Nonmotor signs and symptoms of Parkinson’s disease [23, 24, 25].
\r\n\tEwing's sarcoma (ES) is a highly malignant tumor of children and young adults. The specific and accurate diagnosis of the Ewing sarcoma is challenging with routine hematoxylin-eosin sections. The age of the patient, the site involved, the radiologic findings, and the histological features are all individually invaluable for determining the diagnosis. However, immunohistochemistry, FISH , RT-PCR technologies and immunophenotyping, contribute to the objectivity in the correct diagnosis and prognosis. Clinical, histopathological and molecular diagnoses are addressed, and tumor histopathology is employed as the basis of treatment recommendations including surgery, radiation therapy, systemic therapy and novel therapeutics. Modern therapy for Ewing's sarcoma combines high-dose chemotherapy for systemic control of disease, with advanced surgical and/or radiation therapeutic approaches for local control. The identification of new targets for innovative therapeutic approaches is, therefore, strongly needed for its treatment. Many new pharmaceutical agents will be discussed in early phases of clinical trials in ES patients who have recurrent disease. Discussion of the agents led to partial response or stable disease, the percentages of drugs eliciting responses or causing an overall effect will take place. Some of the topics addressed are advances in future therapy, new target therapies, cytokine therapies and natural killer cells.
",isbn:null,printIsbn:"979-953-307-X-X",pdfIsbn:null,doi:null,price:0,priceEur:null,priceUsd:null,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"66703c47842d55d528eebd0a8601c5d9",bookSignature:"Prof. Gamal Abdul Hamid",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/8320.jpg",keywords:"Ewing Sarcoma Epidemiology, Ewing Sarcoma Pathogenesis, Ewing Sarcoma Pathology, Ewing Sarcoma Histopathology, ES Diagnostic Strategies, Ewing Sarcoma Therapy, Cancer Stem Cell, Ewing Sarcoma Radiotherapy, Ewing Sarcoma Surgery, Local Control, Tumor Burden, Target Therapy",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 16th 2018",dateEndSecondStepPublish:"November 6th 2018",dateEndThirdStepPublish:"January 5th 2019",dateEndFourthStepPublish:"March 26th 2019",dateEndFifthStepPublish:"May 25th 2019",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"4 years",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"36487",title:"Prof.",name:"Gamal",middleName:null,surname:"Abdul Hamid",slug:"gamal-abdul-hamid",fullName:"Gamal Abdul Hamid",profilePictureURL:"https://mts.intechopen.com/storage/users/36487/images/system/36487.jfif",biography:"Prof Dr med Gamal Abdul Hamid received his German board in internal medicine and PhD in Hematology-oncology from Faculty of Medicine (Caral Gustav Carus), University of Dresden, during the period of 1987- 1993. 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It is neuropathologically characterized by nigrostriatal cell loss and the presence of intracellular a-synuclein-positive inclusions called Lewy bodies [3].
\nIt is the most common movement disorder with approximately 1–2% of the population over 65 years of age suffering from PD. This percentage increases in people of 85 years of age and older, about 3–5% [3]. According to the World Health Organization, 6.1 million individuals have Parkinson’s disease globally [4]. Some authors have shown that the burden of Parkinson’s disease has more than doubled over 26 years worldwide, from 2.5 million patients in 1990 to 6.1 million patients in 2016. So, we can expect that the trend will continue in the next 30 years having approximately more than 12 million individuals suffering from PD [5]. In 2016, there were 211,296 estimated deaths caused by Parkinson’s disease [4].
\nPD is characterized mainly by four motor symptoms: resting tremor, bradykinesia, rigidity, and postural instability [1] with balance decrements and gait disruption [2]. It may present problems in performing personal activities of daily living, such as eating, drinking, cutting food, walking in the neighborhood, and writing [6].
\nThe diagnosis of PD is based on medical history and a neurological examination since there are no blood tests, laboratory tests, or imaging examinations that have been proven to help in diagnosing PD [7], and its treatment is based on a pharmacological approach. The main therapy is based on levodopa and dopamine agonists and is very successful in the early stages of the disease, when dopaminergic symptoms and signs are predominant and long-term motor complications still have not developed [8].
\nThe traditional classification and disease progression of Parkinson’s disease (PD) orient toward disease milestones that can be most obviously followed along motor domains. However, diverse nonmotor domains, quality of life, psychosocial burden, and stigma have been used as important domains for the course of PD and the outcome parameters of clinical trials [9].
\nAt present, there is no cure for PD, but a variety of medications provide relief from the symptoms. Individuals who are affected usually are given levodopa combined with carbidopa. Levodopa helps in at least three-quarters of Parkinsonian cases; however, not all symptoms respond equally to the drug. Bradykinesia and rigidity respond best, while tremor may be only marginally reduced. Problems with balance and other symptoms may not be alleviated at all [7].
\nIn this scenario, physiotherapy has a significant importance in a multidisciplinary team focused on the rehabilitation of individuals with PD, with the purpose of maximizing functional ability and minimizing secondary complications through movement rehabilitation within a context of education and to support the person as a whole [10].
\nThe main focuses of physiotherapy for individuals with PD are transfers, posture, upper limb function, balance (and falls), gait, and physical capacity and activity. Physiotherapy also uses cueing strategies, cognitive movement strategies, and exercises to maintain or to increase independence, safety, and quality of life. The traditional and new strategies will be addressed in this chapter [10].
\nPhysiologically, the symptoms associated with Parkinson’s disease are the result of the loss of a number of neurotransmitters, most notably dopamine. It is characterized neuropathological by nigrostriatal cell loss and the presence of intracellular a-synuclein-positive inclusions called Lewy bodies [3, 11]. All these alterations change the function of the basal ganglia system, resulting in Parkinson’s main movement disorders.
\nCell loss in the substantia nigra occurs in a region-specific manner, with the lateral ventral tier of the pars compacta being most affected. It is estimated that at least 50% of the nigral neurons must degenerate to produce symptoms, and, at autopsy, most cases show more than 80% reduction [8].
\nThe basic basal ganglia circuitry and the balance between the direct and indirect striatal pathways provide a simple heuristic model for PD’s main signs. According to this model, the pathophysiological hallmark of PD, hypokinetic signs are the prevalence of the indirect pathway over the direct one, consequently, resulting in increased neuronal firing activity in the output nuclei of the basal ganglia and leading to excessive inhibition of thalamocortical and brainstem motor systems, interfering with normal speed of onset movement and execution. On the other hand, overactivity in the direct pathway and imbalance with the indirect one may cause reduced inhibitory basal ganglia output and result in reduced basal ganglia filtering and parallel facilitation of multiple movement fragments. (See \nFigure 1\n) [8].
\nA schematic view of the functional anatomy of the basal ganglia. There are the normal direct and indirect pathways (panel a) and the alteration of direct and indirect pathways in Parkinson’s disease (panel b). Modified from Magrinelli et al. [
Another important region that has been linked to physiopathology of PD is the cerebellum. Its reciprocal connections with basal ganglia, especially with striatum and external segment of the globus pallidus, strengthens the hypothesis that it plays a role in the pathogenesis of some PD symptoms and signs [8].
\nHistopathology alterations can be described in this pathophysiological situation. There usually can be seen some histological characteristics not just in nerve tissue. The most important marker is called Lewy bodies. They are made of a protein called alpha-synuclein, which, in a healthy brain, plays a number of important roles in neurons, especially at synapses [13].
\nLewy bodies can be found in many regions of the brain and some reports have suggested that the substantia nigra is not the first place where they form in Parkinson’s disease [14].
\nNeither cell loss nor the formation of Lewy bodies is absolutely specific for PD, but both are required for a diagnosis of PD under current definitions. Additionally, it’s necessary to consider that not all affected neurons in PD are dopaminergic. An example to be cited is the cholinergic neurons from the dorsal vagal nucleus. This variety of regions has been suggested to be responsible for the complex clinical picture in PD [13].
\nThis pathophysiological situation seems to be multifactorial. It can be considered by genetic factors, inflammation, immune response, and environmental elements [14].
\nWhile having a family member with PD may increase a person’s risk, PD is not normally considered a genetic disease. Variants in three genes (SNCA, UCHL 1, and LRRK 2) have been reported in familial PD. Mutations in three other genes (PARK 2, PARK 7, and PINK 1) have been found in sporadic PD [14, 15].
\nOn the other hand, large population studies have suggested that individuals taking nonsteroidal anti-inflammatory drugs (NSAIDs) have less risk of developing idiopathic PD, which suggests that anti-inflammatory drugs may be a promising disease-modifying treatment for Parkinsonian patients [16].
\nSome reports have provided direct evidence of interactions between α-synuclein and environmental agents. Some options described in the literature are heavy metals (iron, copper, manganese, lead, and mercury), pesticides (including insecticides and herbicides), and illicit substances (amphetamine, methamphetamine, and cocaine) [17].
\nIn a review, Di Monti et al. [18] describe some possibilities of multiple events and interactive mechanisms possibly responsible for alpha-synuclein alterations. These may include (i) the synergistic action of endogenous and exogenous toxins, (ii) the interactions of toxic agents with endogenous elements (e.g., the protein α-synuclein), (iii) the tissue response to an initial toxic insult, and (iv) the effects of environmental factors on the background of genetic predisposition and aging.
\nIt’s important to explain that the symptoms of Parkinson’s disease sometimes can be seen outside the disease itself. In these cases, we call this clinical condition of parkinsonism, also known as “atypical Parkinson’s,” “secondary Parkinson’s,” or “Parkinson’s syndrome.” Parkinsonism often has an identifiable cause, such as exposure to toxins, methamphetamine, trauma, multiple strokes, other nervous system disorders, or illness. Generally, Lewy bodies are not seen in parkinsonism [14].
\nThe three clinical motor cardinal signs of PD, a-/hypo-/bradykinesia, rest tremor, and rigidity, are directly related to the degeneration of dopaminergic neurons. However, other motor symptoms and signs, secondary to degeneration of nondopaminergic pathways, can be described such as loss of postural control, postural stability/balance, and gait disturbance. In addition, the most well-known nonmotor characteristic motor symptoms have also been described. There can be additional psychiatric and autonomic features found, as well as cognitive impairment, sleep disorders, olfactory dysfunction, and pain.
\n\n
A-/hypo-/bradykinesia: These terms are defined, collectively, as slowed voluntary movement. Separately, akinesia indicates the absence of voluntary movement, while hypokinesia means smaller movements, and bradykinesia refers to slowness of movement. They usually determine any impairment in fine motor movements, facial expression (hypomimia), monotonic and hypophonic speech with a reduction of speed, and general motion amplitude. This can have an important impact in functional skills like arm swinging when walking, raising from a chair, handwriting, and general gesturing [14, 19].
This cardinal sign is one of the best that emerges from its origin of dysfunction, which is cited in this chapter (see \nFigure 1\n). It has been determined especially by a characteristic involving the movement programming of the cerebral cortex, in particular the supplementary motor area [8, 19].
\nIt is possible to find two modulations of this cardinal sign of Parkinson’s disease: freezing phenomenon and kinesia paradoxa. In the first one, the individual presents a sudden and transient motor block, mainly in the lower limbs during walking. This may include start hesitation, hesitation, or inability to move through the presence of contradictory visual cues (floors with different colors and small steps), when there is a need to change direction of gait or be still in open spaces. The second one, kinesia paradoxa, occurs under certain emotional circumstances where the patient is able to exhibit a sudden brief period of mobility (walking or even running and catching a ball). This phenomenon shows that, even though individuals with Parkinson’s disease have their motor programs intact, the disease prevents them from accessing them in the correct way, requiring external stimuli for this to happen even if done poorly [19, 20].
2.
The pathophysiology of rest tremor is largely unknown. Clinical-pathological studies have demonstrated that patients with PD and prominent tremor have dysfunction of a subgroup of midbrain (A8) neurons and its magnitude seems to not be related to dopamine deficiency [8, 19].
3.
It is unclear how rigidity is associated with dopamine deficiency and basal ganglia dysfunction. Nevertheless, evidence suggests that this cardinal sign has its pathogenesis in the passive mechanical properties of joints, tendons, and muscles, and spinal and supraspinal reflexes, which together determine an increased response to peripheral stimulation and an increased muscle elongation response [8].
\n\n
\n
\n
One of the most important causes for these signs is the poor ability to integrate visual, vestibular, and proprioceptive inputs associated with a failure to activate central motor programs and their interaction with the mechanisms of sensitive feedback. Postural instability and gait disturbances have been associated with an akinetic-rigid syndrome, as well as an increased incidence of nonmotor features [8, 22].
3.
The current literature suggests there is a prodromal or premotor stage of Parkinson’s disease before the onset of motor symptoms. Nonmotor signs and symptoms of Parkinson’s disease include cognitive, neuropsychiatric, sleep, autonomic, and sensory dysfunctions, which are typically not treated by the dopaminergic therapy. Patients who go on to develop Parkinson’s disease commonly have experienced depression, constipation, anosmia, and rapid eye movement sleep behavior disorder in the years preceding their diagnosis. So, the presence of nonmotor features has contributed during the diagnosis process of Parkinson’s disease. However, if these nonmotor signs were not evaluated well enough during the diagnostic process, they may delay the diagnosis [23, 24].
\nMore specifically, there can be subtle cognitive deficits found affecting attentional, executive, visuospatial, and memory functions. Neuropsychiatric symptoms are also common and include depression, anxiety, apathy, and psychosis. Autonomic dysfunction can manifest as urinary frequency or urgency, constipation, orthostatic hypotension, drooling, erectile dysfunction, or abnormal sweating. These clinical manifestations can have a substantial impact on the patient’s quality of life [25]. We can see a long list of nonmotor signs and symptoms in \nTable 1\n.
\nNeuropsychiatric symptoms | \nDepression | \n
Dementia | \n|
Anxiety | \n|
Anhedonia | \n|
Apathy | \n|
Psychosis (hallucination and delusion) | \n|
Cognitive dysfunction | \n|
Attention deficit | \n|
Off-period–related panic attacks | \n|
Confusion | \n|
Sleep disorders | \nInsomnia | \n
Excessive daytime sleepiness | \n|
Nonrapid eye movement sleep-related movement disorders | \n|
Sleep-disordered breathing | \n|
Periodic limb movement disorder | \n|
Rapid eye movement sleep behavior disorder | \n|
Vivid dreaming | \n|
Restless legs syndrome | \n|
Autonomic symptoms | \nUrgency | \n
Frequency | \n|
Orthostatic hypotension | \n|
Nocturia | \n|
Erectile dysfunction | \n|
Sweating | \n|
Gastrointestinal symptoms | \nDribbling of saliva | \n
Ageusia | \n|
Nausea | \n|
Dysphagia | \n|
Reflux and vomiting | \n|
Constipation | \n|
Diarrhea | \n|
Fecal incontinence | \n|
Unsatisfactory voiding of bowel | \n|
Sensory symptoms | \nPrimary pain | \n
Secondary pain | \n|
Fluctuation-related pain | \n|
Paresthesia | \n|
Olfactory disturbance | \n|
Visual dysfunction | \n|
Other symptoms | \nFatigue | \n
Ankle swelling | \n|
Nonmotor fluctuations | \n|
Blurred vision | \n
Some of the most important nonmotor signs and symptoms for physiotherapists, which require special attention, are fatigue, pain, urinary bladder control, and anal sphincter control. We will discuss how physical therapy functions with these aspects of the disease later in this chapter.
\nDuring the diagnostic process of Parkinson’s disease, one of the first components to be established is the presence of “parkinsonism.” This clinical condition is established by the presence of the cardinal signs of the disease, of which bradykinesia is an indispensable criterion jointly with one of the other two signs [25], associated and exclusionary symptoms, atypical features in the history and on examination, and response to levodopa.
\nThe presence of nonmotor features is important, as these may be prominent even early in the disease’s course. Some diagnostic criteria have been developed by some organizations like the UK Parkinson’s Disease Society Brain Bank, the National Institute of Neurological Disorders and the Stroke (NINDS), and Movement Disorder Society. All of them ask for the presence of the cardinal signs, the application of exclusion criteria and some supportive criteria [25, 26]. They can be consulted in \nTable 2\n.
\n\n | United Kingdom Parkinson’s Disease Society Brain Bank’s | \nNational Institute of Neurological Disorders and Stroke (NINDS) | \nMovement Disorder Society | \n
---|---|---|---|
Step 1 | \n\n | Group A features (characteristic of Parkinson’s disease) | \n1. Diagnosis of parkinsonism | \n
\n | Bradykinesia | \nResting tremor | \n\n
| \n
\n | At least one of the following criteria: | \nRigidity | \n\n
| \n
\n | Rigidity | \nAsymmetric onset | \n\n
| \n
\n | 4–6 Hz rest tremor | \nGroup B features (suggestive of alternative diagnoses) | \n2. Exclusion criteria | \n
\n | Postural instability not caused by primary visual, vestibular, cerebellar, or proprioceptive dysfunction | \nFeatures unusual early in the clinical course | \n\n
| \n
Step 2 | \n\n | Prominent postural instability in the first 3 years after symptom onset | \n\n
| \n
\n | Exclude other causes of parkinsonism | \nFreezing phenomenon in the first 3 years | \n\n
| \n
Step 3 | \n\n | Hallucinations unrelated to medications in the first 3 years | \n\n
| \n
\n | At least one of the following supportive (prospective) criteria: | \nDementia preceding motor symptoms or in the first year | \n\n
| \n
\n | Unilateral onset | \nSupranuclear gaze palsy (other than restriction of upward gaze) or slowing of vertical saccades | \n\n
| \n
\n | Rest tremor | \nSevere, symptomatic dysautonomia unrelated to medications | \n\n
| \n
\n | Progressive disorder | \nDocumentation of condition known to produce parkinsonism and plausibly connected to the patient’s symptoms (such as suitably located focal brain lesions or neuroleptic use within the past 6 months) | \n\n
| \n
\n | Persistent asymmetry primarily affecting side of onset | \nCriteria for definite Parkinson’s disease | \n\n
| \n
\n | Excellent response (70–100%) to levodopa | \nAll criteria for probable Parkinson’s are met and | \n3. Supportive criteria | \n
\n | Severe levodopa-induced chorea (dyskinesia) | \nHistopathological confirmation of the diagnosis is obtained at autopsy | \n\n
| \n
\n | Levodopa response for 5 years or more | \nCriteria for probable PD | \n\n
| \n
\n | Clinical course of 10 years or more | \nAt least three of the four features in group A are present and | \n\n
| \n
\n | \n | None of the features in group B is present (note: symptom duration ≥ 3 years is necessary to meet this requirement) and | \n\n
| \n
\n | \n | Substantial and sustained response to levodopa or a dopamine agonist has been documented | \n4. Red flags | \n
\n | \n | Criteria for possible Parkinson’s disease | \n\n
| \n
\n | \n | At least two of the four features in group A are present; at least one of these is tremor or bradykinesia and | \n\n
| \n
\n | \n | Either none of the features in group B is present or symptoms have been present ≤ 3 years and none of the features in group B is present and | \n\n
| \n
\n | \n | Either substantial and sustained response to levodopa or a dopamine agonist has been documented or the patient has not had an adequate trial of levodopa or a dopamine agonist | \n\n
| \n
\n | \n | \n | \n
| \n
\n | \n | \n | \n
| \n
\n | \n | \n | \n
| \n
\n | \n | \n | \n
| \n
\n | \n | \n | \n
| \n
\n | \n | \n | \n
| \n
\n | \n | \n | For the diagnosis of clinically established Parkinson’s disease | \n
\n | \n | \n | \n
| \n
\n | \n | \n | \n
| \n
\n | \n | \n | \n
| \n
\n | \n | \n | For the diagnosis of clinically probable Parkinson’s disease | \n
\n | \n | \n | \n
| \n
\n | \n | \n | \n
| \n
\n | \n | \n | \n
| \n
Options of diagnostic criteria for Parkinson’s disease.
However, the reliability and validity of them have not been clearly established. In this way, it is common to have a misdiagnosis of Parkinson’s disease. The most common causes of misdiagnosis that are described in literature are Alzheimer’s disease, essential tremor, and vascular parkinsonism. It should be remembered that rigidity, bradykinesia, and gait disturbance can be found during normal aging period or can be determined by other medical conditions of aging [25, 27, 28].
\nA rating scale is a means of providing information on a particular feature by assigning a value to it. Parkinson’s rating scales are a means of assessing the symptoms of the condition. They provide information on the course of the condition and/or assess quality of life. They may also help to evaluate treatment and management strategies, which can be useful to researchers, medical doctors, physiotherapists, and other healthcare professionals, as well as to people with Parkinson’s and their caregivers [29].
\nIn Parkinson’s disease, there are a number of rating scales used. Often, more than one scale is used to give a broader picture of symptoms. The most important and used rating scale for this disease is the Unified Parkinson’s Disease Rating Scale (UPDRS). The scale has three sections that evaluate key areas of disability, together with a fourth section that evaluates any complications of treatment, as shown below:
\nPart 1: Nonmotor experiences of daily living
\nPart 2: Motor experiences of daily living
\nPart 3: Motor examination
\nPart 4: Motor complications
\nThe UPDRS features sections that require independent completion by people affected by Parkinson’s and their caregivers, and sections to be completed by the clinician. The UPDRS is often used with two other Parkinson’s rating scales: The Hoehn and Yahr, and the Schwab and England Activities of Daily Living (ADL) scales [20, 30].
\nIn \nTable 3\n, there is a list of rating scales available and recommended by the European Parkinson’s Disease Association and by the International Parkinson and Movement Disorder Society [29, 30].
\nMDS-owned rating scales | \nThe European Parkinson’s Disease Association (EPDA) | \n
---|---|
Global assessment scale for Wilson’s disease | \nUnified Parkinson\'s disease rating scale (UPDRS) | \n
Global dystonia scale | \nHoehn and Yahr scale | \n
MDS-unified Parkinson’s disease rating scale (MDS-UPDRS) | \nSchwab and England activities of daily living (ADL) scale | \n
Modified bradykinesia rating scale | \nPDQ-39 | \n
Nonmotor symptoms scale (NMSS) | \nPD NMS questionnaire | \n
Nonmotor symptoms questionnaire (NMSQ) | \nNMS survey | \n
PKAN disease rating scale (PKAN-DRS) | \nParkinson’s disease composite scale | \n
Quality of life essential tremor questionnaire | \nKing\'s PD pain scale | \n
Rating scale for psychogenic movement disorders | \nParkinson\'s disease sleep scale‑PDSS-2 | \n
Rush dyskinesia rating scale | \nLindop Parkinson\'s assessment scale | \n
Rush video-based tic rating scale | \nShort-form 36 (SF-36) | \n
UFMG Sydenham\'s Chorea Rating Scale (USCRS) | \nSickness impact profile (SIP) | \n
Unified dyskinesia rating scale (UDysRS) | \nMini-mental state examination (MMSE) | \n
Unified dystonia rating scale (UDRS) | \nMontreal cognitive assessment scale (MoCa) | \n
Unified multiple system atrophy rating scale (UMSARS) | \nCaregiver strain index (CSI) | \n
It is important to note that many of these scales and questionnaires are owned and licensed by some organization. Hence, it is necessary to require a rating scales permission request form before working with them.
\nIn a nonclinical way, Braak and coworkers [31] proposed staging procedures of the pathology of Parkinson’s disease, based on central nervous system involvement. Their proposal has six stages:
\nStage 1: Premotor period in which typical pathological changes, Lewy neurites, and Lewy bodies spread from the olfactory bulb and vagus nerve to lower brainstem regions (medulla oblongata and pontine tegmentum).
\nStage 2: Additional lesions in the raphe nuclei and gigantocellular reticular nucleus of the medulla oblongata, locus coeruleus in the pontine tegmentum.
\nStage 3: The symptomatic period when pathological changes involve the midbrain including substantia nigra pars compacta, basal nuclei of Meynert. Structures affected in stages 1 and 2 develop more Lewy bodies.
\nStage 4: Severe dopaminergic cell destruction in the pars compacta with additional mesocortex and allocortex involvement, especially seen in amygdala and subnuclei of the thalamus.
\nStage 5: There are initial changes in neocortex (cortical lobes). Cellular death can be seen in the substantia nigra, the dorsal motor nucleus of the vagus nerve, the gigantocellular reticular nucleus, and the locus coeruleus.
\nStage 6: Neocortex entirely affected (motor and sensory areas).
\nThis kind of rate is totally based on histological development of the disease. It is important to remember that, historically, the definitive diagnosis of Parkinson’s disease is closed in a postmortem autopsy [32].
\n\n
Among them, the most used in clinical practice is levodopa or levodopa plus dopa-decarboxylase inhibitors (DDC-I), designed to replace the dopamine in the depleted striatum, undoubtedly, the most efficient medication for Parkinson’s disease [33]. They improve motor functions in a cyclic way during the day period. When they reduce the motor impairment, the period is called “on time.” When the motor signs and symptoms start to return, the period is called “off time” or “wearing-off period.” However, during the “wearing-off period,” symptoms may not be related only to movement. It is also usual for patients to report increased anxiety, fatigue, mood changes, difficulty thinking, restlessness, and sweating [29].
\nInitially, levodopa offers a stable alleviation of PD symptoms so it is usual for it to be offered in low doses, being well-tolerated by patients. This period of treatment is called the “honeymoon.” However, as the disease becomes more advanced, the effect of the drug usually wears off quickly, and an increased frequency of dosing is often required. This marks the end of the “honeymoon” period. After some years (4–6 years), patients begin to experience, most strikingly, its intense side effects [33, 34].
\nThese long-term complications included many kinds of motor fluctuations. In addition to the on-off phenomenon, already described above, the patients may also experience delay on, when medication takes a longer period to take its effect; freezing phenomenon, which was already discussed during the motor signs presentation; and dyskinesia, which is determined by the presence of hyperkinetic involuntary movements, including twitches, jerking, twisting, or simple restlessness but no tremor, occurring when the drug is at its peak dose, during the wearing-off period or even during off-periods of the medication [29, 34]. Several new formulations of levodopa have been developed to provide a more stable levodopa plasma concentration, reducing some of the side effects, including dyskinesia. Among them, as aforementioned is a levodopa/carbidopa combination [33].
\nOther drugs on treatment of motor signs are dopaminergic agonists, amantadine, dopamine receptor agonists, catechol-O-methyltransferase (COMT), and monoaminoxidase (MAO) inhibitors. Recently, new pharmacological treatment has been studied such as the use of cannabis (to reduce mainly the three cardinal signs) and the angiotensin IV ligand-based compound, which influences motor and nonmotor signs (memory) [33].
\nSince Parkinson’s disease is not considered a pure movement disorder anymore, the treatment of nonmotor signs and symptoms is justified. However, the treatment of nonmotor symptoms is still an unsatisfactory field for patients and their families [35]. A cholinesterase inhibitor has been used for dementia treatment, while noradrenergic medications (like tricyclic antidepressants) have shown some effect in depression and serotoninergic agonists (like clozapine) in psychosis. Amantadine is used with some success in the management of levodopa-induced dyskinesia. For autonomic dysfunction, there are many options such as mineralocorticoid, fludrocortisone and adrenergic agents, the noradrenaline precursor for orthostatic hypotension, antimuscarinics for urinary urgency or incontinence, and prokinetic drugs to treat constipation [35].
\n\n
The technological advances in the area of medicine have led to the development of a new kind and nonablative surgical procedure: deep brain stimulation (DBS). It involves sending electrical impulses to certain parts of the brain by a neurostimulator device that is a brain implant known as a ‘brain pacemaker.’ The general procedure of this surgery is an intracranial electrode precisely implanted in the target area (see \nTable 4\n), followed by implantation of lead extension wires that connect the intracranial leads to a power-generating and programming source and, then finally, the implantation of an internal pulse generator (\nFigure 2\n). The main target areas can be seen in \nTable 4\n such as the signs/symptoms that are most prominently modulated by DBS [36, 38]. When PD symptoms are very severe and medications cannot moderate them, surgery and deep brain stimulation can be considered as the final options of treatment.
\nTypical deep brain stimulation setup. The electrode is placed in the brain and connected to a brain pacemaker permanently placed under the skin of the chest. Source: Shamir et al. [
\n
Physical therapy shows a number of different strategies that has been frequently used in rehabilitation of Parkinson’s disease patients, having the most important goal to enhance the quality of life of these individuals.
\nPhysiotherapists are members within a multiprofessional team, which has the purpose of maximizing functions and abilities and minimizing secondary complications of several diseases. They use movement rehabilitation within a context of education and support for the person as a whole. In patients with Parkinson’s disease, physical therapy focuses on many functions such as transfer, posture, balance improvement and fall prevention, gait, upper limb functions, and physical capacity (including cardiorespiratory capacity) essential to carry out activities of daily life. All of these goals, worked together with cueing strategies, cognitive movement and exercises, increased independence, and safety, as a consequence, improve quality of life [10].
\nSome evidence presented in the literature supported that therapeutic exercises applied in individuals with Parkinson’s disease were effective in improving both the motor and nonmotor impairments [39, 40]. This improvement may be linked to a number of plasticity-related physiological events including synaptogenesis, angiogenesis, and neurogenesis. This process can be mediated by use-dependent expression of endogenous neurotrophic factors. In an unedited systematic review and meta-analysis, Hirsch and his coworkers show aggregated evidence that physical exercise training increases brain-derived neurotrophic factor (BDNF) blood levels in individuals with Parkinson’s disease. This BDNF increase results in concomitant reduction in motor signs and symptoms, measured by UPDRS, confirming possible effects on dopaminergic pathways [41].
\nTogether with neuroplasticity, there is some evidence pointing to the participation of motor modules (coordinated patterns of muscle activity that combine to produce functional motor behaviors) like a physiological theory for good results of physical therapy in Parkinson’s disease. For this purpose, it is proposed to consider five neuromechanical principles: motor abundance, which means that for any given task, many equivalent motor solutions are possible; motor structure, which means that motor modules reflect biomechanical task relevance; motor variability, which means that variations on motor modules are higher as much as the motor output is lower; individuality, which means that different motor repertory must be considered among different individuals; and multifunctionality, which means that muscle activity can generate a large number of different actions. It is important to emphasize that in Parkinson’s disease the basal ganglia dysfunction supposedly leads to inappropriate selection of motor modules [8].
\nIt is still important to remember that motor rehabilitation is a motor relearning practice and training where it is essential to reacquire motor skills. Although individuals with Parkinson’s disease show preserved motor learning abilities, the basal ganglia dysfunction may impair the consolidation of them. Therefore, the basic rules of neural plasticity practice must be used to be successful in the rehabilitation process. It includes intensity, repetition, specificity, difficulty, and complexity of practice [8, 42].
\nSeveral rehabilitative approaches have been proposed in Parkinson’s disease.
\nIn the last two decades, exercise, such as resistance training, has shown to be beneficial for the improvement of both motor and nonmotor signs and symptoms. It increases low strength determined by hypokinesia and disuse, besides playing a neuroprotective effect in individuals with Parkinson’s disease. Its effect is probably determined by an increase of mitochondrial respiration and of neuroplasticity mechanisms, improving the recruitment of motor unit and generating selective activation of the muscles [14, 43, 44].
\nHowever, there is no consensus about the parameters for resistance training prescription for individuals who have Parkinson’s disease [43]. In a systematic review and meta-analysis, Saltychev and his coworkers [45] concluded that there is no evidence on the superiority of progressive resistance training compared with other treatments to support the use of this approach in rehabilitation procedures.
\nOn the contrary, it is possible to find successful directions to use this therapeutic strategy in rehabilitation of individuals with Parkinson’s disease from other systematic reviews, meta-analysis, and clinical research. Studies shows that low (2 times per week over 12 weeks) to moderate (2–3 times per week over 8–10 weeks) intensity resistance training appears to be effective in people with early, mild-to-moderate Parkinson’s disease. They still show that this specific approach resulted in gaining muscle strength, balance, Parkinson’s motor symptoms, and quality of life, with low or no improvement in gait performance, freezing phenomenon, and the number of falls [43, 44, 46, 47]. The load of the exercises can be chosen using the test of maximal strength (1-RM). The number of sets may vary between 2 and 3 during initial periods. The retest of 1-RM can provide additional information to adjust the load and sets along the rehabilitation period. The resting time between the sets can be controlled by cardiovascular parameters and can vary from 30 seconds up to 3 or 4 minutes [43, 44].
\nThere are numerous ways to work with resistance training, and it is up to the physiotherapists to choose the most appropriate one for the individual under their care. In resistance training, the following examples of exercises can be used: bench press, lat pulldown, military press, seated row, leg 45o, barbell squat, leg curl, leg extension, calf raises, lower abdominal exercises, and manual or external (theraband, barbell, ankle-weight, and pulley system) resistance in active movement. Treadmill and bicycle intervention can be used when performing against resistance [43, 44, 45, 47]. Da Silva and her coworkers [48] suggest a long-term effect in nonmotor signs and symptoms of Parkinson’s disease, especially in cognitive aspects, in individuals performing treadmill training, just as Ferreira and her coworkers [49] showed that resistance training was an effective intervention in the reduction of anxiety symptoms and improved the quality of life in this population.
\nEven if the treatment of Parkinson’s disease tremor focuses on medication, and there is indication to deep brain stimulation for those patients with tremor recalcitrant using oral medication, electrotherapy has been shown to be beneficial to control this special cardinal sign.
\nFew studies have been performed to provide further evidence on the effects of electrotherapy on Parkinson’s tremor reduction. The theory supporting the use of this strategy is based on evidence revealing that propriospinal neurons in the C3–4 spinal cord mediate voluntary commands from the motor cortex (in Parkinson’s disease, these commands are oscillating and give rise to resting tremor) and project directly to forelimb motor neurons. This proposal assumes the importance of propriospinal neurons to interfere in tremor signal transmission, especially because there are a rich variety of afferents, including cutaneous afferents [6].
\nBased on this concept, Xu and coworkers [50] hypothesize that cutaneous afferents evoked by surface stimulation could produce an inhibitory effect on propriospinal neurons, which in turn could suppress tremor signals passing through the propriospinal neurons.
\nAdditionally, evidence shows benefits of electrical stimulation, especially when applied to the superficial cutaneous radial nerve area, in reduction refractory resting tremor. This effect is possibly mediated by cutaneous reflex via premotor neuron interneurons, through a disynaptic inhibitory postsynaptic potential. Some initial research was performed to confirm this theory using transcutaneous electrical nerve stimulation (TENS), with good results [6, 52]. The position of the electrodes can be verified in \nFigure 3\n.
\nUse of transcutaneous electrical nerve stimulation to reduce resting tremor in Parkinson’s disease. The figure brings cutaneous superficial radial nerve area and electrodes position for transcutaneous electrical nerve stimulation (TENS). Source: Modified from Gray [
The parameters used for TENS stimulation were 200 μs pulse width at 250 Hz pulse frequency. The pulse amplitude of stimuli must be adjusted during the stimulation period. First, it is necessary to discover the radiating threshold of the patient. It occurs when the patient refers to a radiating sensation, such as a paresthesia, running from the dorsal skin to the fingers. This radiating threshold has been used as a sensory marker because it indicates that the superficial radial nerve is actually activated by electrical stimulation. After detecting the radiating threshold, the intensity of electrical stimulation must be adjusted to 1.5–1.75 times radiating threshold to produce better effects on tremor control [6].
\nNowadays, researchers have been studying a way to detect the tremors and control them simultaneously and automatically by electrostimulation. They already developed and tested a closed-loop system for tremor suppression by transcutaneous electrical nerve stimulation (TENS) using EMGs of the forearm muscles. Through this record, when a tremor is detected, a command signal triggers a stimulator to output TENS pulses to a pair of surface electrodes positioned just as described in \nFigure 3\n. The preliminary results showed that a closed-loop system can detect tremor properly and suppress significantly the tremor, by electrical stimulation of cutaneous afferents, in Parkinson’s disease patients. Within this new concept, a tremor’s glove was developed reaching also good results [50, 51, 52].
\nIt’s known that aerobic exercises can reduce inflammation, suppress oxidative stress, and stabilize calcium homeostasis in the brain. So, it has been prescribed as an important activity for the elderly. The form of aerobic exercise used may be adapted to the capability of the individual. In individuals with Parkinson’s disease, these exercises show important functions, once they can trigger plasticity-related changes, including synaptogenesis, enhanced glucose utilization, and neurogenesis [2, 53].
\nIn general, aerobic training has been reported to improve both motor and nonmotor signs and symptoms of Parkinson’s disease. The motor effects are extensively known and have been studied the most so far, showing the most unequivocal benefits on health across the life span. Furthermore, the neural mechanisms involving dopaminergic pathways are studied and suggest a significant preservation of nigrostriatal neuronal connections as well as striatal dopamine levels in experimental models. As a result, exercise-dependent plasticity following aerobic exercises acts on the brain in a similar manner as dopaminergic-derived treatments, using the same pathways to produce symptomatic relief [54].
\nIn nonmotor signs and symptoms, aerobic training promotes positive and significant effects on global cognitive function, processing speed, sustained attention and mental flexibility, memory, and mood disorder aspects (anxiety and depression) in patients who are considered in a moderate stage of Parkinson’s disease [49]. In sleep disorder, present in Parkinson’s disease, aerobic exercise has been shown to have small-to-moderate effects. The mechanism involved in these effects evolved increased dopaminergic signaling and a wide variety of effects on nondopaminergic neurotransmitter systems, including serotonergic, noradrenergic, and GABAergic systems, which is relevant for depression, anxiety, and sleep [53, 54].
\nThe most common and studied form of aerobic training is using a treadmill. In some systematic reviews, the majority of articles considered in analyses use treadmills for aerobic training. This approach can be used with or without a body-weight-support system, depending on the motor difficulties of the individual with Parkinson’s disease. It may be related with improvement in motor signs like motor action, balance, and gait, although the evidence is not so strong [2, 48].
\nIn the same way, free walking and Nordic walking (a total body version of walking performed with specially designed walking poles similar to ski poles) also have good effects on motor and nonmotor domains of Parkinson’s disease and must be stimulated and used in physical therapy practice in rehabilitation of individuals with Parkinson’s disease [55].
\nSimilar to the aerobic training used on the treadmill, moderate intensity of interval training for cycling has shown several beneficial effects on the DA-dependent motor and nonmotor signs that compromise Parkinson’s disease patients. Researchers have reported improvement on bimanual motor control, automatic interlimb coordination, executive functions, and neurological (UPDRS) symptoms [56].
\nAn interval protocol template that can be used can be the following: from 8 to 12 weeks of training, 3 times per week, 1-hour session training with 10 minutes of warm-up, 40 minutes of aerobic training, and 10 minutes of cooldown). During the 40 minutes of aerobic training, the patient can perform 8 sets of 3 minutes of cycling or treadmill at 60–80 rpms and 2 minutes of less than 60 rpms. The heart rate also can be used as a parameter to improve effort during the training period. Hence, the physiotherapist may adjust the resistance to ensure the patient is cycling at 60–75% of his/her maximal heart rate. This effort can increase gradually during the training period [56]. A guideline with some exercise modes to be used in Parkinson’s disease was provided by Meng and coworkers in a systematic review and meta-analysis [57].
\nOther forms of aerobic exercises have been stimulated in the rehabilitation process in Parkinson’s disease. Several data have shown that dance can provide increased activation of the reward system, determining better mood aspects in people. In patients with Parkinson’s disease, practicing dance has induced better responses and a substantial relevant improvement in motor symptoms (such as static and dynamic balance, freezing phenomenon, and gait) and functional mobility. This improvement determines also a better quality of life in performers. It probably occurs because rhythmic stimulation leads to time-perception compensation due to the synchronization of movement with rhythm [58, 59].
\nTo get these effects, a dance program must include visual and auditory cues, rhythm tasks, and recreational activities that motivate socialization. Another important aspect is to reach the ideal heart rate during practice, just as discussed previously in the aerobic training protocol [58].
\nOriental martial arts, such as tai chi, have been successfully used in treatment of individuals with Parkinson’s disease. Tai chi combines deep breathing and slow movements and studies have provided moderate evidence that tai chi improves balance and functional mobility, reducing the number of falls, but with no significant effect in gait velocity, step length, and gait endurance improvement [33, 60, 61]. A systematic review and meta-analysis showed that tai chi, plus medication, showed greater gains than medication alone or another therapy plus medication in motor function and balance. Presumably, these gains were due to the development of new motor programs, which allow faster reactions responding to postural challenge promoting better behavioral recovery through new synaptic connections [62]. It is necessary to know and practice this technique before using it on patients.
\nThe aim of the multimodal exercise program is to develop the patients’ functional capacity, cognitive functions, posture, and locomotion. It’s comprised of a variety of activities that simultaneously focus on the components of functional capacity, such as muscular resistance, motor coordination, and balance [14]. It’s a 6-month program, performed 3 times per week, 1 hour per session. Each session consists of five parts (warm-up, pre-exercise stretching, the exercise session, the cooldown, and postexercise stretching). The program is divided into six phases with different uses of coordination, muscular resistance, and balance strategies [63, 64]. A description of each phase can be seen in \nTable 5\n.
\n\nSubthalamic nucleus | \nDisabling motor symptoms | \n
Dyskinesia | \n|
Motor fluctuations | \n|
Globus pallidus internus | \nImprovement of motor symptoms in general | \n
Ventral intermediate thalamic nucleus | \nTremor | \n
Pedunculopontine nucleus | \nGait instability | \n
Gait freezing phenomenon | \n
Main target areas for deep brain stimulation (DBS) in Parkinson’s disease.
Note: Based on Dallapiazza et al [36].
Phases | \nCapacities | \n||
---|---|---|---|
Coordination | \nMuscular resistance | \nBalance | \n|
Phase 1 | \nUpper and lower limb movements. | \nExercises without weights. | \nRecreational activities that stimulated the vestibular system. | \n
Phase 2 | \nTrunk movements were added to upper and lower limb movements. | \nLight-weight equipment (hoops, ropes, and batons). | \nRecreational activities that stimulated the visual and vestibular systems. | \n
Phase 3 | \nTrunk movements were substituted by head movements. | \nHeavier equipment (barbells, ankle weights, and medicine balls). | \nRecreational activities that stimulated the visual and somatosensorial systems. | \n
Phase 4 | \nHead, trunk, and upper and lower limb movements. | \nLoad was again increased with heavier equipment for resistance training (increase of intensity) or increased repetitions (increased volume). | \nRecreational activities integrated the vestibular, visual, and somatosensorial systems. | \n
Phase 5 | \nFour different movement sequences, two of which were the same for upper and lower limbs and two other sequences that alternated movements for upper and lower limbs in place and in movement. | \nExercises were done with weights: leg press, pulley, seated cable rows, peck deck, and bench press. Load was adjusted according to patients\' convenience (in two series of 15 repetitions). | \nRecreational activities included static balance, dynamic balance, half-turn, and complete turn (all with visual cues). | \n
Phase 6 | \nFour sequences of different movements, two sequences of alternating movement for upper and lower limbs, and two sequences of different movement for upper and lower limbs, with or without trunk movement and equipment (balloons, balls, hoops, and rope). | \nThe same exercises with load increase. Series of 15 repetitions were added. | \nRecreational activities were composed of activities with tactile cues. | \n
Multimodal exercise program in Parkinson´s disease.
Note: Based on Vitório and coworkers [63].
The little data that are available in the literature point to improvement in some kinematic gait parameters of mild-to-moderate idiopathic PD patients using multimodal exercise programs [63, 64].
\nSeveral data show acupuncture and electroacupuncture (still performed on animal models) as beneficial strategies in Parkinson’s disease treatment, used either isolated or combined with other treatments. It has been described as showing improvement in the UPDRS total score and in its subsections after an acupuncture session. So, even motor and nonmotor signs and symptoms, including pain, can be improved with the use of acupuncture [65, 66, 67]. However, the most important source of data that proves the beneficial effects of acupuncture in treatment of signs and symptoms in Parkinson’s disease is provided from functional neuroimaging studies. These studies have shown huge modifications in neural functions after acupuncture sessions [68, 69].
\nAs tai chi use was previously discussed, acupuncture requires previous academic training so that it can be used in an accurate way in the treatment of Parkinsonian individuals.
\nHydrotherapy has been widely used to treat individuals with Parkinson’s disease. It has been proven to be effective for different gait rehabilitation programs, as well as to improve balance and quality of life, and reduce pain and falls. The warm property of water used for hydrotherapy potentially also reduces rigidity [70, 71].
\nIn water, innumerable forms of exercises can be performed including warm-up exercises (like jumping and walking), stretching exercises, gait training, cooldown exercises, trunk mobility, balance, coordination and proprioceptive exercises, the Halliwick method, posture exercises, the Ai Chi method, aerobic exercise, the Bad Ragaz method, motor dexterity exercises, and swimming exercises, among others [71].
\nVirtual reality potentially optimizes motor learning in a safe environment, and by replicating real-life scenarios, it could help to improve functional activities of daily living in individuals with Parkinson’s disease. However, the use of commercially available devices makes this tool contiguous to many other physical therapy instruments, leading to low evidence in the results [72]. Despite this, several studies have reported greater improvement in many signs and symptoms such as balance, gait, functional capacity, and self-confidence, improving quality of life and reducing the risk of falling [73, 74, 75].
\nAs an example of specific virtual reality developed for Parkinson’s disease rehabilitation, Gomez-Jordana and coworkers [76] developed visual cues that could be presented in an immersive, interactive virtual reality environment. With this, they created different forms of spatial and temporal information where black footprints presented at a prespecified distance apart could recreate different step lengths (spatial cues), and by controlling when the black footprints changed color to red, they could convey information about the timing of the foot placement (temporal cues). With this device, they could get significantly improved gait performance in participants.
\nAdditionally, exercise-based video gaming (exergaming), a form of physical training that is delivered through virtual reality technology, facilitates motor learning and is efficacious in improving balance in aged populations. This approach can use commercial devices such as Nintendo Wii Fit System®, X-box 360o with Kinect®, or rehabilitation-specific software program like Jintronix® [70, 74, 77].
\nThese devices usually combine automated game instructions as well as visual and auditory and tactile inputs to correct performance and sustain motivation levels during and following game play. Therefore, exergames employ visual and auditory feedback techniques to create a quasi-immersive environment that can facilitate motor and cognitive learning. Since individuals with Parkinson’s disease are dependent on sensory cues to maintain postural stability and show difficulties with long-term consolidation of new motor skills, this sensorial integration provided by using exergames may help to upregulate neuroplasticity and facilitate motor skill acquisition and retention [77].
\nThese resources can be used isolated or associated in a clinical approach or in a telerehabilitation program like a home-based virtual reality or home-based exergame [74].
\nGroups are used in physical therapy to improve global health status and bring relief from typical disability symptoms of several diseases, competing with individual rehabilitation at least in short-term follow-up. Therapeutic groups have been beneficial to the health care system by decreasing the cost and time spent on rehabilitation.
\nSimilar to other techniques, group therapy can use several kinds of exercise goals such as general mobility, using muscular strength, free movement, and relaxation exercises; trunk control, using trunk displacement and rotation during dynamic exercises performed in a sitting posture; static balance, using the same strategies for trunk control but in a standing position; dynamic balance and gait, using free gait; and gait with obstacles, stairs, ramp, uneven ground, performed in and outside the room. The use of hearing and visual cues during the procedure provides several stimulus associations for the patients. This approach was reported to improve gait, balance, and activity of daily life performance in patients with PD [78].
\nMental imagery is the cognitive process of creating visual, auditory, or kinesthetic experiences in the mind with or without overt physical execution. In many people, this procedure can help or improve motor performance. This strategy has the potential to increase the function of both the motor cortex and the spinal neurons, resulting in improved muscle function [79, 80]. Thus, it is an important technique in motor learning and control, and although it has its origin in sports science, it has been introduced into the field of neurorehabilitation.
\nIn a few sources about mental imagery in Parkinson’s disease rehabilitation, some data show a better muscle recruitment measured by electromyography or other form or neurophysiologic register. But available data are, sometimes, contradictory [80, 81].
\nSpecifically in individuals with Parkinson’s disease, this approach has shown to be beneficial to motor (measured by UPRDS-III‑motor signs) and cognitive functions [79].
\nSince smartphones became popular, numerous health-related apps have been developed for professionals, patients, and the general population. However, many of these apps are not validated, so their efficacy may be not satisfactory. Nowadays, this resource still has been used as a complementary treatment [82].
\nIt is a well-known fact that it is important to emphasize that apps are a democratic source of information and rehabilitation, since they maintain the main principles of usability, accessibility, and equal opportunities for healthcare professionals, patients, relatives, and caregivers [82].
\nFor Parkinson’s disease, there are a few apps available, and just one with some data partially published. On the Parkinson’s UK webpage, we can find a list of apps reviewed and recommended for individuals with Parkinson’s disease. There are apps for sleep, volume of voice, mood, swallowing, memory (recording stories of patients), mobility, speech, and dexterity [83].
\nAnother source from the International Parkinson’s Community recommended eight extra apps. They focus on measurement and tracking the patient’s symptoms, give information about Parkinson’s disease, record and measure the magnitude of tremor and speech, and manage and track the individual’s health condition. The only one that has some physical approach is the Parkinson’s home exercise [84].
\nThe Parkinson’s Home Exercise®, promoted by the European Foundation for Health and Exercise, was easy-to-use and designed to be used by patients and physiotherapists. It provides advice and instructions for daily exercises and movements through over 50 videos and text instructions. It has a cost involved [85]. There are no references in literature about its efficacy.
\nAnother app, developed by TEVA Pharmaceutical Industries, named Parkinsounds®, is a free app that helps patients with Parkinson’s disease to find their gait rhythm using music and rhythmic beats (like a metronome). They use a predetermined music list or one that can be linked to Spotify®. Once the rhythm is chosen, Parkinsounds is able to find music that combines with the preselected rhythm adding beats in the music. The physiologic base for this strategy is centered on the synchronic activation of neurons provided by the music and the rhythmic stimulus, added to an increase of dopamine liberation [86].
\nOur group has been developing research using this specific app in rehabilitation of gait in Parkinson’s disease. The partial data were already presented at the World Confederation of Physical Therapy Conference (research data are not still available). However, a huge acute effect could be seen in the gait of Parkinsonians using Parkinsounds, even in a long-term period of rehabilitation. We could see an improvement in width and length of gait, with a reduction of base and number of steps, which were measured in a 10 meters’ route, after 10 weeks of treatment. It is important to emphasize that the walking test was performed with and without Parkinsounds® use for patients at the moment of evaluation (initial and final), and in both cases, the improvement was significant. So, it can be considered an important feature for gait rehabilitation in Parkinson’s disease.
\nAccording to the literature data, there is no apparent consistency in the effect of whole body vibration shown on mobility, balance, and gait in individuals with Parkinson’s disease [87]. However, the majority of the studies point to a favorable effect of this therapeutic strategy [87, 88].
\nDisregarding the differences between the various types of equipment, a lot of research has proposed some parameters that are useful in improving mobility and balance in individuals with Parkinson’s disease. The majority recommend orthostatic position and 7 to 14 mm amplitude with a frequency ranging between 3 and 25 Hz, in cycles of 5 bouts of 1 minute each. Until now, there is no consensus about which frequency in better [87]. So, it is recommended that the physical therapist evaluate these functions constantly after using this resource.
\nThe effect of whole body vibration on tremor is less prominent [87]. Moreover, it also does not appear to lead to better cardiovascular conditions reducing the feeling of fatigue when compared to treadmill training [89].
\nThe physiological mechanism involved in the effects of whole body vibration on reducing some of the motor signs of Parkinson’s disease remains elusive. Some theories suggest that whole body vibration provides tactile and proprioceptive stimulus to the whole body originated from the vertical oscillating mechanical movement or the movement along the horizontal axis, which through neuromuscular activation and metabolic mechanism may bypass dysfunctional basal ganglia, resulting in better adjustments for postural stability and gait [88, 90].
\nIn this chapter, we can notice how profound the discussions about Parkinson’s disease are, especially about treatment. Physical therapy has increased its participation in Parkinson’s disease treatment. However, research is still lacking to substantiate its real effectiveness. It is imperative that further research be done to strengthen performance and the excellent results obtained with physical therapy in treating individuals with Parkinson’s disease.
\nI would like to thank Pontifical University of Minas Gerais for funding the research cited in this chapter: PROBIC PUC Minas 95/35 {80}; Parkinsounds Project PROBIC PUC/FAPEMIG 2018/1510.
\nBuildings are a major source of environmental impact, such as greenhouse gas (GHG) emissions, and use large amounts of energy and natural resources. Building construction and operation account for 36% of global final energy use and of 39% of energy related GHG emissions [1]. Awareness of the threat of a climate crisis and its recognition in global Sustainable Development Goals, and in European and national political targets, has increased the pressure to do necessary measures to reduce anthropogenic GHG emissions. The importance of decreasing the impact from building and construction industry has also been highlighted. Apart from legislation, taxation and benefit packages, environmental assessment methods can be considered as a voluntary neoliberal way to work with environmental governance [2]. They may also influence legislation. For example, the Swedish EAM Miljöbyggnad (MB) has inspired a new legislation regarding mandatory climate declaration for all new buildings in Sweden which is mandatory from January 2021 [3]. It is therefore of great importance how the environmental assessment tools content, indicators and criteria guide building design and decision-making in the building sector.
In Sweden, the most commonly used system for environmental certification of buildings is Miljöbyggnad (MB), translated to English “Environmental building”. MB was developed as a joint project between Swedish government, companies in the building and construction sector, several municipalities, insurance companies and academia, as a voluntary environmental rating tool to assess all new buildings in Sweden [4]. This still influences its characteristics. More than 1900 buildings are certified with MB [5]. Environmental certification is a third-party verification that a building meets the environmental certification criteria that the system address. Sweden’s largest organization for sustainable community building, Sweden Green Building Council (SGBC) owns and develops the system, and performs certifications [5]. MB certifies both new and existing/renovated buildings of different kinds: such as detached and semi-detached houses, blocks of flats and most types of commercial and public buildings (here called non-residential buildings), encompassing hotels, offices, restaurants, healthcare buildings, schools, kindergartens, and sport centers. MB analyzes and evaluates fifteen different indicators for new buildings. The processes for MB certification include registration of the project, pre-notification, application, review, clarification, and certification and in addition, requires reporting and verification of results with follow up inspections within three years after completion and certification, and then reporting back on maintained performance every fifth year to prolong the gained certification grade.
Each indicator can achieve Bronze, Silver or Gold grade. To achieve Gold grade, the building should have enhanced environmental performance and measurements or questionnaires should be made to guarantee the enhanced building performance and indoor climate levels [5]. If any of the indicators are classified Bronze, there is no possibility to achieve the total grade Gold.
The 15 indicators (16 indicators for existing buildings) are clustered into the areas
Indicator | Aspect | Area | Building | |||
---|---|---|---|---|---|---|
1 | Heat power demand | SILVER | BRONZE | SILVER | SILVER | |
2 | Solar heat load | BRONZE | ||||
3 | Energy use | GOLD | GOLD | |||
4 | Share of renewable energy | SILVER | SILVER | |||
5 | Noise | SILVER | SILVER | SILVER | ||
6 | Radon | SILVER | SILVER | |||
7 | Ventilation | SILVER | ||||
8 | Moisture safety | SILVER | SILVER | |||
9 | Thermal climate, winter | SILVER | BRONZE | |||
10 | Thermal climate, summer | BRONZE | ||||
11 | Daylight | BRONZE | BRONZE | |||
12 | Legionella | SILVER | SILVER | |||
13 | Logbook of building material | SILVER | SILVER | SILVER | ||
14 | Phasing out the hazardous material | SILVER | SILVER | |||
15 | Building structure and the foundations climate impact | BRONZE | BRONZE |
Example of how indicator grades are valued and aggregated to a final building grade for a certified building, Almgården pre-school, Gävle, Sweden.
The aim of this this book chapter is to reflect some viewpoints about the MB’s potential impact on energy use, GHG emissions and effect on building performance. By analyzing and investigating nine of MB’s 15 indicators, it is studied to what degree MB may influence the design of buildings, the energy system and lower the GHG emissions. The analysis focuses on whether the certification system influences the design of the building and its energy system as intended and what challenges and possibilities the indicators, criteria and linked regulations can have on buildings and GHG emissions. The nine indicators that affect the GHG emissions the most in the areas Energy, Indoor environment and Material were identified and have been studied. Their potential impact on GHG emissions and building design will be presented and discussed.
The method used in the project is primarily a study of the MB manual and literature linked to the subject. The authors have had regular workshops to discuss the documents and literature and a reference group of five people from both building industry and academia with knowledge regarding MB, energy and environmental issues related to buildings have had input to the process. Some certified planned and built buildings have also been analyzed separately.
In order to have an understanding for why four indicators are included in the Energy area, a brief overview of Sweden’s energy system, building stock energy performance and energy supply/distribution are presented below. The four indicators within the energy area are: Heat power demand, Solar thermal load, Energy use and Renewable energy.
Sweden’s use of energy is divided among the industry, the transportation, and the residential and tertiary sectors. The latter accounts for approximately 40% of Sweden’s energy use, namely 147 TWh in 2018. Shares that sum up to this number are residences 59%, public service 11% and service businesses 21%, the building construction sector 3% and remaining 6% owing to agriculture, forestry and fishing [6]. More than half of this energy is used for space and domestic hot water (DHW) heating; 54% in 2018 [6]. For this reason, the building stock should confine energy use, the rate at which energy is used (power), from which sources and its quality. Table 2 displays statistics on space and DHW heating for various buildings. A large share of multifamily and non-residential buildings is heated with district heating (DH) whereas detached buildings are predominantly heated with electricity (direct and/or various heat pump types). Table 2 does not include facility electricity (electricity for pumps, fans, certain common lighting, elevators, etc.). Nor is household and office/business electricity, which by default are calculated as 30 kWh/(m2∙a) [8] and 50 kWh/(m2∙a) [9], respectively.
Building type | Share of total heat supply [%] | Share of DH supply [%] | Share of building type heated by DH [%] | Specific energy demand [kWh/(m2∙a)] | Specific energy demand (DH heated) [kWh/(m2∙a)] |
---|---|---|---|---|---|
40 | 12 | 17 | 107 | 138 | |
33 | 52 | 90 | 140 | 143 | |
27 | 36 | 77 | 127 | 149 |
Average final specific energy demand for space heat and domestic hot water preparation in 2016 [7].
It is important to differentiate energy carriers, primarily electricity and DH in view of when the power demand of the building stock is high due to issues during cold weather. Even if Sweden per capita is an extreme electricity consumer, electricity is generated using energy sources with low or moderate GHG emissions. For example, 160 TWh electricity were produced in 2019, from hydropower 39%, nuclear 39%, wind 12%, and the remaining 9% from combined heat and power (CHP) plants serving electricity to industry and society [6]. There is a growing demand for cooling energy, especially for non-residential buildings.
Electricity involves problems with power or capacity shortage.
It is cold in the whole country;
Wind generates little power since cold weather seldom are windy;
Nuclear power does not produce as predicted or is being phased out;
Drought leaves hydropower dams with low water levels;
Imported electricity is limited due to low overproduction in neighboring countries or grid links to those countries are not in operation;
Reserve power sources do not deliver enough power;
Grid shortage of capacity in Sweden (see below).
DH can come from burning fuels, incineration and/or waste/residual heat from the industry with the purpose of heating buildings (or for industrial applications). DH can also come from a CHP plant, which produces thermal and electric power for the local community, with very high thermal efficiency. CHP delivers most power when outdoor temperatures plummet. Cold periods involve burning fuels with high energy content, such as costly renewable types (such as tall oil) or fossil fuels, which are being phased out due to high GHG emissions. In view of MB, every new building will increase the pressure on energy generation, grids and networks. Renovation of old buildings often reduce thermal energy requirement, but will in turn often imply increased use of electricity for this purpose. Therefore, power requirements, which are not explicitly expressed in Swedish Building Regulations (BBR), are important in MB and consequently reduce the increase of GHG emissions. From a future community development perspective, minimized electricity consumption should be rewarded.
One of the indicators in MB assesses the heat power demand during winter. When outdoor temperatures drop, heat demand of the building stock increases, which implies that energy systems must use fossil and/or expensive renewable fuels. The purpose of this indicator is according to MB, translated to
Building type | Bronze | Silver | Gold |
---|---|---|---|
Residential | |||
Non-residential |
Indicator 1, heat power demand limits, related to envelope area [W/m2] [5].
These two calculation methods are suggested by MB:
The building’s heat loss coefficient (with unit W/K) and time constant are calculated to assess DVUT. The heat demand comes from multiplying the heat loss coefficient with the difference between design indoor temperature and DVUT, divided by the envelope area.
The heating demand can be simulated with a building energy simulation software, where solar and internal heat gains are set to zero, while the building is ventilated as if it were occupied. The climate file is that of a typical reference year for the location. Space heating demand is divided by the envelope area.
Verification is done in two ways: either with the energy signature of the building (measured supplied power versus outdoor temperature) or making a more exact calculation by using actual/measured values as input in the model used to predict the power demand.
The idea of limiting thermal power losses through transmission, ventilation and air leakage is encouraging, since this requirement is not explicitly stated in BBR, aside from criterion on maximum installed electricity power for space heating and an average area-weighted U-value of the envelope. It is also an aspect which is becoming increasingly important due to the energy systems problems with power and capacity shortage, and for limiting increased GHG emissions that new buildings entails. However, calculation procedures evaluation criterions can be doubted for several reasons, described below.
The definition of the indicator creates uncertainties. While it is called
Another aspect is that the building’s heat loss coefficient is normalized by division with the envelope area. The compactness of a building, measured with the Heat Loss Form Factor (HKFF is the ratio between envelope and heated floor area), affects heat losses. A compact building with low HKFF, reduces losses. Normalization with envelope area allows less energy-efficient buildings to fulfill the criteria, in contrast to reducing losses on basis of heated floor area. Moreover, envelope area can be complicated to calculate for buildings with complex facades. But this could perhaps be one way to avoid that the indicator drives building design towards buildings with low ceiling heights and low slab/intermediate floor thicknesses, such as made of wood instead of concrete.
The geographic factor
If a heat demand criterion is set the same at the two sites, the heat loss coefficient ratio of 0.72 (= 1/1.4) is obtained, indicating that buildings in the north must primarily have increased insulation thicknesses (thus reducing energy losses, too). The introduction of
The relationship between DVUT and the time constant of the building comes from SS-EN ISO 15927-5 [12]. Yet, the theories behind the standards have not been documented in a scientific way: the authors have not been able to find reports, peer-reviewed articles etc. on the topic. Nor has research been carried out to test and validate these concepts. Same criticism has been forwarded in view of building simulation tools standards [14]. Some inconsistencies can be noted: In order for heat to be stored and retrieved from building components, the indoor temperature must be able to fluctuate. However, calculation routines prescribe the use of a design indoor temperature that should be no lower than 21°C. Meanwhile, the time constant of the building is related to the response of the building subjected to a constant cold outdoor temperature, if the heating system is shut off, and the indoor temperature drops to approximately 63% of the temperature difference between the indoor and outdoor temperatures. It is questionable if the design of buildings with different time constants, in the same location, exposed to the same weather, can be verified, for example by measuring power supply versus outdoor temperature. Neither DVUT nor the time constant are measurable entities. This poses problems for verification, where a proposed method is the so-called energy signature. DVUT also appears in the winter thermal comfort indicator assessment.
Another weakness is that the typical climate of a location used in the indicator criteria is the “average” weather that was measured between 1981 and 2010. This climate format has substituted normal reference climate, based on 1961–1990, owing to climate changes. These climate files are based on previous historical 30 years of data. Given that an energy simulation of the building must be done (see Section 2.4), the same building model can be used for thermal power assessment. Today, this can be performed with the typical climate year, given that the internal and solar gains are set to zero, but it is not clear if this typical climate file contains design outdoor temperatures. Yet, certified buildings will be exposed to a future climate. Accordingly, predictive simulations should consider future weather exposure; not mean values of historic climate. A proposal is that extreme winter and summer conditions be projected in a design reference climate for designing future building heating and cooling power demand. The importance of using different climate files for various purposes is discussed by Petersen [15].
The purpose is to reward buildings that are designed to limit excessive indoor temperatures and reduce space-cooling requirement during the summer (see Table 4). The solar thermal load (STL) is defined as the solar energy that is transmitted through the window and contributes to heating/overheating of the room, based on the unit W/m2 (here, floor area of the considered room/zone).
Building type | Bronze | Silver | Gold |
---|---|---|---|
Residential | |||
Non-residential |
Indicator 2, solar thermal load limits based on zone floor area [W/m2] [5].
Calculations are performed on facades that are oriented to the east, west and/or south. Active/movable shading devices should be activated. An important part of the assessment is to estimate the solar heat gain factor
A simplified method in MB is utilized unless more detailed simulation tools are available. STL is for rooms with window in one orientation, assuming solar irradiation 800 W/m2 onto vertical surface, calculated according to Eq. (1):
Depending on results from the two STL-equations, the highest value should be chosen for evaluation of reward according to Table 4.
This indicator has the aim of reducing solar loads primarily through passive means. It is closely linked to Indicator 10
As previously mentioned, buildings should be designed in view of future climate projections. Though the solar intensity will probably remain unchanged in the future [15], the outdoor temperature will rise. This will significantly increase cooling requirement. The authors suggest that this indicator focus more on space cooling requirement, also considering internal heat gains, cool recovery from exhaust air, minimizing solar heat gains (as now) and have calculations based on projected future heat waves. Though energy implications are included in Indicator 3
Swedish regulations have historically understood that by decreasing energy losses, supply needs will be reduced. Requirements on building envelope component U-values and heat recovery from exhaust ventilation, rendered reduced supplied thermal power demand and thermal energy use. Building regulations have previously been based on the concept of specific energy use (i.e., purchased energy). In being an EU member state, building regulations have harmonized with EU formats using the concept of primary energy. In essence, the basis for the primary energy number (
where.
The weighting factors are for building regulations imposed in 2020 as follows: electricity 1.8; DH 0.7; district cooling 0.6; solid, liquid or gaseous biofuels 0.6; fossil oil 1.8 and fossil gas 1.8 [13].
The upper limits for detached houses are 90–100 kWh/(m2∙a) depending on size, 75 kWh/(m2∙a) for multi-family buildings and 70 kWh/(m2∙a) for non-residential buildings. The limits may be increased if the activities within the building require enhanced ventilation rates (for hygienic and health reasons). There are also limitations on maximum electricity power for heating purposes and mean envelope U-values (0.30, 0.40 and 0.5 W/(m2∙K)), respectively for the building types. Table 5 displays MB’s reward criterions.
Building type | Bronze | Silver | Gold |
---|---|---|---|
Residential | Bronze + | Bronze + | |
Non-residential | Bronze + | Bronze + |
Indicator 3, energy use requirements [kWh/(m2∙a)] [5].
Energy use of new buildings has to be predicted with a whole-building energy simulation software that calculates time step of one hour or less, using a typical year climate file for the location. The monitoring plan in Table 5 requires sub-metering so that space heating, heating of ventilation air, DHW heating, space cooling, facility energy (electricity) and in non-residential buildings the business/service activity electricity can be determined. Monitored values must be normalized for comparison and verification with BBR requirements.
In the process of harmonizing building regulations to EU formulations, Swedish regulations had to impose criterions in terms of primary energy and derive a definition of Nearly Zero Energy Buildings (nZEB). The weighting factors (see Eq. (3)) were introduced in BBR 25 in 2017 and have undergone changes until BBR 29 in 2020. These can be seen as partially politically determined as they do not fully reflect differences in primary energy of energy sources. This is partly due to disagreements on how to calculate primary energy factors in district heating and cooling, from bio energy from forest residuals, waste to energy and free cooling (also to discourage direct use of fossil energy, oil and fossil gas were assigned factors equal to electricity). A stated aim has also been to derive values which are more “technological neutral” and “cost optimal” [16].
The relationship between BBR’s weighting factors for electricity and district heating (1.8/0.7 = 2.6) “coincides” with Boverket’s outmoded experience of average seasonal coefficients of performance (SCOP) for heat pumps, though with the ambition to be technology neutral. However, this value is considerably lower than the design SCOP’s of most modern heat pumps. Below, an example of a real building is presented to illustrate how the building regulations influences how much primary energy is potentially available for space heating, depending on choice of heating system.
For Strömsbro school in Gävle, BBR 29 [11] sets a nominal maximum value for
Eq. (3) can be rewritten for DH (Eq. (4)) and heat pump (Eq. (5)) heated building. The heat pump efficiency is estimated by varying three
For DH, the maximum allowable space heating energy use is expressed as:
For heat pumps, the remaining energy use for fulfilling requirement is as follows:
Results in Table 6 indicate that it is easier to fulfill energy requirement limits with an efficient heat pump than DH. This implies that heat pump heated buildings can fulfill energy requirements with low insulation levels in the envelope and/or ventilation and air infiltration losses. However, this problem does not come from MB – this indicator is directly based on BBR’s calculation methods and weighing factors. As long as this bias exists in BBR, it will be reflected in MB, unless MB sets more stringent requirements than BBR. However, it should be noted that other limitations in BBR restrict supplied energy (such as the envelopes average U-value and electricity use for heating purposes).
Energy carrier | BRONZE [kWh/(m2∙a)] | SILVER [kWh/(m2∙a)] | GOLD [kWh/(m2∙a)] |
---|---|---|---|
District heating HP SCOP = 3 HP SCOP = 4 HP SCOP = 5 | 72.0 83.8 114.7 145.5 | 39.0 45.3 63.4 81.3 | 28.0 32.5 46.3 60.0 |
Available energy use for space heating for a kindergarten in Gävle, given that other energy entities are prescribed, heated by DH or heat pump (HP) with SCOP = 3, 4 and 5, respectively [5].
The purpose of Indictor 4
The provided tool categorizes energy source in three categories as follows:
Criterions for rewards are presented in Table 7 and instructions state some definitions. These are, coarsely summed up, as follows:
Building type | Bronze | Silver | Gold |
---|---|---|---|
Residential and non-residential | > 50% of used energy is renewable. Guarantee of origin of electricity and allocated DH is accepted. | Alternative 1: > 75% of used energy is renewable whereof >10% is from flow sources. Alternative 2: > 80% of used energy is renewable. For both alternatives: electricity has guarantee of origin and third-party review of allocated DH is accepted. | > 80% of used energy is renewable, whereof >5% is from local flow source and used in the building. Electricity has guarantee of origin and third-party review of allocated DH is accepted. |
Indicator 4, requirements on shares of renewable energy [%] [5].
Gold requires
The energies origin for electricity from the grid is classified according to Energimarknadsinspektionen’s (the Swedish Energy Market Inspectorate) guarantee of origin. Electricity originating from solar-, hydro- and wind power are renewable and flowing. The Nordic residual mix is the produced electricity that is not sold with guaranteed renewable origin. The Swedish Energy Market Inspectorate provides annual information on its shares.
The origin of the energy that is supplied by the specific DH system is classified depending on fuel mix. Only the origin is assessed; not technical solutions or equipment in neither building nor DH system. Allocated DH shall be checked by an environmental auditor. The energy supplier shall guarantee that it will be available for at least three years. Consequences of the residual’s constituents are accounted, i.e., DH which is not sold with guaranteed origins. For Silver and Gold, allocation and residual must be reviewed by a third party. For heat pumps in the DH system, energy supplied to heat pumps, excluding electricity, will be allocated in Category 1. Electricity to heat pumps are allocated depending on origin. Energy with unknown origin is classified as non-renewable (category 3) and electricity as Nordic residual mix.
Origin-labeled or allocated energy is verified with contracts, invoices, etc. Solar collectors or photovoltaics can be verified with photo or as-built documents. The intentions of awarding the use of renewable energy and specifically to encourage establishment of new renewable production units, is appropriate, such that energy use of new buildings will not burden the existing energy production systems. If origins of electricity will result in expanding electricity from renewable sources can on the other hand be discussed. As long as not all the renewable electricity produced is bought with green certifications it will not have much influence over the energy production.
The three categories could also be discussed from an environmental point of view. Should a more differentiated categorization represent the actual environmental impact from different energy sources be more appropriate, transparent and meaningful? Both life cycle assessment data for different energy sources and the energy efficiency in the energy production process could be included. The differences between different systems can be very large. For example, the lifecycle estimates of GHG emissions from wind power and coal is 10 gCO2e/kWh vs. 1050 gCO2e/kWh [17]. Variations can also be large between the environmental loads from the same type of energy generator depending on the source. For example, photovoltaic panels (PV panels) can have very different GHG emission impact if produced with coal in China or with the Swedish energy mix in Sweden.
Eight indicators related to the indoor environment are included in MB; Noise, Radon, Ventilation, Moisture safety, Thermal climate in winter, Thermal climate in summer, Daylight and Legionella [5]. The focus in this part is the ventilation, thermal comfort and daylight.
Several of the environmental indicators have a synergy and affect each other as well as energy indicators. For instance, ventilation can affect the indicators for energy (both the heating load and energy use), radon content inside the building, thermal comfort both in summer and winter, the noise level (due to the running fan and ducting networks in the ventilation system) and the logbook of the material (choice of environmentally friendly material for the ventilation system). Therefore, the ventilation system is a decisive indicator for the total grading of the MB assessment.
In a building, the ventilation system has the role of regulating and ensuring optimal indoor air quality and good thermal comfort. In terms of air quality, the uncertainty is greater when it comes to people’s experience than for the thermal climate. However, there is no doubt that the quality of the indoor air is of great importance for comfort, health and performance. The balance between air quality and thermal comfort depends on a number of factors, which includes thermal regulation, control of internal and external sources of pollutants, air change rate, air distribution system, residents’ activities and preferences, and reasonable operation and maintenance of the building system [18]. Guidelines for good indoor air quality have over the years often specified the highest acceptable levels of a wide range of airborne pollutants, such as dust content, CO2, volatile organic compounds, microorganisms. However, very few unambiguous correlations have been found between pollution levels and symptom outcomes for the low-dose range to which people in non-industrial premises are usually exposed. For human-generating pollutants (so-called bio effluents), CO2 content is often used as an indicator. Studies show that for larger populations, the number of dissatisfied users is 14% if all people are exposed to a CO2 content of 800 ppm [19].
The ventilation indicator in MB assesses the building’s ventilation solution and the purpose of the indicator is to reward buildings with good air quality. For ventilation, there are both minimum flow requirements as well as CO2 level limits in MB. In residential buildings, the focus is on minimum flow rate and in non-residential buildings, both flow rate and air quality (CO2 levels) are emphasized.
In new residential buildings, the minimum requirement is providing at least 0.35 l/sm2 (Atemp) outdoor fresh air by the ventilation system. In non-residential buildings, 7 l/s per person should be added and to get higher grades. For Silver and Gold, CO2 level should not exceed 1000 and 900 ppm respectively, except for temporary occasions. If the ceiling height in non-residential buildings is more than 3 m, smaller flow rates can be accepted if the CO2 levels are within the accepted limits. In addition, the 1000 ppm CO2 limits is per room and for the number of occupants the room is designed for [5]. The grading criteria for indicator of ventilation is shown in Table 8.
Indicator 7 | BRONZE | SILVER | GOLD |
---|---|---|---|
Residential building | Fresh outdoor flow rate ≥ 0.35 l/s·m2 Atemp | Bronze + | Silver + |
Building care-taking routines for control of air quality. | Exhaust flow in kitchen according to Table 3. | Exhaust flow in kitchen according to Table 3 | |
Approved questionnaire or measurement. | |||
Non-residential buildings | Fresh outdoor flow rate ≥ 7 l/s and person +0.35 l/s·m2 Atemp. Building care-taking routines for control of air quality. | Bronze + CO2 concentration in the room should not exceed 1000 ppm except in very temporarily occasions | Silver + Alternative 1: Approved questionnaire. Alternative 2: Locally measured ventilation index ≥90% in the occupied room Alternative 3: CO2 concentration in the room should not exceed 900 ppm except in very temporarily occasions. |
The grading criteria for Indicator 7 ventilation [5].
In addition, for the ventilation of wet rooms such as kitchen, bathroom, washroom and toilet, the minimum exhaust flow is 10 l/s. Moreover, for kitchens, there should be a minimum 10 l/s flow with at least 75% capture efficiency for the air pollutions and contaminants emitted during cooking and food preparation. The capture efficiency limits require efficient ventilation hoods equipped with carbon filters or other type of filters, which in turn may lead to larger fans with higher power and energy use. Thus, it will be more challenging to get a higher grade for the ventilation indicator and at the same time get higher grades for energy indicators.
According to Table 8, in order to get Gold, the criteria for Silver must be fulfilled and a questionnaire should be provided among the building users or to have measurement of ventilation index. This additional criterion is important and well-suited since specifying required ventilation rates cannot guarantee an adequately low exposure to indoor pollutants. Guidelines by The Swedish Work Environment Authority address the important question of efficient air distribution. In addition, dissatisfaction with the quality of the indoor air cannot only be explained by incorrect ventilation, but also by the fact that the activities in the building/room could have changed after the design.
Ventilation index is a measure on how well the interior is ventilated and is defined according to Eq. 6 below:
Csp = set-point value of the average pollutant concentration in the occupied zone, ppm or mg·m−3.
Ci = pollution concentration in the supply air, ppm or mg·m−3.
Ce = pollution concentration in the exhaust air, ppm or mg·m−3.
Ꜫc = the ventilation index or ventilation effectiveness for contaminant removal.
Ventilation index is 1.0 for perfect mixing condition because the concentration in the exhaust is the same as in the whole occupied zone. Ventilation index below 0.9 indicates ill-functioning air distribution in the room such as short-cuts and stagnation zones. To be able to get Gold for the ventilation indicator, the measured ventilation index should be more than 90% in the occupied zone. Alternatively, for the non-residential buildings, the measured CO2 levels should be below 900 ppm. As many building energy simulation programs assume a well-mixed condition, which is not the case for stratified systems, it is suggested to prioritize measurements. Stratified ventilation is a concept that often creates high ventilation effectiveness (ventilation index over 1.0) and good indoor air quality [20, 21, 22, 23]. There are many different air distribution strategies creating stratified conditions, such as impinging jet ventilation, displacement ventilation and confluent jet ventilation. These systems have the potential to create better air quality that mixing ventilation or the same level of air quality as mixing ventilation but with lower air flow rates and hence energy use [24, 25, 26]. Personalized ventilation systems have even higher effectiveness with the possibility to achieve ventilation effectiveness above 3 [27].
The recommended/minimum air flow rates given in the European standard EN 16798.1 [28] and MB assume complete mixing in the room. For non-residential buildings ventilation rates could be adjusted by the ventilation effectiveness in accordance with the European Standard EN 16798–3 [29] if the air distribution differs from complete mixing. However, this is not allowed in MB, which is one weakness.
Ventilation unit or the air-handling unit affects the electricity load and the heating power demand (due to possible heating coils). The deciding parameters are the operation schedule, the specific fan power (SFP), flow rates and heat recovery. To guarantee an acceptable indoor air quality it is not possible to compromise on the ventilation requirements. However, a time-controlled ventilation system is more efficient and can save energy together with heat recovery from the exhaust airflow. Thus, effective and energy efficient ventilation systems (with low SFPs and higher heat exchanger efficiencies) are essential in order to get higher grades for MB indicators. To remove the contaminants and pollutants from the interior, it is also important to get the filters cleaned and have it instructed in the building care-taking schedule. Such routines and instructions can be implemented in the compulsory ventilation control protocol (OVK) of the building [30].
Uncontrolled ventilation through air leakages is not included in the indicator. Air leakage influences ventilation and stands for a part of transmission losses and affect the heating power indicator as well as the total energy use [31, 32]. Building air tightness is not directly defined in the Swedish building regulation codes and it is not specified in this indicator. It can also increase the heating power demand and building energy use. Thermal comfort especially during winter can be affected due to possible draft and unwanted cold airflow from outdoor connected leakage and openings to occupancy zone. Therefore, it is suggested to add airtightness as a separate indicator, expecting minimum air tightness for newly and modern building and rewarding airtight building. An airtight building can decrease the energy use throughout the year while maintaining the thermal comfort level. In addition, it is suggested to perform airtightness measurement during the building process so that the possible leakage can be detected and get fixed with the minimum costs. This should be implemented in the regulations and criteria so that it can be verified and followed later on. Air leakage does also affect the ventilation designed flow and pressures and there is not any guide or recommendations on that. An indicator for air tightness, which can be merged with the indicator for ventilation into one aspect for ventilation would therefore be appropriate.
In addition, possibilities of airing, i.e. opening external doors and windows is important to occasionally introduce extra fresh air. This is considered for ventilation of bathrooms. However, it can be also considered for the main occupancy rooms. Airing is used also as a cooling method to adjust the inside temperature and in this case, it saves cooling energy; however, in the heating season, airing will increase the energy use by at least 4 kWh/m2 and year [8, 9].
Thermal climate in winter, indicator 9 in MB, is essential in cold climates like in Sweden, and linked to the indicator
To get the Bronze grade, the PPD should be less than 15% with DVUT, and building care-taking routines should be provided to control the thermal climate and thermal comfort in winters. The routine should include the function of the heating system, control measurement of the temperature, user questionnaire or manuals to fix the issues leading to possible complaints (regarding the thermal comfort). The PPD should be calculated for a critical room located on a top floor with steady occupants the PPD can be calculated for several rooms and the critical rooms with highest PPD numbers can be chosen to fulfill the criteria.
For Silver grade, the PPD should be less than 10% with DVUT and for Gold, a questionnaire or measurement should be provided. The questionnaire and measurement are done during a year with its specific weather, however, PPD is calculated within the design temperature, DVUT. The weather during the measurement year might be quite different from a normal year, and this would affect the thermal comfort results.
A building has the capacity to store heat and release it when it gets colder, thus it affects the choice the DVUT within the same climate, i.e., a heavier building can withstand more temperature variations than a building with less thermal mass. For calculation of DVUT the building thermal mass is considered as one day and night (24 hours) and without the heating gain from solar and the internal loads (occupants, devices and lighting). Thus, it has been considered a worst scenario, i.e., the building is considered light and one of the reasons is that the thermal comfort should be measured in individual rooms (with lower thermal mass in compare with the whole building) and not for the whole building.
Unwanted cold air movement is called downdraft and might worsen the thermal comfort especially during winter. Air speed is specified and measured in the occupancy zone, 0.5 m inside of wall/window. In the simulation models, it is considered as 0.15 m/s for air speeds in the occupied room, but temporarily, there might be higher air speeds for instance if the person is sitting too close to a window with downdraft especially during colder periods. This will also lead to an increase in PPD and thermal dissatisfaction, however, it is difficult to simulate draft and more detailed CFD simulations would be needed.
Thermal climate in summer is decided based on the PPD index in a critical warm and sunny day. The assessments can be based on indicator 2, solar heat load together with the building management routines. For Bronze, Silver and Gold grades, the PPD should be less than 20, 15 and 10% with the most critical conditions, respectively. To get Silver, the building should be equipped with openable windows and doors (in residential buildings) and to get Gold, questionnaire or measurement should be provided [5].
For building without cooling facilities, the grading for the thermal climate in summer is referred to indicator 2, which is about reducing solar heat loads during the summer. For buildings without cooling system, the critical room should have internal loads (occupants, appliances and lighting) below 20 W/m2. The PPD should be calculated for a critical room located on a top floor with steady occupancy; the PPD can be calculated for several rooms and the critical rooms with highest PPD numbers can be chosen to fulfill the criteria.
Having smaller windows would lead to less solar heat gain during summer and improve the grade for indicator 10. However, the smaller window size would also decrease the received daylight, which makes it more challenging to get enough daylight. In addition, it will decrease the building’s purchased heating energy during winter and hence benefit indicator 3, the energy use. There might be a balance between the window size and the related indicators for solar heat gain, energy use, thermal climate and daylight. Research studies have shown that, the building equipped with modern windows (lower U-values and transmission losses as well as higher visible light transmittance) can have higher window areas and still fulfilling the criteria for both solar heat gain, thermal comfort and daylight requirements [35]. Also airing possibilities should be limited to the time when the indoor temperature is lower than the outdoor. For instance, in case of heat waves, it is better to have the windows closed during the daytime and instead, if possible, have them opened during the night, when it is cooler, i.e. night cooling ventilation [36].
One problem and weakness with the requirements for Gold is that the questionnaires and measurements are done during a specific summer with its specific weather, whereas, calculations are performed using historical weather data (normal year based on 1981–2010). This means that the fulfillment of Gold depends much on how warm the hottest day, in relation to the normal year, have been for the specific summer the measurements or questionnaires have been performed. Therefore, it is also suggested for the design and calculation of indicator Thermal climate in summer to use more extreme summer conditions than the typical year based on 1981–2010.
The windows in the building, their location, size, light transmission factor and U-value, have a large impact on the daylight condition, the solar heat load, energy use and indoor comfort discussed earlier. They also influence the indoor light quality in the building, which affect the people using the building. Human eyes have evolved in sunlight and therefore responds much better to it than artificial light. In addition, it can be troublesome for people to work in a room without windows with no awareness of the weather and contact with the outdoors. We spend around 80–90% of our lives within buildings and numerous research studies have demonstrated and indicated that glazing has profound implications in terms of human health, happiness and productivity [37, 38, 39, 40], and in northern countries lack of daylight can lead to Seasonal Affective Disorder (SAD), a syndrome characterized by recurrent depressions that occur annually at the same time each year which is affected by access to daylight [41].
In MB, indicator
Percentage of outlook area (with view to the outside) can be applied for workplaces in sales halls and halls (rooms with high ceilings that are intended for, e.g. sports, warehouses, trade fairs, light industry and logistics) and associated facilities that are only used temporarily. Then the proportion of view area (outlook area) is defined as being able to look out with 5° or more indoors at a height of 1.5 m, both horizontally and vertically. Floor area where these conditions are met is defined as the view area or outlook area and is expressed as a proportion of the whole floor surface.
Daylight affects the total energy use in a building as the penetrated light into the building will turn into heat and increase the internal gain. This will lead to a decrease of heating demand in the heating season and increase in the cooling demand in the cooling season. The heated parts inside the building will get higher temperatures, and in addition, the air around the floor areas will be warmed up and create plumes which also affect the thermal comfort especially during the summer season. The same phenomena might improve the thermal comfort during the winter period.
Increased glazing area will lead to more daylight. However, the transmission losses through the windows will also be increased. Thus, there is a trade-off between the glazing area (which transmit the daylight) and the total energy use, thermal comfort and solar thermal load. The buildings equipped with new modern windowpanes with lower U-values and transmission losses as well as higher visible light transmittance, can have higher glazing areas, providing more daylight with acceptable thermal comfort during summer and at the same time keeping the energy use low [35]. Obviously, this comes with the penalty of higher initial cost of the windows.
The criteria in MB regarding daylight can be difficult to reach if designing and building a thick/deep building were the rooms are deeper than 6 m. Even though median DF can be used as indicator, it can be difficult to compensate the lack of daylight in the rooms with light areas closer to the windows. Getting enough daylight can also be a problem for tall buildings located in dense and highly populated city districts with narrow streets. Alternatively, if large balconies are blocking light from the sky. In addition, for residential building, some rooms such as bedrooms are protected so that the interior cannot be viewed from the neighbors and the privacy can be obtained. In such cases, if there are surrounding buildings, it will be challenging to receive enough daylight especially for rooms located in the lower floor levels.
It can therefore be discussed if it could be possible to adjust the indicator and focus on daylight demand in the rooms where there is less demand of privacy and accept lower DF in other rooms. Then rooms where people spend most of their awake time at home, like the dining or living rooms, would have to meet high DF criteria. A total median or medium DF in a whole apartment could also be another way to make the indicator more flexible. However, a risk could be that rooms with very poor DF conditions would be designed and built. The occupants view on the daylight could also be asked via questionnaires, especially in the rooms with low DF levels.
Internationally, there are examples that the limit values for sufficient amount of daylight are set differently depending on room and building function as opposed to the static approach, which is used in MB [43]. The indicator could also develop to use more dynamic daylight performance metrics that consider the quantity and character of daily and seasonal variations of daylight for a given building site [44]. Today the criteria are the same for a building independent if it is located in the northern and southern Sweden. Hence, one should consider implementing a more dynamic approach for daylight in MB.
In the material area, indicator 15
Building’s life cycle stages according to EN 15978 (2011) [
For the grade Silver and Gold, emissions from transports (Stage A4) are included as well as a requirement that a certain part of the life cycle analysis data comes from EPDs (Environmental Product Declarations). Gold rating requires proving of reduction of GHG emissions by at least 10% lower than the Silver level for the already chosen building design, frame and foundation. This can be done, for example, through changes of material choice, dimensions or quantities in the load-bearing structure.
When analyzing what impact the indicator has on greenhouse gas (GHG) emissions and energy use, there are a number of issues that can be discussed. To start with the indicator in general, it does not have absolute criteria with a specific absolute level of emissions that the building has to meet. This makes it difficult to compare the environmental performance of different buildings. However, for the Gold level is a relative decrease of 10% required. This type of relative criteria that credit an improvement compared to a reference building, is similar to indicators used in the American EAM LEED (Leadership in Energy and Environmental Design) [49] and the British BREEAM (Building Research Establishment Environmental Assessment Method) [50]. Moreover, the decrease is calculated relative to an optional pre-design that can be designed as a worst case scenario with high levels of embodied GHG emissions. Other research show that the GHG emissions from buildings can vary a lot, between 165 and 665 kg CO2e/m2 for residential buildings and 355–580 kg CO2e/m2 for office buildings (first quartile and third quartile) [46]. Therefore, 10% lower GHG emissions than a building with high levels of embodied GHG emissions can still be much higher than the average levels of embodied GHG emissions. At the same time it is difficult to set more absolute targets or criteria as there are many aspects of the design of a building that influence the choice of material and the amount of material needed in the load-bearing structure. The same reason makes it difficult to have a reference building or reference GHG emissions to measure the buildings performance against.
Moreover, for Bronze, only generic data may be used which will not promote choosing materials with lower environmental impact within a product or material group. For Silver and Gold, it is different. Then at least 50% vs. 70% of the climate impact for the production of the building materials need to be based on product-specific EPDs. Then specific products or materials can be promoted. A variety of parameters and methodological choices influence LCA and EPDs. The embodied GHG levels in the generic data used in LCA tools used for the MB assessment is therefore of great importance. Values can vary a lot making the choice of used data important [51]. For example, the median of embodied carbon per kg concrete is equal to 0.19 kg CO2e/kg, and has rather small variability of outcomes, (the interquartile range varies between 0.14 and 0.28 kg CO2e/kg), and the interquartile range of structural steel can vary between 1.7 and 2.8 kg CO2e/kg, with total variation ranging from 0.34 to 4.55 kg CO2e/kg [52]. The chosen generic embodied GHG emission data for steel can thus influence if the material is perceived as a more environmental material in comparison to another material with an EPD and what the buildings absolute calculated embodied GHG emissions will be.
As mentioned before, buildings embodied GHG emissions represent a large proportion of a buildings total life cycle emissions. In indicator 15, part of this embodied GHG emissions are included as only the load-bearing structure belonging to the frame is accounted for (here meaning load-bearing walls, pillars, beams, floors and foundation down to the drainage layer). Other parts of the building are not included, such as the building envelope or entire internal or external walls. Nor is technical equipment or finishing materials included.
Other studies indicate that variations regarding the embodied GHG for only the structure can be 200–350 kgCO2e/m2 and for the whole building 600–850 kg CO2e /m2 [53]. Thus, the embodied GHG in the structure can, according to this data, represent between 25 and 40% of the buildings total embodied GHG emissions. The embodied GHG emissions from a building can also be influenced by the building’s geographical contexts, climate zones and building type [46].
Another system boundary aspect is that all life cycle stages are not included; only stages A1-A4. Other life cycle phases such as maintenance, replacements or end of life, which deals with an uncertain future, are excluded. This is in line with the Cradle-to-Gate approach which is one of the three different life cycle models for buildings system boundary that EN 15978 proposes [54], which is used in EPDs. The other ones are Cradle-to-Grave, which also include buildings use phase and end of life impacts, and Cradle-to-Cradle which include potential benefits of reuse, recovery and/or recycling potentials. One consequence of MBs limited life cycle perspective is that material aspects linked to the future that may influence the environmental impact of a material during the use phase from a 50 to 100 year perspective are not taken into consideration. The benefits with long lasting products with low maintenance and replacement rate are thus not getting any credits. There is therefore a risk that suboptimizations are made. On the other hand is it not possible to have exact data beforehand regarding future management, refurbishments, service and end of life procedures. If not including future lifecycle stages in some way, the indicator does not differentiate between materials that are recyclable and non-recyclable. It is not clear how the environmental impact of recycled and reused products, or the potential benefits with reusing, or recycling the material should be calculated. For the generic data in the tool, materials with recycled content is not an option.
Another issue very close to the system boundary aspect is the room for variations in results when calculating the amount of materials that are included in the load bearing structure. Variations can be based on how detailed the structure is dimensioned, and the marginal regarding loads that has been used, as well as the detailing in calculation, for example if it is based on a BIM model or if it is based on general data linked to square meters of slabs, walls, etc. Variations in how Atemp is measured can also influence the results. If a building has a large garage, storage in the attic, or installation/service room for ventilation equipment that is heated above 10°C, it will be included as part of the Atemp. The number of square meters in Atemp will then increase and lower the calculated GHG emissions from the structure per square meter. This is the effect even though the amount of useable floor area in the building is the same as for a similar building without the same additional areas.
MB clearly states that it wants to promote the use of EPDs, which contain reliable and verifiable LCA-based information as a way to promote more specific and accurate LCA data for used materials. EPDs are in one way essential if wanting to compare and assess construction products environmental performance [55]. It is one way to get the building industry aware of the environmental impact from building products. However, there is no clear cause-effect relationship between environmental impact and use of EPD documented materials compared to materials lacking EPD. On one hand, companies doing EPDs will become aware of the GHG emissions and the EPD can also be an incentive motivating producers to develop and retailers to sell products with lower GHG emissions [56] which may promote development of products with lower embodied GHG emissions. On the other hand, local materials or reused materials produced by small and medium-sized enterprises (SMEs), local companies, or new startups might not have the economic power or see economic reasons for doing EPDs. They could then be outcompeted by other materials and larger companies who are able to put in the necessary investment in doing an EPD, which according to surveys are 13,000–41,000 USD and includes a workload of 22–44 person-days [56]. This can be a substantial cost for SMEs.
To achieve silver or gold Indicator 15 also demands documentation of transport of building material and products with generic information of GHG emissions from trucks, trains, boats and airplanes. This criteria has the potential to make building companies aware of the impact transportation distance and way of transport has on the GHG emissions. However, there are no criteria levels for total emissions from transport and there are no differentiation made between different fuels, even though there is a large difference in emissions from trucks with fossil fuels, bio-fuels or electricity as fuel and also between electric trains and trains using fossil fuels. These differences would be appropriate to include in such a calculation. If this is not included, the indicator will not push the industry towards using transportation methods with low emitting fuels.
With the current situation, Indicator 15 has no direct measurable impact on the lowering the embodied GHG emissions from buildings. The 10% reduction criteria for Gold could give some effect. However, the impact is dependent on what construction material that is used for the optional pre-design building that is improved. Moreover, to understand if this 10% reduction is enough for lowering the GHG emissions from the building structure, one has to look at how much the GHG emission levels for buildings need to be decreased and set benchmarks for buildings. Creating benchmarks is difficult and could be one reason why MB at this stage not has any absolute criteria regarding embodied GHG emissions. Benchmarks can be set in different ways. These can be based on a relative improvement of conventional buildings average GHG emissions. As more and more LCA studies are conducted, this type of data will increase and become more available, but there have already [57] been attempts to create benchmarks. The Swedish certification system NollCO2 or the Swiss SIA 2040 [58] are established benchmarks, which could be used. For example NollCO2 demands a reduction in energy use and GHG emissions from building materials (phase A1-A5) in comparison with calculated project specific reference building based on parameters for building materials and systems. Furthermore, measures to reach net zero through balancing the remaining GHG emissions are demanded [57]. Different types of reference buildings have different GHG emission criteria levels and the specific projects receives a project-specific limit value that is approximately 30% lower than the baseline, which is expressed in kgCO2e/m2 BTA. This varies between 140 and 312 kgCO2e/m2 depending on type of building, layout and design [59]. The Swiss SIA 2040 benchmark is based on the German Environment Agency goal of reducing GHG emissions to 1 t CO2e per capita per year by the year 2050 [60] to be able to achieve the target of staying below a global temperature increase of “well below 2 °C”. Benchmarks for GHG emissions from buildings represent 36% of these GHG emissions, i.e. 360 kg CO2e per capita per year. To follow the Swiss SIA with benchmarks with GHG emissions per capita the number of square meters per capita also needs to be decided upon. What would then be a reasonable level number of square meter per capita and for future GHG emission targets for buildings? As an example, four Swedish buildings that have been MB certified had embodied GHG emissions between 110 and 305 kg CO2e/Atemp. It is forecasted that there is a need to build 592,000 new homes until 2029 in Sweden [61], i.e. 65,778 homes per year, for a population that was 10.3 million inhabitants 2020 and is estimated to reach 11 million in 2029 [61]. If each home is 50 m2 this would result in 0.3 m2 new housing per year per inhabitant and 35–97 kg CO2e/ year per inhabitant in GHG emissions from the load bearing structure of these houses if built as the certified buildings. If compared to the Swiss SIA carbon benchmarks, GHG emissions from structure of new housing would represent 10–20% of the total GHG emission budget per inhabitant in Sweden. Working with lowering the embodied GHG emissions from building is thus an important issue. Especially in countries like Sweden where the GHG emissions from the average district heating and the Nordic electricity mix is comparably low (0.059 kg CO2e/kWh [62] vs. 0.090 kg CO2e/kWh [63], keeping in mind that MB and forthcoming mandatory climate declaration of buildings consider only phases A1-A5.
How and on what level the GHG benchmarks for buildings should be set has not been elaborated on more in this study. However, it can be concluded that to have ambitious and effective climate mitigation targets, it is necessary to develop clear targets that are transparent and consider both embodied GHG emissions and operational GHG emissions. This would be the next step for MB indicator 15 - to ensure that the impact influence building design to lower the buildings embodied GHG emissions. Despite the fact that indicator 15 does not have any benchmark levels at the moment, several certified buildings have only reached the Bronze level. The reason behind this is not clear. If they were searching for a total Gold score, they would have needed to have Silver on this indicator. If fixed benchmarks with GHG emission criteria would be welcomed or not by the buildings sector is difficult to know, but it is not promising when the indicators without benchmarks are not reached.
This study has scrutinized nine of the indicators with the strongest link to GHG emissions in the Swedish environmental assessment tool MB. It has highlighted a number of things with the indicators that influence what aspects of building that are assessed and has a potential to also influence the GHG emissions, building design and choice of building systems. It clarifies the strong link MB has to the Swedish energy regulations and how both MBs’ and BBRs’ energy aspects are linked to the national energy system.
In general, MBs certification system is highly appreciated covering different aspects of the energy use, indoor environment as well as the material choice of the building. The follow-up inspection (within three years after the built/renovation) verify the gained certification grade and guarantee sustainable choices and good performance. Therefore, MB is an effective system with a comprehensive view on environmental assessment of buildings. However, a few limitations with the indicators and how the criteria drive sustainable building design have been identified. To improve the assessment criteria and make it even more handy and applicable the most important conclusions are here presented for the areas Energy, Indoor environment and Material:
Conclusions regarding energy-related indicators:
The power demand of buildings addressed in MB is important to limit peak demand related emissions. Analysis of quantification methods and the criterions conclude that the unit for quantification, space heat losses divided by envelope area, may lead to less energy efficient building design; design outdoor temperatures or climate files for simulation should be based on future climate projections. The criterions set by MB involve energy factors, which do not reflect power demand.
The solar thermal load assessment serves to reduce cooling demand. The major criticism is whether or not STL should be allocated in junction with the summer thermal comfort indicator instead of in the energy area. Introduction of a cooling demand indicator as a whole (considering solar thermal, internal heat loads and climate changes) is more justified.
Energy use is completely based on BBR procedures, which is an advantage in the design and building permit processes. However, BBR criteria, hence MB’s criteria, are dependent on weighting factors to assess primary energy use. These are not primary energy factors. Instead of leading to neutrality among heating systems types, results are biased and may lead to increased emissions since characteristics of local energy systems are not considered. The question is linked to the indicator
Conclusions regarding the indoor climate indicators:
To guarantee an acceptable indoor air quality, it is not possible to compromise on the ventilation requirements in MB. Effective and energy efficient ventilation systems (with low SFPs and higher heat exchanger efficiencies and scheduled use based on the actual demand) are essential in order to get higher grades for MB indicators. For non-residential buildings, it is suggested that ventilation rates could be adjusted by the ventilation effectiveness in accordance with European Standard to incite energy-efficient air distribution systems.
A separate indicator for air tightness is suggested. It affects draft, thermal comfort, heat power demand and energy use. Expecting minimum air tightness for newly and modern building and rewarding airtight buildings could be an indicator merged with the indicator for ventilation. Airtightness measurements during the building process and after completion could be demanded to detect and fix possible air leakages.
To assure good thermal comfort, it is suggested that performed modeling and simulations are also made with representative weather for the specific location. The thermal comfort criteria in MB is based on PPD, calculated within the design temperature, DVUT, which is based on a 30-year period, available for 1981–2010. The weather during the measurement year might be quite different from a normal year, and this would affect the thermal comfort results. This yields in general for other indicators and for the calculation and simulation of the energy and thermal comfort.
The most important conclusions regarding the material indicator are:
The actual effect of the indicator on building design, GHG emissions and the environment can be questioned when the indicator does not include absolute criteria that demand a measurable reduction of the embodied GHG emissions.
There is a large part of the building that is not included in the LCA as it is not part of the load-bearing structure, and there are life cycle stages that not are considered. Therefore, the indicators lose the possibility to reduce GHG emissions from many building parts and do not encourage building with recyclable material or material with low environmental impact from a longer life cycle perspective.
Next step to assure the indicator pushes buildings to lower embodied GHG emissions would be to set some type of benchmarks for maximum embodied GHG emissions.
Moreover, a clearer distinction between local environmental aspects, which mainly concern local environment, health, and quality aspects, versus global environmental aspect would be welcomed. It would make the existing conflict between environmental quality and environmental loads, which affect building design, environmental assessment tools, and environmental decision-making in general, more visible.
MB is a certification system that pushes building design and the building sector towards more environmental and high-quality buildings. However, the indicators and criteria seam to beset to improve conventional buildings. To reach the environmental targets in the building and property sector, especially regarding GHG emissions, and make the urban transition that is necessary the indicators and criteria levels need to be adopted more towards these environmental targets.
The comments and fruitful discussions with Agneta Persson, Andreas Hagnell, Eje Sandberg, Jonas Gräslund and Mauritz Glaumann are deeply appreciated.
The authors declare no conflict of interest.
Funding of the study by the Swedish Energy Agency, E2B2 program, is greatly acknowledged (Dnr: 2018–016216).
Atemp | Floor area that is heated above 10°C |
Aenv | Building envelope area |
BBR | Boverket’s Building Regulations |
BIM | Building information modeling |
CFD | Computational fluid dynamics |
CHP | Combined heat and power plant |
CO2e | Carbon dioxide equivalent |
DF | Daylight factor |
DH | District heating |
DHW | Domestic hot water |
DVUT | Design winter outdoor temperature |
EPD | Environmental product declaration |
EPpet | Primary energy number |
Fgeo | Geographic factor according to BBR |
GHG | Green house gases |
gsys | Solar heat gain coefficient for windows and shading devices |
HLKK | Heat loss form factor |
HP | Heat pump |
LCA | Life cycle assessment |
MB | Miljöbyggnad |
PPD | Predicted percentage of dissatisfied |
SAD | Seasonal Affective Disorder |
SCOP | Seasonal coefficient of performance |
SFP | Specific fan power |
SGBC | Sweden Green Building Council |
STL | Summer thermal load |
USD | US Dollars |
IntechOpen - where academia and industry create content with global impact
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\\n\\nSara Uhac, COO
\\n\\nSara Uhac was appointed Managing Director of IntechOpen at the beginning of 2014. She directs and controls the company’s operations. Sara joined IntechOpen in 2010 as Head of Journal Publishing, a new strategically underdeveloped department at that time. After obtaining a Master's degree in Media Management, she completed her Ph.D. at the University of Lugano, Switzerland. She holds a BA in Financial Market Management from the Bocconi University in Milan, Italy, where she started her career in the American publishing house Condé Nast and further collaborated with the UK-based publishing company Time Out. Sara was awarded a professional degree in Publishing from Yale University (2012). She is a member of the professional branch association of "Publishers, Designers and Graphic Artists" at the Croatian Chamber of Commerce.
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\\n\\nAdrian Assad De Marco joined the company as a Director in 2017. With his extensive experience in management, acquired while working for regional and global leaders, he took over direction and control of all the company's publishing processes. Adrian holds a degree in Economy and Management from the University of Zagreb, School of Economics, Croatia. A former sportsman, he continually strives to develop his skills through professional courses and specializations such as NLP (Neuro-linguistic programming).
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\n\nBut, one thing we have in common is -- we are all scientists at heart!
\n\nSara Uhac, COO
\n\nSara Uhac was appointed Managing Director of IntechOpen at the beginning of 2014. She directs and controls the company’s operations. Sara joined IntechOpen in 2010 as Head of Journal Publishing, a new strategically underdeveloped department at that time. After obtaining a Master's degree in Media Management, she completed her Ph.D. at the University of Lugano, Switzerland. She holds a BA in Financial Market Management from the Bocconi University in Milan, Italy, where she started her career in the American publishing house Condé Nast and further collaborated with the UK-based publishing company Time Out. Sara was awarded a professional degree in Publishing from Yale University (2012). She is a member of the professional branch association of "Publishers, Designers and Graphic Artists" at the Croatian Chamber of Commerce.
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\n\nAlex Lazinica is co-founder and Board member of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his Ph.D. in Robotics at the Vienna University of Technology. There, he worked as a robotics researcher with the university's Intelligent Manufacturing Systems Group, as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and, most importantly, co-founded and built the International Journal of Advanced Robotic Systems, the world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career since it proved to be the pathway to the foundation of IntechOpen with its focus on addressing academic researchers’ needs. Alex personifies many of IntechOpen´s key values, including the commitment to developing mutual trust, openness, and a spirit of entrepreneurialism. Today, his focus is on defining the growth and development strategy for the company.
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Cabanelas"}]},{id:"53973",doi:"10.5772/66927",title:"Phenolic Compounds in Water: Sources, Reactivity, Toxicity and Treatment Methods",slug:"phenolic-compounds-in-water-sources-reactivity-toxicity-and-treatment-methods",totalDownloads:7324,totalCrossrefCites:77,totalDimensionsCites:170,abstract:"Phenolic compounds exist in water bodies due to the discharge of polluted wastewater from industrial, agricultural and domestic activities into water bodies. They also occur as a result of natural phenomena. These compounds are known to be toxic and inflict both severe and long‐lasting effects on both humans and animals. They act as carcinogens and cause damage to the red blood cells and the liver, even at low concentrations. Interaction of these compounds with microorganisms, inorganic and other organic compounds in water can produce substituted compounds or other moieties, which may be as toxic as the original phenolic compounds. This chapter dwells on the sources and reactivity of phenolic compounds in water, their toxic effects on humans, and methods of their removal from water. Specific emphasis is placed on the techniques of their removal from water with attention on both conventional and advanced methods. Among these methods are ozonation, adsorption, extraction, photocatalytic degradation, biological, electro‐Fenton, adsorption and ion exchange and membrane‐based separation.",book:{id:"6029",slug:"phenolic-compounds-natural-sources-importance-and-applications",title:"Phenolic Compounds",fullTitle:"Phenolic Compounds - Natural Sources, Importance and Applications"},signatures:"William W. Anku, Messai A. Mamo and Penny P. Govender",authors:[{id:"195237",title:"Dr.",name:"Messai",middleName:"A.",surname:"Mamo",slug:"messai-mamo",fullName:"Messai Mamo"},{id:"196465",title:"Dr.",name:"William Wilson",middleName:null,surname:"Anku",slug:"william-wilson-anku",fullName:"William Wilson Anku"},{id:"196466",title:"Dr.",name:"Penny",middleName:null,surname:"Govender",slug:"penny-govender",fullName:"Penny Govender"}]},{id:"36184",doi:"10.5772/36186",title:"Infrared Spectroscopy in the Analysis of Building and Construction Materials",slug:"infrared-spectroscopy-of-cementitious-materials",totalDownloads:7817,totalCrossrefCites:77,totalDimensionsCites:157,abstract:null,book:{id:"1591",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",title:"Infrared Spectroscopy",fullTitle:"Infrared Spectroscopy - Materials Science, Engineering and Technology"},signatures:"Lucia Fernández-Carrasco, D. Torrens-Martín, L.M. Morales and Sagrario Martínez-Ramírez",authors:[{id:"107401",title:"Dr.",name:"Lucia J",middleName:null,surname:"Fernández",slug:"lucia-j-fernandez",fullName:"Lucia J Fernández"}]},{id:"53128",doi:"10.5772/66368",title:"Phenolic Compounds: Functional Properties, Impact of Processing and Bioavailability",slug:"phenolic-compounds-functional-properties-impact-of-processing-and-bioavailability",totalDownloads:9393,totalCrossrefCites:78,totalDimensionsCites:149,abstract:"In this chapter, we discuss the influence of the processing methods on the content of phenolic compounds in fruits and vegetables. The intake of fruits and vegetables based‐foods are associated with delayed aging and a decreased risk of chronic disease development. Fruits and vegetables can be consumed in natura, but the highest amounts are ingested after some processing methods, such as cooking procedures or sanitizing methods. These methods are directly methods are directly related to alteration on the phenolic content. In addition, the postharvest conditions may modify several phytochemical substances. Phenolic compounds are referred to as phytochemicals found in a large number of foods and beverages. The relative high diversity of these molecules produced by plants must be taken into account when methods of preparation are employed to obtain industrial or homemade products. Phenolic compounds comprise one (phenolic acids) or more (polyphenols) aromatic rings with attached hydroxyl groups in their structures. Their antioxidant capacities are related to these hydroxyl groups and phenolic rings. Despite the antioxidant activity, they have many other beneficial effects on human health. However, before attributing health benefits to these compounds, absorption, distribution, and metabolism of each phenolic compound in the body are important points that should be considered.",book:{id:"5609",slug:"phenolic-compounds-biological-activity",title:"Phenolic Compounds",fullTitle:"Phenolic Compounds - Biological Activity"},signatures:"Igor Otavio Minatel, Cristine Vanz Borges, Maria Izabela Ferreira,\nHector Alonzo Gomez Gomez, Chung-Yen Oliver Chen and\nGiuseppina Pace Pereira Lima",authors:[{id:"146379",title:"Dr.",name:"Giuseppina",middleName:null,surname:"Lima",slug:"giuseppina-lima",fullName:"Giuseppina Lima"},{id:"194002",title:"MSc.",name:"Cristine",middleName:null,surname:"Vanz Borges",slug:"cristine-vanz-borges",fullName:"Cristine Vanz Borges"},{id:"194003",title:"Prof.",name:"Igor Otavio",middleName:null,surname:"Minatel",slug:"igor-otavio-minatel",fullName:"Igor Otavio Minatel"},{id:"194004",title:"Dr.",name:"Maria Izabela",middleName:null,surname:"Ferreira",slug:"maria-izabela-ferreira",fullName:"Maria Izabela Ferreira"},{id:"194005",title:"Prof.",name:"Hector",middleName:null,surname:"Gomez-Gomez",slug:"hector-gomez-gomez",fullName:"Hector Gomez-Gomez"},{id:"194006",title:"Prof.",name:"Chung-Yen Oliver",middleName:null,surname:"Chen",slug:"chung-yen-oliver-chen",fullName:"Chung-Yen Oliver Chen"}]}],mostDownloadedChaptersLast30Days:[{id:"55500",title:"Interpretation of Mass Spectra",slug:"interpretation-of-mass-spectra",totalDownloads:12524,totalCrossrefCites:12,totalDimensionsCites:25,abstract:"The chapter includes an introduction to the main ionisation techniques in mass spectrometry and the way the resulting fragments can be analysed. First, the fundamental notions of mass spectrometry are explained, so that the reader can easily cover this chapter (graphs, main pick, molecular ion, illogical pick, nitrogen rule, etc.). Isotopic percentage and nominal mass calculation are also explained along with fragmentation mechanism. A paragraph emphasises the ionisation energy issues, the basics of ionisation voltage, the developing potential and the energy balance. A frame time of the main theoretical milestones in both theory and experimental mass spectrometry is highlighted here. In the second part of the chapter, the molecular fragmentation for alkanes, iso-alkanes, cycloalkanes, halogen, alcohols, phenols, ethers, carbonyl compounds, carboxylic acids and functional derivatives, nitrogen compounds (amines, nitro compounds), sulphur compounds, heterocycles and biomolecules (amino acids, steroids, triglycerides) is explained. Fragmentation schemes are followed by the simplified spectra, which help the understanding of such complex phenomena. At the end of the chapter, acquisition of mass spectrum is discussed. The chapter presented here is an introduction to mass spectrometry, which, we think, helps the understanding of the mechanism of fragmentation corroborating spectral data and molecular structures.",book:{id:"5735",slug:"mass-spectrometry",title:"Mass Spectrometry",fullTitle:"Mass Spectrometry"},signatures:"Teodor Octavian Nicolescu",authors:[{id:"196775",title:"Dr.",name:"Teodor Octavian",middleName:"Octavian",surname:"Nicolescu",slug:"teodor-octavian-nicolescu",fullName:"Teodor Octavian Nicolescu"}]},{id:"57909",title:"Validation of Analytical Methods",slug:"validation-of-analytical-methods",totalDownloads:7023,totalCrossrefCites:13,totalDimensionsCites:23,abstract:"Method validation is a key element in the establishment of reference methods and within the assessment of a laboratory’s competence in generating dependable analytical records. Validation has been placed within the context of the procedure, generating chemical data. Analytical method validation, thinking about the maximum relevant processes for checking the best parameters of analytical methods, using numerous relevant overall performance indicators inclusive of selectivity, specificity, accuracy, precision, linearity, range, limit of detection (LOD), limit of quantification (LOQ), ruggedness, and robustness are severely discussed in an effort to prevent their misguided utilization and ensure scientific correctness and consistency among publications.",book:{id:"6379",slug:"calibration-and-validation-of-analytical-methods-a-sampling-of-current-approaches",title:"Calibration and Validation of Analytical Methods",fullTitle:"Calibration and Validation of Analytical Methods - A Sampling of Current Approaches"},signatures:"Tentu Nageswara Rao",authors:[{id:"220824",title:"Dr.",name:"Tentu",middleName:null,surname:"Nageswara Rao",slug:"tentu-nageswara-rao",fullName:"Tentu Nageswara Rao"}]},{id:"55440",title:"Solubility Products and Solubility Concepts",slug:"solubility-products-and-solubility-concepts",totalDownloads:3095,totalCrossrefCites:6,totalDimensionsCites:7,abstract:"The chapter refers to a general concept of solubility product Ksp of sparingly soluble hydroxides and different salts and calculation of solubility of some hydroxides, oxides, and different salts in aqueous media. A (criticized) conventional approach, based on stoichiometry of a reaction notation and the solubility product of a precipitate, is compared with the unconventional/correct approach based on charge and concentration balances and a detailed physicochemical knowledge on the system considered, and calculations realized according to generalized approach to electrolytic systems (GATES) principles. An indisputable advantage of the latter approach is proved in simulation of static or dynamic, two-phase nonredox or redox systems.",book:{id:"5891",slug:"descriptive-inorganic-chemistry-researches-of-metal-compounds",title:"Descriptive Inorganic Chemistry Researches of Metal Compounds",fullTitle:"Descriptive Inorganic Chemistry Researches of Metal Compounds"},signatures:"Anna Maria Michałowska-Kaczmarczyk, Aneta Spórna-Kucab and\nTadeusz Michałowski",authors:[{id:"35273",title:"Prof.",name:"Tadeusz",middleName:null,surname:"Michalowski",slug:"tadeusz-michalowski",fullName:"Tadeusz Michalowski"},{id:"203867",title:"Dr.",name:"Anna Maria",middleName:null,surname:"Michałowska-Kaczmarczyk",slug:"anna-maria-michalowska-kaczmarczyk",fullName:"Anna Maria Michałowska-Kaczmarczyk"},{id:"203868",title:"Dr.",name:"Aneta",middleName:null,surname:"Spórna-Kucab",slug:"aneta-sporna-kucab",fullName:"Aneta Spórna-Kucab"}]},{id:"62736",title:"Radioisotope: Applications, Effects, and Occupational Protection",slug:"radioisotope-applications-effects-and-occupational-protection",totalDownloads:4552,totalCrossrefCites:10,totalDimensionsCites:17,abstract:"This chapter presents a brief introduction to radioisotopes, sources and types of radiation, applications, effects, and occupational protection. The natural and artificial sources of radiations are discussed with special reference to natural radioactive decay series and artificial radioisotopes. Applications have played significant role in improving the quality of human life. The application of radioisotopes in tracing, radiography, food preservation and sterilization, eradication of insects and pests, medical diagnosis and therapy, and new variety of crops in agricultural field is briefly described. Radiation interacts with matter to produce excitation and ionization of an atom or molecule; as a result physical and biological effects are produced. These effects and mechanisms are discussed. The dosimetric quantities used in radiological protection are described. Radiological protections and the control of occupational and medical exposures are briefly described.",book:{id:"5903",slug:"principles-and-applications-in-nuclear-engineering-radiation-effects-thermal-hydraulics-radionuclide-migration-in-the-environment",title:"Principles and Applications in Nuclear Engineering",fullTitle:"Principles and Applications in Nuclear Engineering - Radiation Effects, Thermal Hydraulics, Radionuclide Migration in the Environment"},signatures:"Sannappa Jadiyappa",authors:[{id:"239626",title:"Dr.",name:null,middleName:null,surname:"Sannappa J.",slug:"sannappa-j.",fullName:"Sannappa J."}]},{id:"58596",title:"Linearity of Calibration Curves for Analytical Methods: A Review of Criteria for Assessment of Method Reliability",slug:"linearity-of-calibration-curves-for-analytical-methods-a-review-of-criteria-for-assessment-of-method",totalDownloads:8115,totalCrossrefCites:20,totalDimensionsCites:44,abstract:"Calibration curve is a regression model used to predict the unknown concentrations of analytes of interest based on the response of the instrument to the known standards. Some statistical analyses are required to choose the best model fitting to the experimental data and also evaluate the linearity and homoscedasticity of the calibration curve. Using an internal standard corrects for the loss of analyte during sample preparation and analysis provided that it is selected appropriately. After the best regression model is selected, the analytical method needs to be validated using quality control (QC) samples prepared and stored in the same temperature as intended for the study samples. Most of the international guidelines require that the parameters, including linearity, specificity, selectivity, accuracy, precision, lower limit of quantification (LLOQ), matrix effect and stability, be assessed during validation. Despite the highly regulated area, some challenges still exist regarding the validation of some analytical methods including methods when no analyte-free matrix is available.",book:{id:"6379",slug:"calibration-and-validation-of-analytical-methods-a-sampling-of-current-approaches",title:"Calibration and Validation of Analytical Methods",fullTitle:"Calibration and Validation of Analytical Methods - A Sampling of Current Approaches"},signatures:"Seyed Mojtaba Moosavi and Sussan Ghassabian",authors:[{id:"216099",title:"Dr.",name:"Sussan",middleName:null,surname:"Ghassabian",slug:"sussan-ghassabian",fullName:"Sussan Ghassabian"},{id:"216101",title:"Mr.",name:"Seyed Mojtaba",middleName:null,surname:"Moosavi",slug:"seyed-mojtaba-moosavi",fullName:"Seyed Mojtaba Moosavi"}]}],onlineFirstChaptersFilter:{topicId:"8",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"83036",title:"Continuous Scan and Repetitive Mode FT-IR Spectroscopy and Its Application in Isomeric Identification, Conformational Analysis and Photochemistry",slug:"continuous-scan-and-repetitive-mode-ft-ir-spectroscopy-and-its-application-in-isomeric-identificatio",totalDownloads:7,totalDimensionsCites:0,doi:"10.5772/intechopen.106448",abstract:"This chapter intends to cover the instrumentation of gas phase Fourier transform infrared spectroscopy (FT-IR), its recent advancement, and applications. The major focus have been given to the principle and data acquisition scheme of the repetitive mode measurement method of FT-IR spectrometer. The application of this spectroscopy in the isomeric identification of the methylated polycyclic aromatic hydrocarbons (MPAHs) and the conformational analysis of diols have been discussed. Furthermore, the application of the repetitive measurement mode of FT-IR combined with the UV laser in monitoring the atmospherically relevant photochemical reactions has been covered. In conclusion, this chapter briefly summarizes the current applications and discusses future applications of this technique in following drug degradation.",book:{id:"11564",title:"Infrared Spectroscopy - Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/11564.jpg"},signatures:"Prasanta Das"},{id:"83005",title:"Catalytic Behavior of Extended π-Conjugation in the Kinetics of Sensitizer-Mediator Interaction",slug:"catalytic-behavior-of-extended-conjugation-in-the-kinetics-of-sensitizer-mediator-interaction",totalDownloads:7,totalDimensionsCites:0,doi:"10.5772/intechopen.106511",abstract:"This chapter discusses the catalytic effect of extended π-conjugation on the electron transfer process between ferricyphen-ferrocyanide and ferricypyr-ferrocyanide in an aqueous medium. Ferricyphen and ferricypyr may be feasible options for the sensitizer in dye-sensitized solar cells due to their high reduction potential, stability, capability as an outer-sphere oxidant, and photosensitivity. Meanwhile, ferrocyanide could be used as a mediator in DSSCs instead of iodide to avoid iodate production and achieve a similar reduction potential and stability. This chapter compared the ability of competent putative sensitizers to oxidize the likely mediator in water. In contrast to the 2,2′-dipyridyl chelate, the extended π-conjugation in 1,10-phenanthroline accelerated the redox process by increasing the electron affinity of ferricyphen as compared to ferricypyr. The reactions had the same kinetics but different rate constants, indicating that the ferricyphen-ferrocyanide reaction was several times faster than the ferricypyr-ferrocyanide reaction, revealing and confirming the catalytic influence of extended π-conjugation on the redox process.",book:{id:"11217",title:"Recent Advances in Chemical Kinetics",coverURL:"https://cdn.intechopen.com/books/images_new/11217.jpg"},signatures:"Rozina Khattak"},{id:"83004",title:"Pyridine Heterocycles in the Therapy of Oncological Diseases",slug:"pyridine-heterocycles-in-the-therapy-of-oncological-diseases",totalDownloads:5,totalDimensionsCites:0,doi:"10.5772/intechopen.106406",abstract:"Oncological diseases pose a major challenge for modern medicine. Heterocyclic compounds play a vital role in modern medical and pharmaceutical science as most medicinal substances incorporate them. Nitrogen-containing heterocycles serve as the basis of numerous drugs and, therefore, are deeply involved in the design and synthesis of promising new therapeutic agents. Pyridine or pyrimidine scaffolds, with a number of substituents attached, comprise a large portion of FDA-approved drugs. They are chemically stable in the human body, manifest an affinity for DNA via hydrogen bonding, and present an opportunity for the development of novel anticancer agents. A large number of pyridine-based molecules are synthesized and tested for anticancer activity each year. The present chapter aims to introduce the most current synthetic approaches, published in scientific literature, and would also elaborate on structure-activity relationships described therein.",book:{id:"11562",title:"Chemistry with Pyridine Derivatives",coverURL:"https://cdn.intechopen.com/books/images_new/11562.jpg"},signatures:"Lozan T. Todorov and Irena P. 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This chapter presents an overview of the NFr, its characterization, the problems associated with adding NFr to polymer composites. This literature survey suggests an in-depth review of photocatalysis by utilizing photocatalysts nanoparticle (PHNPs) aimed at increasing the hydrophobicity and interfacial bonding between the NFr and the matrix Using a photo-induced oxidation mechanism to disassemble water molecules, pollutants, and bacteria in a wet environment. Additionally, we reviewed the effects of these PHNPs on the moisture absorption, mechanical characteristics, and dimensional stability of NFr composites. As a result, this review article may make a valuable contribution to researchers interested in coating and treating NFr to further enhance their surface characteristics.",book:{id:"11559",title:"Photocatalysts - New Perspectives",coverURL:"https://cdn.intechopen.com/books/images_new/11559.jpg"},signatures:"Mohammed Mohammed and Rozyanty Rahman"},{id:"82853",title:"Revealing Retention Mechanisms in Liquid Chromatography: QSRR Approach",slug:"revealing-retention-mechanisms-in-liquid-chromatography-qsrr-approach",totalDownloads:10,totalDimensionsCites:0,doi:"10.5772/intechopen.106245",abstract:"One-factor-at-a-time experimentation was used for a long time as gold-standard optimization for liquid chromatographic (LC) method development. This approach has two downsides as it requires a needlessly great number of experimental runs and it is unable to identify possible factor interactions. At the end of the last century, however, this problem could be solved with the introduction of new chemometric strategies. This chapter aims at presenting quantitative structure–retention relationship (QSRR) models with structuring possibilities, from the point of feature selection through various machine learning algorithms that can be used in model building, for internal and external validation of the proposed models. The presented strategies of QSRR model can be a good starting point for analysts to use and adopt them as a good practice for their applications. QSRR models can be used in predicting the retention behavior of compounds, to point out the molecular features governing the retention, and consequently to gain insight into the retention mechanisms. In terms of these applications, special attention was drawn to modified chromatographic systems, characterized by mobile or stationary phase modifications. Although chromatographic methods are applied in a wide variety of fields, the greatest attention has been devoted to the analysis of pharmaceuticals.",book:{id:"11557",title:"Chemometrics - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/11557.jpg"},signatures:"Jovana Krmar, Bojana Svrkota, Nevena Đajić, Jevrem Stojanović, Ana Protić and Biljana Otašević"},{id:"82796",title:"A Revisit of the Underlying Fundamentals in the Laser Emission from BODIPYs",slug:"a-revisit-of-the-underlying-fundamentals-in-the-laser-emission-from-bodipys",totalDownloads:15,totalDimensionsCites:0,doi:"10.5772/intechopen.106334",abstract:"This chapter aims to provide a comprehensive assessment of the laser performance of commercially available laser dyes based on the boron-dipyrromethene (BODIPY) chromophore in a liquid state, as well as to remark the main underlying photophysical signatures triggering such photonic behavior. First, we describe their light absorption and fluorescence properties in solution. This spectroscopic study is supplemented with quantum mechanics calculations and electrochemical measurements. Afterward, the dyes are tested as active media of tunable lasers under transversal pumping. The recorded laser efficiencies and photostabilities are correlated with the registered photophysical properties identifying the main structural guidelines and photonic parameters, which rule the laser bands’ position, intensity, and stability. As a result, we provide a comparative dataset of the laser performance, not available hitherto. Besides, the unraveling of the complex molecular structure-photophysics-laser relationship should help in the rational design of new tunable dye lasers with an improved photonic response along the entire visible region and reaching eventually the near infrared.",book:{id:"12081",title:"Dyes and Pigments - Insights and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/12081.jpg"},signatures:"Alaitz Peñafiel, Ainhoa Oliden-Sánchez, Edurne Avellanal-Zaballa, Leire Gartzia-Rivero, Rebeca Sola-Llano and Jorge Bañuelos"}],onlineFirstChaptersTotal:65},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:11,numberOfPublishedChapters:91,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:108,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:333,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:11,numberOfPublishedChapters:144,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:126,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:113,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:23,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:13,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{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"}}}},{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"}}}}]},series:{item:{id:"6",title:"Infectious Diseases",doi:"10.5772/intechopen.71852",issn:"2631-6188",scope:"This series will provide a comprehensive overview of recent research trends in various Infectious Diseases (as per the most recent Baltimore classification). Topics will include general overviews of infections, immunopathology, diagnosis, treatment, epidemiology, etiology, and current clinical recommendations for managing infectious diseases. Ongoing issues, recent advances, and future diagnostic approaches and therapeutic strategies will also be discussed. This book series will focus on various aspects and properties of infectious diseases whose deep understanding is essential for safeguarding the human race from losing resources and economies due to pathogens.",coverUrl:"https://cdn.intechopen.com/series/covers/6.jpg",latestPublicationDate:"August 18th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:13,editor:{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},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:16,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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Heshmati",slug:"comparative-senescence-and-lifespan",totalDownloads:17,totalCrossrefCites:0,totalDimensionsCites:0,authors:[{name:"Hassan M.",surname:"Heshmati"}],book:{title:"Mechanisms and Management of Senescence",coverURL:"https://cdn.intechopen.com/books/images_new/10935.jpg",subseries:{id:"11",title:"Cell Physiology"}}},{id:"81796",title:"Apoptosis-Related Diseases and Peroxisomes",doi:"10.5772/intechopen.105052",signatures:"Meimei Wang, Yakun Liu, Ni Chen, Juan Wang and Ye Zhao",slug:"apoptosis-related-diseases-and-peroxisomes",totalDownloads:11,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"The Metabolic Role of Peroxisome in Health and Disease",coverURL:"https://cdn.intechopen.com/books/images_new/10837.jpg",subseries:{id:"11",title:"Cell Physiology"}}},{id:"81723",title:"Peroxisomal Modulation as Therapeutic Alternative for Tackling Multiple Cancers",doi:"10.5772/intechopen.104873",signatures:"Shazia Usmani, Shadma Wahab, Abdul Hafeez, Shabana Khatoon and Syed Misbahul Hasan",slug:"peroxisomal-modulation-as-therapeutic-alternative-for-tackling-multiple-cancers",totalDownloads:18,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"The Metabolic Role of Peroxisome in Health and Disease",coverURL:"https://cdn.intechopen.com/books/images_new/10837.jpg",subseries:{id:"11",title:"Cell Physiology"}}}]},overviewPagePublishedBooks:{paginationCount:14,paginationItems:[{type:"book",id:"7264",title:"Calcium and Signal Transduction",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7264.jpg",slug:"calcium-and-signal-transduction",publishedDate:"October 24th 2018",editedByType:"Edited by",bookSignature:"John N. Buchholz and Erik J. Behringer",hash:"e373a3d1123dbd45fddf75d90e3e7c38",volumeInSeries:1,fullTitle:"Calcium and Signal Transduction",editors:[{id:"89438",title:"Dr.",name:"John N.",middleName:null,surname:"Buchholz",slug:"john-n.-buchholz",fullName:"John N. Buchholz",profilePictureURL:"https://mts.intechopen.com/storage/users/89438/images/6463_n.jpg",biography:"Full Professor and Vice Chair, Division of Pharmacology, Loma Linda University, School of Medicine. He received his B.S. Degree in Biology at La Sierra University, Riverside California (1980) and a PhD in Pharmacology from Loma Linda University School of Medicine (1988). Post-Doctoral Fellow at University of California, Irvine, College of Medicine 1989-1992 with a focus on autonomic nerve function in blood vessels and the impact of aging on the function of these nerves and overall blood vessel function. Twenty years of research funding and served on NIH R01 review panels, Editor-In-Chief of Edorium Journal of Aging Research. 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. He is the co-editor of The Open Biology Journal and associate editor for Oxidative Medicine and Cellular Longevity.",institutionString:"Universidad Nacional de La Plata",institution:{name:"National University of La Plata",institutionURL:null,country:{name:"Argentina"}}}]},{type:"book",id:"6924",title:"Adenosine Triphosphate in Health and Disease",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6924.jpg",slug:"adenosine-triphosphate-in-health-and-disease",publishedDate:"April 24th 2019",editedByType:"Edited by",bookSignature:"Gyula Mozsik",hash:"04106c232a3c68fec07ba7cf00d2522d",volumeInSeries:3,fullTitle:"Adenosine Triphosphate in Health and Disease",editors:[{id:"58390",title:"Dr.",name:"Gyula",middleName:null,surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik",profilePictureURL:"https://mts.intechopen.com/storage/users/58390/images/system/58390.png",biography:"Gyula Mózsik MD, Ph.D., ScD (med), is an emeritus professor of Medicine at the First Department of Medicine, Univesity of Pécs, Hungary. 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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In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. 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The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"117248",title:"Dr.",name:"Andrew",middleName:null,surname:"Macnab",slug:"andrew-macnab",fullName:"Andrew Macnab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of British Columbia",country:{name:"Canada"}}},{id:"322007",title:"Dr.",name:"Maria Elizbeth",middleName:null,surname:"Alvarez-Sánchez",slug:"maria-elizbeth-alvarez-sanchez",fullName:"Maria Elizbeth Alvarez-Sánchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",country:{name:"Mexico"}}},{id:"337443",title:"Dr.",name:"Juan",middleName:null,surname:"A. Gonzalez-Sanchez",slug:"juan-a.-gonzalez-sanchez",fullName:"Juan A. Gonzalez-Sanchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico System",country:{name:"United States of America"}}},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}}]}},subseries:{item:{id:"8",type:"subseries",title:"Bioinspired Technology and Biomechanics",keywords:"Bioinspired Systems, Biomechanics, Assistive Technology, Rehabilitation",scope:'Bioinspired technologies take advantage of understanding the actual biological system to provide solutions to problems in several areas. Recently, bioinspired systems have been successfully employing biomechanics to develop and improve assistive technology and rehabilitation devices. The research topic "Bioinspired Technology and Biomechanics" welcomes studies reporting recent advances in bioinspired technologies that contribute to individuals\' health, inclusion, and rehabilitation. Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11404,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. 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