Submitted by ANGELA JULIANA CAPPELI (juliana.cappeli@yahoo.com.br) on 2018-04-10T16:54:03Z No. of bitstreams: 1 DISSERTAÇÃO ANGELA JULIANA CAPPELI (após defesa).pdf: 1545854 bytes, checksum: ded0e02f1313a6e0779d7135a2093080 (MD5) / Approved for entry into archive by Luciana Pizzani null (luciana@btu.unesp.br) on 2018-04-10T19:55:25Z (GMT) No. of bitstreams: 1 cappeli_aj_me_bot.pdf: 1545854 bytes, checksum: ded0e02f1313a6e0779d7135a2093080 (MD5) / Made available in DSpace on 2018-04-10T19:55:25Z (GMT). No. of bitstreams: 1 cappeli_aj_me_bot.pdf: 1545854 bytes, checksum: ded0e02f1313a6e0779d7135a2093080 (MD5) Previous issue date: 2018-02-23 / Objetivo: Avaliar a eficácia da aplicação da estimulação elétrica nervosa transcutânea (TENS) no controle da dor durante o período da dilatação do trabalho de parto. Método: Foi realizado um ensaio clínico, paralelo e randomizado. Sessenta e oito parturientes com gestação única, de baixo risco, no termo, com dilatação cervical ≥ 4 cm e ≤ 7 cm e sem uso de medicação analgésica prévia. Foram randomizadas em dois grupos: TENS (n=34) e placebo (n=34) e avaliados os desfechos primários (intensidade da dor após a intervenção, grau de desconforto e grau de satisfação materna) e secundários (uso de outros métodos não farmacológicos para alívio da dor, fármacos no parto vaginal, taxa de cesárea e duração do trabalho de parto). A TENS foi aplicada por 30 minutos, entre T10 – L1 e S2 – S4. A intensidade da dor e o grau de desconforto foram avaliados por meio da escala visual analógica (EVA) e o grau de satisfação materna por nota de 0 a 10. Considerando a diferença de 34% entre os grupos para detectar efetividade do tratamento e assumindo a margem de erro de 10% e confiabilidade de 95%, o tamanho amostral calculado foi de 34 parturientes por grupo. Os resultados foram analisados estatisticamente para comparação entre os grupos estudados, adotando-se o limite mínimo de significância de 95% (p<0,05) Resultados: No grupo TENS houve maior número de parturientes classificando a dor como leve/moderada (RR= 2,4; IC95%: 1,6-3,7), melhora do grau de desconforto (RR= 4,1; IC95%: 2,1-8,1), maior número de mulheres referindo plena satisfação (RR= 2,8; IC95%: 1,5-5,0) e menor taxa de cesárea (RR= 0,3; IC95%: 0,1-0,8), quando comparadas ao grupo placebo. Não houve diferença estatística entre os grupos em relação ao uso de métodos não farmacológicos, farmacológicos e na duração do trabalho de parto. Conclusões: a TENS é um método eficaz na melhora da dor e com alto grau de satisfação materna, quando aplicado em parturientes de baixo risco, durante o período da dilatação, podendo ser utilizado como método não farmacológico de alivio da dor. Registro de ensaio clínico: RBR-2ZGDGJ. / Objective: To evaluate the efficacy of transcutaneous electrical nerve stimulation (TENS) in the control of pain during the period of labor. Method: A clinical, parallel and randomized trial was performed. Sixty-eight parturients with single, low-risk pregnancies at term, with cervical dilatation ≥ 4 cm and ≤ 7 cm and without previous analgesic medication. They were randomized into two groups: TENS (n = 34) and placebo (n = 34) and primary outcomes (pain intensity after intervention, degree of discomfort and degree of maternal satisfaction) and secondary outcomes (use of other non-pharmacological methods for pain relief, vaginal delivery drugs, cesarean section rate and duration of labor). The TENS was applied for 30 minutes between T10 - L1 and S2 - S4. The intensity of the pain and the degree of discomfort were evaluated through the visual analogue scale (VAS) and the degree of maternal satisfaction by grade from 0 to 10. Considering the difference of 34% between the groups to detect treatment effectiveness and assuming the margin of error of 10% and reliability of 95%, the sample size calculated was 34 parturients per group. The results were statistically analyzed for comparison between the groups studied, adopting the minimum significance level of 95% (p <0.05). Results: In the TENS group, there was a higher number of parturients classifying pain as mild / moderate (RR = 2.4, 95% CI: 1.6-3.7), improvement in the degree of discomfort (RR = 4.1, 95% CI, (RR = 2.8, 95% CI: 1.5-5.0) and lower rate of cesarean section (RR = 0.3, 95% CI: 0.1-0.8) when compared to the placebo group. There was no statistical difference between the groups regarding the use of non-pharmacological, pharmacological and duration of labor methods. Conclusions: TENS is an effective method to improve pain and with a high degree of maternal satisfaction when applied to low-risk parturients during the period of dilation and can be used as a non-pharmacological method of pain relief. Trial registration: RBR-2ZGDGJ.

A fisioterapia é uma área medicina veterinária com um crescente interesse científico, da mesma forma que sua aplicação em pequenos animais. Em cães, entre as indicações da reabilitação está o pós-operatório ortopédico recente, em que os objetivos principais são o controle álgico e da inflamação, possibilitando um restabelecimento funcional precoce. Dentre as afecções ortopédicas, a ruptura de ligamento cruzado cranial é a mais comum na articulação fêmoro-tíbio-patelar em cães, sendo a técnica de nivelamento do platô tibial amplamente empregada. O presente estudo teve como objetivo a análise dos efeitos da eletroterapia e da laserterapia nos aspectos de dor e inflamação no pós-operatório recente da referida cirurgia ortopédica. Para esta avaliação, foi utilizada uma metodologia multimodal que incluiu escalas de dor unidimensional (ENV) e multidimensional (Glasgow), escalas de claudicação, análise cinética por baropodometria, análises perimétricas e termográficas da articulação. Vinte e quatro cães foram selecionados, sendo que efetivamente distribuídos e randomizados entre os grupos, 16. Dentre eles, 9 animais foram distribuídos no grupo Fisioterapia (F) e 7 no grupo Placebo(P). Os animais do grupo fisioterapia foram submetidos a 6 sessões de eletroterapia associada à laserterapia, enquanto os animais do segundo grupo submetidos a 6 sessões placebo. Ambos os grupos foram avaliados antes da cirurgia, no pós-operatório previamente às sessões e ao término das 6 sessões. O grupo fisioterapia teve benefícios evidenciados nas análises seriadas das escalas de dor, com valores de P=0,0156 e P=0,011, nos quesitos de ENV do avaliador e do cuidador respectivamente. Nas análises de dor através da escala de Glasgow, os valores de P=0.0272 na análise seriada do grupo tratado, confirmando a melhora deste grupo em relação ao controle, onde o resultado de P=0.4375. Porém, não foram observadas diferenças nos quesitos de escalas de claudicação, avaliação de edema através de perimetria, e, inflamação através da termografia, em relação ao grupo placebo. Na avaliação cinética, houve diferença na análise dos parâmetros de impulso vertical, tendendo à melhora do grupo fisioterapia, porém na análise do pico de força vertical, que é mais sensível, não houve diferença entre os grupos. Houve também a necessidade de resgate analgésico em três animais do grupo placebo, sendo que nenhum animal do grupo Fisioterapia necessitou de resgate. Conclui-se que os animais submetidos às sessões de fisioterapia tiveram melhor evolução nos quesitos de dor, além de não necessitarem de resgate analgésico. Não houve influência da laserterapia no controle da inflamação e do edema através dos métodos avaliados. Evidencia-se a necessidade de mais estudos sobre os resultados das técnicas de fisioterapia quando aplicadas à rotina clínica veterinária, especialmente, com um maior número de amostras / Physical therapy is a veterinary medicine area with a growing scientific interest, as its application in small animals. In dogs, among the physiotherapy indications is the recent orthopedic post operatory period, in order to control pain and inflammation to get an early functional recovery. Among the orthopedic diseases, the cranial cruciate ligament rupture is the most common disease in the femoral-tibio-patellar joint in dogs, and the tibial plateau leveling osteotomy, the to more common surgical approach. This study aimed to evidence the effects of electrotherapy and laser therapy on aspects of pain and inflammation in the post operatory of that recent surgery. For this evaluation were used multimodal methods that included unidirectional and multidirectional pain scales, lameness scales, kinetic analysis by baropodometry, perimeter and thermographic analysis. Twenty-four dogs were selected, which effectively distributed between the groups 16. Among them, 9 animals in physiotherapy group (F) 7 and the placebo group (P). Animals in the physical therapy group underwent 6 electrotherapy sessions associated with laser therapy, and the other group underwent 6 placebo sessions. Both groups were evaluated before surgery, in the post recent post operatory, before the treatment, and after 6 sessions. The physiotherapy group had benefits shown in the serial analysis of pain scales, with P = 0.0156 and P = 0.011 values for the treated group, for ENV questions of the evaluator and the owner, respectively. The pain analysis by the Glasgow scale, the values of P = 0.0272 in the serial analysis of the treated group, confirming the improvement of this group compared to the control group, which had the P = 0.4375. Despite of these findings, no differences were observed in the categories of lameness scales, edema assessment through perimetry and thermography. In the kinetic evaluation, there were differences in the analysis of vertical impulse parameters, tending to improve of the physiotherapy group, but in the analysis of vertical peak force, which is more sensitive, there was no difference between groups. There was also the need for analgesic rescue medication in three animals of the placebo group. We conclude that animals subjected to actual physical therapy sessions had improvement in pain scores, and do not require analgesic rescue. There was no influence on the swelling or on the inflammation through the methods used in this study. Further studies are needed, especially with a larger number of animals

Diabetes mellitus und seine Folgeerkrankungen haben aufgrund der hohen Prävalenz in der Bevölkerung eine starke medizinsche Relevanz. Dabei stellen die durch eine diabetische Neuropathie ausgelösten Schmerzen ein Herausforderung in der Schmerztherapie dar. Die Behandlung dieser Schmerzen mit TENS ist eine oft angewendete Therapieoption, welche jedoch in ihrer Wirksamkeit nicht ausreichend evidenzbasiert gesichert ist, da es methodenbedingt bei klinischen Studien zur Wirksamkeit der TENS-Therapie oft Zweifel an einer ausreichenden Verblindung gibt. Die vorliegende Studie untersuchte deshalb Mikro-TENS als Therapiealternative zur TENS-Behandlung im Rahmen einer einfach verblindeten, placebokontrollierten, klinischen Studie mit 41 Patienten. Die Placebokontrolle ist bei der Anwendung von Mikroreizstrom möglich, weil dieser unterhalb der Wahrnehmungsschwelle für sensible Nervenfasern liegt. Damit können die Patienten nicht zwischen MENS-Therapie und Placebo-Therapie unterscheiden. Die Diabetespatienten wurden über 4 Wochen in insgesamt 12 Sitzungen à 30 Minuten mit Mikro-TENS am distalen Fuß beidseits behandelt. Als Messgrößen dienten der PDI, der NPS, der ADS und die durchschnittliche Schmerzintensität auf einer numerischen Ratingskala von 0 bis 10. Diese Variablen wurden jeweils zu Beginn der Studie, direkt am letzten Behandlungstag und einen Monat nach der letzten Behandlung erhoben. Der PDI Score zeigte nach vierwöchiger Therapie eine durchschnittliche absolute Reduktion von 4,27 \\pm 4,17 in der Verum- und 3,79 \\pm 7,71 in der Placebogruppe. Eine mindestens 30 %ige Verbesserung des NPS- und PDI-Scores wurde als Ansprechen auf die Therapie gewertet. Insgesamt konnte bei circa 30 % der 40 Studienteilnehmer eine Therapieresponse festgestellt werden. Laut NPS sprachen nach vier Wochen Reizstromtherapie 6 von 22 Patienten in der Verumgruppe und 10 von 19 Patienten in der Placebogruppe auf die Therapie an. Die Unterschiede zwischen den Studiengruppen waren statistisch nicht signifikant. Letztlich konnte die Wirksamkeit von Mikroreizstromtherapie bei diabetischer Polyneuropathie nicht bestätigt werden. Mit einer größeren Fallzahl und damit größerer statistischer Power könnte möglicherweise ein geringer Unterschied im Therapieerfolg zwischen Placebo- und Verumbehandlung statistisch signifikant werden. Dieser Therapieeffekt wäre aber möglicherweise schmerztherapeutisch als nicht relevant einzuschätzen, da es sich mit 80 %iger Wahrscheinlichkeit (Power der vorliegenden Studie) um eine Reduktion von weniger als 15 Punkten im PDI handelt. Daher kann die Mikroreizstromtherapie zur symptomatischen Therapie bei schmerzhafter diabetischer Neuropathie (dPNP) nicht empfohlen werden. Auf die Wirksamkeit von TENS mit höheren Stromstärken zur Behandlung der dPNP kann anhand der vorliegenden Studie kein Rückschluß gezogen werden. Es profitieren dennoch circa 30 % der insgesamt 40 Studienteilnehmer von der Intervention. Da in der Schmerztherapie Ansprechraten auf eine Placebotherapie von 7 bis 49 % möglich sind, stellt TENS eine Möglichkeit dar, diesen Effekt zusätzlich mit relativ geringem Aufwand auszuschöpfen. Vorteile in der Therapie mit Reizstrom sind außerdem geringe Kosten, nahezu keine unerwünschten Nebenwirkungen und fast kein Vorliegen von Kontraindikationen. Damit ist diese zusätzliche Therapieoptionen der dPNP neben einer optimale Einstellung des Blutzuckers und einer medikamentösen Schmerztherapie nicht außer Acht zu lassen und die Wirksamkeit komplexer Therapieprogramme mit Langzeitreizstromtherapie sollte in weiteren kontrollierten klinischen Studien eruiert werden.

abstract: Sleep is an essential human function. Modern day society has made it so that sleep is prioritized less and less. Professionals in critical positions such as doctors, nurses, and emergency medical technicians can often have hectic schedules that are unforgiving toward sleep due to the increase in shift work that dominates these fields. Sleep deficits can have detrimental effects on one’s psyche and mood. Depression and anxiety both have high comorbidity rates with insomnia because of sleeping deficits. Transdermal Electrical Nerve Stimulation (TENS) offers a potential solution to improving sleep quality and mood by modulating the ascending reticular activating system (RAS). This system starts in the anterior portion of the head with trigeminal nerve branches and is stimulated using a 500-550 Hz waveform. In this experiment Positive Affect and Negative Affect Schedule (PANAS) scores are recorded daily to monitor mood differences between pre and post treatment (TENS vs Sham). PANAS scores were found to be insignificant between groups. Pittsburgh Sleep Quality Index (PSQI), and Fitbit were chosen to study perceived sleep, and objective sleep. Both PSQI, and Fitbit found insignificant differences between TENS and Sham. Finally, the Beck Depression and Beck Anxiety Inventories were administered weekly to determine if there are immediate changes to depressive and anxiety symptom, after a week of treatment (TENS vs Sham). A significant difference was found between the pre and post of the TENS treatment group. The TENS group was not found to be significantly different from Sham, potentially the result of a placebo effect. These results were found with n=10 participants in the TENS treatment group and n=6 in the sham group. / Dissertation/Thesis / Masters Thesis Engineering 2018

abstract: Proprioception is the sense of body position, movement, force, and effort. Loss of proprioception can affect planning and control of limb and body movements, negatively impacting activities of daily living and quality of life. Assessments employing planar robots have shown that proprioceptive sensitivity is directionally dependent within the horizontal plane however, few studies have looked at proprioceptive sensitivity in 3d space. In addition, the extent to which proprioceptive sensitivity is modifiable by factors such as exogenous neuromodulation is unclear. To investigate proprioceptive sensitivity in 3d we developed a novel experimental paradigm employing a 7-DoF robot arm, which enables reliable testing of arm proprioception along arbitrary paths in 3d space, including vertical motion which has previously been neglected. A participant’s right arm was coupled to a trough held by the robot that stabilized the wrist and forearm, allowing for changes in configuration only at the elbow and shoulder. Sensitivity to imposed displacements of the endpoint of the arm were evaluated using a “same/different” task, where participant’s hands were moved 1-4 cm from a previously visited reference position. A measure of sensitivity (d’) was compared across 6 movement directions and between 2 postures. For all directions, sensitivity increased monotonically as the distance from the reference location increased. Sensitivity was also shown to be anisotropic (directionally dependent) which has implications for our understanding of the planning and control of reaching movements in 3d space. The effect of neuromodulation on proprioceptive sensitivity was assessed using transcutaneous electrical nerve stimulation (TENS), which has been shown to have beneficial effects on human cognitive and sensorimotor performance in other contexts. In this pilot study the effects of two frequencies (30hz and 300hz) and three electrode configurations were examined. No effect of electrode configuration was found, however sensitivity with 30hz stimulation was significantly lower than with 300hz stimulation (which was similar to sensitivity without stimulation). Although TENS was shown to modulate proprioceptive sensitivity, additional experiments are required to determine if TENS can produce enhancement rather than depression of sensitivity which would have positive implications for rehabilitation of proprioceptive deficits arising from stroke and other disorders. / Dissertation/Thesis / Doctoral Dissertation Neuroscience 2018

abstract: Every year, 3 million older people are treated for fall injuries, and nearly 800,000 are hospitalized, many of which due to head injuries or hip fractures. In 2015 alone, Medicare and Medicaid paid nearly 75% of the $50 Billion in medical costs generated by falls. As the US population continues to age, more adults are beginning to deal with movement related disorders, and the need to be able to detect and mitigate these risks is becoming more necessary. Classical metrics of fall risk can capture static stability, but recent advancements have yielded new metrics to analyze balance and stability during movement, such as the Maximum Lyapunov Exponent (MLE). Much work has been devoted to characterizing gait, but little has explored novel way to reduce fall risk with interventional therapy. Targeting certain cranial nerves using electrical stimulation has shown potential for treatment of movement disorders such as Parkinson’s Disease (PD) in certain animal models. For human models, based on ease of access, connection to afferents leading to the lower lumber region and key brain regions, as well as general parasympathetic response, targeting the cervical nerves may have a more significant effect on balance and posture. This project explored the effects of transcutaneous Cervical Nerve Stimulation (CNS) on posture stability and gait with the practical application of ultimately applying this treatment to fall risk populations. Data was collected on each of the 31 healthy adults (22.3 ± 6.3 yrs) both pre and post stimulation for metrics representative of fall risk such as postural stability both eyes open and closed, Timed-Up-and-Go (TUG) time, gait velocity, and MLE. Significant differences manifested in the postural stability sub-metric of sway area with subject eyes open in the active stimulation group. The additional 8 metrics and sub-metrics did not show statistically significant differences among the active or sham groups. It is reasonable to conclude that transcutaneous CNS does not significantly affect fall risk metrics in healthy adults. This can potentially be attributed to either the stimulation method chosen, internal brain control mechanisms of posture and balance, analysis methods, and the Yerkes-Dodson law of optimal arousal. However, no adverse events were reported in the active group and thus is a safe therapy option for future experimentation. / Dissertation/Thesis / Masters Thesis Biomedical Engineering 2019

The American College of Rheumatology (ACR) 1990 criterion classifies fibromyalgia as a clinical syndrome characterized by chronic widespread muscular pain and tenderness with hyperalgesia to pressure over 11/18 tender points of at least 3 months duration. Fibromyalgia is characterized by chronic widespread musculoskeletal pain and is associated with fatigue and cognitive dysfunction. The cause of fibromyalgia is unknown, but it has been shown to demonstrate sensitization of the central nervous system pain pathways by demonstrating lower pain pressure thresholds and reduced conditioned pain modulation (CPM). Pain and fatigue associated with fibromyalgia can interfere with daily function, work, and social activities. Without greater understanding of the interaction of pain, fatigue and function, we are limited in our ability to improve these symptoms for individuals with fibromyalgia. We designed three experiments to examine the relationship of pain, fatigue and function in individuals with fibromyalgia. Regression analyses demonstrated significant models that included pain, fatigue and fear of movement for prediction of function and quality of life in individuals with fibromyalgia and healthy controls. The fatigue study (cognitive fatigue, physical fatigue and dual fatigue task) demonstrated that people with fibromyalgia show enhanced pain and fatigue to both cognitive and physical fatigue tasks and reduced function in the physical fatigue task in comparison to healthy controls. Our final study showed active TENS restores CPM, decreases deep tissue pressure pain, decreases pain and fatigue during movement for individuals with fibromyalgia.

The research to date, of transcutaneous electric nerve stimulation on cutaneous blood flow, is equivocal. The purpose of this report is to review the TENS body of knowledge, in particular synthesizing the literature on acupuncture stimulation of cutaneous blood flow with the two fold goal of creating a protocol to increase skin blood flow through the exogenous application of electrical stimulation, as well as creating an engaging engineering challenge for high school anatomy and physiology students. The hypothesis developed was TENS stimulation with electrode placement on specific acupuncture points would influence cutaneous blood flow as measured using laser Doppler flowmetry. The findings of this project did not support the hypothesis of TENS or Interferential electrical stimulation, in combination with acupuncture points or not, influencing skin blood flow. Perhaps this is due to the physiological differences between glabrous and non-glabrous skin and the different electrical resistances of each dermal layer, nerve stimulation, age and gender of subject or some combination thereof. These equivocal findings may also be the result of inconsistencies in testing protocols, such as subject preconditioning or not, subject’s position during administration of stimulation, electrode size and placement to name a few. Ultimately, this report provides a summary of the research to date, as well as outlining how this research could be adapted to supply engaging bio engineering challenges in the classroom including challenges to develop a model for delivering current to muscle; develop a model for skin blood flow management to name a few. / text

ABSTRACTBackground: Thoracic surgery includes surgical diseases in the thorax and is dominated by coronary artery surgery. Pain after heart surgery is often most intense three to four days after the surgery. The pain treatment has improved over the last 20-30 years. Despite this, 30-50% report unbearable postoperative pain. Pain can in many cases be relieved by non- pharmacological methods such as Transcutaneous Electric Nerve Stimulation (TENS). TENS activates the body's own pain-relieving mechanisms by stimulating peripheral nerves. Aim: The aim of this study was to explore whether TENS has an effect on postoperative pain after thoracic surgery and to describe obstacles and opportunities for TENS as a pain management method. Method: The study has a descriptive design. The method of the study is a quantitative literature review that included 11 articles. The database PubMed was used to find articles. Result: TENS had a positive effect on self-estimated pain and reduced the consumption of analgesics after thoracic surgery. The few articles that included obstacles and opportunities showed that nurses perceived using TENS moderately difficult. Furthermore, they did not show any side effects. Conclusion: TENS as a pain management method after thoracic surgery relieves pain and reduces the consumption of analgesics, which could lead to less suffering for the individual, reduced burden on healthcare and a lower social cost.

In 1645, Blaise Pascal presented his Pascaline to the public. Using only addition and the method of tens complement, the device could add, subtract, multiply, and divide. We discuss tens complement as an introduction to signed representations in binary.