Management of Post-Traumatic Piriformis Syndrome: Case Study

Management of Post-Traumatic Piriformis Syndrome: Case Study Diagnosis and Chiropractic Management of Post-Traumatic Piriformis Syndrome: A Case Study Chief complaint A 37-year-old male patient presented himself at a local chiropractic clinic with a chief complaint of persistent low back pain that was radiating into his left buttock, all along the posterolateral aspect of his left thigh and calf, and to the lateral aspect of the foot. History of the patient illness The pain initiated 2 years ago. The patient reported a blunt trauma of his left buttock in a motorcycle accident 8 months before his symptoms were first noticed. The patient was presented with low back pain, radiating from sacrum and gluteal region to the lateral aspect of the foot, all along the posterolateral aspect of his left thigh and calf. The pain was occasionally accompanied by paresthaesia and burning sensation. When asked to rate his pain with a numeric rating scale (NRS), he noted his low back pain to be 3/10 at best and 7/10 at worst. Prolonged sitting and car driving aggravated his symptoms. And standing up and walking a few steps for a moment would make the pain partially relieved. The patient also noted that prolonged external rotation of the affected hip (sitting posture) made the symptoms more intense. He avoided sitting in a cross-leg posture due to the pain. The patient had a transient relief of his pain after treatment of physiotherapy. However, the pain came back after a few days. Other than the traumatic fall on his left hip in a motorcycle accident, the patient’s medical history was not remarkable. Relative family history, social and environment history Both of the patient’s parents were diagnosed with disc herniation of the lumbar spine in their 50s. The patient went to gym 4 times per week, doing cardiovascular and weight bearing training. And he used to play soccer once a week. However he had to stop playing since his low back pain and leg pain started to bother him. The patient was an attorney and his job required him to sit in front of his desk for more than 6 hours per day. He reported that he had to stand up and walk a few steps in the office every 30 minutes due to the pain. Relevant medications The patient’s symptoms were partially relieved by taking Panadols. He was not taking any other prescribed or non-prescribed medications. List of possible diagnoses from the patient history Lumbar disc herniation The patient was presented with symptoms and signs of radiculopathy including sensation disturbance of the lower limb, pain shooting to the foot, and pain worsened by sitting and relieved by walking. According to the dermatome, the nerve roots of L5, S1 or S2 were possibly affected. Considering that both of the patient’s parents are diagnosed with lumbar disc herniation, it should be on top of the differential diagnosis list, for recent studies have suggested that lumbar disc herniation may be attributed more to genetic factors than to environmental and constitutional risk factors. The patient’s occupation which kept him sitting for a prolonged time increases the chance of lumbar disc herniation. The history of blunt trauma could also be a factor of developing lumbar disc herniation. Sciatic nerve irritation of other origins The patient’s altered sensation on the lower extremity is in the distribution of sciatic nerve. Sciatica should be taken into consideration. However, the underlying cause of compression or irritation of sciatic nerve should be revealed with further examination and investigation. Piriformis syndrome Piriformis syndrome is an uncommon form of sciatica in which the sciatic nerve is compressed and irritated by piriformis muscle. It usually occurs in people who are middle-aged (mean age 38 years old). Robinson described 5 significant manifestations of piriformis syndrome in 1947, including: (1) history of trauma in the gluteal region; (2) pain in the sciatic nerve distribution; (3) symptoms relieved by traction and aggravated by sitting or stooping; (4) palpable tenderness or mass over piriformis muscle; (5) positive straight leg raise test. This patient was presented with the first 3 features of piriformis syndrome, whereas the 4th and 5th need further examination. Sacroiliac joint syndrome Sacroiliac joint syndrome is the dysfunction of sacroiliac joint that is attributed to either hypermobility or hypomobility, causing low back pain, buttock pain and sciatic lower limb pain. Lower abdomen, groin and medial thigh are occasionally affected as well. The symptoms of sacroiliac joint syndrome and sciatica are often similar. Hamstring syndrome Another possible differential diagnosis is hamstring syndrome. Hamstring syndrome is caused by entrapment of the proximal sciatic nerve by the hamstring tendons (1). It usually occurs associated with trauma such as hamstring tears or strain (2). However, in many cases, not significant history of trauma is noted (1, 2). Patients with hamstring syndrome present with lower gluteal pain and radiate down to posterior thigh and knee (2). The symptoms are similar to sciatica of other origins. Results of the neurological exams Observation, static palpation and range of motion Observation and static palpation are performed to look for any degree of antalgic posturing, any deviation from a normal spinal curve, pelvic position, and muscle spasm or bulks. Characteristic findings of each differential diagnosis are listed below. Lumbar disc herniation Possible hyper-lordosis of lumbar spine in an antalgic posture; Significant decrease in lumbar active and passive range of motion, especially in lumbar flexion and unilateral lateral flexion; Possible limited hip range of active motion due to muscle weakness; Possible palpable restricted lumbar vertebral segments; Hypertonic or tender lumbar muscles on static palpation, especially erector spinae (ES) muscles; Piriformis syndrome Possible limping or walking with the assistance with crutches due to pain and lower extremity muscle weakness; Possible hip external rotation on the affected side due to excessive piriformis muscle contraction, which is also known as â€Å"piriformis sign† (3); Significant decrease in hip active and passive range of motion, especially in hip internal rotation and adduction; Ipsilateral short leg (3); Tenderness at the sciatic notch on palpation; Possible hypertonic gluteal muscles (3); Sciatica Findings depend on the causes of sciatica such as lumbar disc herniation, piriformis syndrome and hamstring syndrome. Sacroiliac syndrome The posterior superior iliac spines (PSIS) on both sides are not at the same horizontal level; Possible redness and swelling at the affected sacroiliac joint; Possible leg length discrepancy; Significant decrease in sacroiliac joint mobility; Possible local tenderness on static palpation; Hamstring syndrome The pain is more localized, but possibly radiating; Tenderness of hamstring tendons or over ischial tuberosity on static in palpation; Significant decrease in hip active range of motion, especially in hip extension; On observation, static palpation and range of motion assessment, the patient was noticed for: Positive piriformis sign (hip external rotation) on the ipsilateral (left) side; A relatively shorter left leg compared with the right leg; Tenderness over contralateral (right) sacroiliac joint; A palpable â€Å"sausage-shaped† mass in the ipsilateral (left) gluteal region (3); Hypertonic left hamstrings; Tenderness over left sciatic notch on static palpation; Limited hip active and passive range of motion, especially internal rotation; Decrease in sacroiliac joint mobility; Other findings were not remarkable. The results of the assessment suggested that piriformis syndrome and sacroiliac syndrome were most possible diagnoses. Coordination and gait analysis Coordination and gait should be examined before other assessments are done, for this test provides us a big picture of the patient’s lower extremity function including motor function, joint integrity and coordination. Any gait dysfunction or antalgic gait should be recognized and further tests should be performed to look for the causes. No abnormal movement or disturbance of the patient’s gait was observed. He also reported a partial relief of symptoms when he was walking. The insignificant findings made lumbar disc herniation less likely, however, there was still a possibility. Sensory exam Sensory exams of peripheral nerves were performed to look for any sensation change on the symptomatic lower limb, which would lead to localization of the lesion. Assessments included fine touch, pain, temperature, and proprioception. Decrease in two-point discrimination and light touch was noticed over the lateral aspect of the left leg and foot. Motor exam Lower extremity muscle strength was tested to identify which nerve roots were affected according to myotomes. On examination, no significant findings were noticed. deep tendon Reflex Abnormal deep tendon reflex may be seen in lesions of muscles, sensory neurons, lower/upper motor neurons, neuromuscular junction and mechanical factors such as joint disease. On examination, the patient’s Achilles reflexes were normal (+2) on both sides. An abnormal Achilles reflex suggests a tibial nerve lesion (S1-2). Neurodynamic assessment Straight leg raise The test is designed to look for any impingement of the dura and spinal cord or nerve roots of the lower lumbar spine, especially in sciatic nerve (L4, L5, S1). The patient’s result was negative (70 °), suggesting less possible lumbar disc herniation. Bonnet’s test Bonnet’s test is a variant of straight leg raise and used to test for entrapment of sciatic nerve by piriformis muscle. The patient’s result was positive, indicating possible piriformis syndrome. Bowstring test Bowstring test is another variant of straight leg raise and used to test for entrapment of sciatic nerve by hamstrings. The patient’s result was negative, suggesting less possible hamstring syndrome. Orthopaedic examinations Valsalva maneuver Valsalva maneuver was done to look for any disc herniation causing radiculopathy. This would increase intrathecal pressure which may reproduce the patient’s symptoms. The patient’s result was negative, indicating less possible lumbar disc herniation. Lumbar compression-distraction test This test is also designed to look for disc herniation. When the compressive force is applied, it increases the intrathecal pressure and replicates symptoms if the patient has disc herniation. And the symptoms are relieved by distraction. The patient’s result was negative, suggesting it was less likely to be disc herniation. Gaenslen’s test Gaenslen’s test is to assess sacroiliac joint involvement. The patient’s result is negative. Yeoman’s test Yeoman’s test is designed to assess the integrity of the sacroiliac joint. The patient’s result is negative. Squat test Squat test is designed for quick screening of lower limb pathologies including joint disease, motor and sensory neuron lesions. The patient’s result was positive. Supported belt test Supported belt test helps to determine whether the pain is of lumbar origin or pelvic origin. The patient was noticed for having pain only without supported belt, suggesting his symptoms were caused by pelvic dysfunction. List of possible diagnoses from the neurological exam Piriformis syndrome Sacroiliac syndrome Further blood and radiological tests At this stage, no further imaging or other tests are needed, for the diagnosis can be made based on the patient’s history and results of neurological and orthopaedic examinations. It is recommended that the patient should be treated for piriformis syndrome at the start. A conservative treatment plan should be designed to reduce pain intensity, stretch hypertonic muscles and increase lumbar and sacroiliac joint mobility. However, if the patient does not respond to the treatment or the symptoms are worsened after the treatment, further investigations should be done. Considering a large extent of soft tissue and nerve involvement, magnetic resonance imaging (MRI) would be the most effective imaging method. A lumbopelvic view should be taken. This does not only demonstrate possible hypertrophied piriformis muscle and sciatic nerve entrapment, but also helps to rule out other differential diagnoses such as lumbar disc herniation. Nevertheless, many studies failed to show consistence of radiographic abnormalities in piriformis syndrome. Therefore, no significant findings on MRI do not necessarily exclude piriformis syndrome. CT and ultrasound are also used to look for abnormality of piriformis muscle, but they are not as sensitive as MRI. EMG is an investigation to assess abnormal spontaneous activity of muscles which are innervated by sciatic nerve, thus differentiating sciatica and lumbosacral radiculopathy; however, EMG findings are often normal in piriformis syndrome. Local injection of anaesthetics or steroid can be applied for both diagnostic and therapeutic purposes (4). This technique is widely used after initial evaluation. However, the specificity and efficacy is not well determined by clinical trials (4). A certain portion of patients with piriformis syndrome do not respond to piriformis muscle injection (5). Final diagnosis Based on the patient’s history, the results of neurologic and orthopaedic examinations, and likely radiographic findings, piriformis syndrome is the most likely diagnosis. Chiropractic management Conservative treatment is recommended at this stage, for 79% of patients with piriformis syndrome showed a significant improvement with use of non-steroid anti-inflammatory drugs (NSAIDs), muscle relaxants, thermo-therapy and rest (fishman, osteopathic approach). The aim of the chiropractic treatment is to reduce the intensity of pain, relax piriformis muscle, increase the range of motion of the hip joint, and increase mobility of lumbar and sacroiliac joint. The tone and length of the left piriformis muscle and other affected muscles (hamstrings, other lateral rotators, gluteus muscles) should be assessed with chiropractic muscle test and static palpation. Any trigger point, tenderness, hypertonia are noted. Stretching exercise and muscle release are introduced first to help the patient relax the hypertonic piriformis muscle. The patient needs to receive the muscle release training daily for 2 weeks until the muscle tone is assessed again and any improvement of his symptoms is seen. Stretching of other affected hypertonic muscles is also required. The mobility of the patient’s lumbar spine and sacroiliac joint should be assessed with orthopaedic examinations and chiropractic motion palpation. Any restricted segment is adjusted with high-velocity low-amplitude (HVLA) spinal manipulation. Chiropractic adjustments help to relieve pain, increase joint mobility and re-establish biomechanical stability of the body. References 1.Saikku K. Entrapment of the proximal sciatic nerve by the hamstring tendons. Acta orthopaedica belgica. 2010 06;76(3):321-4. 2.Puranen J. The hamstring syndrome. A new diagnosis of gluteal sciatic pain. The American journal of sports medicine. 1988;16(5):517-21. 3.Boyajian-ONeill LA. Diagnosis and management of piriformis syndrome: an osteopathic approach. The Journal of the American Osteopathic Association. 2008 11;108(11):657-64. 4.Jankovic D. Brief review: Piriformis syndrome: etiology, diagnosis, and management Article de synthà ¨se court: Le syndrome du muscle piriforme – à ©tiologie, diagnostic et prise en charge. Canadian journal of anesthesia. 2013 10;60(10):1003-12. 5.Martin HD, Martin H. Diagnostic accuracy of clinical tests for sciatic nerve entrapment in the gluteal region. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2014 04;22(4):882-8.

Impact of Uber on UK Mini Cabs

Impact of Uber on UK Mini Cabs Introduction The intense rivalry among competitors in the market is a critical driving force for each organisation. A healthy competition among competitors builds fuel for organisation long run, and while seeking progress firm practices influences other companies in the industry. The present research enables the researcher to find out such influences produced by Uber through their innovative practices. The research attempt shed lights on Uber Cab Company performance and the impact made by the organisation on other minicabs in the UK taxi industry. The researcher looks to utilise the journals of Wallsten (2015) and Edward, George and Sarkar (2010) for perceiving current issues efficiently. The investigation tries to perceive strategies and practices executed by Uber to advance in the UK taxi industry along with identifying the influence made on minicabs performance. Literature review The rise of Uber and the subsequent disruption in taxi industry has been a key research issue in recent years. For example, the study of Sundararajan (2014) revealed that the success of Uber was mainly due to the convenience offered by the service compared to existing cab services. This view has been upheld by other researchers such as Malhotra and Van Alstyne (2014) and Isaac (2014). All these studies point to the fact that Uber offer higher value to taxi customers in terms of lower charge, higher convenience and better safety offered by Uber. The theory of quality-value-loyalty chain was used by Wallsten (2015) to evaluate the success of Uber in Taxi industry. Figure 1.1: Quality-value-loyalty chain Source: Wallsten (2015) As per Quality-value-loyalty chain, price, product quality and service quality develop the perceived value of a product or service which in turn contributes to customer loyalty towards the product or service. Among these elements, competitors are easily able to imitate product quality and price. But it is very difficult to imitate service quality (Edward, George and Sarkar, 2010). Due to this, service quality has an enhanced role in creating value and loyalty for the product or service. Wallsten (2015) notes that the superior service quality of Uber has helped the company in creating value for customers and in developing loyal customer base in taxi industry. From the review of existing literature available on Ubers success in taxi industry, it can be understood that the ability of the company to offer better value, service quality and convenience was the main reasons for its success. Research purpose The study intends to identify the impacts that created by Uber Cab Company in the UK taxi industry and analyse influence that the company made on minicabs in the country.   Ã‚   The research objectives of the current research are: To evaluate the factors affecting satisfaction of cab customers To assess the factors contributing to the competitive advantage of Uber in UK Taxi industry To analyse the impact of Ubers growth on mini cabs of UK To provide suggestions to mini cabs of UK to remain competitive in UK Taxi industry Rationale Despite being a start-up in the UK taxi industry, Uber cab services had provided growth to the traditional taxi service in the country. The process made the countrys private taxi firm to stand tall where other numerous taxi companies had failed. According to Megaw (2016), 97% of the organisation that tried fit their name in the industry had fallen within the first four months where Uber showed resilience in making an impact which flew beyond the capital. The company had expanded beyond borders leaving a note on taxi industry to look for an urgent lift in which the mini cabs have experienced most of the damage. Uber was able to advance in each market that they have entered which led to protests and strikes in the UK. Uber Cab company flexibility had attracted few drivers who worked in mini cabs in London to join in the company. The low pricing strategy that the company presented has made controversies as competitors had alleged the practice unhealthy and artificial. Uber started its o peration in the UK with four locations and increased the size to eighteen with 30,000 drivers in London (Torrance, 2016). Data analysis interprets that since Uber started its operation, the private hire operations in London has attained a decline of 11% assuming minimum ten private taxi business close in every month. The research seeks to identify major reasons for the customer to choose Uber cab over minicabs by comparing their service using service quality framework and looks to interpret recommendation for minicabs in order to survive the situation. Scope and limitation of research The Uber Cab Company intervention to the UK taxi industry has been questioned severely by the minicab operators as their low payment system and other operations has affected minicabs and provoked few operators to end their operations in London area. The investigation gathers ample evidence for interpreting the features that attracted customers to Uber service so that certain recommendations could be drawn to the minicab operators in the UK for improving their business in the location. Research methodology For constituting the study, the researcher has to acquire efficient information on operations of both Uber Cab and minicab services. For carrying out the research both primary and secondary data collection method is used by the researcher. The literature and journals on the topic are utilised to attain secondary data, and the primary information is collected through executing a survey on taxi customers. The survey is conducted on 55 customers who use taxi services in London in which 30 female and 25 male customers are targeted. The survey method enables researcher to understand consumer perspectives on services provided by Uber Cab and minicab companies improving study strength. The data achieved from books, journals, articles and websites belong to the secondary resources which are used by the researcher to analyse the issue further. The adequate information attained from these practices is used to provide significant interpretations for present research problems from which efficien t recommendations are drawn for the minicab operators. Action plan      Ã‚   Research objective By when Resources to be used (2.1) when do you know this objective is achieved which is after the by when to ensure that you have actually achieve the objective How will you monitor this objective is being achieved? method of monitoring Topic selection 17th December to 22nd December 2017 Books, articles and online journals for study topic selection 21st December 2017 22nd December 2017 Reporting Regularly to supervisor Aim and objective preparation 23rd to 24th December 2017 Adequate journals and books 23rd December 2017 24th December 2017 Reporting Regularly to supervisor Literature review 25th December to 10th January 2017 Secondary resources like books and publications both online and offline for literature review preparation 8th January 2017 10th January 2017 Timely informing supervisor work status updates Research methods 12th January to 16th April 2017 Journals and books for perceiving research methods 13th January 2017 15th April 2017 Updating report status to supervisor Data collection 17th January to 16th February 2017 Survey on customers as primary resource and data from books, journals and company reports as secondary resource 15th February 2017 16th February 2017 Communicating status to supervisor Interpretation of data 17th February 1st March 2017 Comparison of primary and secondary information and analysis descriptive methods 25th February 2017 1st March 2017 Updating work status to supervisor Conclusion and recommendation March 2nd 14th March 2017 On the basis of interpreted data and analysis 13th March 2017 14th March 2017 Timely report to supervisor Final submission 15th March 2017 2.2 Undertake the proposed research investigation in accordance with the agreed specification and procedures. Questionnaire design This research was deliberated to mainly evaluate the effect of UBER Cab Company on mini cabs in the UK. For conducting the study, the research has opted UBER Cab Company to carry out the study. The research has mainly opted questionnaire method so as to gather data and information from the customers of UBER Cab Company to know more about taxi and the scope of them. For developing and evolving the questionnaire, the research has adopted Likert scale method, and to the customers of UBER Cab Company, the questionnaire was distributed with the aid of survey method. By opting the customers of UBER Cab Company for conducting the survey, the data gathered by the researcher was accurate and appropriate to the question of the research. Data collection method For the study, the research decided to opt primary data collection using survey method. The research was done with the aid of survey that was carried out on the customers of a minicab in London. The researcher decided to opt about 55 as the sample size for the study where 30 were women, and 25 were men. With the aid of survey method, the researcher could gain more knowledge and understanding about the company and the taxi services. All the research questions were related to the study and the questions prepared was simple and very easy to understand. This helped the researcher to get the opinions of customers. Advantages of survey method: With the aid of primary research, the research could gain relevant, apt and specific answers when compared to any other research methods. With the aid of Likert scales, the researcher could understand more about the topic and do not spend more time on the data collection. Survey method is cost effective and time-consuming. Disadvantages of survey method: The survey that is closed and structured might have less validity and reliability than other methods. There can be favourable answers been marked by the researcher so as to support the subject. The respondents will not be able to give their maximum as they will not be aware of the reason behind the survey. Advantages and disadvantages of ANOVA method The survey method was analysed with the aid of ANOVA method through which qualitative data collection was collected. Over more than two groups the data are examined and reviewed constancy for gaining the result in the case ANOVA method. The t-test is mainly compared to ANOVA methods as instead for ANOVA method t-test is used for the similar use. The advantages of ANOVA are: ANOVA method is mainly opted to relate groups of various samples sizes when compared to the t-test. Without cumulating the probabilities of Type, I error, with the aid of ANOVA more than two grouped can be evaluated. The disadvantages of ANOVA are: Incorrect results can be gained from ANOVA if the samples are gathered from the average population. ANOVA helps to makes sure if the samples are different from each other and also indicates the samples that are different from the similar ones. D3: Justify the choice of data collection methods To get accurate and reliable data and information the researcher adopted primary research for this study conducted on UBER Cab Company. The research has adopted survey method as the research strategy to gather data from the customers of UBER Cab Company London. The responses gathered from different customers were different and had different opinion and suggestions. The questions were closed and structured through Likert scales. Likert scales also aided the researcher in understanding the questionnaire. It was comparatively easy for the researcher to gather quantitative data with the help of survey methodology that made the research to be analysed easily with the aid of ANOVA method. 2.3 Record and collate relevant data where appropriate The researcher has used ANOVA analysis for testing the data collected from taxi customers of London. The researcher collected data from 55 taxi customers (30 female and 25 male customers). The working hypothesis adopted by the researcher is that there is clear difference in taxi service preferences of male and female taxi customers of London. This working hypothesis is tested with the help of ANOVA analysis. SS df MS F P Price 388.9286 1 388.9286 9.24 0.028759 Accessibility 388.9286 1 388.9286 5.08 0.073916 Convenience 388.9286 1 388.9286 3.56 0.117844 Driver behaviour 388.9286 1 388.9286 6.69 0.049044 Quality of car 388.9286 1 388.9286 10.89 0.021476 Safety 388.9286 1 388.9286 14.9 0.011879 2.1 ANOVA analysis of customer needs from taxi service From the above ANOVA analysis it can be understood that the opinions of male and female taxi customers significantly diverge in terms of their needs and expectations from taxi services available in UK. The analysis shows that female customers gave greater importance of safety, quality of car and driver behaviour when compared to male customers. On the other hand, male customers gave higher importance to convenience aspect while choosing taxi services. SS Df MS F P Reliability 388.9286 1 388.9286 6.65 0.049507 Assurance 388.9286 1 388.9286 14.25 0.012957 Tangibility 388.9286 1 388.9286 4.12 0.098139 Empathy 388.9286 1 388.9286 11.68 0.018887 Responsiveness 388.9286 1 388.9286 2.83 0.153344 2.2 ANOVA analysis of customer rating of service quality of Uber From the ANOVA analysis of the customer rating of service quality of Uber it is clear that both male and female customers have diverging opinions regarding the different dimensions of service quality of Uber. For example, it is evident that reliability, empathy and assurance elements of service quality of were given higher rating by female customers while male customers gave higher importance to responsiveness of the service of Uber. SS df MS F P Reliability 388.9286 1 388.9286 8.36 0.034132 Assurance 388.9286 1 388.9286 5.71 0.062422 Tangibility 388.9286 1 388.9286 21.02 0.005922 Empathy 388.9286 1 388.9286 3.28 0.129892 Responsiveness 388.9286 1 388.9286 11.02 0.021017 Methodology I used simple random sample because it is the simplest way to select participants from a population. According to Saunders, et al., using these methods means that each individual in the population has the same chance of being selected for the sample (2012) The survey questionnaire was developed on free online source distributed to employees via email, and social media messaging. Printed sheets of questionnaire were also provided for data collection. The expected sample size is set to 100 participants from the target population and the sampling is undertaken based on simple random sampling method. 2.3 ANOVA analysis of customer rating of service quality of UK minicab The above analysis of customer rating of service quality of UK minicabs reveal that female customers hold very different view regarding the service of minicabs when compared to female customers. It is evident from the analysis that female customers opinion regarding the reliability, assurance, tangibility and responsiveness of minicabs diverge from that of their male counterparts. SS Df MS F P Uber 388.9286 1 388.9286 2.43 0.179774 Minicab 388.9286 1 388.9286 14.25 0.012957 2.4 ANOVA analysis of customer likelihood of using of Uber and Minicab The above ANOVA analysis shows that female customers are much more likely to not use minicabs than male customers. On the other both male and female customers are equally likely to use Uber as taxi service in London. 3.1 Use appropriate research evaluation techniques Effectiveness of Project planning was developed by the researcher for implementing the current research project. The plan entailed the main steps of the project alongside milestones, objectives, review dates and resource allocation. This research plan was highly efficient in enabling the implementation of the research within the allocated time frame. One area where the research faced difficulty was in using ANOVA analysis method in data collation stage. The lack of knowledge and experience of the researcher in using ANOVA analysis method was a key obstacle in the smooth implementation of the research. Achievement of research objectives: Objective 1: To evaluate the factors affecting satisfaction of cab customers The primary objective of the current research was to evaluate the factors affecting satisfaction of cab customers. From the survey of taxi customers in London, the researcher was able to understand that convenience and accessibility were the most important factors that customers considered while selecting taxi service. From this it was inferred that convenience and accessibility of the cab service were the most important factors affecting satisfaction of UK cab customers. Objective 2: To assess the factors contributing to the competitive advantage of Uber in UK Taxi industry One of the other objectives of the research project was to assess the factors contributing to the competitive advantage of Uber in UK Taxi industry. With the help of the customer survey, the researcher evaluated the service quality dimensions of Uber. From this analysis it was understood that reliability, responsiveness and tangibility of service of Uber was rated highly by customers. From this it can be understood that Uber gains competitive advantage in UK taxi sector by offering reliable, responsive and tangible service. Objective 3: To analyse the impact of Ubers growth on mini cabs of UK The other objective of the research to analyse the impact of Ubers growth on mini cabs of UK. This was achieved by comparing the service quality of minicabs with that of Uber. From this comparison it was revealed that that reliability, responsiveness and tangibility of service of minicabs were inferior to that of Uber. This gap in service quality dimensions can be adjudged as the reason for the success of Uber in UK taxi market at the expense of minicabs. Objective 4: To provide suggestions to mini cabs of UK to remain competitive in UK Taxi industry The last objective of the research project was to provide suggestions to mini cabs of UK to remain competitive in UK Taxi industry. Form the research project it was understood that reliability, responsiveness and tangibility of service of minicabs were inferior to that of Uber. Hence it is recommended that minicabs seek improvement in reliability, responsiveness and tangibility elements of their service. Effectiveness of research methods: In the current research, survey method was used for collecting data from taxi customers in London. This data collection method was highly effective as it helped the researcher in collecting data from large number of customers with relative ease. As the data was collected from London this improves the validity of the research findings as London has a very diverse population. However, the research findings cannot be extrapolated across UK as the scope of the study was limited to London city. The research study is using both primary and secondary data. Primary data is obtained from the online survey and appropriate case study examples to interpret the results and Analysis. Secondary data has been used in Literature review .This section starts off by introducing you to four commonly used qualitative data collection methods. These collection methods and many others are also described and explained how to use them in evaluation. It then explains how you may go about involving participants: This is also known as sampling. The section ends with a discussion of a couple of approaches to qualitative data analysis. I will have to use some of these methods as part of your routine project monitoring activities, in a needs assessment or baseline or as part of an evaluation exercise. Quantitative and Qualitative data collection methods There are two ways of analysing qualitative data. One approach is to examine your findings with a pre-defined framework, which reflects your aims, objectives and interests. This approach is relatively easy and is closely aligned with policy and programmatic research which has pre-determined interests. This approach allows you to focus on particular answers and abandon the rest. I refer to this approach as framework analysis (Pope et al, 2000). The second approach takes a more exploratory perspective, encouraging me to consider and code all your data, allowing for new impressions to shape my interpretation in different and unexpected directions. I refer to this approach as thematic network analysis (Attride, 2001). Benefits of research results: The main benefit of the research results is that they outline the scope of competition between Uber and minicabs in UK taxi sector. This would help minicab service providers in understanding the areas where there is scope for improvement in their service. Difficulties faced in the research: One of the main difficulties faced in the current research was related to collecting data from taxi customers in London. The researcher faced difficulty in collecting data as the researcher lacked previous experience in collecting primary data through survey. 3.2 Interpretation and analysis of data 1. Gender Pie chart 1: Gender of the survey respondents Source: Created by the author Gender of the survey respondents is represented by the above pie diagram. From the above diagram, it is observed that relatively increased number of females (54.55%) constituted the participants of this survey program. 2. Rate the following factor in terms of their significance in your selecting a particular taxi serve (Scale of 1-5 where 1= Very high and 5= Very low) Bar chart 1: Ranking of factors that customers considers in selecting a taxi serve Source: Created by the author Analysing the significance of the various factors that a customer considers while adopting a taxi service, it is observed that convenience and accessibility were the mostly rated elements. The importance of safety element and pricing strategy were also identified from the customer responses. Thus it could be interpreted from this survey result that service efficiency, product attribute and pricing constitutes the main elements that influence the decision-making the process of the customers. This is in line with the literature study of Wallsten (2015) that explains the concept of Quality-value-loyalty chain. 3. Rate the following elements of service quality of Uber on a scale of 1-5 where 1 = Very good and 5= Very bad? Bar chart 2: Customer rating for the service attributes of Uber Source: Created by the author Responsiveness, tangibility and reliability were the highly rated characteristic features of Uber services. This is in line with the findings of Sundararajan (2014) and Isaac (2014) who identified that service excellence was the key element that provided an improved competitive advantage for Uber. However, it is also observed from the above pie diagram that Uber has received a negative customer response regarding its assurance. 4. Rate the following elements of service quality of minicabs of UK on a scale of 1-5 where 1 = Very good and 5= Very bad? Bar chart 3: Rating for the service quality of minicabs of UK Source: Created by the author A multitude of opinions was gathered from the customers regarding their rating for the service quality of minicabs. However analysing the above bar diagram it is apparent that majority of the customers has given comparatively a higher rating for the empathy element in the service quality of UK minicabs. 5. Rate the likelihood of you using the following services when you use taxi service next time on a scale of 1-5 (1= Very high and 5=Very low) Bar chart 4: Probability of selecting Uber and minicab services Source: Created by the author Analysing the probability of customers in selecting a taxi service, it is observed that majority of the participants opined that they prefer to opt Uber services. This signifies that Uber has achieved an improved recognition and competitive advantage compared to other minicab services of UK, which is in line with the reports of Isaac (2014) and Wallsten

Charles Perraults Puss in Boots Essay examples -- Charles Perrault Pu

Charles Perrault's Puss in Boots Charles Perrault's version "Puss in Boots" is a simple enough tale, in which the cleverness of the small prevails over the merits of size and strength and the lowly thirdborn son of a miller transcends his own expectations to achieve personal success. A major part of the tale is the archetypes used within, those easily recognisable symbols of common association and subconscious significance. Among these are symbols standing for the boy's transformation into self-determined adulthood, others associated with the miller's son's growth and achievement, and Puss himself, by whose characteristics and machinations the boy achieves his success. Like so many other fairy tales, "Puss in Boots" recounts the progression from one stage of life to another, in this case from a child's dependence on his parents for shelter and guidance to a separate existence as a self-sufficient adult away from the childhood home. This development is reflected in the archetypes found in the story, which at points draw attention to and accentuate the changes the miller's son undergoes. To begin with, the very identity of the hero's father - a miller - is an indication of where the boy starts out. Millers grind flour to be made into bread, bread being a common symbol of childhood, and the son has no need to begin his progression toward independence until his father dies, effectively cutting off his source of that childhood standby. This lack of bread means, from another perspective, that he cannot eat and as the act of eating is an archetype indicating transformation, it's notable in its absence - he is not yet ready for that next stage of life. So, the miller's son turns to the cat to form a whole new relationship of ... ...tainment value, if nothing else. It is all these aspects which the boy must be able to draw on to succeed, all neatly condensed into a small, furry body. Though "Puss in Boots" is about the miller's son's movement from childhood to a mature, adult societal role, it is Puss who steals the spotlight. The boy is pushed into the background in favour of his more flamboyant and active servant, and though he achieves his transformation, it cannot happen without the cat's use and manipulation of what is already present inside him. As such, Puss embodies what the miller's son needs most following his loss of adult shelter to push into the adult world himself, becoming the principal archetype of all used within the tale. Perrault, Charles. "Puss in Boots." Folk & Fairy Tales Comp. Martin Hallett and Barbara Karasek. 2nd ed. Peterborough, Ontario: Broadview, 1996. 94-97.

Julius Caesar Essay: Loyalty and Chaos -- Julius Caesar Essays

Julius Caesar: Loyalty and Chaos In the play, Julius Caesar, Shakespeare suggests that a society without loyalty will inevitably find itself in chaos. Loyalty and similar traits of love and faithfulness arguably form the framework of societies present and past. Negative forces such as ego, greed and the quest for power continually attack this framework. Julius Caesar illustrates the rapid decay of a Roman society's law and harmony, until it finds itself in the chaos of civil war before concluding in an uneasy order. The absence of loyalty in a society does not necessarily constitute chaos; it is rather variants like extremism and shifting loyalties that are the problem. It is true that the assassination of Caesar was a clear example of disloyalty and betrayal. The relatively cool relationships that Caesar had beforehand with the other conspirators, made Brutus' betrayal clearly the most disloyal: "For Brutus as you know was Caesar's angel: Judge, O you Gods! how dearly Caesar lov'd him. This was the most unkindest cut of all". The sight of his beloved Brutus among the conspirators overcomes Caesar even more than his wounds- "Ingratitude, more strong than traitors' arms, quite vanquish'd him: then burst his mighty heart". This is supported by the most climatic line in the play- "Et tu, Brute! Then fall, Caesar!" Mark Antony also demonstrates disloyalty as he takes intentionally takes advantage of Brutus' grace and goodwill, to turn the mob against him. From the moment Caesar is stabbed, the... ...d, faithful and just to me", and his promise to revenge Caesar's death. His theatrical well-timed words in his funeral oration incite the crowd to rampage through Rome, as he plays on the constantly changing loyalties of the citizens. In the play, Julius Caesar, Shakespeare suggests that a society without loyalty will find itself in chaos. Loyalty, love and faithfulness form the framework of societies while negative forces such as ego, greed and the quest for power continually attack this framework. Julius Caesar illustrates the rapid decay of a Roman society's law and harmony, until it finds itself in the chaos of civil war. The absence of loyalty in a society does not necessarily constitute chaos; it is rather variants like extremism and shifting loyalties that are the problem.

New Payment Methods in Health System and Quality of Care :: Argumentative Persuasive Government Papers

New Payment Methods in Health System and Quality of Care Introduction For the purpose of this article I will make some generalizations and I will define some words to facilitate the reading and understanding. These definitions are not intended to be exhaustive and must be understood only in the context of this article. In America health has had its own evolution, passing from the personal relationship between a physician and a patient to a complex system with many actors. As technology developed, on one hand, the costs increased and patients or their families weren’t able to pay by themselves. As a consequence, new payers, such as Government and employers appeared in the health industry. But once again, one treatment could be so expensive, that the resources of a small employer wouldn’t be enough to cover it, and his business could get in financial risk. Consequently, the typical insurers began to play their own role: The affiliation of large number of people paying a fixed premium per person and period of time, regardless the cost of the treatments needed by each of their affiliates. A patient could choose the provider, pay the treatment by itself, and later the insurer reimbursed him the cost of it. If the number of affiliates is high, the probability of a high cost treatment becom es more standard or predictable and the excess of money the insurer earns with people who pay and don’t get sick can absorb its costs. This is known as the â€Å"big numbers† law. On the other hand, physicians became more specialized, and needed more technology not affordable on an individual basis. Now we have physicians, nurses, hospices, clinics, hospitals and complex systems joining all them in order to provide the care needed by patients. For the purpose of this article I’ll call all of them providers. Cost continued increasing, the relations between these actors continued changing, and the characteristics of each of them too. In the side of the insurers, in the 1980’s, the Health Maintenance Organizations or HMO’s appeared. Despite their differences, in the beginning most had similar characteristics: they were non-profit organizations providing care to their affiliates with a selected net of providers and special rules and procedures that patients and providers should follow in order to accept the service and pay the provider. Recently, in the search to achieve the key objective of cost containment, the

Defining Race and Ethnicity Essay

The term â€Å"race† means to me a group of people with the similar backgrounds and cultures. Race can also be defined as a species of people. Society defines race as the color of your skin but this is a myth. Race is more than the color of your skin; it is your lineage and heritage. It is who you are. The term â€Å"ethnic† means belonging to races or nations based on distinctions of race or ethnological. Ethnic is when you relate to a sizable group of people and share a common and distinctive racial, national, religious, linguistic, or cultural heritage. When I hear the word ethnic, I associate it with the race of black people. I’m not sure why but somewhere in my life, this was instilled in my mind. I have read somewhere that this word means heathens. I don’t agree with this analogy of the word but society has labeled this word to mean something bad. Ethnic has also been defined as a group of people who denounce Christianity. These concepts are important in today’s society because of the issues of racism and prejudice. People should not be classified by the color of their skin but by their citizenships. All people that were born in America should be classified as Americans alone, not White, Blacks, Latinos, Mexicans. These terms border on the issue of prejudice and racism. This is a very touchy subject and one has to be careful not to offend anyone when addressing these issues. It is important that when people are classified by race, that the proper terms are use when identifying these groups. Some black people prefer to be called â€Å"African Americans† rather than black and vice versus. Prejudice is a big issue in our nation and needs to be overcome. No one wants to be discriminated against no matter what their race or ethnic background is.

Significant Moment

I sighed and leaned back into my seat. It made a squeaky noise. I had just been given as assignment where I needed to write about a person who had made a great influence in my life. As I sat silently and listened in my seat, my mind went racing to the past, searching for ideas and digging up precious memories. It had been years since I looked back at those memories but I still remember them. By the end of class that day, I had already decided on whom to write about. I remember that momentous time in my life like it was yesterday. Two years ago on a hot Wednesday afternoon on the month of August, as I was walking home from school, I kept replaying the earlier events of the day in my mind. I was not having a good day. That day during speech class, I failed my first oral presentation. I either could not stop stuttering or talked extremely fast. I was so nervous it felt as if my gut was about to turn itself inside out. Instead of trying to finish my speech, I went back to my seat and glued my head to my desk for the rest of the day. I was utterly convinced that I just couldn’t do it. It took me about at least thirty minutes to get home. By the time I arrived, I was covered in sweat and despite my exhaustion, I was also stressing about possible ways to make up for my last failure. I tried to shake away the thought as I pushed open the front door. Instantly, I knew that my grandfather was in the kitchen. The cool air that was being dispersed by the ceiling fan was mixed the sweet, soothing aroma of my grandfather’s home-made pancakes and freshly brewed coffee. As much as I wanted some of those delicious pancakes, I wanted more to just lock myself in my room and bury my head in my pillow. I attempted to tiptoe through the living room pass the kitchen and run to my room but he greeted me with a voice so understanding that I found myself seated at the kitchen table without even thinking about it. After he had set the pancakes on the table, he pulled up a chair across me, sat down and put his eyeglasses on. For a man of his age, he always seemed younger than he really is. He wore his usual clothing, the kind he wears on hot days. His Hawaiian shirt would always have the first three buttons unbuttoned. Along with that, he had on his favorite pair of white shorts. Sometimes, I even wonder if he had been a surfer. He took a sip from his coffee mug and went back to his puzzle book. I took advantage of the silent moment to eat a few pancakes. I hated disappointing him so I decided not to tell him about speech class. After I hastily stuffed myself with eight delicious pancakes and two glasses of iced tea, I stood up slowly making an effort to leave. However, a single question came from him asking if something was wrong made me want to tell him everything not because I expected him to tell me it was ok, but because I felt guilty not telling him. His voice was also so promising that I knew that he would understand. I sat down in the chair I sat in earlier so that I faced him. After taking four deep, cleansing breaths and centered myself, I told him everything. He was a great listener. Throughout the course of my explanation, he eventually nodded and sometimes responded with â€Å"I understand. After I had told him everything, I held my breath and waited for his response. He was quiet for what seemed like a very long time. My forehead started beading up with sweat. I was afraid he might scold me for being nervous in front of a class of only fifteen students. I was also worried about what he might say about my latest â€Å"F† that I received because of my lack of confidence in myself. I was on the verge of panic when he fina lly spoke. I was surprised when he laughed. He literally laughed as if I had told him a very funny joke. Instead of getting angry or disappointed, he patted me on the shoulder and smiled at me reassuringly. He held my hand and told me that I reminded him of himself when he was young. He went through similar situations. It was almost impossible for me to believe that. How can he, the first speaker of the Federated States of Micronesia and the senior pastor of our church, who always touched the hearts of many through simple words, have the same issues as I? He told me that every time he gave a speech or a message, he was always nervous. He told me that no matter how nervous he felt or how much he believed he couldn’t do it, he would always try again. He gave it his all. He kept doing it until he overcame his lack of confidence. No matter how much he wanted to give up, he just kept pushing until he had full faith and trust in himself. Hearing this, especially from him, whom I respect the most, I promised myself that I will always be persistent in all that I do and try my best to gain self-confidence. His words motivated me and made me see that I already had the persistence and the confidence that I needed. All I needed to do was believe I could do it. Looking back to that significant moment in my life, I realized that without the encouragement given to me by my grandfather, I do not think I would be as confident and as persistent as I am today. That day he had helped me become more persistent and more confident. That moment will always be forever branded into my memories as one of the most precious ones. Even though the time we spent talking was for a small amount of time, it made a big difference in my life. I am thankful for having B****** H**** as my mentor and most importantly, as my grandfather.