Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
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This achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
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We are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
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Thank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
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He is an expert in genetic toxicology and is, or has been, a referee for more than 20 international scientific journals. He was a member of the International Panel of Experts at the International Agency for Research on Cancer (IARC, WHO, Lyon, France) in 2015 for the evaluation of DDT, 2,4-D and Lindane. Presently, Prof. Dr. Larramendy is Head of the Laboratory of Molecular Cytogenetics and Genotoxicology at the UNLP.",institutionString:"National University of La Plata",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"18",institution:{name:"National University of La Plata",institutionURL:null,country:{name:"Argentina"}}}],coeditorOne:{id:"14863",title:"Dr.",name:"Sonia",middleName:null,surname:"Soloneski",slug:"sonia-soloneski",fullName:"Sonia Soloneski",profilePictureURL:"https://mts.intechopen.com/storage/users/14863/images/system/14863.jpg",biography:"Sonia Soloneski has a Ph.D. in Natural Sciences and is an Assistant Professor of Molecular Cell Biology at the School of Natural Sciences and Museum of La Plata, National University of La Plata, Argentina. She is a member of the National Scientific and Technological Research Council (CONICET) of Argentina in the genetic toxicology field, the Latin American Association of Environmental Mutagenesis, Teratogenesis and Carcinogenesis (ALAMCTA), the Argentinean Society of Toxicology (ATA), the Argentinean Society of Genetics (SAG), the Argentinean Society of Biology (SAB), and the Society of Environmental Toxicology and Chemistry (SETAC). She has authored more than 380 contributions in the field, including scientific publications in peer-reviewed journals and research communications. She has served as a review member for more than 30 scientific international journals. She has been a plenary speaker in scientific conferences and a member of scientific committees. She is a specialist in issues related to genetic toxicology, mutagenesis, and ecotoxicology.",institutionString:"National University of La Plata",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"6",institution:{name:"National University of La Plata",institutionURL:null,country:{name:"Argentina"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"307",title:"Agroecology",slug:"agroecology"}],chapters:[{id:"71812",title:"Fungal Endophytes: Australian Terrestrial Orchids",slug:"fungal-endophytes-australian-terrestrial-orchids",totalDownloads:178,totalCrossrefCites:0,authors:[{id:"315183",title:"Dr.",name:"Shalika",surname:"Mehra",slug:"shalika-mehra",fullName:"Shalika Mehra"}]},{id:"72341",title:"Impact Brassinolide on Two Fig Varieties",slug:"impact-brassinolide-on-two-fig-varieties",totalDownloads:82,totalCrossrefCites:0,authors:[{id:"318963",title:"Dr.",name:"Zulias",surname:"Mardinata Zulkarnaini",slug:"zulias-mardinata-zulkarnaini",fullName:"Zulias Mardinata Zulkarnaini"},{id:"346266",title:"Dr.",name:"Mardaleni",surname:null,slug:"mardaleni",fullName:"Mardaleni null"},{id:"346267",title:"Dr.",name:"Tengku Edy",surname:"Sabli",slug:"tengku-edy-sabli",fullName:"Tengku Edy Sabli"}]},{id:"73090",title:"The Creation of Resistant Berries’ Agrobiocenosis",slug:"the-creation-of-resistant-berries-agrobiocenosis",totalDownloads:13,totalCrossrefCites:0,authors:[{id:"319385",title:"Dr.",name:"Zoya",surname:"Ozherelieva",slug:"zoya-ozherelieva",fullName:"Zoya Ozherelieva"},{id:"319387",title:"Dr.",name:"Pavel",surname:"Prudnikov",slug:"pavel-prudnikov",fullName:"Pavel Prudnikov"},{id:"319388",title:"MSc.",name:"Diana",surname:"Krivushina",slug:"diana-krivushina",fullName:"Diana Krivushina"},{id:"319389",title:"Ms.",name:"Marina",surname:"Zubkova",slug:"marina-zubkova",fullName:"Marina Zubkova"},{id:"319390",title:"MSc.",name:"Anna",surname:"Androsova",slug:"anna-androsova",fullName:"Anna Androsova"}]},{id:"72423",title:"Castor (Ricinus communis): An Underutilized Oil Crop in the South East Asia",slug:"castor-em-ricinus-communis-em-an-underutilized-oil-crop-in-the-south-east-asia",totalDownloads:90,totalCrossrefCites:0,authors:[{id:"77958",title:"Dr.",name:"Zahira",surname:"Yaakub",slug:"zahira-yaakub",fullName:"Zahira Yaakub"},{id:"191072",title:"Prof.",name:"A. 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1. Introduction
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Students are at risk for daily stress, often caused by the increasing load of the material to study, limited time and resources necessary to fulfill assignments, personal demands, high expectations, as well as socioeconomic pressures, and frustrations. In some cases, the above problems can be aggravated by difficulties in adjusting to the new environment and lack of support from family and friends. All these factors can create distress and subsequently may contribute to decreased ability to learn, impaired academic performance, psychosomatic disorders or diseases, and decreased quality of life among many students. There is no doubt about the fact that dealing with multiple negative biopsychosocial consequences of daily stress is very difficult and expensive. Therefore, addressing these issues early, among 1st and 2nd year university students seems particularly important. A review of the literature on reducing stress, and preventing its damaging consequences in student population, indicates that person-focused interventions, such as different types of relaxation techniques, can be effective in reducing anxiety, irritability, sadness, depressed mood, insomnia, and many other general symptoms of distress, compared to no intervention. The beneficial results of various stress reduction programs may last from 6 months to 2 years, after their formal ending [1]. For instance, beneficial effects of one specific relaxation technique, mindfulness-based stress reduction (MBSR), developed by Kabat-Zinn, have been documented in various populations (both among healthy individuals, exposed at high level of a daily stress, and among patients, suffering from different psychosomatic diseases) in diversified medical and psychological contexts [2, 3, 4, 5, 6, 7]. In particular, some studies related to students and professionals in the medical field have revealed positive effects of mindfulness on stress reduction, health condition, quality of life, empathy, and quality of patient care [8, 9]. Furthermore, a small recent study, conducted among university students, provided data, which support the possibility that a deep breathing technique is able to induce some improvements in mood and control of stress (e.g., illustrated in the form of self-reports and objective parameters, like heart rate and cortisol levels, measured in saliva) [10]. Although MBSR has been successfully used for the last 40 years in the USA, Canada, and Western Europe in many psychosomatic disorders related to stress [11, 12, 13], it is still little known as a relaxation technique in Eastern or Central Europe. Due to some logistic obstacles, the entire MBSR program may be too difficult to implement at the universities in this location. However, an important component of the MBSR, the deep diaphragmatic breathing (DDB) technique, has also been separately studied as a stress reduction modality, and convincing evidence exists that DDB is useful in stress management [14]. For instance, a recent study has demonstrated a beneficial influence of DDB on mental functions and normalization of stress-induced cortisol levels. This indicates that such a simple and easily available technique has enormous implications for the promotion of mental hygiene and prevention of adverse health consequences of stress [14]. However, the specific advantages of DDB on stress reduction, cognitive abilities, and mood among students still remain largely unknown. To explore this topic in mere details and fulfill the unmet needs, a “portable intervention,” such as stress management brief training (SMBT), focused on the reduction of the perceived stress levels among students will be outlined. The SMBT consists of a short review of stress mechanisms and coping approaches, followed by the instruction of a simple stress management relaxation/technique [e.g., deep diaphragmatic breathing (DDB)]. Practical considerations regarding the DDB will be emphasized.
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2. Review of the literature on stress and coping: a focus on the student population
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A review of the literature was conducted using PubMed. The following keywords: stress, stress management, perceived stress, coping, relaxation, and students were utilized. The review was limited to full-text articles, in English language, which were published within the last 15 years. After this search, the following study-specific areas were determined: the hypothalamic-pituitary-adrenal (HPA) axis; the HPA axis dysregulation from stress; impact of chronic stress on memory and cognition; stress perception; stress-related maladaptive behaviors; appraisal of the stressors; coping with stress among students; relations between stress, coping strategies, academic performance, and quality of life; managing stress in the students; relaxation techniques; deep diaphragmatic breathing; and the effects of stress management programs.
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2.1 Stress and the hypothalamic-pituitary-adrenal (HPA) axis
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Human stress is the psychophysiological reaction of a person, who confronts a situation, in which there is an imbalance between the demands (e.g., real or imagined) and the ability to fulfill them [15]. When a person confronts a stressor (e.g., an internal or external, physical, or psychological factor, which creates disequilibrium), the body activates a series of reactions to enhance coping with the stressful situation. In particular, when an individual experiences different stressors, the hypothalamus (the main hormone-regulating brain “station”) releases corticotrophin-releasing hormone (CRH), which stimulates the release of adrenocorticotropic hormone (ACTH) from the pituitary gland [16]. ACTH stimulates the production of glucocorticoids (e.g., cortisol) by the adrenal glands. In this manner, the hypothalamic-pituitary-adrenal (HPA) axis is “in charge” of the systemic adaptive changes that are induced by stressors [17]. Simultaneously, catecholamines are being secreted from the adrenal glands.
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2.2 The HPA axis dysregulation from stress: negative consequences for health
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In the case of the prolonged HPA axis activation (e.g., due to some undesirable, cumulated stressors, such as difficult tasks and personal, family, or financial problems), the chronically increased stress hormone levels can cause negative psychosomatic consequences [18]. An adaptation to stress initially includes the physiological mobilization of resources, such as an increased catecholamine’s release [19]. This is often followed by the resistance stage, which represents a prolonged adaptation to stressful challenges (e.g., increased cortisol levels) [19]. Finally, decompensation of the HPA axis, which is often characterized by decreased cortisol and catecholamine production, can cause serious disorders and diseases in each organ or system of the human body [19]. In particular, chronic stress elevates the risk for central obesity, metabolic syndrome, type 2 diabetes mellitus (T2DM), cardiovascular disease (CVD) [e.g., arterial hypertension, coronary artery disease (CAD), myocardial infarction (MI), heart failure (HF), and stroke], neoplastic, degenerative, or inflammatory diseases, allergies, asthma, gastroesophageal reflux disease, peptic ulcer disease, osteoporosis, and mental disorders (e.g., major depression and insomnia) [19, 20]. In addition, several studies have revealed associations between stress and maladaptive behaviors (e.g., increased alcohol consumption, tobacco smoking, or substance abuse) and increased anxiety or depressive symptoms [21, 22]. Due to such detrimental consequences of chronic stress, it is imperative to prevent them as early as possible, by introducing helpful nonpharmacological stress management interventions [23].
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2.3 Impact of chronic stress on memory and cognition
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Everyone has an inherited ability to deal with stress. For instance, after a person confronts a stressful event, the “fight-or-flight” response occurs, which is characterized by elevated catecholamine’s level. However, in the chronic phase of stress, cortisol levels are usually high and can lead to impaired neurogenesis and cause structural and functional changes in the central nervous system (CNS) (e.g., in the brain areas responsible for short-term memory, cognition, affect, and impulse control) [21, 23]. In addition, sleep deprivation can negatively influence the abilities to learn due to decreased clarity of the thought process, poor creativity, or problem-solving skills, which are often linked with impaired scholarly performance among students [24]. In particular, the rapid eye movement (REM) sleep phase is crucial for processing the information that has been stored in the short-term memory reservoir (e.g., hippocampus) and consolidating the memory traces in the long-term memory reservoir (e.g., the temporal lobes of brain cortex) [24]. Furthermore, a person’s working memory can only contain approximately seven units of information, and thus, when a student is under stress, and her/his mind is being occupied with several stressors, the student’s learning capabilities can be deteriorated [25]. In addition, since a student’s attention is often not focused on the learning task, the relevant memory trace will be difficult to retrieve in the future. Moreover, stress in students has also been found to contribute to avoidant coping behavior and depressed mood [26]. In this light, the modulation of stress response seems to be particularly important in students, who are exposed to chronic stressors. It should be noted that high levels of the perceived stress and the inefficient adaptation to stressors have been correlated with increased rates of anxiety and depression [23, 27]. Unfortunately, in the case of chronic stress, a desynchronization of the HPA axis contributes to various stress-related conditions and impaired cognitive performance [23, 27].
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2.4 Stress perception: different intellectual and emotional aspects
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In general, stress can be caused by challenge stressors (e.g., that allow someone to have sufficient motivation to accomplish a certain task) and threat stressors (e.g., that evoke fear, such as a signal of imminent danger) [28]. In fact, all stimuli that are perceived as harmful can have devastating effects on one’s psychosomatic health [27]. For instance, if a given situation is perceived as a threat, the organism’s response is identical, regardless of whether the stressor is a wide animal ready to attack or an upcoming exam. Thus, a person’s specific perception and interpretation of given circumstances, regardless of their real danger, represent a key factor indicating how much stress the person is actually experiencing [28]. Furthermore, stress may also steam from situations that are subjectively viewed as positive. For instance, some students may have positive feelings about their assignments and like being busy, yet they may be under considerable stress that they are not fully aware of having. In contrast, a situation is considered to be stressful, when students think that they do not have the abilities or sufficient resources to deal with it [28]. On the other hand, a higher level of one’s confidence can modify the perception of stressors, so that a person’s appraisal (e.g., intellectual and emotional) of the stressful situation can alter her/his level of subsequent stress-induced response [28].
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2.5 Stress-related maladaptive behaviors: common presentations and long-term risks
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In essence, if a situation is viewed through the lens of negative emotions, the perceived stress level is higher, compared to observing the identical situation, from the perspective of positive emotions or mental connotations [23, 26]. In addition, verbal complaining and “ruminating” about the difficulties can perpetuate and “disseminate” stress, so every negative emotional response to a similar stressor becomes incorporated into the brain’s neural networks [23, 26]. This, in consequence, may become the automatic response to such a stressor in the future, leading to an undesirable habit formation [18, 27]. There are some dangerous habits that university students are especially prone to acquire during examination sessions (e.g., frequent lack of sleep, which can adversely affect their physical, mental, and emotional health) [24, 26]. Unquestionably, restful sleep is necessary for proper mental hygiene and the immune system functioning [26, 29]. Fortunately, it appears that by proactive recognition of the stressful situations, and modification of the stress response effects, students could possibly avoid maladaptive coping behaviors and learn helpful stress reduction interventions (e.g., at the beginning of their academic career), in order to protect their psychophysical health in the future. Some other common habits that students often acquire include excessive drinking of coffee and other beverages, containing a high content of caffeine or similar stimulants (e.g., which can elevate blood pressure and heart rate or exacerbate anxiety) [26]. An analysis of other risk behaviors that students often demonstrate while under stress (e.g., tobacco smoking and alcohol or substance abuse) causing potential detrimental health consequences is beyond the scope of discussion in this chapter.
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2.6 The key role of appraisal of the stressors
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Stress reflects a bi-directional process, which consists of the creation of stressors by the environment and the individual’s response to them. As a consequence, when there is a real or imagined imbalance between demands and resources, in which the demands outweigh resources, a person experiences stress [23, 27]. During this process, a cognitive appraisal is an initial step in the coping mechanism, which varies individually. It occurs when a person knows the reason why a given interaction creates stress [21, 23, 30]. It should be underscored that both the past experiences and the present events influence the way a person reacts to a current situation [21, 23, 30]. Also, it is important to point out that the stress reaction takes place after a certain meaning has been attached to a current situation, evoking an emotional response [21, 23, 30]. As a consequence, cognitive appraisal influences how a person will cope with a given event and how she/he will most likely react to analogical circumstances in the future [21, 23, 30]. According to a current model of stress, the primary appraisal of a stressful situation relates to the initial perception of the stressor (e.g., as negative, positive, or neutral), and the secondary appraisal refers to the coping strategies and resources (e.g., how to overcome or adapt to the stressor) [21, 23, 30]. At this point, an individual’s coping approach can be positive (e.g., addressing a stressor as a challenge) or negative (e.g., viewing a stressor as a threat, especially if an adverse outcome is expected, which is associated with anxiety, anger, or fear) [21, 23, 30]. In addition, the repeated negative appraisal may lead to maladaptive behaviors and long-term negative consequences [21, 23, 30]. Overall, it appears that modifying the perception of stressors can help students to enhance their learning skills and academic achievements [28, 31]. For instance, assessing stressful situations as being challenging (and thus apprised as helpful) rather than as being threatening (and thus apprised as harmful) changes the stress physiology [32]. In particular, if the students perceived certain stressors as motivating them to overcome some obstacles, their learning skills and academic performance were positively correlated with the increased motivation [32]. Conversely, if the students perceived a dangerous situation (e.g., in which the demands were exceeding their resources), their motivation to learn was decreased, leading to impaired scholarly performance [33].
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2.7 Coping with stress: important considerations regarding the student population
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It should be highlighted that coping is the process of confronting adversities, in an attempt to overcome them or to adapt to the stressful situations [34]. “Positive coping” includes some basic knowledge of factors that underlie personal coping strategies, which are related with the individual’s strengths and effective coping techniques, and offers meaningful solutions to ineffective or even harmful stereotypical behaviors [35]. In essence, coping with stress relates to the way how an individual is able to achieve the balance between different life demands and the ability to deal with them. In fact, daily stress is an inevitable and natural part of everybody’s life. However, extreme, chronic, or psychological stress can cause adverse health consequences and poor academic performance for every university student [34]. Therefore, there is a growing need to implement feasible stress management intervention programs in the academic setting [35]. Two main coping styles, which are being applied to deal with the ongoing demands, include problem-focused (e.g., that consists of defining problems, generating solutions, and evaluating results) and emotion-focused (e.g., that occurs when a person feels helpless upon confronting the stressful events) methods. The most effective and available stress management approaches for students include relaxation techniques and goal-oriented, positive coping strategies [34, 35, 36, 37].
\n
\n
\n
2.8 Interrelations between stress, coping strategies, academic performance, and quality of life: lessons learned from recent research studies
\n
Unquestionably, effective coping strategies are critically important for reducing elevated stress levels among students. In general, successful coping involves managing the interactions between the environment, and the perceived stress levels, where the accompanying emotions are essential parts of this process [23, 30]. Since stress is multifactorial and impacts each person in a different way, a diverse spectrum of coping methods is required [23, 38]. Therefore, providing “well-targeted” tools, necessary to effectively cope with different stressors, is critically important to students, who are under stress. It should be pointed out that on the one hand, short-term stress can play a role of the positive motivator for learning [21, 23]. On the other hand, however, excessive or long-term stress can adversely influence the learning process and deteriorate academic performance [39]. Furthermore, a plethora of stressors, especially in students, who use poor coping techniques, can adversely influence many aspects of their health and scholarly performance [40]. For instance, the prevalence of stress, anxiety, and depression in nursing students was recently explored, and correlations between ineffective coping methods (e.g., avoidance, denial, and substance abuse) and high-risk lifestyles (e.g., in terms of busy study/work schedule, family obligations, poor support systems) were found in those students, who had significantly elevated scores in the depression, anxiety, and distress categories [41]. Furthermore, in a study investigating relations between stress and quality of life (QOL), among nursing students in Norway, one-third of the students reported moderate to high levels of experienced stress, which were impaired QOL [42].
\n
\n
\n
\n
3. Relaxation techniques: nonpharmacological interventions to reduce stress
\n
According to the National Center for Complementary and Alternative Medicine (NCCAM), meditation is a mind-body process, which has been scientifically explored as an intervention to reduce stress [43]. It is a cognitive practice, focused on calming the mind and observing intrusive thoughts, without judging them [44]. In this state of consciousness, the mind is focused on the moment-to-moment experience of one’s internal (e.g., thoughts, feelings, and sensations) and external (e.g., events or situations) environment [33]. Individuals who focus their attention on “here and now” and become fully aware (mindful) of their thoughts’ processes and emotions are able to create calm, relaxed, and balanced psychophysical condition [43]. Studies have revealed that many people, who have been practicing meditation (even for a short time), have decreased their perceived stress levels, improved health status, and increased QOL [44, 45]. However, classical meditation programs are usually long or expensive and, thus, inconvenient or unavailable for a majority of students. This inspired a new research direction, aimed at exploring whether or not similar benefits can be achieved via shorter-time interventions [46]. For instance, a brief meditation training program (that also incorporated therapeutic breathing), which investigated the effects of this technique on perceived stress, anxiety, and negative emotions, has revealed that the healthy participants experienced significant reductions in negative affect, distress, and anxiety [46]. A similar study has revealed that participation in a single-paced breathing meditation training session resulted in improved QOL and reduced perceived stress levels [47]. Research aimed at exploring stress reduction should combine a few stress management strategies that can be effective in different contexts, among various populations of students [33]. As an illustration of this concept, one of the online stress management programs (e.g., Stress-Free Now) has incorporated meditation and therapeutic breathing. This study was examining the program’s effectiveness in decreasing stress and improving psychological well-being by exploring the effects of a 2-month online stress reduction program in three groups, including two intervention groups (that participated in the online program and were receiving a different stress management technique every week, based on mindfulness meditation, visualization, and therapeutic breathing) and one control group [33]. The results of this study have revealed that the online stress reduction program, which incorporated diversified activities, such as mindfulness, relaxation, and meditation techniques, was effective in decreasing the perceived stress levels and improving well-being, among the participants in two intervention groups [33].
\n
\n
3.1 Deep diaphragmatic breathing: a “spotlight” on a “portable intervention”
\n
Relaxation technique, such as deep diaphragmatic breathing (DDB), is feasible and can be practiced anywhere. In essence, DDB includes controlled deep (abdominal) breathing that enables the individual to enter a relaxed state, in an effortless manner. Simultaneously, this simple technique has been found to be very effective in stress reduction among students [48]. In addition, some relaxation techniques have been revealed to reduce stress levels, even after a single session [19]. Therefore, a proposed “portable intervention” for an effective coping with stressors should be universal and safe strategy for numerous university students. An early introduction of this simple and helpful technique can result in desirable health-related habits and long-term beneficial psychophysical conditions.
\n
\n
\n
Conflict of interest
There is no “conflict of interest” to declare.
\n',keywords:"distress, stress reduction, coping, relaxation techniques, deep diaphragmatic breathing (DDB), university students",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/69111.pdf",chapterXML:"https://mts.intechopen.com/source/xml/69111.xml",downloadPdfUrl:"/chapter/pdf-download/69111",previewPdfUrl:"/chapter/pdf-preview/69111",totalDownloads:411,totalViews:0,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:1,dateSubmitted:"February 4th 2019",dateReviewed:"May 7th 2019",datePrePublished:"September 18th 2019",datePublished:"May 13th 2020",dateFinished:"September 18th 2019",readingETA:"0",abstract:"Students are at risk for daily stress, often caused by an increasing load of the material to study, limited time and resources necessary to fulfill assignments, personal or family demands, high expectations, pressures, and frustrations. All these factors can create distress, decreased learning abilities, and psychosomatic disorders or diseases. To mitigate such negative biopsychosocial effects of stress, different types of relaxation techniques can be used. Addressing these issues early (e.g., among the 1st and 2nd year university students) seems particularly important, due to possible prevention of the long-term adverse health consequences of stress (compared to no intervention). To fulfill this important need, a “portable intervention,” such as stress management brief training (SMBT), focused on the reduction of the perceived stress levels among students will be briefly outlined. The SMBT consists of a short review of stress and coping approaches, followed by the instruction of a simple stress management relaxation/technique [e.g., deep diaphragmatic breathing (DDB)]. Practical considerations regarding the DDB will be highlighted. The feasibility and usefulness of the DDB training for stress management among the 1st and 2nd year university students should encourage implementation of this innovative, safe, inexpensive, and friendly technique.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/69111",risUrl:"/chapter/ris/69111",book:{slug:"effects-of-stress-on-human-health"},signatures:"Katarzyna (Kate) Rygiel",authors:[{id:"203912",title:"Dr.",name:"Kate",middleName:null,surname:"Rygiel",fullName:"Kate Rygiel",slug:"kate-rygiel",email:"kasiaalpha@yahoo.co.uk",position:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Review of the literature on stress and coping: a focus on the student population",level:"1"},{id:"sec_2_2",title:"2.1 Stress and the hypothalamic-pituitary-adrenal (HPA) axis",level:"2"},{id:"sec_3_2",title:"2.2 The HPA axis dysregulation from stress: negative consequences for health",level:"2"},{id:"sec_4_2",title:"2.3 Impact of chronic stress on memory and cognition",level:"2"},{id:"sec_5_2",title:"2.4 Stress perception: different intellectual and emotional aspects",level:"2"},{id:"sec_6_2",title:"2.5 Stress-related maladaptive behaviors: common presentations and long-term risks",level:"2"},{id:"sec_7_2",title:"2.6 The key role of appraisal of the stressors",level:"2"},{id:"sec_8_2",title:"2.7 Coping with stress: important considerations regarding the student population",level:"2"},{id:"sec_9_2",title:"2.8 Interrelations between stress, coping strategies, academic performance, and quality of life: lessons learned from recent research studies",level:"2"},{id:"sec_11",title:"3. Relaxation techniques: nonpharmacological interventions to reduce stress",level:"1"},{id:"sec_11_2",title:"3.1 Deep diaphragmatic breathing: a “spotlight” on a “portable intervention”",level:"2"},{id:"sec_16",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'\nMarine A, Ruotsalainen J, Serra C, Verbeek J. Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD002892\n'},{id:"B2",body:'\nKabat-Zinn J. Full Catastrophe Living: Using the Wisdom of your Body and Mind to Face Stress, Pain and Illness. New York: Delta Trade Paperbacks; 2005\n'},{id:"B3",body:'\nKabat-Zinn J, Massion AO, Kristeller J, et al. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. The American Journal of Psychiatry. 1992;149:936-943\n'},{id:"B4",body:'\nKabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine. 1985;8:163-190\n'},{id:"B5",body:'\nKabat-Zinn J, Lipworth L, Burney R, Sellers W. Four-year follow-up of a meditation program for the self-regulation of chronic pain: Treatment outcome and compliance. The Clinical Journal of Pain. 1987;2:159-173\n'},{id:"B6",body:'\nKabat-Zinn J, Wheeler E, Light T, et al. Influence of a mindfulness-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychological Medicine. 1998;60:625-632\n'},{id:"B7",body:'\nDavidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine. 2003;65(4):564-570\n'},{id:"B8",body:'\nSchenstrom A, Ronnberg S, Bodlund O. Mindfulness-based cognitive attitude training for primary care staff: A pilot study. Complementary Health Practice Review. 2006;11:144-152\n'},{id:"B9",body:'\nShapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine. 1998;21:581-599\n'},{id:"B10",body:'\nPerciavalle V, Blandini M, Fecarotta P, et al. The role of deep breathing on stress. Neurological Sciences. 2016;38(3):451-458. DOI: 10.1007/s10072-016-2790-8\n'},{id:"B11",body:'\nWright LD. Meditation: A new role for an old friend. American Journal of Hospice & Palliative Medicine. 2006;23(4):323-327\n'},{id:"B12",body:'\nMiller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry. 1995;17:192-200\n'},{id:"B13",body:'\nTitlebaum H. Relaxation. Complementary Health Practice Review. 1998;4:123-148\n'},{id:"B14",body:'\nMa X, Zi-Qi Y, Zhu-Qing G, et al. The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Frontiers in Psychology. 2017;8:874. DOI: 10.3389/fpsyg.2017.00874\n'},{id:"B15",body:'\nPalmer S. Occupational stress. Health and safety practitioners. 1989;7(8):16-18\n'},{id:"B16",body:'\nMcEwen BS, Stellar E. Stress and the individual. Mechanisms leading to disease. Archives of Internal Medicine. 1993;153(18):2093-2101\n'},{id:"B17",body:'\nMcEwen BS, Wingfield JC. What is in a name? Integrating homeostasis, allostasis and stress. Hormones and Behavior. 2010;57(2):105-111\n'},{id:"B18",body:'\nGanzel BL, Morris PA, Wethington E. Allostasis and the human brain: Integrating models of stress from the social and life sciences. Psychological Review. 2010;117(1):134-174\n'},{id:"B19",body:'\nCohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007;298(14):1685-1687\n'},{id:"B20",body:'\nLucini D, Di Fede G, Parati G, et al. Impact of chronic psychosocial stress on autonomic cardiovascular regulation in otherwise healthy subjects. Hypertension. 2005;46:1201-1206\n'},{id:"B21",body:'\nJuster RP, McEwen BS, Lupien SJ. Allostatic load biomarkers of chronic stress and impact on health and cognition. Neuroscience & Biobehavioral Reviews. 2010;35(1):2-16\n'},{id:"B22",body:'\nKanji N, White A, Ernst E. Autogenic training to reduce anxiety in nursing students: Randomized controlled trial. Journal of Advanced Nursing. 2006;53(6):729-735\n'},{id:"B23",body:'\nTonhajzerova I, Mestanik M. New perspectives in the model of stress response. Physiological Research. 2017;66(Supplement 2):S173-S185\n'},{id:"B24",body:'\nMaquet P. The role of sleep in learning and memory. Science. 2001;294(5544):1048-1052\n'},{id:"B25",body:'\nOrmrod JE. Human Learning. 4th ed. Upper Saddle River, NJ: Pearson Education, Inc.; 2004\n'},{id:"B26",body:'\nDyson R, Renk K. Freshman adaptation to university life: Depressive symptoms, stress, and coping. Journal of Clinical Psychology. 2006;62(10):1231-1244\n'},{id:"B27",body:'\nKaratsoreos IN, McEwen BS. Psychobiological allostasis: Resistance, resilience and vulnerability. Trends in Cognitive Sciences. 2011;15(12):576-584\n'},{id:"B28",body:'\nLargo-Wight E, Peterson PM, Chen WW. Perceived problem solving, stress, and health among college students. American Journal of Health Behavior. 2005;29(4):360-370\n'},{id:"B29",body:'\nGlaser R, Kiecolt-Glaser JK. Stress-induced immune dysfunction: Implications for health. Nature Reviews. Immunology. 2005;5:243-251\n'},{id:"B30",body:'\nLazarus RS, Folkman S. Stress, Appraisal and Coping. New York: Springer; 1984\n'},{id:"B31",body:'\nRausch SM, Gramling SE, Auerbach SM. Effects of a single session of large group meditation and progressive muscle relaxation training on stress reduction, reactivity, and recovery. International Journal of Stress Management. 2006;13(3):273-290\n'},{id:"B32",body:'\nLePine JA, LePine MA, Jackson CL. Challenge and hindrance stress: Relationships with exhaustion, motivation to learn, and learning performance. Journal of Applied Psychology. 2004;89(5):883-891\n'},{id:"B33",body:'\nMorledge TJ, Allexandre D, Fox E, et al. Feasibility of an online mindfulness program for stress management – A randomized controlled trial. Annals of Behavioral Medicine. 2013;4:137-148\n'},{id:"B34",body:'\nGibbons C. Stress, coping and burn-out in nursing students. International Journal of Nursing Studies. 2010;47(10):1299-1309\n'},{id:"B35",body:'\nJones M, Johnston D. Is the introduction of a student-centered, problem-based curriculum associated with improvements in student nurse well-being and performance? An observational study of effect. International Journal of Nursing Studies. 2006;43:941-952\n'},{id:"B36",body:'\nPeterson U, Berstrom G, Samuelson M, et al. Reflecting peer-support groups in the prevention of stress and burnout:Randomized control trial. Journal of Advanced Nursing. 2008;63(5):506-516\n'},{id:"B37",body:'\nYearwood E, Riley JB. Curriculum infusion to promote nursing student well-being. Journal of Advanced Nursing. 2010;66(6):1356-1364\n'},{id:"B38",body:'\nWeiss M, Nordlie JW, Siegel EP. Mindfulness-based stress reduction as an adjunct to outpatient psychotherapy. Psychotherapy and Psychosomatics. 2005;74:108-112\n'},{id:"B39",body:'\nWichianson JR, Bughi SA, Unger JB, et al. Perceived stress, coping, and eating in college students. Stress and Health. 2009;25(3):235-240\n'},{id:"B40",body:'\nDeary IJ, Watson R, Hogston R. A longitudinal cohort study of burnout and attrition in nursing students. Journal of Advanced Nursing. 2003;43(1):71-81\n'},{id:"B41",body:'\nChernomas W, Shapiro W. Stress, depression, anxiety among undergraduate nursing students. International Journal of Nursing Education Scholarship. 2013;10:1-12\n'},{id:"B42",body:'\nKleiveland B, Natvig GK, Jepsen R. Stress, sense of coherence and quality of life among Norwegian nurse students after a period of clinical period. PeerJ. 2015;3:74-82\n'},{id:"B43",body:'\nThe National Center for Complementary and Alternative Medicine (NCCAM). 2012. Available from: www.nccam.nih.org [Accessed on: 20 December 2018]\n'},{id:"B44",body:'\nLazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. NeuroReport. 2005;16(17):1893-1897\n'},{id:"B45",body:'\nOman D, Beddoe AE. Health interventions combining meditation with learning from spiritual exemplars: Conceptualization and review. Annals of Behavioral Medicine. 2005;29:S126\n'},{id:"B46",body:'\nLane JD, Seskevich JE, Pieper CF. Brief mediation training can improve perceived stress and negative mood. Alternative Therapies in Health and Medicine. 2007;13(1):38-44\n'},{id:"B47",body:'\nPrasad K, Wahner-Roedler D, Cha S, et al. Effect of a single-session meditation training to reduce stress and improve quality of life among health care professionals: A "dose-ranging" feasibility study. Alternative Therapies in Health and Medicine. 2011;17(3):46-49\n'},{id:"B48",body:'\nInanlu M, Baha R, Seyedfatemi N, et al. Coping strategies among nursing students in Hayat. Iranian Journal of Nursing and Midwifery Research. 2012;18:66-75\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Katarzyna (Kate) Rygiel",address:"kasiaalpha@yahoo.co.uk",affiliation:'
Department of Family Practice, Medical University of Silesia (SUM), Zabrze, Poland
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\n
1. Introduction
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The actual state-of-the-art in suture-coaptation bringing together two stumps of a severed peripheral nerve requires good histologic quality of both stumps, a gap that may overcome by acceptable tension, and a good microsurgical technique when performing epineural or epi-perineural mattress sutures, leading finally to a nearly invisible congruent “anastomosis”.
\n
Few authors have dealt so far with aspects of technical improvement of nerve stump coaptation, but fascicular alignment seems to be a major factor to ensure proper regeneration [1].
\n
Peripheral nerves contain elastic fibers and after nerve transsection, even without any loss of substance, a gap between the two stumps becomes apparent. The local nerve tissue damage and ingrowing fibrosis of both stumps may increase and/or fix the gap in an irreversible manner, than the further coaptation becomes hazardous.
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Although “reasonable” tension may be applied to try to overcome the gap, it is generally recommended to perform nerve sutures in a tension-free environment using 9/0 and 10/0 microsurgical suture material. When these stitches break, a nerve graft is recommended.
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Recently, we gained reasonable experience in the reconstruction of upper and extended upper obstetric brachial plexus lesions (OBPL) in general [2] and with direct sutures [3], showing very good clinical results of motor recovery after severe obstetric traction injury with complete trunk ruptures. Optimizing the functional result after surgical reconstruction in all types of OBPL is always the prevalent aim, especially to recover an adequate hand function [4].
\n
The OBPL direct suture repair technique was introduced already over hundred years ago [5] and we know that several peripheral nerve surgeons are incline to perform a direct coaptation of two peripheral nerve stumps with a “reasonable” tension, to avoid short grafting with less dense nerve fiber interposition.
\n
There is thus a striking controversy between a clinical axioma (tensionless nerve coaptation) and surgical experience, leading us to investigate this issue further and to discuss both the existing literature and possible research protocols.
\n
\n
\n
2. Surgical technique
\n
The nerve suture should bring together two stumps of good tissue quality, that is, free of fibrosis (i.e., infiltration of collagen fibers) or neuroma (predominance of misoriented peripheral minifascicles), with good fascicular appearance and a gap overcome by slight traction and finally hold by the sutures [6, 7]. de Medinaceli introduced a microsurgical technique focusing on good fascicular alignment in both stumps [1], mainly to avoid random fascicular ingrowth of the regeneration cones.
\n
Every nerve microsurgeon knows that if there is tension, the first suture point is the most difficult to be achieved and at risk for filament rupture (Figure 1).
\n
Figure 1.
Problem of the first epineural suture knot under undue tension.
\n
As there are more points added, the tension lowers (Figure 2) and at the end, the coaptation site shows a good appearance and mechanical resistance.
\n
Figure 2.
Tension decreases with more anchor points.
\n
To prevent undue tension, either the proximal and/or the distal nerve stump may be mobilized, that is, freed from their paraneural tissue, thus giving additional length, gained at the price of decreased local blood supply (as the vasa nervorum might be interrupted by this circumferential paraneurolysis).
\n
Also may one take advantage of the existence of “reserve capacity” of each peripheral nerve at the level of major joints, which are flexed to release more tissues.
\n
In dramatic situations, like in war injuries or when considering very large nerve repairs (like the ischiatic nerve), bone shortening might be considered to reduce or overcome the gap.
\n
In very young children, like those suffering from OBPL, the structural elasticity of the longitudinally growing nerves is assumed to be enhanced, as is also the capacity of nerve regeneration and overall cortical plasticity. The young connective tissue is loose, nerve fibers and myelin sheaths are thin and the peripheral nerve structure itself is continually under a longitudinal growth stretch.
\n
Concerning nerve stump coaptation at every age, there is no way to overcome the fascicular malalignment due to the intrinsic plexual structure constitutional of most multifascicular peripheral nerves (Figure 3).
\n
Figure 3.
Intraneural plexiform fascicular structure.
\n
Moreover, we actually do not have an insight into the physiologic regeneration once the suture is completed and the wound is closed, as the diffusion tensor imaging (DTI) technology related to MRI images is actually not performed regularly after peripheral nerve surgery.
\n
When it comes to the suture material, nerve microsurgeons routinely use 8–10 or 11/0 nylon (nonabsorbable monofilament) material with fine needles proportional to the filament diameter, that is, needles for 11/0 sutures are smaller and thinner than those for 8/0 sutures.
\n
Recently, we developed in cooperation with Onatec (Pößneck Jestetten, Germany), a specific microsurgical suture material, made up of a 6/0 filament with a real microsurgical needle (Figure 4), allowing epineural nerve sutures of “bigger” nerves like the upper or middle trunk in OBPL repair or adult radial and median nerve coaptations.
\n
Figure 4.
Onalon 6/0 microsurgical filament: fine needle, 6/0 strand.
\n
As the 6/0 filament is inserted strictly epineural and thus lays outside the fascicular structures, and as nylon is supposed to be biologically inert, we continued that practice on a prospective series of OBPL repairs we actually published with a follow up of 18 months and still very promising results of sensory and motor function recovery [3].
\n
Figures 5, 6, 7 show one clinical example of a typical upper and middle trunk neuroma repair with the identification of the rupture site (Figure 5), trimming of both proximal and distal stumps (Figure 6), and the direct suture (Figure 7).
\n
Figure 5.
Clinical example of OBPL direct suture: upper and middle trunk rupture.
\n
Figure 6.
Clinical example of OBPL direct suture: after proximal and distal stump trimming.
\n
Figure 7.
Clinical example of OBPL direct suture: upper and middle trunk direct suture.
\n
The 6/0 strand together with a rather thick epineurium in larger nerves (like those mentioned above) gave us satisfactory coaptation stability already after two or three sutures, where thinner suture filaments needed more sutures to stabilize the coaptation. Nevertheless, in our OBPL trunk coaptations, we regularly used a minimum of 6–8 6/0 epineural sutures (Figure 2) before surrounding the coaptation site with a sleeve of fibrin glue.
\n
The only similar stabilizing technique using foreign material promoted polylacton (vicryl) strips applied outside the epineurium to decrease the tension onto the suture points [8].
\n
\n
\n
3. Morphologic and mechanic analysis
\n
Tension is a force applied onto a surface and might be reduced on a circumference while using more anchor points (remind Figure 2). Suture tension has so far not been quantified or measured, we probably could state that it is even unmeasurable in the in vivo situation of a surgical procedure.
\n
The question is how much of the maintained tension into the nerve stump coaptation is transmitted to the periphery, that is, the stumps, and if this affects nerve regeneration and the physiologic function afterwards.
\n
Some experiences support the concept of a negative influence of nerve stretching on the physiologic function [9]. But clinical results show the feasibility of this method without lowering the functional outcome, even providing unexpected good results.
\n
Tension could harm by decreasing the blood flow in the vasa nervorum (a stretch on a circular blood vessel-tube would flatten it and diminish the cross section, thus theoretically lower the blood flow); but one could argue that through the initial nerve lesion and the surgical paraneurolysis, those freed segments are anyhow separated from the local blood supply.
\n
Tension is also said to increase local fibrosis (the amount of collagen fibers), but we should further investigate if the tension in the epineural layer, holding the suture material, is equally transmitted to the deeper structures (the deep interfascicular epineurium and finally the perineurium and the fascicular sheets).
\n
One could imagine that the tension is hold within the thicker epineural layer of a thicker peripheral nerve and that the aligned fascicles in the nerve depth are no longer experiencing distraction stress—thus the nerve regeneration happening on the highways of the deeper fascicules would not be disturbed (that’s what our clinical cases seem to show, like a “tube-in-tube” concept).
\n
Tension is not measured easily, or even not at all, and once it comes to textbook descriptions like “reasonable tension” or “avoiding excessive tension” we should be convinced that the actually accepted dogma is weak.
\n
On the other hand, there is the real danger of “promoting” bad microsurgical technique and overindication for direct coaptation, bringing together bad quality stumps under undue tension just to avoid a graft (donor site morbidity, longer procedure, two coaptation sites, but overall less fiber density).
\n
Table 1 summarizes ideal clinical conditions for a direct suture approach; Table 2 summarizes strong arguments for a limited tension, suture approach.
\n
\n
\n\n
\n
\n
Very young patient
Acceptable nerve diameter (OBPL trunk or cord)
Limited scar and/or gap
Compliance for postoperative immobilization
\n
\n
\n\n
Table 1.
Ideal conditions for a direct suture approach.
\n
\n
\n\n
\n
\n
Good clinical result in OBPL direct sutures
Longitudinal growth in young patients
Tissue adaptation: elastic fibers, low collagen content, and postoperative immobilization
\n
\n
\n\n
Table 2.
Strong arguments for a limited tension-suture model.
\n
\n
\n
4. Literature research
\n
Between 1975 and 2017, a PubMed MEDLINE research about “nerve suture” and “tension” only prompted eight valuable articles on nerve-suture related tension [8, 10, 11, 12, 13, 14, 15, 16]; presenting animal studies in rats, cats, dogs, and monkeys; using sciatic or upper limb nerves, and studying the outcome by histology and nerve conduction studies. There are so far no conclusive data about what is better and how much tension is tolerated.
\n
\n
\n
5. Further investigations and today’s conclusions
\n
There is still enough controversy about tension tolerance in peripheral nerve surgery.
\n
Clinical outcomes oppose to the experimental background, which on deeper analysis is rather weak, as the literature on the subject is scarce.
\n
Out of our actual clinical and scientific knowledge, we believe that further investigation could be conducted in several ways:
biomechanical analysis of various suture filament strengths used in nerve coaptation
nylon suture: long term interaction with the fascicular anatomy studied by late histologic examination
a model of a tube, in tube, behavior of the peripheral nerve (epineural versus fascicular tubes)
in vivo observation of coapted nerves in a regeneration chamber.
\n
Meanwhile, we continue to use all available “tricks” and refinements to decrease the gap and the suture tension, to allow optimal nerve fiber regeneration, without any visual help to follow this biological process after reconstructive surgery.
\n
Never should our analysis allow bad techniques with insufficiently cleared stumps, undue tension on the coaptation after three or four knots, the introduction of stronger filament material (3 or 4/0), not adapted to the local anatomy, extension of the proposed technique to smaller nerves with fine epineurium, and not supporting suture material thicker than 10 or 11/0.
\n
But with further developments, we may define indications and good surgical background conditions with limited nerve damage, good mobilization capacity of stumps, good microsurgical coaptation, and rewarded after a good technique with a significant functional result.
\n
\n\n',keywords:"nerve suture, coaptation, tension, brachial plexus injury, obstetrical, peripheral nerve, microsurgery",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/62054.pdf",chapterXML:"https://mts.intechopen.com/source/xml/62054.xml",downloadPdfUrl:"/chapter/pdf-download/62054",previewPdfUrl:"/chapter/pdf-preview/62054",totalDownloads:425,totalViews:47,totalCrossrefCites:1,dateSubmitted:"November 19th 2017",dateReviewed:"May 15th 2018",datePrePublished:"November 5th 2018",datePublished:"July 17th 2019",dateFinished:"June 11th 2018",readingETA:"0",abstract:"Avoiding suture tension in peripheral nerve coaptation seems to be a clinical dogma since 30 years, although experimental data are weak and clinical practice shows good functional outcome after peripheral nerve repair by direct coaptation under “reasonable” tension, defined by local anatomic feasibility and the use of specific suture material. In this article, we focus on the microsurgical technique of nerve stump coaptation and the distribution of tension through epineural sutures with various suture materials; we also analyze the impact on the different nerve tissue layers, the limit of this approach and its combination with other tissue releasing techniques like paraneurolysis, adjacent joint flexion, or bone shortening.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/62054",risUrl:"/chapter/ris/62054",signatures:"Jörg Bahm, Tobias Esser, Bernd Sellhaus, Wissam El-kazzi and Frederic Schuind",book:{id:"6546",title:"Treatment of Brachial Plexus Injuries",subtitle:null,fullTitle:"Treatment of Brachial Plexus Injuries",slug:"treatment-of-brachial-plexus-injuries",publishedDate:"July 17th 2019",bookSignature:"Vicente Vanaclocha and Nieves Sáiz-Sapena",coverURL:"https://cdn.intechopen.com/books/images_new/6546.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"199099",title:"Ph.D.",name:"Vicente",middleName:null,surname:"Vanachlocha",slug:"vicente-vanachlocha",fullName:"Vicente Vanachlocha"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Surgical technique",level:"1"},{id:"sec_3",title:"3. Morphologic and mechanic analysis",level:"1"},{id:"sec_4",title:"4. Literature research",level:"1"},{id:"sec_5",title:"5. Further investigations and today’s conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'de Medinaceli L, Seaber AV. Experimental nerve reconnection: Importance of initial repair. Microsurgery. 1989;10:56-70\n'},{id:"B2",body:'Bahm J, Ocampo-Pavez C, Noaman H. Microsurgical technique in obstetric brachial plexus repair: A personal experience in 200 cases over 10 years. Journal of Brachial Plexus and Peripheral Nerve Injury. 2007;2:1\n'},{id:"B3",body:'Bahm J, Gkotsi A, Bouslama S, El-kazzi W, Schuind F. Direct nerve sutures in [extended]upper obstetric brachial plexus repair. Journal of Brachial Plexus and Peripheral Nerve Injury. 2017;12(1):e17-e20\n'},{id:"B4",body:'Kirjavainen M, Remes V, Peltonen J, Rautakorpi S, Helenius I, Nietosvaara Y. The function of the hand after operations for obstetric injuries to the brachial plexus. Journal of Bone and Joint Surgery (British). 2008;90(3):349-355\n'},{id:"B5",body:'Kennedy R. Suture of the brachial plexus in birth paralysis of the upper extremity. British Medical Journal. 1903;1(2197):298-301\n'},{id:"B6",body:'Millesi H. The nerve gap: Theory and clinical practice. Hand Clinics. 1986;2:651-663\n'},{id:"B7",body:'Trumble T. Overcoming defects in peripheral nerves. In: Gelberman RH, editor. Operative Nerve Repair and Reconstruction. Philadelphia: Lippincott; 1991\n'},{id:"B8",body:'Haas HG, Holste J. Spannungsentlastung bei Nähten peripherer Nerven. Handchirurgie, Mikrochirurgie, Plastische Chirurgie. 1990;22:156-162\n'},{id:"B9",body:'Driscoll PJ, Glasby MA, Lawson GM. An in vivo study of peripheral nerves in continuity: Biomechanical and physiological responses to elongation. Journal of Orthopaedic Research. 2002;20:370-375\n'},{id:"B10",body:'Hentz VR, Rosen JM, Xiao SJ, McGill KC, Abraham G. The nerve gap dilemma: A comparison of nerves repaired end to end under tension with nerve grafts in a primate model. Journal of Hand Surgery. 1993;18(3):417-425\n'},{id:"B11",body:'Maeda T, Hori S, Sasaki S, Maruo S. Effects of tension at the site of coaptation on recovery of sciatic nerve function after neurorrhaphy: Evaluation by walking-track measurement, electrophysiology, histomorphometry, and electron probe X-ray microanalysis. Microsurgery. 1999;19:200-207\n'},{id:"B12",body:'Miyamoto Y. Experimental study of results of nerve suture under tension vs. nerve grafting. Plastic and Reconstructive Surgery. 1979;64(4):540-549\n'},{id:"B13",body:'Okamoto H, Oka Y. Experimental study on tension and stretching to peripheral nerve. Nihon Seikeigeka Gakkai Zasshi. 1990;64(5):472-484\n'},{id:"B14",body:'Rodkey WG, Cabaud HE, McCarroll HR Jr. Neurorrhaphy after loss of a nerve segment: Comparison of epineurial suture under tension versus multiple nerve grafts. Journal of Hand Surgery. 1980;5(4):366-371\n'},{id:"B15",body:'Scherman P, Kanje M, Dahlin LB. Bridging short nerve defects by direct repair under tension, nerve grafts or longitudinal sutures. Restorative Neurology and Neuroscience. 2004;22(2):65-72\n'},{id:"B16",body:'Terzis J, Faibisoff B, Williams HB. The nerve gap: suture under tension vs. graft. Plastic and Reconstructive Surgery. 1975;56(2):166-170\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Jörg Bahm",address:"jorg.bahm@belgacom.net",affiliation:'
Euregio Reconstructive Microsurgery Unit, Franziskus hospital Aachen, Germany
Department for Orthopaedics and Traumatology, ULB Erasme University Hospital, Belgium
Department for Orthopaedics and Traumatology, ULB Erasme University Hospital, Belgium
'}],corrections:null},book:{id:"6546",title:"Treatment of Brachial Plexus Injuries",subtitle:null,fullTitle:"Treatment of Brachial Plexus Injuries",slug:"treatment-of-brachial-plexus-injuries",publishedDate:"July 17th 2019",bookSignature:"Vicente Vanaclocha and Nieves Sáiz-Sapena",coverURL:"https://cdn.intechopen.com/books/images_new/6546.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"199099",title:"Ph.D.",name:"Vicente",middleName:null,surname:"Vanachlocha",slug:"vicente-vanachlocha",fullName:"Vicente Vanachlocha"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},profile:{item:{id:"237145",title:"Prof.",name:"Ioan Stefan",middleName:null,surname:"Florian",email:"stefanfloriannch@gmail.com",fullName:"Ioan Stefan Florian",slug:"ioan-stefan-florian",position:null,biography:null,institutionString:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",totalCites:0,totalChapterViews:"0",outsideEditionCount:0,totalAuthoredChapters:"2",totalEditedBooks:"0",personalWebsiteURL:null,twitterURL:null,linkedinURL:null,institution:null},booksEdited:[],chaptersAuthored:[{title:"Diffuse Astrocytoma and Oligodendroglioma: An Integrated Diagnosis and Management",slug:"diffuse-astrocytoma-and-oligodendroglioma-an-integrated-diagnosis-and-management",abstract:"For the first time, the WHO classification of brain tumors has introduced molecular parameters in the diagnosis of brain tumors. Together with embryonal tumors, the diffuse gliomas have suffered significant changes in diagnosis, prognosis, and response to treatment. A new concept of “integrated diagnosis” comes to combine the classical diagnosis with the molecular one. While it is still impossible to disregard the histopathological component, according to the new rule (“molecular beats histology”) makes molecular parameters dominant in the final diagnosis. Currently, the diffuse gliomas (oligodendroglial or astrocytic) are nosologically closer than the astrocytomas with a diffuse growth pattern, and the astrocytomas with a more circumscribed growth pattern defined by the presence of the IDH mutation. The family tree was redefined by the presence of the IDH mutation and of the 1p/19q codeletion. The implementation of this new concept in clinical practice will improve patient management, as well as the design of clinical trials and experimental studies. This must also be seen as a model for diagnosis setting in the new molecular era.",signatures:"Ștefan Ioan Florian and Sergiu Șuşman",authors:[{id:"237145",title:"Prof.",name:"Ioan Stefan",surname:"Florian",fullName:"Ioan Stefan Florian",slug:"ioan-stefan-florian",email:"stefanfloriannch@gmail.com"},{id:"237350",title:"Prof.",name:"Sergiu",surname:"Susman",fullName:"Sergiu Susman",slug:"sergiu-susman",email:"sermans2015@gmail.com"}],book:{title:"Glioma",slug:"glioma-contemporary-diagnostic-and-therapeutic-approaches",productType:{id:"1",title:"Edited Volume"}}},{title:"Preventing Rupture: Clipping of Unruptured Intracranial Aneurysms",slug:"preventing-rupture-clipping-of-unruptured-intracranial-aneurysms",abstract:"Unruptured intracranial aneurysms (UIAs) represent a major public health issue due to their unpredictable natural history. Whether to actively treat them or to maintain them under observation remains a hotly disputed topic. In this chapter, we present a review of the literature regarding the history of clipping and its use in UIAs, as well as the experience of our senior author in this field. We performed an extensive Medline and Google Academic search of the relevant literature. We have also made a retrospective analysis on patients harboring UIAs and multiple intracranial aneurysms (MIAs) clipped by the senior author between 1997 and 2017. About 89 patients had solitary UIAs, alongside 101 with MIAs possessing 257 individual aneurysms in total. All UIA patients were discharged with a favorable neurological outcome and no mortality. Concerning MIAs, the majority of cases had 2 aneurysms, the highest number being 6. And, 61 patients from this group had a favorable outcome. In the hands of experienced vascular neurosurgeons, clipping remains a safe option for both UIAs and MIAs. This procedure offers a long-lasting protection from aneurysmal rupture. In the future, new clip technologies and intraprocedural methods of verifying vessel patency and aneurysmal occlusion may further enhance postoperative results.",signatures:"Ioan Alexandru Florian, Teodora Larisa Timis, Cristina Caterina Aldea and Ioan Stefan Florian",authors:[{id:"237145",title:"Prof.",name:"Ioan Stefan",surname:"Florian",fullName:"Ioan Stefan Florian",slug:"ioan-stefan-florian",email:"stefanfloriannch@gmail.com"},{id:"292401",title:"Dr.",name:"Ioan Alexandru",surname:"Florian",fullName:"Ioan Alexandru Florian",slug:"ioan-alexandru-florian",email:"florian.ioan.alexandru@gmail.com"},{id:"301858",title:"Dr.",name:"Teodora Larisa",surname:"Timis",fullName:"Teodora Larisa Timis",slug:"teodora-larisa-timis",email:"doratimis@gmail.com"},{id:"301859",title:"Dr.",name:"Cristina Caterina",surname:"Aldea",fullName:"Cristina Caterina Aldea",slug:"cristina-caterina-aldea",email:"crstnaldea@gmail.com"}],book:{title:"New Insight into Cerebrovascular Diseases",slug:"new-insight-into-cerebrovascular-diseases-an-updated-comprehensive-review",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"236240",title:"M.D.",name:"Anastasiya",surname:"Ryabova",slug:"anastasiya-ryabova",fullName:"Anastasiya Ryabova",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Tomsk National Research Medical Center",institutionURL:null,country:{name:"Russia"}}},{id:"237350",title:"Prof.",name:"Sergiu",surname:"Susman",slug:"sergiu-susman",fullName:"Sergiu Susman",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"242903",title:"Prof.",name:"Valery A.",surname:"Novikov",slug:"valery-a.-novikov",fullName:"Valery A. Novikov",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"242904",title:"Dr.",name:"Olga V.",surname:"Gribova",slug:"olga-v.-gribova",fullName:"Olga V. Gribova",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"242905",title:"Prof.",name:"Evgeny L.",surname:"Choynzonov",slug:"evgeny-l.-choynzonov",fullName:"Evgeny L. Choynzonov",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"242906",title:"Dr.",name:"Zhanna A.",surname:"Startseva",slug:"zhanna-a.-startseva",fullName:"Zhanna A. Startseva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"242908",title:"Dr.",name:"Evgeny G.",surname:"Grigoryev",slug:"evgeny-g.-grigoryev",fullName:"Evgeny G. Grigoryev",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"242910",title:"MSc.",name:"Irina A.",surname:"Miloichikova",slug:"irina-a.-miloichikova",fullName:"Irina A. Miloichikova",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"242912",title:"Dr.",name:"Polina V.",surname:"Surkova",slug:"polina-v.-surkova",fullName:"Polina V. Surkova",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"253421",title:"MSc.",name:"Nataliya",surname:"Turgunova",slug:"nataliya-turgunova",fullName:"Nataliya Turgunova",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null}]},generic:{page:{slug:"OA-publishing-fees",title:"Open Access Publishing Fees",intro:"
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To explore funding opportunities and learn more about how you can finance your IntechOpen publication, go to our Open Access Funding page. IntechOpen offers expert assistance to all of its Authors. We can support you in approaching funding bodies and institutions in relation to publishing fees by providing information about compliance with the Open Access policies of your funder or institution. We can also assist with communicating the benefits of Open Access in order to support and strengthen your funding request and provide personal guidance through your application process. You can contact us at oapf@intechopen.com for further details or assistance.
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For Authors who are still unable to obtain funding from their institutions or research funding bodies for individual projects, IntechOpen does offer the possibility of applying for a Waiver to offset some or all processing feed. Details regarding our Waiver Policy can be found here.
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Added Value of Publishing with IntechOpen
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Choosing to publish with IntechOpen ensures the following benefits:
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Indexing and listing across major repositories, see details ...
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Long-term archiving
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Visibility on the world's strongest OA platform
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Live Performance Metrics to track readership and the impact of your chapter
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Dissemination and Promotion
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Benefits of Publishing with IntechOpen
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Proven world leader in Open Access book publishing with over 10 years experience
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+5,200 OA books published
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Most competitive prices in the market
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Fully compliant with OA funding requirements
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Optimized processes, enabling publication between 8 and 12 months
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Personal support during every step of the publication process
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+146,150 citations in Web of Science databases
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Currently strongest OA platform with over 150 million downloads
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