responsible for the uptake of information. The receptors are modulated by the state of surrounding tissue and the condition of the peripheral nerve. 1.1.4.2. The dorsal horn of the spinal medulla The dorsal horn modulates the incoming signals and is influenced by the state of the dorsal horn and the quantity and kind of gathered stimuli. 1.1.4.3. The brainstem The brainstem provides the primary responses with autonomic and hormonal modulations as a response to stimulation. 1.1.4.4. Sub cortical and cortical levels The sub cortical and cortical area provides the conscious cognitive and psycho-emotional modulation. The processing of the information and response on stimulation depends on the hierarchic manner, but always occurs with a total integration of the whole nerve system. 1.1.4.5. The Archi-, Paleo- and Neo level of the nervous system The nervous system can be ordered depending on a hierarchic manner in an archi, paleo and a neo level. 7 1.1.4.5.1. The Archi level The archi level consists of the gray matter (dorsal horn) of the spinal medulla, the ascending multisynaptic pathways in and around the gray matter, the medial pathways of the anterolateral quadrant, the mid part of the cerebellum and the brainstem (reticular formation). It is responsible for the à ¢Ã¢â€š ¬Ã…“most automatic movementsà ¢Ã¢â€š ¬? after Hughlings Jackson. 7 1.1.4.5.2. The Paleo level The paleo level consists of the ascending pathways of the anterolateral quadrant, the descending pathways in the ventro-lateral quadrant, the hormonal and vestibular nuclei in the brainstem, the hypothalamus, certain parts of the cerebellum and the limbic system. Humoral influences from the liquor can influence (endofins) the sensibility of the pain system. 7 1.1.4.5.3. The Neo level The neo level consists of the dorsal ascending pathways, the dorso-lateral and ventral descending pathways, the cerebellar cortex, the lateral thamalus nuclei and the cerebral cortex. It is responsible for the cognitive mental processes, accurate skills and à ¢Ã¢â€š ¬Ã…“least automatic functionsà ¢Ã¢â€š ¬?. 7 1.1.4.6. Phylogenetic development of the nervous system The phylogenetic development of the nervous system differs in time for the different levels. The archi-system is the oldest and is identical to that of the lower vertebrates. It is completely developed when born. The paleo-system is younger than the archi-system. It is identical of that of the lower vertebrates but only half developed when born. The neo-system is het youngest system in the phylogenetic evolution. It is much more developed than that of the lower vertebrates and not developed when born. 7 1.1.4.7. Functional properties of the different hierarchic systems of the nervous system Specific properties can be indicated to the different hierarchic levels of the nervous system. 1.1.4.7.1. Functional properties of the Archi level The archi level consists of C and A-d fibres. It is a relatively slow and tonic (continuous) working system that stands for the basic needs of life e.g.: à ¢Ã¢â€š ¬Ã…“basic survivalà ¢Ã¢â€š ¬? or à ¢Ã¢â€š ¬Ã…“most automatic movementsà ¢Ã¢â€š ¬? and autonomic functions such as basic tonus regulation in the brainstem and medial cerebellum. It is responsible for primary pain modulation e.g.: redraw reflex and increased tonus. 1.1.4.7.2. Functional properties of the Paleo level The paleo level consists especially of A-d, A-b, and C-fibres as well. It is a relative quicker system but also has tonic activity properties. The paleo level supports the archi-level by use of hormonal adaptation and psycho-emotional adaptation. It takes part of the autonomic function (hormonal function), fight/flight reactions in case of stress and pain and posture regulation (static posture balance). 1.1.4.7.3. Functional properties of the Neo level The neo level consists especially of A-a and A-b fibres and is very quick with phasic responses on stimulation. It analyses the information of the archi- and paleosystem and is guided by use of cognitive responses. The least automatic movements are à ¢Ã¢â€š ¬Ã…“guidedà ¢Ã¢â€š ¬? and à ¢Ã¢â€š ¬Ã…“consciousà ¢Ã¢â€š ¬? movements. It regulates the dynamic posture balance and automatisation of movements. It is responsible for the organ sense perception and dissociated movement. 1.1.4.7.4. Interaction and control of the different hierarchic systems in the nervous system General principles of interaction among the different hierarchic systems in the nervous system can be summarized as follows. The paleo-system controls the archi-system and guides it. The neo-level controls the archi- and paleo system and guides both. The neo-level surrounds literally the archi and paleo level. The grey matter is situated medially in the nervous system medial in spinal medulla, the white matter laterally. The neo-system keeps the paleo-level and archi-level à ¢Ã¢â€š ¬Ã…“in harnessà ¢Ã¢â€š ¬?. The hierarchic construction of the nervous system can be seen as a gate control system that exists on all levels. 7 1.1.4.7.5. Gate-control in the peripheral nerve fibres Axo-axonal connections between lower and higher fibres exist. The A-a and A-b fibres give off collaterals in the dorsal horn. The A-a and A-b attain the spinal medulla faster and à ¢Ã¢â€š ¬Ã…“prepare ità ¢Ã¢â€š ¬? for the arrival of A-d and C-stimuli. Selective stimulation of higher fibres (A-a and A-b fibres) inhibits the working of the fibres of lower order (A-d and C-fibres). 1.1.4.7.6. Gate control in the dorsal horn At the level of the dorsal horn interaction and control mechanisms exist and this phenomen known as à ¢Ã¢â€š ¬Ã…“Gate-control in the dorsal hornà ¢Ã¢â€š ¬? is also known as the gate theory of Melzack en Wall. The outlets of the A-a en A-b neurons shunt on the outlets of the A-d and C-neurons and their neurotransmitters close the ion-channels of these. The descending pathways of the paleo- and neosystem do the same and work on the interneurons and inhibit the A-d and C-neurons. 11 1.1.4.7.7. Gate-control in the brain The cortical pathways control the sub cortical pathways. They inhibit the brainstem reflexes. à ¢Ã¢â€š ¬Ã…“Consciousà ¢Ã¢â€š ¬? movements and intentions inhibit à ¢Ã¢â€š ¬Ã…“unconsciousà ¢Ã¢â€š ¬? tonic reflexes (Example: relaxation). The cortical and sub cortical pathways regulate a directed and conscious life. The brainstem provides the autonomic support. This is all controlled by neurotransmitters. The perception of nociceptive pain not only involves the sensation transmitted and regulated by peripheral and central neurons, but is also affected by higher brain functions. 11 1.1.4.7.8. The uptake of nociception information A-d and C-fibres are the only fibres that can registrate nociception. The A-d fibres are quicker and give à ¢Ã¢â€š ¬Ã…“epicriticà ¢Ã¢â€š ¬? pain when the stimulus is attaining the pain centres. Epicritic pain means precise localisation with immediate redraw reflexes. The kind of pain is described as stabbing, boring, tearing or pulling. The impulses of the C-fibres attain the pain centres much later. They give à ¢Ã¢â€š ¬Ã…“protopathicà ¢Ã¢â€š ¬? pain, which is a continuous pain. That pain is not precisely located. Protopathic pain is burning, booring of a kind and continues much longer. It goes together with autonomic reactions, for expample: oedema. 11 1.1.5. The dorsal horn of the spinal medulla 1.1.5.1. General survey of the classification of the grey matter of the spinal medulla The grey matter is divided in the 10 layers of Rexed. This system is named by Rexed who discovered that the neurons in the dorsal horn where organised in à ¢Ã¢â€š ¬Ã…“layersà ¢Ã¢â€š ¬? depending on their function. Every layer is present in different segments and forms rostro-caudal nuclear columns. The counting happens from the dorsal horn to the anterior horn. Every layer is in contact with another by interneurons and dendrites. Layer I and II: nocisensory outlets of both: musculo-skeletal and visceral structures Layer III: intersegmental ascending pathways (dorsal proprium tract) and outlets to the spinothalamic tract (anterolateral quadrant) Layer IV: exclusive nocisensors from the musculoskeletal system Layer V-VI: fibres arriving from the nocisensors of the skin and viscera Layer VII: lateral horn: interneurons and sympathetic neurons Layer VIII en IX: motoneurons for musculoskeletal system Layer X: hormonal neurons In all levels descending pathways arrive from diverse levels of the brain. 1.1.5.2. Somatotopic ordering of nocisensors in the dorsal horn In layer I-II the nocisensors of viscera and musculo-skeletal structures are laying next to each other. They are ordered in a sagittal way from medial to lateral. The medial structures project medial and lateral structures project laterally. In layer V the nocisensors of certain skin areas are lying next to the nocisensors of viscera. Those are ordered in à ¢Ã¢â€š ¬Ã…“horizontalà ¢Ã¢â€š ¬? layers. For example: the organ-nocisensors under the level of the diafragm are lying next to the skin sensors from Th7-Th10. 1.1.5.3. Segmental interactions in the dorsal horn Normal reactions in musculo-skeletal influence the nocisensoric function. Outlets of nocisensors stimulate interneurons. There exists interaction with the spinothalamic tract and interaction with motoric anterior horn cells (somato-somatic relation). Normal reactions in musculo-skeletal nocisensoric function and influence the outlets of nocisensors stimulate the interneurons causing interaction with spinothalamic tract and with the sympathetic lateral horn cells (viscero-visceral relation). 11 Abnormal reactions can occur when the outlets of nocisensors à ¢Ã¢â€š ¬Ã…“infectà ¢Ã¢â€š ¬? the other nocisensors. Those react in turn causing interaction between motoric and visceral responses. This results in a somato-visceral relation, a somato-sympathetic relation and a viscero-somatic relation. 1.1.5.4. The Importance of Wide Dynamic Range Neurons In layer III, wide dynamic range neurons (WDR-neurons) exist. 21 Those WDR-neurons are interneurons that connect all the A-d en C-fibres from the dorsal horn. They project on the spinothalamic tract (antero-lateral quadrant). The ventral pathways go to the reticular formation, medial thalamus and the medial limbic system. The lateral pathways go to the lateral thalamus and cortex. They connect all visceral and motoric stimuli (= summation) with as consequences that motoric and visceral stimuli are sent together to the brain. The brain receives à ¢Ã¢â€š ¬Ã…“segmentalà ¢Ã¢â€š ¬? information and no à ¢Ã¢â€š ¬Ã…“individualà ¢Ã¢â€š ¬? information. The brain can project pain to segmental connected structures. This is termed à ¢Ã¢â€š ¬Ã…“referred painà ¢Ã¢â€š ¬?. Examples are: the stomach ulcer can provoke inter scapular pain or cardiac complaints and can give ulnaris nerve pain. Pain does not always indicate the exact location and origine. Anamnesis, assessment and clinical rea soning are very important. 1.1.5.5. Inhibition and excitation of the dorsal horn Inhibition and excitation of impulses in the dorsal horn can be caused by outlets of peripheral nerves. For example the A-a and A-b can inhibit the A-d and C fibres (pre-synaptic inhibiton). The outlets of the descending pathways can influence the the nerve ends and the interneurons (postsynaptic inhibition/excitation). The interneurons themselves can cause pre- or postsynaptic inhibition/excitation. Summation of stimuli defines the state of the dorsal horn. If a segment is excited or inhibited depends on the som of stimuli. Nocisensory impulses of the peripheral nerves always excite the dorsal horn. Summation of exciting nocisensoric impulses is defined by à ¢Ã¢â€š ¬Ã…“spatialà ¢Ã¢â€š ¬? and à ¢Ã¢â€š ¬Ã…“temporalà ¢Ã¢â€š ¬? facilitation. Temporal facilitation means the timing; spatial facilitation, the diverse structures that are involved. Impulses of A-a and A-b neurons act à ¢Ã¢â€š ¬Ã…“generallyà ¢Ã¢â€š ¬? inhibiting. The impulses from the descending pathways can act i n both ways. They are also regulated by temporal and spatial factors. The sum of stimulating and inhibiting stimuli defines the state of the dorsal horn. An excitated dorsal horn provokes a lot of irradiating pain. 1.2. Assessment of Primary and Secondary Hyperalgesia 1.2.1. Definition of primary hyperalgesia à ¢Ã¢â€š ¬Ã…“Changes in the local sensibility of the afferent neurons as a result of a lesion in the peripheral tissues are termed hyperalgesiaà ¢Ã¢â€š ¬?. In case of an increased sensibility of the A-a and A-b fibres the primary hyperalgesia is termed allodynia. In case of an increased sensibility of the A-d and C fibres the primary hyperalgesia is termed hyperalgesia. The lesion in the peripheral tissue can be of inflammation or neurogenic origin. 22 1.2.1.1. Pathophysiology of primary hyperalgesia In case of tissue injury bradykinin and ATP is produced at the site of lesion. Those mediators stimulate the blood- and lymphatic vessels, the mast cells and nociceptors. In the circulation inflammatory mediators are released aswell as histamine, serotonin, NGF, leucocytes, trombocytes and others. C-fibres released neuropeptides such as SP and CGRP. Those modulate and stimulate the release of other inflammatory mediators aswell. All those mediators are termed the à ¢Ã¢â€š ¬Ã…“inflammatory soupà ¢Ã¢â€š ¬?. Those mediators also stimulate the C-fibres which causes a vicious circle. The sympathetic nerve terminals are stimulated by inflammation and release noradrenalin which also stimulates the C-fibres. The à ¢Ã¢â€š ¬Ã…“sympathetic couplingà ¢Ã¢â€š ¬? between C-fibres and sympathetic end neurons occurs. The presence of inflammatory mediators decreases the threshold of all types of endneurons with as a result local allodynia and hyperalgesia. The allodynia and hyperalgesia can sp read in the surrounding tissue, by stimulating the surrounding neurons. This is termed the flair zone. 22,23 Figure 16: Consequences of tissue injury: the inflammatory soup. 14 1.2.1.2. Primary hyperalgesia and the dorsal horn The A-d mechanoreceptors and nociceptors, and C-nocisensors stimulate the dorsal horn of somatic connected segments. As a consequence a temporary wind-up can occur. A wind-up is an over stimulation that can hold on for 72 hours. A refectory muscular reaction occurs around the lesion aswell. As a result the stimulation via the ascending pathways (antero-lateral quadrant) to the brain increases. Protopatic pain (quick, stabbing pain) followed by epicritical pain (boring, continuous pain) occurs. The brainstem regulates the autonomic reactions further such as sympathetic, hormonal, and emotional. The C-nocisensors give stimuli to the sympathetic connected segments. As a result the sympathetic system stimulates the C-endneurons (= sympathetic coupling) and vasoconstriction on the arterioles and lymphatic vessels. 20,24 1.2.1.3. Primary hyperalgesia and nerve injury When compressed inflammation occurs as prescribed above. In case of long standing injury, an ectopic injury occurs. This can be located on different locations on the peripheral nerve with the result that hyperalgesia and allodynia occurs on the course of the nerve, the connected dermatomes and this from the nerve root! In the spinal ganglion of the nerve, the sympathetic endneurons grow round the nerve cells with the occurrence of basket formations as a result. Consequently sympathetic maintained pain (SMP) occurs, also termed causalgia. This phenomon can continue for 7 to 10 weeks after the lesion but can also continue afterwards. 10 25 To summarize we can state that inflammation provokes a à ¢Ã¢â€š ¬Ã…“localà ¢Ã¢â€š ¬? hyperalgesia and allodynia, which spreads over the flair zone. Locally a vicious circle between the inflammatory soup and C-fibres takes place and sympathetic coupling between sympathetic end-neurons and C-fibres occurs. This continues until the tissue heals. Normally the medulla reacts with a temporary wind-up and a normal stimulus-response reaction. In case of neurogenic injury, causalgia may occur and sensitisation of the dorsal horn is possible. 22 1.2.1.4. Clinical pain assessment in case of primary hyperalgesia During the pain assessment, in case of primary hyperalgesia, when brushing or by use of punctuate stimuli the following properties are local allodynia and hyperalgesia restricted to the flair zone. In case of a nerve injury the flair zone is restricted to the course of the nerve root. Local sympathetic reactions occur when inflamed but are restricted in time. In case of allodynia and hyperalgesia when brushing and applying punctuated stimuli on the course of the nerve or a part of it, sympathetic reactions in the dermatome of the nerve can occure aswell. 22 1.2.2. Definition of Secondary Hyperalgesia à ¢Ã¢â€š ¬Ã…“An increased sensibility of all types of nerve fibres that continues outside the flair zone of the original lesion, linked to the course of the hyperalgesia and allodynia around the tissue, is termed secondary hyperalgesiaà ¢Ã¢â€š ¬?. 22 1.2.2.1. Pathophysiology of secondary hyperalgesia When tissue is injured, nociceptors stimulate the interneurons by use of neurotransmitters such as SP, CGRP, NO, Ca, etc. The A-a and A-b neurons provide inhibiting neurotransmitters and the descending pathways give exciting or inhibiting mediators. The WDR-neurons receive al those impulses and send them to the spino-thalamic tract. WDR-neuron receptors differ. Some open ion-channels using inhibiting neurotransmitters, others open ion-channels using exciting neurotransmitters depending on the kind of receptor. If the stimulus acts inhibiting or exciting depends on the quantity of the opened inhibiting- or exciting ion-channels. In case of secondary hyperalgesia, more excitatory stimuli exist and insufficient inhibiting ways are activated. The WDR-neurons will work exiciting as well because of the fact they do not only activate the spino-thalamic pathways but also on the incoming stimulating neurons. As a result a vicious circle occurs in the dorsal horn. This provokes a decreased thr eshold of the present neurons. The sensors are also stimulated by the dorsal horn and not only by the local lesion. They become sensitized over their whole course with the consequence that the central hyperalgesia is linked to the lesion. When the local lesion is healing, the central allodynia will also disappear. Hyperalgesia is not as much linked to the course of the lesion but can last longer. Its origin is mostly caused by temporal and spatial summation of exciting stimuli. 22 1.2.2.2. Clinical pain assessment in case of secondary hyperalgesia During the pain assessment, when touching (brushing) and applying punctuate stimuli local hyperalgesia en allodynia and extending hyperalgesia and allodynia can be observed. When the pain occurs outsite the spinal column area the touching (brushing) and applied punctuate stimuli starting from the lesion and over the dermatome near by. The application must be enlarged to the neighbouring dermatomes and also to the corresponding segments of the spine. Always compare with the opposite side. Differentiate allodynia and hyperalgesia. 22 In case of primary hyperalgia the allodynia and/or hyperalgesia is restricted to the lesion area and flair zone. The allodynia disappears before the hyperalgesia when healing. In case of secondary hyperalgesia the allodynia and or hyperalgesia is present in several dermatomes and sometimes occurs up to the spinal segments. The allodynia disappears sooner than the hyperalgesia when healing. When the pain occurs at the level of and around the spine, the touching (brushing) and applying punctuate stimuli must first be applied on the painful segments and continued to higher and lower segments. The findings in the different segmental zones must be compared with each another. The conclusions are identical as case of peripheral pain. 22 1.2.3. Sympathethic maintained pain 1.2.3.1. Definition of sympathetic maintained pain: à ¢Ã¢â€š ¬Ã…“Pain, which is maintained by local or central over stimulation of the sympathethic nervous system, is termed sympathetic maintained painà ¢Ã¢â€š ¬?. Sympathetic maintained pain can occur as a consequence of local maintained inflammation and provoke phenomons such as sympathetic reflex dystrophy or complex regional pain syndrome (= CRPS). 26-28 1.2.3.2. Pathophysiology of sympathetic maintained pain In case of sympathetic maintained pain, local inflammation is maintained by local sympathetic coupling. This can be caused by a continuous stimulation of the secondary neurons in the lateral horn. This stimulation can be the result of stress situations or local input from organs. In pain physiology sympathetic reflex dystrophy (CRPS) is described as CRPS type I of II. CRPS I is the classic algoneuro dystrophy and CRPS II is the earlier described causalgia. Both types have a different pathophysiology. CRPS I is caused by a continuous sympathetic coupling as seen in maintained inflammation. The CRPS II is caused by the presence of basket formations in the spinal ganglion in case of a nerve lesion. Sympathethic maintained pain can be mild to extreme. In both cases of pain, the sympathetic system is involved. It depends from case to case, if its role becomes dominating. 26-28 1.2.3.3. Clinical pain assessment of sympathetic activity When assessing patients with chronic pain it is important to evaluate the sympathetic activity. This can be done with superficial observation and palpation of the skin. Herefore the therapist strikes softly over the skin of the back with the dorsal side of the hand. Look for colour changes, connective tissue abnormalities (strings), sweaty skin, pilo erection (chicken skin reaction). Afterword the Kibler-skin roll test can be applied. Hereby the skin is taken up between the thumb and index or mid finger. Lift and roll out the skin softly while proceeding in the paravertebral area over the whole spinal column. This must be repeated about 4 times. During the assessment; special attention must be made for possible presence of adhesions, the elasticity and dampness of the skin. Pain and red colouring may occur. The Headsche zones can be disturbed. Deep irritation of the skin can occure accompanied with muscular tension (McKenzie zones). To assess deeper tissues, enforced circularly frict ions around the paravertebral musculature can be applied over the whole spine and repeated sufficiently. When palpating for hypertonic paravertebral musculature, also look for sweat reactions, the red colour and Headsche zones, pain, hypertonia (Mc Kenzie zones). Sometimes the Headsche zones and the Mc Kenzie zones can correlate and indicate an underlying pathology. 7,26-28 1.2.3.4. Clinical neurodynamic pain assessment During clinical pain assessment special attension must be made for peripheral nerve lesions. While neurodynamic testing, the à ¢Ã¢â€š ¬Ã…“mobilityà ¢Ã¢â€š ¬? of the peripheral nerve is assessed when elongated. The sensibility or à ¢Ã¢â€š ¬Ã…“irritabilityà ¢Ã¢â€š ¬? of the peripheral nerve must be evaluated and the involvement of the peripheral nerve in case of a locomotoric lesion must be investigated. The neurodynamic testing involves à ¢Ã¢â€š ¬Ã…“mobilityà ¢Ã¢â€š ¬? or sensibility assessment of the dura mater aswell. The sympathetic chains must be must also been assessed. More details are described in literature 10,29-35. 1.2.4. Organisation of the Sympathetic Nervous System The functional properties of the sympathetic- en parasympathetic system are the regulation of the physiological basic functions such as: blood pressure, heart- and lung function, energy regulation and the functioning of organs. The function of the exo- and endocrine glands are regulated. The autonomic nervous system plays an important role regulating the the balance of the à ¢Ã¢â€š ¬Ã…“milieu interneà ¢Ã¢â€š ¬? (homeostasis). 2 Table 6: Organisation of the autonomic system. 1.2.4.1. Sympathetic nervous system: musculo-skeletal distribution 1.2.4.1.1. Primairy or first order neurons The primary or first order neurons are situated in locus coerolus (b-fibres) and in the reticular formation. The axons or first order neurons attain the whole spinal medulla and have collaterals to the dorsal horn. They produce catecholamine provoking inhibition. They have collaterals to cells in the lateral horn between C8-L2 as well. The first order neurons are stimulated by the limbic system, the cerebellum and the hormonal system. 22,36 1.2.4.1.2. Secondary or second order neurons The secondary or second order neurons are situated in the lateral horn (intermedio-lateral tract (ILT)) between C8-L2 (b-fibres). The axons go externally via the ventral horn together with the spinal nerves through the intervertebral foramen attaining the paravertebral ganglions. The secondary neurons are stimulated by the first neurons, the interneurons from the dorsal horn and from impulses of visceral or motoric origin. Before they attain the paravertebral ganglia, the second order neurons go as close as possible to the target tissue. 24,37 This phenomen can be summerized in 3 golden rules. Figure 7 Musculoskeletal distribution of sympathetic origin: 3 golden rules. 1.2.4.1.3. Tertiary or third order neurons The tertiary or third order neurons are situated in the paravertebral ganglia. They go direct to the target tissue. They are postganglionic end neurons (C-fibres). The teriary neurons go from every ganglion fibre back to the spinal channel (recurrent nerves). From every ganglion fibres go back to the spinal ganglion. Tertiary fibres follow the local blood- and lymphfatic vessels: radical arterial nerves. They follow peripheral nerves to muscles, joints and skin aswell (grey rami communicantes). 2 1.2.4.1.4. Functions of the sympathetic system on somatic structures The general action occurs from the locus coerulus. It is responsible for the activation of the alert state. Those conditions are also termed: fight/flight reactions. A sympathetic state also provokes an increased basic-tonus, vasodilatation of the large arteries, except for the vertebral arteries, an increased heart beat (tachycardia), increased respiratory volume, and increased adrenaline- and cortisol levels. It inhibits the digestion, provokes pupil dilation (mydriasis), constriction of the arterioles and lymphatic vessels and stimulates sweat- and talg glands. Sympathetic facilitation provokes segmental or general reactions on the skin, in general: on the pilomotoric stimulation (chickenskin reaction), sudomotoric stimulation (sweating) and vasomotoric (vasoconstriction: pale skin). The clinical signs at rest or when touched softly are: pale skin, chickenskin reaction and sweating. When stimulated a red skin, swelling and sweating occurs. By working on the musculature (segmental or general) the Headsche areas can be palpated. Ischemic contractures can appear (Mc-Kenzie areas). 7,38-43 1.2.4.2. Autonomic Nervous system: anatomical considerations The nervous system can be devided in a somatic and autonomic nervous system. Both systems have afferent and efferent properties. The autonomic nervous system receives afferent information of all kind. The efferent part of the autonomic system consists of sympathetic and parasympathetic division. The answer on stimulation depends of the tuning of the nervous system itselve. 7 Table 8: Classification of the nervous system. 1.2.4.3. Anatomical difference between the somatic and autonomic nervous system 1.2.4.3.1. The origin of the somatic and autonomic nervous system in the CNS The peripheral part of the somatic nervous system starts over the whole length of the spinal medulla and medulla oblongata. The peripheral origine of the autonomic nervous system differs for the sympathetic and parasympathetic division. The sympathetic division originates in the medullar segments from C8 to L2 and the parasympathetic division originates in the medulla oblongata and the medullar segments of the sacral medulla. 2,7 1.2.4.3.2. The configuration of the reflex bow The configuration of the reflex bow differs in the somatic and autonomic nervous system. In the reflex bow of the somatic nervous system there exist an afferent and an efferent neuron. The traject of afferent viscerosensible pathways differs from the traject of the somatic sensible pathways. For both systems the perikarion is situated in the spinal ganglions. The autonomic nervous system has a receptor neuron, a centroganglionar neuron and an effector neuron in its reflex bow. The centroganglionar neuron is situated between the receptor and effector neuron. The centroganglionar neurons originate in the lateral horn. It synapses with the effector neuron outside the CNS. The effector neuro connects the centroganglionar neuron with smooth muscles, glands or organs. 2 The receptor neuron or afferent neuron is the same for both divisions of autonomic nervous system. 1.2.4.3.3. Anatomical differences between the sympathetic and parasympathetic nervous system 1.2.4.3.3.1. Position of centroganglionar neuron The centroganglionar neuron is the second autonomic neuron which does not exist in the somatic nervous system. In the sympathetic division, the origin of the centroganglionar neuron is situated between C8-L2 in the lateral horn (intermedio lateral and medial nucleus). 2 In the sympathetic division the origin of the centroganglionar neuron is situated cranial and sacral. The cranial parasympathetic origin is situated in the medular levels C3-C4 of the medulla oblongata and consists of the accessory (Edinger-Westphal) nucleus of the ocullomotor nerve (CN III) (visceral motor), the superior (CN VII) and inferior (CN IX) salivatory nuclei, and the posterior (dorsal) vagal nucleus (CN XI). The sacral parasympathetic origin is situated in the medullar segments S2-S3-S4 of the medio-ventral grey matter of the sacral medulla. 1.2.4.3.3.2. Difference in position of the ganglion or synapse between the 2nd and 3rd autonomic endganglion In the sympathetic division the synapse (ganglion) between the 2nd and 3rd neuron can be situated close to the spinal medulla in the sympathetic chain, or halfway between the spinal medulla and the end organ (splanchnic ganglia, celiac plexus, hypogastric plexus), or close to the organ (parenchymatic gangliae). In the parasympathetic division the synapse (ganglion) between the 2nd and 3rd neuron is never situated in or around the sympathetic chain. Fibres of the parasympathetic system even do not go through the sympathetic chain. The synapse between the preganglionar and postganglionar neuron is situated halfway between the CNS and the target organ (for example: the cardiac, pulmonar, celiac, mesenteric or hypogastric plexus). Mostly the synapse between the 2nd and 3rd neuron is situated close to or into the target organ. All those are parasympathetic exept for the adrenals. Therefore the sympathetic division has typical short preganglionar neurons and long postganglionar neurons. The parasympathetic division has an opposite configuration with long preganglionar neurons and short postganglionar neurons. 2 The grey rami communicantes exist at every medullar level. The white rami communicantes are situated at the level of C8-L2. Sympathetic efferent impulses that must attain higher or lower areas follow the sympathetic chain to their target. The fibres follow the wall of blood vessels. The sympathetic chain attains cranial structures via the internal carotic arterie that enters the skull via the carotic formamen in the temporal bone. 1.2.4.3.3.3. Neurotransmitter properties of the autonomic nervous system The sympathetic neurotransmitters are adrenalin, noradrenalin, amfetamin, dopamine etc. The parasympathetic neurotransmitter is acethylcholin. At the end of the postganglionar neurons of the autonomic nervous system, a different neurotransmitter is used. The postganglionar parasympathetic nerve fibres secrete acethylcholine; the postganglionar sympathetic nerve fibres secrete noradrenalin. In the synapse between the 2nd and 3rd autonomic neuron for both systems acethylcholine is secreted. Therefore the sympathetic nervous system is termed adrenergic and the parasympathetic nervous system is termed cholinergic. 1.2.4.3.4. The sympathetic division The cell bodies of the sympathetic nerves are situated in the lateral horn of the thoracal and upper part of the lumbar medullar segments. The axons leave the spinal medulla via the anterior roots together with the efferent nerves from the somatic system. They connect the the sympathetic chain. The connections between the spinal nerve and the sympathetic chain are termed: the white rami communicantes. The preganglionar fibres can connect the second on different locations. They can connect the 2nd neuron in the sympathetic chain. After synapsing they follow the peripheral nerves of the somatic nervous system. The connections between the sympathetic chain and the peripheral nerve are termed the grey rami communicantes. In the white rami communicantes myelinated fibers are present. In the grey rami communicantes the fibres are unmyelinated. When the preganglionar fibres attain the sympathetic chain they can attain higher or lower medullar segments where they synapse in higher or lower sympathetic chain ganglions. From there they connect the peripheral nerve via the grey rami communicantes. The second neurons can follow the wall of bloodvessels aswell in the periphery. Preganglionar fibres can go through the sympathetic chain without making any synapse to attain the preganglionar plexusses e.g.: the celiac, mesenteric or hypogastric ganglions situated in the prevertebral plexus where they synapse. The sympathetic division provides the cardiac and pulmonary plexus from the medullar levels T1-T6. Via the celiac plexus (T5-T9) the stomach, liver, gallbladder, spleen, kidney (T10-L1), adrenals (T11) and a part of the duodenum and pancreas is supplied. The superior mesenteric plexus (T10-T12) supplies a part of the pancreas and duodenum, the jujenum, ilium, the colon ascendens and the proximal 2/3rd of the transverse colon. The inferior mesenteric plexus (T12-L2) supplies the distal 1/3rd of the transverse colon, the colon descendens, sigmoid and rectum. The hypogastric plexus (T12-L2) supplies the distal 1/3rd of the colon, the colon descendens, sigmoid, rectum, bladder and gender organs. 2,8,43-45 From the level of T5-T9 the n. splanchnicus major occurs and supplies the upper gastrointestinal tract, the duodenum and pancreas via the celiac ganglions. The minor splanchnic nerves occur from the medullar levels T10-T11. Via the superior mesenteric plexus they supply the intestinum tenue, the right colon, the adrenals, the testes, ovaria, kidney, and upper half of the ureters. The nervus spanchnicus minimus occurs from T12 and joins the lumbar splanchnic nerves (L1-L2) in the inferior mesenteric plexus to supply the left colon, the lower half of the ureters, the pelvis, the bladder and gender organs. The sympathetic supply for the arterial blood vessels of the upper limb is provided from the medullar levels T2-T6 and for the lower limb from T11-L2. 1.2.4.3.5. The parasympathetic division The parasympathetic division of the autonomic nervous system originates from fibres that start from the brainstem and the sacral medullar segments. The parasympathetic fibres are joining the cranial nerves such as the occulomotory nerve (III), the fascial nerve (VII), the glossopharyngeal nerve (IX) and the vagal nerve (X). The vagal nerve is considered to be the most important parasympathetic nerve but is discussed further. The parasympathetic preganglionar fibres are long, the postganglionar fibres short because the ganglions where they synapse are situated close to the target organ in the cranium. The parasympathetic fibres that originate from the brainstem and join the cranial nerves (III, VIII, IX) serve the supply for the innervation of the pupil and the glands in the cranium. 2,8,43-45 1.2.4.3.5.1. The ciliar ganglion The ciliar ganglion is situated in the orbital fossa between the lateral rectus muscle and the optic nerve. The preganglionar fibres occur from the autonomic accessory nucleus (nucleus of Edinger Westphal) in the brainstem. They join the occulomotory nerve to the ciliar ganglion where they synapse. From the ciliar ganglion the ciliar breves nerves occur that go through the sclera to the constrictor pupillae muscle and the ciliar body. The sympathetic fibres originate form the cavernous plexus and innervate the dilatator pupillae muscle. 2,8,43-45 1.2.4.3.5.2. The pterygopalatinum ganglion The ganglion pherygopalatinum is situated in the fossa pterygopalatinum under the maxillar part of the trigeminal nerve. The preganglionar fibres originate from the superior salivatory nucleus, which is part of the fascial nerve nucleus. The fibres attain the pterygopalatinum ganglion via major petrosus nerve and the canalis pterygoideal nerve (Vidian nerve). The postganglionar supply the mouth, nose cavities and pharynx. 2,8,43-45 1.2.4.3.5.3. The otic ganglion The otic ganglion is situated medial of the mandibular nerve. The preganglionar fibres occur from the inferior salivatorius nucleus and attain the otic ganglion via the minor petrosus nerve. Theire most important supply is the parotis gland. 2,8,43-45 1.2.4.3.5.4. Submandibular ganglion The submandibular ganglion is situated near by the tube of submandibular gland. The preganglionar fibres occur also from the superior salivatori nucleus. The fibres join the fascial nerve (intermedius n.) and leave it with taste fibres in the tympanic chord. From here they go via the lingual nerve to the base of the mouth where they become a ganglion. They supply the submandibular and submaxillary glands and the anterior part of the tongue. 1.2.4.3.5.5. The vagal nerve The vagal nerve leaves the skull via the jugular formamen and goes through the cervical area near by the oesophagus and provides supply for the heart and lungs. Together with the oesophagus they go through the respiratory diaphragm into the abdomen. Under the diaphragm the vagal nerve joins the celiac plexus and goes via the mesenteric plexus to its target organs. 1.2.4.3.5.6. The pelvic nerve The sacral part of the parasympathetic division exists of branches from S2-S3-S4 that form the pelvic nerve that supplies the pelvis organs. It provides the vesical and uterovaginal plexus. 2,8,43-45 1.2.5. References Loeser JD, Butler SH, Chapman CR, Turk DC. Bonicas Management of Pain. 3th ed. Philadelphia: Lippincott Williams Wilkins, 2001. Lignon A. SchÃÆ' ©matisation Neuro-VÃÆ' ©gÃÆ' ©tative en OstÃÆ' ©opathie. 2nd ed: editions de verlaque, 1989. Gebhart GF. Visceral pain. Seattle, Wash.: International Association for the Study of Pain, 1995. Tortora GJ. Anatomy and Physiology. Laboratory Manual. 5th ed. London: Prentice-Hall, 1998. Korr IM. Somatic dysfunction, osteopathic manipulative treatment, and the nervous system: a few facts, some theories, many questions. J Am Osteopath Assoc 1986;86(2):109-14. Smith JW, Murphy TR, Blair JSG, Lowe KG. Regional Anatomy Illustrated. New York: Churchill Livingstone, 1983. Van Cranenburgh B. Inleiding in de toegepaste neurowetenschappen Deel 1. 2de ed. Gent: De tijdstroom, 1987. Netter FH. Atlas of Human Anatomy. 2th ed. East Hanover, New Jersey: Novartis, 1997. Butler DS. Mobilisation of the Nervous System. 7th ed. Melbourne: Churchill Livingstone, 1996. Butler DS. The sensitive nervous system. Adelaide, Australia: NoiGroup publications, 2000. McMahon SB, Koltzenburg M. Textbook of Pain. Wall and Melzacks. 5th ed. Philadelphia: Elsevier Churchill Livingstone, 2006. Bernards JA, Bouman LN. Fysiologie van de mens. 6de ed. Diegem: Bohn Staffleu Van Loghem, 1996. Purves D, ed. Neuroscience. Sunderland, USA: Sinauer Associates, Inc, 1997. Pauly N, Rondel G. Syllabus: Manuele Neurotherapie. IRSK-WINGS 2006:Graad I,II,III,IV. Melzack R, Wall PD. Handbook of pain management. Edinburgh: Churchill Livingstone, 2003. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150(699):971-979. Netter FH. Nervensystem I: Neuroanatomie und Physiologie. GÃÆ' ¼nter KrÃÆ' ¤mer ed. New York: Georg Thieme Verlag Stuttgart, 1987. Netter FH. Farbatlanten der Medizin. The Ciba Collection of Medical Illustrations. Band 5: Nervensystem I. Neuroanatomie und Physiologie. New York: Georg Thieme Verlag Stuttgart, 1987. Duus Peter. Topical Diagnosis in Neurology. 2nd ed. New York: Thieme, 1989. 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Coppieters M BP, Stappaerts K,. Incorporating nerve gliding techniques in the conservative treatment of cubital tunnel syndrome. Journal of Manipulative and Physiological Therapeutics 2004:1-10. Coppieters MW. Hst 14. In: Dijkstra PE , et al, eds. Jaarboek kinesitherapie. Houten: Bohn Stafleu van Longum, 2003: 181-202. Elvey RI, Idozak RM, Dewhurst I, et al. Aspects of manual therapy. Brachial plexus tension tests and the pathoanatomical origin of arm pain. Melbourne: Lincoln Institute of Heath Sciences, 1979. Elvey RL. Pathophysiology of radiculopathy: A clinical interpretation. Fifth Biennial M.T.A.A. Conference 1987, Melbourne. Elvey RL, Quintner JL, Thomas AN. A clinical study of RSI. Aust Family Physician 1986;15:1314-1319. Meyer RA, Campbell JN, Raja SN. Peripheral Neural Mechanisms of Nociception. In: Wall PD, Melzack R, eds. Textbook of Pain. 3th ed. Edinburgh, UK: Churchill Livingston, 1994. Bielefeldt K, Gebhart GF. Visceral pain: basic mechanisms. 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The subordinates ‘ level of following the order is another major factor that make transformational approach the most efficiency leadership approach. As the being leaded party in 21 century , followers need inspiration and motivation to complete their task , individuals ‘ rights and benefits are the main task always bring up the discussion within society .As long

Impact of Organised Retail Chains on Unorganised Retail Sector Free Essays

string(27) " were estimated at over 2\." â€Å"A COMPARITIVE STUDY ON PREFERENCE OF SOFT DRINKS IN YOUTH REPORT Submitted to: Submitted by: DR. RAJKUMARCHIRAG GUPTA Roll no. 5382 MBA 5. We will write a custom essay sample on Impact of Organised Retail Chains on Unorganised Retail Sector or any similar topic only for you Order Now 4 MASTER OF BUSINESS ADMINISTRATION [pic] INSTITUTE OF MANAGEMENT STUDIES AND RESEARCH MDU,ROHTAK 2010-2011 DECLARATION I Chirag Gupta, student of 5 year M. B. A 4th semester of Institute of Management Studies and Research hereby declare that the project report titled â€Å"Preference of soft drink in youth† is a code of critical independent work carried out by me under supervision guidance of Dr. Raj Kumar. This has not been previously submitted for the award of any other diploma, degree or other similar degree. The feasibility suggestion has been duly incorporated in the consultation with the supervisor. Signature of the Candidate EXECUTIVE SUMMARY Soft Drinks were common preference among all the individuals, irrespective of their age groups as it had great brand value and great advertisement. Market Research is based on some underlying parameters like: †¢ Changing consumption pattern †¢ Advertisements †¢ Taste †¢ Status consciousness †¢ Varying lifestyle The study starts with determining the major players in the soft drinks, their overall consumption pattern among the people and ends up with the conclusion as per the state of mind of the average rational human being. Consumer preferences are changing towards healthier food, and thus such a trend will carry on for some time to come. In the soft drinks market of late, most recent new products launched have been focused on the health benefits of the soft drinks, like pomegranate juices, calcium-fortified bottled water and a series of reduced-sugar alternatives, with such features not previously so readily available to or heavily promoted at the target audience. TABLE OF CONTENTS SERIAL NO. TITLE PAGE NO. 1) INTRODUCTION 1) Industrial profile 01 2) Major players in soft drinks segment 04 3) Study of growth of soft drink market 09 2) RESEARCH METHODOLOGY ) Purpose of the study 10 2) Objectives of the study 10 3) Scope of the study 10 4) Research Design 11 5) Sampling Technique used 12 6) Selection of Sample Size 12 7) Sources of Data collection 12 8) Statistical Tools Used 12 3) DATA ANALYSIS AND FINDINGS 13 ) LIMITATION OF THE STUDY 24 5) CONCLUSION 25 6) ANNEXURE 6. 1) Questionnaire 26 7) BIBLIOGRAPHY 28 INTRODUCTION INDUSTRIAL PROFILE The soft-drink industry comprises companies that manufacture nonalcoholic beverages and carbonated mineral waters or concentrates and syrups for the manufacture of carbonated beverages. Naturally occurring bubbling or sparkling mineral waters have been popular for thousands of years: the ancient Greeks believed that such waters had medicinal properties and bathed in them regularly; the Romans established resorts around mineral springs throughout Europe. In the 1500s the village of Spa in Belgium became famous for its waters, which by the early 1600s were sold, in bottles, as far away as London, Eng. Development of the first man-made sparkling or carbonated water is credited to Joseph Priestley, the British scientist who discovered oxygen. In 1772 he invented a method of â€Å"pushing† carbon dioxide into water by dissolving it under pressure, thus creating fairly long-lasting bubbles. The technique led to development of the soft-drink industry. By the beginning of the 19th century, carbonated water was being made commercially in France and North America; shortly thereafter, flavours (normally fruit concentrates) were added to enliven the taste. In the 1820s, small carbonated bottling operations were established in Canada, producing carbonated drinks in refillable bottles which were merchandised as medicinal elixirs or tonics. Most soft drinks are still carbonated to give drinks a â€Å"tangy bite† and to stimulate the tongue. Furthermore, because scent is an important part of taste, the flavours carried as vapours in the bubbles enhance taste. The principle of â€Å"pushing† carbon dioxide is still used, but now the water is first purified in a process known as â€Å"polishing. † Cooled carbon dioxide is then injected at pressures of 275-550 kilopascals. Some of the early drinks bottled in Canada were called Birch Beer, Ginger Beer, Sarsaparilla, Sour Lemon, None-Such Soda Water and Cream Soda. The first carbonated beverage or â€Å"pop† bottles were sealed with corks held tightly in place with a wire binding. Because they had to be stored neck down so that the cork would not dry and allow the carbonation to leak away, they were manufactured with rounded bottoms. By the mid-1800s, soft drinks sold in Canada were packaged in 8-ounce (227. 2 ml) round-bottom bottles for about 25 cents a dozen, except ginger beer, which was sold in draught form from wooden kegs. Wired cork closures were used until about 1884 with Codd’s Patented Globe Stoppers (25 types in all). Such closures were replaced by the Hutcheson Spring Stopper. The crown cap was introduced around 1905 and improved versions are still widely used, although they are gradually being replaced, especially on larger containers, with reclosable screw caps. Other packaging innovations since the mid-1960s include canned carbonated beverages, nonreturnable glass bottles and containers made from rigid plastics. However, an effort is being made, often through provincial legislation, to increase the use of returnable glass containers. In the industry’s early years the number of carbonated-beverage plants increased steadily, most serving small regional markets. In 1929 the industry was made up of 345 production plants and the value of shipments reached $12. 3 million. By 1960 the number of plants had increased to 502 and the value of sales to $172. 7 million. Subsequently, consolidation began, prompted by improved production, packaging and distribution facilities. By 1973, 337 plants were in production and the value of shipments was $484 million. In 1985, with sales of about $1. 8 billion, the industry had 187 plants in production: Newfoundland had 3; PEI, 1; Nova Scotia, 7; New Brunswick, 8; Quebec, 66; Ontario, 58; Manitoba, 7; Saskatchewan, 10; Alberta, 13; and BC, 14. Production volume has also increased dramatically: in 1939, soft-drink bottlers produced about 162 million litres of carbonated beverages; by 1967, production passed 758 million litres; in 1986, shipments were estimated at over 2. You read "Impact of Organised Retail Chains on Unorganised Retail Sector" in category "Papers" 1 billion litres; and in 1998 that figure rose to 3. 5 billion litres. The industry is regulated by both federal and provincial agencies, 3 of the most important being CONSUMER AND CORPORATE AFFAIRS (responsible for the Consumer Packaging and Labelling Act), HEALTH CANADA (which administers the Food and Drugs Act) and Environment Canada (which focuses on environmental matters). The industry is represented by the Canadian Soft Drink Association in Toronto and by several provincial associations. The introduction of diet carbonated beverages has changed the industry’s profile. Several years ago, in response to increasing consumer diet consciousness, the industry introduced the first successful sugar-free diet drinks using the artificial sweetener cyclamate. But questions were raised about the safety of this additive and, based on existing scientific data, Health Canada banned its use in Canadian commercial FOODS AND BEVERAGES. This decision, estimated to have cost the industry more than $15 million, was a setback to diet-drink development. The industry turned to saccharin, but this too was eventually banned. Now, a new sugar-free additive, aspartame, has been approved for use in diet soft drinks, and the cyclamate/saccharin situation is not expected to recur because aspartame consists of amino acids, which occur naturally. Aspartame-sweetened diet drinks have had a dramatic effect on the Canadian carbonated-beverage industry. Just before the saccharin ban in 1977, diet drinks accounted for about 10% of the soft-drink market; following the ban the diet share dropped to about 2%, consisting of beverages partially sweetened with small amounts of sugar. In 1982, the first full year that aspartame was used in Canada, diet drinks increased by 15. 2% of total soft-drink sales, while the total soft-drink industry grew 8%. In 1987 total soft-drink sales increased 5. 3% over 1986, while diet soft-drink sales increased by 10. 7%. This single development has encouraged strong growth in the industry. MAJOR PLAYERS IN SOFT DRINKS SEGMENT COCA COLA [pic] â€Å"thanda matlab coca cola!!! † Coca cola has truly remarkable heritage. From a humble beginning in 1886 it has now become the flagship brand of largest manufacturer, distributor of non alcoholic beverages in the world. In India, coca cola was the leading soft drink till 1977 when govt. policies necessitated its departure. Coca cola has made its return to the country in 1993. and made significant investment to ensure that the beverage is available to more and more people in remote as well as inaccessible parts of the world. Coca cola returned to India in 1993 and over the past ten years has captured the imagination of the nation, building strong association with cricket, the thriving cinema industry, music etc. coca cola has been very strongly associated with cricket, sponsoring the world cup in 1996. In 2002, coca cola launched the campaign,†Thanda Matlab coca cola†. in 2003,coke was available for just rs,5 crores in the country. FANTA GHOONTH BHAR SHARARAT KAR LEY!!! [pic] Fanta entered the Indian market in year 1996 under the coca cola brand . ver the years, Fanta has occupied a strong market place and is identified as â€Å"the fun catalyst†. Fanta stands for its vibrant color, tempting taste and tingling bubbles that not just uplifts feelings but also helps free spirit thus encouraging one to indulge in the moment. LIMCA â€Å" LIME AND LEMONI!!! [pic] Drink that can cast a tangy refreshing spell on anyone, anywhere. Born in 1971, Limca has been the original thirst choice, of mi llions of consumers for over three decades. The brand has been displaying healthy volume growing year on year and limca continues to be leading flavoring soft drinks in the country. Dive into the zingy refreshment of limca and walk away a new person. THUMS UP TASTE THE THUNDER!!! [pic] Strong cola taste, exciting personality. Thums up is a leading carbonated soft drink and most trusted brand in India. Originally introduced in 1977, thums up was acquired by the coca cola company in 1993. Thums up, is, known for strong, fizzy taste and its confident, mature and uniquely masculine attitude. This brand clearly seeks to separate the man from the boys. SPRITE â€Å"SPIRITE BHUJAYE PYAAS BAKI SAB BAKWAAS!!! [pic] World wide sprite ranked as no. soft drink and is sold in more than 190 countries In India, sprite was launched in year 1999 and today it has grown to be one of the fastest growing soft drinks, leading clear lime category. Today sprite is perceived as a youth icon. With strong appeal to youth sprite has stood for a straight forward and honest attitude. Its clear crisp hingtaste encourages today’s youth to trust their instincts, influence them to be tru e who they are and to obey their thirst. MAAZA YAARI DOSTI TAAZA MAAZA!!! [pic] Maaza was launched in 1976. In 1993, maaza was acquired by coca cola India. Maaza currently dominates the fruit drink category. Over the years, maaza has become synonymous with mango. â€Å"Taaza Mango, Maaza mango, Botal mei aam, maaza hai naam†. consumers regard maaza as wholesome, natural, fun loving drink real experience of fruit. The campaign builds on the existing equity of the brand and delivers a relevant emotional benefit to the moms rightly captured in tagline, â€Å"yaari dosti, and taaza maaza†. PEPSI YEH DIL MAANGE MORE!!! [pic] Pepsi cola is a carbonated beverage that is produced and manufactured by Pepsi co. It is sold in stores, restaurants and from vending machines. The drink was first made in the 1890’s in North Carolina. The brand was trademarked on June 16, 1903. There have been many Pepsi variants produced over the years. †¢ Diet Pepsi †¢ Crystal Pepsi †¢ Pepsi twist †¢ Pepsi max †¢ Pepsi samba †¢ Pepsi blue †¢ Pepsi gold †¢ Pepsi holiday spice †¢ Pepsi jazz †¢ Pepsi x(available in Finland brazil) †¢ Pepsi next(available in Japan south Korea) STUDY OF GROWTH OF SOFT DRINK MARKET SOFT DRINKS Carbonated drinks are dominated by artificial flavors based on cola, orange and lime with Pepsi and coca-cola dominating the market. The entire part of the drink is based on its artificial flavors and sweetening agents as no natural juice is used. MARKET †¢ Cola products account for nearly 61-62% of the total soft drinks market. †¢ Two global majors’ Pepsi and coke dominate the soft drink market. †¢ NCAER survey says 91% of soft drink in the country is in the lower, lower middle and upper middle class people. †¢ The market is worth around Rs. 5000 crores with growth rate of around 10-15%. †¢ The annual per capita consumption in India is only about 6 bottles vis- a- Vis 340 bottles in the U. S. †¢ The production as soft drinks has increased from 5670 million bottles in 1998-99 to 6230 million bottles in 1999-2000 industry source. Growth market this year is expected to be 10-15% in value terms and 20-22% in volume terms. However, the market for carbonated drinks is stagnating and not growing as expected. RESEARCH METHODOLOGY PURPOSE OF THE STUDY The main aim of this research study is to analyze the preference of youth on consumption patterns and preference of Soft Drinks. OBJECTIVE OF THE STU DY †¢ To study the preferences of the youth for soft drinks. †¢ To find out the factor(s) that influences the consumer’s consumption of soft drinks. †¢ To test the know-how of the consumers regarding the various existing brands of soft drinks. To know the size of the soft drink purchase for personal and household purpose. †¢ To know the frequency of consumption of soft drink. SCOPE OF THE STUDY †¢ This study is confined MDU campus Rohtak. †¢ Seasonal drinks are not considered in the study. †¢ We are considering only canned and bottled drinks. †¢ We are not considering health alcoholic drinks. RESEARCH DESIGN A research design is a framework or blueprint for conducting the marketing research project. It specifies the details of the procedures necessary for obtaining the information needed to structure and/or solve marketing research problem. On the basis of fundamental objectives of the research we can classify research design into two general types: 1) EXPLORATORY RESEARCH 2) CONCLUSIVE RESEARCH Exploratory research is one type of research design, which has its primary objective the provision of insights into, and comprehension of, the problem situation confronting the researcher. Conclusive research is designed to assist the decision maker in determining evaluating and selecting the best course of action to take in a given situation. Conclusive research can be further divided into two types:- †¢ Descriptive †¢ Experimental The research design used in this project is a DESCRIPTIVE DESIGN. Descriptive study as the name implies is designed to describe something-for example the characteristics of users of a given product, the degree to which the product use varies with income, age, etc. SAMPLING TECHNIQUE USED: This research has used convenience sampling technique. 1) Convenience sampling technique: Convenience sampling is used in exploratory research where the researcher is interested in getting an inexpensive approximation of the truth. As the name implies, the sample is selected because they are convenient. SELECTION OF SAMPLE SIZE: For the study, a sample size of 60 has been taken into consideration. SOURCES OF DATA COLLECTION: Research will be based on two sources: 1. Primary data 2. Secondary data 1) PRIMARY DATA: Questionnaire: Primary data was collected by preparing questionnaire and the people were randomly being requested to fill them. 2) SECONDARY DATA: Secondary data will consist of different literatures like books which are published, articles, internet and websites. In order to reach relevant conclusion, research work needed to be designed in a proper way. STATISTICAL TOOLS USED The main statistical tools used for the collection and analyses of data in this project are: †¢ Questionnaire †¢ Bar Diagrams DATA ANALYSIS FINDINGS |Statistics | | | |Statistics | | | | | | | | | | |Statistics | | | |Who decide the |Do you read | | | |selection of soft |instruction written | | | |drink for household? on the packaging of | | | | |soft drink? | |N |Valid |60 |60 | | |Missing |0 |0 | | |Mean |2. 8167 |1. 6167 | | |Median |3. 0000 |2. 0000 | | |Mode |3. 00 |2. 0 | | |Variance |. 356 |. 240 | | | | | |Do you like soft drink? | | | | | | | | | | | | | | | | | | | | | | | | [pic] LIMITATIONS OF THE STUDY LIMITATION OF THE STUDY ? The study was confined to University Campus MDU Rohtak only. ? Chances of some biasness could not be eliminated. ? Youth are assumed to be between the age 15 to 25 ? Time was the major constrain. Only limited sample size (60) was possible for such a vast research on such a period of time . i. e. one mon th ? Interaction with the respondents was also limited due to their busy work. Due to the changing life style and preferences, it was not necessary that they will consume same soft drink every time. ? There was a chance that respondent will make assumptions while filling the questionnaire. CONCLUSION CONCLUSION Following are the concluding points taken into consideration after the conduct of the research study: ? An important finding that emerged out of the survey was that 91%of youth like to have soft drinks while 9% not like. ? Through the research it was conveyed that weekly consumption of soft drinks is more than daily consumption. ? Most of the respondents took soft drink without any reason. ? Remaining majority of the respondents consume soft drinks at the time of parties celebrations. Most of the respondents consume soft drinks because of its taste. ? Most of the respondents were of the neutral view that advertisements affect their purchases. ? Most of the respondent likes D ew. ? Most of them consume 300ml pack for personal usage. ? Packaging doesn’t influence the purchase of most of the respondents. ? Most of them don’t read instruction written on the package of soft drink. ANNEXURE QUESTIONNAIRE Respected Sir/Madam A Research Project is being pursued in IMSAR on â€Å"Preference of soft drink in youth†. Kindly extend your cooperation enable us doing the project successfully. This information is used for academic purpose. PERSONAL DETAILS Name – †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. Age – †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. Gender – ? Male ? Female Qualification – ? Graduate ? Under Graduate ? Post Graduate ? Other (Specify) 1) Do you like soft drinks? Yes No 2) Where do you mostly consume soft drink? PartyCafeHome 3) Frequency of consumption of soft drink in a week? Daily 2-4times more than 4 times once in a week 4) On what occasions, do you often consume the Soft Drinks? Feeling Thirsty Without any reason (just like that) ? Parties / Celebrations ? Others, please specify†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 5) What induces you to buy Soft Drinks? Price with quantity Health Drink Status symbol Taste Variety Advertisement 6) Which soft drink do you like more? Dew Sprite Cocacola Pepsi Limca Maaza Other (specify)†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7) Do advertisements influence your purchases? Strongly Agree ? Agree Neutral Disagree Strongly Disagree ? 8) Do you agree that packaging influence consumer purchase decision? Strongly agree Agree Neutral Disagree Strongly disagree ) Please tick the size of soft drink you purchase for personal consumption? 200 ml 250ml 300ml500ml other (specify)†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 10) Which soft drink is served to the guest in your home? Dew Sprite CocacolaPepsi LimcaMaazaOther (specify)†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 11) Who decide the selection of soft drink for household? FatherMother Himself/Herself Other(Specify)†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 12) Do you read instruction written on the packaging of soft drink? YesNo BIBLIOGRAPHY BIBLIOG RAPHY †¢ http://en. wikipedia. org/wiki/Beverage †¢ www. foodindustryindia. com †¢ http://fnbnews. com/article/detarchive. asp? articleid=25105=3 †¢ http://fnbnews. com/article/detarchive. asp? rticleid=24983=3 †¢ http://fnbnews. com/article/detarchive. asp? articleid=24965=3 †¢ http://fnbnews. com/article/detarchive. asp? articleid=24849=3 †¢ http://fnbnews. com/article/detarchive. asp? articleid=25039=3 †¢ http://www. foodindustryindia. com/newfood/detailnews. jsp? n=Xtazy,%20another%20energy%20drink%20for%20the%20Indian%20market=598 †¢ http://fnbnews. com/redfr. asp? fn=/other/aboutus. asp=About%20Us#Food †¢ www. google. com †¢ Kothari C R, â€Å"Research and Methodology- Methods Techniques†, New Age International (P) Ltd. , 2004 [pic] ———————– 1 2 3 4 5 6 8 9[pic][pic] 24 27 25 12 How to cite Impact of Organised Retail Chains on Unorganised Retail Sector, Papers

Analyzing Issues Affecting Personal Dignity

Question: Describe about the Analyzing Issues Affecting Personal Dignity? Answer: The fundamental premise for ensuring human dignity is through ensuring that the fundamental rights pertaining to each employee and executive of the organization are ensured. The presence of employment laws and regulations relating to workplace behavior has been implemented towards ensuring that none of the employees in business organization is subjected to biasness. The presence of bullying and harassment in workplace is of primary concern for issues pertaining to the dignity at work. Bullying comprises of offensive, insulting and derogatory behavior in order to violate another persons dignity. Moreover, creation of an hostile and intimidating environment can be considered as bullying. Harassment can be considered as violation of a human dignity through degrading, unwarranted humiliating and hostile conduct. The inherent nature of bullying and harassment makes them hard to recognize owing to the fact that they are not as explicit or visible as compared to other forms of distresses. Moreover, the detection of genuine cases of harassments are hard to asses resulting from the ambiguity in terms of laying down what is acceptable form of behavior and what is not. The organizational culture thrives on diversity, equitability, accountability. Therefore, presence of cases such as harassment or intimidation tends to display that the organizational culture has become dysfunctional which in turn results in large number of negative repercussions. The primary sets of negative effects comprises of adverse effect on performance, high labor turnover, rise in the level of absenteeism and poor morale. The responsibility regarding resolving of issues pertaining to harassment falls under the purview of human resource management (HRM). The primary initiative towards resolving such issues comprises of acknowledging the fact that harassment and bullying are unacceptable in the organization. The HR manager requires implementing a zero tolerance policy concerning any form of racism, harassment, bullying or unethical behaviors. Moreover, initiatives should be taken towards creating awareness regarding policies against bullying and harassments. Each employee of the organization should be assured protection from victimization. There can be many instances of compromising the dignity of an employee. Examples include derogatory remarks, racism, explicit form of partiality and favoritism, intimidation, bullying among others. Moreover, online behavior requires to be taken into consideration while evaluating instances of derogatory behavior. Implementation of guidelines regulating behavior of employees and management staffs online can mitigate risks of harassments and derogatory conduct online. It can be observed in some instances that when an aggrieved employee approaches a manager regarding harassments or bullying, the manager tends to display complicit behavior. The issue regarding the reported offensive behavior tends to be ignored by some managers or high ranked executives. Thereby, policies preventing harassments, bullying, insulting or any form of derogatory conduct requires taking into account any form of complicit behavior on the part of higher authorities such as operations managers, finance or production managers. Moreover, other forms of workplace behavior are likely to be derogatory even though not falling under bullying or harassment. Such behavior may comprise of exclusion of a team member from team-oriented tasks, biasness in providing opportunities for development or promotions and recruitments in a non-transparent manner. Thereby, through ensuring transparency in the recruitment processes along with initiating a feedback mechanism that facilitates reporting by the aggrieved employees the instance of improper and unjust behavior in an organization can be mitigated. Instances of sexual harassments or derogatory comments regarding employee along with threatening to reveal an employees sexual orientation are highly derogatory in nature and results in violating a persons dignity. Such occurrences can be prevented through constituting a sexual harassment cell preventing the victimization of an employee. Setting up standards relating to workplace behavior through organizational notifications specifying the acceptable behavior from the employees can be construed as another form of remedy regarding workplace behavior. The standards should resolve any form of ambiguity regarding acceptable and unacceptable form of behavior and clearly define relevant terms such as harassment, bullying, racism, partiality and favoritism among others. Further, assurances regarding dealing with such issues in a sensible and confidential manner can help alleviate the frequency of untoward behavior in the organization. Employees and managerial staff can be recognized for their good conduct by initiating rewarding policies. This in turn could result in setting a good example, which can be imitated by other employees of the organization. Thereby, through setting up grievance cells, encouraging good conduct in the organization and facilitating fair and confidential investigation the instances of violating a persons dignity in a organization can be prevented. References and Bibliography: Sguera, F., Bagozzi, R.P., Huy, Q.N., Boss, R.W. and Boss, D.S., 2016. Curtailing the harmful effects of workplace incivility: The role of structural demands and organization-provided resources.Journal of Vocational Behavior,95, pp.115-127. Stievano, A., De Marinis, M.G., Russo, M.T., Rocco, G. and Alvaro, R., 2012. Professional dignity in nursing in clinical and community workplaces.Nursing ethics, p.0969733011414966.