Stressful life events experienced by respondents during the current.
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",isbn:"978-1-83881-111-2",printIsbn:"978-1-83880-992-8",pdfIsbn:"978-1-83881-112-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"acb2875b3bfc189c9881a9b44b6a5184",bookSignature:"Dr. Abdo Abou Jaoudé",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11865.jpg",keywords:"Linear Operators, Normal Operators, Spectral Theorem, Applications, Differential Operators, Integral Operators, Functional Calculus, Complex Variables, Complex Analysis, Theory, Recent Advances, Latest Trends",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 13th 2022",dateEndSecondStepPublish:"June 21st 2022",dateEndThirdStepPublish:"August 20th 2022",dateEndFourthStepPublish:"November 8th 2022",dateEndFifthStepPublish:"January 7th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"12 days",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Abdo Abou Jaoudé is a pioneering Associate Professor of Mathematics and Statistics at Notre Dame University-Louaizé. 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He also holds two PhDs in Mathematics and Prognostics from the Lebanese University, Lebanon, and Aix-Marseille University, France. Dr. Abou Jaoudé's broad research interests are in the field of applied mathematics. 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Pregnancy as a developmental phase involves both physiological and psychological adaptations that are acceptable to a certain extent, but if excessive, may lead to pathological changes. Psychosocial stressors experienced during pregnancy encompass life experiences that include changes in personal life, job status, family makeup, housing and the possibility of domestic violence [1]. While risks cannot be totally eliminated once pregnancy is established, they can be reduced through effective, accessible and affordable maternity health care. Numerous studies reveal significant depressive symptoms in pregnant women that are associated with sociodemographic and economic status and that depression during pregnancy may negatively influence psychosocial adjustment [2, 3]. Research findings also recommend an integrated approach to antenatal care that focuses on both the physiological and psychosocial dimensions.
Antenatal care has been described as one of the effective forms of preventative care. It involves screening symptomatic and asymptomatic pregnant women, with the aim of detecting and thereby preventing both maternal and neonatal adverse events. The introduction of antenatal care in 1910 in the Royal Adelaide Hospital in Australia has played an important role in preventing high maternal and perinatal mortality rates. Antenatal care should ideally be geared towards the promotion of health and the prevention of physical and psychosocial problems [16].
The psychopathology of pregnancy needs to be understood in terms of the adjustment that all women have to make when they conceive, as pregnancy is also an adaptive process. A pregnant woman should carry the baby safely through to delivery and adjust to the sacrifices that motherhood demands. The challenges that face her, include the acceptance of the pregnancy by the family; development of an attachment to the baby and preparation for birth; and adjustment to the changes in her physical appearance, and to development and maintenance of a positive relationship with the father of the baby. Many women respond to this complex process with grief and anger, especially when the pregnancy is unplanned and unaccepted. Unmanaged grief or anger might ultimately lead to maternal depression [17].
Pregnancy can be enhanced through a coordinated antenatal care programme, which includes both medical and psychosocial care. As such, pregnant women’s mental health should be a primary concern for all midwives due to a reported high prevalence of depressive and anxiety disorders in women. Hollander and Langer [18, 19] reported a 21% incidence of depression and 34% anxiety disorders in women, which may be exacerbated by pregnancy. Pregnancy-specific anxiety may occur as the woman worries about her pregnancy, physical changes and delivery.
Antenatal preparation should be offered to all women during pregnancy as a national policy. Screening during pregnancy is crucial, with the aim of detecting and preventing both maternal and neonatal adverse events and instituting early intervention. During screening, midwives should actively listen to the concerns and needs of pregnant women to be able to assess them comprehensively.
The findings of a cross-cultural survey by Namagembe [20] on the extent of physical and emotional abuse on African American, White American and Hispanic women during pregnancy indicated that one in four women gave a history of battering and physical abuse. The implication for this was that many women’s community subsystems of safety and physical environment are not in harmony and that battering and physical abuse during pregnancy might lead to a significant delay in obtaining antenatal care by 6.5 weeks as compared to non-abused women.
During childbirth, women may look upon their midwives as their advocates despite the existing medically inclined maternity care context. The challenge faced by midwives is the provision of comprehensive and holistic maternity care. This challenge can be achieved through the maintenance of a woman-centred, individualised and caring approach, which needs a caring and responsive midwife. Midwifery care should involve the physical, emotional, social, spiritual and psychological elements for it to be regarded as comprehensive [14].
Psychosocial morbidity is not given enough recognition, it is not thought to be self-limiting as it is the care that is attributed to normal emotionality of pregnancy, and it is less frequently identified, especially if there is no continuity of care by the same midwife or clinician. Pereira et al. [4] reported that antenatal depression affects 4–16% of women, domestic violence during pregnancy rates at 16% and postnatal depression affects 15–20% of postpartum women.
Historically and contemporarily [4], much of what constitutes antenatal care throughout the world remains strongly rooted in the medical model within which it developed. Widespread, institutionalised routine antenatal care began around 80 years ago, focusing on mass screening with the aim of reducing maternal and perinatal morbidity and mortality under medical supervision [5] What is of concern within the context of antenatal care are the beliefs and assumptions that continue to underpin the structure and content of antenatal care.
Traditionally, antenatal care consists of a prescribed set of acts with a focus on the clinical physiological monitoring and screening of pregnant women. This approach was based on the notion by Oakley (1984) that pregnancy is a state of pathology rather than a normal physiological and developmental stage [5]. As further stated by Chitra and Gnanadurai [1], “antenatal care is usually offered in a form of routine physical assessment and care with limited or no psychosocial assessment and care”.
Inadequate psychosocial risk assessment may lead to lack of psychosocial support afforded to the pregnant women. Pregnant women who lack psychosocial support may experience stress during their pregnancy and childbirth. These changes may increase the woman’s vulnerability to depression, which may in turn have adverse effects on both maternal and foetal well-being [6]. Unrelieved stress can also increase vulnerability to physical and emotional problems, for example, insomnia, fatigue, development of ulcers and heart problems [7].
Supportive care during childbirth may have long-term positive effects and may protect some women from a long-lasting negative birth experience. The latter was found in a longitudinal cohort study on “why some women change their opinions about childbirth over time” [8]. Mixed feelings were elicited from women regarding their attitude towards childbirth, changing from positive to less-positive opinions based on, for instance, dissatisfaction with intra-partum care and lack of support for psychosocial problems such as single marital status or the presence of depressive symptoms. Changing from negative to less-negative feelings was associated with less worry about birth in early pregnancy and a more positive experience of support by the midwife.
According to O’Keane and Marsh [9], psychosocial support not only lowers prematurity and low birth weight rates but also inspires healthier behaviours and lifestyle among pregnant women and discourages behaviours like smoking, substance abuse and poor nutritional intake, which can have other detrimental effects on the mother and baby. Psychosocial support calls for a multi-level approach, consisting of strengthening partners and families and enhancing system capacity by ensuring the availability of resources. Interventions need to bolster the support provided within the woman’s existing social network in order to maintain the woman’s cultural beliefs and values.
Dodd et al. [10] tested a hypothesis on the relationship between psychosocial stress, social support, self-efficacy and circulating pro- and anti-inflammatory cytokines in women throughout pregnancy. Pregnant women within the study completed the Denver Maternal Health Assessment. The conclusion was that high social support was associated with low stress scores. Elevated stress scores positively correlated with higher levels of pro-inflammatory cytokine interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α).
A longitudinal community-based study conducted by Gelder et al. [11] through the use of the Edinburgh Postnatal Depression Scale (EPDS) revealed that women who lacked social support showed more symptoms of depressed mood. The maternal depressive mood had a negative impact on breastfeeding, the experiences of motherhood and the relationship with partners.
Appropriate psychosocial assessment is important for designing relevant intervention strategies and for public health policy formulation [12]. Ethically, psychosocial risk assessment should be linked to a plan of care through the provision of appropriate psychosocial support. The plan of care should ensure that the maternal referral arrangements are in place at the participating facilities. The plan of care should be coordinated with all appropriate disciplines.
Irrespective of how maternity care providers perceive antenatal care, the important issue to be taken into consideration is the woman. From a psychosocial point of view, for midwives using a midwifery model, antenatal care is a time of building a relationship with each woman and her family. It is a time when a partnership is developed and negotiated; expectations, roles and responsibilities are identified; options are discussed and choices are made by women and supported by midwives.
While not neglecting physical safety, antenatal care should be emotionally, socially, culturally and religiously acceptable to the woman. Physical care alone is not sufficient for the woman, as her needs and expectations are unique. The effectiveness of antenatal care as a central focus is still being discussed by midwives, obstetricians, medical anthropologists, sociologists and women’s organisations. Handley [13] cited Oakley (1984) in her book “Captured Womb” and wrote extensively on pregnancy, antenatal care and childbirth. She argues the importance of antenatal care but also believes that antenatal care is something that is done in an attempt to control the behaviour of women’s bodies, an intervention offered to women that does not benefit all women, but probably a few who do not know what to expect from an antenatal care service.
Purdy (2001) as cited by Woodward [14] defines medicalisation as the process that transpires when health practitioners treat natural bodily functions as if they were diseased. Purdy further stated that it is essential that conventional medicine re-evaluates its health care model towards the needs of patients and not its own.
Conventional medicine must also accept other health care practices such as midwifery-led maternity care as a valid source of healthcare, especially to address psychosocial risk factors. Women’s health problems, including pregnancy, should cease to be medicalised.
Parry [15] in a study exploring whether Canadian women’s choice of midwifery care identifies a resistance to the medicalisation of pregnancy and childbirth came to the conclusion that women have a desire for personal control of their pregnancy as reflected in this comment:
“
An ideal option for effective antenatal care is the incorporation of psychosocial care as a component of antenatal care, acknowledging the women’s own experiences of pregnancy [2]. Midwifery, which means “to be with women”, is based upon a philosophy of care in which the management of pregnancy is shared between the midwife and the woman, with a focus on informed choice, shared responsibility, mutual decision making and women articulating their health needs.
According to Baldo [7], maternal risk is defined as the probability of experiencing various levels of injuries or even dying as a result of pregnancy or childbirth. Physiological and psychosocial risk screening should therefore be conducted during the first and subsequent visits of antenatal care as part of a comprehensive assessment during antenatal care.
The opinions of Handwerker (1994), Lupton (1999) and Saxell (2000) as cited by Refs. [1, 21] were that risk assessment during childbirth is made more complex by the differences in the perceptions of risks between midwives and pregnant women, as risk from a midwife’s perspective is based on her specialised knowledge and training, epidemiology, personal values and experience, whereas a woman’s understanding of risk is far more contextual, individualised and embedded in her social environment and everyday life experience.
Historically, the definition of maternal risk emphasises mainly medical factors and includes few psychological and socioeconomic factors. To add to this, the interest of midwives seems to be directed towards foetal well-being and the newborn child, ignoring the psychosocial needs of the mother. Furthermore, when a woman reports for delivery, her family member’s concern is mostly on the well-being of the newborn rather than on the maternal well-being.
Psychosocial factors are an important area to assess during pregnancy. Various studies, for example, those of [12, 22, 23, 24] demonstrate that stress, depression, alcohol abuse and lack of social support during pregnancy are commonly associated with low birth weight and perinatal morbidity and mortality. Furthermore, in this era of HIV/AIDS, psychosocial problems are common among affected populations. These issues may have an indirect influence by affecting antenatal care attendance, the woman’s coping capacity and the physiology of pregnancy.
Most of the risk assessment systems in midwifery care focuses on physical characteristics such as age, parity and education; however, these assessment systems are not exclusively suggestive of a risk for maternal morbidity and mortality as they mostly exclude psychosocial factors. A review of several studies by Hamid et al. [25] on the perceptions of antenatal care by women suggests that there are several psychosocial risk factors that need to be taken into consideration in order to ensure a safe pregnancy and delivery. Psychosocial interventions have proved to be beneficial in providing comprehensive antenatal care.
Furthermore, a systematic review of 16 studies on antenatal screening for postnatal depression by Hamid et al. [25], which involved 23,000 participants, revealed that the proportion of women who are at risk for postnatal depression was between 10 and 67%. The authors further commented that the preliminary evidence suggested that the introduction of screening tools to aid early detection and diagnosis of depression has helped to raise awareness among health care providers regarding social and psychological maternal risk factors.
Psychosocial risks are described as the demands or challenges that are psychological or social in origin, having the potential to directly or indirectly alter homeostasis during pregnancy and childbirth [21]. They relate to a combination of the affective states and cognitive factors of anxiety, depression, self-esteem mastery and perceived stress as measured by the scale of Gunn et al. [30].
According to Glazier et al. [28], a psychosocial problem may occur in response to an exposure to a stressful life event, for example, unemployment. The psychosocial response will, however, be determined by the effect it has on an individual, for example, loss of self-esteem and feelings of worthlessness.
Fawole et al. [29] have identified the following as some of the psychosocial risk factors that a woman may have experienced or may experience during pregnancy: woman battering; family violence or intimate partner abuse; sexual abuse and harassment; discrimination; gender inequality; past history of depressive disorders; absent/abusive or non-supportive spouse; marital difficulties; pregnancy occurring below 18 years of age, which antedates social development; unintended, unplanned or unwanted pregnancy; maternal or paternal unemployment; adverse life events, for example, loss of spouse; socio-economic factors, for example, poverty; barriers to accessing health care services, for example, distance travelled and transport unavailability; medical disorders, for example, hypertension and HIV/AIDS and poor quality of interaction with health care providers that may lead to non-compliance to planned interventions and defaulting treatment.
Pregnancy may have an enormous psychological and physiological effect on a woman’s body and mind. This is due to suppression of the hypothalamic-pituitary-adrenal axis, which leads to dramatic changes in oestrogen and progesterone levels. Changes in these hormone levels may alter a pregnant woman’s coping mechanisms. The physical discomfort of pregnancy, accompanied by anticipation of childbirth and the responsibility of parenthood, often causes anxiety and emotional changes [27].
There is a growing body of data suggesting that psychosocial factors such as high stress and low social support negatively affect the success of pregnancy. The findings of a survey by Shamim ul Moula [26] to address relationships between psychosocial variables and serum inflammatory markers during pregnancy support the notion that prenatal stress alters maternal physiology and immune function in a manner that is consistent with an increased risk of pregnancy complications such as preterm delivery and pregnancy-induced hypertension. The conclusion based on the findings of the above survey was a need for the development of strategies for supporting maternal mental health.
It is clear that birth and infant development are affected by prenatal events that could lead to maternal stress. Maternal psychosocial stress has been recently identified as a factor in early foetal development. There is growing evidence that perinatal psychological and environmental stressors are detrimental to pregnancy success and infant outcomes. Stress is often defined as events, situations, emotions and interactions that are perceived as negatively affecting the well-being of an individual or that cause responses that are perceived as harmful [10].
A direct relationship is said to exist between maternal psychological stress and low birth weight, prematurity and intra-uterine growth retention. This is related to the release of catecholamines that results in placental hypo-perfusion and consequent restriction of oxygen and inhibition of nutrients to the foetus, leading to foetal growth impairment [27].
There is considerable evidence that postnatal depression is a public health care challenge as it can become chronic, can damage the relationship between the woman and her partner and might have adverse consequences for the emotional and cognitive development of the newborn. Regular assessment of mood during pregnancy should be routine for all women to establish the risk for depression, as postnatal depression can recur. Antenatal mood assessment is one of the most robust predictors of postnatal depression, as 50% of postnatal depression is reported to have begun during pregnancy [27].
There is evidence from research that women with antenatal psychosocial risk factors are more likely to have a postnatal mood disorder, and as such, antenatal assessment can be beneficial for these women. The early identification and management of psychosocial risk factors have been shown to be beneficial in various studies. For example, in the study by Ref. [29], regarding the review of existing tools that are used to assess psychosocial morbidity in pregnant women, and a study by Gunn et al. [30] on anxiety and depression during pregnancy, outcomes were improved by minimising the occurrence of postpartum depression.
Recommendations from a survey by Namagembe [20] were that a search for battering and abuse should be carried out during the antenatal assessment of pregnant women and midwives should have knowledge of the appropriate interventions and be familiar with the resources for referral. The increased cost and complications that may arise as a result of any delays should be a concern for maternal-child health professionals. Routine antenatal and postnatal screening for psychosocial distress has been supported by investigators as a preventive measure for postnatal depression [28].
Psychosocial assessment is defined by Chitra and Gnanadurai [1] as an evaluation of an individual’s mental health, social status and functional capacity. The individual’s physical status, appearance and modes of behaviour are observed for factors that may indicate or contribute to emotional distress or mental illness. Observation includes posture, facial expressions, manner of dress, speech and thought patterns, degree of motor activity and level of consciousness. The individual is questioned concerning patterns of daily living, including work schedule and social and leisure activities. Data should include the individual’s response to and methods of coping with stress, relationships, cultural orientation, unemployment or change of employment, change of residence, marriage, divorce or death of a loved one [30].
The above-listed risk factors can directly or indirectly affect the outcome of pregnancy in a negative way [7]. A meta-analysis of perinatal depression identified depression as a major complication of pregnancy affecting 14.5% of pregnant women [19].
Traditionally and in many contemporary contexts, including in South Africa, antenatal care consists of a prescribed set of acts based around the clinical monitoring and screening of all pregnant women. This establishment of routine care was based on the notion that pregnancy is a state of pathology rather than normal physiology. There is evidence of a focus on technological dominance and a focus on the detection of obstetric and medical conditions occurring during pregnancy. This is based on a review of seven guidelines for antenatal care from the USA, Canada, Australia and Germany and mostly reflects expert opinion rather than scientific evidence [21].
For example, antenatal care in South Africa is provided at the primary, secondary and tertiary levels of care in both the public and private health care systems. Basic antenatal care services include physical examination, weight measurement, urinalysis, blood pressure monitoring, blood investigations and health information and are supposedly provided at all levels of antenatal care as routine practice.
The ongoing debate on antenatal care regarding its frequency, content, continuity, quality and effectiveness in reducing maternal and neonatal morbidity and mortality led to a new evidence-based protocol on the frequency of antenatal care. This is the result of randomised trials carried out in the United Kingdom and Zimbabwe and of the World Health Organisation trials in Thailand, Argentina, Cuba and Saudi Arabia during 1996 [31].
The new schedule, as recommended by WHO [30], consists of four visits during pregnancy, the first one being early in pregnancy, with subsequent visits at 26, 32 and 36 weeks. This schedule is designed for the pregnant woman at low risk. These fewer antenatal visits led to poorer psychosocial outcomes and drew attention to greater maternal satisfaction with the routine care that was previously provided. The question is whether there would be an opportunity for the midwives to address psychosocial care within this regime.
Baldo [7] in a review of the antenatal care debate quoted Mcllwaine (1980) highlighting that he was amazed that pregnant women came for antenatal care and waited in the clinic for 2 hours, only to be seen for 2 minutes by someone laying his or her hands on them, and then leave. The reason for this is the traditional focus on the biophysiology of pregnancy. The author recommended that antenatal care appointments should be structured, focused and advocated for longer first appointments to allow comprehensive assessment in order to address both physiological and psychosocial risk factors.
The Changing Childbirth report explicitly confirmed that women should be the focus of antenatal care to enable a woman to make informed decisions based on her needs, having discussed her matters with the midwife involved. Key aspects of care valued by women are reported to be respect, competence, communication, support and convenience [32].
The above are supported by the researcher’s findings from a phenomenological study on the expectations of antenatal care by pregnant women. Most women were happy with the physical health care but were dissatisfied with interpersonal aspects, for example, involvement, guidance and communication from the health care providers [33].
As a midwifery lecturer, the researcher often accompanied students for clinical facilitation. On guiding students on psychosocial care of women in the antenatal care clinic, women frequently verbalised social and emotional concerns. The researcher’s further experience is that if psychosocial assessment is indeed conducted on a pregnant woman, it usually elicits the woman’s current active and significant psychosocial challenges.
The following are common remarks that were expressed by women during their antenatal visits while the researcher was engaged in student accompaniment.
A woman carrying her first pregnancy at age 25, gravida 1 para 0, from one of Gauteng’s provincial hospital’s antenatal clinic remarked:
A pregnant woman, 42 years old, was asked if the pregnancy was planned at this vulnerable age as her first child was 20 years old. Her response was that she had lost a husband 5 years ago and had recently remarried. She was coping but her challenge was that the first child was rejecting both the new husband and the pregnancy. This was a reflection of another need for psychosocial support that could have been achieved through a proper psychosocial assessment by a midwife and appropriate referral offered.
The concept of psychosocial stressors during pregnancy encompasses life experiences, including among others, changes in personal life, job status, family makeup, housing and domestic violence [1]. All these require adaptive coping mechanisms on the part of the pregnant woman, which can be achieved through the support of the midwife.
Risk screening, according to Refs. [1, 7], involves using a list of risk factors and some form of scoring system to classify pregnant women into specific risk categories, typically high risk or low risk, using cutoff points or thresholds. The focus of risk screening is to detect early symptoms and to predict the likelihood of complications. The intention of risk assessment is to predict problems before they occur and, as such, take appropriate action by providing optimal maternal care.
Bibring (1959) as cited by Stahl and Hundley [16] was among the first psychoanalytic writers to claim that “pregnancy is a psychobiological crisis affecting all expectant mothers, no matter what their state of psychic health is. As [with] every normal crisis that constitutes a turning point in life, it precipitates an acute disequilibrium…may lead to a new level of psychological maturity and integration. The outcome of this crisis might have a profound effect not only on the woman herself but also on the mother-child relationship”.
A cross-sectional study to identify a relationship between life stress, perceived social support and symptoms of depression and anxiety was conducted by Waldenstrom [34]. Based on her findings, it was recommended that psychosocial assessment of pregnant women and their partners may facilitate interventions to augment support networks and as such reduce the risk of psychosocial stress.
The New Antenatal Care Model proposed by WHO [35] recommends a set of activities during each visit for those women who are identified to be at low risk by screening for conditions likely to increase adverse outcomes of pregnancy, providing therapeutic intervention known to be beneficial and educating women about safe birth. However, the model does not emphasise psychosocial issues but proposes that some time should be set aside during each visit to discuss the pregnancy and related issues. Emphasis was put on the importance of communication.
As a measure to promote psychosocial risk assessment, a new approach to psychosocial risk assessment during pregnancy (ANEW) was implemented in Australia during 2000, in a form of a project to provide an alternative way to psychological risk screening in pregnancy. A training programme in advanced communication skills and common psychosocial aspects of childbirth was offered to midwives and doctors at the Mercy Hospital for women, with the aim of improving the identification and support of women with psychosocial needs in pregnancy [36]. The outcome of the programme was that it improved the ability of the health care professionals to identify and care for women with psychosocial needs.
A randomised controlled trial examining the effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial risk factors in pregnant women revealed that 72.7% of the women in the ALPHA group showed interest in discussing psychosocial issues The experimental group was twice as likely to declare psychosocial problems as the control group (based on odds ratio 1.8, 95% confidence interval and 1.1–3.0, ρ = 0.02).
Two-thirds of health care providers in the ALPHA group found the form easy to use, and 86% said they would use it if it were recommended as standard practice. The conclusion of the trial showed that the assessment of psychosocial well-being during antenatal care was acceptable to both women and health care professionals [4, 31] in a project on antenatal psychosocial risk assessment in Australia, stating that antenatal depression, domestic violence and postnatal depression occurred more frequently than gestational diabetes, placenta praevia, pre-eclampsia and other obstetric and medical conditions, but most midwifery care settings still do not routinely screen for psychosocial problems.
As stated in Ref. [5] and other literature, for example, Hall (2001) as cited in Ref. [5], the procedures that are commonly undertaken to monitor pregnancy are aimed at reducing morbidity and mortality, but have been found to often cause physical, social and emotional harm. The physiological care that is routinely offered during antenatal care clearly illustrates that the scope of antenatal care is primarily derived from a medical perspective. The implication is that routine antenatal care fails to meet reasonable expectations and the needs of women.
Midwives are urged to overcome the perception in literature and media that health care providers are unkind, rude, unsympathetic and uncaring, as negative emotions such as anger may arise when a woman receives insensitive care. Delwo [37] concluded her study of Swedish women’s satisfaction with medical and emotional aspects of antenatal care by urging midwives working in antenatal care to support pregnant women and their partners in a professional and friendly way in order to increase their satisfaction with care. They also advised that identifying and responding to women who are dissatisfied with their antenatal care could help to improve their satisfaction.
The aim of this study was to develop guidelines for the enhancement of psychosocial risk assessment of pregnant women, with a focus on the provision of psychosocial support.
It was hoped that the results of the study would provide evidence that could motivate interventions aimed at closing the gap between the routine assessment of physiological risks factors and the assessment of psychosocial risk factors during antenatal care. This would provide a basis for midwives to implement an appropriate action should any psychosocial risk be identified. Once formally tested, such guidelines could be incorporated into national guidelines for best practice.
Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee, protocol number M081013. Participation was voluntary. Anonymity and confidentiality were maintained throughout the research process. The ethical principles of autonomy, beneficence, non-maleficence and justice were observed accordingly.
A mixed-method research was used for this study. A sequential explanatory design was employed, whereby quantitative data were first collected and analysed, followed by qualitative data collection and analysis in two consecutive phases [38]. The investigation was conducted within the following contexts:
Sampling was purposive for all data sources, which were midwifery education and training regulations from the South African Nursing Council; midwifery education and training records of the three nursing colleges providing basic nurse education in Gauteng Province in South Africa; records of antenatal care for women attending government antenatal facilities in Gauteng Province were reviewed to establish the inclusion of psychosocial care; the administration of questionnaires to pregnant women attending antenatal care in Gauteng Province clinics; focus group discussions with both midwives and pregnant women at the antenatal care clinics; a survey to establish the extent of psychosocial assessment and psychosocial care by midwives during pregnancy, through a self-administered questionnaire; and in-depth interviews conducted with midwifery experts from various settings at which midwifery was offered, for example, universities, nursing colleges and midwifery obstetric units (MOUs).
Quantitative data were analysed using Stata Release 10 statistical software. Data analysis generally included summary statistics (mean, standard deviation for continuous variables, frequencies and percentages for discrete variables) and Cronbach’s alpha for internal consistency. Confidence intervals of 95% were used to report for discrete variable.
Qualitative data analysis occurred concurrently with data collection. To enhance the depth of qualitative analysis, multiple approaches to data analysis were used (e.g., constant comparison, thematic analysis and framework analysis) comparing themes and categories as a form of across-case analysis technique [38]. The stages that were involved in reducing data were examining, categorising and tabulating data [39].
Data analysis was systematic, sequential, verifiable and continuous in order to minimise potential bias. A “Framework Analysis” was mostly used in qualitative data analysis.
The findings confirmed that women experience stressful life events during pregnancy as illustrated in Table 1.
Pregnancy stressful life events | Women’s responses n (%) | |
---|---|---|
Yes | No | |
1.1. Have you experienced death of a spouse or family member? | 82(27) | 218(73) |
1.2. Have you gone through a divorce or marital separation? | 26(9) | 274(91) |
1.3. Were you retrenched or fired from work? | 37(12) | 264(88) |
1.4. Have you been a victim of rape or sexual assault? | 15(5) | 286(95) |
1.5. Have you ever experienced any pregnancy loss? | 60(20) | 242(80) |
2. Was the pregnancy planned? | 140(46) | 162(54) |
3. Have you been sick during this pregnancy? | 141(47) | 160(53) |
If yes, what was the illness? | Note response to the questions below | |
4. Have you ever attempted suicide? | 15(5) | 285(95) |
5. Have you ever been diagnosed with a mental health condition? | 14(5) | 286(95) |
6. Have you been hospitalised for a mental health problem? | 16(5) | 284(95) |
7. Did you attend any mental health counselling session? | 27(9) | 274(91) |
Stressful life events experienced by respondents during the current.
The response from 300 participants was that 184 (61.3%) were experiencing stressful life events during the current pregnancy, whereas 116 (38.6%) did not experience any stressful life events. Among those who experienced stressful life events, 72 (24%) experienced two events and 44 (14%) experienced three or more stressful life events. This provides evidence of the importance of assessing women psychosocially as almost all women present with psychosocial problems.
The SANC Regulations, the curriculum and learning guides display a broad approach to psychosocial care as the focus is on holistic care. Written tests, examinations and clinical tools implemented at the colleges address psychosocial care to a minimal level. The Gauteng antenatal care guideline policy, the Guidelines for Maternity Care in South Africa (2015) and the midwifery competency register do not reflect psychosocial content in their guidelines or psychosocial criteria to be met during antenatal care. The antenatal card does not reflect guidelines on psychosocial care, as midwives recorded what they perceived as relevant to be assessed psychosocially.
The findings from the focus group discussions within this study also indicated that psychosocial assessment and care were important during pregnancy. The respondents further highlighted the importance of an appropriate guideline and a record for psychosocial assessment and care as reflected within the following responses:
The concern about the need for training and support for midwives and other health professionals undertaking care to pregnant women [40] led to the development of a psychosocial risk assessment tool that was also based on the findings of the study. Furthermore, there are few studies worldwide reporting the development, evaluation and implementation of screening tools for psychosocial risk factors in pregnant women and subsequent intervention and prevention programs [45]. The assessment tool developed from the findings of this study is currently being piloted in 21 Community Health Centers in Gauteng Province as a 3-year project (2017–2019). The aim of the pilot study is to evaluate the tool, modify it and incorporate it as part of routine antenatal care. The long-term plan is to have a policy developed that integrates psychosocial risk assessment and support with routine physical care.
Based on the increasing international move to standardise as routine the psychosocial assessment and depression screening of all pregnant women and offer relevant support [40, 41, 42], different options need to be considered in order to enhance psychosocial care. Some of the interventions that are applied in certain countries globally are reflected in Table 2.
Type of intervention | Description |
---|---|
Group antenatal care (Centering Pregnancy, USA) | Consist of a group facilitated by the clinician that lasts approximately 90–120 minutes. This allows a discussion of a wide range of pregnancy-related issues that include psychosocial issues [43]. |
Hawaiian-style “Talkstory” | The talk-story is integrated into the woman’s antenatal and postnatal assessment and care and involves an exchange of thoughts between the woman and midwife. It is based on the woman’s values, beliefs and experiences, acknowledging custom and culture. |
A psychosocial risk assessment model (PRAM) Australia | Offers a conceptual framework, measures and methods suitable for a brief psychosocial assessment of pregnant and postpartum women [44]. |
ALPHA tool (Canada) | 35 items used to detect 15 risk factors for postnatal adverse psychosocial outcomes [31]. |
KINDEX (University of Konstanz, Germany) | Assess 11 risk arears during pregnancy, the presence of psychosocial factors and the experience of adversities by women [45]. Has been applied in European countries. |
Antenatal risk questionnaire (ANQR) | Composed of 12 items retrieved from the original 23 pregnancy risks [46]. |
Interventions to enhance psychosocial care.
Based on the shortage of midwives or clinicians reported in this and other studies, and coupled with a limitation in psychosocial care, group antenatal care might be another option.
Group antenatal care originated a decade ago in Minnesota, USA, during the early 1970s. It was introduced in Denmark in 1998, followed by Sweden in 2000. It is offered concurrently with traditional antenatal care. Antenatal visits are carried out in groups of 6–8. There is evidence that this approach increases networking between pregnant women, women are able to validate and sort information within the group and it also allows a midwife to devote more time to pregnant women by saving about 3 hours per woman [47]. Groups may address common psychosocial problems, and those who need further individual consultation can be offered the same, which will probably not be often, with routine individualised care.
The Schindler-Rising model of “centering pregnancy”, one of the recommended models for antenatal care, is presented in Figure 1.
“Centering pregnancy”.
A “centering pregnancy” model is an innovative model for prenatal care. It focuses on “woman-centred care” by integrating antenatal care, health information and group support. It acknowledges a woman as an expert regarding her needs. The approach is practised, for example, in Canada, where women are involved in their basic assessment by weighing one another, checking one’s own urine sample, and intragroup checking of blood pressure. Each woman also records results in her own antenatal card [47].
Although the “centering pregnancy” model might free midwives or clinicians from routine investigations and as such allow them more time to address issues like psychosocial care, it carries a limitation in a sense that women should be literate, and the process should still be supervised by a midwife or a clinician until women are familiar with all aspects.
A Hawaiian-style “talkstory” originated from a needs-assessment project undertaken in Hawaii during 2000, where women indicated that their psychosocial needs were largely unmet.
A Hawaiian-style “talkstory” could offer an ideal approach in offering culturally focused antenatal care as it is a culturally based interactive communication approach, aimed at addressing the pregnant woman’s psychosocial needs. It could be mostly effective during the initial antenatal care booking as the woman is taking the lead in sharing her childbirth experiences. Figure 2 explains the talkstory process as a guideline for midwives who might be interested in its implementation.
The “talkstory” process.
The “talkstory” approach, as illustrated in Figure 3, served as an ideal way of assessing women psychosocially. It offers an opportunity to provide the woman with relevant health information and to validate myths or misconceptions about childbirth that the woman might be having, while also addressing her expectations. This is a type of psychosocial assessment and care that is women-centred, through placing an emphasis on a woman’s own beliefs, offering her autonomy and a right to informed choice [48].
Outcomes achieved through the “talkstory process”.
A “talkstory” is an ideal approach during the initial contact of the woman and the midwife or a clinician, and as such it might promote communication between the two; it needs some time and requires a midwife or clinician who is skilled in listening and who has an ability to convey compassion, acceptance and encouragement to the woman. This approach might be a challenge in institutions experiencing the shortage of staff.
The implementation of psychosocial care incorporates adherence to the following principles: human rights and equality, justice and confidentiality. Measures to be put in place as part of psychosocial support are availability of referral resources (social, mental, economic and judicial); the assessor should be well informed about the options of referral and to consider the possibility of the accompaniment of the woman throughout the process as a form of continuity of care and as stated by the United Nations Entity for Gender Equality and the Empowerment of Women.
The issue of psychosocial risk assessment and support seems to be a concern both nationally and internationally. The process of adapting to pregnancy and the resulting life changes are often difficult, even if the pregnancy is planned as pregnancy involves intense emotional, spiritual, psychological and social factors that need a midwife’s caring awareness and responsiveness. A pregnant woman should be assisted to recognise and incorporate these changes into her self-image, her social network and her lifestyle. When the pregnancy is unplanned, the psychosocial changes may be more profound and lead to uncertainty, anxiety and depression [19].
There is a growing need for understanding the place and significance of maternal psychology and other psychosocial factors in the management of pregnant women by midwives or clinicians. Strategies for supporting maternal and foetal mental health need to be developed, as the importance of a good-quality pregnancy extends beyond antenatal care. Psychosocial risk assessment during pregnancy is further considered as the first strategy to support maternal well-being as this will allow the pregnant woman to cope with her pregnancy [26].
In theory, risk assessment is a logical tool for rationalising service delivery to ensure that those in greater need receive special attention and care. However, it is becoming increasingly clear that with incorrect and inadequate psychosocial risk assessment, scarce resources may be diverted away from pregnant women who are in real need. However, in the absence of evidence of an effective risk screening process, risk assessment cannot be relied on as a basis for matching needs and care in maternity services [7]. Ideally, psychosocial risk assessment should be included within the overall risk assessment or could be administered as a separate tool in the form of a checklist.
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The skin is the largest organ in the body. It provides a crucial interface between the body and its environment. It has very diverse functions, which include: a defensive barrier against toxic agents and micro-organisms, a multidimensional sensor between the body and the external environment, a protective shield from sunlight, a harnesser of sunlight to begin the process of Vitamin D production in the body, and host to a large part of our microbiome [1, 2]. The skin is thinnest at the eyelids and thickest on the soles of the feet. Skin consists of the epidermis and the dermis, which differ markedly in their structure and function.
\nThe epidermis, the outermost layer is a stratified keratinizing epithelium, approximately 1 mm thick, which is in constant turnover. It maintains a shield against environmental toxins, resists water and protects against heat. The main types of cell found in the epidermis are the keratinocytes, but there are also melanocytes, Langerhans cells, T-lymphocytes and Merkel cells.
\nBasal keratinocytes are known to differentiate and flatten out to create the stratum corneum. The balance of proliferation and differentiation of the basal keratinocytes is essential for epidermal integrity and ongoing epidermal tissue renewal. Keratinocytes are in close physical contact with free sensory afferent nerve endings and therefore involved in nociceptive responses [3]. Keratinocytes also have some specialised functions, such as: synthesis of keratin, neuropeptides, neurotransmitters, endogenous opioids and autacoids; involvement in local inflammatory responses; as well as expression of multiple different receptors [3]. Tactile stimulation is known to induce peripheral oxytocin release from keratinocytes to mediate local, peripheral oxytocin mediated analgesia [4]. In addition, keratinocytes play a fundamental role in the pathogenesis of neuropathic pain and central sensitization [3, 5, 6, 7, 8]. Keratinocytes play a significant role in skin tissue repair, but an abnormal balance of proliferation and differentiation of keratinocytes may lead to generation of pathological scars [9].
\nMelanocytes are responsible for the primary pigment colour of the skin and the production of melanin. Melanin content is the differentiator for skin colour. Lighter skin or depigmented skin has less melanin, associated with living in more northern climates, where the lighter skin can synthesise more Vitamin D from exposure to sunlight. Merkel corpuscles are skin mechanoreceptors, whereas Langerhans cells and the T-lymphocytes have immunomodulatory properties.
\nThe dermis is a thick layer of connective tissue, which is elastic, pliable, and has substantial tensile strength. The dermis is split into the upper papillary dermis, and the lower reticular dermis. The reticular dermis is characterised by dense irregularly packed collagen, elastin, and reticulin, from which it derives its name. It will be seen later that the duration and intensity of the inflammatory process within the reticular dermis, following surgery or injury, has an impact in the development of pathological scars. The dermis houses other essential organs of the skin including hair follicles, sebaceous glands, endocrine glands and apocrine glands which are absent in scarred skin.
\nWhereas the primary cells of the epidermis are the keratinocytes, the primary cells of the dermis are the fibroblasts. The dermis gets its strength from a combination of collagen and elastin fibres. The fibroblast is a connective tissue cell that secretes collagen, elastin and other elements of the extracellular matrix. Collagen bundles in healthy normal skin are organised in a three-dimensional basket-weave pattern [10], whereas collagen bundles in scarred skin are organised in parallel to the epithelial surface [11]. Fibroblasts are critical in all phases of wound healing, wound contraction, and remodelling of scars. There are multiple distinct subpopulations of dermal fibroblasts. Fibroblasts with abnormal phenotypes (altered proliferation profile and different patterns of cytokine release) are associated with the development of pathological scars [12].
\nThere are different receptors within the skin, which include: Meissner’s corpuscles for light touch; Merkel’s discs for constant pressure; Pacinian corpuscles for deep pressure or vibration sense; and Ruffini corpuscles for skin stretch and temperature sensation. The skin is also a primary site of small fibre nociceptive endings [13]. Underneath the dermis is the subcutaneous layer, which contains fat that insulates us to prevent heat loss, and fascial layers that give the skin mobility relative to the muscles, tendons and bones.
\nAdipose tissue has long been considered just a means of fat storage. However, it has important metabolic and endocrine functions. Regulation of whole-body energy metabolism occurs through its storage function in white, brown or beige adipocytes. Its endocrine function occurs through production of adipocytokines, including leptin and adiponectin. Neurons of the sympathetic nervous system innervate different fat deposits to create communication with adipocytes. Leptin is hormone secreted from white adipose tissue to alter the sympathetic outflow centrally. This leptin-dependent neuro-adipose tissue connection plays an important part in regulating lipolysis and thermogenesis [14]. Leptin also acts on the hypothalamus to regulate food intake [15]. Adiponectin, also a protein hormone produced by adipocytes, has organ protective functions that result from the binding of adiponectin to receptor sites on many organs to activate exosome formation and release for cellular haemostasis [16]. Adiponectin and adipocytes are key players in skin health and disease [17].
\nThe skin is electrically active and contains many nerve elements for interaction with the nervous system [18], the autonomic nervous system [18, 19], and the locomotor apparatus [20]. There is continual nervous activity, in afferent and efferent mode, between the skin and central nervous system to maintain normal physiological and biomechanical homeostasis [18, 21]. There is an independent central emotional connection, principally between the anterior cingulate cortex and the skin, whereby a sympathetic electrical signal can be detected in the skin in response to viewing emotionally charged images [22].
\nInformation from skin sensors is relayed via A-delta and C-tactile fibres to the spinal cord and from there to the thalamus, then to specific regions in the primary somatosensory cortex and further on to higher somatosensory areas. The somatosensory maps are not represented in direct proportion or alignment to the body. Certain regions are magnified in response to the density of mechanoreceptors in the associated skin; for example, fingers and lips. The brain receives converging input from numerous nerves innervating adjacent regions of the skin to enable recognition of a specific touch sensation. Neuroplastic adaptive changes occur in the somatosensory map related both to increased repetitive activity and to disuse. Although the primary somatosensory cortex responds appropriately to touch information, the brain’s higher centres are more strongly influenced by cognitive factors, such as expectations, context, and attention.
\nWide dynamic range neurones integrate afferent pain and touch information. Others converge afferent viscero-somatic information into the spinal cord [23, 24]. Integration of these pathways can sometimes lead to sensory illusions. For example, referred pain is exemplified by shoulder pain from irritation of air under the diaphragm, or left arm pain in association with angina. Conversely, convergence of efferent sensory and sympathetic innervation to skin vasculature may explain sympathetic involvement in conditions such as complex regional pain syndrome and fibromyalgia [25, 26].
\nIt is clear that the skin is a versatile and important organ, but it cannot be considered in isolation from its underlying fascia when considering the impact of scars.
\n“
Fascia has long been thought of as the annoying tissue that has to be dissected off to get to the underlying anatomy. This traditional view of fascia has now been surpassed. The most up to date definition describes fascia as a sheath, a sheet or any number of dissectible aggregations of connective tissue that forms beneath the skin [28]. However, this definition is too simplistic, and it is the definition of the fascial system that highlights the importance of fascia in biomechanical regulation:
\nFascia is multi-layered and has both loose and hard fibrous connective tissue components. Loose fascia functions to help slide and glide between structures and dense fascia exerts a tensile strength in tissues like tendons. Fascia and muscle tissue have a complex interplay to achieve skeletal balance, co-ordination, posture, and locomotion.
\nFascia contains cells (fibroblasts, fasciacytes, myofibroblasts, and telocytes), an
As the fascia envelops every structure within the body, it creates structural continuity that provides form and function to every tissue and organ. Fascia is one of the essential biological structures that combines with muscles, tendons and bones to create the tensioned and compressed parts that create the
Myofascial chains, from left to right: spiral line, lateral line, front functional line, back functional line, and superficial back line (adapted from Wilke et al. [
The extracellular matrix (ECM) is defined by Grey’s Anatomy as
The ECM is present within every tissue of the body to provide fundamental physical scaffolding for the cellular constituents and orchestrate vital biochemical and biomechanical functions required for morphogenesis, differentiation, and homeostasis. The ECM is basically composed of water, salts, and macromolecules consisting of fibrous proteins (collagen, elastin), adhesive glycoproteins (laminin, fibronectin, tenascin, integrin), and carbohydrate polymers (proteoglycans and glycosaminoglycans). Collagen is the most abundant ECM fibrous protein. However, each individual tissue has a heterogeneous ECM composition providing highly variable but unique biochemical, protective, organisational and biomechanical ECM properties, which differ from one tissue to another. This composition is primarily dependant on that tissue’s particular function [52]. The ECM is a highly dynamic structure, constantly being remodelled with its molecular components subject to a multitude of modifications.
\nMorphological organisation and physiological function of the ECM is orchestrated by binding growth factors and interacting with cell-surface receptors to elicit signal transduction and regulate gene transcription. Enzymes released from fascial cells degrade the ECM, such as cathepsins, heparinase, hyaluronidases, and metalloproteases, to maintain normal tissue turnover.
\nAny breach of the dermal layer will result in a scar. When the dermis is breached by surgery or injury, a healing process occurs that leads to the formation of scar tissue [53]. There are two main types of healing: primary intention and secondary intention. Healing by primary intention occurs in wounds with dermal edges in close proximity; for example, a surgical incision. Healing by secondary intention occurs when there is unavoidable tissue loss with abnormal tension, infection or necrosis, creating a large deficit where the sides of the wound are not opposed or too big to heal by primary intention; therefore, healing must occur from the bottom of the wound upwards. For both primary and secondary intention healing, there are three overlapping stages to healing after haemostasis is achieved; inflammation, proliferation, and remodelling [54]. This extremely complex and co-ordinated process is guided by cytokines plus chemokines secreted by platelets, macrophages, endothelial cells, keratinocytes, fibroblasts, and adipocytes [2, 12, 17, 18, 55, 56].
\nWound healing and scar maturation can take years to complete, but depend on the size and nature of the initial wound. During remodelling, type 3 collagen is replaced by a stronger type 1 collagen, but not in an ordered manner. Scar tissue is therefore strong, but not as elastic or flexible as normal tissue [38, 54]. Normal scars first appear as a red line, but maturation results in a slightly broadened white line, in the same plane with the surrounding skin, known as a normotrophic scar. Normotrophic mature scars are less innervated than the surrounding normal skin [57, 58]. Scar tissue, therefore, has different properties to the tissue it replaced prior to injury. Skin healing is not just dependent on the size and site of the wound, but is also influenced by bacterial contamination, nutrition, comorbid medical conditions, as well as genetic and epigenetic factors [56, 57]. Once normotrophic scars are established, they are often forgotten and ignored unless they constitute a cosmetic embarrassment.
\nIf the healing process is interrupted by tissue disruption, infection or a comorbid disease process, then a pathological scar may occur, which may be atrophic, hypertrophic, tethered, or keloid in nature. Development of pathological scars may be related to genetics, as well as differences in the duration, and intensity of the inflammatory process in the reticular dermis [56, 59, 60, 61]. Excessive scar tissue movement, scar rubbing, scar scratching or abnormal tension related to surgery or injury may also induce an enhanced neurogenic inflammatory response [18, 62, 63, 64, 65]. This may be an important consideration when reflecting on what constitutes a significant scar in terms of myofascial dysfunction later.
\nAtrophic scars are concave indentations resulting from tissue loss (including collagen) associated with relative shift in the ratio of MMPs to tissue inhibitors of MMPs that favours a lytic process and the development of an atrophic scar [66]. Chicken pox scars are atrophic, which can occur in up to 20% of children following chicken pox infection [67, 68]. Acne scars are a common problem in developed countries, occurring in 80% of 11–30 years old and 5% of adults aged over 30 years [69]. Acne scars are usually atrophic, subdivided into rolling, boxcar, or ice-pick. However, acne scars can also present in hypertrophic or keloid morphology. Hypertrophic scars and keloid scars have excess deposition of collagen. Hypertrophic scars form early within the time frame of injury and remain within the boundaries of the inciting injury. Keloid scars have excess thickened hyalinized collagen. Keloid scars may have a delayed onset of formation and extend beyond the boundaries of the original scar. Keloid scars are more likely to occur in dark-skinned individuals, between ages 10–30, at times of peak hormones (puberty, pregnancy), with a positive family history, and in association with hyperimmunoglobulinemia E, or blood type A [70].
\nClinical documentation of scar size, thickness, and treatment effects are usually performed with the use of serial photographs, scar scales (such as the
Scar optimization and mitigation are key principles that are vitally important in medical practice, but beyond the scope of this article. Readers are directed to algorithms of management that exist for both the adult and paediatric populations [70, 80, 81, 82, 83].
\nDiverse symptoms can occur in up to 70% of patients with scars [74]. Symptoms can occur at random timing and even at long intervals after wound healing. Some of these symptoms are highlighted in Figure 2.
\nSymptoms related to scars.
Scars may be intrinsically painful or play a role in pain located at an anatomically distant site. Scars may present as painful or itchy at the site of the healed scar. One potential cause of intrinsic pain in a healed scar is a neuroma, derived from a regenerating nerve trapped in the fibrotic scar tissue. This is usually associated with numbness in the innervated area of the injured nerve and a positive percussion test. In the absence of a neuroma, the estimated prevalence of painful scars is 2%, but increases in the burn population to 30–68% [57]. Intrinsic scar pain occurs in 7–18% of patients following lower segment Caesarean section [84, 85, 86]. Pathological and intrinsically painful scars have been shown to have an in imbalance between non-peptidergic unmyelinated c-fibres and peptidergic c-fibres, but not necessarily in total nerve fibre density [57]. There is also an increased abundance of neuropeptides, and nociceptors in pathological scars, especially hypertrophic scars [18, 87].
\nIt is clear that what is happening underneath a scar is critical to whether it subsequently creates symptoms. Scar tissue can adhere to fascia, underlying muscles, organs, blood vessels and nerves, and recognition has been given to scars as an etiological factor in post-surgical visceral dysfunction [88, 89], nerve entrapment syndromes [90], and symptoms related to obvious contractures. However, very little is documented for the role of scars in locomotor dysfunction [91, 92, 93, 94, 95] or chronic myofascial pain [38, 95, 96, 97].
\nIn patients asked to move actively, electrical activity from a scarred area is higher than that from normal tissue in the same patient doing the same movement [93]. Mechanoreceptors and mechanosensitive nociceptors in scarred areas may sense an alteration in tension from normal and send non-physiological signals creating a pathological reflex arc [18], inducing neurogenic inflammation and worsening scar formation and pain [18, 63].
\nScars can limit normal movement and the flexibility of skin, the underlying fascia, and its associated muscles. It is clear that any scar that restricts fascial or muscular movement will also have an impact on whole body movement related to the myofascial chains discussed in the fascia section above [18, 99]. The fascia is recognised as a significant contributor to chronic pain [100, 101, 102]. Other factors that may play a role include alterations in fascial density. Changes in hyaluronan may lead to fascial densification that restricts fascial sliding and gliding, aggravating fascial dysfunction associated with musculoskeletal disorders and chronic pain [32, 103, 104, 105, 106, 107, 108, 109]. Injury reduces the flexibility of fascia; for example, a compound fracture may be associated with periosteal tethering to the skin during healing. The subsequent defective fascial sliding generates anomalous tension, which affects the fascial continuum leading to musculoskeletal pathology, pain and progressive immobility [18, 32, 103, 110, 111, 112]. Fascial injury also leads to fascial dysfunction as well as significant loss of sports performance [18, 21, 113, 114]. Symptoms may not necessarily just occur at the site of injury, but also at a distant site related to referred pain and impacts through myofascial chains. Reduced fascial mobility, related to movement restriction secondary to injury, worsens over time, but may persist even when movement is subsequently restored [110]. This was demonstrated with ultrasound imaging of adults with chronic low back pain with increased thickness and reduced mobility of the thoracolumbar fascia [102, 110, 115]. Sonoelastography has been used to measure viscoelastic properties of the connective tissue around scars: it superimposes a parametric image, in a range of colours, over the ultrasound anatomical scan image to semi-quantitatively correlate images with that tissue’s elasticity. Sonoelastography has been used to show the changes in post-surgical scars following manual therapy [75, 76].
\nFascial trauma or injury may also irritate primary afferent nociceptive fibres leading to spinal cord wind up and central sensitization as another mechanism of ongoing pain [35, 96].
\nmyoActivation is unique in focusing on aspects of the immediate and past trauma history (often overlooked in a classical medical history) and relating this to the current chronic pain presentation. The
Clinical experience with myoActivation [116] reveals that a scar can play a very significant role in chronic myofascial dysfunction and pain even if that scar has the appearance of a normotrophic scar and is reported to be asymptomatic. An ankle scar may alter the gait dynamics through maldistribution of myofascial loads [18] and may also present with ongoing pain at a distant site on the ipsilateral side. Patients with scars in the abdominal region, such as a Caesarean section scar or an abdominoplasty scar, may present with low lumbar back pain related to impaired mobility of the soft tissues of the abdomen, which then puts stretch on the lumbar muscles, thoracolumbar fascia, and the posterior myofascial chain [92, 93, 112]. Scars may also have an impact on the distribution of forces that pass through the body at the time of an injury, such as during a motor vehicle accident [18], causing a previously asymptomatic scar to be the inciting event for myofascial impairment and pain.
\nClassic scar assessment techniques such as use of adheremeters, cutometers, ultrasonography, and rating scales (POSAS or VSS) [74] were not designed to determine a scar’s relevance to myofascial dysfunction and pain. A scar may be significant in terms of myofascial dysfunction and chronic pain, but not be characterised as a pathological scar in current “classical” medical terminology. Clinical experience with myoActivation therapy has found some features, outlined in Table 1, that indicate a scar may cause significant myofascial dysfunction and/or chronic pain. These observations will have to be researched to determine which ones are the more common and substantial factors in myofascial pain and dysfunction.
\nFeatures in the past medical history and timeline of lifetime trauma (TiLT) inventory | \nScars incurred at a young age, especially the first or earliest scar in childhood | \n
\n | Ongoing pain occurring in the immediate timeframe of a surgical procedure which is unexplained and resistant to other forms of therapy | \n
\n | History of poor wound healing, wound infection or wound dehiscence | \n
\n | Painful/itchy scars | \n
\n | Scars incurred at a time of intense emotional turmoil or trauma. | \n
\n | History of mood disorders may indicate any chin scars will be significant | \n
\n | History of anxiety may indicate any chest wall scars will be significant | \n
\n | History of “brain fog” (confused, disorganised, find it hard to focus or put thoughts into words) may indicate a face/chin/sternal or midline abdominal scars will be significant | \n
\n | History of injury in the presence of an asymptomatic scar (injury may be months or years after scar acquisition), which results in pain in the region of this previously asymptomatic scar | \n
Type of scars | \nScars related to chicken pox infection, surgery and especially surgical drain scars, burns and animal (or human) bites | \n
Site of scar | \nOver bony prominences, e.g. anterior chest, in feet, scar in region of main pain complaint, on the same side as a unilateral pain complaint | \n
\n | At sites of periosteal tethering | \n
Scar characteristics | \nPainful scars, purple discolouration, widened scar, palpable densities within or around the scar, scar dysesthesia, adherent/tethered scars | \n
myoActivation examination BASE test [116] | \nIf scar is situated in region of most painful or restricted BASE test on myoActivation examination, even if it looks like a normal scar and/or reported as asymptomatic | \n
Response to dry needling release | \nEnhanced “biting” sensation when scar is released with dry needling even with appropriate use of topical anaesthesia and/or vapo-coolant spray | \n
\n | Reported pain decreased or moved immediately following scar release | \n
\n | Improvement in ROM and flexibility immediately following scar release | \n
\n | Decreased irritability of other palpable pain points in region of and distant to area of scar release | \n
Size of scar | \nSize of scar does | \n
Less significant scars | \nSome scars seem to be less significant in terms of myofascial dysfunction and chronic pain, e.g. | \n
\n | • Superficial self-harm scars | \n
\n | • Tattoos (although they may be hiding another significant scar) | \n
\n | • Stretch marks | \n
Clinical factors indicating a scar may have potential for myofascial dysfunction and chronic pain.
Non-surgical scar release can be achieved with soft tissue mobilisation techniques, subcision or dry needling [84, 93, 118, 119, 120, 121]. Subcision, or microneedling, also known as percutaneous collagen induction therapy, is a minimally invasive minor surgical procedure used for treating depressed cutaneous scars and wrinkles. A simple hypodermic needle or a dermaroller are the tools used to effect subcision [122]. Subcision was first described in 1995 [123]. It is a safe and effective microneedling technique used as an aesthetic treatment for several different dermatological conditions including scars, rhytids, and striae [122, 124, 125]. Histological changes have been demonstrated with this technique [126]. It is hypothesised that microneedling stimulates the body’s own regenerative mechanisms through collagen bundle break down and new collagen formation (neocollagenesis), stimulation of the release of platelet and neutrophil derived growth factors and cytokines (FGF, TGFα, TGFβ, VEGF, FGF-76, EGF, platelet derived growth factor, connective tissue growth factor, and connective tissue activating protein), resulting in increased production of collagen, elastin and glycosaminoglycans [122, 127, 128, 129, 130, 131, 132]. Up-regulation of TGF-β3 (which prevents aberrant scarring) in excess of TGF-β1 and TGF-β2 may be responsible for the benefits seen with microneedling [129, 133].
\nThe other physiological effects of dry needling are not yet fully elucidated, but may include local, hormonal, neuronal, and placebo effects [134]. Neuronal effects include: modulation of the peripheral nervous system; gate control mechanisms; and central pain modulation, such as activation of the diffuse noxious inhibitory control systems [135]. Dry-needling stimulation of skin nociceptive nerve fibres may release endogenous opioids to activate enkephalinergic inhibitory dorsal horn interneurons and oxytocin to mediate peripheral inhibition of c-fibre discharge [4].
\nFor the release of scars, the myoActivation needling technique involves the sequential insertion of 30 g hollow bore needle in the line of the scar and in any areas of densification around the scar performing multiple perforations approximately 3 mm apart. Clinical experience reveals that a patient report of a “biting sensation” with needling is characteristic of a myofascially significant scar. This biting occurs even if the scar has been treated with appropriately timed topical anaesthetic or pre-needling vapocoolant spray.
\nThe release of scars with micro-needling techniques has been shown to produce relief of chronic pain [116, 136]. Currently, the immediate relief of chronic pain following needling of surgical scars is limited to case reports [116, 120, 136], and to date there is insufficient evidence to advise on the right time to treat scars after injury or surgery. It has been suggested that the skin can keep a memory of trauma [118, 137]. It is clinically important to consider this and be cognizant of events which were associated with creation of a scar. Scars inflicted at a time of severe emotional distress or at the time of a traumatic event can be associated with flashbacks or emotional release at the time of, or a number of hours after, treatment whether the therapy was with a needling procedure or manual manipulation [138].
\nAs all structures of the human body are intricately connected through skin and the myofascial system, scar and myofascial release (often at a distant site) can result in immediate improvement of pain, flexibility and range of motion [116] (Table 2), but it is imperative that this is combined in a multidisciplinary approach to address the whole biopsychosocial aspects of pain especially in the paediatric population [136]. It is absolutely essential to prevent needle-related pain in paediatric patients; the practitioner should employ a variety of non-pharmacological techniques including distraction, breathing techniques, music, virtual reality or mobile devices. Pharmacological modalities can be added when non-pharmacological methods are considered insufficient to address the patient’s anxiety and needle-related pain. Topical anaesthetic cream can be applied to target sites (especially scars) an hour before the appointment to minimise needle pain. Oral benzodiazepines can be useful for anxiolysis. If the above methods are not adequate, IV sedation with appropriate anaesthetic monitoring and care may have to be utilised.
\nImmediate effects | \nDecreased pain or pain which has shifted to a new location | \n
\n | Increased flexibility and range of movement in myoActivation BASE tests | \n
\n | Altered weight distribution on feet | \n
\n | Emotional release | \n
\n | Reports of feeling lighter or “walking on a cloud” | \n
\n | Sympathetic response | \n
\n | Vasovagal response | \n
\n | Bruising | \n
\n | Post treatment pain at site of needle insertions lasting minutes to hours | \n
\n | Exacerbation of muscle spasms (requires additional needle insertions to resolve) | \n
\n | Adverse events (Injury to adjacent structures e.g. pneumothorax when needling around lung fields) | \n
Long-term effects | \nImproved pain | \n
\n | Improved flexibility | \n
\n | Improved mood | \n
\n | Improved sleep | \n
\n | Maturation to a normotrophic scars | \n
Effects of scar release.
Over and above these considerations there are some relative and absolute contraindications to needling of scars (Table 3).
\nAbsolute | \nNew scars in process of normal healing and remodelling | \n
\n | At sites of active infection | \n
Relative | \nNear indwelling metalwork/hardware to minimise risk of hardware infection. | \n
\n | Near indwelling mesh to minimise risk of infection. | \n
\n | Where it is considered to be too painful (especially foot scars) | \n
\n | When patient has needle aversion or needle phobia | \n
Relative and absolute contra-indications to needling scars.
Chronic myofascial pain is common in the paediatric population and its prevalence has increased since the 1980s [139]. Musculoskeletal pain is a common cause of pain in adolescents, with incidence ranging from 30 to 65% [140, 141, 142, 143, 144], and is a leading cause of years lived with disability among children and adolescents [145]; 4% of all primary care consults represent musculoskeletal issues in children aged up to 15. Between 4 and 40% of adolescents report limb pain and 14–24% complain of low back pain [146]. The prevalence of paediatric chronic myofascial pain increases with increasing age [139, 147, 148, 149, 150] and is more common in females [146, 151]. Young children are not immune with a 10% prevalence of musculoskeletal pain in 6-year-old children. A staggering one-third of this six-year-old population has chronic musculoskeletal pain and 44.6% of them report that pain is multisite in nature [152].
\nDespite its prevalence, reported musculoskeletal pain is often under-diagnosed in adolescents [153, 154]. Healthcare providers may be unfamiliar or not trained to diagnose chronic pain, muscle trigger points, palpable pain points, and fascia in tension [155, 156, 157, 158]. Presenting symptoms such as neck pain, shoulder pain, abdominal pain and headaches do not immediately direct a physician to look for a myofascial component to pain. Myofascial pain can also imitate other pathologies; for example, a trigger point in the quadratus lumborum muscle can mimic the symptoms of appendicitis on the ipsilateral side, or fascial tension in the peri-coccygeal soft tissues may present as neck pain. System, practice and time pressures may also limit the ability to undertake a full history and physical examination [159, 160].
\nExperience dictates that dysfunctions in muscles, fascia and scars are common in the paediatric population and are significant contributors to paediatric chronic pain [116, 136]. The following cases highlight the importance of scars in paediatric myofascial pain presentations. It must be emphasised that scars are not treated in isolation, but as one element of myoActivation, which is one component of multidisciplinary care.
\nThe children described in these case studies were referred to the
A 13-year-old, 54 kg female was referred to the CPS for management of multisite chronic pain of 3 years duration with a diagnosis of “pain syndrome” focused mainly on the left knee, but also affecting the low back and neck. The low back pain of 3 years was reported to be secondary to a fall 3 years previously. She had been involved in a motor vehicle accident (MVA) 2 years after that when she was struck on the left side whilst walking across a road. She was admitted by ambulance to the local emergency room (ER) and discharged later that day with a diagnosis of bruising to her left knee and ribs after normal imaging. She initially mobilised with crutches and gradually regained physical functioning, but with ongoing pain.
\nShe described her current pain as dull and achy with stabbing pain elements. Pain was aggravated by walking long distances or any physical activities or exercise. She stated that she had some irritability and sadness related to her pain. She complained about some inability to concentrate due to pain and had been absent from school for 21 days in the previous 3 months. She reported that pain also affected her ability to fall and stay asleep. Her TiLT inventory revealed no other injuries. She reported that she had no scars. She had been using acetaminophen and ibuprofen or naproxen for analgesia as required. She was otherwise healthy and her family history was unremarkable.
\nShe was assessed by her orthopaedic surgeon and family doctor. Previous classical examination, imaging (X-rays and MRI) and bloodwork revealed no remedial cause of her pain.
\nmyoActivation examination revealed unreported scars on the left knee and the right upper back, fascia in tension and multiple muscles in sustained contraction. A myofascial component to her pain was diagnosed. She was enrolled in the 3P care plan. She was started on Magnesium Bisglycinate, Vit K2 and Vit D (MgBis/K2/D3). Written information about myoActivation was given to the family. One month later, there was a reduction in pain with improved fluidity of movements. Her family also reported improved mood and sleep.
\nIt was deemed appropriate to proceed with myoActivation at this one month follow up based on her stoical character. Written consent was obtained. Distraction techniques, vapocoolant spray and topical anaesthetic for scars were used to minimise procedural pain. All needling was done using sterile technique.
\nThe right thoracic paraspinal, right gluteus medius, right gluteus maximus and left iliopsoas were sequentially activated based on the repeat cycles of assessment to determine the most restrictive and painful BASE tests [116]. The three left knee scars and upper back scar were in regions of worst BASE tests so they were considered significant and released. Scar release consisted of sequential perforation needling of the scar using a 30 g hollow bore needle. After this first myoActivation session the patient experienced immediate improvement in pain and flexibility.
\nFive days after her first myoActivation session the patient reported that her low back pain no longer bothered her. She reported that the left knee pain felt less tight and tense and she was able to move “more freely”, but going up and down stairs was still a problem. The left lumbar paraspinal, left rectus femoris, left vastus lateralis and left pubic fascia were sequentially activated based on the repeat cycles of assessment to determine the most restrictive and painful BASE tests [116].
\nAt the next myoActivation session, 1 day later, the patient reported that her pain had moved to the medial aspect of her left knee overnight. Repeat myoActivation examination revealed marked improvement in all core BASE tests with no pain except mild limitation of squats with arms down and arms up. The left vastus medialis was activated with improvement in squat with the arms down. A left shin scar was noted and released with improvement in squats with the arms up. The patient reported no pain at the end of this session.
\nOne month later, the patient again reported that her low back pain no longer bothered her. She reported that the left knee pain returned on stopping MgBis/K2/D3, so she restarted them. Based on the repeat cycles of assessment to determine the most restrictive and painful BASE tests [116], the right lumbar paraspinal, right hamstring, left gluteus medius and left iliopsoas were sequentially activated. Based on core BASE tests, the left knee scars were also re-released.
\nFour months after initial assessment, she only had minimal left knee pain with long walks, was sleeping, and was attending school full time with no absences. She required no prescribed or over-the-counter analgesia medications. On examination, she had normal movements in all core BASE tests with no pain. She was discharged from CPS care and advised to slowly wean MgBis/K2/D3.
\n\n
During examination, it is important to view as much skin as possible to find scars that patients do not remember or acknowledge are present.
Scar found in the region of most restrictive or painful myoActivation BASE test should be released even if they are small, look normotrophic and are reported as asymptomatic.
Scars may have to be re-released on subsequent myoActivation sessions.
myoActivation is unique in enabling the unravelling of multiple contributors to pain, as in this case with low back and left knee pains.
The patient-physician relationship is enhanced by hands-on examination and demonstration of change with sequential examinations.
In children and adolescents, it is important to utilise techniques to minimise procedural needling pain.
As a component of multidisciplinary care, myoActivation enhances recovery, even in patients with a history of years in pain.
An 18-year old, 46 kg, non-verbal, wheelchair bound male with cerebral palsy (Gross Motor Function Classification System V), global developmental delay and seizures, was referred to the CPS. His paediatrician requested that the CPS determine if a series of myoActivation sessions might help with ongoing management of worsening bilateral leg spasms and pain. The patient had multi-physician paediatric care of his condition and was optimised on multiple medications (analgesic, anti-epileptic, and antispasmodic).
\nHis carer believed that his pain was focused to his legs and was worsened with touching his legs or changing his diaper. It would take him 30–45 minutes to settle and seem calm after diaper changes or turns. Benzodiazepine rescue medication was used to help with spasms at these times. There was no specific pain pattern, with the pain occurring daily and restricting ability to move him and change diapers. There were no changes in skin colour or temperature and no oedema. Each night he is moved every 2 hours as he is unable to move himself; however, his carer felt that sleep was further disturbed by pain. He could not tolerate lying prone.
\nMultiple surgeries in the past included: posterior spinal instrumentation and fusion T3-Pelvis; right femoral head excision and subtrochanteric valgus osteotomy; circumferential release of capsule right hip; right and left pelvic osteotomy; left femoral osteotomy; and bilateral leg soft tissue releases and Botox injections. His imaging confirmed normal healing and no complications related to his multiple surgeries.
\nA complete myoActivation assessment examination could not be performed given his non-verbal and wheelchair-bound status. Lying flat multiple bilateral scars were noted from the listed surgeries. His right leg was shortened and externally rotated. There was a torso shift to the right and the pelvis was lower on the right. The right knee was hyper-flexed. The left iliopsoas, rectus femoris and vastus medialis appeared to be in sustained contraction. He was started on MgBis/K2/D3 supplements. One month after initial assessment, scar release was performed under anaesthesia to release all the right-sided leg scars. Scar release consisted of sequential perforation needling of the scar using a 30 g hollow bore needle, using sterile technique.
\nTwo months after initial assessment, myoActivation scar release was done to release all the left sided leg scars and activate the left iliopsoas, left rectus femoris and left vastus medialis under anaesthesia.
\nAt follow up 1 month later, 3 months after initial assessment, his caregiver reported that he was much happier with no further episodes of crying out in pain with movement or diaper changes. He was also able to lie on his front without any issues.
\n\n
It is difficult to assess pain in a non-verbal patient.
Children and adolescents with developmental delay may not be able to participate in a structured myoActivation examination; therefore, the pain physician will have to rely on parent or carer observations (most painful movements or triggers of pain, most comfortable positions when awake and during sleep).
In a non-verbal patient, clinical experience and acumen determine if there is a myofascial component to the patient’s pain and help direct therapy to the most likely sources of myofascial pain.
As in developmentally normal children, techniques to minimise procedural needling pain are essential, as in this case where multiple scars were released utilising procedural sedation.
A 14-year old, 57 kg male was referred to the CPS for management of chronic left shoulder pain of 7 months duration. His pain was severe, graded as 8/10 on a visual analogue scale, localised to the left shoulder with no radiation. There was no inciting event to his pain. The pain was exacerbated by any movement of his shoulder. He had mild left sided hemiplegia secondary to removal of a thalamic astrocytoma at age 6. He had undergone a left ankle tendon transfer at age 13. He reported that pain significantly affected his ability to fall and stay asleep. His TiLT inventory revealed he had had a fractured left ankle, but no MVAs. He had scars related to the above surgeries as well as scars from his right sided venous access device, which was inserted at the time of diagnosis of his astrocytoma and removed a year later upon successful treatment of his oncological presentation. He was otherwise healthy, and his family history was unremarkable.
\nHe was assessed by his orthopaedic surgeon, neurologist and oncologist. Previous classical examination, imaging (X-rays, CT and MRI) and bloodwork revealed no remedial cause of his pain and no recurrence of his astrocytoma. Prior to referral to CPS, he was already integrated with regular physiotherapy and intermittent massage therapy. Medications at initial assessment were as required tramadol, acetaminophen, and ibuprofen. myoActivation examination revealed a myofascial component to his pain. In view of distressing pain symptoms, it was agreed that myoActivation should be performed at the initial assessment to help relieve his pain. Written consent was obtained and myoActivation information given to the family. Distraction techniques and vapocoolant spray were used to minimise procedural pain.
\nThe left external oblique, left subscapularis, left platysma were released based on structured regional tests for the shoulder [116]. After this first myoActivation session, the patient experienced immediate improvement in range of motion of the left shoulder and decreased pain. Eight days after this myoActivation session the patient reported that his left shoulder pain was “way better than before” and his mum reported that he was complaining less about his shoulder and was able to sleep better. He had some ongoing left shoulder pain. Repeat myoActivation was performed at one-month intervals using BASE tests and regional test for shoulder function. On the fourth and final myoActivation session his left foot scars were released. As foot scars can be painful, even with appropriately applied topical anaesthetic and vapocoolant spray, it was agreed to release these scars with procedural sedation using standard anaesthetic monitoring and care.
\nAt the time of discharge, 3 months after initial assessment, he had no pain, he was able to function physically within the restrictions of his existing hemiplegia, but with no pain, and was attending school full time. He was discharged from CPS care and advised to slowly wean MgBis/K2/D3. Fourteen months after discharge he remains pain free.
\n\n
In the presentation of severe ongoing pain, it is sometimes important to address regional tests, like the shoulder in this case before addressing potential myofascial triggers in BASE tests.
For some children and adolescents, there is a need for a general anaesthetic to perform needling of scars or trigger points: for example, in anxiety/mood disorder, young age, non-verbal patients, or where it will be considered too painful (e.g., foot scars) as in this case.
Distant site same-side scars can be clinically important with respect to the tension they create through myofascial chains and biotensegrity principles described above. For example, left foot scar release to resolve left shoulder pain as outlined in this case.
A 15-year-old, 57 kg female was referred to the CPS by her orthopaedic physician for management of right knee pain of 3 years duration with a diagnosis of “possible tendonitis or tendinosis of medial hamstring” with normal blood work and imaging (X-rays and MRI). Her main hobby was horse riding and she had sustained multiple injuries related to her recreational activities. She related her knee pain to one of these injuries, 3 years ago, when she was bucked off her horse and then the horse stood on her right knee. Immediately after this injury, she attended the local ER and was discharged after normal imaging. She initially mobilised with crutches and gradually regained physical functioning over the course of the subsequent 2 months.
\nShe described her current pain as dull and achy with stabbing pain elements radiating up her leg and down into her calf. Pain was aggravated by running, horse riding, doing squats, or any other physical activities or exercise. She had to wear a knee brace and only used the left stirrup when riding her horse as use of the right stirrup aggravated her right knee pain. She reported no effect on mood related to her pain. She had not been absent from school in the previous 3 months. She reported that pain sometimes affected her ability to fall asleep. Her TiLT inventory revealed multiple horse-riding related injuries. She reported that she had scars from a recent laparoscopic appendicectomy and scars on her right knee from a wire penetrating injury when she was aged 6. She had been using over-the-counter simple analgesia as required. She was otherwise healthy and her family history was unremarkable.
\nmyoActivation examination revealed unreported scars on the right knee and the abdomen, fascia in tension, and multiple muscles in sustained contraction. A myofascial component to her pain was diagnosed. She was enrolled in the 3P care plan. She was started on MgBis/K2/D3. Written information about myoActivation was given to the family.
\nFive weeks later she reported feeling better and stronger, but no real change in her knee pain. It was deemed appropriate to proceed with myoActivation at this time. Written consent was obtained. Distraction techniques, vapocoolant spray and topical anaesthetic for scars were used to minimise procedural pain. All needling was done using sterile technique.
\nThe right thoracic paraspinal, and right gluteus medius were sequentially activated based on the repeat cycles of assessment to determine the most restrictive and painful BASE tests [116]. The three appendicectomy scars and right knee scar were in regions of worst BASE tests so they were considered significant and released. After this first myoActivation session, the patient experienced immediate improvement in pain and range of motion in all BASE tests.
\nThree weeks after her first myoActivation session, the patient reported that her right knee pain had moved down to the inner aspect of the right calf. The pain felt was less than on initial assessment. She reported that she could sit in saddle, horse riding for longer, but found eversion of her ankles painful. The left iliopsoas and left rectus abdominis were sequentially activated based on the repeat cycles of assessment to determine the most restrictive and painful BASE tests [116]. The three appendicectomy scars were again in regions of worst BASE tests so they were considered significant and re-released. After this myoActivation session, the patient experienced immediate improvement in pain and range of motion in all BASE tests.
\nThree months after initial assessment, she reported she could move better, had less pain, was horse riding for much longer with both feet in the stirrups. She required no over-the-counter analgesia medications. On examination, she had normal movements in all core BASE tests with no pain. She was discharged from CPS care and advised to slowly wean MgBis/K2/D3.
\n\n
The site of pain may not be the true source of pain. The right hamstrings were never activated, even though they were the initial site of pain.
Release of a scar from the youngest age in the region of most restrictive or painful myoActivation BASE test can make clinically substantial change, as was the case for this girl.
Scars acquired after onset of pain may also play an important role in a myofascial pain presentation.
This case again illustrates that myoActivation, as a component of multidisciplinary care, enhances recovery even in patients with a history of years in pain and multiple injuries.
A 16-year old, 57 kg, female was referred to the CPS for management of multi-site pain related to injuries sustained when hit by a car whilst crossing a road. She was referred by her orthopaedic surgeon, 1 year following injury, when ongoing recovery of physical functioning was hampered by multisite pain. She had been fit and healthy prior to this accident.
\nShe was a pedestrian who was struck on the right side and knocked down sustaining multiple pelvic ring fractures and a left femoral fracture. She sustained no other injuries. She required external fixators and an intramedullary femoral rod to stabilise her fractures and control blood loss at the time of admission. She was an inpatient in hospital for a month and then transferred for inpatient rehabilitation at a local rehabilitation centre. The external fixator was removed 2 months after application. She was discharged from the rehabilitation centre 5 months after the date of her presenting injury. She continued with ongoing outpatient physiotherapy, kinesiology, daily exercises and regular counselling but had recently stopped seeing a physiotherapist due to lack of financial support. Imaging confirmed normal healing and no complications related to the surgical sites.
\nThe pain was multisite, affecting the upper, mid and low back, left knee, bilateral thighs, and bilateral ankles with no radiation and no motor or sensory deficits. Her pain was variable and intermittent, but aggravated by exercise. She had been absent from school for 5 days in the previous 3 months due to pain. She reported that pain also affected her ability to fall and stay asleep. Her lifetime trauma history revealed no other injuries. She took ibuprofen as required. She was otherwise healthy and her family history was unremarkable.
\nmyoActivation examination revealed a myofascial component to her pain. Scars were noted from the external fixator and at the site of the left intramedullary nail. There were also abrasion scars from the injury on the left thigh and hip. She was enrolled in the 3P care plan and was started on MgBis/K2/D3. Written myoActivation information was given to the family.
\nOne month later, there was a reduction in pain with improved fluidity of movements just with the addition of MgBis/K2/D3 and re-engagement with physiotherapy. It was deemed appropriate to proceed with myoActivation at this one-month follow-up visit, based on her very stoical character. Written consent was obtained. Distraction techniques and vapocoolant spray were used to minimise procedural pain. Fascial densification, muscles in sustained contraction and the scars in areas of most significant BASE tests [116] were released. Release of the surgical scars and the scars related to the injury made a clinically significant change in pain and range of motion during these sessions.
\nWith such significant injuries and multiple areas required to be treated, she required nine myoActivation session in the course of the following year whilst integrated with the CPS. At the time of discharge, 16 months after initial assessment, she was able to function physically with no restrictions and minimal pain. She was sleeping well and successfully graduated from school with good marks. She noted that her scars were paler, flatter and less obvious than at the start of therapy. She was discharged from CPS care and advised to slowly wean MgBis/K2/D3.
\n\n
Patient reported change in function, just related to institution of the 3P approach, massage, and MgBis/K2/D3, helps to confirm a myofascial component to pain.
This approach, with the addition of myoActivation, can have a substantial impact even in the presence of such devastating previous injuries.
Release of the surgical scars and the scars related to the injury made clinically significant change for this patient.
The cases cited above have provided a view of how scars have made a substantial impact in pain presentation. Scar release (using a needling technique) helped make meaningful change for these patients, often when all other avenues of classic medical care for pain aetiology and resolution had been exhausted. Not only is this rewarding for the patients and their families, but also the CPS team who are helping them in their journey to recovery.
\nHumans exhibit biotensegrity, where each individual part of the organism combines with the mechanical system to create an integrated functional movement unit. All structures of the human body are intricately connected through skin and the myofascial system, they are in a continual process of change dependant on and adapting to the forces acting on and within them. When tissue is breached by surgery or injury, the healing process leads to the formation of scar tissue. Scars can limit normal movement of underlying and remote tissues. Defective fascial sliding, secondary to scars, generates anomalous tension that affects the fascial continuum and may lead to distorted biomechanics and chronic pain.
\nScars are common in the paediatric population and are significant contributory factors to chronic pain. Many years, even decades, may pass between scar acquisition and the development of biomechanical dysfunction or myofascial pain. A subsequent trauma may be the inciting event as force transmission throughout the body is changed by a scar. Hence, it is important to assess the TiLT inventory, and characteristics of all scars, even when they appear to look “normal”.
\nThere are many characteristics of a scar that disrupt the myofascial system, which have been highlighted in the cases discussed. When scars are deemed significant, scar release should be considered as one component in a multidisciplinary approach to address the whole biopsychosocial aspects of chronic pain [136]. Scar and myofascial release, with soft tissue mobilisation or needling techniques, can result in immediate and sustainable improvements in pain, flexibility, and range of motion [116]. When contemplating scar release, consideration should be given to minimising procedural pain and to ensure support for any emotional reactions that may occur immediately or within the hours following scar release.
\nResearch is required to ascertain the exact characteristics of a scar that determine whether it will have a significant contribution to myofascial dysfunction and chronic pain. The cases presented above illustrate that these investigations must recognise the multiple and complex biopsychosocial factors that contribute to a myofascial chronic pain presentation.
\nWhilst definitive answers are awaited, we need to think beyond scars as just being innocuous mementos of the past. Clinical experience indicates that they may be restrictive barriers, exerting pervasive biomechanical and nociceptive effects in the present. Left untreated, that “
The authors would like to thank Dr. Doug Courtemanche and Dr. Greg Siren for their insightful comments on a draft of this chapter.
\nThe authors have no conflicts of interest to declare.
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The effect of factors (such as, nanoparticle size, nanofluid concentration, flowrate of nanofluid and geometry of channel containing nanofluid) influencing the efficiency of PV systems has been discussed. Collective results of different researchers indicate that the efficiency of the PV/T systems (using nanofluids as coolant) increases with increasing flowrate. Efficiency of these systems increases with increasing concentration of nanofluid up to a certain amount, but as the concentration gets above this certain value, the efficiency tends to decline due to agglomeration/clustering of nanoparticles. Pertaining to the most recent studies, stability of nanoparticles is still the major unresolved issue, hindering the commercial scale application of nanofluids for the cooling of PV panels. Eventually, the environmental and economic advantages of these systems are presented.",book:{id:"6514",slug:"microfluidics-and-nanofluidics",title:"Microfluidics and Nanofluidics",fullTitle:"Microfluidics and Nanofluidics"},signatures:"Hafiz Muhammad Ali, Tayyab Raza Shah, Hamza Babar and\nZargham Ahmad Khan",authors:[{id:"187624",title:"Dr.",name:"Hafiz Muhammad",middleName:null,surname:"Ali",slug:"hafiz-muhammad-ali",fullName:"Hafiz Muhammad Ali"},{id:"229676",title:"Mr.",name:"Hamza",middleName:null,surname:"Babar",slug:"hamza-babar",fullName:"Hamza Babar"},{id:"241251",title:"Mr.",name:"Tayyab",middleName:"Raza",surname:"Raza Shah",slug:"tayyab-raza-shah",fullName:"Tayyab Raza Shah"},{id:"241252",title:"Mr.",name:"Zargham Ahmad",middleName:null,surname:"Khan",slug:"zargham-ahmad-khan",fullName:"Zargham Ahmad Khan"}]},{id:"59009",doi:"10.5772/intechopen.72505",title:"Thermal Transport and Challenges on Nanofluids Performance",slug:"thermal-transport-and-challenges-on-nanofluids-performance",totalDownloads:1721,totalCrossrefCites:4,totalDimensionsCites:15,abstract:"Progress in technology and industrial developments demands the efficient and successful energy utilization and its management in a greater extent. Conventional heat-transfer fluids (HTFs) such as water, ethylene glycol, oils and other fluids are typically low-efficiency heat dissipation fluids. Thermal management is a key factor in diverse applications where these fluids can be used, such as in automotive, microelectronics, energy storage, medical, and nuclear cooling among others. Furthermore, the miniaturization and high efficiency of devices in these fields demand successful heat management and energy-efficient materials. The advent of nanofluids could successfully address the low thermal efficiency of HTFs since nanofluids have shown many interesting properties, and the distinctive features offering extraordinary potential for many applications. Nanofluids are engineered by homogeneously suspending nanostructures with average sizes below 100 nm within conventional fluids. This chapter aims to focus on a detail description of the thermal transport behavior, challenges and implications that involve the development and use of HTFs under the influence of atomistic-scale structures and industrial applications. Multifunctional characteristics of these nanofluids, nanostructures variables and features are discussed in this chapter; the mechanisms that promote these effects on the improvement of nanofluids thermal transport performance and the broad range of current and future applications will be included.",book:{id:"6514",slug:"microfluidics-and-nanofluidics",title:"Microfluidics and Nanofluidics",fullTitle:"Microfluidics and Nanofluidics"},signatures:"José Jaime Taha-Tijerina",authors:[{id:"182402",title:"Dr.",name:"Jose",middleName:"Jaime",surname:"Taha-Tijerina",slug:"jose-taha-tijerina",fullName:"Jose Taha-Tijerina"}]},{id:"57228",doi:"10.5772/intechopen.71002",title:"Thresholding Algorithm Optimization for Change Detection to Satellite Imagery",slug:"thresholding-algorithm-optimization-for-change-detection-to-satellite-imagery",totalDownloads:1639,totalCrossrefCites:6,totalDimensionsCites:11,abstract:"To detect changes in satellite imagery, a supervised change detection technique was applied to Landsat images from an area in the south of México. At first, the linear regression (LR) method using the first principal component (1-PC) data, the Chi-square transformation (CST) method using first three principal component (PC-3), and tasseled cap (TC) images were applied to obtain the continuous images of change. Then, the threshold was defined by statistical parameters, and histogram secant techniques to categorize as change or unchanged the pixels. A threshold optimization iterative algorithm is proposed, based on the ground truth data and assessing the accuracy of a range of threshold values through the corresponding Kappa coefficient of concordance. Finally, to evaluate the change detection accuracy of conventional methods and the threshold optimization algorithm, 90 polygons (15,543 pixels) were sampled, categorized as real change/unchanged zones, and defined as ground truth, from the interpretation of color aerial photo slides aided by the land cover maps to obtain the omission/commission errors and the Kappa coefficient of agreement. The results show that the threshold optimization is a suitable approach that can be applied for change detection analysis.",book:{id:"6126",slug:"colorimetry-and-image-processing",title:"Colorimetry and Image Processing",fullTitle:"Colorimetry and Image Processing"},signatures:"René Vázquez-Jiménez, Rocío N. Ramos-Bernal, Raúl Romero-\nCalcerrada, Patricia Arrogante-Funes, Sulpicio Sanchez Tizapa and\nCarlos J. Novillo",authors:[{id:"213505",title:"Dr.",name:"René",middleName:null,surname:"Vázquez-Jiménez",slug:"rene-vazquez-jimenez",fullName:"René Vázquez-Jiménez"},{id:"213527",title:"Dr.",name:"Raúl",middleName:null,surname:"Romero-Calcerrada",slug:"raul-romero-calcerrada",fullName:"Raúl Romero-Calcerrada"},{id:"213529",title:"Dr.",name:"Rocío N.",middleName:null,surname:"Ramos-Bernal",slug:"rocio-n.-ramos-bernal",fullName:"Rocío N. Ramos-Bernal"},{id:"213530",title:"MSc.",name:"Patricia",middleName:null,surname:"Arrogante-Funes",slug:"patricia-arrogante-funes",fullName:"Patricia Arrogante-Funes"},{id:"213531",title:"Dr.",name:"Carlos J.",middleName:null,surname:"Novillo",slug:"carlos-j.-novillo",fullName:"Carlos J. Novillo"},{id:"221412",title:"Dr.",name:"Sulpicio",middleName:null,surname:"Sánchez-Tizapa",slug:"sulpicio-sanchez-tizapa",fullName:"Sulpicio Sánchez-Tizapa"}]},{id:"61556",doi:"10.5772/intechopen.74426",title:"Microfluidics and Nanofluidics: Science, Fabrication Technology (From Cleanrooms to 3D Printing) and Their Application to Chemical Analysis by Battery-Operated Microplasmas-On-Chips",slug:"microfluidics-and-nanofluidics-science-fabrication-technology-from-cleanrooms-to-3d-printing-and-the",totalDownloads:1850,totalCrossrefCites:6,totalDimensionsCites:10,abstract:"The science and phenomena that become important when fluid-flow is confined in microfluidic channels are initially discussed. Then, technologies for channel fabrication (ranging from photolithography and chemical etching, to imprinting, and to 3D-printing) are reviewed. The reference list is extensive and (within each topic) it is arranged chronologically. Examples (with emphasis on those from the authors’ laboratory) are highlighted. Among them, they involve plasma miniaturization via microplasma formation inside micro-fluidic (and in some cases millifluidic) channels fabricated on 2D and 3D-chips. Questions addressed include: How small plasmas can be made? What defines their fundamental size-limit? How small analytical plasmas should be made? And what is their ignition voltage? The discussion then continues with the science, technology and applications of nanofluidics. The conclusions include predictions on potential future development of portable instruments employing either micro or nanofluidic channels. Such portable (or mobile) instruments are expected to be controlled by a smartphone; to have (some) energy autonomy; to employ Artificial Intelligence and Deep Learning, and to have wireless connectivity for their inclusion in the Internet-of-Things (IoT). In essence, those that can be used for chemical analysis in the field for “bringing part of the lab to the sample” types of applications.",book:{id:"6514",slug:"microfluidics-and-nanofluidics",title:"Microfluidics and Nanofluidics",fullTitle:"Microfluidics and Nanofluidics"},signatures:"Vassili Karanassios",authors:[{id:"60925",title:"Prof.",name:"Vassili",middleName:null,surname:"Karanassios",slug:"vassili-karanassios",fullName:"Vassili Karanassios"}]}],mostDownloadedChaptersLast30Days:[{id:"53106",title:"Dynamical Particle Motions in Vortex Flows",slug:"dynamical-particle-motions-in-vortex-flows",totalDownloads:2264,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Circular vortex flows generate interesting self-organizing phenomena of particle motions, that is, particle clustering and classification phenomena. These phenomena result from interaction between vortex dynamics and relaxation of particle velocity due to drag. This chapter introduces particle clustering in stirred vessels and particle classification in Taylor vortex flow based on our previous research works. The first part of this chapter demonstrates and explains a third category of solid-liquid separation physics whereby particles spontaneously localize or cluster into small regions of fluids by taking the clustering phenomena in stirred vessels as an example. The second part of this chapter discusses particle classification phenomena due to shear-induced migration. 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Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. 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He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:null},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:"Manufacturing and Technology Integrated Campus – SENAI CIMATEC",institution:null},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:"Polytechnic University of Timişoara",institution:{name:"Polytechnic University of Timişoara",country:{name:"Romania"}}},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:null},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"357085",title:"Mr.",name:"P. Mohan",middleName:null,surname:"Anand",slug:"p.-mohan-anand",fullName:"P. Mohan Anand",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356696",title:"Ph.D. Student",name:"P.V.",middleName:null,surname:"Sai Charan",slug:"p.v.-sai-charan",fullName:"P.V. Sai Charan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"357086",title:"Prof.",name:"Sandeep K.",middleName:null,surname:"Shukla",slug:"sandeep-k.-shukla",fullName:"Sandeep K. Shukla",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356823",title:"MSc.",name:"Seonghee",middleName:null,surname:"Min",slug:"seonghee-min",fullName:"Seonghee Min",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Daegu University",country:{name:"Korea, South"}}},{id:"353307",title:"Prof.",name:"Yoosoo",middleName:null,surname:"Oh",slug:"yoosoo-oh",fullName:"Yoosoo Oh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:"Yoosoo Oh received his Bachelor's degree in the Department of Electronics and Engineering from Kyungpook National University in 2002. He obtained his Master’s degree in the Department of Information and Communications from Gwangju Institute of Science and Technology (GIST) in 2003. In 2010, he received his Ph.D. degree in the School of Information and Mechatronics from GIST. In the meantime, he was an executed team leader at Culture Technology Institute, GIST, 2010-2012. In 2011, he worked at Lancaster University, the UK as a visiting scholar. In September 2012, he joined Daegu University, where he is currently an associate professor in the School of ICT Conver, Daegu University. Also, he served as the Board of Directors of KSIIS since 2019, and HCI Korea since 2016. From 2017~2019, he worked as a center director of the Mixed Reality Convergence Research Center at Daegu University. From 2015-2017, He worked as a director in the Enterprise Supporting Office of LINC Project Group, Daegu University. His research interests include Activity Fusion & Reasoning, Machine Learning, Context-aware Middleware, Human-Computer Interaction, etc.",institutionString:null,institution:{name:"Daegu Gyeongbuk Institute of Science and Technology",country:{name:"Korea, South"}}},{id:"262719",title:"Dr.",name:"Esma",middleName:null,surname:"Ergüner Özkoç",slug:"esma-erguner-ozkoc",fullName:"Esma Ergüner Özkoç",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Başkent University",country:{name:"Turkey"}}},{id:"346530",title:"Dr.",name:"Ibrahim",middleName:null,surname:"Kaya",slug:"ibrahim-kaya",fullName:"Ibrahim Kaya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"419199",title:"Dr.",name:"Qun",middleName:null,surname:"Yang",slug:"qun-yang",fullName:"Qun Yang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Auckland",country:{name:"New Zealand"}}}]}},subseries:{item:{id:"1",type:"subseries",title:"Oral Health",keywords:"Oral health, Dental care, Diagnosis, Diagnostic imaging, Early diagnosis, Oral cancer, Conservative treatment, Epidemiology, Comprehensive dental care, Complementary therapies, Holistic health",scope:"\r\n This topic aims to provide a comprehensive overview of the latest trends in Oral Health based on recent scientific evidence. Subjects will include an overview of oral diseases and infections, systemic diseases affecting the oral cavity, prevention, diagnosis, treatment, epidemiology, as well as current clinical recommendations for the management of oral, dental, and periodontal diseases.
",coverUrl:"https://cdn.intechopen.com/series_topics/covers/1.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11397,editor:{id:"173955",title:"Prof.",name:"Sandra",middleName:null,surname:"Marinho",slug:"sandra-marinho",fullName:"Sandra Marinho",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRGYMQA4/Profile_Picture_2022-06-01T13:22:41.png",biography:"Dr. Sandra A. Marinho is an Associate Professor and Brazilian researcher at the State University of Paraíba (Universidade Estadual da Paraíba- UEPB), Campus VIII, located in Araruna, state of Paraíba since 2011. She holds a degree in Dentistry from the Federal University of Alfenas (UNIFAL), while her specialization and professional improvement in Stomatology took place at Hospital Heliopolis (São Paulo, SP). Her qualifications are: a specialist in Dental Imaging and Radiology, Master in Dentistry (Periodontics) from the University of São Paulo (FORP-USP, Ribeirão Preto, SP), and Doctor (Ph.D.) in Dentistry (Stomatology Clinic) from Hospital São Lucas of the Pontifical Catholic University of Rio Grande do Sul (HSL-PUCRS, Porto Alegre, RS). She held a postdoctoral internship at the Federal University from Jequitinhonha and Mucuri Valleys (UFVJM, Diamantina, MG). She is currently a member of the Brazilian Society for Dental Research (SBPqO) and the Brazilian Society of Stomatology and Pathology (SOBEP). Dr. Marinho's experience in Dentistry mainly covers the following subjects: oral diagnosis, oral radiology; oral medicine; lesions and oral infections; oral pathology, laser therapy and epidemiological studies.",institutionString:null,institution:{name:"State University of Paraíba",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,series:{id:"3",title:"Dentistry",doi:"10.5772/intechopen.71199",issn:"2631-6218"},editorialBoard:[{id:"267724",title:"Dr.",name:"Febronia",middleName:null,surname:"Kahabuka",slug:"febronia-kahabuka",fullName:"Febronia Kahabuka",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRZpJQAW/Profile_Picture_2022-06-27T12:00:42.JPG",institutionString:null,institution:null}]},onlineFirstChapters:{paginationCount:6,paginationItems:[{id:"82135",title:"Carotenoids in Cassava (Manihot esculenta Crantz)",doi:"10.5772/intechopen.105210",signatures:"Lovina I. Udoh, Josephine U. Agogbua, Eberechi R. 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