Tolerability and Haemodynamic Effects of NMES

Tolerability and Haemodynamic Effects of NMES Tolerability and haemodynamic effects of NMES in young healthy individuals Quinn C1, Cooke J1, Deegan B2, Breen P2, Hannigan A3, Dunne C3, Lyons G2 and Lyons D1. Introduction: Discomfort has been identified as a limiting factor for the use of surface NMES. Early implementation of NMES devices were so uncomfortable that they could only be used when the patient was under anaesthetic1. Furthermore, poor quality electrodes combined with monophasic waveforms often resulted in skin irritation and burns. Pambianco et al had to discontinue the NMES portion of the effects of heparin, intermittent pneumatic compression and NMES on DVT rates in stroke rehabilitation patients due to discomfort and skin blister formtion2. More recently the inclusion of microcontrollers in the design of NMES devices has allowed the implementation of precisely controlled waveforms and novel algorithms3. These waveforms and algorithms have significantly increased the comfort and tolerance of NMES users. Moreover the use of biphasic pulses, either asymmetric or symmetric has minimised ion redistribution and the subsequent risk of skin irritation and burns. Previous studies have examined patient perceptions of NMES. Alon et al. examined the effect of 4 different electrode sizes on excitatory responses (sensory, motor, pain and pain tolerance) on healthy participants and concluded that NMES comfort increases with increase in electrode size4. They also observed that increasing electrode size decreases the peak voltage corresponding to the excitatory levels. Clarke-Moloney et al assessed the comfort associated with and without NMES on patients with chronic venous insufficiency using a visual analogue scale (VAS)5. The authors found that the comfort categorical rating remained unchanged in all but one patient. This indicated that patients found NMES to be an acceptable therapy which could be significant in future studies involving NMES treatments for venous wound healing. Broderick et al. previously conducted a study involving healthy participants who underwent a 4 hour stimulation protocol6. Three participants indicated moderate discomfort and 7 only mild discomfort when NMES was commenced. By the end of the study, 2 participant’s scores increased to moderate while 2 other participant’s scores decreased to mild the remainder were unchanged. Kaplan et al. asked each healthy participant who received NMES of the calf or foot muscles to complete a questionnaire regarding the acceptance of NMES. Both groups found NMES to be comfortable and strongly felt they would use the NMES device if directed by their doctor7. More recently a study by Corley et al. demonstrated the use of a week-long NMES blood flow protocol in conjunction with compression stockings resulted in a high level of compliance and no reported adverse effects8. Our pilot study concluded that NMES may be useful in attenuating blood pressure drops in older subjects with OH. The asynchronous NMES setting demonstrated the most favourable haemodynamic response. The aims of this study were to assess tolerance and acceptability of both synchronous and asynchronous NMES settings in a young, healthy population during head-up tilt testing. A secondary objective was to assess the effect of both settings on haemodynamic parameters in this group. Methods: Subjects Healthy subjects (n=14) were recruited. Ten were male. The subjects’ medical history did not reveal any episodes of vasovagal syncope, cardiovascular diseases or any other morbidity. None of the subjects used any medication, and all subjects were non-smokers. Ethical Approval Ethical approval for this study was granted by University Hospital Limerick Research Ethics Committee. All subjects gave written consent to take part in the study. Tilt Protocol Subjects were asked to fast for a maximum of two hours beforehand. Studies were performed in a quiet syncope syncope laboratory room at ambient temperature (21-23 C). The tilt protocol was completed between 9am and 5pm. The study protocol included 3 Head-Up-Tilts (HUT) comprising asynchronous, synchronous settings and control. The order of each intervention was randomly assigned using closed envelope randomisation technique. HUT testing was performed using standardised conditions in accordance with the 1996 expert consensus document for all patients9. Subjects were required to rest in the supine position for five minutes prior to the onset of a 70 degree positive tilt. This was sustained for three minutes as per European Society of Cardiology guidelines10. Haemodynamic changes were recorded using non-invasive beat-to-beat digital artery photoplethysmography Finometer ® Pro Device (Finapres Medical Systems BV, Amsterdam, The Netherlands www.finapres.com). Continuous cardiac monitoring was performed with three lead ECG (figure 2). OH was defined as a drop in systolic blood pressure of ≠¥ 20mmHg or in diastolic blood pressure of ≠¥ 10mmHg within three minutes of orthostasis10. The delta (or change) in systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), mean arterial pressure (MAP), stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) were rec orded in each subject at baseline and at the lowest point (nadir) for each HUT. Electrical stimulation protocol NMES was applied a custom built, two channel stimulator (Duo-STIM, Bioelectrics Research Cluster, NUI Galway)11. NMES was facilitated through the use of two 5 cmÃâ€"5 cm PALS self-adhesive, hypo-allergenic, skin surface electrodes (Nidd Valley Medical Limited, England) placed over the motor points of the soleus muscles of both legs of consenting patients12 (Figure 3). The stimulator was programmed to provide a pulse width of 350  µs, an inter-pulse interval of 100  µs, a frequency of 36 Hz, a contraction time of 1.2 second, a ramp up time of 500 ms and ramp down time of 300ms. This yielded stimulation amplitudes of 29.18  ± 4.2 V11. The stimulation parameters were selected at a level to achieve maximum blood flow while ensuring subject comfort. A series of test pulses were applied initially at a very low intensity to establish that the patient was comfortable with the sensation of electrical stimulation. The stimulus intensity was gradually increased until a noticeable contrac tion was observed for both legs, as indicated by a visible tightening of the soleus muscle or slight plantar flexion. Stimulation was applied alternatively to each leg with 3 second rest between contractions or synchronously to both legs with 3 second rest period at the onset of each HUT and continued for the three minute study duration. Duplex scanning Duplex Doppler ultrasound was used to monitor the subjects’ lower limb venous hemodynamic responses using a Siemens Sonoline Sienna ultrasound machine with a broadband array probe (Frequency 5 – 13 MHz). All measurements were performed by a single examiner. Blood flow measurements were taken from the popliteal vein at the lateral aspect of the knee (Fig. 1). Doppler ultrasound with angle correction not exceeding 600 was used and matched to the diameter of the popliteal vein. All measurements were taken from the right leg. Three measurements were taken per parameter and the average of these was used for analyses5, 13. Peak venous velocity was recorded from the popliteal vein. The Doppler machine’s own software was used to calculate venous volume flow (ml/min) by multiplying the average blood flow velocity by the cross-sectional area of the popliteal vein. Doppler measurements were taken at baseline and on assumption of the upright stance. Figure 1: Placement of ultrasound probe in popliteal fossa Figure 2: Screen shot of output from ultrasound software demonstrating venous blood flow and peak systolic velocity Comfort evaluation procedure At 2 time points (just after set-up of the NMES and at the end of the protocol), comfort was assessed by asking subjects to mark their level of comfort using a 100 mm, non-hatched visual-analogue scale (VAS). A VAS of 30 mm or less was categorised as mild pain, between 31 and 69 mm as moderate pain and scores of 70 mm or greater as severe pain. The minimum clinical significant difference (MCSD) in VAS was set as an increase in scores between test stages of 12mm14. At the end of the study, the patients were asked to complete a short verbal questionnaire. They were asked: To give a verbal categorical rating of the NMES treatment as very comfortable, comfortable, bearable or unbearable. To clarify preferred stimulation pattern. If they would consider NMES an acceptable form of treatment. Symptom recording Each subject was asked to mark the degree of symptoms encountered during the HUT using a 100 mm, non-hatched visual-analogue scale (VAS) once the tilt table had returned to the horizontal position. Statistical analysis Results: Discussion: Conclusion: Outcomes for tolerability study 1: Tolerability: Pain – pre and post change NMES sensation Acceptability Preference Symptoms 2: Haemodynamic parameters for each intervention: Delta SBP, DBP, HR, MAP, SV, CO TPR Peak systolic velocity Venous flow 3: Associations of presence of initial OH References: Browse NL, Negus D. Prevention of postoperative leg vein thrombosis by electrical muscle stimulation. An evaluation with 125 I-labelled fibrinogen. Br Med J 1970;3:615-618. Pambianco G, Orchard T, Landau P. Deep vein thrombosis: prevention in stroke patients during rehabilitation. Arch Phys Med Rehabil 1995;76:324-330. Broderick B, Breen P, OLaighain G, Eelectrical stimulators for surface neural prosthesis. J Autom Control 2008;18:25-33. Alon G, Kantor G, Ho HS. Effects of electrode size on basic excitatory responses and on selected stimulus parameters. J Orthop Sports Phys Ther 1994;20:29-35. Clarke-Moloney M, Lyons GM, Breen P, Burke PE, Grace PA. Haemodynamic study examining the response of venous blood flow to electrical stimulation of the gastrocnemius muscle in patients with chronic venous disease. Eur J Vasc Endovasc Surg 2005;31:300-305. Broderick BJ, O’Brien DE, Breen PP, Kearns SR, OLaighin G. A pilot evaluation of a neuromuscular electrical stimulation (NMES) based methodology for the prevention of venous stasis during bed rest. Med Eng Phys 2010;32:349-355. Kaplan RE, Czyrny JJ, Fung TS, Unsworth JD, Hirsh J. Electrical foot stimulation and implications for the prevention of venous thromboembolic disease. Thromb Haemost 2002;10:35-45. Corley CJ, Breen PP, Birlea S, Serrador JM, Grace PA, OLaighin G. Hemodynamic effects of habituation to a week-long program of neuromuscular electrical stimulation. Med Eng Phys 2012;34:459-456. Benditt DG, Ferguson DW, Grubb BP, et al. Tilt table testing for assessing syncope. American College of Cardiology. J Am Coll Cardiol. 1996;28: 263-275. Brignole M, Alboni P, Benditt DG, et al. Guidelines on management (diagnosis and treatment) of syncope-update 2004. Executive Summary. Eur Heart J. 2004;25: 2054-2072. Breen PP, Corley CJ, O’Keeffe DT, Conway R, OLaighin G. A programmable and portable NMES device for foot drop correction and blood flow assist applications. Med Eng Phys 2009;31:400-4008. Baker LL, McNeal DR, Benton LA, Bowman BR, Waters RL. Neuromuscular Electrical Stimulation – A practical Guide. 3rd ed. Downey, California: Rancho Llos Amigos Research and Education Institute; 1993. Izumi M, Ikeuchi M, Mitani T, Taniguchi S, Tani T. Prevention of venous stasis in the lower limb by transcutaneous electrical nerve stimulation. Eur J Vasc Endovasc Surg 2010;39:642-645. Kelly AM. The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain. Emerg Med J 2001;18:205-207.

The Evolution of Grant in Ernest J. Gaines A Lesson Before Dying Essay

After the Civil War ended, many blacks and whites, especially in the South, continued living as if nothing had changed with regards to the oppression and poor treatment of African Americans. Narrator Grant Wiggins, of Ernest J. Gaines' A Lesson Before Dying, possesses a similar attitude toward race relations. Through his experiences with a young man wrongly accused of murder, Grant transforms from a pessimistic, hopeless, and insensitive man into a more selfless and compassionate human being who can see the possibility of change in relations between whites and blacks. Grant Wiggins, one of the few black men of the time to have a college education, lives with his aunt on a plantation just outside Bayonne, Louisiana in 1948, and teaches at the all-black school held at the all-black plantation church. Considering the poor relations between blacks and whites at the time in which the story is set, it comes as no surprise that Grant sees tension frequently in his community – not only through the ways in which persons of various races treat one another, but also in the justice, or lack thereof, served in court cases. The white authorities accuse Jefferson, an innocent student Grant taught a few years prior, of first-degree murder. During the trial, Jefferson's state-appointed defense lawyer pleads for the jury to have sympathy on Jefferson as he is a hog and does not possess the intelligence to commit the crimes of which he is accused. Because the whites dominate the society, the court finds Jefferson guilty as charged and the judge sentences him to death by electrocution. Upon hearing the verdict, Miss Emma, Jefferson's aunt, resolves to persuade Grant to teach Jefferson that he is, in fact, a man – not a hog – and to get him to wal... ...statements as truth reveals Grant's transformation into a selfless, compassionate, and optimistic man. Grant realizes he has made mistakes and does not desire to be esteemed higher than he believes he deserves. Paul expresses his desire to befriend Grant, thus breaking the barriers of race and reaching out to Grant. Grant returns to his classroom, crying, a changed man. Work Cited Gaines, Ernest J. A Lesson before Dying. New York: Vintage, 1993. Works Consulted Folks, Jeffrey. â€Å"Communal responsibility in Ernest J. Gaines‘s A Lesson Before Dying. Mississippi Quarterly 52.2 (1999): 253 Piacentino, Ed. â€Å"The Common humanity that is in us all†: Toward Racial Reconciliation in Gaines’s A Lesson Before Dying.† Southern Quarterly 42.3 (2004): 71 Vancil, David. â€Å"Redemption According to Ernest Gaines,† African American Review, 28 (Fall 1994), 490.

Development of Sexual Identity

Ethical relativism means, that I reject the Idea that there Is a single correct moral view. I think this because I believe that everyone has a right to choose and have their own moral view. I also think that in my own opinion that everyone that wants to do or say or feel a certain way should be able to and that no matter how much people say it may be wrong they should be able to show how we feel. I have also thought about critical thinking a lot different when it comes to sexuality. I think that we as younger adults, considering I am only 28, need to stop and think about the decisions that we eke as we are growing up.Now a days kids are getting younger and younger when they are having their babies, but the problem is that they are still babies themselves. They are ruing their lives and in some cases their baby's lives as well. Society needs to stop with all the media and showing the good things with babies and show the more negative things. With me though if I would have known what I know now I do not think that I would have had a child at 20, but no matter what I would not change it for anything and I know it is hard but in my opinion it was and is worth it. ;Describe the effect of environment and historical perspectives on your sexuality. In the environment that I was raised, I was raised to be tough and to be a manly man. My father really did not like gay, lesbian, or bi-sexual people and even treated them like they were nothing. I understand that if I was gay I would have been â€Å"disc- owned† and probably thrown out of the family, I did though have a lesbian cousin and I think that it must be the way my dad and his family were raised because her dad was very, very rude and really disheartening towards her.Being that my dad Is Native American and his family Is very proud I think that Just being raised around this type of family and their values can really affect you as a person. I think that the historical perspectives have really had no Influence on me personally because I think that we should learn from the past and historical events but we can choose whether or not to actually use them In our lives or make our lives ;our lives† that we live. ; Discuss the development of your gender Identity.A few things that have helped me In determining my gender Identity are that I have always felt that I need to take care of my family and to do my best when I am trying, his is one of the reasons that I chose to go back to school and further my education Ana try to get a netter JODI winner I can earn more money Ana Tell netter Dialectally secure about our future. I always feel that growing up my dad did a lot of working and really never spent time with us kids and I was always told that it was because he needed to take care of us kids and the family.And if I have gotten anything from him it was that taking care of your family was the first and most important thing to do. Another is that I am a sports fanatic and love the competitio n that comes with it. While watching TV. Hen I was younger I really never got what was happening but I knew that my dad did it so I thought it was the right thing to do. And when our team lost he was disappointed and really showed, so I thought that was normal activity, but I know now that it is Just a game and am now teaching my son that it is k to loose but having fun is the main goal.And lastly, and one of the most important things that I would say helped me with my gender identity was that growing up boys were the ;tough† ones and the girls were the ;weak' ones of course now that I am older I know that this untrue and that some girls are in fact stronger than some guys. Even though now that I think about it I and how wrong I really was I Just laugh about it because we were kids and it was only the perception of other kids that influenced me. ; Analyze the effect of attraction and love in your relationships.I think that the effect that attraction has had on me in my relatio nships has a lot of who I dated when I was younger. I used to see a girl that I felt was attractive and try to ask her out on a date. Then as I got older I used to see a girl that was attractive to me and I would try to take her out and start a relationship with her based solely on the first initial attraction. I understand that a real and stable relationship takes a whole lot more than Just looks to be a successful relationship and to be serious.I now am married to the most wonderful women on this planet and really and truly understand love. She is my best friend, my lover, and my world. We have nothing in common but that is what makes it so much fun, every day we either try something different or Just hang out together. Being different I think is Just like people say ;opposites attract† well in our case it has and I believe that life could not get any better. To me love really means something a to deeper than to other people.To me it means to love unconditionally and no matt er what you do not give up on that person Just because you or they are mad. So when I say ;l love you† I really mean it with all my heart and it is not Just a turn of phrase to me, like some of these kids that Just through it out there to Just say it. ; Discuss another topic of this course that is interesting and useful to you. Relate this topic to your life. I think that after taking this course another topic that has interested me and really related to my life is that of child and sexual molesters.The reason that this topic has really interested me is because I personally think that these men and women are very mentally and physically sick people. I think that these people should be giving help but only if they admit that they have done wrong and need the help. Now some people that think that this may be something they need to say to get out of Jail or whatever else that they are being held in, but they are only saying this to get out and are more than likely going to refine d and hurt someone else's child or them personally by raping them.I think that we as a society need to make a law that is a en strike for these offenders and be put away for life. I have a child and I know that being a father and if one was to hurt or molest my son I would be engulfed with rage Tanat may not De addle to nylon Deck IT I met ten person won a a It. So In my pollen I think that this would not only be looking out for the children but for the person who did this and to the parents or loved ones that the sex offender has done this to.Many people think that there should be either stricter rules for sex offenders and some think that the laws are fine as long as they register as a sex offender, but I think that story has shown that many of them go out and refined and hurt another child or person. So instead of stopping this while we could at the first time that they did it we let them out and they go out and destroy another life. I think that this is Just too risky and should leave them in the prisons to live their life out.An idea that I would suggest is that maybe build a facility on an island to serve as a place to put offenders and let them live a normal life but far, far away from people they may hurt and the children they may hurt. Now that I am done with this class I will still be doing my own research on a lot of he things that we have learned here and I hope to be able to pass them on not only to my kids but to anyone that may want to learn about this as well.This class has not only taught me a lot but it has opened my eyes to things that I may have never known or even thought about learning. I thank you and I hope that one day I may be able to share this with people to ensure that we understand our bodies and how they work, and what to do when things happen to us. Format your personal response consistent with PAP guidelines. Post your personal response as an attachment.

An Analysis Of Percy Jackson - 947 Words

Ethnography Percy Jackson is a twelve year old boy that lives in New York, in modern time. He has attended a few private schools for troubled students (Riordan 1). In fact, he describes himself as a â€Å"troubled kid† with dyslexia and ADHD (Riordan 7). Percy is used to being the loner of the group, after attending six schools in the past six years which probably means he doesn’t make many friends. (Schmoop). His classmates do not have a need to scramble for money. â€Å"The other guys were joking around, talking about their vacation plans. One of them was going on a hiking trip to Switzerland. Another was cruising the Caribbean for a month. They were juvenile delinquents, like me, but they were rich juvenile delinquents. Their daddies were executives, or ambassadors, or celebrities. I was a nobody, from a family of nobodies.† (Riordan 22). While the other students know their parents, specifically their fathers, Percy has never known his father. He lives with his mother, whom he thinks is the best person in the world (Riordan 29) but he has no idea who his father is. Percy’s mom has just always told him his father was â€Å"lost at sea† (Riordan 30). Later on in the chapters, Percy discovers that the modern world he lives in is not what he thinks. He finds that ancient Greek theology is very much real. He gets shipped to a camp in the middle of nowhere as a safe haven from dangers of ancient Greek mythology. This camp (Camp Half Blood) is a haven for young demi-gods to find theirShow MoreRelatedAnalysis of Percy Jackson and the Olympians2772 Words   |  12 PagesThe fact that Percy Jackson has friends is incredible. It’s an unshakable fact that any friend of his within a ten mile radius will be in a life or death situation with him by dinner, and they aren’t always so lucky as him. But that ’s getting ahead of ourselves. 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Also in Good mind it shows dedication because Good mind works really hard on recreating the world and making the earth a better place for animals.In the myths of â€Å"Percy Jackson†, â€Å"Nanabush† and Iroquois creationRead MoreAnalysis Of Percy Jackson And The Battle Of The Labyrinth859 Words   |  4 PagesPercy Jackson And the Battle of the Labyrinth Draft Prompt: In this book, Hera talks about how important family is. However, we then learn that she really only values people who are perfect. Write an essay describing three characters in this book who have flaws and imperfections. Are these characters still useful? You should write a paragraph about each one, and make sure to describe a time where they were helpful because of their imperfections. 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As the story progresses its settings become more elaborate. The book’s major settings are Percy’s school, camp Half Blood, Greek God Hades’s Underworld, a beach in Santa Monica, and the top of the Empire State building which is secretly Mount. Olympus. It is writtenRead MoreGreek Mythology And The Lightening Thief1940 Words   |  8 Pagesthe lightening thief we see the very interesting part about Greek mythology. The lightening thief uses the modern day society to tell the adventure packed story. In this essay I will give you an overview of Greek mythology, along with a summary and analysis of The Lightening Thief. Hero is the main theme of this story. We see the theme of hero throughout various parts of 2 the story. Courage, Love and sacrifice, and man vs. society all connect back to the idea of heroism. Cultural and HistoricalRead MoreClassical Influences On Modern Films And Literature1171 Words   |  5 Pagesfoundation of humanities in various fields. 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Through an analysis of classical elements often portrayed in popular media, this essa y attempts to illustrate how the representation of ancient Greece and Rome in books and movies influence our lives and emphasize the need to stay informed as these influences can beRead MoreResearch Papers for Eudora Welty4544 Words   |  19 Pages—Eudora Welty, One Writer’s Beginnings I owe a special debt to Jan Nordby Gretlund for his Eudora Welty’s Aesthetics of Place (Odense, Denmark: Odense University Press; Newark: University of Delaware Press,  ¡994). Given his extensive and intensive analysis of Welty’s ï ¬ ction, which he makes in response not only to that ï ¬ ction but also to the considerable body of historical and critical work that has been done on it, Professor Gretlund establishes both a scholarly and a critical context upon which my