Physical characteristics and sample size (mean ± SD).
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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This is an ongoing challenge that commenced many years ago. Recent design criteria endeavour to quantify the effect of residual stresses on fatigue strength of welded joints to allow a more efficient use of materials and a greater reliability of welded structures. The aim of the present book is contributing to these aspects of design through a collection of case-studies that illustrate both standard and advanced experimental and numerical methodologies used to assess the residual stress field in welded joints. The work is intended to be of assistance to designers, industrial engineers and academics who want to deepen their knowledge of this challenging topic.",isbn:"978-1-78923-107-6",printIsbn:"978-1-78923-106-9",pdfIsbn:"978-1-83881-373-4",doi:"10.5772/intechopen.69093",price:119,priceEur:129,priceUsd:155,slug:"residual-stress-analysis-on-welded-joints-by-means-of-numerical-simulation-and-experiments",numberOfPages:162,isOpenForSubmission:!1,isInWos:1,hash:"df9c0c97df0bed4d93eed96c30903b2b",bookSignature:"Paolo Ferro and Filippo Berto",publishedDate:"May 16th 2018",coverURL:"https://cdn.intechopen.com/books/images_new/6276.jpg",numberOfDownloads:5095,numberOfWosCitations:3,numberOfCrossrefCitations:0,numberOfDimensionsCitations:5,hasAltmetrics:0,numberOfTotalCitations:8,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 11th 2017",dateEndSecondStepPublish:"June 1st 2017",dateEndThirdStepPublish:"September 24th 2017",dateEndFourthStepPublish:"November 26th 2017",dateEndFifthStepPublish:"January 25th 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,editors:[{id:"43915",title:"Dr.",name:"Paolo",middleName:null,surname:"Ferro",slug:"paolo-ferro",fullName:"Paolo Ferro",profilePictureURL:"https://mts.intechopen.com/storage/users/43915/images/5365_n.jpg",biography:"Paolo Ferro is actually Associate Professor of Metallurgy and Materials Selection at the University of Padua (Italy). After the degree in Materials Engineering (with first-class honours) he received the Ph.D. degree from University of Padua in Metallurgical Engineering. From 2006 to April 2015 he served as Assistant Professor in the Department of Engineering and Management of the same University. He was scientific director of the research program \\'Numerical and Experimental Determination of Residual Stresses in Welded Joints and their Influence on Fatigue Strength\\' (Young Researchers Project, 2003-2004). He won the prize for young researchers ‘Aldo Daccò’ 2002. He is a member of CMBM (Centre for Mechanics of Biological Materials). His research is mainly focused on the analytical and numerical modelling of welding and heat treatment processes. He is interested in the local criteria based on the Notch Stress Intensity Factor (NSIF) and the Strain Energy Density (SED) averaged over a control volume for the evaluation of fatigue strength of welded joints. He works also on the modelling of intermetallic phases evolution during heat treatments of Duplex and Superduplex Stainless Steels and mechanical and metallurgical characterisation of Cast Irons. He has published more than 100 papers in international peer-reviewed journals, conference proceedings and contributed book chapters. In addition to his editorial role with Advances in Materials Science and Engineering he frequently serves as reviewer for many other professional journals and national as well as international funding agencies.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Padua",institutionURL:null,country:{name:"Italy"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"199954",title:"Dr.",name:"Filippo",middleName:null,surname:"Berto",slug:"filippo-berto",fullName:"Filippo Berto",profilePictureURL:"https://mts.intechopen.com/storage/users/199954/images/5366_n.jpg",biography:"Filippo Berto got his degree summa cum laude in \\'Management Engineering\\' in 2003 at the University of Padua (Italy). 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Since the first years of the introduction of cocaine by Carl Koller in 1884, the evolution of regional anesthesia has been continuous, gradual and safe. Its development has been based on anatomy, the pharmacology of local anesthetics and adjuvant drugs, as well as advances in the various blocking techniques, with ultrasound guidance being the most recent advent. The use of ultrasound in regional anesthesia has shown the reduction of complications, which makes it mandatory to knowledge and acquire skills in all ultrasound-guided techniques.
\r\n\r\n\tUltrasound-guided regional blocks will be reviewed extensively, as well as intravenous regional anesthesia, thoracic spinal anesthesia. The role of regional anesthesia and analgesia in critically ill patients is of paramount importance. In addition, we will review the current role of regional techniques during the Covid-19 pandemic. Complications and malpractice is another topic that should be reviewed. Regional anesthesia procedures in some specialties such as pediatrics, orthopedics, cancer surgery, neurosurgery, acute and chronic pain will be discussed.
",isbn:"978-1-83969-570-4",printIsbn:"978-1-83969-569-8",pdfIsbn:"978-1-83969-571-1",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"264f7f37033b4867cace7912287fccaa",bookSignature:"Prof. Víctor M. Whizar-Lugo, Dr. José Ramón Saucillo-Osuna and Dr. Guillermo A. Castorena-Arellano",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10708.jpg",keywords:"Regional Anesthesia, Ultrasound-Guided Regional Anesthesia, Local Anesthetics, Preventive Analgesia, Peripheral Blocks, Pediatric Regional Anesthesia, Intravenous Regional Anesthesia, Techniques, Complications, Adjuvants in Regional Anesthesia, Opioids, Alfa2 Agonists",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 25th 2021",dateEndSecondStepPublish:"March 25th 2021",dateEndThirdStepPublish:"May 24th 2021",dateEndFourthStepPublish:"August 12th 2021",dateEndFifthStepPublish:"October 11th 2021",remainingDaysToSecondStep:"23 days",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Whizar-Lugo has published more than 100 publications on Anesthesia, Pain, Critical Care, and Internal Medicine. He works as an anesthesiologist at Lotus Med Group and belongs to the Institutos Nacionales de Salud as an associated researcher.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"169249",title:"Prof.",name:"Víctor M.",middleName:null,surname:"Whizar-Lugo",slug:"victor-m.-whizar-lugo",fullName:"Víctor M. Whizar-Lugo",profilePictureURL:"https://mts.intechopen.com/storage/users/169249/images/system/169249.jpg",biography:"Víctor M. Whizar-Lugo graduated from Universidad Nacional Autónoma de México and completed residencies in Internal Medicine at Hospital General de México and Anaesthesiology and Critical Care Medicine at Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in México City. He also completed a fellowship at the Anesthesia Department, Pain Clinic at University of California, Los Angeles, USA. Currently, Dr. Whizar-Lugo works as anesthesiologist at Lotus Med Group, and belongs to the Institutos Nacionales de Salud as associated researcher. He has published many works on anesthesia, pain, internal medicine, and critical care, edited four books, and given countless conferences in congresses and meetings around the world. He has been a member of various editorial committees for anesthesiology journals, is past chief editor of the journal Anestesia en México, and is currently editor-in-chief of the Journal of Anesthesia and Critical Care. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"57095",title:"Felted Terrain: Interactive Textile Landscape; Transforming the Experience of Knitted Textile with Computation and Soft Electronics",doi:"10.5772/intechopen.71124",slug:"felted-terrain-interactive-textile-landscape-transforming-the-experience-of-knitted-textile-with-com",body:'\nKnitting, creating fabric from weaving of worsted fibers, has been with us since the old days. As a material at the scale of our body, we are familiar with its touch, use, and experience. Textiles have also been used at the scale of the interior as wall tapestries and affect our experience with the space through esthetics. Through its interlaced yarn and colors, textile wall hangings were important elements of story-telling, communicating stories to the inhabitants of the space [6].
\nWith the advent of soft electronics, there is an opportunity to take the experience of the textiles to the next level of multi-sensoriality. This project aims to explore two aspects of ‘craft research’ in interactive textiles; the generative design/craft process of textile and creation of spatial experience through public exhibition (reflective-on-action). The first part discusses the production process of an interactive textile using embedded soft electronics, computation, and generative design that “focus on aesthetics, personal expression, and the idea of play, as opposed to the prevalent utilitarian focus of wearable technology design on universal connectivity and productivity applications” [2]. The slow-paced craft process of the felted textile embraces the practice of ‘reflective-in-action’, where final interaction design of the project was continuously designed and iterated throughout the process of making [11]. The second part of the project focuses on the experience of interactive textile in a spatial (exhibition) setting where it becomes a mediator of experiential elements, that transforms an everyday space into a multi-sensorial ‘practice space’ [5]. The combination of haptic, visual, and auditory experience that is placed throughout the exhibition space provides users to ‘reflect-on-action’ [11] and discover the various interactive elements of the textile.
\nFelted Terrain attempts to subvert the notion of primitive handcraft in knitted/felted textile through its integration of soft electronics, computation design, and fabrication method. Using traditional textile techniques such as knitting, embroidery, and felting, the project aims to create textile of an ‘ambient display’ [14] that sense, transmit data, and create spatial sensory effect by presenting information within a space through subtle changes in the background of awareness (in this case, sound) (Figure 1).
\nFelted Terrain—an interactive sensorial textile that generates sound and visual graphics upon touch.
There are two parts to the creation of ‘Felted Terrain’—designing of knit pattern to create three-dimensional knit structures with parametric computation design tools, and making of the electronic textile “that incorporates capabilities for sensing, communication, and interconnection technology” [2] with soft computation. Felted Terrain is a result of this two-part process and aims to present a seamless integration of technology and interactive experience in a knitted woven textile. As a handcraft process, the slow pace of the design and production of the textile enables ‘reflection-in-action’ [11], to continuously reflect on the project as a whole and also at every stage of the process to ensure the integration of design, craft, and intended user interaction in the production of the interactive textile. The following documents every step of the design and making process, that involves both digital and manual methods.
\nAs the initial inspiration from the project came from the rolling mossy landscape of Iceland (Figure 2), creating a three-dimensional pattern to express the soft terrain was the first step in the process. To generate pattern, a circle packing Grasshopper script for Rhino 3D was used. The size of the circles varied from large to small (which corresponds to the pitch of the musical notes). The script also allowed easy planning in mapping of conductive areas, as shown in Figure 3 (the red circles indicate where the conductive thread will be added to create a capacitive sensor tips). The parametrically generated pattern was then overlaid on a grid to translated these into a knitting pattern. The pattern used in this project was one of many iterations generated from the computational design tool, which opened up a wide possibility to quickly generate variations for different visual effects.
\nInterpreting the mossy terrain of Iceland to a knitted pattern.
(Left) Circle-packing pattern generated from parametric scripts. (Center) The pattern was overlaid on a grid to create a knitting pattern, and red circles indicate where the conductive thread should be added during the knitting process to create capacitive sensor tips. (Right) Gray-shaded area indicates the conductive tips, with circuit path showing its connection to the central microcontroller placed on the bottom left corner.
Using the same pattern, a soft circuit diagram was made to plan out the embroidery of conductive circuits on felted textile. The curved lines indicated the circuit that links all of the conductive tips (gray-shaded area) to the Lilypad microcontroller (Figure 3). Soft circuits were embroidered along the designated pattern using conductive stainless steel thread. The Lilypad microcontroller and x-Bee wireless modules were also hand sewn using conductive thread, creating a full e-textile.
\nThe knitting process involved using two different types of yarn, a regular wool yarn and a conductive stainless steel yarn. As seen in Figure 4, stainless steel yarn was knitted together at the tips of the bumps to give “electro-mechanical properties” that will enable the fabrication of complex textile with interactivity [1]. This allowed integration of flexible sensors to build electronic circuits on soft substrates, and enables a move away from traditional electronics, of using PCB boards and hard materials, to an exploration of emergent flexible materials to create interactive physical designs [2]. When connected to the microcontroller, these tips can be programmed to become touch sensitive through capacitance. In this project, a low-profile stainless steel yarn was used instead of visible silver or gold metallic threads in creating soft circuits, so it could be blended in with the wool fiber and create a seamless look, paving its way for unexpected interaction in the final stage.
\nKnitting with two different types of yarn to create a conductive 3D structure knit. Conductive fibers are embedded in each tip of the three-dimensional forms.
To produce a textile at the scale of the interior, yet using a domestic scale of the knitting machine, the project was made in small size patches of 1 m × 1 m as shown in Figure 5. Knitted patches were stitched together to create a large wall-sized piece woven textile with three-dimensional ‘bump’ forms. The process produced a loosely knit woven textile with areas of embedded conductivity where stainless steel yarn was added to the wool yarn during the knitting process. Hand stitched seams and stainless steel yarn at tips of the three-dimensional bumps were still visible at this stage—in order to create a seamless esthetics of a non-woven textile, the completed knit textile went through the multi-step process of wet-felting.
\nKnitting in 1 m × 1 m patches to produce a spatial-scale of knitted textile.
Wet felting shrinks the knitted textile by 30–40% from its original size (Figure 6). The felting process is a result of the ‘tangling of wool fibers’, due to the reptile-like scales on the surface of individual fibers. These scales are the main reasons in giving traditional wool its abrasive texture. When washed with hot water, these scales interlock and become lighter and tighter causing shrinkage, becoming a non-woven felted textile (Figure 7). Using this natural mechanism, the above knitted textile went through the wet-felting process, where it was agitated multiple times in the washing machine with hot water and soap, until the knitted structure was no longer visible and became a homogenous texture of felted fabric. Afterwards the entire piece was formed, flattened and then air dried to retain the shape of the bumps.
\nFelting process shrinks the woven wool textile by 30–40%. Felting transforms a woven knitted fabric into a seamless non-woven fabric.
Diagram of wool fibers and the interlocking mechanism of wool scales in felting.
The previous section explored the use of computation as a tool to generate design for the three-dimensional pattern of the knitted textile. Computation can go beyond the role of design tool, and become ‘part of the designed things themselves’ [12].
\nThe three-dimensional form of the felted textile is designed with an intention to draw users touch, squeeze, and stroke each of the bumps. In addition to the apparent visual and tactile experience of the textile, auditory experience was programmed to the textile as an output of the touch interaction. In this project, a Lilypad microcontroller, an Arduino variant that is designed to be easily integrated with flexible circuits on textiles through sewing with conductive threads, was used along with a wireless x-Bee module to transform the experience of the everyday textile into an interactive e-textile.
\nThe interaction had two parts to the design. First was leveraging on the expected behavior of people with textiles (especially since the bumpy form intrigued users to touch) and second was designing an interaction that is intuitive for users to find out the rules of the game after a short engagement. In this project, a simple music notes were assigned to selected bumps on the felted textile. The size of the bumps corresponded to the pitch of the notes, for example, large bump played a lower octave note, and the note/pitch of the sound would go up the scale as the bump sizes get smaller (Figures 8 and 9).
\nLilypad microcontroller was sewn onto the felted fabric along with x-Bee module for wireless transmission of data to the main computer.
Using Arduino and Processing, touching of the conductive felted tips produced individual sound of piano notes, at the same time visualizing the pitch through real-time projection of the sine wave curve on the wall.
In order to enable the textile as a simple sound keyboard, Lilypad microcontroller was loaded with a modified Capsense Arduino Code. The received serial data was then transferred to a Processing script (adapted from MIT Media Lab High-Low Tech Group’s Piano Code). With these codes each touch on the tips were translated into a sound, which was then played through a speaker placed in the room. To create a visual connection to the sound the textile was producing, a real-time projection of the sound pitch was projected on the wall, in a form of a sine curve. Through this tri-part experience, a tactile touch could be both felt acoustically and visually.
\nFelted Terrain was installed at the MIT Keller Gallery for open interaction with visitors and passersby. The exhibition context could influence how one experiences the material of the exhibit [9]. With the design of the layout, the exhibitor can guide the visitor to engage with the material in a specific way and order, adding additional interaction element to the whole experience (Figure 10)
Exhibition of the textile—it was placed on a custom designed clear table with reflective film on floor.
The exhibition was designed to invite visitors to reflect-on-action [11], to unveil the experiences of the interactive textile by engaging with it step by step. The square felted textile was placed on a clear table with a spotlight providing visual focus. A circular shiny mirrored film was placed beneath the table to enlarge the presence of the felted textile as well as providing additional view of the textile (negative space of the three-dimensional pattern). Upon entry, the three-dimensional form and fuzzy texture of the felted textile lures users to engage in touch. Each touch of the capacitive sensor tips, produced different musical notes, which was played through embedded sound system in the gallery space. By touching various sized tips, users could gradually understand the connection between bump sizes and sound notes, where the pitches of the notes correspond to the size of the bumps. Over time, one could make the parallel analogy of the textile as musical keyboard, and many of the users started to play a tune with the felted textile bumps. Various touch gestures were observed during the exhibition—in addition to lightly tapping the bumps, other gestures such as stroking, squeezing, pressing, and pulling of the bumps were made. Regardless of the types of gestures, in this version of the textile, the touch was accompanied by real-time visualization of the sounds, which was a wall projection of a sine wave curve.
\nThe interactive textile also became mediator of experiential elements, and as a result it created an opportunity for a ‘practiced space’ by bringing meaning to a static space [5], where one’s actions and engagement with the textile produced different perception of space (from space of sound, space of visual movement, and space of tacility). The interactive textile influenced how people experience their surroundings (Figure 11).
\nThe tactility and three-dimensional design of the textile invites users to touch, which generates sounds and visualizes the pitch of the sound on a nearby wall.
The Felted Terrain project explored the creation of different sensorial experiences to the everyday surface of textile through computation-based design and integration of soft electronics. The exploration described in this paper is just the beginning, as many variations, effects and experiences can be created. For simplification, there are three components to the project for further exploration. First is in the design of the esthetics through pattern making. Through generative computation design, many dynamic and diverse designs can be made for application on textile. When combined with traditional techniques in knitting (such as creating “bumps” in this project by adding and decreasing stitches) the parametric design tool can quickly generate iterations of design forms.
\nSecond, design of the interaction can be explored further. The project engaged few sensorial experiences, from auditory to visual, however, multitudes of combinations of experiences can be designed. The sensorial output from the touching of felted bumps are unlimited; further exploration can be made to produce other outputs such as changes in lighting of the space, temperature, haptic vibration, etc. Interaction modes are another part of the interaction design that can be modified. Additional touch behaviors on fabrics, such as stroking, squeezing, pushing can be studied to embed actuating sensors (conductive areas) to encourage other modes of engagement with the textile.
\nLastly, the scale of the textile experience can be varied, from a scale of the body to the scale of the interior and building, to produce different emotional effects and affect understanding of the space. Other production methods and tools, such as thermo-forming of non-woven textile on digitally produced forms (CNC milled form base as an example), or using an industrial scale knitting machine to scale up and automate the process can produce the soft, responsive, sculptural textile surface at a scale of the interior. The e-textile surface can also be modularized in a form of e-textile for application on larger surface. The placement of tiles can produce different overall visual patterns as well as sensory outputs (Figure 12).
\nDiagram of components to be further explored.
The Felted Terrain project is an exploration of creating a soft textile surface that creates rich interaction and activities between people, computer, and the physical space to be expressive, unexpected, and enjoyable.
\nThe slow crafting process of designing and making the interactive multi-sensorial textile provided many moments of ‘reflection-in-action’ [9], where the designer-maker can reflect in each action of the process to inform the experience of the whole and design decisions of parts. The exhibition context provided opportunities for ‘reflection-on-action’ [9], by allowing visitors to unveil layers of experiences and figuring out the pattern (rule) of interaction by reflecting on past experiences, knowledge and actions.
\nTextiles have a “uniquely intimate relationship with the human body” [1]. We wear them as clothing and also live around them as interior furnishing. We are naturally drawn to touching and feeling the tactility of the textile. What further explorations can be made to create soft surfaces that intuitively draw people to feel, respond, and interact? Would production at various scales, from the body-scale wearable to the level of interior and building produce different experiential effect of the interactive textile surface?
\nTextiles, whether knit or woven, worn on body or hung in space, is ubiquitous in our lives. The everyday presence of textile surfaces and its application to create soft, fabric-based computers embody Mark Weiser’s vision of ubiquitous computing [13]: providing functionality while disappearing discreetly into the soft surface of the ‘textiled’ space. The esthetics, material qualities, and flexibility of the textiles present large possibility for embedded computation [4], or as a medium to form ‘computational composite’ [9] to create a pervasive, playful, and theatrical interactive experience for all.
\nThanks to MIT Department of Architecture and Council for Arts at MIT for funding and support.
\nPopulation Health continues to expand especially as new research demonstrates ways to better manage a person’s health. One area of interest is the impact muscle has on enhancing health and disease prevention [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12]. A healthy and strong muscle mass increases the chance of better managing and preventing certain diseases such as Type II diabetes, cardiovascular disease, certain cancers, dementia and hypertension to name a few [3, 4, 5]. A healthy muscle mass also helps in maintaining a healthier body weight, the ability to sustain an adequate overall body metabolism with age and an enhanced immune system to help fight off various viruses and disease [6, 8, 9]. Muscular strength with aging puts individuals at greater risk for sarcopenia (loss of muscle) not only for the diseases already mentioned by also for slips, falls, functionality and frailty [4, 11, 12].
\nIn 2006, Wolfe discussed the underappreciated role of muscle in health and disease [1]. He discussed the importance of future research to include factors related to muscle mass, strength and metabolic syndrome. Wolfe focused on the importance of muscle protein and the pool of amino acids in maintaining a relatively constant plasma glucose concentration. He also discussed the role muscle plays in obesity and Type II diabetes. Argiles and associates in 2016 supports Wolfe’s research on the importance of muscle regulating protein metabolism throughout the body [4]. Both of these studies strongly support maintaining a healthy and strong muscle mass throughout one’s lifespan especially to prevent sarcopenia and certain diseases. This was further emphasized by Mrowka and Westphal in their article on “skeletal muscle in the fight against chronic disease” published in 2018 [5]. DeCarvalho and associates showed an inverse relationship between skeletal muscle mass adjusted for weight and BMI with metabolic syndrome in both males and females [2]. Their study researched 689 adults between the ages of 20–59. Mesinovic and associates discussed the connection between sarcopenia and Type II diabetes [10]. The loss of muscle alters glucose uptake in the muscle leading to more glucose in the blood which increases the risk of Type II diabetes.
\nSarcopenia is a critical concern not just because of the loss of muscle and its ability to fight disease and infection, but because the individual is at greater risk for slips, falls and injury [4, 11, 12, 13, 14, 15, 16]. If not remedied, the loss of muscle can lead to a frail state which can be fatal [4]. Every day functionality and daily activities become more difficult to perform with the loss of muscle. Muscle protein breaks down and rebuilds daily. Sarcopenia can start as early age of 25 and accelerates after age 60 years and sometimes sooner. The inability to rebuild muscle protein as the body ages contributes to sarcopenia. It should be noted that as the body loses muscle, the loss of muscle strength (dynapenia) occurs more rapidly. It also should be noted that obese individuals are at greater risk for sarcopenia.
\nInflammation is associated with most chronic diseases [8, 9, 17]. There is compelling evidence that shows physical activity to include strength training offers a defense to chronic diseases. David Nieman discussed the link between physical activity and the body’s immune system [9]. While there is compelling evidence to suggest that physical exercise will enhance the body’s immune system, there is also evidence that suggests lengthy, intense workout sessions might be harmful to the body’s immune system. Nieman suggests physical activity workouts should be no more than 60-minutes at a moderate-vigorous intensity to safely enhance the immune system [9].
\nOne area of research that has increased dramatically focuses on muscle mass and strength related to cancer treatment and prevention [18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28]. Caan and associates in 2018 showed that women with non-metastatic breast cancer had 41% better chance of surviving with a healthier muscle mass compared to sarcopenic non-metastatic breast cancer patients [18]. The American College of Sports Medicine (ACSM) has published research showing the impact physical activity has in lowering the risk of at least 7 different cancers and increasing survivability [22, 23, 24, 26, 27]. ACSM recommends a variety of physical activities to include resistance training (strength), aerobic and balance with options for light, moderate or vigorous intensity. The ACSM and the National Academy of Sports Medicine certify health and exercise professionals to work directly with cancer patients to improve their strength and muscle mass.
\nThere is evidence demonstrating muscular strength as a predictor of mortality in a healthy population [29, 30, 31, 32, 33, 34]. A meta-analysis by Garcia-Hermosa and colleagues show that individuals with good upper body and lower body strength have lower risk of mortality regardless of age [29]. ACSM has published numerous research studies demonstrating the effectiveness of resistance training on health for individuals from 15 to 90 plus years old [22, 23, 24, 26, 27]. Moberg recently published data about the significance of a “muscle memory” found in each myonucleous [30]. This study focused on how much impact does resistance training when done earlier in life has on muscle later in life. It appears that if resistance training was done earlier in life that your muscle will
Despite the incredible abundance of research showing how a healthy muscle mass leads to a healthier lifestyle, the worker today in general is weaker and heavier than the worker 25 years ago. One reason for this is that physical demands of many jobs have been decreased due to robots and other ergonomic assists [35, 36]. Automation is good, especially in industry. It contributes to a safer workplace. But automation greatly diminishes the physical demands of the job which has impacted the overall health of the industrial worker.
\nSince 1960, the percentage of moderate intensity physically demanding jobs in the United States has decreased from about 50% to 20% in 2010, but the light intensity jobs have increased from 38% to about 55% [35]. Sedentary jobs increased as well from 15–22%. Most of these changes took place because of automation. This means the amount of physical work done by today’s worker has greatly diminished.
\nUnfortunately, the less physically active the worker becomes, the greater the risk for injury and certain diseases. Some of this increased risk occurs because of an increase in body weight (fat weight) tied to the loss of muscle mass and strength.
\nIndustrial Physical Capability Services, Inc. (dba IPCS) performs muscular strength assessments for industry in the United States using isokinetic equipment for shoulder and knee flexion and extension at 60 degrees per second [37, 38]. Between 2005 and 2019, 406,731 strength tests were completed (327,913 males and 78,818 females). To compare changes in muscular strength, an analysis was made comparing the year 2005 to 2019 (a 15-year span).
\n\nTable 1 shows the physical characteristics of those new hire industrial applicants tested in 2005 compared to 2019 based on gender. Due to unequal sample sizes and unequal variances, the Kolmogorov–Smirnov Test was used to test for significance within gender between 2005 and 2019. There was no significant difference for age (>.001) within gender between 2005 and 2019. Height, weight and BMI was significantly different within gender between the two time periods. The female body weight increased most between 2005 and 2019 (+9.5 pounds). The BMI increased for both genders.
\n\n | Descriptive data for males and females (Means ± SD) | \n|||||
---|---|---|---|---|---|---|
\n | Female | \nMale | \n||||
\n | 2005 | \n2019 | \nKolmogorov–Smirnov Test | \n2005 | \n2019 | \nKolmogorov–Smirnov Test | \n
Age (yrs) | \n34.1 ± 10.34 | \n33.8 ± 11.72 | \n>.001 | \n34.0 ± 10.34 | \n34.1 ± 11.63 | \n>.001 | \n
Height (in) | \n64.8 ± 2.94 | \n64.3 ± 64.34 | \n<.001 | \n70.3 ± 2.99 | \n71.0 ± 3.03 | \n<.001 | \n
Weight (lbs) | \n167.8 ± 41.48 | \n177.3 ± 47.92 | \n<.001 | \n205 ± 44.01 | \n207.6 ± 49.50 | \n<.001 | \n
BMI | \n28.1 ± 6.65 | \n30.1 ± 7.59 | \n<.001 | \n29.1 ± 5.66 | \n29.8 ± 6.57 | \n<.001 | \n
Sample Size | \n2637 | \n6701 | \n\n | 23,274 | \n13,219 | \n\n |
Physical characteristics and sample size (mean ± SD).
Changes in the absolute strength of the shoulder and knee flexors and extensors of the worker by age group between 2005 and 2019 is shown in Table 2. The absolute shoulder strength and knee strength decreased significantly (<.001) between 2005 and 2019 for males and females.
\n\n | Knee and shoulder strength measures for males and females (Means ± SD) | \n|||||
---|---|---|---|---|---|---|
\n | Female | \nMale | \n||||
Absolute Strength | \n2005 | \n2019 | \nKolmogorov–Smirnov Test | \n2005 | \n2019 | \nKolmogorov–Smirnov Test | \n
Shoulder (ft. pds) | \n102 ± 26.32 | \n90 ± 25.74 | \n<.001 | \n189 ± 43.26 | \n170 ± 43.27 | \n<.001 | \n
Knee (ft. pds) | \n246 ± 81.76 | \n235 ± 76.50 | \n<.001 | \n388 ± 89.23 | \n347 ± 91.69 | \n<.001 | \n
Absolute strength measures for the knee and shoulders (means ± SD).
Changes in the absolute strength of the shoulder and knee flexors and extensors of the worker by age group between 2005 and 2019 are shown in Figures 1 and 2, respectively.
\nChanges in absolute shoulder strength (ft. pds.) of the worker by age group.
Changes in absolute knee strength (ft. pds.) of the worker by age group.
\nFigure 1 shows for each age group that the shoulder strength is anywhere from 14.5% to 18.9% weaker in 2019 compared to 2005.
\n\nFigure 2 shows for each age group the absolute knee strength is anywhere from 18.2% to 22.2% weaker in 2019 compared to 2005. Both Figures 1 and 2 show substantial difference in the strength of the worker between 2005 and 2019. Figure 3 shows the differences between years by age groups as a percent change.
\nPercent deficit in shoulder and knee strength between 2005 and 2019.
The first three figures show the absolute shoulder and knee strength has decreased on average by 18% across all age groups between 2005 and 2019. The figures also show after the 40–49 age group there is a rapid decrease in absolute strength which supports the concept of loss of muscle mass and strength with aging along with an increase in sedentary lifestyles. Interestingly, the youngest age group (20–29) had the greatest deficit for the shoulder and knee strength when compared to the three age groups between 30 and 59. This is a reflection on the sedentary lifestyles found in children and youth which then carries over into industry.
\nDuring the IPCS testing process, height (in) and weight (pds) are measured. For research purposes IPCS calculates Body Mass Index (BMI) to monitor trends in obesity within the workplace. Figure 4 compares the changes in the percent number of workers in each BMI category from 2005 to 2019. IPCS looks at changes in BMI for the category 50 or more or extreme morbid obesity. When comparing 2005 to 2019, the overweight category (BMI 25–30) decreased from 38–32% whereas the BMI categories equal to severe obesity (BMI 35 or more) and greater increased from 13.6% to 20.7% which represents a 52.2% increase. It is these higher BMI categories associated with an increase in certain diseases such as Type II diabetes, hypertension and cardiovascular disease. Further, work by Ostebye in 2007 has shown that those workers with a BMI of 35 or more have 2 times the number of soft tissue injuries, 7 times the workers’ compensation costs and 13 times more lost work days [39].
\nPercent changes in number of Workers for each BMI category.
IPCS has been involved providing a comprehensive strength screening evaluation for the new hires for the Cleveland Clinic since January 2011 [40]. This has resulted in the collection of new hire data related to strength and medical claims which have been studied from 2011 through 2017.
\nThis quasi-experimental, non-randomized study was conducted at Cleveland Clinic in northeast Ohio. It was designed to assess the impact of a strength screening assessment for nurses used at the time of hire, and compare the difference in health plan costs to newly employed nurses who did not receive the strength screening. Participants were identified from the applicant pool as part of the new hire process from January 2008 through December 2017. Applicants were either registered nurses, licensed vocational nurses, licensed practical nurses, or patient care nursing assistants applying for a nursing position in any unit of the hospital. The interviewing process for potential candidates consisted of an online application, followed by a phone interview and then an in-person interview if warranted. Nurses that passed these initial requirements for selection were then scheduled for a physical exam and a drug screen. A strength assessment screening was added to the existing hiring protocol as the last segment of the interview process for nurses hired from January 2011 through December 2017.
\nNurses hired in January 2008 through December 2010, prior to the strength assessment screening implementation, served as a Historical Comparison Group. There were no significant environmental or business practice changes observed during this time period from January 2008 through December 2017, and health plan coverage did not change across the two time frames. The only difference in the selection process in 2011–2017 compared to 2008–2010 was the addition of the physical capability evaluation (PCE™). The project was overseen by hospital administrators, and conducted based on quality improvement protocols. Given that this was a retrospective analysis of a hiring practice policy, and not a formal research study, Institutional Review Board approval or research consent was not required.
\nThe strength screening was conducted through an objective physical capability evaluation (PCE™). The PCE is designed to measure the applicant’s isokinetic force generating capability (strength) of muscle groups based on the outcomes of a defensible job task analysis (JTA) [37]. The JTA was conducted according to guidelines of the Americans with Disabilities Act of 1990 (ADA) to determine the skills necessary to safely and effectively perform the essential functions associated with the nursing duties (e.g., lifting, carrying, bending, stooping, climbing, etc.). These validation studies were used to identify appropriate cut-off scores using the U.S. Department of Labor strength definitions for medium, heavy and very heavy job tasks [41]. It was determined that the “target score” for the nursing job category would be set at the medium strength level. The results of the JTA indicated that movement patterns of the major muscle groups involved with shoulder flexion and extension and knee flexion and extension were critical to safely performing the essential functions of the nursing jobs.
\nThe PCE testing was conducted in the Occupational Medicine department, in a controlled environment using isokinetic equipment and a standardized testing process (tested at 60 degrees per second, two sets of five repetitions flexion and extension for knees and shoulders) administered by trained professionals [38]. To improve reliability of the measure, health system physical therapists and athletic instructors were trained and observed for proper technique administering the PCE, verifying that they completed the evaluation correctly. PCE results were collected at the time of conducting the assessment, and submitted to a centralized database for data interpretation. These objective evaluations were then interpreted by IPCS (a third party company). The interpretation included isokinetic measurements through:
a force curve analysis in which the applicant’s force curves generated were compared to an unmatched normative force curve derived from nearly 500,000 normative curves in the existing database;
a body muscle symmetry analysis which involved comparing the applicant’s right and left shoulder and knee scores, agonist to antagonist muscle groups and upper and lower body scores to a normative database consisting of more than 500,000 normative symmetry scores;
assessing the applicant’s strength to body weight ratio score.
The screening took approximately 30 minutes to complete per applicant.
\nPCE data were analyzed based on proprietary algorithms, and scores were electronically returned to Human Resources through summary reports [37]. An applicant was recommended for hire if the PCE strength screening score was equal to or greater than the “target score”.
\nMedical claims cost data for the first 12-months of employment were obtained for each annual cohort from the employer-sponsored health plan. The analyses include data for all newly hired nurses that have 12-months of continuous enrollment in the employer-sponsored health plan after their hire date.
\nTotal annual and per employee per month (PEPM) paid medical costs were calculated for nurses hired in each of the three years prior to initiation of the PCE (2008–2010), as well as for nurses hired after the PCE program was initiated (2011–2017).
\nOf the 16,113 nurses who were included in this study, 85% were females and 15% were males. There were no refusals to take the physical capability screening.
\n\nTable 3 shows the number of eligible nurses hired in each group. There were 2481 eligible nurses hired in 2008–2010 in the Historical Comparison Group, and 13,632 eligible nurses in the PCE Group. The total member months for the Historical Comparison Group was 15,788 months, and for the PCE™ Group the total was 34,102 as shown in Table 3.
\n\n | Historical group | \nPCE group | \n
---|---|---|
Number Hired | \n2481 | \n13,632 | \n
Number Medical Claims | \n1425 | \n3869 | \n
Number Member Months | \n15,788 | \n34,102 | \n
The number of new hires, medical claims and member months for each group.
\nFigure 5 shows what percent of the new hires had medical claims for each group. The Historical group had significantly higher percentage of claims for those hired (57.4%) compared to those hired in the PCE group (28.4%).
\nPercentage of claims for each group based on number of new hires.
As shown in Table 4, the difference for Average Medical Paid and the PEPM between the Historical Comparison Group and the PCE™ Group is $882 and $77.07, respectively. Due to unequal sample sizes and unequal variances, the Kolmogorov–Smirnov Test was used to test for significance between the Historical Comparison Group and the PCE Group.
\n\n | Average Medical Claim Cost Mean ± SD | \nPer Empl Per Month Mean ± SD | \nKolmogorov–Smirnov Test | \n
---|---|---|---|
Historical Group | \n$2878 ± 6930.73 | \n$239.80 ± 577.49 | \n<.001 | \n
PCE Group | \n$1996 ± 4836.42 | \n$165.73 ± 399.53 | \n<.001 | \n
Comparing average medical claim and PEPM costs between historical and PCE groups (means ± SD).
The costs to implement the PCE™ program for 2011–2017 were $1,192,672. To calculate the savings for medical claim costs, the average claim cost for Historical group was multiplied by the number of new hires for the PCE group (13,632) times the percentage of new hire applicants that had a claim for the Historical group (57.4%) which is $22,519,682 (Table 5). The actual medical claim cost for the PCE group was $7,722,524. The combination of a smaller percentage of claims for the PCE group along with the lower average medical claim cost resulted in $14,797,158 in savings between 2011 and 2017 (Table 5). The return on investment for the program was $12.41.
\n\n | Total Medical Costs | \n
---|---|
No PCE | \n$22,519,682 | \n
W/PCE | \n$7,722,524 | \n
Savings | \n$14,797,158 | \n
Total savings resulting from the PCE program.
The combination of increased fat weight and loss of muscular strength results in a substantial decrease in the worker’s strength to body weight ratio (SBW). (A worker’s strength should be proportionate to his/her body weight.) It is clear that workers with a healthy strength to body weight ratio perform better, are safer and have fewer employee health claim costs. An analysis of the Cleveland Clinic SBW data shows that those nurses with the lower SBW scores (1st Quartile) medical costs were about 42% more compared to those nurses with a higher SBW score (4th Quartile) as shown in Figure 6. A non-parametric test computed the statistical differences between the four quartiles. A Kolmogorov–Smirnov Test was used to test for significance between the first and fourth quartile which was significant at the .001 level (Figure 6).
\nComparing medical claim costs for nurses based on quartile measures.
Those individuals in the lower quartile have either weak absolute strength and/or excess body weight compared to those who are in the upper quartile who have good absolute strength and a health body weight. The SBW is a good measure and predictor of health and injury risk. The SBW also shows the importance of maintain a healthy muscle mass and healthy body weight throughout life.
\nThe Cleveland Clinic study shows that it is possible to design a defensible strength test to be used in the selection process for physically demanding nursing jobs. This study shows the importance of physical strength specifically in the nursing profession. When a nurse’s physical capability is correctly matched to the physical demands of the job, a nurse can better meet the essential functions of the job and better serve patients. Also, the analysis of this study shows it is possible to hire through a work justified strength screening program a healthier worker who will have lower paid average medical and per employee per month costs in the first year of benefit eligibility. The results of this study support the premise that strength is a new vital sign of workplace health.
\nAs automation continues to improve in the workplace and with fewer physically demanding jobs, the industrial worker will need to rely on means other than work to maintain a healthy and strong muscle mass. Without a resistance training intervention, the worker will continue to become weaker and heavier putting the worker at greater risk for injury and disease. This will lead to greater costs and absenteeism. How much of a responsibility will the employer have in providing such intervention programs remains to be seen. The intervention could be in short durations (10 minutes) several times a day at the workplace or providing some incentive to reimburse memberships at fitness centers. This is nothing new and it has not been very successful in the past. But making muscle health tied into a health/benefit deductible plan could improve participation rates in resistance training programs.
\nThe research is now clear that muscle strength is the new vital sign of the worker’s physical health. Musculo-skeletal health of the worker can be improved. When a worker maintains good muscular strength, the worker is more productive and has fewer medical claims.
\nThe authors declare no conflicts of interest with respect to research, authorship and/or publication of this article.
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\n\nIn other words, publishing with IntechOpen guarantees compliance.
\n\nRead more about Open Access in Horizon 2020 here.
\n\nWhich scientific publication to choose?
\n\nWhen choosing a publication, Horizon 2020 grant recipients are encouraged to provide open access to various types of scientific publications including monographs, edited books and conference proceedings.
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