Detail of articles included about acupuncture.
\r\n\tFrom a public health perspective, reduced health literacy can lead to widespread consequences. “Low health literacy is also costly for the country because when people don't understand health information and instructions, they are more likely to have worse health outcomes and unnecessarily use emergency room services,”. Experts agree that health literacy is vital to reducing healthcare costs and improving public health. The path to improving health literacy isn’t always straightforward, however.
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\r\n\t“Unfortunately, up to 9 out of 10 adults can have limited health literacy, and this can be fluid,” Blue says. “It can be more challenging to be health literate when we are sick or in pain, so even someone who normally has a high level of health literacy may struggle at times to understand and process health information.”
The often expressed, but usually trite cliché about history duplicating fiction, nonetheless, reflects a deeper reality, about the human penchant for mystery behind modern technological marvels like brain-computer interfacing (BCI). Indeed, by combining the elusiveness of mental representations with unseen links to motor movements, BCI seemingly appealed to fictional accounts of unlimited mobility and teleportation. This mystique behind the mechanism has lessened somewhat since Jacque Vidal first coined the term in the 1970s [1]. Nevertheless, there remains ongoing excitement over therapeutic prospects that continue to drive interest in advancing BCI applications. Recent domains for example have included the rehabilitation of stroke victims, improved learning with artificial sensory feedback, and real-time control over fine motor movements, as well as the traditional mobilization of external devices usually associated with BCI.
\nAs a strategic response to cognitive and CNS impairments, BCI is a theoretical outgrowth of several generations of endogenous devices that have as a prime strategy the direct replacement of lost neural function. Devices like pacemakers, cochlear implants, and vagal stimulators for example have all been successfully deployed in the relatively simpler anatomical substrate of sensorial and motor nerves where nerve transmission is largely unidirectional and composed of sequences of transmitting signals [2, 3]. In these applications the premise of administering therapy by replacing lost function has been limited to the restoration of signal-generating capacity [4]. Cochlear implants, for instance, transduce pitch vibrations that occur outside the ear to coded electrical signals within the cochlea in order to elicit action potentials in the frequency to place receptors that form the auditory nerve. Implants sited more internally are similarly designed but require the presence of a bidirectional interface for nerve signals, that is, one that can both receive electrical impulses from the intact nerve tissue and yield an equivalently spaced temporal output beyond the point of lesion. For these devices the replacement of action potentials is akin to the restoration of language syntax, here linearly related to temporal spiking sequences.
\nIn building on these earlier devices, BCI has appropriated not only a similar premise but also a similar design and has, therefore, been largely sequence based and output driven. One consequence of this approach, for example, has been the search for an electrical feature that can be used in a fashion analogous to that of spiking in implant devices for peripheral nerves, such as the local field potential [5]. The premise of a temporally defined syntax is increasingly challenged, however, as knowledge of the anatomical recurrency of the brain is made manifest and the need to distinguish transmitted signals from a dominant background of noise becomes evident [6, 7, 8]. How the brain resolves the challenges posed by its complex operation is now thought to occur through the structuring of temporally independent and cyclically repetitive activity, that is, nonlinear dynamical elements that, while using spiking activity as a fundamental mechanistic feature, nonetheless relate only indirectly to it for communication. This is to say that the brain employs a very different type of coding syntax from that of the peripheral nerves. Such fundamentally distinct conditions for communicating information in turn require a different premise on which to base BCI therapy.
\nQualitatively different premises for technology, in fact, are hardly new in science, often exerting profound influences on the subsequent course a field may take. The difference in the way information content is represented, when transitioning from peripheral to central nervous tissue resembles, for example, the transition made in computational programming architectures before and after the introduction of autonomous robotic design [9]. Attempts to endow field-situated robotic agents with autonomous mobility initially employed basic program planning formats where decision-making points were encoded in a series of steps telling the robot how to respond. In the field however, it became apparent that programmed contingencies were incapable of responding to the vast array of circumstances that could act as input variables. The need to accommodate this nearly unlimited variability resulted in a new approach to program planning that adopted a more interactive format where plans comprised only one among several input resources that autonomous robots could call upon [10]. In their formatting, these plans adopted a parallel architecture to accommodate multiple and simultaneous inputs. World information was thus assimilated and assembled as blocks of knowledge rather than temporally consecutive incidents.
\nAn analogous shift is now needed for conceiving of BCI as a therapeutic medium, that is, as one that no longer entails only the restoring of signal transmission capacity but also the repairing of processes that structure basic functions. The direction in which this shift will need to evolve, therefore, is not merely in duplicating how the brain transmits information but also in a larger grasp of organismal design that is mediated globally. This becomes apparent when analogized to a linguistic hierarchy, which is used to structure multilevel representational content.
\nIn the distinct circumstances of brain cognition, this is apparent, first, at a syntactical level. Given a prevailing background of noise, signal preservation is prioritized, by use of recurrent connectivities that possess reciprocal inhibitory and excitatory contributions [11, 12, 13]. The emphasis of this anatomical architecture is to create circumstances of signal stability, to enable information-bearing signals to persist, thereby minimizing any corruption of information content. Hence, the physical architecture of the brain is anatomically configured to create patterns of cyclical flow, where the pattern of the cycle contains the information representation. Current estimates indicate that nearly 95% of brain neurons exhibit some form of feedback, with some zones noted for especially dense innervation [14, 15]. The physiological consequence of this arrangement is the generation of energetically favored zones where signal propagation is retained. Such persistent activity is a necessity to enable the brain to monitor ongoing bodily activity. However, persistent activity also makes brain operation susceptible to the pervasive influence of a noisy background. This susceptibility is overcome by structuring flow within energetically favorable zones, which minimizes the influence of noise and maximizes signal retention.
\nThe dynamical motifs that are generated adapt spiking activity to exhibit a periodicity that frees syntactical expression from its temporal dependence. This periodicity fundamentally restructures the representation of information content. Hence, basic elements of syntax in the brain are not pulsed sequences, but blocked patterns.
\nCritically, these stabilized patterns are unique outcomes determined by the resolution of numerous physical forces; that is, they emerge from a high-dimensional state space within the global activity of the brain. They can therefore potentially assume an indefinite number of mathematical configurations that are defined by these physical circumstances. In a simple model, like a fixed point attractor, the rate of change of the attractor back to its original configuration is linearly related to the brain state, which is typically represented by a signal feature related to that state. More complex models entail the continuous and repetitive traversal of brain states by the attractor, which are described mathematically by a second derivative function, while still other models are complex and multiparameterized [16, 17]. The result of this variation is a significant expansion of syntactical range that is likely to substantially differ from that in peripheral nerves.
\nFor BCI therapy the use of a different syntactical expression can be expected to have several consequences. The transposition of one syntax for another means, first, that an interfacial medium relying only on the original syntax introduces gaps in syntactical interpretation, with the immediate consequence of interpretive redundancy [18, 19]. That is, the mapping from one coding structure to the second is not one to one, but instead elicits multiple readouts. For a therapy premised on signal restoration, this overextends the intended output range and diminishes if not obviates therapeutic effectiveness. Hence, bidirectional interfacing premised on duplicating spiking sequences alone is likely to be inadequate for information transfer.
\nBy acquiring temporal independence additionally, the manner in which syntactical elements are assembled is also altered. As cyclical patterns it is only through their modular assembly into larger architectures that they can yield representational variation, a feature that is seen, for instance, in cases of stable heteroclinic channels [20, 21]. Such variation is potentially amenable to exploitation for constructing extended symbolical architectures [22]. Rodrigues et al., for example, have shown that simple combinations of dynamical elements can be exploited to significantly expand the range of syntactical elements [23]. Using an attractor and repellor, they were able to demonstrate that networks generating these elements not only variably combine in specific ratios but also generalize from external inputs; that is, they learned to represent external input information. This is significant for relating the structure of the network in its connectivity features to a dynamical generation of symbolical structures that establish equivalency with external representation, that is, as codes that map content.
\nYet, the generation of symbolical content is not the only consequence of acquiring temporal independence. The manner in which syntactical elements are assembled is also altered. As cyclical patterns it is only through their modular assemble into larger architectures that they can yield representational variation. Significantly, this change offers the immediacy of parallel-based representation. Hence, the role of syntax as representational sign, that is, as in a symbolical, Peircean coding, is itself transformed, linked instead to semantic elements that duplicate through self-organization feature-specific content of the external world [24]. For BCI, information extraction premised on symbolical articulation alone and not accounting for such modular assembly reduces structural content, diminishing the capacity for representation.
\nThe complexity and magnitude of dynamical variation encountered in the state space of the brain, moreover, is a capacity amenable to environmental exigencies, in much the manner that field-situated robotic artifacts become amenable to local input by transferring responsivity from programmatic architectures to distributed processing. Here, sensorial input can elicit motor responsivity directly, structuring forms that directly respond to molding stimuli [25].
\nSome of the essence of this process of feature-specific duplication can be seen in the motor image, a covert action that is a representation of a non-executed action. The concept of the motor image itself evolved from several experimental legacies. Classical observations made by Lashley [26, 27] in a subject with a deafferented limb showed that humans, and animals, were able to generate actions without sensorial input, in contrast to the broadly assumed hypothesis prevalent in the nineteenth century. Later, experiments in monkeys showed that with deafferentation of spinal dorsal motor roots the animals nonetheless could execute pointing movements in all the phases of motion [28]. This indicated that the movement was predetermined centrally. How this was done and how executed became apparent in studies of ongoing motion. Held [29] observed that limb movements in such circumstances usually do not correspond to their expected trajectories, but entail a misreaching followed by progressive compensatory movements. To explain his finding he proposed Von Holst and Mittelstaedt [30] hypothesis that the command for the executed movement was stored as an efference copy, sent to the sensory cortex, where it was then compared with the actual movement undertaken so as to correct the misaligned motions. The experimental observation of misalignment and correction seen experimentally served as evidence of the memorized storage. A corollary of this hypothesis was that self-made motions could be contextualized to the individual who initiated the actions, a conclusion drawn by Frith in his comparator model [31, 32]. This is to say that the comprehension of the actions as those of one’s own was a necessary feature of movement; while the actions could be initiated without afferences, they nonetheless required them for motor cognitions in order to be understood as self-executed functions.
\nIn continuous motions the sensory cues are coupled to motor execution in a mutually reciprocal and sustained process [33]. This is necessary, since as the body undergoes motion, its spatiotemporal position is continually changing and so also the sensory cues that reference it. While these cues entail contributions from all the senses, those having the greatest influence are of somatotopic origin due to their capacity to delimit the three-dimensional topological perimeter of the body [34]; this is also to say that it is necessary to know where the body is situated in space and time in order to know where next to move it. Linda Smith has described this as a point of criticality, analogous to a phase transition in a material substance, where the body is framed as a stable reference that is transitioning to a fluid and behaviorally flexible state [35].
\nThe validity of this observation, and also as a demonstration of the need to frame the whole body, is well documented in the Piaget A not B error where a young infant continues to perseverate toward an object goal despite having been informed of its prior displacement. This error is explained by the delay in development of maturational processes of the brain needed to formulate and execute goal-directed actions [36]. From these, and other experimental studies, it is intuitive to see why the observed events and processes hypothesized by Von Holst and Mittelstaedt and by Frith require a “predictive processing” to engage motion [37]. Predictions are needed if one is to engage in actions, that is, actions that are intended to be carried out by the self, and are not merely passive responses to external events. Since all external contingencies cannot be known beforehand, like the field-situated autonomous artifact, neither can all consequences of the intended actions. The expectation of the action, its prediction, affords a first approximation that is open to correction that can structure the sequence that follows and that is energetically efficient.
\nThis interplay between predictive actions, goals, and a holistic bodily sense point, further, to the presence, indeed need of mechanisms that involve a simulation of intended actions. Covert actions are thus a motor planning stage needed for subsequent motor execution. In this, the motor image is the key element. The construction of the image, its contextualization to the whole, and its traversal of stability flexibility bifurcations are all basic elements that entail feature duplications of the projected events. That is, they constitute semantic representation of objective events directly and not coded symbols of what is intended.
\nHence, at deeper levels, linguistic primitives function as determinants for assimilating semantic content. That is, the assembly of these elements creates the semantic content of what is communicated through the action. For BCI therapy, this expands the role of therapy from interpretive assessment to the construction of semantic form, like that occurring when coupling sensorial input to the elicitation of motor imagery [25]. Here, semantic content is added by combining the specific motions that are undertaken to their semantic representation in the whole form of the individual, a process likely to the precision of motor processing primitives of the cerebellum [38, 39].
\nTaken together, what is made apparent in analogizing from a linguistic perspective is the strategical implementation of multilevel representational content to structure goal-oriented motor actions. By extension, there is thus also the implicit subordination of this strategy to ontological demands, that is, actions undertaken for the good of the organism. Hence, they entail more than the execution of actions, a traditional objective performed in BCI, and so also include the formulation of organismal goals. For BCI therapy, accordingly, this formulation of representational content will be a critical objective for therapeutic strategy, encompassing diagnosis and therapy, and dictated at syntactic and semantic levels.
\nFor the motor image, notably, it is apparent that representational content is articulated at multiple levels, built upon a dynamical syntax that acquires semantic content by binding representational, feature-specific, i.e., simulated, forms together. Distinguishing the level of functional disturbance therefore is an objective needed in order to administer therapy adequately. Yet, in decoding approaches that have evolved to date, the central technical concern is that of classification, that is, the mapping of a brain state in its activity patterns to an external object or event. Older techniques like mass univariate analysis sequentially evaluate brain regions for a specific activity at a specific location. Measuring covariance between multiple single units is thereby taken as a diagnostic feature of how select images are encoded, like the activation of long regions of the occipital cortex on presentation of a single object. Discerning the underlying structure of the representational content, therefore, remains unknown and an obstacle to focal BCI therapy [40].
\nIn more recently developed multivariate classification approaches, previously determined activity patterns are linked to specific object features that can assess or predict the content of a specific activity. While this approach can be employed without the presentation of an object, many potential representations are left unclassifiable. These limitations have led to current model-based classification approaches that use models to predict patterns not elicited by training data. Such promising efforts seek to extract greater information content from patterned activity than obtained from linear mapping strategies alone. These latter strategies are likely to be strengthened by expanding the capacity to extract information content by combining deep neural learning with wavelet analysis, like that seen in Chapter 2. Hence, they can be expected to extrapolate from syntactical structure to simulated actions; that is, they will be better capable of extracting how meaning is formulated in the assembly of simulated executable sequences. Enlisting technological methods that can optimize distinctions between signal and noise, like that of Chapter 3, can be expected to further this capacity and particularly evident where discerning the syntactical expression of dynamical architectures is key, in order to communicate the motor image, as in Chapters 6, 7, and 8 of this text.
\nCrucially, issues of deciphering multilevel representational content and formulating semantic architectures for action-oriented goal seeking enter into primitive motor assembly levels, where, for example, the capacity for assimilating meaningful content is impaired. These will require new therapeutic paradigms where BCI may be one among several adjunct approaches used together to restore the functional modalities needed for simulated motor articulation. In practice, these paradigms will need to recreate the multilevel, brain-based operation that occurs in motor planning, like that used in sensory motor coupling. Models of such therapy, for example, are presented in Chapters 4 and 5 of the current volume.
\nNovel insights into the multilevel construction of representational content promise a new phase of BCI therapy, embracing not only the restoration of executable actions but also the formulation of the motor image and motor planning sequences. Built upon the fundamentally distinct syntactic and semantic architecture of dynamic cognition, new forms of therapy will undertake to simulate the brain’s approach to information transfer and to attain goal-directed planning. These will likely entail enhanced information extraction in classification and predictive technology, dynamically structured command and communication methodologies, and integrative, mixed-mode BCI approaches that can restructure motor semantics.
\nMuscular pain is a very common pathology in the physiotherapy treatment of outpatient care. The invasive techniques for treating these patients have aroused great interest, there are many reviews made in recent years about its effectiveness but none with conclusive results [1, 2, 3, 4, 5, 6]. Articles about post-needling pain [7, 8] and adverse side effects that may occur due to dry needling are being published until this day.
Dry needling is a minimally invasive technique into the most hypersensitive area/point of a tense band in a skeletal muscle (called myofascial trigger point), without the addition of any drug (Figure 1). It can be classified as deep or superficial [9]. There is not much evidence about which of the two options is better, it seems that deep dry needling has shown greater effectiveness due to penetrating the myofascial trigger point while the superficial dry needling penetrates the skin and the subcutaneous cellular tissue [10, 11]. In the same way, the appearance of local twitch response would guarantee its effectiveness [12, 13].
Myofascial trigger point.
These myofascial trigger points present a high equivalence with the ashi points of acupuncture, corresponding to approximately 71% as Melzack introduced [14]. Acupuncture is based on a traditional and invasive Chinese technique of thousand years of age based on metaphysical concepts of "Ch\'i" (Qi), the body energy flows through channels called "meridians" that has hypersensitive areas called ashi points (Figure 2). Its treatment also consists in the insertion of a needle in these points without any type of drugs [15].
Acupuncture Meridians.
On the other hand, injections have also been the subject of many reviews, [16, 17] they have combined the effects of needling with the effect of local anesthetics. However, in 1943 Lewit [18] demonstrated that the true effectiveness of the infiltrations was due to the mechanical effect generated by the insertion of the needle itself and not the anesthetic.
The objective of this study is to summarize the articles published in relation to adverse effects of needling therapies to promote a good practice and knowledge.
A review of the literature was carried out in Pubmed, Web of Science, Medline and PEDro databases. The search was limited to studies on adverse effects and possible complications due to invasive/needling techniques: acupuncture, injections and dry needling in English and Spanish.
The keywords in English first introduced separately were: "acupuncture", "injection", "dry needling" and "adverse effect/event". In a second time, in order to limit the article sample, 12 searches were added: 1–3: “acupuncture/dry needling/injection” AND "complication"; 4–6: “acupuncture/dry needling/injection” AND "iatrogenic"; 7–9: “acupuncture/dry needling/injection” AND "safe practice" and 10–12: “acupuncture/dry needling/injection” AND "academic training". A manual search of the references of pre-selected articles was also carried out.
The search fields were title/abstract of the keywords of the studies publishes by the journals indexed in Pubmed during the period between 2000 (January) AND 2020 (January). In Web of Science the search fields were TS (theme)/TI (title). In Medline search field was TI (title) and in PEDro a simple search was done. The manuscripts selected for this systematic review met the following inclusion criteria: (i) articles that report the adverse effects and/or complications of invasive/needling techniques; (ii) reviews of such complications; (iii) articles in English and Spanish and (iv) articles with protocols or recommendations on the safe practice of these techniques. We excluded theoretical articles on the application of these techniques and articles that were not published in English or Spanish.
A summary of the findings of the included studies was performed, structured in the incidence/frequency of adverse effects, most prevalent adverse effects, type of intervention, type of population and other associated diseases which could influence the results (Tables 1–3). Each article was named by the author and date; they have a brief description of the intervention, the type of the adverse effect and the conclusion/resolution of the inconvenience.
The initial search provided 4.034 potential reports, after applying the inclusion and exclusion criteria, the sample consisted of 2.169 articles from Pubmed, 814 articles from Web of Science, 781 articles from Medline, 270 from PEDro and 9 found manually through preselected references from the Google Scholar database (Figure 3). After duplicated were excluded, 1.881 articles were selected. Both reviewers screened abstracts in a first time. In a second time, articles selected had a more detailed evaluation and 46 articles were excluded by the language, being letters to the editor or comments on other articles. Finally, 102 articles considered valid (93 from the initial search and 9 found manually). Detailed characteristics of the included studies are described in Tables 1–3 in relation to acupuncture, injection or dry needling respectively.
Flow chart for different stages of the review.
Author/year | Description |
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Tandon, S. (1998) [19] | 48-year-old male suffering from bronchial asthma. Pneumothorax following acupuncture with electrical stimulation in the third and fourth intercostal spaces. |
Peuker, ET. (1999) [20] | To review the traumatic injuries after acupuncture and discuss how to avoid these adverse effects. |
Kirchgatterer, A. (2000) [21] | 83-year-old female. Syncope and cardiogenic shock after acupuncture into the sternum. |
Lao, L. (2003) [22] | 1965-1999 review: 202 incidents in 98 papers from 22 countries. |
Ha, KY. (2003) [23] | 68-year-old female. Low back pain and sciatica aggravated by acupuncture. Chronic inflammatory granuloma with compression of the lumbar fourth nerve and dural sac. |
Chang, SA. (2004) [24] | 68-year-old male. Death for massive hematemesis resulting from aortoduodenal fistula caused by acupuncture. |
Saw, A.(2004) [25] | 55-year-old female, diabetic. Necrotising fasciitis due to acupuncture in a knee osteoarthritis. |
Lee, WM. (2005) [26] | 36-year-old female. Bilateral pneumothorax after acupuncture. |
Ryu, HJ. (2005) [27] | Clinical manifestations and treatment for Mycobacterium abscessus due to acupuncture. |
Kung, YY. (2005) [28] | 2 elderly patients: 72-year-old male and 63-year-old female. Between 2000 and 2002: syncope after acupuncture. |
Chauffe, RJ. (2006) [29] | Since 1985: 9 pneumothorax cases after acupuncture. 27-year-old student seeking acupuncture at levator scapular. |
Su, J. (2007) [30] | 52-year-old female with chronic coughing. Acupuncture at BL131: paravertebral point at the level of the spinous process of the third vertebra: bilateral pneumothorax. |
Lee, S. (2008) [31] | 79-year-old male (hypertension and diabetes). Bacterial aortitis with pseudoaneurysm formation after acupuncture. |
Hwang, JK. (2008) [32] | 25-year-old female: Pneumoretroperitoneumen after acupuncture in right psoas muscle. |
Juss, JK. (2008) [33] | 50-year-old female. Pneumothorax by acupuncture at scapulothoracic region. |
Jindal, V. (2008) [34] | Acupuncture to prevent postoperative nausea in children and to inhibit chemotherapy vomiting in adults. |
Tsukazaki, Y. (2008) [35] | 32-year-old female (recurrent headache). Subarachnoid hemorrhage following acupuncture. |
Witt, CM. (2009) [36] | Review of acupuncture for osteoarthritis knee or hip, low back pain, neck pain or headache, asthma, rinitis or dysmenorrhoea. 229.230 patients: 19.726 suffered at least one adverse effect. |
Kim, JH. (2009) [37] | 55-year-old female. Hemopericardium after acupuncture. |
Kuo, HF. (2010) [38] | 39-year-old female with paresthesia and soreness at popliteal fossa. Fistula arteriovenous: vascular complication after acupuncture. |
Ernst, E. (2010) [39] | Systematic review of cardiac tamponade due to acupuncture. 5 Databases, no restrictions in time or language. 26 cases (14 fatal consequences). |
Nam, KH. (2010) [40] | 4 cases of epidural hematomas after facet block, acupuncture and epidural injections. |
Inayama, M. (2011) [41] | 37-year-old female. Pneumothorax and pleural fluid collection after acupuncture on neck and upper back. |
Hsieh, RL. (2011) [42] | 44-year-old female (aplastic anemia). Staphylococcus infection after acupuncture at right calf. |
He, W. (2012) [43] | Chinese review of 167 papers: 1.038 cases (35 deaths). |
Xu, S. (2012) [44] | Frequency and severity of adverse events of acupuncture, moxibustion and cupping between 2000-11: 117 reports with 308 adverse effects from 25 countries. |
Lee, JH. (2012) [45] | 47-year-old female: epidural abscess at C1-C3 after acupuncture and cupping. |
Tagami, R. (2013) [46] | 69-year-old male: bilateral pneumothorax after acupuncture at upper back. |
Stenger, M. (2013) [47] | 64-year-old male: pneumothorax after acupuncture for lumbar pain and sciatica. |
82-year-old female: pneumothorax after acupuncture for herpes zoster. | |
Lee, SW. (2014) [48] | 47-year-old female with abdominal pain after acupuncture. Endoscopy: needle in the posterior wall of the antrum. |
Hamptom, DA. (2014) [49] | 43-year-old female with chronic neck pain. Pneumothorax after acupuncture. |
Peuker, E. (2014) [50] | 38-year-old female. Pneumothorax after acupuncture at subacromial region (BL13), paravertebral point at the spinous process of the third thoracic vertebrae. |
Chun, KJ. (2014) [51] | 48-year-old female, (breast cancer 7 years before). Cardiac tamponade after acupuncture at fourth intercostal space. |
Peuker, E. (2014) [52] | Review of traumatic lesions after acupuncture. |
Wu, J. (2014) [53] | Chinese review of adverse effects between 1980 and 2013. 3 databases: 182 incidents in 133 relevant papers. |
Ji, GY. (2014) [54] | 54-year-old female; 38-year-old female and 60-year-old male: 3 cases of hemiplegia after cervical paraespinal needling (intramuscular stimulation, acupuncture or lidocaine) in 2002-2013 in Korea. |
Schar, ML. (2015) [55] | 39-year-old female with peripheral neuropathy history. Pneumothorax and broken needle in her chest. |
Karavis, MY. (2015) [56] | 37-year-old female. Haemothorax after acupuncture for neck and right upper back pain. |
Callan, AK. (2015) [57] | 15-year-old female with scoliosis. Periscapular abscess after acupuncture due to instrumentation. |
White, A (2015) [58] | 715 adverse effects: 90 trauma (186 secondary reports); 204 infections (91 reports); 144 miscellaneous (12 deaths). |
Brogan, RJ. (2015) [59] | 66-year-old male. Left pneumothorax after acupuncture (paraespinal, infrascapular and axillary regions bilaterally) for low back pain secondary to arthritis. |
Wigger, O. (2015) [60] | 51-year-old female with breast pain and dyspnea. Cardiac perforation due to acupuncture. |
Yao, Y. (2015) [61] | 54-year-old male. Epidural abscess at C4-T2 due to acupuncture. |
Huisma, F. (2015) [62] | 53-year-old female. Pneumothorax after acupuncture at posterior left hemithorax medial to the scapula. |
Kim, JS. (2016) [63] | Review between 2011 and 2015: 17 pneumothoraxes (1 bilateral and 16 unilateral). |
Ehgbal, K. (2016) [64] | 74-year-old female. Quadriparesis and sensory deficit due to cervical subdural hematoma at C4-C6 after acupuncture at neck and shoulder. |
Li, X. (2017) [65] | Meta-analysis of 33 randomized controlled trials about dry needling and manual acupuncture until February 2016. 33 trials with 1.692 patients. |
Kim, D. (2017) [66] | 55-year-old female. She died by acute peritonitis three days after acupuncture. |
Domenicucci, M. (2017) [67] | 64-year-old male. Hematoma epidural spinal C2-T12 (hemiparesis and paresthesias) after acupuncture for lumbosciatic pain. |
Lee, HJ. (2017) [68] | Retrospective observational study (2010-2014): 10 pneumothorax and 2 pneumoperitoneum. |
Sia, CH. (2018) [69] | 50-year-old women. Pneumothorax after acupuncture for neck pain. |
Lin, SK. (2019) [70] | Pneumothorax incidence after acupuncture in Taiwan (1997-2012) 411.734 patients, 5.407.378 treatments. |
Lee, H. (2019) [71] | 80-year-old male. Retroperitoneal abscess after lumbar acupuncture. |
Lin, SK. (2019) [72] | Cellulitis after acupuncture incidence in Taiwan (1997-2012). 407.80 patients, 6.207.378 treatments. |
Liu, ZH. (2019) [73] | 42-year-old male. Broken needle in retroperitoneum after acupuncture treatments 2 years ago. |
Tucciarone, M. (2019) [74] | 36-year-old male. Abscess in prevertebral muscles after acupuncture. |
Ullah, W. (2019) [75] | Old man. Pericarditis secondary to acupuncture after Staphilococus aureus infection. |
Priola, SM. (2019) [76] | 47-year-old female. Epidural intracraneal abscess after acupuncture. |
Ullah, W. (2019) [77] | Systematic review about cardiac complications after acupuncture. 30 articles: 8 infections, 22 cardiac tamponades. |
Corado, SC. (2019) [78] | 79-year-old female. Pneumothorax 2 days after interscapular acupuncture. |
Detail of articles included about acupuncture.
Author/year | Description |
---|---|
Antoni, RO. (1961) [79] | Review of 226 cases between 1955 and 1959: 71 iatrogenic pneumothoraxes. |
Shafer, N. (1970) [80] | 29-year-old female with severe neck pain with radiation into her right arm and limitation of motion. Pneumothorax after injection. |
Cheng, J. (2007) [81] | Review from 1966 to November 2006: 35 papers. Infections, nerve injury, pneumothorax, embolism. |
Usman, F. (2011) [82] | 37-year-old female, 20 weeks pregnant. Retrosternal abscess after injection at sternoclavicular joint. |
Ahiskalioglu, EO. (2016) [83] | 25-year-old female. Pneumothorax after 4ml injection of lidocaine at thoracic region for neck and low back pain. |
Soriano, PK. (2017) [84] | 39-year-old male. Hipokalemic paralisis after injection guided by ultrasound in iliopsoas. |
Choe, JY. (2017) [85] | 70-year-old male (diabetic and cardiac history). Descending necrotizing mediastinitis after lidocaine injection at upper trapezius. Death by septic shock. |
Lee, DG. (2018) [86] | 38-year-old male. Scapular neuropathy after 1% lidocaine injection and 6ml of saline. |
De la Torre-Canales, G. (2019) [87] | Systematic review about adverse effects of botulinum toxin A for masticatory muscles. 16 articles. |
Camões-Barbosa, A. (2019) [88] | 33-year-old female. Weakness after botulinum toxin A injection for spasticity. |
Mozafari, N. (2019) [89] | 55-year-old male. Cutaneous necrotic lesion after interferon beta 1-b injection. |
Yurük, D. (2019) [90] | Rhabdomyolysis after epidural steroid injection. |
Marcus, F. (2019) [91] | 4 cases of Nicolau Syndrome: rare complication after intramuscular injections. |
Kang, HY. (2019) [92] | Systemic toxicity after cervical epidural steroid injection guided (February 2016-October 2017) 11 patients. |
Park, HB. (2019) [93] | Possible association between injections and calcification in lateral epicondylitis. |
Al-Omari, AA. (2019) [94] | 78-year-old male. Avascular necrosis after one intra-articular injection. |
Lobaton, GO. (2019) [95] | 62-year-old male. Vertebral osteomyelitis after epidural steroid injection. Permanent neurological injury. |
Quincer, E. (2019) [96] | 5-year-old male. Nicolau Syndrome after intramuscular injection in deltoid muscle. |
Anderson, SE. (2019) [97] | Adverse effects after intra-articular corticosteroid injections (2000-2016), 1.708 patients, 104 adverse effects. |
Kim, BR. (2019) [98] | Review of adverse events of intra-articular facet joint injections. (2007-2017). 11.980 procedures, 101 adverse events in 99 patients. |
Wang, RN. (2019) [99] | 61-year-old female. Oculo-motor nerve palsy after epidural lumbar injection. |
Petrin, Z. (2019) [100] | 87-year-old female. Paralysis without hematoma after lumbar epidural steroid injection. |
Rensma, HG. (2019) [101] | 33-year-old male. Nicolau syndrome after elbow injection. |
Hu, Y. (2019) [102] | Optic perineuritis after hyaluronic acid injections. |
Lee, JH. (2019) [103] | 81-year-old female. Osteonecrosis after intra-articular corticosteroid injection. |
Ali, D. (2019) [104] | 72-year-old female. Ischaemic stroke after cervical transforaminal injection. |
Rouientan, A. (2019) [105] | 22-year-old male. Complication after botulinum toxin A. |
Jani, P. (2019) [106] | Iatrogenic adrenal suppression after facet joint injection. |
Desai, K. (2019) [107] | Review of 354 cases about iatrogenic peripheral nerve injuries. |
Park, CW. (2019) [108] | 68-year-old male. Iatrogenic injury of sciatic nerve after intramuscular injections. |
Ali, SS. (2019) [109] | Iatrogenic spinal epidural hematoma and intracranial hypotension after thoracic epidural injection. |
Sencan, S. (2019) [110] | 3 males treated with transsacral blocks. Neuropatic sciatic after gluteal injection. |
Detail of articles included about injections.
Author/year | Description |
---|---|
Lee, JH. (2011) [111] | 58-year-old female with neck and upper extremity pain. Acute cervical epidural hematoma (C3-T1) after dry needling. |
McCutcheon, L. (2011) [112] | Techniques modifications to avoid pleura and lung. Understanding anatomy and its variants. Safe technique for training physiotherapists. |
Brady, S. (2014) [113] | 2 questionnaires for 10 months. 39 physiotherapists and 1463 adverse effects. Safe technique. |
Halle, JS. (2016) [114] | To evaluate benefits/risks of these techniques to minimize them. |
Halle, JS. (2016) [115] | Adequate training and education: safe and effective technique. To inform patients via informed consent. |
McManus, R. (2018) [116] | 27-year-old female, secretary. Neurapraxia of radial nerve after dry needling. |
Berrigan, WA. (2018) [117] | 62-year-old female. Epidural hematoma and broken needle after dry needling. |
Uzar, T. (2018) [118] | 36-year-old male. Pneumothorax after dry needling for pain in back muscles. |
Kim, DC. (2018) [119] | 16-year-old male. Local abscess after dry needling at the thigh for pain after a knee injury. |
McDowell, JM. (2018) [120] | Safety of acupuncture and dry needling in pregnant women. 124 responses: only 60 needle pregnant women and a 60% of them feel safety. |
Detail of articles included about dry needling.
102 articles met the inclusion criteria of the research in the period between 2000 (January) and 2020 (January) in form of original articles, case reports and reviews.
From these 102 articles selected, 23 refer to pneumothorax including more than 120 cases (19 of acupuncture, 3 of injection and 2 of dry needling); 4 articles refer to cardiac tamponade with more than 25 cases (both of acupuncture), 21 in relation to infections, abscesses or hemorrhages (14 of acupuncture, 6 of injection and 1 of dry needling) and other 7 articles refer to adverse effects such as syncope and cardiogenic shock (acupuncture), 3 pneumoperitoneo (acupuncture), 9 hematoma (6 of acupuncture, 1 of injection, 2 of dry needling), hemiplegia (acupuncture), cardiac perforation (acupuncture), hypokalemic paralysis (injection), 6 neuropathies (injection), 1 neuroapraxia (dry needling) and 12 cutaneous lesions/Nicolau syndrome/necrosis (3 of acupuncture, 9 of injection). In 11 articles there already was an existing disease, in other 4 the needle was broken and unfortunately in 4 articles the consequences were fatal. It has also collected 21 review articles of these needling therapies (more than 21.000 adverse effects described). Finally, 6 articles have synthetized information about benefits, risks, perception of security and even modifications of the application of these techniques (Figure 4).
Prevalence of most common adverse events.
Considering the outpatient care treatment, adverse effects are possible complications that can occur during or even after the application of these techniques. In more cases there has little importance such as pain, a slight bleeding or a small bruise that disappears quickly. However, other adverse effects without a clear cause can suppose a serious risk for the patient.
These risks have always been present, but in recent years publications have increased considerably. There is no consensus about the classification of these adverse effects. Some authors [111] categorized them into four groups: delayed or missed diagnosis, adverse effects during treatment, bacterial or viral infections, or tissue or organ trauma.
The incidence/frequency of these adverse effects is not clear. Acupuncture seems to have an incidence of 2/125.000 cases [30]; White et al. [58] estimated the risk of a serious adverse event with acupuncture at 0.05 per 10.000 treatments, and 0.55 per 10.000 individual patients, Lin et al. [70] reported a pneumothorax incidence of 0.87 per 1.000.000 acupuncture treatments and 1.75 per 1.000.000 in anatomical risk areas; these authors also showed a cellulitis incidence [72] about 64.4 per 100.000 treatments.
In relation to injections, Anderson et al. [97] explained an incidence of 5.8% of adverse effects. Kim et al. [93] introduced the incidence separately in relation with the case: 0.84% and 1.63% in relation to the patient; on the other hand, the procedure had an incidence of 0.07% and the administrated drug 0.15%. Finally, the unknown etiology had a 0.63% for this author [93] and for other authors it is unknown [121].
Data about incidence of dry needling procedures has not been found.
The most reviewed articles refer isolated cases and not a periodicity, but other authors have published several reviews that try to synthesize this information. Considering these 3 needling techniques, acupuncture leaves a clear superiority in relation to the number of publications with adverse effects.
Peuker et al. [20] investigated the traumatic wounds caused by acupuncture and discuss how these complications could be avoided. Lao et al. [22] reviewed 98 publications (1965–1999) and they found 202 complications (infections, tissue/organ damage and nerve injury). Cutaneous disorders, hypotension, fainting and vomiting were some adverse effects described. Chauffe et al. [29] found 9 cases of pneumothorax since 1985. Witt et al. [36] reviewed acupuncture studies in chronic osteoarthritis pain of the knee or hip, lumbar, cervical, head, allergic rhinitis, dysmenorrhea and asthma. Out of 229.230, 19.726 reported at least 1 adverse effect (bleeding, pain, vegetative symptoms). The longest duration of these adverse effects was 180 days (nerve injury). Ernst et al. [39] conducted a review of cardiac tamponade after acupuncture: 26 cases were found and 14 with fatal complications. He et al. [43] reviewed 167 articles with 1.038 cases (35 deaths) from Chinese literature. 468 cases were syncope, 307 pneumothorax, and 64 subarachnoid hemorrhage. Xu et al. [44] checked the frequency and severity of these effects (2000–2011): 117 articles with 308 adverse effects in 25 countries (294 for acupuncture, 4 moxibustion and 10 cupping). Peuker et al. [52] reviewed the traumatic lesions after acupuncture. Wu et al. [53] performed a review in China (1980–2013), finding 182 incidents in 133 papers (internal organ, tissue and nerve injury are the major complications). The adverse effects included were syncope, infection, hemorrhage, allergy, burn, aphonia, hysteria, cough, thirst, fever, somnolence and broken needles. White et al. [58] found 715 incidents in their review: 90 reports of trauma and 12 reports of death. In Taiwan, Lin et al. [70, 72] published 2 reviews (1997–2012) about pneumothorax and cellulitis incidence respectively. They evaluated 411.734 patients with 5.407.378 treatments of acupuncture [70] and 407.802 patients with 6.207.378 acupuncture treatments [72]. In both articles the authors emphasized the importance of the previous medical history. Ullah et al. [77] reviewed 133 articles and selected 30 cases with relevant cardiac complications: 8 were infective complications and 22 cardiac tamponades.
Regarding injections, 8 articles have been found. Antoni Ro et al. [79] reviewed 226 cases (1955–1959), finding 71 cases of pneumothorax and Cheng et al. [81] performed a review (1966–2006) explaining the complications of this technique: “infections, spinal cord injury and peripheral nerve injuries, pneumothorax, air embolism, pain or swelling at the site of injection, chemical meningism, granulomatous inflammation of the synovium, aseptic acute arthritis, embolia cutis medicamentosa, skeletal muscle toxicity, and tendon and fascial ruptures”. De la Torre et al. [87] introduced a review about the adverse effects caused by botulinum toxin A in masticatory muscles. They used 436 citations and concluded with 16:7 were myofascial pain and 9 were trigeminal neuralgia. The most frequent adverse effects were “temporary regional weakness, tenderness over the injection sites and minor discomfort during chewing”. Most of them had a spontaneous resolution. Marcus et al. [91] found a very rare complication due to injections (diclofenac, dexamethasone and benzathine penicilin): Nicolau Syndrome. They found 4 cases (2016–2018). Park et al. [93] investigates an association between steroid injection and calcification in lateral epicondylitis. They evaluated 110 patients (February 2016-October 2018) and concluded that the injections history and the number of them has a significative association with soft tissue calcifications. A review (January 2000-April 2016) about adverse events due to intra-articular corticosteroid injections was made by Anderson et al. [97] 1.708 patients from 3 regional hospital participated: 99 patients had 104 adverse effects within 90 days post-injection. The most prevalent symptom was flare (78 patients) and 10 patients had skin reactions. There were no infections. Years before, Kim et al. [98] had reviewed 11.980 injections in 6.066 patients (January 2007-December 2017). There were 101 facet-joint injections and 99 patients developed adverse effects. 7 patients had an infectious spondylitis, 1 patient died of an uncontrolled infection and 2 patients had partial recovery of their neurological condition. Finally, Desai et al. [107] published a review of 17 years where reflected the iatrogenic peripheral nerve injuries due to injections. They included “intramuscular injections, brachial nerves procedures, subclavian and jugular venous cannulation and routine intravenous injections”. The most frequents symptoms were pain, paresthesia and sensory-motor deficits. 190 patients needed surgical intervention, 164 had any sequel or no recovery and 9 had neurological deterioration with weakness.
There is not standard data on the incidence of these events. Unfortunately, the huge diversity of pathologies, interventions, therapists… makes difficult a generalization.
There is no consensus about the most frequent adverse effect in the literature. Some of them are pneumothorax, cardiac tamponade, air embolism, spinal epidural haematoma/abscess, abdominal visceral injury, median and fibular nerve injury and infection [20, 36, 75, 77, 81, 87, 111].
Some authors reflected that pneumothorax is the most cited adverse effect, [50, 63] while for others is infection [44]. White et al. [58] agree with both theories being the most common complication pneumothorax and injury to the central nervous system and infection will be in second place. Ullah et al. [77] concluded that cardiac tamponade is the most frequent complication.
It seems that invasive techniques on the thorax are related to a high incidence of pneumothorax [118]. There are some investigations in different countries (United Kingdom, Japan, Czechoslovakia, Switzerland, Germany, Japan and Taiwan) about it. The incidence of these cases is low, less than 1/10.000. However, there have been more than 100 cases reporting iatrogenic pneumothorax due to acupuncture and dry needling, including cases of death [112]. Lin et al. [70] showed an incidence of 0.84/1.000.000 and 1,75/1.000.000 at risk anatomical areas. Most iatrogenic pneumothorax used to be unilateral, but there are bilateral cases too [26, 30]. In this article there are 23 articles related to pneumothorax [19, 26, 29, 30, 33, 46, 47, 49, 50, 55, 56, 59, 62, 63, 68, 69, 70, 78, 79, 80, 83, 112, 118].
Other incidents (less frequent) reported in the literature but not less important are cardiac tamponade [21, 39, 51, 75, 77], granulomas [23], fistulas [24, 38], necrosis [25, 42, 85], infections [27, 57, 119], abscesses [27, 45, 61, 71, 74, 76], pneumoretroperitoneum [32], hemorrhages [35], hemopericardium [37], haematomas [40, 64, 67, 109, 111, 117], chilotorax [41], organ perforation [48, 60], needle rupture [53, 55, 117], hemiplegia [54], hemothorax [56], peritonitis [66], cellulitis [72], hypokalemic paralysis [84], nerve injury [86, 99, 102, 107, 108, 110, 116], weakness [88], necrosis [89, 90, 94, 103], Nicolau Sydrome [91, 96, 101], toxicity…[92] Almost all had a complete resolution of the symptoms. However, publications with fatal and irreversible consequences have also been found [24, 37, 98].
There are several aspects must be considered when carrying out these techniques in the treatment of muscular pain in outpatients. These incidents, even taking caution may occur; therefore, it is important to obtain a complete clinical history highlighting possible underlying pathologies [70, 71, 72]. Several articles have found patients with asthma [19], diabetes [25, 85], anemia [42], herpes zoster [47], cancer [51], miastenia gravis [55] and scoliosis [57] and sclerosis [89]. These pathologies could influence the appearance or greater probability of developing a complication.
The age of the patients is other aspect to discuss. A review performed in children (acupuncture to prevent postoperative nausea) has been published without conclusion about its effectiveness [34]. Quincer et al. [96] showed the case of a 5-year-old boy who developed a Nicolau Syndrome after an intramuscular injection in deltoid. Besides, cases of elderly people who have suffered syncope’s due to acupuncture have also been described [28]. These patients (the most prevalent population in the outpatient) may be more debilitated and suffer more adverse effects even taking precautions.
There are some types of population could be considered “at risk” when using these needling techniques, like pregnant women. We have found an article that exposes a retrosternal abscess due to sternoclavicular joint injection with resolution [82]. McDowell et al. have developed a review on the safety of acupuncture and dry needling in pregnant women in New Zealand. They conclude that of 124 responses obtained, only 60 therapists needle pregnant women and only 66% of them express safety. More training is needed in this field, particularly on dry needling [120].
In relation to sex, only one article showed major incidence in men than in woman [70].
It seems that the most frequent application of these techniques is analgesia, including analgesic blocks [40], but there are other applications such hyaluronic acid in eyebrow [102], botulinum toxin A for axilar hiperhidrosis [105] and aesthetics for rejuvenation have also presented adverse effects [122, 123].
Among all reviews a meta-analysis of 33 randomized controlled trials was found. The authors conclude that acupuncture and dry needling are effective techniques, but more research on the safety of them is needed [65]. McCutcheon et al. [112] also reviewed the safety of acupuncture and dry needling, suggesting modifications of these techniques to avoid pleura and the lung. However, there are no conclusive results.
Considering the severity of these techniques, Brady et al. [113] conducted a study to check the adverse effects of dry needling. They filled in 2 questionnaires for 10 months to 39 physiotherapists and regrouped 1.463 adverse effects (common/less common/rare). They showed that it was a safe technique. Similarly, Halle et al. have published 2 articles [114, 115]. They assessed the risk/benefit of these techniques to minimize them, proposed an adequate education, knowledge of anatomy, training and to inform the patient via informed consent.
Guided techniques should be an interesting option to reduce these complications, but several articles do not support this affirmation [92, 110]. More investigation in this line is needed. On the other side, if dry needling seems to be safe, maybe it would be chosen instead injections to avoid the possible events effects derivate to the administered drugs like Kim et al. [93] exposed.
Language was the first limitation, several articles have been found in France [124, 125], Portugal [126], Russia [127], Germany [128], Italy [129], Denmark [130], and Iceland [131] that have not been included in the revision due to its original language. 3 reviews in Chinese [132], German [128] and Danish [133] respectively were excluded for the same reason. The first two expose a synthesis or classification of adverse effects and the third, is a review on acupuncture in children in Denmark. Letters and comments were also excluded; however, we highlight the case of acupuncture in the disease of behgets [134]; a letter to editor where they expose a case of pneumothorax during a demonstration of dry needling in the thoracic iliocostal [135] and a needle broken as a complication of acupuncture [136]. Neither has been taken into account articles on practical applications, effectiveness of such techniques or superiority of some over others.
Acupuncture seems to have the most adverse effects reported throughout the literature, while injections and dry needling are increasing their publications, probably due to the increase in popularity especially of the second [114, 115]. Nowadays adverse effects seem to be common, but complications are rare. All authors of these articles agree in some tips to take in consideration:
The anatomy of the area to treat should be familiar to the healthcare professionals before undertaking the procedure.
Communication with the patient via informed consent is needed.
Aseptic conditions during the procedure are necessary.
The appropriate time to apply the treatments correctly becomes essential for a good practice and an adequate achievement of the results.
A correct training and continuous formation of healthcare practitioners are necessary.
This is a brief summary of the adverse effects found in the literature. There is no clear consensus about incidence, the most prevalent adverse effect, the intervention protocols, or experience of the therapist… As a conclusion, needling therapies are usual techniques in the outpatient care and complications are possible even considering all the precautions. Therapists have to know how to react, recognize the adverse effects and correct them as far as possible or refer the patient to the corresponding service, being always updated to new advances and familiar to the normal and variants of anatomy of the patients to avoid complications as much as possible. Caring the aseptic conditions and the communication with the patient to inform them about all the parts of the treatment with needling therapies are essential.
None declared.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. His research interests include the application of agent technology for achieving agile control in the manufacturing environment.",institutionString:null,institution:null},{id:"605",title:"Prof",name:"Dil",middleName:null,surname:"Hussain",slug:"dil-hussain",fullName:"Dil Hussain",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/605/images/system/605.jpg",biography:"Dr. Dil Muhammad Akbar Hussain is a professor of Electronics Engineering & Computer Science at the Department of Energy Technology, Aalborg University Denmark. Professor Akbar has a Master degree in Digital Electronics from Govt. College University, Lahore Pakistan and a P-hD degree in Control Engineering from the School of Engineering and Applied Sciences, University of Sussex United Kingdom. Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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The literature source was Web of Science and SSCI, SCI-EXPANDED, A&HCI, CPCI-S, CPCI-SSH, and ESCI indexes. Fifty-two articles were reviewed; however, 14 of them were not been included in the study. As a result, 38 articles were examined. Level of education, field of education, and material types of AR used in education and reported educational advantages of AR have been investigated. All articles are categorized according to target groups, which are early childhood education, primary education, secondary education, high school education, graduate education, and others. AR technology has been mostly carried out in primary and graduate education. “Science education” is the most explored field of education. Mobile applications and marker-based materials on paper have been mostly preferred. The major advantages indicated in the articles are “Learning/Academic Achievement,” “Motivation,” and “Attitude”.",book:{id:"6543",slug:"state-of-the-art-virtual-reality-and-augmented-reality-knowhow",title:"State of the Art Virtual Reality and Augmented Reality Knowhow",fullTitle:"State of the Art Virtual Reality and Augmented Reality Knowhow"},signatures:"Rabia M. Yilmaz",authors:[{id:"225838",title:"Dr.",name:"Rabia",middleName:null,surname:"Yilmaz",slug:"rabia-yilmaz",fullName:"Rabia Yilmaz"}]},{id:"63639",doi:"10.5772/intechopen.81086",title:"Cooperative Learning: The Foundation for Active Learning",slug:"cooperative-learning-the-foundation-for-active-learning",totalDownloads:3391,totalCrossrefCites:17,totalDimensionsCites:23,abstract:"The role of instructors is evolving from the presenter of information to the designer of active learning processes, environments, and experiences that maximize student engagement. The more active a lesson, the more students tend to engage intellectually and emotionally in the learning activities. Cooperative learning is the foundation on which many of the active learning procedures are based. Cooperative learning is the instructional use of small groups so that students work together to maximize their own and each other’s learning. Most of the active learning procedures, such as problem-based learning, team-learning, collaborative learning, and PALS, require that students work cooperatively in small groups to achieve joint learning goals. Cooperative learning is based on two theories: Structure-Process-Outcome theory and Social Interdependence theory. Four types of cooperative learning have been derived: formal cooperative learning, informal cooperative learning, cooperative base groups, and constructive controversy. There is considerable research confirming the effectiveness of cooperative learning. To be cooperative, however, five basic elements must be structured into the situation: positive interdependence, individual accountability, promotive interaction, social skills, and group processing.",book:{id:"6929",slug:"active-learning-beyond-the-future",title:"Active Learning",fullTitle:"Active Learning - Beyond the Future"},signatures:"David W. Johnson and Roger T. 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The importance of VR/AR for the mental health field comes from three main concepts: (1) VR/AR as an imaginal technology, people can feel “as if they are” in a reality that does not exist in external world; (2) VR/AR as an embodied technology, the experience to feel user’s body inside the virtual environment; and (3) VR/AR as connectivity technology, the “end of geography’. In this chapter, we explore the opportunities provided by VR/AR as technologies to improve people’s quality of life and to discuss new frontiers for their application in mental health and psychological well-being promotion.",book:{id:"6543",slug:"state-of-the-art-virtual-reality-and-augmented-reality-knowhow",title:"State of the Art Virtual Reality and Augmented Reality Knowhow",fullTitle:"State of the Art Virtual Reality and Augmented Reality Knowhow"},signatures:"Sara Ventura, Rosa M. Baños and Cristina Botella",authors:[{id:"106036",title:"Dr.",name:"Rosa Maria",middleName:null,surname:"Baños",slug:"rosa-maria-banos",fullName:"Rosa Maria Baños"},{id:"227763",title:"Ph.D.",name:"Sara",middleName:null,surname:"Ventura",slug:"sara-ventura",fullName:"Sara Ventura"},{id:"229056",title:"Dr.",name:"Cristina",middleName:null,surname:"Botella",slug:"cristina-botella",fullName:"Cristina Botella"}]},{id:"58060",doi:"10.5772/intechopen.72341",title:"Pedagogy of the Twenty-First Century: Innovative Teaching Methods",slug:"pedagogy-of-the-twenty-first-century-innovative-teaching-methods",totalDownloads:8728,totalCrossrefCites:15,totalDimensionsCites:21,abstract:"In the twenty-first century, significant changes are occurring related to new scientific discoveries, informatization, globalization, the development of astronautics, robotics, and artificial intelligence. This century is called the age of digital technologies and knowledge. How is the school changing in the new century? How does learning theory change? Currently, you can hear a lot of criticism that the classroom has not changed significantly compared to the last century or even like two centuries ago. Do the teachers succeed in modern changes? The purpose of the chapter is to summarize the current changes in didactics for the use of innovative teaching methods and study the understanding of changes by teachers. In this chapter, we consider four areas: the expansion of the subject of pedagogy, environmental approach to teaching, the digital generation and the changes taking place, and innovation in teaching. The theory of education, figuratively speaking, has two levels. At the macro-level, in the “education-society” relationship, decentralization and diversification, internationalization of education, and the introduction of digital technologies occur. At the micro-level in the “teacher-learner” relationship, there is an active mix of traditional and innovative methods, combination of an activity approach with an energy-informational environment approach, cognition with constructivism and connectivism.",book:{id:"5980",slug:"new-pedagogical-challenges-in-the-21st-century-contributions-of-research-in-education",title:"New Pedagogical Challenges in the 21st Century",fullTitle:"New Pedagogical Challenges in the 21st Century - Contributions of Research in Education"},signatures:"Aigerim Mynbayeva, Zukhra Sadvakassova and Bakhytkul\nAkshalova",authors:[{id:"201997",title:"Dr.",name:"Aigerim",middleName:null,surname:"Mynbayeva",slug:"aigerim-mynbayeva",fullName:"Aigerim Mynbayeva"},{id:"209208",title:"Dr.",name:"Zukhra",middleName:null,surname:"Sadvakassova",slug:"zukhra-sadvakassova",fullName:"Zukhra Sadvakassova"},{id:"209210",title:"Dr.",name:"Bakhytkul",middleName:null,surname:"Akshalova",slug:"bakhytkul-akshalova",fullName:"Bakhytkul Akshalova"}]},{id:"64583",doi:"10.5772/intechopen.81714",title:"Evaluating a Course for Teaching Advanced Programming Concepts with Scratch to Preservice Kindergarten Teachers: A Case Study in Greece",slug:"evaluating-a-course-for-teaching-advanced-programming-concepts-with-scratch-to-preservice-kindergart",totalDownloads:1405,totalCrossrefCites:13,totalDimensionsCites:18,abstract:"Coding is a new literacy for the twenty-first century, and as a literacy, coding enables new ways of thinking and new ways of communicating and expressing ideas, as well as new ways of civic participation. A growing number of countries, in Europe and beyond, have established clear policies and frameworks for introducing computational thinking (CT) and computer programming to young children. In this chapter, we discuss a game-based approach to coding education for preservice kindergarten teachers using Scratch. The aim of using Scratch was to excite students’ interest and familiarize them with the basics of programming in an open-ended, project-based, and personally meaningful environment for a semester course in the Department of Preschool Education in the University of Crete. For 13 weeks, students were introduced to the main Scratch concepts and, afterward, were asked to prepare their projects. For the projects, they were required to design their own interactive stories to teach certain concepts about mathematics or physical science to preschool-age students. The results we obtained were more satisfactory than expected and, in some regards, encouraging if one considers the fact that the research participants had no prior experiences with computational thinking.",book:{id:"6936",slug:"early-childhood-education",title:"Early Childhood Education",fullTitle:"Early Childhood Education"},signatures:"Stamatios Papadakis and Michail Kalogiannakis",authors:null}],mostDownloadedChaptersLast30Days:[{id:"58060",title:"Pedagogy of the Twenty-First Century: Innovative Teaching Methods",slug:"pedagogy-of-the-twenty-first-century-innovative-teaching-methods",totalDownloads:8728,totalCrossrefCites:15,totalDimensionsCites:21,abstract:"In the twenty-first century, significant changes are occurring related to new scientific discoveries, informatization, globalization, the development of astronautics, robotics, and artificial intelligence. This century is called the age of digital technologies and knowledge. How is the school changing in the new century? How does learning theory change? Currently, you can hear a lot of criticism that the classroom has not changed significantly compared to the last century or even like two centuries ago. Do the teachers succeed in modern changes? The purpose of the chapter is to summarize the current changes in didactics for the use of innovative teaching methods and study the understanding of changes by teachers. In this chapter, we consider four areas: the expansion of the subject of pedagogy, environmental approach to teaching, the digital generation and the changes taking place, and innovation in teaching. The theory of education, figuratively speaking, has two levels. At the macro-level, in the “education-society” relationship, decentralization and diversification, internationalization of education, and the introduction of digital technologies occur. At the micro-level in the “teacher-learner” relationship, there is an active mix of traditional and innovative methods, combination of an activity approach with an energy-informational environment approach, cognition with constructivism and connectivism.",book:{id:"5980",slug:"new-pedagogical-challenges-in-the-21st-century-contributions-of-research-in-education",title:"New Pedagogical Challenges in the 21st Century",fullTitle:"New Pedagogical Challenges in the 21st Century - Contributions of Research in Education"},signatures:"Aigerim Mynbayeva, Zukhra Sadvakassova and Bakhytkul\nAkshalova",authors:[{id:"201997",title:"Dr.",name:"Aigerim",middleName:null,surname:"Mynbayeva",slug:"aigerim-mynbayeva",fullName:"Aigerim Mynbayeva"},{id:"209208",title:"Dr.",name:"Zukhra",middleName:null,surname:"Sadvakassova",slug:"zukhra-sadvakassova",fullName:"Zukhra Sadvakassova"},{id:"209210",title:"Dr.",name:"Bakhytkul",middleName:null,surname:"Akshalova",slug:"bakhytkul-akshalova",fullName:"Bakhytkul Akshalova"}]},{id:"61746",title:"Facilitation of Teachers’ Professional Development through Principals’ Instructional Supervision and Teachers’ Knowledge- Management Behaviors",slug:"facilitation-of-teachers-professional-development-through-principals-instructional-supervision-and-t",totalDownloads:3338,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"With the rise of global competition and the focus on teacher quality, teacher professional development is becoming increasingly crucial, and the stress and challenges for principals are more severe than ever. Teachers can improve their professional abilities through principals’ instructional supervision and their own knowledge-management (KM) behaviors to benefit students. Thus, this chapter analyzes the relationship among principals’ instructional supervision, teachers’ KM, and teachers’ professional development. The author believes that principals’ instructional supervision and effective KM can facilitate the professional development of teachers. The author also believes the readers can know the relationships among them, and teachers’ professional development can be improved through principal’s instructional supervision and teachers’ KM behaviors.",book:{id:"6674",slug:"contemporary-pedagogies-in-teacher-education-and-development",title:"Contemporary Pedagogies in Teacher Education and Development",fullTitle:"Contemporary Pedagogies in Teacher Education and Development"},signatures:"Chien-Chin Chen",authors:[{id:"232569",title:"Ph.D.",name:"Chien Chih",middleName:null,surname:"Chen",slug:"chien-chih-chen",fullName:"Chien Chih Chen"}]},{id:"75908",title:"From the Classroom into Virtual Learning Environments: Essential Knowledge, Competences, Skills and Pedagogical Strategies for the 21st Century Teacher Education in Kenya",slug:"from-the-classroom-into-virtual-learning-environments-essential-knowledge-competences-skills-and-ped",totalDownloads:499,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"As teachers in Kenya begin to migrate from the classroom to virtual learning spaces following COVID 19 pandemic, there is pressing need to realign Teacher Education to requisite Knowledge, competences, skills, and attitudes that will support online teaching. This chapter explores these needs using a combination of lived experiences and literature review that captured a meta-analysis of research trends on e-learning. While trends in Teacher Education indicate progression towards adoption of technology, there are disparities between the theory and practice. Evidence from recent research and reports; and the recollected experiences confirmed knowledge, competence, skills and pedagogical gaps in the implementation of online learning, that have been exacerbated by COVID-19. The researcher recommends that teacher education should sensitize and train teacher trainees on how to access, analyze and use new knowledge emerging with technology; they also should be coached on how learners learn with technology and on fundamentals of the communication process. Particularly the course on educational technology, should focus on how to create and manage online courses. The 5-stage E-Moderator Model and Universal Design for Learning (UDL) are recommended as effective pedagogical scaffold for online teaching.",book:{id:"10229",slug:"teacher-education-in-the-21st-century-emerging-skills-for-a-changing-world",title:"Teacher Education in the 21st Century",fullTitle:"Teacher Education in the 21st Century - Emerging Skills for a Changing World"},signatures:"Catherine Adhiambo Amimo",authors:[{id:"333482",title:"Dr.",name:"Catherine Adhiambo",middleName:null,surname:"Amimo",slug:"catherine-adhiambo-amimo",fullName:"Catherine Adhiambo Amimo"}]},{id:"75224",title:"Decoding the Digital Gap in Teacher Education: Three Perspectives across the Globe",slug:"decoding-the-digital-gap-in-teacher-education-three-perspectives-across-the-globe",totalDownloads:545,totalCrossrefCites:0,totalDimensionsCites:3,abstract:"Educational use of technology is regularly assessed, and results often show a gap between educational policies and what is actually practiced. This chapter will help clarify how teacher educators experience the changing educational contexts due to the digital revolution, how their meaning-making shifts, and how outside forces influence those processes. The results are based on comparative international studies. Central for this study is practitioners’ professional digital competence, their attitudes towards digital technology and the use of digital technology in education. We found that the influence and contribution of digital practice is carried out quite differently across the globe. Our research questions were: How do practitioners experience teaching in a rapidly changing context? How do attitudes change due to top-down governing of education? and What motivates teacher educators to implement digital technology?",book:{id:"10229",slug:"teacher-education-in-the-21st-century-emerging-skills-for-a-changing-world",title:"Teacher Education in the 21st Century",fullTitle:"Teacher Education in the 21st Century - Emerging Skills for a Changing World"},signatures:"Steinar Thorvaldsen and Siri Sollied Madsen",authors:[{id:"332624",title:"Associate Prof.",name:"Siri Sollied",middleName:null,surname:"Madsen",slug:"siri-sollied-madsen",fullName:"Siri Sollied Madsen"},{id:"332626",title:"Prof.",name:"Steinar",middleName:null,surname:"Thorvaldsen",slug:"steinar-thorvaldsen",fullName:"Steinar Thorvaldsen"}]},{id:"75416",title:"Self-Study Research: Challenges and Opportunities in Teacher Education",slug:"self-study-research-challenges-and-opportunities-in-teacher-education",totalDownloads:718,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"This article aims to describe what self-study research is, why self-study can be a good approach to teacher educators’ professional development and improvements in practice and highlight some challenges and opportunities in this research approach. In addition, the article will shed light on some methodological aspects related to self-study. Self-study refers to teacher educators who in an intentionally and systematically way examine their practice to improve it, based on a deeper understanding of practice, as well as the context practice takes place. In the article, I argue that engaging in self-study is a learning and development process and an approach to developing personal professionalism, collective professionalism and improvements in practice.",book:{id:"10229",slug:"teacher-education-in-the-21st-century-emerging-skills-for-a-changing-world",title:"Teacher Education in the 21st Century",fullTitle:"Teacher Education in the 21st Century - Emerging Skills for a Changing World"},signatures:"Kåre Hauge",authors:[{id:"332053",title:"Associate Prof.",name:"Kåre",middleName:null,surname:"Hauge",slug:"kare-hauge",fullName:"Kåre Hauge"}]}],onlineFirstChaptersFilter:{topicId:"265",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81937",title:"Socialization Experiences among Undergraduate Students in Higher Learning Institutions (HLI)",slug:"socialization-experiences-among-undergraduate-students-in-higher-learning-institutions-hli",totalDownloads:18,totalDimensionsCites:0,doi:"10.5772/intechopen.99007",abstract:"This work portrays the problems of socialization among undergraduate students in higher learning institutions. The socialization processes in higher learning institution are significant for the successful navigation of students in the academic programs and university environment in preparing the next generation of professional practitioners and scholars. But the undergraduate student socialization experiences of students at university environment are overlooked. To navigate in the higher learning institutions, students should be socialized effectively to the normative contexts of the higher learning institutions. The normative contexts of the higher learning institutions are generally categorized into social and academic contexts, because these context academic and social context integration have been linked to student retention and success. Social integration involves interpersonal relationships, support, interactions with others, and a sense of belonging at a university, which stems from extracurricular activities, informal dealings with peer groups, and interactions with faculty and staff, whereas academic integration is described through grade performance and intellectual development that reflects an ability to meet the standards of the academic system; intellectual development involves a student valuing their education as a process of development in which they gain knowledge and ideas. Students’ background is also the contributing factor for students’ socialization in the University.",book:{id:"10911",title:"Higher Education - New Approaches to Accreditation, Digitalization, and Globalization in the Age of Covid",coverURL:"https://cdn.intechopen.com/books/images_new/10911.jpg"},signatures:"Mulusew Birhanu Ayalew"},{id:"80280",title:"Adoption of Online Learning during the Covid19 Pandemic Lockdown by Universities in Garowe",slug:"adoption-of-online-learning-during-the-covid19-pandemic-lockdown-by-universities-in-garowe",totalDownloads:85,totalDimensionsCites:0,doi:"10.5772/intechopen.99941",abstract:"In response to the Covid-19 outbreak the world closed and therefore countries like Somalia have not been exceptional. The government of Somalia and all higher education institutions adopted crisis intervention measures on implementation of blended learning approaches like online teaching and learning. In this chapter we explore the process and challenges of adopting online learning in response to the world wide lockdown due to the pandemic. Given that this was an abrupt requirement, the survey was interested in finding out whether universities adopted and adapted easily. Researchers compared findings from previous studies and theoretical inclinations on online learning. Results indicate that the adoption of online learning among universities in Garowe was as a matter of crisis management whereby administration, lecturers and students were all not ready and had no prior grounding in this pedagogical learning platform. Just like previous studies online learning implementers have continued to encounter several challenges like intermittent internet network, cost of gadgets and facilities, inadequate skills of both the instructors and students, aspects of communication and satisfaction from stakeholders. With the research survey in Garowe, results show that this is still pervading and therefore need for more rigorous contextualised research on this subject.",book:{id:"10911",title:"Higher Education - New Approaches to Accreditation, Digitalization, and Globalization in the Age of Covid",coverURL:"https://cdn.intechopen.com/books/images_new/10911.jpg"},signatures:"Tumwebaze Alicon Auf and Omer Abdi Hamdi"},{id:"78597",title:"Public-Private Participation in Funding University Education in Sub-Saharan Africa: A Nigerian Case-Study for Sustainable Development",slug:"public-private-participation-in-funding-university-education-in-sub-saharan-africa-a-nigerian-case-s",totalDownloads:131,totalDimensionsCites:0,doi:"10.5772/intechopen.99940",abstract:"The developing countries in Africa still cannot withstand the pressure of the highly competitive global education market. Together with the large numbers of people who make a living in various innovative companies, these countries have solved key contemporary issues affecting global education. For this reason, it is necessary to actively respond to current technological innovation and educational challenges and to eliminate new technology graduates who can effectively interact with students through the responsive expansion of education and training. Expansion of education can produce effective expansion that promotes educational development, but due to budget constraints, most African governments cannot successfully and sustainably implement such educational programs. This is difficult. However, public-private partnership efforts provide a way out of this financial dilemma. The Sub-Saharan Africa initiative has achieved important educational objectives, such as: ensuring relevance for quality; secure funding for sustainability and establish resource mobilization partnerships and connections; and promote international cooperation. This discussion is relevant to the basic conditions for a successful public-private partnership with educational institutions and extended education and sheds light on the impact, lessons, and challenges. The public is increasingly concerned about the importance of higher education in the 21st century. This chapter explores some of the key functions of an innovative education system that supports the development of education in Nigeria and enhances people’s ability to use information. Nigeria’s education system re-emphasizes the importance of public and private universities, but the country does not have a sustainable education system and well-equipped educational institutions to support people’s ability to use information, learning, education, and research activities.",book:{id:"10911",title:"Higher Education - New Approaches to Accreditation, Digitalization, and Globalization in the Age of Covid",coverURL:"https://cdn.intechopen.com/books/images_new/10911.jpg"},signatures:"Lawrence Jones-Esan"},{id:"79197",title:"University Teachers’ Conceptions of What University Is: Implications for the Future of Higher Education",slug:"university-teachers-conceptions-of-what-university-is-implications-for-the-future-of-higher-educatio",totalDownloads:106,totalDimensionsCites:0,doi:"10.5772/intechopen.100813",abstract:"This chapter presents the perception of university teachers about the university, the most recent changes and how they have influenced their activity. The phenomenographic study was conducted with 10 university teachers, nine females and one male with more than 15 years of professional activity. The perception of the university emerges, in the teachers’ voice, focused on the description of its mission, namely as a context for the production and diffusion of knowledge to society, as a space for creative and critical thinking about the world, as an interdisciplinary space and as a system focused on teaching and research. It also includes characteristics related to its structure and functioning, such as the level of hierarchization, bureaucratization, competitiveness, dehumanization and bibliometrics overvaluation. Regarding the perceived changes, they are related to the structural reforms resulting from the Bologna Process, diverse student populations, research and internationalization, new technologies, institutional cooperation, bureaucratization and relationship with the community. Teachers also revealed some dissatisfaction in the way they are experiencing university life due to the overwork resulting from the multiple tasks required in the four activity strands (teaching, research, management and extension) with an impact on quality and innovation, but in line with what the institution demands.",book:{id:"10911",title:"Higher Education - New Approaches to Accreditation, Digitalization, and Globalization in the Age of Covid",coverURL:"https://cdn.intechopen.com/books/images_new/10911.jpg"},signatures:"Elisa Chaleta"},{id:"78595",title:"Globalization and Education: Trends towards Sustainability",slug:"globalization-and-education-trends-towards-sustainability",totalDownloads:57,totalDimensionsCites:0,doi:"10.5772/intechopen.99974",abstract:"Higher Education Institutions (IES) have a very relevant role in the path towards sustainability. The problem of the implementation of curricular sustainability is the disparity of solutions that can be adopted depending on the political and economic situation of each country. The study of a practical case in the south of Honduras allows the student to approach key decisions in a real scenario to bring improvements to a very disadvantaged population, lacking basic services, such as water and electricity, under the premise of sustainability, facing aspects as relevant such as sustainable mobility, water resources management, energy and construction models, in a context where globalization and technological innovation play a very important role. It is essential to know in depth the real context where structural changes will be applied to understand that there is no single reality, that actions are built adapting to specific situations and that the effectiveness of the measures that can be adopted to establish models that prioritize that part of sustainability that best weighs the balance between the environment, society and the economy for each case.",book:{id:"10911",title:"Higher Education - New Approaches to Accreditation, Digitalization, and Globalization in the Age of Covid",coverURL:"https://cdn.intechopen.com/books/images_new/10911.jpg"},signatures:"Maria Olga Bernaldo and Gonzalo Fernandez-Sanchez"},{id:"79255",title:"Higher Education Institutions (HEIs) in Africa Embracing the “New Normal” for Knowledge Production and Innovation: Barriers, Realities, and Possibilities",slug:"higher-education-institutions-heis-in-africa-embracing-the-new-normal-for-knowledge-production-and-i",totalDownloads:125,totalDimensionsCites:1,doi:"10.5772/intechopen.101063",abstract:"If Africa is to remain relevant and competitive in today’s knowledge-based economy, it has to rely on higher education institutions (HEIs) as centers of excellence for knowledge production. HEIs nurture and sustain the production of highly-skilled individuals to support Africa’s growing economies. Among all possible ways, this could be achievable through strategic curricula innovation driven by emerging mobile technologies. Consequently, Africa’s HEIs need to embrace the ‘New Normal’ by optimizing online teaching and learning in their pursuit to expand information and communications technology (ICT) literacy as a means to increase students’ opportunities in higher education (HE). However, Africa’s ability to embrace the ‘New Normal’ has been marred by inadequate ICT infrastructures, low connectivity, unreliable power supply, and national budget constraints that may undermine Africa’s HEIs’ potential to augment knowledge production and innovation.",book:{id:"10911",title:"Higher Education - New Approaches to Accreditation, Digitalization, and Globalization in the Age of Covid",coverURL:"https://cdn.intechopen.com/books/images_new/10911.jpg"},signatures:"Christopher B. Mugimu"}],onlineFirstChaptersTotal:17},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:31,numberOfPublishedChapters:314,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:11,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:17,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:14,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"10",title:"Physiology",doi:"10.5772/intechopen.72796",issn:"2631-8261",scope:"Modern physiology requires a comprehensive understanding of the integration of tissues and organs throughout the mammalian body, including the cooperation between structure and function at the cellular and molecular levels governed by gene and protein expression. While a daunting task, learning is facilitated by identifying common and effective signaling pathways mediated by a variety of factors employed by nature to preserve and sustain homeostatic life. \r\nAs a leading example, the cellular interaction between intracellular concentration of Ca+2 increases, and changes in plasma membrane potential is integral for coordinating blood flow, governing the exocytosis of neurotransmitters, and modulating gene expression and cell effector secretory functions. Furthermore, in this manner, understanding the systemic interaction between the cardiovascular and nervous systems has become more important than ever as human populations' life prolongation, aging and mechanisms of cellular oxidative signaling are utilised for sustaining life. \r\nAltogether, physiological research enables our identification of distinct and precise points of transition from health to the development of multimorbidity throughout the inevitable aging disorders (e.g., diabetes, hypertension, chronic kidney disease, heart failure, peptic ulcer, inflammatory bowel disease, age-related macular degeneration, cancer). With consideration of all organ systems (e.g., brain, heart, lung, gut, skeletal and smooth muscle, liver, pancreas, kidney, eye) and the interactions thereof, this Physiology Series will address the goals of resolving (1) Aging physiology and chronic disease progression (2) Examination of key cellular pathways as they relate to calcium, oxidative stress, and electrical signaling, and (3) how changes in plasma membrane produced by lipid peroxidation products can affect aging physiology, covering new research in the area of cell, human, plant and animal physiology.",coverUrl:"https://cdn.intechopen.com/series/covers/10.jpg",latestPublicationDate:"June 20th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:11,editor:{id:"35854",title:"Prof.",name:"Tomasz",middleName:null,surname:"Brzozowski",slug:"tomasz-brzozowski",fullName:"Tomasz Brzozowski",profilePictureURL:"https://mts.intechopen.com/storage/users/35854/images/system/35854.jpg",biography:"Prof. Dr. Thomas Brzozowski works as a professor of Human Physiology and is currently Chairman at the Department of Physiology and is V-Dean of the Medical Faculty at Jagiellonian University Medical College, Cracow, Poland. His primary area of interest is physiology and pathophysiology of the gastrointestinal (GI) tract, with the major focus on the mechanism of GI mucosal defense, protection, and ulcer healing. He was a postdoctoral NIH fellow at the University of California and the Gastroenterology VA Medical Center, Irvine, Long Beach, CA, USA, and at the Gastroenterology Clinics Erlangen-Nuremberg and Munster in Germany. He has published 290 original articles in some of the most prestigious scientific journals and seven book chapters on the pathophysiology of the GI tract, gastroprotection, ulcer healing, drug therapy of peptic ulcers, hormonal regulation of the gut, and inflammatory bowel disease.",institutionString:null,institution:{name:"Jagiellonian University",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"10",title:"Animal Physiology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/10.jpg",isOpenForSubmission:!0,editor:{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. Dr. Rutland has also written popular science books for the public. https://orcid.org/0000-0002-2009-4898. www.nottingham.ac.uk/vet/people/catrin.rutland",institutionString:null,institution:{name:"University of Nottingham",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null},{id:"11",title:"Cell Physiology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/11.jpg",isOpenForSubmission:!0,editor:{id:"133493",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala",profilePictureURL:"https://mts.intechopen.com/storage/users/133493/images/3091_n.jpg",biography:"Prof. Dr. Angel Catalá \r\nShort Biography Angel Catalá was born in Rodeo (San Juan, Argentina). He studied \r\nchemistry at the Universidad Nacional de La Plata, Argentina, where received aPh.D. degree in chemistry (Biological Branch) in 1965. From\r\n1964 to 1974, he worked as Assistant in Biochemistry at the School of MedicineUniversidad Nacional de La Plata, Argentina. From 1974 to 1976, he was a Fellowof the National Institutes of Health (NIH) at the University of Connecticut, Health Center, USA. From 1985 to 2004, he served as a Full Professor oBiochemistry at the Universidad Nacional de La Plata, Argentina. He is Member ofthe National Research Council (CONICET), Argentina, and Argentine Society foBiochemistry and Molecular Biology (SAIB). His laboratory has been interested for manyears in the lipid peroxidation of biological membranes from various tissues and different species. Professor Catalá has directed twelve doctoral theses, publishedover 100 papers in peer reviewed journals, several chapters in books andtwelve edited books. Angel Catalá received awards at the 40th InternationaConference Biochemistry of Lipids 1999: Dijon (France). W inner of the Bimbo PanAmerican Nutrition, Food Science and Technology Award 2006 and 2012, South AmericaHuman Nutrition, Professional Category. 2006 award in pharmacology, Bernardo\r\nHoussay, in recognition of his meritorious works of research. Angel Catalá belongto the Editorial Board of Journal of lipids, International Review of Biophysical ChemistryFrontiers in Membrane Physiology and Biophysics, World Journal oExperimental Medicine and Biochemistry Research International, W orld Journal oBiological Chemistry, Oxidative Medicine and Cellular Longevity, Diabetes and thePancreas, International Journal of Chronic Diseases & Therapy, International Journal oNutrition, Co-Editor of The Open Biology Journal.",institutionString:null,institution:{name:"National University of La Plata",institutionURL:null,country:{name:"Argentina"}}},editorTwo:null,editorThree:null},{id:"12",title:"Human Physiology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/12.jpg",isOpenForSubmission:!0,editor:{id:"195829",title:"Prof.",name:"Kunihiro",middleName:null,surname:"Sakuma",slug:"kunihiro-sakuma",fullName:"Kunihiro Sakuma",profilePictureURL:"https://mts.intechopen.com/storage/users/195829/images/system/195829.jpg",biography:"Professor Kunihiro Sakuma, Ph.D., currently works in the Institute for Liberal Arts at the Tokyo Institute of Technology. He is a physiologist working in the field of skeletal muscle. He was awarded his sports science diploma in 1995 by the University of Tsukuba and began his scientific work at the Department of Physiology, Aichi Human Service Center, focusing on the molecular mechanism of congenital muscular dystrophy and normal muscle regeneration. His interest later turned to the molecular mechanism and attenuating strategy of sarcopenia (age-related muscle atrophy). His opinion is to attenuate sarcopenia by improving autophagic defects using nutrient- and pharmaceutical-based treatments.",institutionString:null,institution:{name:"Tokyo Institute of Technology",institutionURL:null,country:{name:"Japan"}}},editorTwo:{id:"331519",title:"Dr.",name:"Kotomi",middleName:null,surname:"Sakai",slug:"kotomi-sakai",fullName:"Kotomi Sakai",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000031QtFXQA0/Profile_Picture_1637053227318",biography:"Senior researcher Kotomi Sakai, Ph.D., MPH, works at the Research Organization of Science and Technology in Ritsumeikan University. She is a researcher in the geriatric rehabilitation and public health field. She received Ph.D. from Nihon University and MPH from St.Luke’s International University. Her main research interest is sarcopenia in older adults, especially its association with nutritional status. Additionally, to understand how to maintain and improve physical function in older adults, to conduct studies about the mechanism of sarcopenia and determine when possible interventions are needed.",institutionString:null,institution:{name:"Ritsumeikan University",institutionURL:null,country:{name:"Japan"}}},editorThree:null},{id:"13",title:"Plant Physiology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/13.jpg",isOpenForSubmission:!0,editor:{id:"332229",title:"Prof.",name:"Jen-Tsung",middleName:null,surname:"Chen",slug:"jen-tsung-chen",fullName:"Jen-Tsung Chen",profilePictureURL:"https://mts.intechopen.com/storage/users/332229/images/system/332229.png",biography:"Dr. Jen-Tsung Chen is currently a professor at the National University of Kaohsiung, Taiwan. He teaches cell biology, genomics, proteomics, medicinal plant biotechnology, and plant tissue culture. Dr. Chen\\'s research interests include bioactive compounds, chromatography techniques, in vitro culture, medicinal plants, phytochemicals, and plant biotechnology. He has published more than ninety scientific papers and serves as an editorial board member for Plant Methods, Biomolecules, and International Journal of Molecular Sciences.",institutionString:"National University of Kaohsiung",institution:{name:"National University of Kaohsiung",institutionURL:null,country:{name:"Taiwan"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:45,paginationItems:[{id:"82135",title:"Carotenoids in Cassava (Manihot esculenta Crantz)",doi:"10.5772/intechopen.105210",signatures:"Lovina I. Udoh, Josephine U. Agogbua, Eberechi R. Keyagha and Itorobong I. 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Serves as a peer reviewer for biomedical journals. Military Reserve Officer serving with the 100 Support Command, 100 Troop Command, 40 Infantry Division, CA National Guard.",institutionString:null,institution:{name:"Loma Linda University",institutionURL:null,country:{name:"United States of America"}}}]},{type:"book",id:"6925",title:"Endoplasmic Reticulum",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6925.jpg",slug:"endoplasmic-reticulum",publishedDate:"April 17th 2019",editedByType:"Edited by",bookSignature:"Angel Català",hash:"a9e90d2dbdbc46128dfe7dac9f87c6b4",volumeInSeries:2,fullTitle:"Endoplasmic Reticulum",editors:[{id:"196544",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala",profilePictureURL:"https://mts.intechopen.com/storage/users/196544/images/system/196544.jpg",biography:"Angel Catalá studied chemistry at Universidad Nacional de La Plata, Argentina, where he received a Ph.D. in Chemistry (Biological Branch) in 1965. From 1964 to 1974, he worked as an Assistant in Biochemistry at the School of Medicine at the same university. From 1974 to 1976, he was a fellow of the National Institutes of Health (NIH) at the University of Connecticut, Health Center, USA. From 1985 to 2004, he served as a Full Professor of Biochemistry at the Universidad Nacional de La Plata. He is a member of the National Research Council (CONICET), Argentina, and the Argentine Society for Biochemistry and Molecular Biology (SAIB). His laboratory has been interested for many years in the lipid peroxidation of biological membranes from various tissues and different species. Dr. Catalá has directed twelve doctoral theses, published more than 100 papers in peer-reviewed journals, several chapters in books, and edited twelve books. He received awards at the 40th International Conference Biochemistry of Lipids 1999 in Dijon, France. He is the winner of the Bimbo Pan-American Nutrition, Food Science and Technology Award 2006 and 2012, South America, Human Nutrition, Professional Category. In 2006, he won the Bernardo Houssay award in pharmacology, in recognition of his meritorious works of research. Dr. Catalá belongs to the editorial board of several journals including Journal of Lipids; International Review of Biophysical Chemistry; Frontiers in Membrane Physiology and Biophysics; World Journal of Experimental Medicine and Biochemistry Research International; World Journal of Biological Chemistry, Diabetes, and the Pancreas; International Journal of Chronic Diseases & Therapy; and International Journal of Nutrition. 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He was head of this department from 1993 to 2003. His specializations are medicine, gastroenterology, clinical pharmacology, clinical nutrition, and dietetics. His research fields are biochemical pharmacological examinations in the human gastrointestinal (GI) mucosa, mechanisms of retinoids, drugs, capsaicin-sensitive afferent nerves, and innovative pharmacological, pharmaceutical, and nutritional (dietary) research in humans. He has published about 360 peer-reviewed papers, 197 book chapters, 692 abstracts, 19 monographs, and has edited 37 books. He has given about 1120 regular and review lectures. He has organized thirty-eight national and international congresses and symposia. He is the founder of the International Conference on Ulcer Research (ICUR); International Union of Pharmacology, Gastrointestinal Section (IUPHAR-GI); Brain-Gut Society symposiums, and gastrointestinal cytoprotective symposiums. He received the Andre Robert Award from IUPHAR-GI in 2014. 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