Interview: Bill Cosby, Navistar
CM: Describe your current position?
BC:I am a product support specialist, serving 24 dealers in 5 U.S. states. My goal is to assist my service departments in creating lean and profitable businesses that serve our customers’ needs quickly and efficiently.
CM: What was your experience prior to your current assignment?
BC:I was a service manager in a large dealer location for 7 years prior to this role, having worked my way up from Foremen and technician.
CM: How long have you been in this industry?
BC:I have been in the heavy diesel repair industry for 30 years
CM: Describe the business you are in.
BC:Heavy Diesel transports everything you touch every day. Navistar builds International trucks and IC buses which are sold and serviced through a large dealer network in North and South America as well as Russia, S. Korea and several African nations.
CM: What are your company’s current strategic goals?
BC:Drive operational Excellence by reducing manufacturing costs, grow our core business through increased channel effectiveness and build new sources of revenue through our product expansions and connected services.
CM: 3 year goals?
BC:A 5% increase in overall market share of truck and bus sales
CM: What is your company’s “global footprint? In other words, with what countries does your company conduct business?
BC:Navistar has manufacturing facilities in the U.S., Canada, Mexico and Brazil. We sell our products in those regions as well as Asia, Europe, Africa and Australia.
CM: Is the current state of global woes impacting your company?
BC:Currently, we are doing better globally than previous years.
CM: How so?
BC:Our productshave been well received overseas recently as we can build to their required emissions standards where as other OEM’s are challenged to build multiple emissions platforms.
CM: In your opinion, is the current state of global woes likely to trigger demand for a new style of corporate leadership? If so, what would this new leadership style look like? If not, then how does the exciting leadership style support your company’s future goals?
BC:Corporate leadership is always evolving. Leaders are constantly adapting to changes in culture, economies and regulations. The current evolution has leaders more focused on environmental impacts as well as new technologies that will aid both their core businesses as well as help our customer base with their needs and desires.
CM: With the current rate of change in the various business environments outpacing established abilities for US to meet demand for human resources, physical resources’, financial resources, how is your company meeting these demands?
BC:In reality, we’re not. Our industry is service based manual labor. With the ever increasing perception from our public school system to college or failure, the youth today do not feel that a skilled profession a viable sustainable living. Yet, most technicians today with 2 years of experie ...
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Analyze the competence of your organization with these Capacity Development PowerPoint Presentation Slides. Our readily available organizational competence PowerPoint slideshow allows you to depict your company’s background, capabilities, accreditation, vision, and mission. Highlight the current vacancies for various profiles and the qualifications required for the same by utilizing this PPT slide deck. Take the assistance of our visually appealing capability model PPT slides to showcase the five levels of capability maturity; namely initial, managed, defined, predictable, and optimizing. You can mention the job description of various profiles and the skills required in this template. Elucidate the recruitment budget components such as total recruitment expenses, no. of employees hired, salary, and complete work experience using these organizational competence PowerPoint layouts. Moreover, the capabilities required for increasing revenue, like objection handling, consultative skills, and prioritizing accounts, can also be demonstrated using this PowerPoint complete deck. Enhance your processes, functions, and systems by downloading this organizational performance PPTslideshow. https://bit.ly/3ymgvM4
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Get access to this professionally designed content-ready Capability Building PowerPoint Presentation Slides to grow your organization with the help of your employees. Support your teammates to develop skills they required in the workplace. Showcase technical, operational and soft skills through capability building PPT templates. This deck comprises of templates such as executive summary, key management, current organization structure, capability assessment, capability maturity model, current vacancies, job description, recruitment budget, etc. These templates are completely customizable. Change color, text, icon and font size as per your requirement. Enhance culture development, integrate feedback into learning, build capacity for change and more with the help of ready-to-use capability building PowerPoint presentation templates. Follow the process of building a capability strategy with the help of easy-to-understand capacity building PowerPoint slideshow. Support workforce change and innovation. Enhance performances using capability building PowerPoint templates. Grab this ready-made capability building complete PowerPoint presentation and create a supportive environment to encourage employees to learn and grow. Enter the clan with our Capability Building Powerpoint Presentation Slides. Gain entry into elite groups.
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I've been asked by many people both individuals, small businesses and organizations on what would l recommend for an individual's first 90 days in a new role. While this is a difficult question to answer, the important part is that you have a plan and that you realize it is a living document because there are no hard and fast rules. Here is a compilation of what l suggest may be a good starting point for anyone looking to accelerate understanding and change in a new role.
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This document provides instructions for editing a presentation template in Canva, Google Slides, or PowerPoint. It includes sections for an agenda, introduction, problems and solutions, key metrics, value proposition, SWOT analysis, competitive advantages, personas, marketing channels, financial projections, statistics, photos, closing, contacts, and more. Font and photo credit is provided.
Violet and Blue Bold Data Science Consulting Presentation.pptxBishalBasnet12
This document provides instructions for editing a presentation template in Canva, Google Slides, or PowerPoint. It includes sections for an agenda, introduction, problems and solutions, key metrics, value proposition, SWOT analysis, competitive advantages, personas, marketing channels, financial projections, statistics, photos, closing, contacts, and more. Font and photo credit is provided.
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Analyze the competence of your organization with these Capacity Development PowerPoint Presentation Slides. Our readily available organizational competence PowerPoint slideshow allows you to depict your company’s background, capabilities, accreditation, vision, and mission. Highlight the current vacancies for various profiles and the qualifications required for the same by utilizing this PPT slide deck. Take the assistance of our visually appealing capability model PPT slides to showcase the five levels of capability maturity; namely initial, managed, defined, predictable, and optimizing. You can mention the job description of various profiles and the skills required in this template. Elucidate the recruitment budget components such as total recruitment expenses, no. of employees hired, salary, and complete work experience using these organizational competence PowerPoint layouts. Moreover, the capabilities required for increasing revenue, like objection handling, consultative skills, and prioritizing accounts, can also be demonstrated using this PowerPoint complete deck. Enhance your processes, functions, and systems by downloading this organizational performance PPTslideshow. https://bit.ly/3ymgvM4
Life Coaching PowerPoint Presentation SlidesSlideTeam
Life Coaching PowerPoint Presentation Slides features a highly visual format that is easy-to-follow. This business life coaching PPT template deck kicks off with an analysis of the current position of the company. You can showcase your findings related to the current year’s workforce turnover. Represent the total and voluntary yearly employee turnover trend or for every four months. Our designers have included ample data visualization tools to aid easy explanation. Your audience can develop a deeper understanding of the subject using this corporate coaching PowerPoint presentation. Our PPT slideshow helps you in putting forth a life coaching need assessment. You can explain the whole training lifecycle with the help of this leadership coaching PowerPoint theme. Elucidate the goals and objectives that form the primary reason for business mentoring. Briefly portray the life coaching process using a linear diagram. So, hit the download icon and begin instant personalizing. https://bit.ly/2KuAap8
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Get access to this professionally designed content-ready Capability Building PowerPoint Presentation Slides to grow your organization with the help of your employees. Support your teammates to develop skills they required in the workplace. Showcase technical, operational and soft skills through capability building PPT templates. This deck comprises of templates such as executive summary, key management, current organization structure, capability assessment, capability maturity model, current vacancies, job description, recruitment budget, etc. These templates are completely customizable. Change color, text, icon and font size as per your requirement. Enhance culture development, integrate feedback into learning, build capacity for change and more with the help of ready-to-use capability building PowerPoint presentation templates. Follow the process of building a capability strategy with the help of easy-to-understand capacity building PowerPoint slideshow. Support workforce change and innovation. Enhance performances using capability building PowerPoint templates. Grab this ready-made capability building complete PowerPoint presentation and create a supportive environment to encourage employees to learn and grow. Enter the clan with our Capability Building Powerpoint Presentation Slides. Gain entry into elite groups.
This document contains a presentation on project management with questions and answers. It discusses managing time across multiple classes like working in a matrix structure, recommending project management structures for new product developments, and assessing organizational culture. For one question, the respondent recommends a matrix structure for a company developing a new binocular product. For another, they recommend a functional structure for a project to develop new audio technology. It also assesses the cultures of BMW, Vivo SMD, and the respondent's school.
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Explore our Building Hr Capacity PowerPoint Presentation Slides. Develop effective HR policies and strategies using human capital capacity building PPT visuals. The HR capacity development PowerPoint complete deck contains slides such as strategic human resource plan framework, HRM plan, assessing the current HR capacity, forecasting HR requirements, skill gap analysis plan, organizational skills program matrix, steps of talent management in an organization, company’s recruitment strategies, recruitment budget, etc. Showcase HR developments with this content ready human resource planning presentation design. With a variety of visual and images, you can create a more engaging presentation for your audience. This allows users to assess current HR capacities and forecast requirements. Besides that, the ready to use human resource capacity development presentation layout is completely customizable. You can add or delete the content from templates. Our team of experts has also included icons for your convenience. Download strategic human resource development PowerPoint templates to develop talent management strategies.
I've been asked by many people both individuals, small businesses and organizations on what would l recommend for an individual's first 90 days in a new role. While this is a difficult question to answer, the important part is that you have a plan and that you realize it is a living document because there are no hard and fast rules. Here is a compilation of what l suggest may be a good starting point for anyone looking to accelerate understanding and change in a new role.
Violet and Blue Bold Data Science Consulting Presentation.pptxAmanDahiya33
This document provides instructions for editing a presentation template in Canva, Google Slides, or PowerPoint. It includes sections for an agenda, introduction, problems and solutions, key metrics, value proposition, SWOT analysis, competitive advantages, personas, marketing channels, financial projections, statistics, photos, closing, contacts, and more. Font and photo credit is provided.
Violet and Blue Bold Data Science Consulting Presentation.pptxBishalBasnet12
This document provides instructions for editing a presentation template in Canva, Google Slides, or PowerPoint. It includes sections for an agenda, introduction, problems and solutions, key metrics, value proposition, SWOT analysis, competitive advantages, personas, marketing channels, financial projections, statistics, photos, closing, contacts, and more. Font and photo credit is provided.
Strategic Human Resource Planning Powerpoint Presentation SlidesSlideTeam
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Workforce planning is essential for high performing organizations, our Strategic Human Resource Planning PowerPoint Presentation Slides enable you to align your workforce requirements with your business goals. With the help of this sample deck, you can showcase strategic human resource plan framework, assessing the current HR capacity, forecasting HR requirements, skill gap analysis plan, organizational skills program matrix, company’s recruitment strategies, evaluating recruitment strategies, recruitment budget, etc. Structure human resource plan with this content ready strategic HRM planning PPT visuals. Using this visually stunning strategic human resource management process, HR managers can easily present the content to target management. Furthermore, this will guide you on how a business should move from its current to the desired manpower position. Get a clear idea about the HRM process. Download the strategic human resource management plan in just a few seconds. Deliver an effective presentation and explain your points more efficiently. Pamper yourself with our Strategic Human Resource Planning Powerpoint Presentation Slides. They will rejuvenate your thoughts. https://bit.ly/3Dh7QNn
Strategic Human Resource Planning PowerPoint Presentation Slides SlideTeam
Workforce planning is essential for high performing organizations, our Strategic Human Resource Planning PowerPoint Presentation Slides enable you to align your workforce requirements with your business goals. With the help of this sample deck, you can showcase strategic human resource plan framework, assessing the current HR capacity, forecasting HR requirements, skill gap analysis plan, organizational skills program matrix, company’s recruitment strategies, evaluating recruitment strategies, recruitment budget, etc. Structure human resource plan with this content ready strategic HRM planning PPT visuals. Using this visually stunning strategic human resource management process, HR managers can easily present the content to target management. Furthermore, this will guide you on how a business should move from its current to the desired manpower position. Get a clear idea about the HRM process. Download the strategic human resource management plan in just a few seconds. Deliver an effective presentation and explain your points more efficiently. Pamper yourself with our Strategic Human Resource Planning Powerpoint Presentation Slides. They will rejuvenate your thoughts.
Presenting this set of slides with name - Performance Planning Powerpoint Presentation Slides. Our topic specific Performance Planning Powerpoint Presentation Slides presentation deck contains sixty one slides to formulate the topic with a sound understanding. This PPT deck is what you can bank upon. With diverse and professional slides at your side, worry the least for a powerpack presentation. A range of editable and ready to use slides with all sorts of relevant charts and graphs, overviews, topics subtopics templates, and analysis templates makes it all the more worth. This deck displays creative and professional looking slides of all sorts. Whether you are a member of an assigned team or a designated official on the look out for impacting slides, it caters to every professional field.
Structure your human resource plan with this content ready Organisation Workforce Planning PowerPoint Presentation Slides. With the help of this sample deck you can showcase strategic human resource plan framework, assessing the current HR capacity, forecasting HR requirements, skill gap analysis plan, organizational skills program matrix, company’s recruitment strategies, evaluating recruitment strategies, recruitment budget, etc. You can incorporate these readymade PowerPoint templates to emphasize core functions of human resource management. Workforce planning is essential for high performing organizations. This strategic workforce planning PPT layout will guide you on how a business should move from its current to the desired manpower position. Get a clear idea about the HRM process using our manpower planning PowerPoint templates. Another exciting feature of our human capital plan PPT visuals is that you can manually adjust presentation background, text font, color to complement your style. Demonstrate pathways to implement HR strategy using the manpower planning process PPT visuals
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Present your next marketing plan, campaign, social media strategy or newsletter with these free Google Slides and PowerPoint templates. Their creative design and easy-to-edit graphic resources will help you get your message across.
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Ability Building PowerPoint Presentation SlidesSlideTeam
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Capability Development PowerPoint Presentation SlidesSlideTeam
Use Capability Development PowerPoint Presentation Slides to focus on the development of an individual or team through various strategies and activities to achieve business goals. Meet and work on future challenges. Build capacity for change using professionally designed content-ready capability development PPT slides. This capability development model PowerPoint slideshow will serve your team extensive learning opportunities and support experimental practices. Incorporate easy-to-understand capability development PowerPoint templates such as capability assessment, capability maturity model, current vacancies, job description, recruitment budget, training plan, and more. This ready-made capability development PowerPoint presentation is completely customizable. You can edit the templates as per your requirement. Change color, text, icon and font size as per your need. Download capability development PowerPoint presentation to help your team develop the skills they need to meet the business goals. Our Capability Development Powerpoint Presentation Slides will go behind you. They will endorse your every thought.
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Presenting this set of slides with name - Organisational Development Powerpoint Presentation Slides. This aptly crafted editable PPT deck contains sixty slides. Our topic specific Organisational Development Powerpoint Presentation Slides presentation deck helps devise the topic with a clear approach. We offer a wide range of custom made slides with all sorts of relevant charts and graphs, overviews, topics subtopics templates, and analysis templates. Speculate, discuss, design or demonstrate all the underlying aspects with zero difficulty. This deck also consists creative and professional looking slides of all sorts to achieve the target of a presentation effectively. You can present it individually or as a team working in any company organization.
EX Assembly: COVID19 and its Impact on Employee Peformance & RewardsLearningCafe
COVID19 has thrown business plans into disarray. While the impact of COVID on the workforce is manifold, measuring and rewarding employees will be a particularly challenging one.
We discuss
Do we need to adapt or “inactivate” Employee Performance Processes specially for employees whose work has been directly impacted ?
How do we recognise and reward employees who go above and beyond their job description during these challenging times ?
Does COVID19 provide us an opportunity to transform the Perf Mgt system which is perceived as ineffective ?
This document provides a framework and steps for developing a strategic human resources plan. It includes templates for assessing current HR capacity, forecasting future HR requirements, identifying skills gaps, and developing recruitment and training strategies. Sections cover determining HR needs, recruiting and selecting employees, developing training programs, compensation, and performance management. The overall plan aims to strategically manage an organization's human resources.
Attracting qualified technicians takes more than a "help wanted" sign in the window. Learn the latest in digital recruitment trends, why you need a recruitment strategy, and how to build a great one.
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For seven years, CLO’s LearningElite awards have recognized the organizations that excel at managing the learning function from end to end. How do elite learning organizations align learning with organizational goals, engage their learners, measure success, engage leadership in employee development and use learning to make a measureable impact on the organization? Join Sarah Kimmel, vice president of research at Human Capital Media, as she discusses the practices that make LearningElite organizations effective, and that contribute to their high scores on the LearningElite benchmark.
You’ll learn:
The practices that distinguish LearningElite organizations from the rest.
How elite learning organizations achieve alignment of learning with organizational goals.
How the LearningElite engage leaders at all levels to support employee development and create a culture of learning.
What metrics elite learning organization use to measure impact on the learner and impact on the business.
Tips for maximizing your organization’s scores on the LearningElite application.
Participants will receive early access to the 2018 LearningElite application worksheets.
When marketing and sales are working in lockstep, your revenue soars and your business grows. Resident marketing technology expert, James Kenler, has been on both sides of the sales and marketing divide. Learn how James used marketing automation to align the sales and marketing processes at CareerBuilder around a common business goal to ultimately develop a unified sales strategy driving overall revenue and resulting in the creation of new teams and resources.
The document outlines steps for developing a strategic human resources plan, including forecasting HR requirements, assessing current capacity, developing recruitment strategies, and evaluating strategies. It provides templates for skills gap analysis, an organizational skills program matrix, and evaluating recruitment costs and hiring outcomes. The overall plan framework specifies demand forecasting, supply forecasting, developing talent strategies, and reviewing and evaluating the HR plan on an ongoing basis.
Presenting this set of slides with name - Resource Planning Powerpoint Presentation Slides. Our topic specific Resource Planning Powerpoint Presentation Slides presentation deck contains twenty six slides to formulate the topic with a sound understanding. This PPT deck is what you can bank upon. With diverse and professional slides at your side, worry the least for a powerpack presentation. A range of editable and ready to use slides with all sorts of relevant charts and graphs, overviews, topics subtopics templates, and analysis templates makes it all the more worth. This deck displays creative and professional looking slides of all sorts. Whether you are a member of an assigned team or a designated official on the look out for impacting slides, it caters to every professional field.
Please readRobert Geraci, Russia Minorities and Empire,” in .docxTatianaMajor22
Please read:
Robert Geraci, “Russia: Minorities and Empire,” in Abbott Gleason, ed., A Companion to Russian History (Oxford: Wiley-Blackwell, 2009), 243-260.
And discuss:
How does Geraci portray the legacy of the early Russian history for the make-up of 18-19th century Russia?
Please read: Leonard Victor Rutgers, “Roman Policy Towards the Jews: Expulsions from the City of Rome during the First Century C.E.,” in Classical Antiquity, Vol. 13, No. 1 (Apr., 1994), pp. 56-74.
And discuss: Rutgers surveys the different reasons historians have given for the expulsion of the Jews from Rome in the first century C.E. Who place did Jews have in Roman society at this time? Were they expelled because of their religious practices, or because they were ‘unruly’ as Rutgers argues? If so, what caused them to act in this way? What kind of historical evidence does the author use?
There are 2 essay, each one should write at least 300-350 words and plus one reference page.
MLA format. Must use quote( “ ”) for every source you use from website. And put (author, page number) behind quote.
Roman Policy towards the Jews: Expulsions from the City of Rome during the First Century
C.E.
Author(s): Leonard Victor Rutgers
Source: Classical Antiquity, Vol. 13, No. 1 (Apr., 1994), pp. 56-74
Published by: University of California Press
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Accessed: 26/08/2011 13:35
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LEONARD VICTOR RUTGERS
Roman Policy towards the Jews:
Expulsions from the City of Rome
during the First Century c. E.
Tant de causes secretes se melent souvent a la cause apparente, tant de ressorts
inconnus servent a persecuter un homme, qu'il est impossible de demeler dans les
siecles posterieures la source cachee des malheurs des hommes les plus consider
ables, a plus forte raison celle du supplice d'un particulier qui ne pouvait etre
connu que par ceux de son parti.
-Voltaire, Traite sur la tolerance (1763)
IN THIS ARTICLE I want to discuss the evidence for expulsions of Jews from
the city of Rome in the first century C.E. Scholars have long been interested in the
reasons underlying these expulsions. Because the anci.
Ford VS ChevroletThere are many reasons that make the Chevy.docxTatianaMajor22
Ford VS Chevrolet
There are many reasons that make the Chevy’s and Ford’s motors two most common trucks. Studies reveal that that they are the most popular vehicles on sales today. It is because they are powerful, versatile and reasonably priced. They also come in a wide variety of configurations and styles. However, many buyers and sellers have questioned themselves on the better vehicle compared to the other in terms of quality, Wi-Fi, price ranges, value, and costs. To compare and contrast on this subject, let us take an example of two vehicles each from each company to facilitate comparison.
Ford offers the full-size track with automatic high-beam control, automatic parallel parking and power-retractable running boards. Fords are elegant, and they are mostly aluminum making them save weight and bolster gas mileage. None of these features are offered Chevy’s. Chevrolets have outstanding quality. They are mostly comprised of steel, for instance, the Chevrolet Silverado. This makes them good for rough roads and difficult terrains.
Fords have employed the use of up to date Wi-Fi technology. Ford intends to provide the Ford Sync, which will provide robust connections for occupants. Latest Chevrolet brands Malibu utilize the 4G LTE Wi-Fi Technology that provides rich in-vehicle experiences. This technology is powerful compared to Ford Sync, and is used for connecting devices and executing few remote operations within the car.
From the value and cost standpoint, Ford can consume a little more, and its payload capacity is a little higher. Additionally, its mileage is too better. The prices vary from nation to nation. Chevrolet seems to be a little cheaper, and reasonably priced going for $33,044, which is slightly less than Ford, but the differences are not serious to propel buyers towards one truck leaving the other
Technophiles are likely to put their preferences on Ford to Chevrolet. On overall, Fords have many features as compared Chevy’s. However, they may be hard to maintain. Compared to Fords, Chevrolets are reliable and cheaper. However, the two brands are equally good performers. It is, therefore, prudent to pick what one thinks would fit his or her usage and preference and personal style
Ethical Systems, Research Paper, Spring 2015, Douglas Green, Page 1 of 1
Ethical
Systems/Final
Research
Paper
2,000
words
minimum,
double-‐spaced
Final
Draft
Due:
Tuesday,
April
28,
12:00
pm
(afternoon)
Please
email
your
final
research
paper
to
me
via
MS
Word
attachment
AND
by
cutting/pasting
the
entire
document
into
the
body
of
your
email.
IF
YOU
DO
NOT
RECEIVE
A
CONFIRMATION
EMAIL
BACK,
I
DID
NOT
RECEIVE
YOUR
ESSAY
AND
YOU
WILL
LOSE
ALL
CREDIT
FOR
THIS
REQUIREMENT.
NO
LATE
WORK
WILL
BE
ACCEPTED…
PERIOD!
.
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Workforce planning is essential for high performing organizations, our Strategic Human Resource Planning PowerPoint Presentation Slides enable you to align your workforce requirements with your business goals. With the help of this sample deck, you can showcase strategic human resource plan framework, assessing the current HR capacity, forecasting HR requirements, skill gap analysis plan, organizational skills program matrix, company’s recruitment strategies, evaluating recruitment strategies, recruitment budget, etc. Structure human resource plan with this content ready strategic HRM planning PPT visuals. Using this visually stunning strategic human resource management process, HR managers can easily present the content to target management. Furthermore, this will guide you on how a business should move from its current to the desired manpower position. Get a clear idea about the HRM process. Download the strategic human resource management plan in just a few seconds. Deliver an effective presentation and explain your points more efficiently. Pamper yourself with our Strategic Human Resource Planning Powerpoint Presentation Slides. They will rejuvenate your thoughts.
Presenting this set of slides with name - Performance Planning Powerpoint Presentation Slides. Our topic specific Performance Planning Powerpoint Presentation Slides presentation deck contains sixty one slides to formulate the topic with a sound understanding. This PPT deck is what you can bank upon. With diverse and professional slides at your side, worry the least for a powerpack presentation. A range of editable and ready to use slides with all sorts of relevant charts and graphs, overviews, topics subtopics templates, and analysis templates makes it all the more worth. This deck displays creative and professional looking slides of all sorts. Whether you are a member of an assigned team or a designated official on the look out for impacting slides, it caters to every professional field.
Structure your human resource plan with this content ready Organisation Workforce Planning PowerPoint Presentation Slides. With the help of this sample deck you can showcase strategic human resource plan framework, assessing the current HR capacity, forecasting HR requirements, skill gap analysis plan, organizational skills program matrix, company’s recruitment strategies, evaluating recruitment strategies, recruitment budget, etc. You can incorporate these readymade PowerPoint templates to emphasize core functions of human resource management. Workforce planning is essential for high performing organizations. This strategic workforce planning PPT layout will guide you on how a business should move from its current to the desired manpower position. Get a clear idea about the HRM process using our manpower planning PowerPoint templates. Another exciting feature of our human capital plan PPT visuals is that you can manually adjust presentation background, text font, color to complement your style. Demonstrate pathways to implement HR strategy using the manpower planning process PPT visuals
Mr. Subir Ghosh discusses key considerations for customer experience management (CEM) programs and strategies. He notes that while technical skills are important, developing the right mindset and understanding customer motivations are critical gaps. Smaller companies can excel through strong customer focus regardless of size. Experiential marketing will take more time to develop in India compared to the West. Developing a strong service culture across all industries and roles is vital for customer loyalty.
This document provides an overview of a presentation on business model innovation and management. It includes an agenda with topics such as defining a business model, different types of innovation, case studies, and implementing and measuring business model success. There are also examples provided of a business model framework and applying it to a soccer club case study. The framework covers areas such as value proposition, customer segments, distribution channels, revenue streams, and more.
Present your next marketing plan, campaign, social media strategy or newsletter with these free Google Slides and PowerPoint templates. Their creative design and easy-to-edit graphic resources will help you get your message across.
The document outlines the current strengths, weaknesses, opportunities, and threats of a company. The company's key strengths include its well-known brand, experience processing apples, apple acreage, and distribution partnerships. Weaknesses consist of insufficient cash and apple acres for growth plans. Opportunities exist in expanding distribution, improving production efficiency, and developing new product lines. Threats involve competition undercutting on pricing and challenges completing strategic agreements.
Ability Building PowerPoint Presentation SlidesSlideTeam
This PPT deck displays twenty one slides with in depth research. Our Ability Building PowerPoint Presentation Slides presentation deck is a helpful tool to plan, prepare, document and analyse the topic with a clear approach. We provide a ready to use deck with all sorts of relevant topics subtopics templates, charts and graphs, overviews, analysis templates. Outline all the important aspects without any hassle. It showcases of all kind of editable templates infographics for an inclusive and comprehensive Ability Building PowerPoint Presentation Slides presentation. Professionals, managers, individual and team involved in any company organization from any field can use them as per requirement.
http://bit.ly/384MCCB
Capability Development PowerPoint Presentation SlidesSlideTeam
Use Capability Development PowerPoint Presentation Slides to focus on the development of an individual or team through various strategies and activities to achieve business goals. Meet and work on future challenges. Build capacity for change using professionally designed content-ready capability development PPT slides. This capability development model PowerPoint slideshow will serve your team extensive learning opportunities and support experimental practices. Incorporate easy-to-understand capability development PowerPoint templates such as capability assessment, capability maturity model, current vacancies, job description, recruitment budget, training plan, and more. This ready-made capability development PowerPoint presentation is completely customizable. You can edit the templates as per your requirement. Change color, text, icon and font size as per your need. Download capability development PowerPoint presentation to help your team develop the skills they need to meet the business goals. Our Capability Development Powerpoint Presentation Slides will go behind you. They will endorse your every thought.
Organisational Development PowerPoint Presentation SlidesSlideTeam
Presenting this set of slides with name - Organisational Development Powerpoint Presentation Slides. This aptly crafted editable PPT deck contains sixty slides. Our topic specific Organisational Development Powerpoint Presentation Slides presentation deck helps devise the topic with a clear approach. We offer a wide range of custom made slides with all sorts of relevant charts and graphs, overviews, topics subtopics templates, and analysis templates. Speculate, discuss, design or demonstrate all the underlying aspects with zero difficulty. This deck also consists creative and professional looking slides of all sorts to achieve the target of a presentation effectively. You can present it individually or as a team working in any company organization.
EX Assembly: COVID19 and its Impact on Employee Peformance & RewardsLearningCafe
COVID19 has thrown business plans into disarray. While the impact of COVID on the workforce is manifold, measuring and rewarding employees will be a particularly challenging one.
We discuss
Do we need to adapt or “inactivate” Employee Performance Processes specially for employees whose work has been directly impacted ?
How do we recognise and reward employees who go above and beyond their job description during these challenging times ?
Does COVID19 provide us an opportunity to transform the Perf Mgt system which is perceived as ineffective ?
This document provides a framework and steps for developing a strategic human resources plan. It includes templates for assessing current HR capacity, forecasting future HR requirements, identifying skills gaps, and developing recruitment and training strategies. Sections cover determining HR needs, recruiting and selecting employees, developing training programs, compensation, and performance management. The overall plan aims to strategically manage an organization's human resources.
Attracting qualified technicians takes more than a "help wanted" sign in the window. Learn the latest in digital recruitment trends, why you need a recruitment strategy, and how to build a great one.
Door To Door Sales Techniques PowerPoint Presentation SlidesSlideTeam
The document provides an overview of door-to-door sales techniques. It includes sections on identifying ideal clients, mapping out locations, training processes, product ratings, comparisons, and pricing. Quick tips are provided on dressing appropriately, timing visits for maximum effectiveness, greeting customers with a friendly demeanor, and being persistent while maintaining confidence. Goals and activities are outlined for self-evaluation.
For seven years, CLO’s LearningElite awards have recognized the organizations that excel at managing the learning function from end to end. How do elite learning organizations align learning with organizational goals, engage their learners, measure success, engage leadership in employee development and use learning to make a measureable impact on the organization? Join Sarah Kimmel, vice president of research at Human Capital Media, as she discusses the practices that make LearningElite organizations effective, and that contribute to their high scores on the LearningElite benchmark.
You’ll learn:
The practices that distinguish LearningElite organizations from the rest.
How elite learning organizations achieve alignment of learning with organizational goals.
How the LearningElite engage leaders at all levels to support employee development and create a culture of learning.
What metrics elite learning organization use to measure impact on the learner and impact on the business.
Tips for maximizing your organization’s scores on the LearningElite application.
Participants will receive early access to the 2018 LearningElite application worksheets.
When marketing and sales are working in lockstep, your revenue soars and your business grows. Resident marketing technology expert, James Kenler, has been on both sides of the sales and marketing divide. Learn how James used marketing automation to align the sales and marketing processes at CareerBuilder around a common business goal to ultimately develop a unified sales strategy driving overall revenue and resulting in the creation of new teams and resources.
The document outlines steps for developing a strategic human resources plan, including forecasting HR requirements, assessing current capacity, developing recruitment strategies, and evaluating strategies. It provides templates for skills gap analysis, an organizational skills program matrix, and evaluating recruitment costs and hiring outcomes. The overall plan framework specifies demand forecasting, supply forecasting, developing talent strategies, and reviewing and evaluating the HR plan on an ongoing basis.
Presenting this set of slides with name - Resource Planning Powerpoint Presentation Slides. Our topic specific Resource Planning Powerpoint Presentation Slides presentation deck contains twenty six slides to formulate the topic with a sound understanding. This PPT deck is what you can bank upon. With diverse and professional slides at your side, worry the least for a powerpack presentation. A range of editable and ready to use slides with all sorts of relevant charts and graphs, overviews, topics subtopics templates, and analysis templates makes it all the more worth. This deck displays creative and professional looking slides of all sorts. Whether you are a member of an assigned team or a designated official on the look out for impacting slides, it caters to every professional field.
Similar to Interview Bill Cosby, NavistarCM Describe your current p (20)
Please readRobert Geraci, Russia Minorities and Empire,” in .docxTatianaMajor22
Please read:
Robert Geraci, “Russia: Minorities and Empire,” in Abbott Gleason, ed., A Companion to Russian History (Oxford: Wiley-Blackwell, 2009), 243-260.
And discuss:
How does Geraci portray the legacy of the early Russian history for the make-up of 18-19th century Russia?
Please read: Leonard Victor Rutgers, “Roman Policy Towards the Jews: Expulsions from the City of Rome during the First Century C.E.,” in Classical Antiquity, Vol. 13, No. 1 (Apr., 1994), pp. 56-74.
And discuss: Rutgers surveys the different reasons historians have given for the expulsion of the Jews from Rome in the first century C.E. Who place did Jews have in Roman society at this time? Were they expelled because of their religious practices, or because they were ‘unruly’ as Rutgers argues? If so, what caused them to act in this way? What kind of historical evidence does the author use?
There are 2 essay, each one should write at least 300-350 words and plus one reference page.
MLA format. Must use quote( “ ”) for every source you use from website. And put (author, page number) behind quote.
Roman Policy towards the Jews: Expulsions from the City of Rome during the First Century
C.E.
Author(s): Leonard Victor Rutgers
Source: Classical Antiquity, Vol. 13, No. 1 (Apr., 1994), pp. 56-74
Published by: University of California Press
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LEONARD VICTOR RUTGERS
Roman Policy towards the Jews:
Expulsions from the City of Rome
during the First Century c. E.
Tant de causes secretes se melent souvent a la cause apparente, tant de ressorts
inconnus servent a persecuter un homme, qu'il est impossible de demeler dans les
siecles posterieures la source cachee des malheurs des hommes les plus consider
ables, a plus forte raison celle du supplice d'un particulier qui ne pouvait etre
connu que par ceux de son parti.
-Voltaire, Traite sur la tolerance (1763)
IN THIS ARTICLE I want to discuss the evidence for expulsions of Jews from
the city of Rome in the first century C.E. Scholars have long been interested in the
reasons underlying these expulsions. Because the anci.
Ford VS ChevroletThere are many reasons that make the Chevy.docxTatianaMajor22
Ford VS Chevrolet
There are many reasons that make the Chevy’s and Ford’s motors two most common trucks. Studies reveal that that they are the most popular vehicles on sales today. It is because they are powerful, versatile and reasonably priced. They also come in a wide variety of configurations and styles. However, many buyers and sellers have questioned themselves on the better vehicle compared to the other in terms of quality, Wi-Fi, price ranges, value, and costs. To compare and contrast on this subject, let us take an example of two vehicles each from each company to facilitate comparison.
Ford offers the full-size track with automatic high-beam control, automatic parallel parking and power-retractable running boards. Fords are elegant, and they are mostly aluminum making them save weight and bolster gas mileage. None of these features are offered Chevy’s. Chevrolets have outstanding quality. They are mostly comprised of steel, for instance, the Chevrolet Silverado. This makes them good for rough roads and difficult terrains.
Fords have employed the use of up to date Wi-Fi technology. Ford intends to provide the Ford Sync, which will provide robust connections for occupants. Latest Chevrolet brands Malibu utilize the 4G LTE Wi-Fi Technology that provides rich in-vehicle experiences. This technology is powerful compared to Ford Sync, and is used for connecting devices and executing few remote operations within the car.
From the value and cost standpoint, Ford can consume a little more, and its payload capacity is a little higher. Additionally, its mileage is too better. The prices vary from nation to nation. Chevrolet seems to be a little cheaper, and reasonably priced going for $33,044, which is slightly less than Ford, but the differences are not serious to propel buyers towards one truck leaving the other
Technophiles are likely to put their preferences on Ford to Chevrolet. On overall, Fords have many features as compared Chevy’s. However, they may be hard to maintain. Compared to Fords, Chevrolets are reliable and cheaper. However, the two brands are equally good performers. It is, therefore, prudent to pick what one thinks would fit his or her usage and preference and personal style
Ethical Systems, Research Paper, Spring 2015, Douglas Green, Page 1 of 1
Ethical
Systems/Final
Research
Paper
2,000
words
minimum,
double-‐spaced
Final
Draft
Due:
Tuesday,
April
28,
12:00
pm
(afternoon)
Please
email
your
final
research
paper
to
me
via
MS
Word
attachment
AND
by
cutting/pasting
the
entire
document
into
the
body
of
your
email.
IF
YOU
DO
NOT
RECEIVE
A
CONFIRMATION
EMAIL
BACK,
I
DID
NOT
RECEIVE
YOUR
ESSAY
AND
YOU
WILL
LOSE
ALL
CREDIT
FOR
THIS
REQUIREMENT.
NO
LATE
WORK
WILL
BE
ACCEPTED…
PERIOD!
.
Fairness and Discipline Weve all been disciplined at one.docxTatianaMajor22
Fairness and Discipline
We've all been disciplined at one time or another by a parent or a teacher. What disciplinary experiences have you had as a child that took a non-punitive approach?
I need paragraph or half page with reference
.
Appendix 12A Statement of Cash Flows—Direct MethodLEARNING .docxTatianaMajor22
Appendix 12A
Statement of Cash Flows—Direct Method
LEARNING OBJECTIVE
6
Prepare a statement of cash flows using the direct method.
To explain and illustrate the direct method, we will use the transactions of Computer Services Company for 2014, to prepare a statement of cash flows. Illustration 12A-1 presents information related to 2014 for Computer Services Company.
To prepare a statement of cash flows under the direct approach, we will apply the three steps outlined in Illustration 12-4.
Illustration 12A-1
Comparative balance sheets, income statement, and additional information for Computer Services Company
STEP 1: OPERATING ACTIVITIES
DETERMINE NET CASH PROVIDED/USED BY OPERATING ACTIVITIES BY CONVERTING NET INCOME FROM AN ACCRUAL BASIS TO A CASH BASIS
Under the direct method, companies compute net cash provided by operating activities by adjusting each item in the income statement from the accrual basis to the cash basis. To simplify and condense the operating activities section, companies report only major classes of operating cash receipts and cash payments. For these major classes, the difference between cash receipts and cash payments is the net cash provided by operating activities. These relationships are as shown in Illustration 12A-2.
Illustration 12A-2
Major classes of cash receipts and payments
An efficient way to apply the direct method is to analyze the items reported in the income statement in the order in which they are listed. We then determine cash receipts and cash payments related to these revenues and expenses. The following pages present the adjustments required to prepare a statement of cash flows for Computer Services Company using the direct approach.
CASH RECEIPTS FROM CUSTOMERS.
The income statement for Computer Services Company reported sales revenue from customers of $507,000. How much of that was cash receipts? To answer that, companies need to consider the change in accounts receivable during the year. When accounts receivable increase during the year, revenues on an accrual basis are higher than cash receipts from customers. Operations led to revenues, but not all of these revenues resulted in cash receipts.
To determine the amount of cash receipts, the company deducts from sales revenue the increase in accounts receivable. On the other hand, there may be a decrease in accounts receivable. That would occur if cash receipts from customers exceeded sales revenue. In that case, the company adds to sales revenue the decrease in accounts receivable. For Computer Services Company, accounts receivable decreased $10,000. Thus, cash receipts from customers were $517,000, computed as shown in Illustration 12A-3.
Illustration 12A-3
Computation of cash receipts from customers
Computer Services can also determine cash receipts from customers from an analysis of the Accounts Receivable account, as shown in Illustration 12A-4.
Illustration 12A-4
Analysis of Accounts Receivable
Illustration.
Effects of StressProvide a 1-page description of a stressful .docxTatianaMajor22
Effects of Stress
Provide a 1-page description of a stressful event currently occurring in your life.
Discuss I am married work a full time job as an occupational therapy assistant am taking two courses
Have to take care of a home feed the animals attend to laundry
Think of my pateitns worry about their well being and what I can do for them ( I bring home my patients issues)
Constantly doing paper work for work such as documentation for billing
I feel like I have no free time for me some days I don’t even eat dinner or lunch because I don’t have time to make anything or am just too tired to cook
On top of this I am married and married ppl do argue and my husband am I have been bunting heads on finances.
Then, referring to information you learned throughout this course, address the following:
· What physiological changes occur in the brain due to the stress response?
· What emotional and cognitive effects might occur due to this stressful situation?
· Would the above changes (physiological, cognitive, or emotional) be any different if the same stress were being experienced by a person of the opposite sex or someone much older or younger than you?
· If the situation continues, how might your physical health be affected?
· What three behavioral strategies would you implement to reduce the effects of this stressor? Describe each strategy. Explain how each behavior could cause changes in brain physiology (e.g., exercise can raise serotonin levels).
· If you were encouraging an adult client to make the above changes, what ethical considerations would you have to keep in mind? How would you address those ethical considerations?
In addition to citing the online course and the text, you are also required to cite a minimum of four scholarly sources. For reputable web sources, look for .gov or .edu sites as opposed to .com sites. Please do not use Wikipedia.
Your paper should be double-spaced, in 12-point Times New Roman font, and with normal 1-inch margins; written in APA style; and free of typographical and grammatical errors. It should include a title page with a running head, an abstract, and a reference page.
The body of the paper should be at least 6 pages in length total
not including the reference or title page
Assignment 1 Grading Criteria
Maximum Points
Described a stressful event.
20
Explained the physiological changes that occur in the brain due to the stress response.
36
Explained the emotional and cognitive effects that may occur due to this stressful situation.
32
Analyzed potential differences in physiological, cognitive, and emotional responses in someone of a different age or sex.
32
Discussed the physical health risks.
28
Provided three behavioral strategies to reduce the effects of the stressor and explained how each could cause changes in brain physiology.
40
Analyzed ethical considerations in implementing behavioral strategies and offered suggestions for addressing these.
40
Integrated at least two scholarly references .
Design Factors NotesCIO’s Office 5 People IT Chief’s Offi.docxTatianaMajor22
Design Factors
Notes
CIO’s Office
5 People
IT Chief’s Office
5 People
LAN/WAN Maint.
20 People
Reception
4 People
Telecommunications
20 People
LAN Management
50 People
Server Room A
2 Person
Server Room B
4 Person
Equipment:
Patch Cable
Computer to Wall
Patch Cable
LAN Room
Cable Trays/Runs
Horizontal Runs
Cisco Border Router
Research: Attached to 5 Floor Switches
Server Room A
10 Servers
Server Room B
10 Servers
Computers
One Per Person
Standard floor (first floor) Lesson 2 Project Plan info
Design Factors
Notes
CIO’s Office
5 People
IT Chief’s Office
5 People
LAN/WAN Maint.
20 People
Reception
4 People
Telecommunications
20 People
LAN Management
50 People
Server Room A
2 Person
Server Room B
4 Person
Equipment:
Patch Cable
Computer to Wall
Patch Cable
LAN Room
Cable Trays/Runs
Horizontal Runs
Cisco Border Router
Research: Attached to 5 Floor Switches
Server Room A
10 Servers
Server Room B
10 Servers
Computers
One Per Person
Basement floor
Design Factors
Notes
Vertical Riser Run
On Outside Wall of LAN Room on Each Floor.
Fiber-Optic Multimode
Riser Runs: Backbone
SC Connectors
Fiber-Optic Cable
Cisco Catalyst: Switch: WS-C3750G-24PS-S: 24 Ports
Leave a Minimum of four ports free on each switch
Color Laser Printer
Minimum of One per Room or One per 20 people
Vertical Riser Run
On Outside Wall of LAN Room on Each Floor and Server RM B on this floor.
Fiber-Optic Multimode
Riser Runs: Backbone
SC Connectors
Fiber-Optic Cable
Cable Trays/Runs
Horizontal Runs
Horizontal Runs
Leave a Minimum of four ports free on each switch
Applicataion
U.S. Minimum Requirement Ranges
Space per Employee - 1997
Two people, such as a supervisor and an employee, can meet in an office with a table or desk between them
60" to 72" x 90" to 126:/5.78m2 to 11.7m2
280Sq. Ft./26.0m2
Worker has a primary desk plus a return
60" to 72"x60"to 84"/5.78 to 7.8m2
193Sq. Ft./17.9m2
Executive office - three to four people can meet around a desk
105 to 130"x96 to 123"/9.75 to 11.4 m2
142Sq. Ft./13.2m2
Basic workstation such as a call center
42" to 52" x 60" to 72"/3.9 to 6.7 m2
114Sq. Ft./10.6 m2
NT1310: Project
Page 1
PRO JECT D ESC RIPT ION
As the project manager for the Cable Planning team, you will manage the creation of the cable plan for
the new building that will be built, with construction set to begin in six weeks.
The deliverables for the entire Cable Plan will consist of an Executive Summary, a PowerPoint
Presentation and an Excel Spreadsheet. You will develop different parts of each of these in three parts.
The final organization should contain these elements:
The Executive Summary:
o Project Introduction
o Standards and Codes
Cable Standards and Codes
Building Standards and Codes
o Project Materials
o Copper Cable, Tools, and Test Equipment
o Fiber-Optic Cable, Tools, and Test Equipment
o Fiber-Optic Design Considerations
o Basement Server Comp.
Question 12.5 pointsSaveThe OSU studies concluded that le.docxTatianaMajor22
The document contains questions about leadership, motivation, communication, groups/teams, and decision making. The questions assess knowledge of topics like situational leadership theory, Maslow's hierarchy of needs, organizational communication barriers, stages of team development, and group decision making techniques like brainstorming.
Case Study 1 Questions1. What is the allocated budget .docxTatianaMajor22
Case Study 1 Questions:
1. What is the allocated budget ? $250,000
2. Where does the server room located? Currently, there is no server room
3. What is the number of users with PCs inside each existing site?
Currently there are
4. What is the current cabling used in each location? (cat5e or cat6) Current cabling does not meet the company’s current and future needs
5. Do want us to upgrade token Ring or use a completely new Ethernet network What is your recommendation and why?
6. regarding the ordering system , it is not clear what the we should do , do you want to talk about how to connect the system to the network or how to built the ordering online system because it is more software engineering than networking . Talk about the kind of network (hardware) you recommend based on the business requirements
7. all the sites should have access to our servers in the main branch? yes
8. Regarding the order software, do you need more details about the way it works or just about its connection with the network? Your solution should be from a network point of view
9. Distances are given in Meters or feet? feet
10. Shipment is done by truck, or ships? Currently, only trucking
11. In Dimebox branch, where are administration offices located? See Business goals # 4
12. What is the current network connectivity status? How many devices are currently on the network? How they are physically laid out? Is cabling running all over the floor, hidden in walls or threaded through the ceiling? What are the switches used and its speed? Currently, only the office is networked (token ring) NOVELL
13. What is the minimum Internet speed wanted? See Business Goals on page 2 – I only can tell you what we need the network for, you must tell me what we need to meet the business needs
14. Will the corporation provide wireless access? If yes will it be in all department and buildings? Wireless access would be helpful if we can justify the cost
15. Are there phones in offices? yes
16. What is the internet speed available now? What speed do you want for future? Internet access is through time warner cable company which is not very reliable
17. Do employees access their emails outside the company? yes
18. Do you have plans for future expansion? We like to increase our customer base by 20% over the next year
REMEMBER, you are the IT expert, I’m only a business person who must rely on your expertise.
Network Design and Performance
Case Study
Dooma-Flochies, Inc. with headquarters located on Podunk Road in Trumansburg, NY, is the sole manufacturer of Dooma-Flochies (big surprise). They currently have a manufacturing facility in, Lake Ridge, NY (across Cayuga Lake) on Cayuga Dr. and have recently diversified by purchasing a company, This-N-That, on Industry Ave. in, Dime Box Texas. This-N-That is the sole competitor of Domma-Flochies with their product Thinga-Ma-Jigs. This acquisition gives Dooma-Flochies, Inc a monopoly in this mark.
Behavior in OrganizationsIntercultural Communications Exercise .docxTatianaMajor22
Behavior in Organizations
Intercultural Communications Exercise Response Paper –
Week 5
The most overt cultural differences, such as greeting rituals and name format, can be overcome most easily. The underlying, intangible differences are very difficult to overcome. In this case, the underlying cultural differences are
· Assumptions about the purpose of the event (is the party strictly for fun and for relationship building, or are their business matters to take care of?).
· Assumptions about the purpose and the nature of business relationship.
· Assumptions about power and leadership relationships (who makes the decisions and how?).
· Response styles (verbal and nonverbal signals of agreement, disagreement, politeness, etc.).
Many (though not all) cultural differences can be overcome if you carefully observe other people, think creatively, remain flexible, and remember that your own culture is not inherently superior to others.
The Scenario
Three corporations are planning a joint venture to sponsor an international concert tour. The corporations are Decibel, an agency representing the musicians (from the US, Britain, and Japan); Images, a marketing firm which will handle sales of tickets, snacks and beverages, clothing, and CDs; and Event, a special events company which will hire the ushers, concessionaires, and security officers; print the programs; and clean up the arenas after the shows. The companies come from three different cultures: Blue, Green, and Red. Each has specific cultural traits, customs, and practices.
You are a manager in one of these companies. You will attend the opening cocktail party in Perth, Australia the evening before a 3-day meeting during which the three companies will negotiate the details of the partnership. Your management team includes a Vice President and a number of other managers.
During the 3-day meeting, the companies have the following goals:
Decibel
· As high a royalty rate as possible on sales of T-shirts, videos, and CDs
· Aggressive marketing and advertising to increase attendance and sales
· Good security, both before and during the show Image
Image
· Well known bands that will be easy to market
· As much income as possible from the concerts
· Smoothly functioning event so that publicity from early concerts is positive
Event
· Bands that are not likely to provoke stampedes, riots, or other antisocial behavior
· Bands that are reliable and will show up on time, ready to play
· As much income as possible from the concerts
The cultures that are assigned to the various companies are:
BLUE CULTURE
Image (Marketing Company)
Beliefs, Values, and Attitudes that Underlie This Culture’s Communication
Believe that fate and luck control most things.
Believe in feelings more than reasoning.
An authoritarian leader makes the ultimate decisions.
Nonverbal Traits of This Culture
Treat time as something that is unimportant. It is not a commodity that can be lost.
Conversation distance is close (about 15 inches, face-.
Discussion Question Comparison of Theories on Anxiety Disord.docxTatianaMajor22
Discussion Question:
Comparison of Theories on Anxiety Disorders
There are numerous theories that attempt to explain the development and manifestation of psychological disorders. Some researchers hold that certain disorders result from learned behaviors (behavioral theory), while other researchers believe that there is a genetic or biological basis to psychological disorders (medical model), while still others hold that psychological disorders stem from unresolved unconscious conflict (psychoanalytic theory). How would each of these theoretical viewpoints explain anxiety disorders? Does one explain the development and manifestation of anxiety disorders better than the others?
200- 400 words please
Three min resources with
in text citations and examples
you can use the following as a module reference
cite as university 2014
Anxiety Disorders
Anxiety disorders such as panic disorder, specific phobias, and social anxiety disorder feature a heightened autonomic nervous system response that is above and beyond what would be considered normal when faced with the object or situation that the person reacts to. For example, a person with a specific phobia of spiders (called arachnophobia) experiences a heightened autonomic response when confronted with a spider (or even an image of a spider). This anxiety response must result in significant distress or impairment. In general, anxiety disorders have been linked to underactive gamma-aminobutyric acid (GABA) in the brain, resulting in overexcitability of the amygdala and the anterior cingulate cortex. Additionally, genetic research shows that anxiety disorders demonstrate a clear pattern of genetic predisposition
Charles Darwin's Perspective
We talked about Charles Darwin when discussing evolution and natural selection. Darwin was also very interested in emotions. One of his books published in 1872,The Expression of Emotions in Man and Animals, was devoted to this topic.
Darwin believed that emotions play an important role in the survival of the species and result from evolutionary processes in the same way as other behaviors and psychological functions. Darwin's writing on this topic also prompted psychologists to study animal behavior as a way to better understand human behavior.
James–Lange Theory of Emotions
Modern theories of emotion can be traced to William James and Carl Lange (Pinel, 2011). William James was a renowned Harvard psychologist who is sometimes called the father of American psychology. Carl Lange was a Danish physician. James and Lange formulated the same theory of emotions independently at about the same time (1884). As a result, it is called the James–Lange theory of emotions. This theory reversed the commonsensical notion that emotions are automatic responses to events around us. Instead, it proposes that emotions are the brain's interpretation of physiological responses to emotionally provocative stimuli.
Cannon–Bard Theory of Emotions
In 1915, Harvard physiologist Walt.
I have always liked Dustin Hoffmans style of acting, in this mov.docxTatianaMajor22
I have always liked Dustin Hoffman's style of acting, in this movie he takes on a sexually deprived young male just out of college, and has never been with a female, and is duped by horny older woman that feels neglected. Dustin Hoffman takes the characters form of a young male, goofy, respectful virgin and intelligent male, missing something but not really sure at the beginning till Ann Bancroft coaxes him with seduction to fulfill her own needs. In an other movie called "The life of Little Big Man" he plays almost the same character but as a white child raised by the Native Americans and a wise old chief that deeply care and loves him as his own, and Fay Dunaway plays a Holy rollers wife that is older and sexually deprived and feeling neglected by her husband and also she goes through major changes in her life from devoted wife, to a honey bell/ house hooker, whats funny Dustin Hoffman is a awesome actor but has to have his surrounding characters bring his character to life. The Graduate was Dustin Hoffman's first big movie of his career.
I actually liked movie "Little Big man" way better due to he went through major changes in his life, from being a Native boy warrior, captured by Yankees, meets Fay Dunaway who loves to give baths, to finding his sister who teaches him to be a gunslinger and then returns to his Grand Father to be a native again and tells his blind Grand Father the world of the white man is a crazy one, then his see the Psyho Col. Custer and gets his revenge by telling Custer the truth. The movie Little Big Man makes you laugh, teaches you things about people and survial and cry at times... its a must see...
Although a stray away from the Benjamin Braddock written about in the novel The Graduate, Dustin Hoffman does an awesome job with this character on film. When you first meet Ben he is at a party that his parents are throwing in his academic honor upon his graduation from school and return home. The whole night, Hoffman stumbles though various conversations and tries to coyly escape from the festivities. Small things such as this Hoffman did a great job at, conveying the hesitance and crisis that Ben was going through as a graduate. There are multiple times in the movie he hardly expresses anything at all, yet it clearly shows you that Ben is having a very hard time internally with everything going on. Even through his relationships with Mrs. Robinson and her daughter Elaine you see the young man struggling with himself through either failed attempts at affection or lack thereof.
.
Is obedience to the law sufficient to ensure ethical behavior Wh.docxTatianaMajor22
Is obedience to the law sufficient to ensure ethical behavior? Why, or why not? Support your answer with at least three reasons that justify your position.
100 words
Discuss the differences between an attitude and a behavior. Provide 4 substantive reasons why it is important for organizations to monitor and mitigate employee behavior that is either beneficial or detrimental to the organization's goals and existence.
150 words
.
If you are using the Blackboard Mobile Learn IOS App, please clic.docxTatianaMajor22
If you are using the Blackboard Mobile Learn IOS App, please click "View in Browser." V BUS 520Week 9 Assignment 4 Paper
I need the paper as soon as possible
Students, please view the "Submit a Clickable Rubric Assignment" in the Student Center.
Instructors, training on how to grade is within the Instructor Center.
Assignment 4: Leadership Style: What Do People Do When They Are Leading?
Due Week 9 and worth 100 points
Choose one (1) of the following CEOs for this assignment: Larry Page (Google), Tony Hsieh (Zappos), Gary Kelly (Southwest Airlines), Meg Whitman (Hewlett Packard), Ursula Burns (Xerox), Terri Kelly (W.L. Gore), Ellen Kullman (DuPont), or Bob McDonald (Procter & Gamble). Use the Internet to investigate the leadership style and effectiveness of the selected CEO. (Note: Just choose one that is easier for you to right about.) It does not matter to me which CEO you pick
Write a five to six (5-6) page paper in which you:
1. Provide a brief (one [1] paragraph) background of the CEO.
2. Analyze the CEO’s leadership style and philosophy, and how the CEO’s leadership style aligns with the culture.
3. Examine the CEO’s personal and organizational values.
4. Evaluate how the values of the CEO are likely to influence ethical behavior within the organization.
5. Determine the CEO’s three (3) greatest strengths and three (3) greatest weaknesses.
6. Select the quality that you believe contributes most to this leader’s success. Support your reasoning.
7. Assess how communication and collaboration, and power and politics influence group (i.e., the organization’s) dynamics.
8. Use at least five (5) quality academic resources in this assignment. Note: Wikipedia and other Websites do not qualify as academic resources.
Your assignment must follow these formatting requirements:
· Be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides; citations and references must follow APA or school-specific format. Check with your professor for any additional instructions.
· Include a cover page containing the title of the assignment, the student’s name, the professor’s name, the course title, and the date. The cover page and the reference page are not included in the required assignment page length.
The specific course learning outcomes associated with this assignment are:
· Analyze the formation and dynamics of group behavior and work teams, including the application of power in groups.
· Outline various individual and group decision-making processes and key factors affecting these processes.
· Examine the primary conflict levels within organization and the process for negotiating resolutions.
· Examine how power and influence empower and affect office politics, political interpretations, and political behavior.
· Use technology and information resources to research issues in organizational behavior.
· Write clearly and concisely about organizational behavior using proper writing mechanics.
Click here.
Is the proliferation of social media and communication devices a .docxTatianaMajor22
Social media and communication devices have both benefits and drawbacks for society. While they allow easy connection with others and access to information, overuse can negatively impact relationships and mental health. Overall, moderation is key to reap the upsides of technology while avoiding the downsides.
MATH 107 FINAL EXAMINATIONMULTIPLE CHOICE1. Deter.docxTatianaMajor22
The document contains a 30-question math exam covering topics like functions, graphs, equations, inequalities, logarithms, and other math concepts. It includes multiple choice, short answer, and show work questions assessing skills like domain and range, solving equations, graphing, composites, inverses, lines, maximizing profit, and more. Students must demonstrate mathematical reasoning and problem-solving abilities.
If the CIO is to be valued as a strategic actor, how can he bring.docxTatianaMajor22
If the CIO is to be valued as a strategic actor, how can he bring to the table the ethos of alignment, bound to the demands of process strategic planning to move IT to the forefront of the organization's future? Is there a lack of information on strategic planning? Nope. I think the process of planning is poorly understood, and rarely endorsed. The reasons are simple enough. Planning requires a commitment of resources (time, talent, money); it requires insight; it requires a total immersion in the corporate culture. While organizations do plan, planning is invariably attached to the budget process. It is typically here that the CIO lays out his/her vision for the coming year Now a few years ago authors began writing on the value of aligning IT purpose to organizational purpose. They wrote at a time when enterprise architectural planning was fairly new, and enterprise resource management was on the lips of every executive. My view is that alignment is a natural process driven by the availability of the tools to accomplish it. Twenty years ago making sense of IT was more about processing power, and database management. We are in a new age of IT, and it is the computer that is the network, not the network as an independent self-contained exchange of information. If you will spend some time reviewing the basic materials I provided on strategic planning and alignment, we can begin our discussions for the course. Again, here is the problem I would like for us to tackle: If the CIO is to be valued as a strategic actor, how can he bring to the table the ethos of alignment, bound to the demands of process strategic planning to move IT to the forefront of the organization's future? Most of the articles I bundled together for this week are replete with tables and charts. These can be a heavy read. Your approach should be to review these articles for the "big ideas" or lessons that are take away. I think these studies are significant enough that we will conclude our first week with an understanding of the roles between executive leaders, and how they see Information Technology playing a role in shaping a business strategy.
Read the articles to answer the question. Please No Plagerism or verbatim but you are allowed to quote from the article.
Achieving and Sustaining
Business-IT Alignment
Jerry Luftman
Tom Brier
I
n recent decades, billions of dollars have been invested in intormation tech-
nology (IT). A key concern of business executives is alignment—applying IT
in an appropriate and timely way and in harmony with business strategies,
goals, and needs. This issue addresses both how IT is aligned with the busi-
ness and how the business should be aligned with IT Frustratingly, organizations
seem to find it difficult or impossible to harness the power of information tech-
nology for their own long-term benefit, even though there is worldwide evi-
dence that IT has the power to transform whole industries and markets.' How
can companies.
I am showing below the proof of breakeven, which is fixed costs .docxTatianaMajor22
I am showing below the proof of breakeven, which is fixed costs/ contribution margin.
We start with the definition of breakeven and proceed using elementary algebra to derive the formula. Breakeven is a number and is created by knowing fixed and variable costs, and the retail sales price. It is thus not a point of discussion but is based on the assumptions of these variables.
Proof of Breakeven
Definition of BreakevenVolume: Total Revenue = Total Expenses
Definition
1.Total Revenue = Total Expenses
Breakdown of Definition
2. Retail Price * Volume = Fixed Expenses + Variable Expenses
Further Analysis
3. Retail Price * Volume = Fixed Expenses + (Volume * Unit Variable Expenses)
Subtract (Volume * Unit Variable Expenses) from both sides
4. Fixed Expenses = (Retail Price * Volume) — (Volume * Unit Variable Expenses)
Factor
5. Fixed Expenses = Volume * (Retail Price – Unit Variable Expenses)
Divide both sides by (Retail Price – Unit Variable Expenses)
6. Volume = Fixed Expenses
(Retail Price – Unit Variable Expenses)
Substitution based on Definition
7. Since (Retail Price — Unit Variable Expenses) is called Contribution Margin,
Therefore:
Breakeven Volume = Fixed Expenses / Contribution Margin
NAME_________________________________________________ DATE ____________
1. Explain some of the economic, social, and political considerations involved in changing the tax law.
2. Explain the difference between a Partnership, a Limited Liability Partnership (LLP) and a Limited Liability Company (LLC). In each structure who has liability?
3. How is “control” defined for purposes of Section 351 of the IRS Code?
4. What are the advantages and disadvantages of using debt in a firm’s capital structure?
5. Under what circumstances is a corporation’s assumption of liabilities considered boot in a Section 351exchange?
6. What are the tax consequences for the transferor and transferee when property is transferred to a newly created corporation in an exchange qualifying as nontaxable under Section 351?
7. Why are corporations allowed a dividend-received deduction? What dividends qualify for this special deduction?
8. Provide 3 examples of a Constructive Dividend. Are these Constructive Dividends taxable?
9. Discuss the tax consequences of a new Partnership Formation and give details to gain and losses and basis?
10. Provide 2 similarities and 2 differences when comparing Sections 351 and 721 of the IRS Code.
11. What is the difference between inside and outside basis with a partnership?
12. ABC Partnership distributes $12,000 of taxable income to partner Bob and $24,000 of tax-exempt income to Partner Bob. As a result of these two distributions, how does Bob’s basis change?
13. On January 1, Katie pays $2,000 for a 10% capital, profits, and loss interest in a partnership.
Examine the way in which death and dying are viewed at different .docxTatianaMajor22
Examine the way in which death and dying are viewed at different points in human development.
Using only my text as a reference:
Berger, K.S. (2011). The developing person through the life span (8th ed.).
I need 3 detailed PowerPoint slide with very detailed speaker notes. There must be detailed speaker notes on each slide. The 4th slide will be the reference.
.
Karimi 1 Big Picture Blog Post First Draft College .docxTatianaMajor22
Karimi 1
Big Picture Blog Post First Draft
College Girls in Media
Sogand Karimi
Media and Hollywood movies have affected and influenced society’s perception on
female college students. Due to Hollywood movies and media, society mostly recognizes the
negative stereotypes of a college women. Saran Donahoo, an associate professor and education
administration of Southern Illinois University, once said, “The messages in these films
consistently emphasized college as a place where young women come to have fun, engage in
romances with young men, experiment with sex and alcohol, face dilemmas regarding body
image, and encounter difficulties in associating with other college women.” In this essay I will
be talking about the recurring stereotypes and themes portrayed in three hollywood movies,
Spring Breakers, The house bunny and Legally Blond and how these stereotypes affect our
society.
The movie Spring Breakers is about four college girls who are bored with their daily
routines and want to escape on a spring break vacation to Florida. After realizing they don’t have
enough money, they rub a local diner with fake guns and ski masks. They break the laws in order
to get down to Florida, just to break more rules and laws once they’re there. During the film, you
will notice a lot of partying, drugs and sexual activity. The four girls wear bikinis for majority of
the film and are overly sexual. These are some common themes and stereotypes seen in all three
movies. Media and movies like spring breakers have made it a norm to constantly want to party,
get drunk and have sex as a college woman. In an article by Heather Long, she mentions how the
movie can even be seen as supporting rape culture. She believes because of these stereotypes
always being shown in media, it is contributing to the “girls asking for it” excuse when it comes
to rape cases with young girls. Long also said “...never mind the fact that thousands of college
students are spending their spring break not on a beach, but volunteering with groups like Habitat
for Humanity and the United Way, especially after Hurricanes Katrina and Sandy.” THIS shows
how media only displays one side of a certain group or story. Even though not all college girls
like to party and lay on a beach naked for spring break, that’s what media likes to portray. Not
only does this give the wrong message to our society but it influences bigger issues like rape, as
the author mentioned.
http://www.huffingtonpost.com/2010/03/10/alternative-spring-break_n_494028.html
http://www.huffingtonpost.com/2010/03/10/alternative-spring-break_n_494028.html
Karimi 2
The movie House bunny. The House bunny is a movie about an ex playmate or girlfriend
if Hugh Hefner that gets kicked out of the Playboy Mansion due to her aging. She then becomes
a mother of an unpopular sorority with girls that are bit geeky, and unusual compared to other
girls on campus. The story.
Please try not to use hard words Thank youWeek 3Individual.docxTatianaMajor22
Please try not to use hard words Thank you
Week 3
Individual
Problems and Goals Case Study
Select one of the following three case studies in Ch. 6 of The Helping Process:
· Case Susanna
· Case James and Samantha
· Case Alicia and Montford
Identify three to five problems in the case study you have selected.
Write a 500- to 700-word paperthatincludes the following:
· A problem-solving strategy and a goal for each problem
· The services, resources, and supports the client may need and why
· A description of how goals are measurable and realistically attainable for the client
Here is the case studies
Exercise 3: Careful Assessment
The following case studies are about Susanna, James, Samantha, Alicia, and Montford, all
homeless children attending school. The principal of the school has asked you to conduct
an assessment of these children and provide initial recommendations.
Before you begin this exercise, go to the website that accompanies this book: www.
wadsworth.com/counseling/mcclam, Chapter Three, Link 1, to read more about homeless
families and children.
Susanna
Susanna is 15 years old. Th e city where she lives has four schools: two elementary, one
middle, and one high school. Th ere are about 1,500 students enrolled in the city/county
school district and about 450 in the local high school that Susanna is attending. For the
past six months, Susanna has been living with her boyfriend and his parents. Prior to this,
she left her mother’s home and lived on the streets. She is pregnant and her boyfriend’s
parents want her to move out of their home. Her father lives in a town with his girlfriend,
about 50 miles from the city. Her mother lives outside the city with Susanna’s baby brother.
Right now Susanna’s mother is receiving child support for the two children. Susanna wants
to have a portion of the child support so that she can find a place of her own to live. Her
mother says that the only way that Susanna can have access to that money is to move back
home. Susanna refuses to move back in with her mother.
You receive a call from the behavior specialist at Susanna’s high school. Susanna’s
mother is at the school demanding that Susanna be withdrawn from school. Susanna’s
mother indicates that Susanna will be moving in with her and will be enrolling in another
school district.
Currently Susanna is not doing very well in school. She misses school and she tells the
helper it is because she is tired and that she does not have good food to eat. She has not told
the helper that she is looking for a place to live. Right now she is failing two of her classes
and she has one B and two Ds. Her boyfriend has missed a lot of school, too.
James and Samantha
James is 10 years old and he has a sister, Samantha, who is 8. At the beginning of the
school year, both of the children were attending Boone Elementary School. Both children
live with their aunt and uncle; their parents are in prison. In the middle of the scho.
Reimagining Your Library Space: How to Increase the Vibes in Your Library No ...Diana Rendina
Librarians are leading the way in creating future-ready citizens – now we need to update our spaces to match. In this session, attendees will get inspiration for transforming their library spaces. You’ll learn how to survey students and patrons, create a focus group, and use design thinking to brainstorm ideas for your space. We’ll discuss budget friendly ways to change your space as well as how to find funding. No matter where you’re at, you’ll find ideas for reimagining your space in this session.
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
Interview Bill Cosby, NavistarCM Describe your current p
1. Interview: Bill Cosby, Navistar
CM: Describe your current position?
BC:I am a product support specialist, serving 24 dealers in 5
U.S. states. My goal is to assist my service departments in
creating lean and profitable businesses that serve our
customers’ needs quickly and efficiently.
CM: What was your experience prior to your current
assignment?
BC:I was a service manager in a large dealer location for 7
years prior to this role, having worked my way up from
Foremen and technician.
CM: How long have you been in this industry?
BC:I have been in the heavy diesel repair industry for 30 years
CM: Describe the business you are in.
BC:Heavy Diesel transports everything you touch every day.
Navistar builds International trucks and IC buses which are sold
and serviced through a large dealer network in North and South
America as well as Russia, S. Korea and several African
nations.
CM: What are your company’s current strategic goals?
BC:Drive operational Excellence by reducing manufacturing
costs, grow our core business through increased channel
effectiveness and build new sources of revenue through our
product expansions and connected services.
CM: 3 year goals?
BC:A 5% increase in overall market share of truck and bus sales
2. CM: What is your company’s “global footprint? In other words,
with what countries does your company conduct business?
BC:Navistar has manufacturing facilities in the U.S., Canada,
Mexico and Brazil. We sell our products in those regions as
well as Asia, Europe, Africa and Australia.
CM: Is the current state of global woes impacting your
company?
BC:Currently, we are doing better globally than previous years.
CM: How so?
BC:Our productshave been well received overseas recently as
we can build to their required emissions standards where as
other OEM’s are challenged to build multiple emissions
platforms.
CM: In your opinion, is the current state of global woes likely
to trigger demand for a new style of corporate leadership? If so,
what would this new leadership style look like? If not, then how
does the exciting leadership style support your company’s
future goals?
BC:Corporate leadership is always evolving. Leaders are
constantly adapting to changes in culture, economies and
regulations. The current evolution has leaders more focused on
environmental impacts as well as new technologies that will aid
both their core businesses as well as help our customer base
with their needs and desires.
CM: With the current rate of change in the various business
environments outpacing established abilities for US to meet
demand for human resources, physical resources’, financial
resources, how is your company meeting these demands?
BC:In reality, we’re not. Our industry is service based manual
3. labor. With the ever increasing perception from our public
school system to college or failure, the youth today do not feel
that a skilled profession a viable sustainable living. Yet, most
technicians today with 2 years of experience are making $50k a
year and that doubles at 5 years of experience. Our company has
created our own training program within a technical college in
an effort to recruit and train those interested in our field.
CM: What are your company’s opportunities for import/export
expansion?
BC:Navistar has been increasing our export sales year over year
for several years now and we will continue that trend into the
foreseeable future.
CM: What are some of the significant changes in workforce
demographics and how are they affecting your organization?
BC:As our long term employees retire, we are faced with the
challenges of a younger more mobile work force. Retention
among today’s younger workforce has been a significant
challenge.
CM: What is your company’s mission statement?
BC:It takes more than just a mission to succeed. It takes
perseverance. It takes courage. And it takes drive. At Navistar
we believe the world is propelled forward by new ideas, brave
inventors and bold thinkers. That's why we're committed to
giving our customers our best every day. We find new ways to
help America's workers go that extra mile. We pioneer
technologies that burn cleaner fuel. And we use the latest
innovations to protect our troops, so they ride more safely into
conflict - and back home. Pushing our industry forward is more
than just our passion. It's our drive to deliver.
CM: What is your advice to professionals who desire to advance
4. in a global business environment? Give three specific
recommendations.
BC:Invest in people.How you treat someone is the only true
aspect you have control of.
Add value. Don’t wait for someone to tell you what to do.
Anticipate what needs to be done and do it.
Go the extra mile. It’s never crowed there.
CM: What is the key to your success?
BC:Understanding the products and services I have to offer and
how those can become solutions for my customer base.
Being innovative. Looking at a problem from a 360 degree
perspective and taking an outside the box approach to solving it.
Working hard. There is no substitute for putting in the
work.
Literature Review (Oral)
· Points 100
Objective: Students will provide an oral presentation of a
literature review.
General Instructions: Prepare a PowerPoint to convey
information included in the written literature review. Use Tips
for Effective Visual Presentation guide which is included below
as you prepare the PowerPoint.
Specific Instructions:
1. All studies reviewed should be included in the presentation.
2. Include speaking notes* in PowerPoint.
*Speaking notes should capture much of what will be said, but
complete sentences are not required.
5. Rubric
Literature Review Oral Presentation
Literature Review Oral Presentation
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeAll studies
included in the presentation
5.0 pts
Full Marks
0.0 pts
No Marks
5.0 pts
This criterion is linked to a Learning OutcomeSpeaking notes
included in the submitted presentation.
10.0 pts
Full Marks
0.0 pts
No Marks
10.0 pts
This criterion is linked to a Learning OutcomeReferences
included in final slides and are formatted as per the Publication
Manual of the American Psychological Association, but may be
single-spaced.
10.0 pts
Full Marks
0.0 pts
No Marks
10.0 pts
This criterion is linked to a Learning OutcomeAdherence to
Guidelines for Effective Visual Presentation
70.0 pts
Full Marks
6. 0.0 pts
No Marks
70.0 pts
This criterion is linked to a Learning OutcomeAll students
presented and are able to speak without reading continuously
from notes.
view longer description
5.0 pts
Full Marks
0.0 pts
No Marks
5.0 pts
Total Points: 100.0
TIPS FOR EFFECTIVE VISUAL PRESENTATION
Color
· Choose complementary colors yet contrasting colors.
· Use dark on light and light on dark.
· For hints on use of color:
http://owl.english.purdue.edu/owl/resource/715/01/
Background
Textured backgrounds may look beautiful, but they do not
translate well when projected. When too many colors are used
in the background the text may vary with respect to contrast.
Strong contrast is preferable.
Motion
Motion is useful for capturing attention, but is easily overused
7. and often distracting. Use motion when it makes sense to do so.
Most problematic is motion that occurs too quickly to be
meaningful or too slowly (causing boredom).
Font Style
· Use sans serif font especially for the body text. Serif font is
acceptable for titles and larger font size.
· Font size minimums: 36- 44 point for titles, 24 - 32 point for
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331
cause of the high prevalence of CP (1-
2 in 1000 in developed countries)4,5
and conservative nature of the treat-
ment. It is postulated that by decreas-
ing spasticity, there will be improved
control of movement patterns, stretch-
ing and increased excursion of short-
ened muscles, improved posture, and
secondary strengthening of antagonis-
tic muscles. By implication, these
changes should be associated with im-
proved motor function. Most studies to
date have focused on the use of BTA
9. injections into the lower extremity gas-
trocnemius muscle and have demon-
strated a temporary reduction in spas-
ticity, temporary improvement in gait,
and improved range of motion.6-9 Min-
imal information is available on the
impact on function of upper extremity
injections in children with CP. Wall et
al10 report positive gains in function
and cosmetic appearance in a prospec-
tive case series of 5 children with a
“thumb in palm” deformity associated
with CP treated with BTA injected into
the adductor pollicis muscle and rigid
splinting of the thumb.10 Denislic and
Meh11 injected BTA into the upper
limbs of 10 children with CP and
Intramuscular injections of Clostridium
botulinum-A toxin into spastic muscles
cause a local temporary muscle paraly-
sis associated with decreased spastici-
ty. The biologic effects of BTA are well
understood.1 Botulinum toxin has
An evaluation of botulinum-A toxin injections
to improve upper extremity function in children
with hemiplegic cerebral palsy
Darcy Fehlings, MD, MSc, Mercer Rang, MB, BS, Janet
Glazier, BSc(OT), and Catherine Steele, PhD
been used therapeutically in adults
over the last 25 years in neuromuscu-
lar conditions associated with focal
dystonia (strabismus, torticollis).2
11. pothesis that botulinum-A toxin (BTA) injections into the upper
extremity
of children with spastic hemiplegia improve upper extremity
function.
Study design: Thirty children with hemiplegia, aged 2.5 to 10
years, were
randomly assigned to receive: (1) a BTA injection into 1 or
more of 3 mus-
cle groups (biceps, volar forearm muscles, adductor pollicis)
plus occupa-
tional therapy or (2) occupational therapy alone. Blinded
outcomes ob-
tained at baseline and at 1, 3, and 6 months included the Quality
of Upper
Extremity Skills Test (QUEST), goniometry measurements, grip
strength,
and Ashworth scores. The caregiver completed the self-care
domain of the
Pediatric Evaluation of Disability Inventory.
Results: Twenty-nine subjects completed the study. The QUEST
demon-
strated a significant improvement favoring the treatment group
on a 2-way
analysis of variance (F = 4.69, df = 1,83; P = .039). BTA
treatment was also
associated with an improvement in score on the self-care
domain of the Pe-
diatric Evaluation of Disability Inventory (F = 4.68, df = 1,82;
P = .04).
Conclusions: This study supports the effectiveness of BTA
injections to im-
prove upper extremity function of children with hemiplegia who
have at
12. least moderate spasticity. (J Pediatr 2000;137:331-7)
See editorial, p. 300.
FEHLINGS ET AL THE JOURNAL OF PEDIATRICS
SEPTEMBER 2000
found an improvement in upper limb
function in 9. A double-blind controlled
study by Corry et al12 reports mixed re-
sults on the impact on function in hemi-
plegic CP. Functional improvements
were not found 2 weeks after injection.
A small improvement was found at 12
weeks, favoring the BTA group in a
grasp-and-release activity, but was not
found in another grasp activity (the
ability to pick up coins).
We report the results of a random-
ized, controlled, single-blind trial of
BTA injections into the involved hand
or arm of 30 children with hemiplegic
CP using the Quality of Upper Ex-
tremity Skills Test, a standardized mea-
sure of quality of function of the upper
extremity, as our principal outcome.
METHODS
Participants
Eligible children met the following
criteria: 2.5 to 10 years of age; a diag-
nosis of hemiplegic CP; moderate spas-
13. ticity at the elbow, wrist, or thumb
with a modified Ashworth score ≥213;
full passive range (defined in this study
as elbow extension to neutral, wrist ex-
tension to 30 degrees past neutral with
the fingers extended, forearm supina-
tion to 30 degrees past neutral, and
thumb extension to neutral); and the
ability to initiate voluntary movement
of the digits. Children were excluded if
they were using a rigid splint to maxi-
mize homogeneity and allow active
movement in the hand.
Study Design
The study was approved by the
Bloorview MacMillan Centre Re-
search Ethics Review Board. The
ethics board, guided by Canadian ethi-
cal standards, did not grant approval
for a double-blind BTA study in which
the control group would receive an in-
tramuscular injection of saline solution
because this was judged to be too
painful and invasive for a placebo.14
When the eligibility criteria were met
and written informed consent was ob-
tained, children were randomly as-
signed, by using a uniform random
number generator, to a treatment or
control group. The treatment group re-
ceived an intramuscular injection of
BTA (Botox, Allergan, USA), at a
14. dosage of 2 to 6 U/kg body weight, into
at least 1 of 3 muscle groups (biceps,
volar forearm muscles, or adductor
pollicis muscle). Two investigators
(D.F. and M.R.) determined jointly
which muscle groups to inject during
reach-and-grasp activities of the in-
volved hand or arm. If the child
demonstrated persistent elbow flexion,
the biceps was injected; for thumb ad-
duction, the adductor pollicis muscle
was injected. In the volar forearm mus-
cles, for pronation, the pronator teres
muscle was injected; wrist flexion was
an indication for flexor carpi ulnaris
muscle injections; and finger flexion
was an indication for injection of the
finger flexors. The location of the in-
jection was determined by anatomic
knowledge and muscle palpation.15-17
The biceps was injected in the top
third of the muscle at 2 sites, the volar
flexor muscle was injected at 2 sites, 2
to 3 cm below the medial epicondyle.
The pronator teres was injected at one
site in the upper third of the muscle,
and the adductor pollicis was injected
in one site in the belly of the muscle.
Children in both groups were asked
to continue with community-based oc-
cupational therapy at a minimum fre-
quency of one session every 2 weeks.
Research funding was not available
15. to provide occupational therapy by
research personnel. An occupational
therapy manual with guidelines was de-
veloped for the study and sent to each
of the participating occupational thera-
pists. The guidelines were based on
standard practice for therapy manage-
ment of spastic hemiplegia and incor-
porated activities for upper extremity
strengthening and the development of
skills for activities of daily living.18,19
Children were seen at baseline and at
1, 3, and 6 months. A single investigator
(J.G.), blinded to the subject group
assignment, obtained all objective out-
come measurements. The primary out-
come measure was the QUEST.20-22
This is an objective standardized mea-
sure evaluating the quality of upper
extremity function in 4 domains: disso-
ciated movement (an isolated joint
movement of the upper extremity that
counters a pattern of spastic synergy),
grasp, protective extension, and weight
bearing. Scores for the QUEST are cal-
culated as percentages with a maximum
score of 100. The QUEST was de-
signed with minimal developmental se-
quencing so that scoring reflects the
severity of the disability rather than age.
A caregiver completed the self-care
domain of the Pediatric Evaluation of
Disability Inventory to assess the
16. child’s activities of daily living.23 The
self-care domain has 73 items in 15
332
Treatment group Control group
Characteristic (n = 14) (n = 15) P value
Age (mo) 68 ± 31 64 ± 28 .71
Gender (M/F) 10/5 10/5 1.00
Involved side (right/left) 10/4 7/8 .17
Modified Ashworth score* 2.3 ± 0.75 2.2 ± 0.59 .89
QUEST baseline 19.2 ± 15.1 27.6 ± 19.0 .41
PEDI baseline 50.2 ± 11.1 52.2 ± 15.4 .25
Grip strength (mm Hg) 56.40 ± 16.59 53.38 ± 21.33 .46
Values are expressed as means ± SD.
*Represents the mean of Ashworth measurements for elbow and
wrist extension, forearm
supination, and thumb extension.
Table I. Baseline comparability of the treatment and control
groups*
THE JOURNAL OF PEDIATRICS FEHLINGS ET AL
VOLUME 137, NUMBER 3
skill areas, such as hand washing. Raw
scores can be converted to a scaled
score with a 0 to 100 distribution based
on Rasch scale modeling. The PEDI
has been designed to measure function
in children with physical disabilities
17. and has established reliability, validity,
and responsiveness.23-26
Secondary outcome measures in-
cluded manual goniometric measure-
ments of passive range of motion27;
modified sphygmomanometer mea-
surements of grip strength28; and the
modified Ashworth score of spasticity
at elbow extension, wrist extension,
forearm supination, and thumb exten-
sion.13 Test-retest reliability for passive
goniometry measurements and grip
strength was evaluated before the
study in children with upper extremity
spasticity and was found to be high,
with correlation coefficients ranging
from 0.58 to 0.97.29
Statistical Analyses
The analyses were conducted by using
the SAS microcomputer-based pack-
age.30 The following tests were used.
1. A preliminary analysis included a
thorough check of the data (re-
view of outliers and missing data),
a descriptive summary, and plots
of each variable.
2. Chi-square and unpaired t tests
were used to check the compara-
bility of the BTA treatment and
control groups at baseline for age,
18. sex, involved side, and baseline
Ashworth, QUEST, and PEDI
scores.
3. A 2-way analysis of variance was
computed to detect differences
between the BTA treatment and
control groups during the study
period in the QUEST, the PEDI,
grip strength, Ashworth scores,
and passive goniometry measure-
ments. To account for baseline ef-
fects, the differences between
baseline and 1 month, baseline
and 3 months, and baseline and 6
months were used. Statistical sig-
nificance was set a priori at P < .05
for the 2 functional outcomes, the
QUEST and the PEDI, and set at
P < .01 for the secondary out-
comes to account for the multiple
testing.
4. A post hoc Wilcoxon rank sums
test was performed to examine the
significance of group differences
at 1, 3, and 6 months for variables
that demonstrated statistical sig-
nificance on the ANOVA.
RESULTS
Participant Characteristics
Fifty children were screened; 20 did
not meet the eligibility criteria (13 had
19. an Ashworth score <2, 6 had an inabil-
ity to initiate voluntary movement in
the involved hand, and 2 had fixed
contractures). Thirty children were re-
cruited into the study and randomly
assigned to the treatment (n = 15) and
control (n = 15) groups. Thus 29 chil-
dren completed the study, with one
child in the treatment group dropping
out before the 1-month assessment.
Table I outlines the comparability of
the 2 groups at baseline. No significant
differences were found.
Table II outlines the BTA treatment
for each child with respect to dosage
and location. Both groups received oc-
cupational therapy in the community
at a recommended frequency of once
every 2 weeks. The treatment group
received a mean of 11.93 (SD 6.89)
333
QUEST
Muscle injected (U/kg)
change Volar Pronator Adductor
Subject No. BTA (U/kg) (to 1 mo) Biceps flexors teres muscle
pollicis muscle
1 4 36.67 — 4.0 — —
2 4 4.48 — 4.0 — —
3 2 19.36 2.0 — — —
4 4 12.19 — 4.0 — —
5 4 8.53 — 4.0 — —
20. 6 4 23.90 — 1.3 1.3 1.3
7 5.2 –1.97 — 3.6 1.6 —
8 3.8 21.37 — 2.9 — 1.0
9 4.3 2.21 3.2 1.1 — —
10 2.7 0.78 — 1.8 — 0.9
11 3.3 –9.71 — 2.2 — 1.1
12 3.6 30.18 1.8 — — 1.8
13 6.6 14.29 — 4.9 — 1.6
14 3.4 Dropout — 1.1 1.1 1.1
15 6.3 12.79 1.6 3.2 — 1.6
Table II. Dosage and location of injection for each participant
in the BTA treatment group
FEHLINGS ET AL THE JOURNAL OF PEDIATRICS
SEPTEMBER 2000
treatment sessions, and the control
group received a mean of 16.07 (SD
7.60) treatment sessions over the 6-
month period of the study. This differ-
ence favored the control group but was
not statistically significant (P = .74).
Main Results
The total score for the involved side
on the QUEST, the primary outcome
measure, demonstrated a statistically
significant improvement favoring the
BTA treatment group on the ANOVA
(F = 4.69, df = 1,83; P = .039). The time-
group interaction was not significant (P
21. = .50). Post hoc testing with the
Wilcoxon rank sum test showed signifi-
cant differences between the treatment
and control groups at 1 month (P = .01)
but not at 3 (P = .13) or 6 months (P =
.14). These results are outlined in the
Figure. On the 4 subtests of the
QUEST, the subtest “weight bearing”
(P = .009) showed a significant im-
provement favoring the treatment
group. On the other 3 subtests, results
favored the treatment group but were
not statistically significant: “dissociated
movement” (P = .63), “grasp” (P = .33),
and “protective extension” (P = .55).
The results of the PEDI and sec-
ondary outcomes are listed in Table
III. A statistical difference was found
in the raw scores of the parent-com-
pleted self-care domain of the PEDI (F
= 4.68, df = 1; P = .04). The time-group
interaction was not significant (P =
.84). Post hoc testing with the Wilcox-
on rank sums test approached signifi-
cance at 1 month (P = .08) and 6
months (P = .06). The corresponding
ANOVA evaluating the PEDI scaled
scores approached significance (F =
3.22, df = 1; P = .08). No significant dif-
ferences between the treatment and
control groups were found in grip
strength, Ashworth scores, or passive
goniometry measurements.
22. The injections in the treatment group
were well tolerated. Aside from the dis-
comfort of the injection, only one child
(Table II, subject 1) reported temporary
decreased grip strength lasting 2 weeks.
No other side effects were noted.
DISCUSSION
This controlled clinical trial provides
evidence to support the use of intra-
muscular BTA injections to improve
both quality of functional movement of
the upper extremity and functional ca-
pability in children with hemiplegic
CP. A clinical and statistically signifi-
cant improvement in quality of func-
tion was found at 1 month. Children in
the BTA group improved from 19.2%
on the QUEST at baseline to 32.5% at
1 month compared with a 1.7% change
in the control group. Moderate im-
provements were maintained up to 6
months after injection. This is clinical-
ly important because the effect of the
BTA injection on function lasts longer
than the neuromuscular blockade,
which disappears, on average, at 3
months.1 In the control group a
gradual improvement in quality of
function was found over the 6-month
period of the study. The positive
change in function in the control
group may reflect both the impact of
the occupational therapy intervention
and developmental improvements
23. with time; and this highlights the im-
portance of including a control group
when studying changes in child devel-
opment. The improvement in the con-
trol group and low statistical power
(16%) may explain the lack of statisti-
cal significance at the 6-month testing.
Within the subtests of the QUEST,
weight-bearing activities demonstrat-
ed the most change.
For children receiving the BTA in-
jections, the parents also reported
small positive functional change in the
children’s self-care skills (eg, dressing,
eating). This supports carry-over of
functional change into the children’s reg-
ular environments and daily activities.
Grip strength declined at 1 and 3
months in the BTA group but normal-
ized by 6 months after injection. This
finding was expected because BTA
blocks conduction at the neuromuscu-
lar junction, which reduces spasticity
but also causes muscle weakness.
334
Figure. Mean change from baseline in the QUEST total scores.
Changes in scores were analyzed
with 2-way ANOVA. Post hoc Wilcoxon rank sums test was
done at 1, 3, and 6 months. Asterisk
indicates P < .05 on post hoc testing.
24. THE JOURNAL OF PEDIATRICS FEHLINGS ET AL
VOLUME 137, NUMBER 3
Though the grip was weaker after
BTA, function improved.
Differences in the modified Ash-
worth score of spasticity favored the
BTA group but were not significantly
different. Both groups showed a de-
cline in spasticity throughout the peri-
od of the study. It is interesting to spec-
ulate on the reason for the decline in
spasticity within the control group.
This may be secondary to developmen-
tal improvements in spasticity with
time, familiarity with the test, the im-
pact of the occupational therapy, or
measurement variation.
The ideal dosage of BTA for upper
extremity spasticity requires further
research. It is hard to predict the func-
tional impact of higher dosing. Increas-
ing the dosage will result in a greater
decline in spasticity but will also lead
to greater reductions in grip strength,
which in turn may have a negative im-
pact on functional outcome.
Passive range of motion also did not
show a significant change between the
BTA and control groups. This reflects
25. the excellent baseline flexibility of the se-
lected subjects who had full range in the
majority of joint measurements assessed.
335
Change from baseline
One month Three months Six months P value*
PEDI (raw score)
BTA group 2.00 ± 5.99 3.85 ± 5.11 6.77 ± 5.82 .04
Control group –1.93 ± 5.78 1.13 ± 5.19 2.64 ± 5.75
PEDI (scaled score)
BTA group 2.57 ± 6.91 2.78 ± 3.72 5.50 ± 4.54 .08
Control group –1.51 ± 4.07 1.09 ± 4.07 3.30 ± 6.05
Grip strength (mm Hg)
BTA group –7.60 ± 14.57 –6.86 ± 13.06 2.00 ± 12.74 .34
Control group 1.50 ± 18.76 3.83 ± 22.81 –0.27 ± 20.77
Ashworth/elbow
BTA group –0.29 ± 0.47 –0.23 ± 0.48 –0.38 ± 0.46 .89
Control group –0.20 ± 0.62 –0.37 ± 0.44 –0.29 ± 0.51
Ashworth/wrist
BTA group –0.43 ± 0.43 –0.31 ± 0.38 –0.35 ± 0.43 .81
Control group –0.36 ± 0.44 –0.33 ± 0.45 –0.25 ± 0.55
Ashworth/forearm
BTA group –0.32 ± 0.42 –0.35 ± 0.38 –0.27 ± 0.60 .51
Control group –0.20 ± 0.49 –0.20 ± 0.53 –0.18 ± 0.58
Ashworth/thumb
BTA group –0.31 ± 0.48 –0.25 ± 0.40 –0.33 ± 0.39 .90
26. Control group –0.28 ± 0.57 –0.29 ± 0.54 –0.27 ± 0.48
Elbow extension†
BTA group 0.07 ± 6.62 5.46 ± 11.74 2.84 ± 6.69 .11
Control group –0.80 ± 6.62 3.00 ± 12.83 0.79 ± 9.32
Forearm supination†
BTA group 3.43 ± 9.00 5.15 ± 8.10 3.00 ± 12.08 .34
Control group 1.67 ± 5.63 1.67 ± 6.28 0.64 ± 6.62
Wrist extension†
BTA group 4.08 ± 7.35 4.58 ± 11.92 2.00 ± 15.02 .55
Control group 0.67 ± 8.78 1.27 ± 9.91 2.07 ± 11.49
Palmar thumb abduction†
BTA group 2.14 ± 5.91 1.46 ± 8.52 2.77 ± 8.12 .48
Control group 1.00 ± 7.97 –0.60 ± 10.01 1.21 ± 6.96
Values are expressed as means ± SD.
*P value refers to the significance of overall differences
between the BTA group and control group on the ANOVA.
†Goniometry measurements.
Table III. Results of the 2-way ANOVA for the secondary
outcome measures
FEHLINGS ET AL THE JOURNAL OF PEDIATRICS
SEPTEMBER 2000
It is important to note that the posi-
27. tive effects on upper-extremity func-
tion observed after BTA injection are
generalizable to children who are clini-
cally similar to the subjects selected for
the study. Many children with a clini-
cal diagnosis of spastic hemiplegic CP
have Ashworth spasticity scores <2 or
poor distal voluntary muscle control.
This clinical trial excluded both of
these groups of children. Further re-
search is required before results are
generalized to these subgroups.
A limitation of the study is the sin-
gle-blind design. Both the children
and their parents knew whether they
were in the treatment or the control
group. This could have an impact on
the parent-completed PEDI. A single
objective evaluator who was blinded
to the group assignment completed all
other outcome measurements, includ-
ing the QUEST. The large number of
subjects assessed and the similarity of
changes in Ashworth score between
the 2 groups prevented the uninten-
tional unblinding of this evaluator,
minimizing the impact of the single-
blind design on the primary results of
this study.
Botulinum toxin injections were
given without electromyographic guid-
ance. This has the advantage that con-
scious sedation is not required, which
has fewer side effects and allows the
28. use of BTA in ambulatory and rehabil-
itation settings. Evaluation of the indi-
vidual responses of subjects showed
that the BTA injection was successful
(positive change >5% on the QUEST)
in 9 of 14 subjects. However, 5 subjects
(33%) received a BTA injection but
did not show improvement in function.
One potential explanation for this is
that the intended muscle groups were
not targeted accurately. There is some
support for improved accuracy of BTA
injections with electromyographic
guidance in the literature.31
Continued research is required to
evaluate the dose response and the im-
pact on function of repeated BTA
upper-extremity injections.
We thank the children and families who par-
ticipated in the study. We also thank Allergan
for providing the botulinum-A toxin for the
study.
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337
Low-dose/high-
concentration localized
botulinum toxin A
improves upper limb
movement and
function in children
with hemiplegic
cerebral palsy
Kevin Lowe* MBBS FRACP FAFRM, Department of Paediatric
Rehabilitation, Sydney Children’s Hospital and University of
New South Wales, Randwick;
Iona Novak MSc BAppSc, Manager Research and Education,
Cerebral Palsy Institute, Sydney;
Anne Cusick BAppSc GradDipBehSc MA (Psych) MA
(Interdisc Stud) PhD, Professor, Associate Dean, College of
Science and Health, University of Western Sydney (UWS),
Australia.
*Correspondence to first author at Department of
Paediatric Rehabilitation, Sydney Children’s Hospital, High
Street, Randwick, Australia.
E-mail: [email protected]
The objective was to determine the effects of low -dose, high-
35. concentration, dual localized botulinum toxin A (BTX-A)
injections on upper limb movement quality and function. Study
design was an evaluator-blinded, randomized, controlled trial.
Forty-two children (31 males, 11 females; range 2–8y, mean 4y
[SD 1.6]) with hemiplegic cerebral palsy (Gross Motor Function
Classification System level I) participated. All received
occupational therapy. The treatment group (n=21) received one
injection series (mean muscles injected 6 [SD 1.05]; total dose
82–220 units, mean 139 [SD 37.48]; dilution 100 units/0.5ml).
Primary outcome of Quality of Upper Extremity Skills Test
(QUEST) at 6 months was not significant (p=0.318). Secondary
outcomes were average treatment effects at 1, 3, and 6 months,
which favoured the treatment group: QUEST (p<0.001);
Canadian Occupational Performance Measure (performance,
p=0.002; satisfaction p=0.007); parent Goal Attainment Scaling
(GAS; p=0.001), therapist GAS (p<0.001); Pediatric
Evaluation of Disability Inventory (PEDI) functional skills
(p=0.030); Ashworth (p<0.001). PEDI caregiver assistance
was not significant (p=0.140). Therapy alone is effective, but at
1 and 3 months movement quality is better where BTX-A is
also used. Moreover, function is better at 1, 3, and 6 months,
suggesting BTX-A enhances therapy outcomes beyond the
pharmacological effect. One- and 3-month Ashworth and
QUEST scores suggest precise needle placement accuracy.
Children with cerebral palsy (CP) experience many daily chal -
lenges as a result of the upper motor neurone syndrome.
Symptoms include the following: spasticity, weakness, loss of
dexterity, poor motor control, and sensory impairment. Bot-
ulinum toxin A (BTX-A) reduces spasticity (Corry et al. 1997,
Love et al. 2001, Delgardo 2002, Boyd et al. 2003, Chin and
Graham 2003, Yang et al. 2003, Hoare and Imms 2004) and is
usually used with interventions such as physical and occupa-
tional therapy to help children attain functional goals. Red-
uction of spasticity in children with CP is clinically important
because the following outcomes can occur: muscle length imp-
36. rovement leading to a slowing of contracture development
rates (Corry et al. 1997); improved tolerance of splinting and
casting interventions, which increase range and function (Del -
gardo 2002); enhanced function (Russman et al. 1997, Love et
al. 2001, Delgardo 2002, Boyd et al. 2003); more opportun-
ity for therapy interventions to be introduced (Russman et al.
1997); and reduction in pain (Delgardo 2002). As recently as
2002 the use of BTX-A in the upper limb in CP was regarded as
experimental (Wasiak et al. 2002); however, expert clinical op-
inion about its potential (Russman et al. 1997) is rapidly being
complemented by positive findings of effect (Fehlings et al.
2000, Boyd and Hays 2001, Boyd et al. 2002, Wallen et al.
2004).
Accurate needle placement in BTX-A injection is important
because this avoids severe side effects and helps to determine
whether an observed lack of response to the drug is related to
the region of injection. The use of localization techniques is
known to improve needle placement accuracy (Chin et al.
2003). Manual localization techniques provide promising fun-
ctional results (Corry et al. 1997, Fehlings et al. 2000). More
recently, localization with the use of electrical stimulation has
demonstrated good functional lower limb outcomes (Love et
al. 2001) and sustained improvement in the upper limb (Boyd
et al. 2003, Wallen et al. 2004). Ultrasound is an emerging
local-
ization technique (Westhoff et al. 2003), and electrical stimula -
tion has been shown to be more accurate in needle placement
than manual techniques (Chin et al. 2005). So far there have
been no studies specifically examining BTX-A injected into
upper limbs of children with CP with the use of both elec-
tromyography and stimulation. The use of electromyography
should enable spastic muscles to be identified (O’Brien 2002)
so that muscles with contracture can be excluded as injection
sites. Enhanced accuracy in needle placement should also
increase efficacy because lower total doses can be used in high-
37. er concentrations within muscles related to functional goals.
This study investigated whether or not there was a differ-
ence in clinical outcomes for young children with spastic hemi -
plegic CP receiving occupational therapy, if they received one
session of low-dose, high-concentration BTX-A injected using
dual-mode localization. The primary clinical outcome measure
was quality of movement at 6 months. Secondary outcomes of
interest were the weighted average of treatment effects at 1, 3,
and 6 months in the following: (1) quality of upper limb move-
ment (1 and 3 months, and percentage of participants with
more than 20% improvement); (2) function; and (3) spasticity.
Methods
DESIGN
This study was a randomized, controlled, evaluator-blinded,
prospective parallel-group trial based on Consolidated Stan-
dards of Reporting Trials (CONSORT) guidelines. Following
170 Developmental Medicine & Child Neurology 2006, 48:
170–175
Localized Injections of Botulinum Toxin A Kevin Lowe et al.
171
subject screening, informed consent was obtained from chil -
dren’s parents using Ethics Committee approved participant
information sheets and consent forms. All outcome measures
were administered at baseline and at 1, 3, and 6 months. The
study was conducted through The Spastic Centre and the
Sydney Children’s Hospital and was approved by the Research
Ethics Committees of South Eastern Sydney Area Health Ser-
vice, the Spastic Centre, and the University of Western Sydney
38. Macarthur, Australia. All analyses were determined prospec-
tively with an intention-to-treat approach.
SAMPLE
To estimate sample size, an improvement of more than 20% in
Quality of Upper Extremity Skills Test (QUEST) scores from
baseline was used in power calculations. This degree of change
was selected on the basis of a pre-study pilot and evidence of
change likely from the control intervention alone (Hickey and
Ziviani 1998). Twenty participants per group were estimated to
have at least 80% power to detect a 10-unit difference in
QUEST
score between groups (two-sided test at 0.05 significance),
assuming that the SD of change in total QUEST score was 8.98
units. A convenience sample was used with participation invit-
ed through statewide recruitment advertisements and a
mailout to all paediatricians.
The inclusion criteria were as follows: age 2 to 8 years;
diagnosis of hemiplegic CP; presence of spasticity scoring at
least 2 on the Ashworth Scale interfering with functional
movement; at least 10˚ active range of movement in antago-
nistic muscle during use; volitional limb use observed by
both parent and investigator when instructed to play bilater-
ally; access to occupational therapy after baseline assessment;
and parental agreement to participate in a home programme.
The exclusion criteria were as follows: lower limb BTX-A
in the past 6 months; upper limb BTX-A in the past 12
months; upper limb fixed contracture greater than 40˚; lack
of sensory response to light touch or pain in the affected
limb; child refused or was unable on 100% of occasions to
demonstrate volitional upper limb movement in response
to parent or investigator instructions and parent confirmed
39. that this was consistent with their upper limb use at home.
During 16 months of recruitment, 57 children were screen-
ed and 43 were enrolled. One child withdrew in the control
group after 1 month because of travel difficulties. A total of 42
patients were analyzed at each follow-up: 21 in the treatment
group and 21 in the control group; all were at GMFCS level I;
age range 2 to 8 years (mean 4y [SD 1.6] for both groups); there
were 31 males and 11 females.
RANDOMIZATION
An independent officer used computer-generated random
allocation sequences in numbered sealed envelopes to achieve
randomization. Participants volunteered from rural and met-
ropolitan locations. To plan for travel and accommodation,
parents were informed of their group allocation before base-
line measures. The study managed allocation awareness by
requesting families not to tell raters their allocation and
explain-
ing why, by using standardized observational assessments in
which performance could not reasonably be manipulated in
the light of known allocation, and by conducting between-
group baseline analyses.
INTERVENTION
Both groups received occupational therapy from the same
occupational therapist, and the treatment group received
intramuscular injections of BTX-A. The therapy provided was
based on best available evidence including the use of individ-
ualized family goals (e.g. independent dressing or sports par -
ticipation) with mutually agreed levels of attainment dev-
eloped through two collaborative interviews. Individualized
home programmes were developed with the family to imple-
ment in goal-relevant contexts of home or school/pre-school.
40. Programmes drew on a suite of interventions offered by the
therapist but driven by the family, including functional training,
strengthening, splinting, casting, and motor learning (Cop-
ley and Kuipers 1999, Wilton 2003, Steultjens et al. 2004).
Standard indicators were used to verify the need for and to
prescribe splinting and casting (Copley and Kuipers 1999).
BTX-A intervention
Electromyography was used to exclude muscle contracture, to
Table I: Botulinum toxin A (BTX-A) exposure by muscle group
Muscle group Total number of units/kg/muscle group
BTX-A-injected
Elbow flexors
n 4
Mean 3.5
SD 0.32
Range 3.1–3.9
Pronators
n 18
Mean 3.3
SD 0.95
Range 1.1–4.3
Wrist flexors
n 14
Mean 2.1
SD 0.75
Range 1.1–3.2
Wrist extensors
41. n 1
Mean 1.0
SD –
Range 1.0–1.0
Finger flexors
n 12
Mean 2.2
SD 0.70
Range 1.0–3.2
Thumb adductor
n 9
Mean 0.6
SD 0.15
Range 0.5–0.9
Thumb opponens
n 20
Mean 0.7
SD 0.18
Range 0.5–1.1
Thumb flexors
n 4
Mean 0.8
SD 0.31
Range 0.5–1.2
assist in identifying the most spastic muscles and to identify
muscle penetration to minimize trauma to other tissues. In all
cases, electromyography guidelines (Perotto 1994) were used
to assist in identifying injection sites. To refine the identifica -
tion of the correct muscle point for injection, stimulation was
42. used at threshold levels by observation of movement respons-
es to stimulus. Injection muscle choice was based on the
degree of spasticity (baseline Ashworth score of at least 2),
esti-
mated effect on functional abilities, and parental preference of
likely arm posture if BTX-A was effective. The number of
partic-
ipants with affected muscles in treatment versus control were
as follows: elbow flexor, 16:15; pronators, 20:21; wrist flexor,
17:16; wrist extensor, 1:2; finger flexor, 14:10; thumb adduc-
tor, 13:18; thumb opponens, 21:21; and thumb flexor, 6:4.
The total dose of BTX-A injected did not exceed 8 units/kg
body weight, which is lower than the expert consensus maxi-
mum dose of 12 units/kg per session (Delgardo 2002). A clini -
cal estimate of likely muscle size was used to guide the app-
ropriate dose calculation per muscle from the total of 8 units
(Table I, range 0.5–2.0 units/kg/muscle). Dilution of 100 units
of BTX-A was with 0.5ml of normal saline, which is more con-
centrated than usual. Volume of injection to muscle was deter -
mined by dose per individual muscle; number of muscles
injected, mean 6 (SD 1.05); total dose 82 to 220 units, mean
139 (SD 37.48). Participants who received injections received
nil by mouth and were admitted to a day-stay ward at the
Sydney Children’s Hospital. A eutectic mixture of local anaes-
thetics cream, chloral hydrate, pethidine, droperidol, and
midazolam were used in various combinations to achieve ade-
quate sedation and analgesia.
DATA COLLECTION AND INSTRUMENTS
Data were collected at baseline and at 1, 3, and 6 months. The
baseline data were a therapy history survey and a physical
examination (height, weight, pulse rate, and blood pressure).
All other instruments were used on all four occasions.
43. Adverse events form
Safety was assessed by recording and reporting to the South
Eastern Sydney Area Health Service Committee any adverse
events (start and stop dates, relationship to the study med-
ication, severity, frequency, action taken, and outcome).
Quality of Upper Extremity Skills Test (QUEST)
The primary outcome measure was two domains of the QUEST
(dissociated movement and grasp) scored blind by one trained
assessor from video footage of the QUEST (DeMatteo et al.
1992). Test authors report that the use of less than the total
four domains is psychometrically sound. QUEST at 6 months
was chosen because there was known sensitivity to capture
change in CP, investigators were interested in whether BTX-
A injection effect plus therapy outlasted known pharmaco-
logical effect timelines, there was a precedent for its use with
young children (Fehlings et al. 2000), and psychometric
properties were good (Hickey and Ziviani 1998). The total
possible standard score across the two domains is 100.
Canadian Occupational Performance Measure (COPM)
Two trained, blinded occupational therapists administered and
scored the COPM (Law et al. 1994), which had been adapted
for use with children. COPM had been used to measure effec-
tiveness of upper limb BTX-A intervention for children with
CP (Boyd et al. 2003). Psychometric properties of the adapt-
ed instrument were generally good (Cusick et al. forthcom-
ing). The total possible score was 20 (10 for performance
and 10 for satisfaction).
Pediatric Evaluation of Disability Inventory (PEDI)
The PEDI (Haley et al. 1992) was scored from parental r eport
44. interviews. The PEDI has robust psychometric properties
(Feldman et al. 1990, Nichols and Case-Smith 1996) and has
been used with children with spastic hemiplegic CP (Fehlings
et al. 2000). The total possible score for self-care/ functional
172 Developmental Medicine & Child Neurology 2006, 48:
170–175
Table II: Efficacy analysis
Measure Baseline 1 mo 3 mo
Control score BTX-A score Control score BTX-A score Control
score BTX-A score
QUEST total 33.3 (2.6) 32.1 (2.4) 36.0 (2.7) 43.9 (3.3) 37.1
(2.6) 46.2 (3.5)
Family GAS 23.1 (0.6) 21.6 (0.9) 27.1 (1.4) 36.1 (2.8) 34.1
(2.0) 42.0 (2.2)
Therapist GAS 30.5 (1.8) 27.5 (1.3) 40.5 (2.6) 57.8 (3.0) 46.8
(2.7) 61.0 (3.8)
COPM performance 3.3 (0.3) 3.3 (0.3) 3.8 (0.3) 4.5 (0.2) 4.5
(0.3) 5.3 (0.3)
COPM satisfaction 3.5 (0.4) 3.8 (0.3) 4.1 (0.4) 5.1 (0.3) 4.7
(0.4) 5.8 (0.3)
PEDI functional skills 43.4 (3.1) 50.7 (3.0) 44.2 (2.9) 53.1 (2.5)
48.3 (2.4) 55.8 (2.5)
PEDI caregiver assistance 21.5 (2.7) 26.2 (2.3) 23.6 (2.4) 28.2
(1.8) 26.0 (2.0) 29.8 (1.7)
Ashworth
Elbow flexors 2.3 (0.1) 2.2 (0.1) 2.3 (0.1) 1.4 (0.1) 2.1 (0.1) 1.4
(0.1)
Pronators 2.5 (0.1) 2.6 (0.1) 2.4 (0.1) 1.5 (0.1) 2.4 (0.1) 1.5
(0.1)
Wrist flexors 2.3 (0.1) 2.2 (0.1) 2.2 (0.1) 1.1 (0.1) 2.1 (0.1) 1.5
45. (0.1)
Wrist extensors 2.0 (0.0) 3.0 (0.0) 2.0 (0.0) 2.0 (0.0) 1.5 (0.5)
2.0 (0.0)
Finger flexors 2.2 (0.1) 2.4 (0.1) 2.2 (0.1) 1.4 (0.1) 2.2 (0.1) 1.6
(0.2)
Thumb adductor 2.2 (0.1) 2.2 (0.1) 2.2 (0.1) 1.1 (0.1) 2.2 (0.1)
1.6 (0.2)
Thumb opponens 2.1 (0.1) 2.2 (0.1) 2.1 (0.1) 1.0 (0.0) 2.1 (0.1)
1.4 (0.1)
Thumb flexors 2.0 (0.0) 2.3 (0.2) 2.0 (0.0) 1.2 (0.2) 1.8 (0.3)
2.0 (0.4)
aTreatment effect is reported in terms of unit of measurement
for each instrument. bThere were insufficient numbers for
calculation.
The p value given is that of repeat-measures analysis. Scores
and effects are shown in brackets as mean. BTX-A, botulinum
toxin A;
QUEST, Quality of Upper Extremity Skills Test (DeMatteo et
al.1992); GAS, Goal Attainment Scaling (Kiresuk et al. 1994);
COPM, Canadian
Occupational Performance Measure (Law et al. 1994); PEDI,
Pediatric Evaluation of Disability Inventory (Haley et al. 1992).
skills is 73, and for self-care caregiver assistance the maximum
score is 40.
Goal Attainment Scaling (GAS)
Goal Attainment Scaling (Kiresuk et al. 1994) is recommended
to identify clinically significant functional change after BTX-A
injections (Russman et al. 1997) and has been used in other
BTX-A upper limb trials (Boyd et al. 2003, Wallen et al. 2004).
The family developed their own ‘family GAS’ of three to five
46. goals before the administration of COPM. The goals and attain-
ment levels were of their selection, design and priority,
facilitat-
ed and later scored by two trained blinded occupational
therapists. Another ‘therapist GAS’ was developed by an inves-
tigator; it identified functional tasks and levels of performance
not covered elsewhere in other measures. Performance of
‘therapy GAS’ tasks was videoed and scored by a blind evalua-
tor (dressing and toileting were not videoed because of child
protection standards; parental report was used instead). There
is no standardized total possible score; however, goal attain-
ment across all goals is indicated by the ‘T’ score. A goal
attain-
ment T score of 50 (SD 10) equates to expected gains.
Ashworth Scale
The Ashworth Scale (Ashworth 1964) is sensitive to change
from spasticity pharmacological management including
BTX-A (Love et al. 2001). It was, therefore, used as a measure
of the technical effect of the BTX-A. Reliability of the Ash-
worth Scale in elbow flexors is good (Bohannon and Smith
1987). Individual muscles are rated on a scale between 0 (nor -
mal) and 5 (most severe), with no total possible score.
Analysis of primary outcome measure
QUEST total score at 6 months was modelled by using linear
regression; baseline QUEST score, age, and intervention
assignment were covariates.
Analysis of secondary outcome measures
Secondary outcomes were changes in QUEST, Ashworth, fami-
ly GAS, therapy GAS, COPM, and PEDI scores from baseline to
1, 3, and 6 months. Treatment effect sizes and standard errors
47. were calculated with repeated-measures analyses (PROC GEN-
MOD) adjusting for corresponding score baseline values, visit
(as a categorical variable used because of the expectation of
participant improvement over time) and age at baseline, and at
1, 3, and 6 months (with the exception of Ashworth scores).
The estimated treatment effect was interpreted as the average
treatment effect measured across the three post-baseline visits
with a 95% confidence interval (CI). All tests were performed
as
two-tailed tests (p≤0.01). Another secondary outcome was the
percentage of participants with at least 20% improvement in
total QUEST scores over baseline at 1, 3, and 6 months. Two-
sided Fisher’s exact tests were used to assess significance.
Results
BETWEEN GROUP BASELINE ANALYSIS
There were no significant differences between groups in base-
line QUEST, COPM, GAS (therapist or family), Ashworth mea-
sures, or self-reported history of involvement in therapy (phys-
ical or occupational; Table II). Baseline PEDI scores for
caregiv-
er assistance were significantly different, favouring intervent-
ion, which might possibly reflect their group allocation aware-
ness, because BTX-A could reasonably be considered a ‘high
promise intervention’ (Russman et al. 1997) and parent inter -
views might have permitted an expression of high hopes rather
than a functional difference as other measures were not signifi -
cantly different. During intervention, there was no difference
in use of splinting (100% for each group) or contracture casting
(n=3 in each group).
BETWEEN-GROUP OUTCOME ANALYSES
Table II summarizes study results in mean scores over time,
and 6-month treatment effects and CIs for primary and sec-
ondary outcomes.
48. Safety
There were 31 adverse events reported by 15 participants and
no between-group difference. No events were considered
related to BTX-A by the South Eastern Sydney Area Health
Service review panel.
QUEST
After adjusting for baseline score and age, differences in mean
QUEST total scores between the treatment and control groups
were significant at 1 month (9.7 points; 95% CI 5.5 to 13.8;
p<0.001) and 3 months (10.8 points; 95% CI 6.0 to 15.7;
p<0.001), but not at 6 months (2.7 points; SE 2.4; 95% CI –2.1
to 7.4; p=0.318; Fig. 1). A significantly larger proportion of
treatment group participants showed more than 20% change
above baseline QUEST scores compared with the control
group at 1 month (67 vs 19%; p=0.004) and 3 months (71 vs
33%; p=0.03), but not at 6 months (52 vs 48%; p=1.0).
Children in the treatment group had better quality of upper
limb movement sooner, even though all children improved
with occupational therapy at higher levels than previously
reported and all children sustained improvement at 6 months.
ASHWORTH
Greatest differences were seen at 1 and 3 months (Table II),
Localized Injections of Botulinum Toxin A Kevin Lowe et al.
173
Table II: continued
6 mo
49. Control score BTX-A score Treatment effecta 95% CI p
39.6 (2.8) 40.7 (3.2) 7.7 (1.9) 4.0 to 11.5 <0.001
40.1 (2.9) 46.8 (2.3) 7.5 (2.3) 2.9 to 12.1 0.001
49.9 (2.7) 58.7 (3.4) 14 (3.5) 7.1 to 21.0 <0.001
5.1 (0.4) 5.9 (0.3) 0.8 (0.3) 0.3 to 1.3 0.002
5.4 (0.5) 6.2 (0.3) 0.8 (0.3) 0.2 to 1.4 0.007
51.1 (2.6) 57.9 (2.2) 3.1 (1.4) 0.3 to 6.0 0.03
26.7 (2.1) 32.0 (1.7) 1.9 (1.3) –0.6 to 4.4 0.140
2.0 (0.2) 1.9 (0.1) –0.5 (0.1) –0.7 to –0.4 <0.001
2.4 (0.1) 2.2 (0.1) –0.8 (0.1) –1.0 to –0.6 <0.001
2.3 (0.1) 1.9 (0.1) –0.7 (0.1) –0.9 to –0.5 <0.001
1.5 (0.5) 2.0 ( . ) 0.3 (0.0) 0.3 to 0.3 b
2.2 (0.2) 2.1 (0.2) –0.8 (0.1) –0.9 to –0.6 <0.001
2.1 (0.1) 2.0 (0.2) –0.6 (0.1) –0.8 to –0.4 <0.001
2.1 (0.1) 2.1 (0.1) –0.6 (0.1) –0.8 to –0.5 <0.001
1.3 (0.3) 2.2 (0.3) –0.3 (0.1) –0.4 to –0.1 0.001
which suggests that the BTX-A was accurately localized.
FAMILY GAS
Table II illustrates that both the treatment and control
groups increased average ‘family’ T scores over study dura-
tion. Results of the repeated-measures analysis showed a treat-
ment effect size of 7.5 points (95% CI 2.9–12.1; p=0.001).
This result shows the weighted average of treatment effects.
It shows that all children made progress towards attaining
goals developed by the family but the treatment group had
50. consistently greater improvement that was sustained beyond
the pharmacologically active period of BTX-A.
THERAPY GAS
Table II illustrates that both groups increased average ‘thera -
pist’ T scores over the study duration. Results of repeated-
measures analysis showed a treatment effect size of 14 points
(95% CI 7.1–21.0; p<0.001). These results indicate that
although all children made progress towards attaining goals
developed by the therapist, the treatment group had the
greatest improvement.
COPM
Both groups showed consistent improvement in performance
and satisfaction scores (Table II). Results of repeated-measures
analysis showed a treatment effect size for performance of
0.8 points (95% CI 0.3–1.3; p=0.002) and for satisfaction of
0.8 points (95% CI 0.2–1.4; p=0.007). These results indicate
that although all children made consistent gains in function
and their parents’ level of satisfaction with their performance,
the treatment group had consistently greater improvement.
PEDI
Both groups showed consistent improvement in functional
skills and caregiver assistance (Table II). Results of the repeat-
ed-measures analysis showed a treatment effect size for func-
tional skills of 3.1 points (95% CI 0.3–6.0; p=0.03) and for
caregiver assistance of 1.9 points (95% CI –0.6– 4.4; p=0.140).
These results indicate that although all children made con-
sistent gains in functional skills, the treatment group had
greater improvement; they also show that although all chil -
dren made gains in caregiver assistance scores, with scores
being higher in the treatment group, they were not signifi-
51. cantly different for the treatment group.
Discussion
BTX-A has already been shown to decrease spasticity in the
hemiplegic upper limb and to enhance functional outcomes
in children with spastic hemiplegic CP. This study comple-
ments previous study findings on BTX-A effects on upper
limbs for children with CP. Our study was adequately pow -
ered, used measures directly targeting domains of interest,
used blinded evaluation in most measures, and had therapy
interventions that were consistently delivered and were
based on best available evidence. The new finding is that
although occupational therapy on its own is effective, clinical
outcomes for children receiving occupational therapy are
markedly enhanced by a single session of dual-mode local-
ized BTX-A injection because it produces greater 1-month
and 3-month gains in upper limb quality of movement, func-
tion, and spasticity, and greater 6-month gains in function.
Children who receive BTX-A in addition to therapy, there-
fore, have greater clinical gain faster and this gain is sus-
tained at 6 months. These short-term and long-term gains
were made with lower doses and higher concentrations
than previously reported, and with higher thresholds for
clinical change required in QUEST scores (20% from base-
line). Apart from this key result, findings related to adminis-
tration technique, therapy programme, and injection cand-
idate characteristics are worth comment.
The dual-mode localized administration technique seems
to be an effective method for precise needle placement because
low-dose, high-concentration injections had a marked clini-
cal and ‘technical’ effect at 1 and 3 months. Because other
non-invasive techniques such as manual or ultrasound local -
ization are usually paired with a higher dose and lower con-
centrations, there may be merit in future research to compare
52. invasive versus non-invasive localization techniques and dif-
ferent dose regimes. For now, it is clear that stimulation with
electromyography provides enhanced precision in adminis-
tration, offering the possibility of lower doses.
Therapy intervention was based on best available evidence
and was delivered by one experienced therapist. This might
explain the high level of improvement in quality of move-
ment and function by all children in the study, including those
who did not receive BTX-A injection. Improvement was
greater than that previously reported in similar studies of
younger children (Fehlings et al. 2000, Boyd et al. 2003,
Wallen et al. 2004), and higher than the 4.5% change estimat-
ed to occur as a result of therapy intervention by QUEST test
developers (DeMatteo et al. 1992). Although the effective-
ness of therapy alone is a good result, the marked clinical
benefit provided by BTX-A is important. It means that faster
and greater functional gains can be made by children who
have therapy if they receive BTX-A.
Injection candidate characteristics can also be considered
in the light of this study. Exclusion and inclusion criteria
were based on previous study findings (Corry et al. 1997,
Fehlings et al. 2000) and they proved to be both practical and
useful in sample selection because a uniform and positive
174 Developmental Medicine & Child Neurology 2006, 48:
170–175
Figure 1: QUEST change over 6 months. QUEST, Quality of
Upper Extremity Skills Test; BTX-A, botulinum toxin A; OT,
occupational therapy.
50
53. 45
40
35
30
25
Baseline 1 mo 3 mo 6 mo
BTX-A & OT Control
QUEST total score
Localized Injections of Botulinum Toxin A Kevin Lowe et al.
175
response to BTX-A was demonstrated. These characteristics
might, therefore, provide useful clinical guides for the selec-
tion of very young children with CP for BTX-A intervention,
particularly when high efficacy is required, spasticity is not
severe, therapy is received, and upper limb quality of move-
ment and function are intervention goals.
LIMITATIONS AND RECOMMENDATIONS
Our study was limited by single evaluator blinding: both par-
ent and child knew whether or not they were in the treat-
ment group because placebo injections were not used. The
study investigated only one injection administration technique.
In practice the CP population of young children is quite
diverse and the study inclusion and exclusion criteria were
54. restrictive. This study used one injection, monitored for
only 6 months, with occupational therapy intervention
begun after baseline. The effect of repeat injections, previous
occupational therapy, and longer-term outcomes of the sin-
gle injection needs investigation.
Conclusion
Low-dose, high-concentration BTX-A injections localized with
the use of both electromyography and stimulation seem clini -
cally worthwhile for young children with CP, because they pro-
vide short-term quality of movement gains that are faster and
greater than those generated by therapy alone, and better
short-term and long-term functional gains are achieved.
DOI: 10.1017/S0012162206000387
Accepted for publication 12th April 2005.
Acknowledgements
Dr Terry Neeman, Principal Statistician, Covance Pty Ltd,
provided
statistical support.
Competing interests
Allergan gave partial support by providing the BTX-A used in
the
study, by payment of a blind rater for the QUEST, data entry,
and
some analysis done by an independent data management firm.
The
authors have no pecuniary interest in Allergan. Investigator and
research assistant labour apart from that already identified were
supported by the Spastic Centre, University of Western Sydney,
and
Sydney Children’s Hospital.
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