The difference of characteristics for each body-mind approaches.
\r\n\tMany tried to define it, and its definition is always related to those who are in power, that being explained by the fact that this power and the abuse of it precisely, gives the access to being corrupted and practicing the acts that fall under corruption.
\r\n\r\n\tWe can find various types of corruption such as bribery, lobbying, extortion, cronyism, nepotism, parochialism, patronage, influence peddling, graft, and embezzlement. Also giving or accepting bribes or inappropriate gifts, double-dealing, under-the-table transactions, manipulating elections, diverting funds, laundering money, and defrauding investors.
\r\n\tNo government is immune to corruption. According to the World Bank, “the causes of corruption are always contextual, rooted in a country's policies, bureaucratic traditions, political development, and social history”.
\r\n\tThis indeed has consequences for increasing inequality, impacts government expenditure and services, shadow economy, and crime.
\r\n\tThis book will be a collection of chapters on Corruption. It welcomes contributions related to the nature of corruption its types and how corruption is undertaken in a certain context and the ways to deal with corruption will be part of this book. We value including materials on Corruption in organizations and ways to solve it. The origins of corruption and the way to deal with corruption, how to provide solutions, and any new insights on corruption will be part of this book.
",isbn:"978-1-80356-696-2",printIsbn:"978-1-80356-695-5",pdfIsbn:"978-1-80356-697-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"9cda6d2feaa52a6d523da74f2e2d7ffb",bookSignature:"Dr. Josiane Fahed-Sreih",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11772.jpg",keywords:"Corruption, Origins, Types, Corporate Governance, Organizational Performance, Solutions, Corruption Index, Private Sector, Lebanon, Accountability, Anti-corruption, Public Policy",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 23rd 2022",dateEndSecondStepPublish:"April 20th 2022",dateEndThirdStepPublish:"June 19th 2022",dateEndFourthStepPublish:"September 7th 2022",dateEndFifthStepPublish:"November 6th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"a month",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Fahed-Sreih is the director of the Institute of Family and Entrepreneurial Business and a chairperson in the Department of Management. She obtained a Ph.D. from Sorbonne University, France, and received the 2007 FFI International Award for outstanding achievement in furthering the understanding of family business issues between two or more countries. She is on the editorial board of the Journal of Family Business Management and a keynote speaker for corporate governance conferences.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"103784",title:"Dr.",name:"Josiane",middleName:null,surname:"Fahed-Sreih",slug:"josiane-fahed-sreih",fullName:"Josiane Fahed-Sreih",profilePictureURL:"https://mts.intechopen.com/storage/users/103784/images/system/103784.jfif",biography:"Dr. Josiane Fahed-Sreih is a full-time associate professor of Management in the School of Business, Lebanese American University. She is the founder and director of the Institute of Family and Entrepreneurial Business and a chairperson in the Department of Management at the same university. She was previously the assistant dean. She obtained a Ph.D. from Sorbonne University, Paris, France. Dr. Fahed-Sreih is the Middle East Coordinator for the Family Firm Institute (FFI), the USA, and a family wealth and family business consultant. She received the 2007 FFI International Award for outstanding achievement in furthering the understanding of family business issues that occur between two or more countries. She has participated in and organized international conferences, workshops, and seminars. She has presented at major conferences locally and internationally and consulted on management issues in many countries, including Saudi Arabia, Dubai, Jordan, Qatar, Kuwait, Syria, Bahrain, Oman, France, Cyprus, and Lebanon. She currently sits on five boards of directors as a shareholder, two as a chairman of the board, and one as an independent director in the private sector. She is also an advisor on boards of community service organizations. \n\nShe speaks regularly to trade and professional groups and presents her research at academic conferences worldwide. She is frequently invited as a keynote speaker to the recognized family business and corporate governance conferences. Her research interests are in management, family business, the functioning of boards of directors, and corporate governance. She has published three books, several book chapters, and academic articles in international journals. She is on the editorial board of the Journal of Family Business Management and is a reviewer for Family Business Review, Corporate Governance, and Journal of Management.",institutionString:"Lebanese American University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Lebanese American University",institutionURL:null,country:{name:"Lebanon"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"23",title:"Social Sciences",slug:"social-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"440212",firstName:"Elena",lastName:"Vracaric",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/440212/images/20007_n.jpg",email:"elena@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"63761",title:"Dynamic and Static Models of Body-Mind Approaches from Neurobiological Perspectives",doi:"10.5772/intechopen.81397",slug:"dynamic-and-static-models-of-body-mind-approaches-from-neurobiological-perspectives",body:'No doctor or medical treatment can be comparable in efficacy to the human feelings of joy and happiness [1]. The variety of feelings we have as humans and our process of recognition make our lives interesting and meaningful. The inter-individual differences in subjective feelings and the processes of recognition are affected by individual differences in our physical function [2]. The human mind comprises both a bottom-up peripheral nervous system and a top-down central nervous system interaction that controls it. For example, playing football or baseball, which are moderate whole-body exercises, creates feelings of happiness. It is thought that this is due to an increase in body temperature, which is the result of an increase in momentum. This rise in temperature leads to an improvement in autonomic nervous system control through exercising the muscles of the torso and other parts of the body, which we then recognize as positive emotions. Also, when people hear of painful experiences of those close to them (e.g., friends, significant others, family), this affects emotions in a way that makes the listener want to help. Altruistic behavior arises when we perceive changes in own body sensations in social interactions and when we guess the feelings of others. On the other hand, before people speak in public, individuals often have shortened breath and a rapid heartbeat, feelings we understand as being nervous. Subsequently we attempt to relax. Stress in both the workplace and academic situations increases our sympathetic nervous system, long-term stress which is difficult to control is harmful for physical and mental health. According to the World Health Organization, one in three people suffer from some type of psychiatric disorder, a statistic that holds true in many countries around the world. In Japan, the economic loss related to mental illness exceeds seven trillion yen yearly, a number that combines direct and indirect expenses. Psychiatric disorders can be interpreted as abnormalities in bodily functions due to external factors, and a breakdown in basic mental functions. For example, depression and anxiety disorder result in abnormalities in the control of cardiac autonomic nervous system. Also, persons with depression and anxiety disorder have abnormal functional connectivity between the prefrontal cortex and insula when compared to healthy subjects. Recently, there is increased attention to body-mind approaches as effective treatment for psychiatric disorders. However, as in terms of the treatment mechanisms of these body-mind approaches, there has been little discussion of a comprehensive framework from neurobiological perspectives. Therefore, the current paper explores two basic frameworks: (1) a dynamic and static model of body-mind approaches from neurobiological perspectives and (2) basic ethical guidelines of the body-mind approach when practicing in the fields of medical care and education.
Body-mind approaches (e.g., yoga, mindfulness meditation, Pilates method, and cognitive behavior therapy) are commonly used by the public today [3]. A body-mind approach focuses on the relationships between the brain, mind, body, and behavior, and their effects on health and disease [4]. To begin, we discuss the dynamic and static models of each body-mind approach from neurobiological perspectives, as well as from the standpoint of practical issues (Figure 1).
The dynamic and static model of body-mind approaches.
Yoga is constructed by practices of postures, breathing techniques, and meditation. Many of the elements of yoga that have been adjusted to Western cultures and became more popular in recent years focus on weight reduction through vigorous physical exercise. However, yoga in general not only aims to help people lose weight but also seeks to modulate an individual’s physical or mental condition during practice. Previous meta-analysis studies indicated that yoga is an effective intervention for psychiatric disorders [5, 6, 7]. Previous studies have demonstrated that yoga improves one’s brain functions and cortical thickness, resulting in improvements in attention control, emotional regulation, and meta-cognitive function. Interestingly, it also seems to improve telomere length and autonomic nervous control in both healthy individuals and those with physical ailments [8, 9, 10, 11, 12, 13, 14, 15, 16]. These results are interpreted as demonstrating that asana, breathing techniques, and meditation work interactively. Here, we explain the treatment mechanisms of asana, breathing technique, and meditation. We also illustrate the dynamic and static components that work in concert with asana, breathing techniques, and meditation.
Asana points to specific physical postures that involve using one’s whole body during yoga practice. These physical postures are categorized as standing, seated, and supine postures; they also include forward folds, adopted forward bend, back bends, hip-openers, twists, and inversions [17]. Some practices, such as Ashtanga Yoga, are characterized by quite intense and continuous physical motion with a focus on creating a “flow” of movement by linking one posture to the next. In other practices, such as Hatha Yoga, the movement is less dynamic and the focus is on holding individual postures for a longer period of time. The effect of asana during yoga practice is briefly explained in the following. First, we examine the effects of asana on autonomic nervous system as a result of exercise for the dorsal vertebrae, musculus erector spinae, musculus trapezius, latissimus dorsi muscle, and adductor longus muscle. Previous review articles have indicated that yoga intervention improved autonomic nervous system control for people with psychiatric disorders and individuals with cardiovascular disease [9, 15]. Iyengar yoga, which is characterized by improving toughness and stamina and correct body distortion, has been shown to reduce anxiety, depressive symptoms, anger, neurotic symptoms, and low frequency heart rate variability for people with depression [18]. According to Lakkireddy et al. [19], structured Iyengar yoga decreased anxiety, and depressive symptoms, while improving quality of life, heart rate, and systolic and diastolic blood pressure for individuals with arrhythmia burden. Streeter et al. [20] reported asana practice significantly increased brain GABA levels. Common asana, which includes exercise for the dorsal vertebrae, musculus erector spinae, musculus trapezius, latissimus dorsi muscle, and adductor longus muscle, is included in these studies. For example, the Sun Salutation, the most popular asana, was studied by Steer et al. [20]. It includes exercises for dorsal vertebrae, musculus erector spinae, musculus trapezius, latissimus dorsi muscle, and adductor longus muscle during flow movements. Adhomukhavirasana (modified child posture), which was used Lakkireddy et al. [19], expands the latissimus dorsi muscle and lower back. The latissimus dorsi muscle is related to extension of shoulder joint, and extending this muscle eases deep breathing (abdominal breathing). During Salamba Sarvangasana, which was used in Shapiro et al. [18], the focus in on individual exercise of the dorsal vertebrae and several muscles (e.g., musculus erector spinae, musculus trapezius, latissimus dorsi muscle, and adductor longus several muscle). We must not disregard the interaction between asana and abdominal breathing; however, from the evidence above, we speculate asana exercise improves autonomic nerve system control which should then lead to the improvement in the symptoms of psychiatric disorders. However, possible side effects of asana exercise should be carefully investigated. Asana is regarded as having bottom up treatment effects during yoga practice.
The conscious practice of altering breathing patterns may have a number of different effects depending on the characteristic of the practice [21]. For instance, slow and rhythmic breathing is said to promote a shift to parasympathetic dominance via vagal afferent stimulation with consequent stress reduction [22], whereas more forceful breathing practices may promote sympathetic activation [23]. Voluntary change of breathing patterns can alter emotional states and influence well-being [21, 24, 25]. In fact, a typical autonomic reaction to stressful situations is rapid thoracic breathing, which in turn leads to hyperventilation, altered tidal volume, and hypocapnia [26]. Yoga is a practice that emphasizes linking breath and movement. For example, in Ashtanga Yoga each asana is coupled to a specific breathing rhythm so that the specific breathing technique helps enhance movement. Sudarshan Kriya Yoga is a yoga practice that incorporates powerful breathing, Ujjiay—slow and forced breathing, 3 cycles per minute; Bhastrika—rapid exhalation at 20–30 cycles per minute; Sudarshan Kriya—rhythmic, cyclical breathing of slow, medium, fast cycles [21]. In the practice of yoga, various breathing methods such as chest respiration, which increases the sympathetic nervous system, and abdominal breathing, which increases the parasympathetic nervous system are used. Previous studies have demonstrated that yoga breathing techniques when used alone improved symptoms in patients with psychiatric disorders and healthy elderly individuals [27, 28, 29]. Santaella et al. [28] reported that the Sudarshan Kriya Yoga breathing technique significantly improves maximum expiratory and inspiratory pressures of pulmonary function, and significantly decreases low component and low frequency/high frequency ratio (marker of sympathovagal balance) of heart rate variability in healthy older individuals. Toschi-Dias et al. [29] demonstrated that the Sudarshan Kriya Yoga breathing technique improved subjective symptoms while decreasing sympathetic modulation and cardiac autonomic control; specifically, it was shown to increase parasympathetic modulation and cardiorespiratory coupling in in patients with anxiety-depression disorders. Intentional change for respiratory rhythms translates into changes in the neural activity of brainstem [30]. Both cardiorespiratory coupling and the cardiac autonomic nervous system are controlled by a network of neurons located within the lower brainstem [31, 32]. Based on this evidence, we hypothesize that yoga breathing techniques change brain stem activation in patients with psychiatric disorders and lead to improvements in the cardiac autonomic nervous system (mainly associated with parasympathetic nervous system) and cardiopulmonary coupling through the vagus nerve. These breathing techniques represent a top down treatment mechanism of yoga. Therefore, during yoga practice, participants experience both bottom up and top down effects of yoga, and these effects can improve cognitive functions. In the next section, we discuss a third treatment mechanism in yoga, a physical technique that improves cognitive function.
Resonance effects between bottom up and top down effects within individuals produced by yoga practice generate a third type of treatment effect. During an asana sequence, the range of motion in a person’s joints expands and joint load will largely be maintained at submaximal levels. As a result, physical stress increases over time, manifesting in the muscles, joints, and connective tissue. Therefore, by stimulating the autonomic nervous system, individual arousal is accelerated. As a result, subjective emotional reaction increases, which prompts avoidance behavior. These negative emotional reactions are similar to emotional reactions in negative situations individuals face in social contexts. This is a bottom up effect of yoga. On other hand, the yoga breathing technique used during asana sequence enhances parasympathetic nervous control and cardiopulmonary coupling. This top-down relax effect reduces the subjectively negative emotional reaction that occurs in the asana sequence. This is the top down effect of yoga. The bottom up and top down effects are functionally resonant within an individual during the asana sequence. These resonance effects reduce one’s subjectively negative emotional reaction and promote awareness of bodily sensations that produce them. Through this increase in body awareness, an individual can monitor (meta-cognition) perceived emotional events that may occur from moment to moment that arise in the context of yoga practice. Therefore, by enhancing meta-cognitive function, an individual’s emotion regulation and self-regulation in practical an aversive context are improved. Previous meta-analysis studies indicated that yoga intervention improved cognitive function for both people with psychiatric disorders and healthy individuals [33, 34]. Eyre et al. [12] reported that patients with mild cognitive impairment who participated in yoga classes had statistically significant improvements in alleviating depression and enhancing visuospatial memory. Jensen and Kenny [13] demonstrated that children with attention deficit hyperactivity disorder who participated in yoga intervention had significantly improved emotional lability at post intervention compared to pre intervention. Furthermore, some studies indicated that yoga intervention significantly enhanced body awareness in individuals with eating disorders [10, 11]. A previous neuroimaging study also demonstrated that gray matter volume of bilateral insula was positive correlated with pain tolerance, and also had positive correlation with yogic experience in yoga practitioners [16]. Additionally, another fMRI study reported healthy elderly yoga practitioners significantly increased gray matter volume in the left lateral prefrontal cortex compared to an age matched healthy control group [8]. The resonance effect of yoga promotes cognitive reappraisal of individuals in terms of negative emotional reactions faced in practical contexts. Cognitive reappraisal gained by the resonance effect of yoga may give new meaning to an individual’s emotional reactions, which in turn lead to improved emotional regulation and self-regulation. Thus, interoceptive awareness and monitoring are essential for most affective, cognitive, and interpersonal processes [35]. These observations suggest that the experience of yoga practice decreases avoidance behavior, and this experience may be generalized to other behaviors in social contexts. These are the dynamic components of yoga. Next we focus on meditation, which is a static component of yoga.
As a static component of yoga, meditation aims to develop mental silence and non-reactive consciousness. Before yoga meditation, participants are instructed to maintain focus on abdominal breathing and observe their interoceptive and physical sensations while keeping their minds blank. During yoga meditation, individuals develop awareness of both their inner experience, and how this experience functions on a meta-cognitive level. Here, the top-down control of using abdominal breathing reduces the emotional response occurring in an individual during meditation. One’s awareness of both their emotional reactions and body are enhanced due to the resonance effect generated by the dynamic component of yoga. Through these effects, individuals can observe emotions and thoughts objectively (non-reactive) without being caught up in them. Static components of yoga promote cognitive reappraisal of one’s self as a baseline. Therefore, static components are also found for mindfulness meditation.
Mindfulness can be defined as the ability to observe thoughts, and bodily sensations or feelings in the present moment with an open and accepting orientation toward one’s experiences [36]. Mindfulness meditation that develops mindfulness uses abdominal breathing in a way similar to yoga, and it is seen as a body-mind approach with static components. Mindfulness meditation has been employed for centuries within Buddhist traditions, yet it is has only been since the 1970s that mindfulness has become a target of intervention for several psychological problems [37]. Through facilitating awareness and non-judgmental acceptance of moment-to-moment experiences, these mindfulness-based meditation techniques alleviate intense emotional states [37, 38]. As evidenced by previous meta-analyses, mindfulness meditation based intervention has proven effective in reducing psychological distress, anxiety, depression, and improving well-being and quality of life in individuals with mental disorders [39, 40, 41]. In this section, we explain the interaction between three types of meditation (focused attention meditation, open monitoring meditation, and compassion meditation) and breathing technique; these are basic techniques that employ several types of mindfulness meditation.
Meditation that develops mindfulness consists of three types of meditation: focused attention meditation, which improves concentration abilities, open monitoring meditation, which improves the ability to monitor our experiences without reactions or judgments, and compassion meditation, which integrates focused attention meditation and open monitoring meditation [42, 43]. Focused attention meditation is a type of systematic training aimed at directing and sustaining attention on a chosen neutral object (e.g., the breath), noticing when the mind wanders from the object, and disengaging from distractions, negative emotions, rumination, or worry by redirecting or shifting one’s attention back to the chosen neutral object [42]. Focused attention meditation cultivates both calmness and stability of mind and reduces attention on negative thoughts and emotions [42]. Open monitoring meditation does not involve any specific object of focus, nor does it focus on disengagement from negative thoughts or emotions or expecting them to diminish [42]. Open monitoring meditation entails cultivating non-reactive awareness of automatic cognitive and emotional interpretations of sensory, perceptual, and endogenous stimuli, regardless of valence [42]. During compassion meditation, meditators focus on developing love and compassion first for themselves and then gradually extend this love to evermore “unlikeable” others, and various other creatures [44]. Compassion meditation is often entails that helps practitioners develop cognitive schemas which cultivate a sense of equanimity and hopefulness. According to a previous review article [45], mindfulness meditation, which consists of focused attention meditation, open monitoring meditation, and compassion meditation, enhances attention control, emotional regulation, and self-awareness in both healthy subjects and individuals with psychosis. Goldin and Gross [46] reported that mindfulness meditation intervention improved self-esteem, and lessened anxiety and depressive symptoms. They additionally reported reduced amygdala activity that corresponded to emotional reactivity during reacting to negative self-beliefs in people with social anxiety disorder. Tomasino and Fabbro [47] demonstrated that focused attention meditation increased activation in the right dorsolateral prefrontal cortex and in the left insula, and that it decreased activation in the rostral prefrontal cortex and in right parietal area. According to Fujino et al. [48], both focused attention meditation and open monitoring meditation specifically reduced functional connectivity between the striatum and posterior cingulate cortex, which is a core hub region of the default mode network. Additionally, open monitoring meditation reduced functional connectivity of the ventral striatum in both the visual cortex related to intentional focused attention in the attentional network and the retrosplenial cortex related to memory function in the default mode network. In contrast, focused attention meditation increased functional connectivity in these regions. Furthermore, other previous studies revealed stronger neural responses to emotional sounds in the anterior insula and anterior cingulate cortex during compassion meditation than when an individual was in a resting state [49, 50]. From these reports, we speculate that mindfulness meditation increases emotional regulation, attention control, and self-awareness. Additionally, we assume the abdominal breathing technique, which is a physical movement, is enormously important in this respect.
Prior to mindfulness meditation, participants are instructed to focus on breathing and to let their minds wander, not to focus attention on worries or negative thoughts [51]. Previous studies demonstrated that mindfulness breathing technique used alone alleviated subjective distress and improved meta-cognitive function, emotional non-reactivity, and autonomic nervous control in healthy individuals and those with physical ailments [51, 52, 53]. According to Ng et al. [53], 5 minutes of brief mindfulness breathing technique lessened subjective distress, and improved blood pressure, pulse rate, and breathing rate in subjects in palliative care cancer patients. Furthermore, Arch and Craske [51] indicated that 15 minutes of mindfulness breathing enhances an individual’s emotional non-reactivity during presentation of negative pictures. Based on these reports, focused attention on breathing is seen to reduce the attention given to distressing experiences or thoughts, and abdominal breathing reduces the role of the sympathetic nervous system and increases that of the parasympathetic nervous system during distressing experiences or thoughts.
The purposes of mindfulness meditation, which is one of the body-mind approaches including static components, alleviate intense emotional states and self-awareness for psychological problems accompanied by aversive emotions, and develop cognitive schemas, which cultivate a sense of equanimity and hopefulness. Here, the psychological problems accompanied by aversive emotions include the problem that is currently occurring and occurred in the past. Participants develop the objective monitoring function for inner emotions and thoughts without being caught up in them during focused attention meditation and open monitoring meditation. It should be also noted that participants observe psychological problems that are obstacles to cultivating love and compassion for themselves and others with objectively monitoring function during compassion meditation too. Therefore, we hypothesize that these meditations enhance individuals’ metacognitive function. Furthermore, before each mindfulness meditations, participants are instructed to maintain focus on abdominal breathing. The top-down control of using abdominal breathing reduces the emotional response occurring in an individual during each meditation. There is suggested that these effects promote cognitive reappraisal of psychological problems which forming the core of the current self and as a result develop cognitive schemas which cultivate a sense of equanimity and hopefulness. This is the effect of the static component which adjusts baseline of self. Thus far, we have explained the characteristics and therapeutic effects of yoga and mindfulness respectively. Mindfulness meditation and yoga are both body-mind approaches which have static components. In addition, previous studies for patients with psychiatric disorders have demonstrated that symptom reduction via attention control, emotional control, and self-awareness are viable treatment mechanisms. On the other hand, mindfulness meditation does not have a dynamic component. Individuals must continue to focus on their own interoceptive sensations and breathing during mindfulness meditation. However, with the dynamic component of yoga, participants are able to automatically focus on their interoceptive sensations or breathing. We assume that yoga-based interventions may be more appropriate for ADHD children who have difficulty sustaining attention. Recently, in order to overcome the problems that currently exist in psychotherapy, yoga, mindfulness, and other body-mind approaches have been aggressively promoted for patients with mental disorders. For example, the aim of conventional cognitive behavioral therapies has been to modify maladaptive cognitive content affecting emotions and behavior. On the other hand, when cognitive behavioral therapy for major depressive disorder is performed, if negative self-cognitive modification is incomplete, it can lead to a return of symptoms [54]. There are also problems in the change of cognitive bias for patients with PTSD, which can increase their pain and emotional burden. These issues can lead to individuals dropping out of the treatment protocol [55, 56, 57]. Therefore, there has been more attention given to body-mind approaches that have an effect on cognitive functions through bodily functions. However, in terms of body-mind approach treatment mechanisms, there has little discussion of a comprehensive framework based on the dynamic and static component models. In the next section we examine the Pilates method, which is another body-mind approach, and behavior activation, a third generation cognitive behavior therapy.
Pilates method was developed in the 1920s by Joseph Pilates and consists of comprehensive body conditioning, which aims to develop better body awareness and improve posture. The Pilates method requires core stability, strength, and flexibility, as well as attention to muscle control, posture, and breathing [58]. At first, the Pilates method gained popularity in rehabilitation settings [59]; however, in recent years Pilates based exercise has become popular among the general population. In the modern Pilates method, after adjusting one’s breath (a costal breathing technique), an individual performs a series of approximately 25–50 simple, low-impact flexibility and muscular endurance exercises with emphasis on muscular exertion in the abdominals, lower back, hips, thighs, and buttocks in combination with timed breathing [60, 61]. The Pilates method is one of the body-mind approaches featuring a dynamic component. According to previous meta-analysis studies, the Pilates method improves physical flexibility, dynamic balance, and muscular endurance in healthy people [62], as well as physical balance in older adults [63]. Additionally, some randomized controlled trials studies have demonstrated that the Pilates method improved subjective degree of pain, subjective degree of disability, and kinesiophobia [62, 64, 65]. However, to the best of our knowledge, few studies have investigated intervention effects of the Pilates method for symptoms of psychiatric disorders, as compared to the research in this area employing other body-mind approaches. We assume that the primary objective of the other body-mind approaches is improving mental condition, while the primary goal of Pilates method is to improve physical health. Second, we speculate that present interventions which use the Pilates method are not sufficient to be effective for psychiatric disorders. However, if the dynamic component of the Pilates method could be adjusted, it is possible this method could be an effective intervention for some psychiatric disorders. In the next section we examine the potential intervention effect of the Pilates method for individuals with psychiatric disorders.
In the Pilates method, participants adjust their physical condition using costal breathing before exercise. This is one of the main differences from yoga. As previously mentioned, costal breathing increases the activity of the sympathetic nervous system. This boost of the sympathetic nervous system both increases the heart rate and enhances the metabolism of one’s body. We speculated that if the aim of the Pilates method is dieting or physical fitness for healthy individuals, this breathing technique is appropriate. However, previous meta-analysis studies have demonstrated that patients with psychiatric disorders had reduced high frequency of heart rate variability (which is influenced by the parasympathetic nervous system) compared to healthy subjects [66, 67]. Therefore, we consider that it may be better to adopt the breathing technique which increases parasympathetic activity, such as abdominal breathing, in the Pilates method. In fact, a numerous interventions which use the modern Pilates method have adopted this breathing technique [58]. However, these techniques are used only to adjust physical condition prior to exercise and are not used during exercise. We assume if one adjusts abdominal breathing while engaging in an easy pose, such as a “cat stretch” or “mermaid stretch”, the effects of the dynamic component of Pilates method may be more effective. In this case, the Pilates method may be an effective intervention for psychiatric disorders.
Based on the approach of Lewinsohn et al. [68], behavioral activation is focused on enhancement of self-monitoring, increasing healthy goal-oriented behavior, and increasing environmental reward frequency. In the course of behavioral activation interventions, participants monitor and assess their daily activities and work to change their habitual behaviors in a way that aims to increase pleasant events and interactions and reduce depressive symptoms [69]. Behavioral activation is another body-mind approach including a dynamic component. Previous meta-analysis studies have demonstrated that behavioral activation is an effective treatment for depression [70, 71]. Dimidjian et al. [72] indicated that treatment effects of behavioral activation are comparable in efficacy to pharmacological therapy for individuals suffering from depression. Our previous studies reported that behavioral activation improved abilities both to access positive reinforcing activities and to engage in rewarding behaviors under adverse circumstances [73, 74]. Additionally, Jacobson et al. [69] showed behavioral activation significantly improved self-concept in people with depression. A few previous neuroimaging studies have also demonstrated that behavioral activation enhances one’s cognitive function and corresponds to brain activations in people with subthreshold depression [75, 76, 77]. Specifically, our previous studies indicated that brief behavioral activation had increased activation in the dorsomedial prefrontal cortex in individuals with subthreshold depression, which is associated with meta-cognitive function, and that this activation is also correlated with an improvement in depressive symptoms [76, 77]. Based on these reports, we hypothesized that there should be two treatment mechanisms of behavioral activation for depression. The first is involved in reducing depressive symptoms to improve the reward system, and the second involved in improving depressive symptoms to enhance meta-cognitive function. Future research is needed to verify the above hypotheses related to these two treatment mechanisms.
The primary purpose of medical research involving human subjects is to understand the causes, development, and effects of diseases and improve preventive, diagnostic, and therapeutic interventions (methods, procedures and treatments). Even the best proven interventions must be evaluated continually through research for safety, effectiveness, efficiency, accessibility, and quality [78]. In this section we review four body-mind approaches that have gained attention in recent years. Each approach has different characteristics (see Table 1). Here, for practitioners and researchers, we discuss the current and future issues of each approach. First, further neurobiological examination is necessary for the body-mind approach. For example, yoga and mindfulness are speculated to be very similar approaches in their emphasis on enhancing attention control, emotional regulation, and self-awareness which using one’s interoceptive sensations or breathing. However, to the best of our knowledge, there are few neurobiological studies that compare yoga and mindfulness. This is also true for research comparing the effects of the Pilates method to other approaches. A second important point regards the enhancement of treatment effects in each of the body-mind approaches. According to a previous meta-analysis study [79], the treatment effect of yoga is not sufficient compared to other types of active control (Hedges’ g = 0.30). However, this study did not fully examine the therapeutic effect of each asana. We assume that a structured asana sequence is necessary to more greatly enhance the therapeutic effect of yoga. Third, as we noted above, there are many therapies applying the mindfulness meditation in recent years (e.g., dialectical behavior therapy, mindfulness-based cognitive therapy, and acceptance and commitment therapy). This is because the disease to be treated, the duration of the treatment effect, and the intervention duration are different for each therapy. On the other hand, it can be more conveniently implemented by someone, and versatility treatment is necessary. Thereby, it is necessary to examine the treatment model used in conventional mindfulness-based therapies from neurobiological perspectives to extract essential factors. Furthermore, new mindfulness meditation-based treatment, which integrates essential factors in conventional mindfulness-based therapies, should be developed. Forth, we speculate it is necessary to examine the treatment effects of body-mind approach for not only basic emotions (e.g., fear, anger) but also complex emotions (e.g., awe, shame) and social cognition. A few previous studies [80] indicated that mindfulness meditation alleviated subjective symptoms of anxiety and enhanced social skills for people with learning disabilities. From the evidence, it could be considered that other body-mind approaches may enhance complex emotions and social cognition. It is necessary to provide a higher-quality body-mind approach based on previous evidence that can be adjusted to fit the needs of medical institutions and school schedules. Finally, the research that uses the body-mind approach for psychiatric disorders is at an early stage at present. We speculate that it is necessary to establish more detailed ethical guidelines for each approach corresponding high-quality body-mind approach in the near future.
Dynamic component | Static component | Subject | Degree of structuralization | Intervention effect | |
---|---|---|---|---|---|
Yoga | Asana sequence and abdominal breathing | Meditation | Healthy -mental diseases | Medium | Medium |
Mindfulness meditation | — | Meditation | Healthy -mental diseases | High | High |
Pilates method | Pose sequence and costal breathing | — | Healthy | Medium | Low |
Behavioral activation | Positive activities | — | Healthy -mental diseases | Low | High |
The difference of characteristics for each body-mind approaches.
In this chapter, we introduced and discussed neurobiological treatment effects and mechanisms of yoga, mindfulness meditation, Pilates method, and cognitive behavior therapy. In recent years, these body-mind approaches have been actively adopted in the educational and medical fields in Western countries. In the future, it is necessary to clarify the detailed neurobiological mechanisms of each body-mind approach and provide higher quality service in both medical and educational settings. At the same time, we should also extend knowledge and technology to countries and regions where body-mind approaches are not widely available.
This article was supported by a Grant-in-Aid for the Japan Society for the Promotion of Science (JSPS) fellows (18J01157).
None of the authors have any conflicts of interest to declare regarding the findings of this study.
Shoulder surgery by arthroscopy or open methods has increased in recent years. The choice of anesthetic technique depends on the patient’s conditions, the preferences of the surgical group, the position the patient is to be placed, and the experience of the anesthesiologist. General anesthesia (GA) has been considered the ideal technique for this type of surgery, but advances in regional anesthesia have gradually changed this statement. The approaches, interscalene (ISBP) block (C5 C6) or the upper trunk (UT) are the most established options; the supraclavicular approach offers optimal coverage, including the proximal arm. Patients with respiratory compromise may not tolerate hemi diaphragmatic paresis (HDP) associated with proximal approaches. Distal approaches are associated with lower rates of HDP, but coverage of the proximal upper extremity may be incomplete. The use of ultrasound guidance (USG) for nerve blocks has increased success and safety and has allowed access to more peripheral brachial plexus blocks to prevent diaphragmatic paralysis. Regional anesthesia is also an excellent supplement to GA to improve postoperative pain management and decrease the need for opioid use.
Clavicle surgery has even more controversy about the choice of the regional block, since the innervation has not been well described. But in recent years, alternative regional block methods to interscalene brachial plexus block have appeared that are suitable as single anesthesia or combined with sedation or GA.
In this chapter, we pretend to describe the innervation of the shoulder and clavicle based on current knowledge and the sonoanatomy of the neck and armpit as a guide for the performance of regional nerve blocks.
Since shoulder surgeries produce severe postoperative pain, regional anesthesia techniques could effectively control pain at rest and in motion, reduce muscle spasm and facilitate early discharge [1].
The BP is formed by the fusion of the ventral ramus of the spinal nerves C5, C6, C7, C8, and T1, with the variable contribution of C4 (15-62% of cases) and T2 (16-73% of cases). The roots emerge in the groove between the anterior scalenus and middle scalenus muscles [2]. Shoulder and proximal arm innervation are provided by branches of the BP: suprascapular nerve (SSN) (from posterior division of UT), axillary and subscapular nerves (from posterior cord), lateral pectoral nerve, and medial brachial cutaneous nerve (MBCN)) (from lateral cord), and the intercostobrachial nerve (ICBN) (originating directly from proximal intercostal nerves). SSN may be spared by an infraclavicular approach (Figure 1) [3, 4].
Brachial plexus. Roots – Start in the spinal cord. Arise from anterior rami C5-T1. Landmark: Pass inferolateral between the anterior and middle scalene muscles. Trunks
The most frequently identified innervation pattern comprises three nerve bridges consisting of articular branches from suprascapular, axillary, and lateral pectoral nerves, connecting trigger points (Figures 2 and 3) [5, 6, 7].
Distribution of shoulder articular branches. Courtesy of MF Rojas.
Shoulder structures and their related innervation.
Articular branches classified in relation to the spinoglenoid notch:
Medial branch (MSAb) originates 1.3 cm proximal to the suprascapular notch, giving branches to the coracoclavicular ligaments and the medial pole of the subacromial bursa, clavicular insertion of the acromioclavicular ligament, and motor branches to the supraspinatus muscle.
Lateral branch (LSAb) originates at the level of the suprascapular notch, giving sensory branches to the lateral subacromial pole and acromial insertion of the acromioclavicular ligament. Two subacromial branches provide medial and lateral sensory innervation (bipolar) to the subacromial bursa.
The posterior glenohumeral branch (PGHb) originates at 3 cm from the suprascapular notch, and posterior to the spinoglenoid ligament, course inferomedial towards the posterior capsule of the shoulder [8].
One or two articular branches of the main trunk travel with the anterior humeral circumflex artery between the tendons of the subscapular and latissimus dorsi muscles branching into medial branch to scapular aspect of the anteroinferior capsule and portions of the axillary recess; lateral branch to humeral portion of the anterior capsule [6]. The posterior division (after leaving the quadrangular space) gives a branch for the teres minor muscle, from which emerge 1 to 4 articular branches, to innervate the posteroinferior capsule. The branch innervating the deltoid muscle gives small multiple articular branches towards the lateral aspect of the humeral head the posterior and lateral supra-lying fascia of the shoulder capsule [6, 9, 10].
The LPN arises from two branches of the anterior divisions of the upper and middle trunks (33.8% of cases), or as a single root of the lateral cord (23.4%). It receives fibers from C5 to C7. Cross the superomedial side of the coracoid process and sends small branches to the coracoclavicular and coracoacromial ligaments, anterior acromioclavicular joint, subacromial bursa and anterosuperior portion of the glenohumeral capsule. It gives branches to the periosteum of the clavicle. Therefore, its blockade produces analgesia for distal clavicle surgery [6, 11]. The muscular branch originates from the articular branch of the LPN and innervates the deltoid muscle and skin over the subacromial region (Figure 4) [7, 11].
Lateral pectoral nerve.
A glenohumeral articular branch anastomosis with branches of the AN to innervate the long head of the biceps tendon (LHBT) and anterior capsule. The superior subscapular nerve gives 1 or 2 articular branches to innervate the anterosuperior quadrant of the glenohumeral joint [12]. Receives fibers for C5-C6.
The
Mechanoreceptors are more concentrated in the medial and lateral insertions of the anterior capsule. Nociceptors are identified primarily in the upper quadrant of the shoulder, including the subacromial bursa (SAB), glenohumeral ligaments (GHL), coracoacromial (CAL), coracoclavicular ligaments (CCL), the proximal portion of the LHBT, and the transverse humeral ligament (THL). The SAB is the area of densest and tripolar nociceptive innervation. These three nociceptive poles may correspond to the location of the lateral/medial subacromial branches of the SSN (i.e., lateral and middle poles) and the articular branch of the lateral pectoral nerve LPN (anterior pole); Thin articular branches of the AN may also participate in the innervation of the lateral pole of SAB [6].
The most painful structures in clavicle surgery include the skin over the incision area and the highly innervated periosteum. The supraclavicular nerve originates as a single trunk from the anterior ramus of cervical nerves C3-C4. It divides into medial (suprasternal), intermediate (supraclavicular), and lateral (supra-acromial) branches. The medial branch supplements the skin over the anterior aspect of the thorax, as far below as the second rib, and the sternoclavicular joint. The intermediate branch pierces the deep cervical fascia just above the clavicle and runs over the pectoralis major and deltoid muscle; supply cutaneous innervation to the skin above these muscles, as far below as the second rib. The lateral branch pierces the deep cervical fascia just above the clavicle, passes over the acromial process, to innervate skin of the upper and posterior shoulder regions (Figure 5) [13, 14].
Nerves involved in clavicular innervation.
Innervation of the clavicle itself is less well described. Different authors attribute contributions from SSN, long thoracic, nerve for the subclavian muscle, and LPN [15].
Situated posterior to the clavicular part of the pectoralis major muscle. It extends from the clavicle, costochondral joints, and coracoid process. It converges in the axilla and acts as a protective structure over the neurovascular package. The clavicular fascia splits to enclose the subclavius muscle before attaching to the clavicle, the posterior layer fuses with the deep cervical fascia which connects the omohyoid muscle to the clavicle. Medially, it is attached to the first rib before coming together with the fascia over the first two intercostal spaces. Laterally, it is attached to the coracoid process before blending with the coracoclavicular ligament. The fascia often thickens to form the costocoracoid ligament, between the first rib and coracoid process. Inferiorly, the fascia becomes thin, splits around pectoralis minor, and descends to blend with the axillary fascia and laterally with the fascia over the short head of the biceps. It is pierced by CALL [cephalic vein, artery (thoracoacromial), lateral pectoral nerve, lymphatics]. The clavipectoral fascia surrounds the clavicle, and the nerve endings of the clavicle penetrate this fascia (Figure 6) [16].
Clavipectoral fascia.
Interscalene or supraclavicular block of the BP are considered the standard technique for anesthesia and analgesia in this type of surgery. The most common adverse effect is HDP due to ipsilateral PN block in 100% of patients and a 27% decrease in forced vital capacity and forced expiratory volume at the first second [17]. At the level of the cricoid cartilage (C6 transverse process (TP)) the PN is 0.18 cm prior to the BP, but it diverges at a rate of 3 mm for each centimeter below the cricoid cartilage.
USG has allowed to decrease the anesthetic minimum volume required in 50% of patients (5-7 mL vs. 30-40 mL) using ropivacaine 0.75% or bupivacaine 0.5%, and a decrease of 50% in the incidence of paralysis of the diaphragm when the injection is performed laterally to the C5-C6 roots. If the concentration of the anesthetic is also diluted to a half or third, the HDP rate is reduced to 20% (it is still a contraindication in patients with decreased lung reserve) but carries the risk of not achieving surgical anesthesia and decreasing the duration of the blockade. According to Renes et al., if the injection is done at the C7 root level, the minimum volume required to block C5-C6 in 50% of patients was 2.9 mL (maximum volume of 6 mL), with no PN block (although there is a substantial risk of vascular lesions from punctures at this level). Renes et al. avoided PN block by administering the anesthetic in the “cornet pocket “ (intersection of the first rib with the subclavian artery and posterolateral aspect of the BP) and a volume less than 20 ml [18]. Aliste et al. compared ISB with supraclavicular block following the Renes technique, finding equal pain control, but with HDP rate of 9% [19]. Cornish found a 1% of HDP rate by advancing a catheter from the supraclavicular level and locating the tip at the infraclavicular level, inferomedial to the coracoid process [20, 21].
A combination that could be effective would be the association of a SSN block with a BP block at infraclavicular level [22] (addresses the axillary, lateral pectoral, subscapular nerves), although Petrar et al. [23] reported a 3% incidence of HDP during infraclavicular BP block (30 mL ropivacaine 0.5%).
The following paragraphs describe different techniques to achieve a selective block of the nerves supplying the shoulder.
It focuses on the anesthetic deposit near the UT, before the take of the SSN. At this level, the phrenic nerve (PN) has diverged from the BP. Compoy et al. [24] found that 5 mL of methylene blue injected around UT stains SSN, lateral pectoral nerve, and roots of C5 and C6, but not of the PN [25]. Kim et al. found analgesic equivalence between UT block and ISB, achieving equivalent surgical anesthesia and HDP incidence of 5% vs. 71% using 15 mL of injectate [26]. Ultrasound (US) examination reveals the plexus in the groove between the anterior and middle scalene muscles, deep to the prevertebral fascia. The sternocleidomastoid muscle (SCM) lies superficially, and the PN can be seen on the anterior surface of the anterior scalene muscle (ASM), crossing it towards the medial side, after the last contribution originating in the C5 root. Sonoanatomy of the transverse processes can be used to identify spinal roots. Serial images reveal the process of confirmation of the UT [27].
The blocking needle is advanced from lateral to medial, under the deep cervical fascia until its tip reaches the UT lateral edge, proximal to the exit of the SSN (it is identified as a rounded hypoechoic structure that separates laterally from the UT and runs deep to the omohyoid muscle). The needle does not pass through the middle scalene muscle (MSM), where the dorsal scapular nerve (DSN) and long thoracic nerve (LTN) are located. The injectate volume is 7 to 12 mL of local anesthetic (LA) (one-half or one-third strength). Here the nerves have a greater amount of perineural tissue, protecting against neurological dysfunction, which has been reported in about 14% of ISBP blocks and can last for up to 10 days (Figure 7).
Upper trunk and supraclavicular nerves blockade. A. C5 and C6 (bifid) roots at interscalene space, near to PN. C7 TP view. B. UT formation (inferior to C7 TP). C. Origin of supraescapular nerve (SSN). D. Back to UT - needle at its posterior surface. Local anesthetic (LA) injection at posterior surface of UT. E. Retreated needle to space between SCM-MSM. LA injected around supraclavicular nerves.
The UT provides anesthesia to nerves from the spinal cord segments C5 and C6 (originating fiber to SSN and AN, inferior subscapular nerve, and partially, to LPN) [25] and decreases the incidence and severity of PN block. HDP was observed in 97.5% in ISB vs. 76.3% of the UT block groups (P = 0.006); paresis was complete in 72.5% vs. 5.3% of the patients, respectively. The decrease in spirometry values from baseline was significantly greater in the ISB block group. UT block provides non inferior analgesia compared to ISBP block [28].
It can be supplemented with blockade of the supraclavicular nerves to anesthetize the skin over the shoulder. The needle is retracted to the space between prevertebral fascia (over the MSM) and superficial (enveloping) layer of the deep cervical fascia, under the SCM, where the supraclavicular nerves are located. A new injection of 2 to 3 mL of LA blocks nerves supplying skin over collarbone and shoulder cap and their sensitive contribution to the acromioclavicular joint.
The supraclavicular nerve trunk (C3 and C4) emerges at the posterior edge of SCM. The superficial cervical plexus (SCP) is localized by placing a transducer on the posterior edge of the SCM at the level of the upper pole of the thyroid cartilage. It can be difficult to identify the individual nerves. The greater auricular nerve (GAN) is a useful reference reliably identified as a small superficial hypoechoic round structure on SCM (Figure 8) [29].
Supraclavicular nerve trunk and SCP scan process.
The posterior approach in the suprascapular fossa (in the space between the suprascapular notch and the spinoglenoid notch) where the nerve travels through its floor under the supraspinatus muscle fascia, results in adequate flooding of SSN with minimal propagation to the BP [30] but may spare MSAb. This approach is inferior to ISBP block for pain control, at least in the first 4 hours [31, 32, 33]. The UT (C5-C6) is the major contributor to the suprascapular, axillary, and subscapular nerves. Hence, UT blockade can provide adequate control of shoulder pain, but it is still remarkably close to the PN [34, 35].
With ultrasound image, the SSN could be identified as it branches from UT, and runs laterodorsally underneath the omohyoid muscle, in 81% of cases vs. 36% in the supraspinatus fossa, at an average depth of 8 mm vs. 35 mm in the supraspinatus fossa. Peripheral nerve stimulator can help in the identification [35]. Rothe et al. studied twelve healthy volunteers; the SSN was followed into the subclavian triangle under the inferior belly of the omohyoid muscle; injecting 1 mL of lidocaine 2%, 10 blocks were performed, 8 demonstrated a reduced manual muscle-testing scale (MMT) of the supra- and infraspinatus muscles at 15 min and 30 min; increasing the injected volume, produced musculocutaneous and radial nerves blockade due to cephalic diffusion of the anesthetic (Figure 9) [36].
Scan sequence of the SSN at the supraclavicular fossa. A: Locate the transverse process of C6 vertebral vertebra and C6 and C5 roots. B: Scanning downward, locate the C7 TP and C7 root, which can be seen laterally to vertebral vessels. C: Just below the C7 transverse process, C7 root runs towards the interscalene groove. The PN is diverging from the BP, on the anterior surface ASM. Caudally to the C7 transverse process, UT and MT conformation can be imaged. D: In the supraclavicular fossa. From the UT branches the SSN. E: The SSN travels below the omohyoid muscle. F: The SSN separates from the UT, below omohyoid muscle. The nerve goes along suprascapular artery.
In 14 BP of 7 corpses, the separation between the SSN and the PN was found to be 2.5-6.4 cm, and the injection of 10 mL of solution around the SSN produced staining of the UT of the BP and its branches (SSN, anterior and posterior divisions - 14 cases, 100%), the middle trunk (MT) (13 cases, 93%), the PN (3 cases; 21.4%) [37]. In the cadaveric study by Sehmbi, the SSN and omohyoid muscle were easily identified and, with nerve injections of 5 mL, nerve staining with contrast dye was seen in 90% of dissections. The UT, MT, and LT were stained in 90%, 80% in 20% of dissections, respectively. The PN was mildly stained in 20% of the dissections [38]. Figure 9 shows the scan sequence of the SSN at the supraclavicular fossa.
The articular branch or LPN crosses the superomedial side of the coracoid process [6, 11]. The US probe is placed between the inferior border of the clavicle and the superior border of the coracoid process. Below the deltoid muscle, the acromial branch of the thoracoacromial artery and, along with it, the nerve can be found (Figure 10).
USG to locate the articular branch of LPN.
The AN provides motor innervation to subscapular, teres major and minor, and deltoids muscles. The nerve branches before entering the quadrangular space. The anterior division of the AN originates the first articular branch, which ends in the anteroinferior capsule; blocking the nerve by the posterior approach can provide incomplete analgesia.
The sensitive skin supply of the medial aspect of the arm is provided by MBCN, ICBN, and variable branches of the intercostal nerves [39].
The AN run into the inferolateral margin of the subscapular muscle and enters the quadrangular space (QS) (limits: upper, teres minor muscle; inferior, teres major muscle; medial, long head of the triceps muscle; lateral, surgical neck of the humerus; anterior, insertion of the subscapular muscle on the minor tuberosity). The subscapular muscle, the upper edge of the teres major muscle, and the humerus are the sonographic marks that lead to the identification of the AN. The ICBN originates mainly from the second intercostal nerve, with variable contributions from intercostal nerves T1, T3, and T4. It is identified in the axillary subfascial space, along.
with fat, lymph nodes, and other cutaneous branches of the upper intercostal nerves. After crossing the axillary subfascial space, it courses on the surface of the latissimus dorse muscle, covered by the superficial axillaryfascia [40].
With the arm abducted 90o, the BP is identified in the armpit (anterior to the teres major and the tendon of the latissimus dorse muscles, seen in short axis) (Position 1, Figure 11). The probe moves slightly in a proximal direction (position 2, Figure 11) towards the QS, which is identified as soon as the upper edge of the teres major muscle deepens. At this point, the AN appears as an oval honeycomb structure, accompanied by the posterior circumflex artery of the humerus (although it has an inconsistent course and presence). The elevation of the arm from 90 o to 180 o brings the nerve closest to the skin by closing the quadrangular space.
AN US images at axillary fossa. A. Transducer position 1. The US imagen corresponds to D. B. Transducer position 2. The US imagen corresponds to E. C. Anterior view of axilla showing the quadrangular space; AN emerges posterior to brachial plexus and enters the QS divided in anterior and posterior ramus. D. Scanning starts viewing the brachial plexus at the axillary level, observing the fascia of the teres major muscle. E. Moving proximally the transducer (towards the axillary fossa) shows the teres major muscle fascia deepening and the subscapular muscle tendon; the QS is seen. F. with 180° arm extension, the teres major muscle closes the QS. G and H. the axillary nerve is observed above the subscapular muscle as a hyperechoic image next to the circumflex humeral artery.
With the arm positioned parallel to the thoracic wall with internal rotation and forearm pronated on the abdomen, a US probe is placed below and parallel to the clavicula identifying the coracoid process and lesser tubercle and intertubercular (bicipital) groove; then the arm is externally rotated, pushing the subscapular muscle rostrally and identifiable under the deep lamina of the deltoid fascia; the first portion of the AN is present between the deep lamina of the deltoid fascia and the superficial lamina of the subscapular muscle, where needle tip is placed. Interfacial position is confirmed after injection of 2 mL of normal saline, then 10 mL of 0.25% bupivacaine is injected. Rotating caudally the medial side of the probe and abducting the limb permits to directly visualize the AN and posterior circumflex humeral artery.
The injection is distributed on the anterior surface of the subscapular muscle and around the proximal insertion of the coracobrachialis and biceps brachial muscles. The sensory block is detected in AN area and areas supplied by the branches of the musculocutaneous nerve, lateral pectoral nerve, lateral supraclavicular nerve, and intercostobrachial nerve.
A complete AN blockade could provide anesthesia to the anteroinferior and lateral edges, and to part of the posterior aspect. of the shoulder joint capsule. The remaining shoulder joint areas are innervated by the SSN, which must be blocked if complete anesthesia of the shoulder is to be achieved. The LPN, or its articular branches, can be blocked by PECS I block or at the space between the coracoid process and clavicle (Figure 12) [41, 42].
US-guided anterior approach to AN blockade. A. Axillary nerve and its relations to subscapular, deltoid, and pectoralis muscles, axillary and circumflex humeral arteries, coracoid process, and humerus bone. B. Sagittal oblique ultrasound anatomy of the anterior axilla. C. Ultrasound scan: Transducer between coracoid process (medial) and the lesser tubercle of the humerus. Arm adducted and internal rotation. D. Transducer parallel to the inferior border of the clavicle, ultrasound mark is lateral. E and F. arm rotated externally/no abduction; subscapular muscle appears over humeral head. G and H. full external rotation and abduction of the arm. The medial side of the transducer is rotated inferiorly to obtain a sagittal oblique view of the axilla. The subscapular muscle is pushed rostrally and is identifiable under the deep lamina of the deltoid fascia. The cephalic vein is seen in the groove between deltoid and pectoralis major muscles. The axillary artery appears in the image and laterally to it, the axillary nerve is located. The needle shows the injection around the axillary nerve, on the surface of the subscapular muscle.
Clavicle fractures account for 2.6–4% of fractures in adults and 35% of shoulder injuries. The annual incidence is estimated between 29 and 64 per 100,000, and are distributed as follows: diaphysis 69-82%, lateral end 21-28%, and medial end 2-3%. There is often caudal displacement of the lateral fragment under the shoulder weight and elevation of the medial fragment by traction by the SCM. Infrequently, posterior displacement of the medial end can cause compression of the mediastinum and main vessels requiring urgent intervention. Non-displaced fractures are managed without surgery, while surgical management is preferred in cases of displaced fractures in active adults [43].
Innervation of the skin above the second rib is supplied by the supraclavicular nerves of the SCP. Terminal branches of suprascapular, subclavian, lateral pectoral, and long thoracic nerves pass through the plane between the clavipectoral fascia and the clavicle and, theoretically, contribute to collarbone innervation.
Common approaches in anesthesia for clavicle fracture surgery are GA, regional anesthesia techniques such as ISBP block combined with SCP block. The clavipectoral fascial plane (CPB) block (Figure 13) is accomplished by injecting 10 to 15 mL of LA deep to the clavipectoral fascia on the medial and lateral side of the fracture site. A SCP or supraclavicular nerves block should be implemented to provide a sensory block of the skin of the shoulder. This nerve block can potentially involve the PN if the injection is not performed accurately in the proper subcutaneous plane and using low volumes. The block can be used for diaphysis and lateral end interventions, but as isolated block for surgical anesthesia, it only works for diaphysis fractures (Figure 13) [44].
The peri clavicular fascial plane or clavipectoral planes block (CPB). A: Scan throughout all clavicle surface, identifying the fracture site (proximal segment is displaced upward) B: Initiate the US scan in a sagittal paramedian position C: Tilting the ultrasound probe, is positioned on the upper surface of the clavicle D: Identify the anterior and posterior borders of clavicle E: 25 G needle tip positioned between bony surface and periosteum (if seen: By the fractured site, the periosteum is usually detached F: After 1-2 ml injected, the periosteum is further disengaged G: A second hyperechoic line appears, which correspond to clavipectoral fascia H: Needle tip positioned in the gap between periosteum and clavipectoral fascia I: Initial injection under clavipectoral fascia. Track Injectate spread in caudal and cephalic way along the anterior surface of clavicle I: Alternatively, Clavipectoral fascia scanning and needle in plane insertion from caudal to cephalic over clavipectoral fascia between pectoral major and minor muscles; this plane is the target for injection of local anesthetic.
For lateral fractures, including acromioclavicular and coracoacromial ligaments, articular branch of lateral pectoral nerve should be blocked. Likewise, if the surgery involves the acromioclavicular joint, the SSN should be blocked. Yamak Altinpulluk states that in the description of Ince et al., the LA was injected between the periosteum of the clavicle and the surrounding fascia (assumed as the clavipectoral fascia), but cadaveric dissections show that the spread is between the clavicle and fascia of the pectoralis major muscle in the upper and anterior aspect of the clavicle, with anesthetic spread under the deep layer of superficial cervical fascia and the superficial layer of pectoralis major fascia. The naming of this block as CPB is misleading and suggests that this block should be named as peri clavicular block (PB) [45]. The publication of a series of cases by Kukreja et al., shows the injection of the LA between the clavipectoral fascia and the pectoralis major muscle, resolving the previous objections described by Yamak Altinpulluk et al. [46].
ISBP block targets the roots and trunks of the BP in the interscalene groove between ASM and MSM, and is directed towards C5-C6 nerve roots or UT. With higher volumes, C7 and even C8 nerve roots may be blocked. The block provides analgesia and anesthesia to the shoulder, lateral two-thirds of the clavicle, proximal humerus, and shoulder joint surgeries. Continuous infusion of 0.15% bupivacaine or ropivacaine (vs GA or intravenous anesthesia) provides adequate pain relief, similar side effects, and high patient satisfaction. ISBP block is associated with a high risk of PN blockade and HDP. Persistent PN palsy after ISBP block has recently gained wider recognition (reported incidence of 1:2000). Phrenic nerve palsy could be due to direct needle trauma or intraneural injection during landmark guided ISB but this complication has not been described with USG ISBP block. More peripheral BP nerve blockades are alternatives in scenarios in which avoiding PN palsy is critical, without clinically meaningful analgesic differences compared with ISBP block, except during recovery room stay [47]. Vocal hoarseness and Horner’s syndrome are due to self-limiting temporary blockade of the ipsilateral recurrent laryngeal nerve and stellate ganglion [48]. ISBP block cannot reliably block the C8 and T1 ventral rami [48, 49].
ISBP Blockade relies on the visualization of the relevant anatomy, needle-tip position and LA spread using USG plus peripheral nerve stimulation with or without injection pressure monitoring. USG allows fewer needle passes, lower volumes of LA, and better postoperative analgesia [1].
Figure 14 shows the scan process of interscalene space: At cricoid cartilage level, with transverse scan, identify the carotid artery and move the transducer laterally to locate the sonographic image of C5 and C6 TP; C5-C6 nerve roots are seen between the anterior and posterior tubercles and are traced in the groove between ASM and MSM, deep to the prevertebral fascia. The SCM lies superficially, and the PN runs medially over the ASM, away from the C5 root. Below the C6 TP and nerve root, C7 TP appears and the C7 nerve root can be seen anteriorly as hypoechoic round structure, lateral to vertebral vessels (identified by doppler color scan); meanwhile C5 and C6 nerve trunk are merging to conform to the UT; inferiorly to C7 transverse process, C7 nerve root conforms the MT. The dorsal scapular nerve (DSN) arises from the C5 nerve root and is imaged as a hyperechoic structure traversing the MSM, accompanied by LTN. Both must be avoided not needling through MSM. The block is performed positioning the tip deep to the C6 nerve root or UT and seeking the spread of LA anterior and posterior to the nerves, within the interscalene groove, and then repositioning of the needle superficial to the C5 nerve root or UT to obtain a satisfactory spread of LA. Do not needle between C5 and C6. 10-15 mL of LA (ropivacaine 0.75%) produce surgical anesthesia. Supraclavicular nerves blockade is added aimed to provide complete anesthesia to the shoulder cap.
Interscalene brachial plexus block.
The PN diverges at a rate of 0.3 mm per cm below the cricoid cartilage. Its blockade is reported in as 100% with a traditional landmark-based approach using volumes greater than 20 mL, and between 25 and 50% with lower volumes. Forced expiratory volume in 1 s (FEV1) may be reduced by up to 40%, and patients with comorbidities (obesity and respiratory disease) may develop troublesome dyspnea. ISBP block has been associated with an incidence of temporary neurological dysfunction in up to 14% at 10 days. Hypotension and bradycardic events occur in up to 20% during shoulder surgery, typically in the sitting position, and at around 30 min after the placement of an ISBP block. High circulating catecholamine concentrations and an underfilled, hyper contractile ventricle (induced by venous pooling) stimulates intramyocardial mechanoreceptors resulting in an abrupt reduction in sympathetic tone together with increased vagal tone. Prompt treatment with an antimuscarinic (ideally atropine) with or without sympathomimetic drugs is indicated [1].
Selective trunk block (SeTB) targets injection around individual trunks, with small volumes of LA. Produces anesthesia of the entire upper extremity (C5-T1) except the ICBN innervated area (T2). Is performed as one injection targeting UT and MT at interscalene and another one targeting LT at the corner pocket of the supraclavicular fossa (Up to 25 ml of LA are used). Produces HDP similar to UT approach [49, 50].
Shoulder surgery is accompanied by severe acute postoperative pain that continues to be an unresolved problem. The gold standard for analgesia after this surgery is the ISBP. Unfortunately, this block is associated with a high incidence of ipsilateral phrenic nerve block and the consequent HDP, which restricts its use in patients with pre-existing pulmonary involvement, so it is prudent to consider the practical options to avoid or reduce the incidence of this complication. Nerve block techniques without diaphragmatic involvement such as supraclavicular blocks, upper trunk blocks, anterior suprascapular nerve blocks, costoclavicular blocks, and combined infraclavicular-suprascapular blocks are some of the possible alternatives. It has been suggested that costoclavicular blocks could provide postoperative analgesia similar to ISBP along with a 0% incidence of HDP. It is not clear whether costoclavicular blocks could achieve surgical anesthesia for shoulder surgery. The anterior suprascapular nerve blocks have been shown to provide surgical anesthesia and analgesia similar to ISBP. However, the risk of HDP has not been adequately quantified. Of the remaining nerve blocks that preserve diaphragm function, supraclavicular blocks (with injection of posterolateral local anesthetic to the brachial plexus), upper trunk blocks, and combined anterior and infraclavicular suprascapular blocks achieve analgesia similar to ISBP, along with an incidence of HDP <10% [17, 25, 51].
Orthopedic surgeries are well known to be very painful. General anesthesia or regional anesthesia, or a combination of both, are optimal options for shoulder surgery. Regional nerve blocks are essential for postoperative analgesia and can be used alone or as a complement to GA, therefore the postoperative analgesia could be prolonged for 24 hours or more [49]. Regional anesthesia in the setting of GA has a relative contraindication but, with the use of USG, this statement has been challenged [52].
ISBP blockade is the most common approach and a highly effective technique, but with a high incidence of HDP, that contraindicates it in patients with lung disease or contralateral PN paralysis [25, 51]. Supraclavicular blocks vs. ISBP, result in similar pain control and patient satisfaction, but with an incidence of HDP exceeding 60%, when LA is injected intracluster, vs. 9% depositing LA posterolateral to neural cluster (in this setting, cluster refers to the confluence of trunks and divisions of BP) [25, 28].
UT block targets C5-C6 nerve fibers traveling with SSN and AN, producing analgesia not inferior to ISBP block and a 75% incidence reduction of PN involvement [21, 22, 23, 24]. The HDP occurs with an incidence of 5% [25].
AN block (posterior access) plus SSN block (sub supraspinous muscle access) produces a good analgesic effect in minor surgeries, compared to ISBP block, but spares the AN anterior articular branches, the lateral pectoral nerve articular branch, and subscapular nerve [25, 41, 45] and is inferior in terms of analgesia when compared to ISB in major surgeries. SSN block at sub omohyoid level extends to the UT almost always and occasionally to the middle trunk, with almost no PN block [33, 34, 35, 37]. It provides surgical anesthesia and similar analgesia to ISB [25]. It remains necessary to formally quantify the incidence of HDP. Both blocks should be accompanied by a supraclavicular nerve block at the lateral edge of the SCM to give analgesia to the skin over the shoulder and its contribution to the acromioclavicular joint [29].
AN block may be performed at the axillary fossa, producing anesthesia/analgesia that includes the anterior and posterior branches, with the advantage that intercostobrachial nerve block may be performed with the same puncture [38]. Access to the AN by anterior route is easy to perform and has the possibility of extending to the musculocutaneous nerve, superior subscapular nerve, lateral pectoral nerve and through the clavipectoral fascia, to the lateral supraclavicular nerve [41]. Clavipectoral fascia and peri clavicular block can provide anesthesia and analgesia for fractures of the middle third of the clavicle, without PN paralysis [44, 45, 46].
To date, the strategy that achieves analgesic equivalence with ISB with a 0%-incidence of HDP is the costoclavicular block. In 2019, Aliste et al. [53] compared ISB and costoclavicular block in 44 patients undergoing arthroscopic surgery, finding equivalent analgesia in both groups. Moreover, there is no evidence that this block results in surgical anesthesia [25]. Supraclavicular blocks (with LA injection posterolateral to the BP), UT blocks, and combined infraclavicular-anterior suprascapular blocks have been shown to achieve similar analgesia to ISB [54], coupled with an HDP incidence <10%. Decreasing LA injectate volume could avoid HDP altogether and should also be investigated for the provision of surgical anesthesia [25].
The anesthetic challenge imposed by shoulder surgery is considerable. This chapter reviews current options for regional anesthesia in this type of surgery. A regional technique, GA, or a combination of both can be appropriately used. Performing nerve blocks distally to the ISBP approach, PN paralysis can be reduced considerably, although not eliminated, taking care when performing them in patients with lung disease or contralateral HDP.
We thank MF Rojas for Figure 2. The authors also thank Dr. Victor Whizar-Lugo for his valuable support with this chapter.
The authors declare that they have no conflicts of interest.
axillary nerve anterior scalene muscle brachial plexus clavipectoral plane block dorsal scapular nerve general analgesia great auricular nerve hemi diaphragmatic paresis intercostobrachial nerve interscalene brachial plexus intravenous analgesia Local anesthetic Long head biceps tendon lateral pectoral nerve lateral suprascapular articular branch Levator scapulae muscle lower trunk long thoracic nerve medial brachial cutaneous nerve medial pectoral nerve medial suprascapular articular Branch middle scalene muscle middle trunk peri clavicular block phrenic nerve Quadrangular space sternocleidomastoid muscle superficial cervical plexus suprascapular nerve Selective trunk block transverse process ultrasound ultrasound guidance ultrasound image upper trunk
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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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Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. 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Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. 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