Rules to determine correct or incorrect movement of rehabilitation exercises.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"445",leadTitle:null,fullTitle:"Designing and Deploying RFID Applications",title:"Designing and Deploying RFID Applications",subtitle:null,reviewType:"peer-reviewed",abstract:"Radio Frequency Identification (RFID), a method of remotely storing and receiving data using devices called RFID tags, brings many real business benefits to today world's organizations. Over the years, RFID research has resulted in many concrete achievements and also contributed to the creation of communities that bring scientists and engineers together with users. This book includes valuable research studies of the experienced scientists in the field of RFID, including most recent developments. The book offers new insights, solutions and ideas for the design of efficient RFID architectures and applications. 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She received her Diploma (M.Sc.) in Automatics and Computers and her Doctorate (Ph.D.) in Automatics, in 1991 and 2000, respectively, both from the Gheorghe Asachi Technical University of Iasi, Romania where she has been Head of Computer Department since 2004. Her research interests include software engineering, RFID applications for the end-consumer, and intelligent systems. Dr. Turcu is an Editor of four books and has served on various program committees of conferences in computing and RFID systems. She also has served as a reviewer for numerous referred journals and conferences. She is the Editor in Chief of the International Journal of Radio Frequency Identification & Wireless Sensor Networks. 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The ePHoRT platform has a “practice module” organized into three stages that are meaningful for the patient’s recovery process. These stages are characterized by a growing level in the intensity of the exercises. Stage 1 is carried out during the week following the surgery and consists mainly of exercises performed lying down. Foot rehabilitation movements begin in stage 2 (the second week after surgery). Finally, stage 3 is characterized by functional exercises, which consist of preparing the patient to recover a regular walk. The ePHoRT platform is in the design stage and follows a process of agile and collaborative development focused on the user.
At the present time, it has been seen that intelligent systems embrace a large number of daily life tasks and activities of the society. The objective of these systems is to solve a variety of existing problems in society more efficiently and with accurate results. One of the characteristics of these systems is the interaction between the user and the computer [1], which allows the optimal handling of these systems intuitively.
The present work proposes the development of a virtual representation of the body structure of a patient who performs rehabilitation exercises. This digital representation is called avatar [2], which duplicates the movement of the human being that has been detected by a Kinect camera from Microsoft’s Xbox One.
The captured movements are imitated by the avatar and executed in real time. Subsequently, if the patient performs an incorrect exercise, the system will show an alert with the part of the body where it is moving wrongly, with colors that help the patient’s interaction. A detector subsystem applies the diffuse logic technique that identifies the execution of rehabilitation exercises; this allows the avatar to be a means of interaction between human and computer.
In the work presented by Ichim et al. [2], the development of three-dimensional facial avatars is detailed. The system detects facial expression from a template and a sequence of recorded images through an optimization that integrates the tracking of expression characteristics. This study helps the design of new applications of computer animation as well as online communication based on personalized avatars. In addition, demonstrations of several applications in real time that verify the process of avatars creation are presented.
In the work published by Pavone et al. [3], the application of immersive virtual reality and electroencephalography recording is presented to explore the avatar’s error incorporation when it is viewed from a one-person perspective. The avatar activates the error monitoring system in a patient’s brain and helps its development. The results show that immersive virtual reality can obtain optimal results with the application of an artificial agent. These tools improve the fine-tuning learning (motor skills), up to critical social functions (reading or anticipating the other people’s intentions).
The study published by Belal et al. [4] presents the study of pulse oximetry. It is a technology used to monitor oxygen saturation in neonates and pediatric patients. The equipment that measures the pulse oximetry is not precise, whereby they generate false alarms. This study proposes the development of a knowledge-based system that uses fuzzy logic to classify plethysmogram pulses into two categories: valid and artifact. The model correctly classified 82% of the valid segments and 93% of the distorted segments.
The study developed by Guevara et al. [5] proposes a model of real-time movement detection of patients of rehabilitation from hip surgery. The model applies the fuzzy logic technique to identify correct and incorrect movements in the performance of rehabilitation exercises using the motion capture device called Kinect of Xbox One. It proposes an algorithm that works with a multivariable logic model. The diffuse model identifies movements of the patient during the performance of rehabilitation exercises. On the other hand, a 3D avatar is applied, which copies and graphically displays the real-time exercises performed by the patients.
The information used for the avatar development was obtained from the capture of body points by the Kinect camera of the Xbox One (Figure 1). In this study, we gained information of four patients who have gone through hip surgery. This information was collected during 5 weeks of rehabilitation, with high-, medium-, and low-difficulty exercises. Patients performed a set of exercises correctly and incorrectly, which enabled the avatar real movement.
Body points captured by Microsoft’s Kinect [
The detected points were 25, the same ones that can identify any movement in three dimensions. For this reason, the database contains 75 attributes. An information preprocessing has been carried out to identify the relevant information, eliminating repeated data as well as noise.
The attribute selection for the algorithm has been identified as 18 essential points of the skeleton detected by the Kinect Xbox One. The specific points are 0y, 6x, 6y, 10x, 10y, 12x, 12y, 13x, 13y, 14x, 14y, 15x, 15y, 16x, 16y, 17x, 17y, and 19x. These points determine the movement in a more detailed way, allowing depth and opening angle detection. The points selected for the front step exercise are those shown in Figure 2 as well as in the lateral step exercise, as shown in Figure 3.
Selected points for front step exercise.
Selected points for lateral step exercise.
The proposed model uses the points identified in the previous section. With this information, we will calculate the speed and angle of the limb opening that have performed the rehabilitation exercises correctly. This information is vital to build the diffuse model and to determine the patient’s correct posture while performing the exercise (arms, shoulders, and head), as well as the execution speed and the opening angle.
To calculate the angle of the limbs, we identified starting points defined as
Limb opening angle calculation.
To complete the movement modeling of the limbs, it has been based on Table 1, which details when the rehabilitation exercise is performed in a low, correct, or high way.
Rules to determine correct or incorrect movement of rehabilitation exercises.
The diffuse model is based on Table 1 variables, where the patient’s correct movement is obtained while performing each of the rehabilitation exercises. Any exercise that is outside the range identified as “good” will be detected as “poorly executed exercise,” where the system will give an alert that the variable is being performed incorrectly. The diffuse model is presented in Figure 5.
Diffuse model for exercise detection in telerehabilitation [
The following section describes the avatar design and development process in three dimensions using the Blender tool, based on the information captured from several patients who performed physiotherapy exercises over a period of 4 weeks. The exercises performed in this data collection phase were lateral step and front step (Figure 6).
Exercise images for lateral step and front step.
The following section describes how the patient’s avatar was designed. This avatar will imitate the patient’s movements during rehabilitation.
The avatar design is fundamentally based on the skeleton in Figure 1, which describes all the points detected by the Kinect. This design was then loaded to Blender and the scale of the header image adjusted, as shown in Figure 7.
Skeleton detected by Kinect uploaded to the Blender tool.
To generate a three-dimensional avatar was necessary to generate two 3D windows (two windows for the avatar frontal and lateral view), as can be seen in Figure 8.
Front view and side view windows of the doctor avatar.
For the avatar design, the work has to be simultaneous with the modeling of two avatars, both doctor (male) and nurse (female). This development has been implemented with all the characteristics of clothing, ethnicity, and age of the employees that work in a health center, as shown in Figure 9. Part of the body of the avatar is designed with proportional measures as well as with skin and clothing textures in order to have a real shape and contour avatar.
Doctor avatar (man) and nurse avatar (woman).
Finally, we obtained two functional avatars that will imitate the patient’s movements in three dimensions. These avatars will be able to move thanks to an interconnected system between the Kinect and a diffuse model of detection of speed, rhythm, and angles of movement of each of the 75 corporal points. This diffuse model is connected to the avatar through Python language and Java for online movement, which results in efficient response time.
The telerehabilitation model implementation was obtained with N-layer development architecture of the intelligent system. As shown in Figure 10, the architecture covers layers such as a database, application server, web server, and application.
N-layer architecture of the telerehabilitation platform.
The database server contains the patient’s information (name, age, gender, and medical history). It also contains the data of each of the rehabilitation exercises performed correctly. This allows that during the execution of a movement in the rehabilitation, the system can identify if the patient is doing the exercises correctly or incorrectly. The application server is the one that contains all the programming to register the information in the database, interconnection with devices (Kinect), consumption of complementary applications (avatar in Blender), and system security. The application server’s architecture is presented in Figure 11. This architecture is service-oriented, due to the fact that many add-ons to the system are not executed in Java.
Telerehabilitation system service-oriented architecture.
In the business rules layer is the diffuse model of detection of rehabilitation exercises. The implemented model uses the points captured by the Kinect, to later calculate the angles and maximum and minimum speeds of the limbs, so that the patient can perform a correct rehabilitation exercise. In addition, it detects the optimal distances of movement for complementary points such as the arms, shoulders, and head. To calculate the appropriate angles for each of the exercises was necessary to identify the starting point B(Xi, Yi), the ending point C(Xj, Yj), and the value of the angle α of the triangle formed by the trajectory.
The diffuse model shown in Figure 5 detects the opening angle between the legs, hip movement, shoulder movement, head movement, and the speed at which the exercise was executed. With these variables, it can be efficiently determined in real time if an exercise has been performed correctly or incorrectly [7, 8].
While the patient is performing the exercises, the avatar copies and performs the patient’s movements in real time, which makes it easier to graphically identify the exact moment of an incorrect movement. The system’s graphical interface developed in Java and hosted in an Apache Tomcat web server allows user’s access around the world through an Internet domain.
The web application is deployed by the user’s device, which must be connected to the Kinect motion capture device, that allows it to be connected to the system and records the patient’s movement in real time. The system requires a bandwidth greater than 2 MB/s Internet access so that the application can perform optimal results.
The results obtained in this proposal have revealed that the exercise detection rate is 97.42% with a false-positive percentage of 2.58%, as shown in Table 2.
Correctly classified | Incorrectly classified | |
---|---|---|
Well-executed exercise | 2100 | 0 |
Badly executed exercise | 1310 | 90 |
Test results in the diffuse model of rehabilitation exercise detection.
In addition, it has been observed in the development of the tests that 18% of the time, the patients perform correctly an exercise with respect to the angle and only 27% do it at an acceptable speed during its execution. On the other hand, the detection time is 0.0045 s while training and 0.002 s in the testing phase.
Usability refers to the degree to which a product can be used to achieve goals in a specific context of use [9]. A software product that has not gone through a process of usability evaluation will not guarantee that users take advantage of the qualities and the benefits of the application. To prevent users from leaving the telerehabilitation platform, it is necessary to carry out exhaustive evaluations of usability.
Several studies have highlighted the main advantages of combining heuristic evaluation and cognitive method for usability assessment [10, 11, 12, 13], among them: facility of interaction with the interfaces, immediacy of the response, non-intrusive methods, time or means are not expensive, these tests can be done inside a laboratory, good for the requirements refining, does not involve end users, does not require a fully functional prototype, does not require advance planning, applicable to the stages of design, coding, testing, and implementation of software.
Other studies [12, 14] presented the results of the usability evaluation carried out on the iterative design of the prototypes, obtaining advantages such as facilitating future actions of the end users and improving the learning and development processes. However, the authors said that an online prototype has several drawbacks since it still presents only part of the final version and a limited one in terms of colors and interactive elements. The previous studies do not systematically present the evolution of usability, through an orderly and cyclical process. In addition, these studies do not show that it is possible to improve the use of telerehabilitation platforms without endangering patient safety.
An experiment was carried out to understand the perceived usability for the ePHoRt platform and to determine a baseline on which to initiate the process of iterative usability improvement of the platform. Figure 12 shows one on the main interfaces of the platform. The experiment began with 23 participants in an age range of 18–24 years old for the first and second iterations, corresponding to the first phase of the experiment. For the second phase, the experiment had 39 participants for the third iteration and 12 participants for the fourth iteration. The age range for these last two iterations was 18–30 years old [15].
ePHoRT active exercise interface.
The research results showed improvements in usability through four iterations. Each of the iterations contributed with a list of improvements that were implemented according to the severity level.
In the first iteration, the experts found 39 heuristic violations; these violations were distributed as follows: 12 of high severity, 16 of medium severity, and 11 of low severity. The heuristics with higher incidence and severity were visibility of system status, help and documentation, feedback, and extraordinary users.
In the second iteration, the number of usability problems decreased. However, two atypical cases were presented: (1) increase in the number of usability problems for heuristic “user control and freedom” and heuristic “physical constraint” and (2) the number of usability problems that did not vary for the heuristic “match between the system and the real world” and heuristic “aesthetic and minimalist design.”
In the third iteration, 14 mock-ups were designed considering the comments of the previous iterations. In the heuristic evaluation, there were a total of 92 heuristic violations. Experts reported that eight interfaces (57.14%) did not achieve the appropriate feedback for users. Therefore, the platform incurred a clear violation of the heuristic “visibility of system status.” In addition, of these eight interfaces, the experts reported the heuristic violation of “help and documentation” on the Login interface and the password reset interface. Finally, experts considered that 42.86% of the interfaces (six) were not flexible or efficient in use.
In the fourth iteration, 17 mock-ups were designed, incorporating the observations from the previous iteration. The experts reported a total of 364 heuristic violations. However, the questionnaire interface had only three low-severity usability problems. This value had been decreasing in severity throughout the evaluation process. The experts assigned greater importance to the following interfaces: questionnaire, acute rehabilitation, active exercise (1/3); acute rehabilitation, active exercise (2/3); acute rehabilitation, active exercise (3/3); and acute rehabilitation, learn (1/5) interfaces.
The Web [16] has revolutionized our daily life, becoming the primary source of information, knowledge, consultation, and provision of services and interaction in various areas. Services related to education as well as learning resources are increasing around the world; therefore, it is essential that users, regardless of their disabilities, have accessible learning resources. This study aims to raise awareness of any professional who develops educational applications that apply accessibility standards to generate inclusive and accessible applications. For within the group of possible users, there may be participants with some type of visual disability, such as users with low vision and elderly people. On the other hand, we must emphasize that developing an accessible application does not have to go against an attractive graphical interface, that is, an accessible application does not necessarily have to be “unsightly.”
It is convenient to remember that not all visual disabilities are the same and computer management skills also depend on the age of the user, so in the article, these two variables will always be considered. Nowadays, it is necessary to consider the different levels of education, especially for elderly patients and those with disabilities. Therefore, the educational resources of the Tele-habilitation platform must provide instantaneous and ubiquitous access to all types of services and content, including documents and digital resources.
The digital educational resources have become a valuable alternative to support the teaching and learning processes, taking advantage of the possibility of presenting the contents through different multimedia formats. Therefore, it is necessary that educational resources for learning apply accessibility features that allow the interaction of users regardless of their conditions and preferences. This document presents a proposal for the evaluation of the accessibility of multimedia educational resources, where it is suggested to apply the WCAG 2.1 in addition to a series of phases to automatically and manually assess the level of accessibility of the educational resources used in the platform of telerehabilitation of the ePHoRT project.
Accessibility is related to the degree to which people can use or access a service, regardless of their technical, cognitive, or physical abilities [17]. Web accessibility describes methods and theories to make resources, in their multiple forms, more accessible for all people especially for the elderly and people with disabilities. In general, the educational resources of any website or platform must provide universal access, that is, if it includes videos, subtitles must be placed so that the content can be interpreted by people with visual disability or low vision; if people have hearing problems, an audio description should be included, making sure that the resources are inclusive.
The United Nations [18] “Recognizes the importance of access to the physical, social, economic and cultural environment, to health and education and to information and communication, so that persons with disabilities can fully enjoy all human rights and fundamental freedoms.”
According to Kurtz et al. [19], the number of people who have undergone surgery for total hip arthroplasty (THA) has increased significantly in the last 10 years, and it is estimated that it will continue to increase.
In line with Ravi et al. [20], THA is a surgery that refers to the replacement of the femoral head and acetabulum of the hip joint. This surgery is usually performed in older adults, due to degenerative joint disease or progressive wear and tear of the joint, and the demographics of patients who decide to undergo THA has become increasingly popular.
In agreement with Salavati et al. [21], the young persons may have higher functional objectives than older persons, which may modify the structuring of rehabilitation protocols. In any of the cases, what is intended after surgery is to calm the pain, restore normal function, and improve the quality of life of people.
In this study, we started with the following question: Are multimedia resources accessible to all users of the telerehabilitation platform?
It is considered an accessible multimedia resource if the content is available to all users, regardless of their disability or application context [22]. It is of vital importance that the educational resources of the platform are accessible even for people who use a screen reader. This research analyzes accessibility problems with multimedia resources, especially those related to video and audio.
According to Rybarczyk et al. [23] in the telerehabilitation platform, learning processes can be oriented in different stages of rehabilitation and include preventive, curative, and maintenance processes.
For the early recovery of the patient on the platform, instructions are included on the general consequences of the procedures and their likely risks, so it is intended to guide the patient through the rehabilitation process at all stages. Proper guidance can help the patient make the right movements to reinforce the safety of functional tasks and motivate the patient to complete the rehabilitation program. Considering that the patient should perform the exercises in a standing position and at a certain distance from the computer, inclusive resources are proposed to guide the patient in the learning process. One of the main elements that have proven to be useful and efficient in education as a means of transmitting and strengthening knowledge is the implementation of multimedia teaching materials, including the use of videos, audios, and PDF files, which constitute an excellent support material. Conforming to Acosta-Vargas et al. [24], the method used to assess access to educational resources consists of identifying the type of resource, reviewing access barriers to the resource according to WCAG 2.1, combining automatic and manual methods to assess the accessibility of resources, recording identified barriers in a spreadsheet, analyzing the results, and finally suggesting possible recommendations.
Baruch et al. [25] indicate that multimedia accessibility policies propose that “All multimedia elements such as audio or video, produced or published must be accessible at the time of publication.” Multimedia accessibility proposes a simple text transcription, so that it is necessary to place a transcript in audio-only recordings, to meet all the success criteria suggested by WCAG 2.1. On the other hand, multimedia resources according to the World Wide Web Consortium (W3C) [26] include texts, images, graphics, animations, video, and sound to present or communicate specific information. Consequently, to cover all the parameters that intervene in the accessibility of educational resources, it is necessary to evaluate a set of dependent components such as human factors, in this case all the users of the telerehabilitation platform are considered, including users with special needs, technological factors to provide accessibility, and user interaction with the device in the environment of the platform, which include criteria to favor accessibility with the indicated components. ISO/IEC 40500: 2012 [27] is equivalent to the Web Content Accessibility Guidelines 2.0 (WCAG 2.0), is related to the Web Content Accessibility Guidelines 2.1 (WCAG 2.1) which consists of 4 principles, 13 guidelines, and 76 compliance criteria (success), plus an undetermined number of sufficient techniques and counseling techniques.
The four principles are the same as those contained in WCAG 2.0:
Principle 1—Perceptibility: information and user interface components should be presented to users in the way they can be perceived. It has 4 guidelines and 29 compliance criteria.
Principle 2—Operability: the user interface and the navigation components must be operable. It has 5 guidelines and 29 compliance criteria.
Principle 3—Comprehensibility: the information and management of the user interface must be understandable. It has 3 guidelines and 17 compliance criteria.
Principle 4—Robustness: the content must be robust enough to be based on its interpretation by a wide variety of user agents, including assistive technologies. It has one guideline and three compliance criteria.
In March 2012, Web Accessibility Initiative (WAI) published the Methodology of Website Accessibility Conformance Evaluation Methodology (WCAG-EM) 1.0. In 2014, a new version was published [28]. The WCAG-EM methodology allows determining if the contents of the websites are evaluated to comply with the WCAG 2.1 accessibility guidelines or not. In this research the WCAG-EM 1.0 was applied. In this case, it was used to apply the evaluation of multimedia resources specifically to the videos. It consists of five sequential phases, as shown in Figure 13.
Evaluation of multimedia resources.
Screenshot of the resource to evaluate.
Table 3 records the results obtained in the evaluation with PEAT. It contains the video identifier, length of material, luminance flash failures, red flash failures, extended flash warnings, result status, and percentage.
URL | Description | Standard | Success criterion | Fr | Lm | Rs | Lff | Rff | Efw |
---|---|---|---|---|---|---|---|---|---|
http://telerehabilitation.udla.edu.ec/learning/resource/2/media/1 | Patient in the process of learning exercises on the telerehabilitation platform | WCAG 2.1 | 2.3 | 25 | 00:06.19 | P | 0 | 0 | 0 |
Evaluation with the photosensitive epilepsy analysis tool.
Fr = frame rate, Lm = length of material, Rs = result status, Lff = luminance flash failures, Rff = red flash failures, Efw = extended flash warnings, P = passed
Success criterion | Level | Comply |
---|---|---|
1.2.1 Audio-only and video-only (prerecorded) | A | 1 |
1.2.2 Captions (prerecorded) | A | 0 |
1.2.3 Audio description or media alternative (prerecorded) | A | 0 |
1.2.4 Captions (live) | AA | 0 |
1.2.5 Audio description (prerecorded) | AA | 0 |
1.2.6 Sign language (prerecorded) | AAA | 0 |
1.2.7 Extended audio description (prerecorded) | AAA | 0 |
1.2.8 Media alternative (prerecorded) | AAA | 0 |
1.2.9 Audio-only (live) | AAA | 0 |
Manual evaluation of the video resource.
Preferences. In this option, it should allow the configuration of subtitles, descriptions, keyboard, and transcription.
Show the subtitle settings. In this case, it should include the options to configure according to the preference of users such as position, font, font size, text color, background, and opacity.
Video speed, subtitles, and audio in the application. The user should have the option to customize the speed of the video, subtitles, and audio according to the user’s preference and disability.
Language. In this option, the user could customize and choose the language for the audio description and subtitles. This option should allow moving the window to the position you want the user to.
Audio description preferences. In this option, the media player must allow the configuration of the audio description format in several ways so that it is displayed in the highlighted form of the color the user wishes while the video is presented. In addition, it is vital to include the option of automatic video pause and the option to make the description visible. On the other hand, it is essential to include keyboard preferences using keyboard shortcuts. This option should allow moving the window to the position you want the user to.
Visualize the speed of the video. In this option, the user can visualize the speed in the video according to the configured speed.
Volume. In this option, the user can configure the volume of the audio.
Screen. In this option, the user can view the video in full screen.
Sign language. In this option, you can include a screen with a description of it in sign language.
Recommendations for the creation of accessible videos.
In the evaluation of the accessibility of an educational resource, it is vital to combine the automatic tools with manual evaluation. In this case, for the video, a resource is not yet known as an automatic tool that performs the evaluation at 100%. In the automatic evaluation, the tool PEAT was applied, which helps to identify the luminance flaw faults, the red flashing faults, and the extended flashing warnings that would affect users with epilepsy. According to the PEAT report, it is observed that it overcomes the problem.
The evaluation was complemented with a manual analysis when considering the possible barriers for the users of the telerehabilitation platform. The results are detailed in Table 4.
In Figure 16, it is observed that the video does not comply with the WCAG 2.1 guidelines, that is, it is not inclusive. When applying the correlation between the success criteria and compliance, the coefficient is −0.5. This implies that the correlation is negative and moderate. Failures are related to the absence to configure user preferences by including keyboard compatibility, colors with good contrast, bright design, text to speech, links, buttons and controls, video subtitles, customizable text, speech recognition, understandable content, notifications, and comments.
Analysis of success criteria vs. compliance.
The results of this study show that the multimedia resource evaluated did not reach an acceptable level of accessibility. Therefore, it is necessary to correct the faults to comply with the level of accessibility recommended by the W3C. It is necessary to include accessibility measures in the development of educational materials through the application of a checklist to correct the problems identified. The results obtained in the evaluation can serve as a starting point to implement future video resources considering WCAG 2.1.
The recommendations suggested in phase 9 can provide ideas on how to develop and create educational videos to make them more accessible and inclusive. This research can serve as base information for future projects with a more significant number of educational resources. Future research may propose new methods to evaluate multimedia resources. With respect to the videos and sound recordings, in both cases, a transcription of the dialogues, a description of the sounds, and control of the reproduction speed must be provided. However, the inappropriate use of multimedia elements may cause a barrier to user access.
The application of the fuzzy logic technique in a telerehabilitation platform allowed identifying correct and incorrect movements in the execution of rehabilitation exercises of patients after hip surgery. The main contributions of the proposed fuzzy detection algorithm are flexibility, tolerance with inaccuracy, and the ability to identify features that best predict different points of movement.
The design of avatars allowed the digital representations of the patient’s movements captured with Microsoft’s Kinect. The main contributions are to monitor exercises in real time, to identify the recovery progress of patients, to provide medical information to physiotherapeutic, and to facilitate an engaging experience for patients.
The limitation that we found in the implemented model is that it was very useful for exercises that are performed standing; however there are exercises that the patient performs lying down, in which Kinect was not able to capture patient’s movements, and it is recommended for future work to use other type of sensors.
The web application of a diffuse 3D model for the detection of rehabilitation exercises after a hip surgery is systematically related to the usability and accessibility of the telerehabilitation system in search of achieving inclusive websites that display correctly on any device.
The method applied in improving the usability and accessibility of educational resources for the telerehabilitation system is very important since access to the Internet is a growing trend. This project addressed the importance of applying the principles specified in WCAG 2.1 to develop accessible resources. The development and execution of this project can serve as a starting point to develop targeted strategies to raise awareness about the importance of the stages of design of a website or educational resources, where the accessibility guidelines and criteria must be applied in order to achieve equal access to information for all people.
Finally, the system has limitations since it is not possible to guarantee for a web page or educational resource to be accessible for all types of users with disabilities or to comply with all accessibility standards.
This research has been partially supported by the
The human body cells need the energy to maintain their functions. This energy is mainly provided by sugar, carbohydrates and fat. To utilize these nutritive substances and to produce energy in return, inspired oxygen (O2) from the air is needed. In the mitochondrial electron transport chain, O2 is the final electron acceptor to generate ATP within the eukaryotic cells [1]. Whilst O2 is needed for most life on earth, most of the earth’s atmosphere does not contain a lot of O2. From the surface of the planet, up to the border of space, the atmosphere contains a constant fraction of around 21% O2 (often expressed as the FiO2 of around 0.21), 78% of nitrogen, 0.9% argon and 0.1% of other gases like carbon dioxide, methane, water vapor, etc. At sea level, the partial pressure of the above-mentioned gases can be estimated to be 593 mmHg for nitrogen, 160 mmHg for oxygen and 7.6 mmHg for argon. Indeed, the weight of air is responsible for atmospheric pressure.
It’s well known that increasing altitude leads to quasi-exponential reductions in barometric pressure (PB). At the summit of Mt. Everest (8848 m), the PB is about one-third of the sea-level values. The reduced atmospheric pressure has therefore a direct influence on the partial pressure of inspired oxygen, which can be seen in Figure 1.
Relationship between barometric pressure (PB), partial pressure of inspired oxygen (PiO2) and altitude. PB and PiO2 decrease exponentially with increasing altitude at a constant FiO2 of 21%. The solid line represents PB and the broken line represents PiO2.
The inspired partial pressure of oxygen (PiO2) is lower than atmospheric oxygen partial pressure because water vapor is in the airways. The pressure of water vapor (PH2O), which is not dependent on atmospheric pressure but temperature, should be taken into account when PiO2 is calculated [2]. The inhaled air gases will get humified and warmed by the airways and as a result, the PH2O will adjust the partial pressure of all inhaled gases, including O2.
Accordingly, the product of PiO2 can be calculated using Eq. (1):
Since PB is known to be approximately 760 mmHg at sea level, PH2O is normally about 47 mmHg and O2 makes up to 20.93% (FiO2 of 0.2093), PiO2 is equal to 0.20932 multiplied by 713 mmHg.
Consequently, hypoxia is defined as a combination of PB and the FiO2 that results in any PiO2 under a normoxic value of 150 mmHg [3]. However, the duration of hypoxic exposures as well as the magnitude of PB reductions has a significant impact on the (patho-)physiological response. Examples of fast-changing normoxic to hypoxic environments are fast ascended on the mountain summits during mountaineering, military and rescue services and travels with fast transportation to altitude. Acute mountain sickness is well-known to occur due to extensive and fast decreases in Pb, normally beginning at an altitude of above 2500 m. The Lake Louis Consensus Group defined acute mountain sickness as the presence of headache in an unacclimatised person (recently arriving at an altitude above 2500 m), plus the presence of one or more of the following symptoms: gastrointestinal symptoms, fatigue and/or weakness, dizziness or a positive clinical functional score, resulting in a total score of ≥3 [4]. If not treated correctly, people with acute mountain sickness can develop high-altitude pulmonary oedema or high-altitude cerebral oedema [5]. However, if the human body is gradually exposed to hypoxic conditions, it can acclimatize and adapt.
The following chapters will focus on the main types of hypoxia, the physiological consequences of acute hypoxia and the clinical consequences of the current chapter.
Insufficient O2 supply to the human tissues can have various reasons and can lead to severely impaired body functions. There are four main types of hypoxia, which can be classified as hypoxaemic hypoxia, anemic hypoxia, stagnant hypoxia and histotoxic hypoxia.
One of the most common types of hypoxia is called generalized or hypoxic hypoxia, which is generated from the actual (natural/simulated) environment and inside the lungs. This type is caused by a reduction of the partial pressure of alveolar O2 (PAO2) [6]. This value is well known and a great help to calculate the partial pressure of oxygen inside the alveoli (as it is not possible to collect gases directly from the alveoli), which can be used for potential cell diffusion [7]. The alveolar gas equation uses three variables to calculate the alveolar concentration of oxygen, which can be seen in Eq. (2):
where PaCO2 is the partial pressure of carbon dioxide which is under normal physiological conditions approximately 40 mmHg. RQ is the respiratory quotient which is, the ratio of the volume of produced CO2 divided by the volume of consumed O2 during the same time [8]. Dependent on metabolic activity and diet, RQ is considered to be around 0.825 [9], within a physiological range between 0.70 and 1.00. Consequently, PAO2 at sea level is: 0.2093 × (760–47) – 40/0.825 = 100.7 mmHg. PAO2 is the main driving factor for alveolar diffusion and thus O2 supply on a cellular level.
Hypoxic hypoxia can be observed typically when FiO2 is low, during hypoventilation of the lungs or at the presence of pathological airway conditions. Low FiO2 levels can occur due to failure of gas delivery systems, inadequate supply from altitude simulating machines, or e.g., exorbitant inhalation of nitrous oxide during anesthesia [10]. Hypoventilation can occur due to insufficient respiratory rate, obstruction of airways, skeletal deformities, respiratory muscle paralysis, etc. Severe lung diseases (e.g., pulmonary fibrosis, pulmonary embolism) can also lead to alveolar-capillary diffusion blockade [11]. Hypoxic hypoxia affects the entire body. Typical symptoms are agitation and anxiety while low blood O2 goes along with increased heart rate, dyspnea and bluish color of the skin.
Anemic hypoxia is caused by reduced oxygen transport capacity in the blood [12]. The red blood cells (erythrocytes) are responsible for the transport of O2 through the body [13]. Around 90% of the erythrocyte is made up of haemoglobin, the iron-containing protein that binds O2 on its heme. Although, the arterial oxygen tension is normal at this type, reduced erythrocytes/haemoglobin or functional insufficiency of haemoglobin leads to impaired oxygen delivery to the tissues [14].
A deficiency in the number of erythrocytes can result, for example, from excessive blood loss after trauma. Other forms of the reduced number of erythrocytes can be present in case of abnormal red blood cell breakdown (haemolytic anemia) [15]. Increased haemolysis can be observed during hereditary spherocytosis, sickle cell disease or autoimmune diseases (e.g., aplastic anemia) [16].
Deficiencies of different factors can also lead to severe anemia. Iron is the main component of haemoglobin, giving the blood the red color and is the prime carrier of oxygen. During the physiological haemolysis, iron will be bound to the glycoprotein transferrin for transportation to the bone marrow, where it will be reused for haemoglobin synthesis. This process helps to limit an extensive loss of iron from the body. However, iron deficiency is one of the main causes of anemia, called microcytic hypochromic anemia [6]. This type of anemia can be caused by any factor which reduces the body’s iron storage, leading to small erythrocytes with reduced haemoglobin mass [17]. In contrast, deficiencies in vitamin B12 or folic acid can cause anemia due to abnormally enlarged erythrocytes and their immature precursors, called macrocytic hyperchromic anemia [18].
Functional insufficiency of haemoglobin is associated with reduced oxygen binding capacity. An example is an intoxication through excessive carbon monoxide inhalation. Compared to oxygen, carbon monoxide has a 200–300 times higher affinity to haemoglobin. After inhalation, carbon monoxide reaches the respiratory gas exchange zone and binds on haemoglobin [10]. This chemical binding process leads to the formation of carboxyhaemoglobin. Consequently, oxygen-carrying capacity is decreased which will lead to reduced oxygen transportation to the tissues and as a consequence tissue hypoxia [19]. Another possibility of functional insufficiency for the transportation of oxygen is methaemoglobinemia. Haemoglobin changes to methaemoglobin, when bivalent iron (Fe2+) is oxidized to Fe3+, which is worthless for oxygen transport [20]. Under normal circumstances, methaemoglobin reductase limits the build-up of methaemoglobin through the reduction of haemoglobin oxidation [21]. Patients with a deficiency of methaemoglobin reductase, strong oxidative stress (e.g., smoking) and medication can therefor experience very low concentrations of tissue oxygenation, demonstrating comparable symptoms as seen in hypoxic hypoxia. However, it must be mentioned, that the unfavorable conditions of low tissue O2 can be compensated better during hypoxic hypoxia than during anemic hypoxia.
Stagnant, also called ischemic or circulatory hypoxia takes place as a cause of insufficient blood supply to the tissues while the blood is normally oxygenated. Ischemic hypoxia can be observed on a central and local level [6].
Central circulatory hypoxia can often be observed in patients with cardiac manifestations. If the left ventricular output is for example decreased, blood flow to the organs is impaired [12]. This can also happen during shock or, at a local level after strong vasoconstriction (e.g., cold exposures) or venous stagnation of blood [22]. Oxygen can only be stored to the very limited amount within the human cells. Even myoglobin, binding O2 on its heme protein, has a very limited oxygen storage capacity [23]. Consequently, myoglobin is more involved in transportation than the storage of oxygen. Oxygen saturated myoglobin enables facilitated intercellular O2 transportation, because the oxygen-enriched myoglobin molecules can “move” within the cells (facilitated diffusion) which is extremely important at a low partial pressure of O2 (PO2) [24]. Although, the gas exchange rate on the alveolar level, the concentration of haemoglobin, oxygen content and tension are on a normal level, O2 extraction at the level of the capillaries will be increased [6]. This process will directly elevate the arteriovenous difference of blood O2 content leading to venous hypoxia. However, as the increased oxygen extraction is normally insufficient to supply the tissue with an adequate amount of O2, this process will lead to impaired cellular oxygen coverage and impaired functioning.
Histotoxic hypoxia or dysoxia is a state, where cells are unable to utilize oxygen effectively [12]. This is the case, when the mitochondrial terminal oxidation is disturbed while there is sufficient oxygen available in the blood. Dysoxia will therefore lead to a pathological reduction in ATP production by the mitochondria and is not preceded by hypoxaemia [6].
An example of histotoxic hypoxia is the intoxication with cyanides, which can occur from fire sources. Intravenous and inhalation of cyanide produce a more rapid onset of hypoxia than the oral or transdermal route due to the fast diffusion into the bloodstream [25]. The main effect of cyanide intoxication is related to the inhibition of oxidative phosphorylation, where oxygen is utilized for ATP production. Cyanide can reversibly bind to the enzyme cytochrome C oxidase, blocking the mitochondrial transport chain. This will cause cellular hypoxia and, as mentioned above, pathological low levels of ATP, causing metabolic acidosis and impairment of vital functions [26, 27].
Rapid ascends from sea level to altitude and sudden exposure to a hypoxic environment will immediately lead to acute physiological responses to adapt to the acute hypoxaemic situation [28]. The degree of acute hypoxic stress about time can lead to symptoms ranging from dizziness, feeling of unreality and dim visions to rapid unconsciousness [29]. Sudden exposure to the summit of Mt. Everest will for example lead to unconsciousness within 2 min. However, when the same amount of hypoxaemia is experienced over several days to weeks, one could function relatively well under these conditions. This adjustment is called acclimatization which is a complex process over time and shows great variability within individuals [29]. In the following chapters, the acute response to sudden exposure to a hypoxic environment is discussed.
The respiratory system will directly respond to the low oxygen availability in the air and is often seen as the primary defense against the hypoxic environment. Chemosensory systems will rapidly lead to increased pulmonary ventilation because of compromised O2 availability [30]. These regulatory responses can be attributed due to specialized chemoreceptors such as the carotid bodies in the arterial circulation and neuroepithelial bodies in the respiratory tract as well as the direct response of vascular smooth muscles to hypoxia [31].
Whilst hypoxia acts as a vasodilator in the systemic circulation, it has been observed, that the vessels of the pulmonary vasculature constrict under hypoxia, leading to pulmonary hypertension [32, 33]. Hypoxic vasoconstriction is intrinsic to the pulmonary vasculature smooth muscle cells and is initiated by the inhibition of K+ channels which set the membrane potential [34]. This process will lead to depolarization, activation of Ca2+ channels as a result of the electrical impulse and, as a consequence, an increase in cytosolic calcium levels and therefore constriction of the myocytes [31]. Pulmonary hypertension might help to match ventilation and perfusion within the lungs. However, pulmonary hypertension can also lead to severe pathological situations (e.g., altitude-related right heart failure).
Carotid bodies, sensitive to monitoring a drop in arterial O2 levels, and neuroepithelial bodies, detecting changes in inspired O2, respond immediately to decreased O2 supply [35]. Both respond by activating efferent chemosensory fibers to produce cardiorespiratory adjustments during hypoxic exposures [36, 37]. When low arterial PO2 is detected, the carotid body signals the central respiratory center to increase the (minute) ventilation. The increased ventilation of the respiratory tract can be primarily associated with an elevated tidal volume and an even greater elevation in respiratory rate [38]. This hypoxic ventilatory response counteracts the hypoxic environment by decreasing PACO2, increasing PAO2 and therefore improving oxygen delivery. Genetical determinants, as well as various external factors (metabolic and respiratory stimulants), lead to wide inter-individual variety of ventilatory response intensity [39]. The increased ventilatory response demonstrates that adaptive processes are taking place and a “good” ventilatory response is known to enhance acclimatization and performance and that a very low response may contribute to the formation of illness [39, 40]. However, hyperventilation will subsequently lead to hypocapnia (increased pH) known as respiratory alkalosis by reducing the amount of carbon dioxide in the alveoli [41]. This condition will cause the oxygen dissociation curve to shift to the left and to further keep respiratory ventilation high. However, hypocapnia will also counteract the central respiratory center activation and thus limit further ventilatory increases [40, 42]. On the other hand, to reduce respiratory alkalosis, more bicarbonate will be produced from the kidneys to decrease the pH toward normal levels. This means that pulmonary ventilation is driven by low arterial PO2 and limited due to hypocapnia-induced alkalosis at the same time. This becomes clear when looking into Eq. (3), defining the alveolar ventilation as follows:
VA is the alveolar ventilation, 0.863 is a constant, VCO2 is the CO2 output and PACO2 is the alveolar CO2. The ability to maintain oxygen homeostasis is essential and the physiological systems compete against each other to provide enough tissue O2 but also to maintain pH-homeostasis.
To compensate for tissue hypoxaemia, the cardiovascular system must respond to maintain body functions. This is accomplished by increasing cardiac output, which is the product of stroke volume and heart rate [43]. Consequently, an increase in one of these variables will also lead to an increased volumetric flow rate. Upon ascent to hypoxic environments, the sympathetic nervous system activation leads to an initial increase in heart rate, cardiac output and blood pressure via the release of stress hormones [40, 44]. Stroke volume remains low in the first hours which is a consequence of reduced blood plasma volume because of bicarbonate diuresis. This occurs as a result of the fluid shift from the intravascular space and the suppression of aldosterone [40]. Interestingly, the sympathetic nervous system activation remains increased even if one is well acclimatized to altitude [45]. In contrast to sympathetic activation, cardiac output decrease once a certain level of hypoxia is reached after several days [46]. After a few days, e.g., muscle tissue adapts and extracts more O2 from the circulating blood by increasing the arterial–venous oxygen difference. This reduces the demand for higher cardiac output. Reductions in stroke volume can be attributed due to decreased plasma volume as well as the above-mentioned increased pulmonary vascular resistance. From the systemic circulation perspective, the endothelial autocoids nitric oxide and prostaglandins have received more attention as they are potentially mediating hypoxic vasodilation in the vessels [47]. Hypoxic-induced vasodilation will therefor quickly increase the blood flow to O2-deprived tissues. Low PaO2 levels will increase Ca2+ concentration inside the endothelial wall which might lead to increased synthetization of vasodilating endothelial factors [48]. The smooth muscle cells of the blood vessels also have K+ ATP-channels, that are activated once the ATP/ADP quotient drops due to hypoxia. As a result of the increased conductivity of K+, the cell membrane is hyperpolarized, followed by relaxation of the vascular muscle cells and vasodilation. This is especially well evoked in coronary and vertebral vessels [49].
PAO2 is, as mentioned earlier, at sea level around 100 mmHg and will decrease at altitude. At sea level, around 96% of haemoglobin is bound to O2 which can be seen in Figure 2. The oxyhaemoglobin dissociation curve plays a crucial role in O2 transport and demonstrates the interaction between the oxygen carrying capacity of haemoglobin and changes in partial pressure of oxygen [50]. When PAO2 drops to 50 mmHg at altitude, only about 80% of haemoglobin sites are bound to O2. The sigmoidal shape of the curve minimizes an abrupt decline in oxygen-carrying capacity of the blood. Another crucial adaptive process is, that the dissociation curve will shift to the left [51]. This is mediated by respiratory alkalosis and therefore rise in blood pH. This left shift causes that at a PAO2 of 50 mmHg, instead of 80%, around 90% of haemoglobin is bound to O2. As a result, more oxygen is bound on haemoglobin and more oxygen can be unloaded to the tissues [52].
S-shaped oxyhaemoglobin dissociation curve at sea level (solid black line). The curve is shifted left due to respiratory alkalosis under acute hypoxic exposure (broken gray line).
The brain consumes around 20% of the available oxygen at rest and is very sensitive to insufficient O2 supply [53]. The ability to process large amounts of oxygen (over a relatively small tissue mass) is necessary to support the high rate of ATP production to maintain an electrically active for the continual transmission of neuronal signals [54]. From this perspective, it is clear that hypoxia can have negative effects on cognitive function [55]. From the literature, it is well known that various factors have an important influence on cognitive impairment during hypoxia, in case they occur. These include the grade of hypoxia (e.g. altitude height), ambient temperatures, performing exercise tasks, individual physiological responses and the influence of PB [56].
One of the most sensitive regions of the central nervous system is the cerebral cortex. However, acute exposure to extreme hypoxia can also cause changes within wide regions of the brain. Subtle changes in the white and gray matter were already observed during ascending Mt. Everest and K2, reducing movement control and planning [57]. Motor speed and precision are also negatively affected in altitude compared to sea level performance [58, 59]. The complexity of central execution tasks seems to play an important role when cognitive impairment is evaluated. Cognitive impairment seems to be more prominent when complex tasks must be solved rather than simple tasks [60, 61]. Indeed, altitude accidents that occur under hypoxia might be more related to poor judgment of complex situations as a consequence of hypoxic depression of cerebral function. However, also small mistakes or even small increases in reaction time [62] can also have fatal consequences.
However, the underlying mechanisms, why cognitive performance can be impaired during hypoxia are not fully understood [61]. Cerebral circulation, which is the product of arterial oxygen content and cerebral blood flow, is dependent on the net balance between hypoxic vasodilation and hypocapnia-induced vasoconstriction. It is well documented, that cerebral blood flow is increased under acute hypoxia to maintain cerebral O2-supply [54]. Cerebral blood flow increases, despite the hypocapnia, when arterial PO2 is less than 60 mmHg (altitude greater than 2800 m). Although, interindividual varieties in cerebral blood are linked to individual variations in the ventilatory response to hypoxia [63], cerebral oxygen delivery and global cerebral metabolism are well maintained under moderate hypoxia. If cerebral oxygen consumption is constant, the question arises of what causes the cognitive impairment at altitude. Cognitive changes might be related to specific neurotransmitters that are affected by mild hypoxia (e.g., serotonin, dopamine). Furthermore, alterations in blood flow and sensory displeasure, hyperhomocysteinemia and potential neuronal damage, and a decrease in catecholamine availability combined with psychological factors appear to play a key role for reduction in cognitive function during hypoxia [61]. In case cerebral tissue oxygenation is not maintained, brain injury will occur with fatal consequences [35]. Compensatory hyperventilation, tachycardia and increased cerebral blood flow can partially maintain cerebral oxygen delivery, however, if these mechanisms work inadequately, the brain will be the first organ to be compromised.
This chapter aimed to give an overview of the main hypoxia types and the main physiological consequences. Hypoxia can occur due to occupational responsibilities, recreationally but also under pathological conditions. Ascend to altitude or exposure to environments that lower the PiO2 will have direct consequences to the entire body systems, however various modulators such as PB, the severity of hypoxia, interindividual variability, health condition and others determine the physiological consequences and adaption processes. Exposing the body specifically to hypoxic environments can be used as a therapeutic tool, to increase sports performance or to achieve other goals [64]. However, it is important to precisely understand the different types of hypoxia and what consequences they have on the human body. Clinical manifestations of hypoxia underly inter-individual variations of cardiorespiratory and other physiological responses as well as the origin of hypoxia. In general, there are two major causes of hypoxia at the tissue level which are reduced blood flow to the tissues or reduced O2 content in the blood itself [65, 66]. As a result, four main types of hypoxia arise. First, hypoxaemic hypoxia, where the O2 transport to or through the alveoli is impaired [6]. Second, anemic hypoxia where the oxygen-carrying capacity is reduced due to e.g., severe blood loss, iron and folate deficiency, haemoglobin pathologies or functional insufficiency to carry O2 [10, 12, 14]. Third, stagnant hypoxia where the transport of O2 to the tissue is impaired while the blood may be sufficiently oxygenated [6]. Finally, histotoxic hypoxia exists, where the O2 is delivered to the tissues but they are unable to utilize oxygen effectively [12].
It is important to understand, how these types influence oxygen delivery to the tissues. The product of O2 content and blood flow is considered to reflect the oxygen delivery for the whole body (or to the individual organ system). As oxygen content is the sum of dissolved oxygen and that bound to haemoglobin, total oxygen delivery can be calculated according to Eq. (4):
DO2 is the O2 delivery (ml min−1); PaO2 is the partial pressure of oxygen (kPa); SaO2 is the arterial oxygen saturation in percentage; Hb is the haemoglobin content (g dl−1); 0.023 is the solubility of oxygen (in ml dl−1 kPa−1); 1.34 is Hüfner’s constant, the oxygen-carrying capacity of saturated haemoglobin (ml g−1); and blood flow (i.e., cardiac output) in dl min−1 [67]. From this equation, it can be seen that hypoxaemic hypoxia (via reduced PaO2 and SaO2), stagnant hypoxia (via reduced blood flow) and anemic hypoxia (via reduced haemoglobin content) may cause tissue hypoxia, as these three types reduce oxygen delivery. In contrast, there is no oxygen delivery deficiency in histotoxic hypoxia but rather an impairment of the tissue to use O2 [35]. Reduced oxygen tension, hypoventilation, ventilation-perfusion mismatch, right to left shunt and impaired diffusion of oxygen can all lead to hypoxia in the body [12].
The primary measurement to evaluate the hypoxic disease state is the analysis of arterial blood gas. Using this measurement, important parameters such as partial pressure of oxygen, partial pressure of carbon dioxide, acidity (pH), oxyhaemoglobin saturation and bicarbonate concentration in arterial blood can be assessed [68]. Management and treatment of persons under hypoxia should be started as soon as the evaluation has been successfully finished, and follows three categories: maintaining patent airways, increasing the oxygen content of the inspired air and improving the diffusion capacity [69, 70, 71]. Without adequate adaption processes and management, an imbalance between oxygen demand and oxygen delivery will occur leading to impaired homeostasis within the body. Therefore, healthcare practitioners (e.g., physiotherapists, sports scientists, exercise physiologists and others) should be able to understand the causes, types and consequences of hypoxia.
In this chapter, an overview is presented on the main types of hypoxia and the physiological consequences of the main systems. Hypoxaemic, anemic, stagnant and histotoxic hypoxia originate from different etiologies. Hypoxia to the tissues can be caused by any obstacle in the oxygen cascade, beginning from the O2 molecule in the atmosphere, until being the final electron acceptor within the mitochondria to generate ATP. However, the adult compensatory mechanisms to counteract the acute hypoxic state are mainly based on our ability to hyperventilate, adequately adapt the cardiovascular response and to increase oxygen uptake to provide enough tissue O2. This chapter might contribute to improving the understanding of the different types of hypoxia and to understand the physiological responses.
The author declares no conflict of interest.
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We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering"}],annualVolumeBook:{},thematicCollection:[],selectedSeries:null,selectedSubseries:null},seriesLanding:{item:{id:"7",title:"Biomedical Engineering",doi:"10.5772/intechopen.71985",issn:"2631-5343",scope:"Biomedical Engineering is one of the fastest-growing interdisciplinary branches of science and industry. The combination of electronics and computer science with biology and medicine has improved patient diagnosis, reduced rehabilitation time, and helped to facilitate a better quality of life. Nowadays, all medical imaging devices, medical instruments, or new laboratory techniques result from the cooperation of specialists in various fields. The series of Biomedical Engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine, and biology. 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Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}},subseries:[{id:"7",title:"Bioinformatics and Medical Informatics",keywords:"Biomedical Data, Drug Discovery, Clinical Diagnostics, Decoding Human Genome, AI in Personalized Medicine, Disease-prevention Strategies, Big Data Analysis in Medicine",scope:"Bioinformatics aims to help understand the functioning of the mechanisms of living organisms through the construction and use of quantitative tools. The applications of this research cover many related fields, such as biotechnology and medicine, where, for example, Bioinformatics contributes to faster drug design, DNA analysis in forensics, and DNA sequence analysis in the field of personalized medicine. Personalized medicine is a type of medical care in which treatment is customized individually for each patient. Personalized medicine enables more effective therapy, reduces the costs of therapy and clinical trials, and also minimizes the risk of side effects. Nevertheless, advances in personalized medicine would not have been possible without bioinformatics, which can analyze the human genome and other vast amounts of biomedical data, especially in genetics. The rapid growth of information technology enabled the development of new tools to decode human genomes, large-scale studies of genetic variations and medical informatics. The considerable development of technology, including the computing power of computers, is also conducive to the development of bioinformatics, including personalized medicine. In an era of rapidly growing data volumes and ever lower costs of generating, storing and computing data, personalized medicine holds great promises. Modern computational methods used as bioinformatics tools can integrate multi-scale, multi-modal and longitudinal patient data to create even more effective and safer therapy and disease prevention methods. 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Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',annualVolume:11404,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"49517",title:"Prof.",name:"Hitoshi",middleName:null,surname:"Tsunashima",fullName:"Hitoshi Tsunashima",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTP4QAO/Profile_Picture_1625819726528",institutionString:null,institution:{name:"Nihon University",institutionURL:null,country:{name:"Japan"}}},{id:"425354",title:"Dr.",name:"Marcus",middleName:"Fraga",surname:"Vieira",fullName:"Marcus Vieira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003BJSgIQAX/Profile_Picture_1627904687309",institutionString:null,institution:{name:"Universidade Federal de Goiás",institutionURL:null,country:{name:"Brazil"}}},{id:"196746",title:"Dr.",name:"Ramana",middleName:null,surname:"Vinjamuri",fullName:"Ramana Vinjamuri",profilePictureURL:"https://mts.intechopen.com/storage/users/196746/images/system/196746.jpeg",institutionString:"University of Maryland, Baltimore County",institution:{name:"University of Maryland, Baltimore County",institutionURL:null,country:{name:"United States of America"}}}]},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering",scope:"The Biotechnology - Biosensors, Biomaterials and Tissue Engineering topic within the Biomedical Engineering Series aims to rapidly publish contributions on all aspects of biotechnology, biosensors, biomaterial and tissue engineering. We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. 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