Finger Strength Research Articles

Subjective symptoms and physiological measures of fatigue in air traffic controllers

This study measured the correlation between fatigue and physiological stress symptoms in 102 air traffic controllers (ATCs) in Taiwan. The subjects were asked to complete a fatigue questionnaire and physiological measurement before and after work. The study results showed that nearly 50% of the subjects felt tired and weary after work. However, according to the results of the critical flicker frequency test, all ATCs performed better after work, and the strength of masculine index fingers improved. The systolic and diastolic blood pressure decreased after work. In addition, the levels of urinary 17-hydroxycorticosteroids (17-OHCS) at the pre-shift and post-shift stages were 1.91 ± 1.01 mg/g cr. and 1.50 ± 0.95 mg/g cr., respectively. This study indicated that, while the ATCs' subjective ratings showed possible work-induced fatigue, it did not affect their physiological response. The findings suggested that ATC is a stressful job, and that complaints regarding excess work stress should be taken seriously. Subsequently the study proposed appropriate intervention strategies to address the identified problems. Relevance to industryThis paper presents the subjective and objective measures of fatigue in ATCs. Recommendations are proposed with respect to potentially viable countermeasures to reduce the impact of fatigue in ATC operations, and achieve a broader understanding of the causal factors for fatigue in ATC.

Handling forces for the use of different inhaler devices

Age and comorbidities can impact on the success of handling an inhaler. In this pilot study, we assessed finger strength in 62 participants (aged 5–17 years [n = 20], 18–65 years [n = 22] and > 65 years [n = 20]) by using different types of inhalers with integrated sensors (Respimat®, Breezhaler®, Aerolizer®, Genuair®, Diskus®, Ellipta®, HandiHaler®, Turbohaler® and a pressurized metered-dose inhaler [Atrovent®]). Parameters under investigation included the spontaneous and maximum achievable force and torque required to operate devices. Satisfaction with individual inhalers, and the relationship between satisfaction and strength, were also assessed. There was a marked difference in the compressive force required to operate individual inhalers, with maximum values ranging between 0.7 N and 39 N. Finger strength differed considerably between age groups, and participants with rheumatic disease showed different preferences and experienced more difficulties compared with healthy subjects. Satisfaction between devices was highly variable, and influenced by comorbidities and the ability to understand user instructions. Our findings suggest that individual patients’ circumstances need to be considered when prescribing an inhaler and may help in the development of future devices, leading to design options with increased ease of operation.

Effects of Grip Adjustable Ergonomic Pruning Shears on Grip Strength and Fatigue of Fingers

Objective: We developed an ergonomic pruning shears that allows the user to freely adjust the width of the grip and conducted this study to examine the effects of the pruning shears on grip strength and the fatigue of the fingers. Method: The maximum grip strength was first measured with an digital dynamometer, and the maximum grip strength was measured again after the subjects repeated scissoring 100 times using general pruning shears or ergonomic pruning shears. Borg s CR-10 scale was used to measure subjective fatigue after using the two pruning shears. Results: When the grip strength values after using the two pruning shears were compared with each other the mean grip strength after using ergonomic pruning shears was 27.69 kg, which was higher than that after using general pruning shears, 25.73 kg (p<.05). The subjective fatigue when the two pruning shears were used was shown to be 3.6 points for general pruning shears and 1.73 points for ergonomic pruning shears (p<.05). Conclusion: After repeating scissoring 100 times, the fatigue of the fingers was lower when ergonomic pruning shears were used than when general pruning shears were used and grip strength was higher when ergonomic pruning shears were used than when general pruning shears were used.

Dorsal transosseous reduction and locking plate fixation for articular depressed middle phalangeal base fracture.

An articular depressed fragment at the base of the middle phalanx can be an obstacle to congruent reduction and stable fixation. This study assessed the outcomes of a transosseous reduction technique combined with locking plate fixation for the treatment of articular depressed middle phalangeal base fracture. Between 2015 and 2017, seven patients (eight fingers) with intraarticular comminuted middle phalangeal base fracture were included in this study. Mean follow-up was 19 months (range 12-30 months). All patients showed depression of the articular fragment on sagittal computed tomography (CT) scan and were treated with a transosseous reduction technique and dorsal locking plate fixation. Radiographic evaluation was performed to ensure restoration of a concentric articular surface postoperatively. Total active range of motion (TAM) of the finger, grip strength, and the quick Disabilities of the Arm, Shoulder and Hand (quick DASH) score were evaluated at the last follow-up. Complications were also assessed. All fractures obtained bony union with a concentric joint. There was no significant loss of reduction during the follow-up period. The mean active proximal interphalangeal (PIP) joint and distal interphalangeal joint motion arcs at follow-up were 89° and 61°, respectively. Mean TAM of the affected finger and mean grip strength were 94% (range 80-100%) and 94% (range 86-100%) of the contralateral side, respectively. Mean quick DASH score was 2.3 (range 0-9.1). All patients returned to work. No surgery-related complications occurred. This technique provides satisfactory restoration of articular congruence and enables the early joint mobilization of articular depression-type fractures of the base of the middle phalanx. Therapeutic, level IV.

Performing pull-ups with small climbing holds influences grip and biomechanical arm action

ABSTRACTPull-ups are often used by sport-climbers and other athletes to train their arm and back muscle capabilities. Sport-climbers use different types of holds to reinforce finger strength concomitantly. However, the effect of grip types on pull-up performance had not previously been investigated. A vertical force platform sensor measured the force exerted by climbers when performing pull-ups under six different grip conditions (gym-bar, large climbing hold, and four small climbing holds: 22mm, 18mm, 14mm, and 10mm). The electromyography of finger flexors and extensor muscles were recorded simultaneously. The maximal arm power and summed mechanical work were computed. The results revealed that the number of pull-ups, maximal power, and summed mechanical work decreased significantly with the size of the climbing hold used, even if no differences were found between a large climbing hold and a gym-bar. Electromyography of the forearm muscles revealed that the use of a climbing hold generated finger flexor fatigue and that the level of cocontraction was impacted by the different segment coordination strategies generated during the pull-ups. These findings are likely to be useful for quantifying training loads more accurately and designing training exercises and programs.

Effects of a massage-like essential oil application procedure using Copaiba and Deep Blue oils in individuals with hand arthritis

Background and PurposeExisting research suggests that both massage and essential oils may have analgesic and anti-inflammatory benefits. We investigate the benefits of the AromaTouch Hand Technique® (ATHT), a procedure that combines a moderate pressure touch with the application of essential oils to the hand, in individuals with hand arthritis. Methods and materialsThirty-six participants with rheumatoid arthritis, osteoarthritis, and/or chronic inflammation received ATHTs with either a 50/50 preparation of Deep Blue® and Copaiba oil or a coconut oil placebo twice daily for 5 consecutive days. Changes in maximum flexion in finger and thumb joints, items from the Arthritis Hand Function Test, and hand pain scores were evaluated. ResultsParticipants treated with the essential oil preparation required significantly less time to complete dexterity tasks and showed about 50% decrease in pain scores, increased finger strength, and significantly increased angle of maximum flexion compared to subjects treated with coconut oil. ConclusionThe ATHT with Copaiba and Deep Blue may have ameliorative effects on hand arthritis.

Effect of localized microclimate heating on peripheral skin temperatures and manual dexterity during cold exposure.

Reduced dexterity is a major problem in cold weather, with a need for a countermeasure that increases hand (Thand) and finger (Tfing) temperatures and improves dexterity. The purpose of this study was to determine whether electric heat (set point, 42°C) applied to the forearm (ARM, 82 W), face (FACE, 9.2 W), or combination of both (COMB, 91.2 W), either at the beginning of cold exposure (COLD; 0.5°C, 120 min; 2 clo insulation, seated, bare-handed) or after Tfing fell to 10.5°C [delayed trials (D)], improves Thand, Tfing, dexterity, and finger key pinch strength (Sfing). Volunteers ( n = 8; 26 ± 9 yr) completed 7 experimental trials in COLD: ARM, ARM-D, FACE, FACE-D, COMB, COMB-D, and no heating (CON). Temperatures were measured before (BASE) and throughout COLD. Tests of dexterity [Purdue Pegboard assembly (PP) and magazine loading (MAGLOAD)] and Sfing were measured at BASE and after 45 and 90 min of COLD. Data presented are at minute 90. Thand was warmer ( P < 0.001) during ARM (18.0 ± 2.6°C) and COMB (18.9 ± 2.0°C) versus CON (15.3 ± 1.5°C) and FACE (15.8 ± 1.5°C) for heating that was initiated at the beginning of COLD. Tfing was higher ( P < 0.04) during COMB (12.7 ± 5.1°C) versus CON (9.7 ± 2.1°C) and FACE (8.9 ± 2.2°C). The change from BASE for PP (no. of pieces) was less ( P < 0.005) in COMB (-4.5 ± 3.3) and ARM (-5.0 ± 6.0) versus CON (-13.0 ± 7.3) and FACE (-10.0 ± 8.3), and for MAGLOAD, it tended ( P = 0.06) to be less in COMB (-8.9 ± 6.2 cartridges) versus CON (-14.8 ± 3.7 cartridges). There was no change in Sfing from BASE (10.5 kg) to minute 90 in ARM or COMB (0.7 ± 1.4 and -0.2 ± 1.7 kg, respectively) but a decrease ( P < 0.01) in CON and FACE (-2.1 ± 2.0 and -1.6 ± 1.9 kg, respectively). There were no differences in Thand, Tfing, dexterity, and Sfing at minute 90 when comparing heating that was initiated at the beginning of COLD versus delayed heating. In conclusion, heating using either COMB or ARM, compared with CON and FACE, improved Thand and Tfing and reduced the decline in dexterity by 20%-50% and Sfing by 90%. Furthermore, delayed heating had no deleterious effect on Thand, Tfing, dexterity, and Sfing compared with heating that started at the beginning of cold exposure. NEW & NOTEWORTHY The present study demonstrated that, during sedentary cold air exposure, localized heating that was applied from the beginning of cold exposure on the forearm increases hand and finger temperatures and finger strength, leading to subsequent improvements in manual dexterity. In addition, localized heating that was delayed until finger temperatures cooled significantly also caused higher peripheral temperatures, leading to better strength and manual dexterity, compared with no heating.

Packaging-Induced Range Tunability of Tactile Sensors for Physiological Signal Monitoring Applications

Packaging-induced performance changes of microelectromechanical systems (MEMS) usually are detrimental in the device development. This paper presents a methodology of tuning the force range of a designated MEMS tactile sensor for broader application potentials by packaging this millinewton-level force sensor with different polymers. The force range of the tactile sensor has been enhanced from 30 mN to 400 mN and 100 N, respectively, which are more than tenfolds or 1000 folds of its original capability, by ruggedizing with the polydimethylsiloxane and polyurethane. Numerical analysis and experimental characterization have verified the tuned force range by these two packaging approaches. Three potential applications for the physiological signal monitoring have been revealed by preliminary emulation test results, including emulated lip pressure measurement, heart rate monitoring, and the finger strength evaluation. This methodology sheds light on reconciling the sensitivity changes induced by the packaging phase from defects to merits for broader application potentials in the MEMS development, accelerating the fabrication flow and lowering the cost with the reusability of concurrent devices.

Reliability and Validity of Finger Strength and Endurance Measurements in Rock Climbing

ABSTRACTPurpose: An advanced system for the assessment of climbing-specific performance was developed and used to: (a) investigate the effect of arm fixation (AF) on construct validity evidence and reliability of climbing-specific finger-strength measurement; (b) assess reliability of finger-strength and endurance measurements; and (c) evaluate the relationship between finger flexor all-out test scores and climbing ability. Methods: To determine the effect of AF, 22 male climbers performed 2 maximal strength and all-out tests with AF (shoulder and elbow flexed at 90°) and without AF (shoulder flexed at 180° and elbow fully extended). To determine reliability, 9 male climbers completed 2 maximal strength tests with and without AF and an all-out and intermittent test without AF. Results: The maximal strength test without AF more strongly determined climbing ability than the test with AF (r2 = .48 and r2 = .42 for sport climbing; r2 = .66 and r2 = .42 for bouldering, respectively). Force and time variables were highly reliable; the rate of force development and fatigue index had moderate and low reliability. The maximal strength test with AF provided slightly higher reliability than without AF (intraclass correlation coefficient [ICC] = 0.94, ICC = 0.88, respectively). However, smaller maximal forces were achieved during AF (484 ± 112 N) than without AF (546 ± 132 N). All-out test average force had sufficiently high reliability (ICC = 0.92) and a relationship to sport climbing (r2 = .42) and bouldering ability (r2 = .58). Conclusion: Finger strength and endurance measurements provided sufficient construct validity evidence and high reliability for time and force parameters. Arm fixation provides more reliable results; however, the position without AF is recommended as it is more related to climbing ability.

Finger strength, individuation, and their interaction: Relationship to hand function and corticospinal tract injury after stroke

ObjectiveThe goal of this study was to determine the relative contributions of finger weakness and reduced finger individuation to reduced hand function after stroke, and their association with corticospinal tract (CST) injury. MethodsWe measured individuated and synergistic maximum voluntary contractions (MVCs) of the index and middle fingers, in both flexion and extension, of 26 individuals with a chronic stroke using a robotic exoskeleton. We quantified finger strength and individuation, and defined a novel metric that combines them – “multifinger capacity”. We used stepwise linear regression to identify which measure best predicted hand function (Box and Blocks Test, Nine Hole Peg Test) and arm impairment (the Upper Extremity Fugl-Meyer Test). ResultsCompared to metrics of strength or individuation, capacity survived the stepwise regression as the strongest predictor of hand function and arm impairment. Capacity was also most strongly related to presence or absence of lesion overlap with the CST. ConclusionsReduced strength and individuation combine to shrink the space of achievable finger torques, and it is the resulting size of this space – the multifinger capacity – that is of elevated importance for predicting loss of hand function. SignificanceMulti-finger capacity may be an important target for rehabilitative hand training.

Comparison Level of Handgrip Strength for the Three Categories among Male Athlete’s Artificial Wall Climbing and Factors WILL Affect

The aim of this study is to compare the level of handgrip strength (HGS) in male’s athletes between three different categories of climbing (boulder, lead, and speed) during competition. Grip strength refers to the ability of the fingers and hand to generate muscle power and force. In sport climbing, performance on climbing athletes are not only depending on handgrip strength but also other factors that should be consider such as anthropometry, finger strength, arm span, experiences in climbing and percentages of body fat. The research design is ex-post facto. The participants were 123 male athletes as subjects (boulders; 41, lead; 41, speed; 41) whose average age is 22.46±4 years. All of them are students of a university in Malaysia. The handgrip strength was measured statically using a hand dynamometer (handgrip). Descriptive statistics were used to explore the differences of handgrip strength in three categories. Descriptive data for boulder (M=102.646; SD=14.71), lead (M=92.42; SD=15.88), and speed (M=88.13; SD=16.43) were determined. The findings showed significant differences handgrip strength score in three categories of climbing [F (2,120) =9.26, p=0.000)]. Data analysis by using post hoc turkey test showed significance difference between boulder and lead (p=0.011), and boulder and speed (p=0.000). Significant difference showed in covariance variable of experience [F (1,115) = 21.41; P = 0.00, eta squared = 0.16], BMI [F (1,115) = 10.50; P = 0.002, eta squared = 0.084], finger strength power [F (1,115) = 60.39; P = 0.00, eta squared = 0.34], and percentage of body fat [F (1,115) = 5.73; P = 0.018, eta squared = 0.047]. Conclusion from this study indicate the level of handgrip strength. Based on the research, boulder climbing found to be stronger compare to lead climbers in handgrip strength. In sport climbing, another factors that should be focus on effected to handgrip strength also on climbing performance.

Cloud-supported framework for patients in post-stroke disability rehabilitation

Given the flexibility and potential of cloud technologies, cloud-based rehabilitation frameworks have shown encouraging results as assistive tools for post-stroke disability rehabilitation exercises and treatment. To treat post-stroke disability, cloud-based rehabilitation offers great advantages over conventional, clinic-based rehabilitation, providing ubiquitous flexible rehabilitation services and storage while offering therapeutic feedback from a therapist in real-time during patients' rehabilitative movements. With the development of sensory technologies, cloud computing technology integrated with Augmented Reality (AR) may make therapeutic exercises more enjoyable. To achieve these objectives, this paper proposes a framework for cloud-based rehabilitation services, which uses AR technology along with other sensory technologies. We have designed a prototype of the framework that uses the mechanism of sensor gloves to recognize gestures, detecting the real-time condition of a patient doing rehabilitative exercises. This prototype framework is tested on twelve patients not using sensor gloves and on four patients wearing sensor gloves over six weeks. We found statistically significant differences between the forces exerted by patients’ fingers at week one compared to week six. Significant improvements in finger strength were found after six weeks of therapeutic rehabilitative exercises.

Fire tests on glued-laminated timber beams with specific local material properties

The fire resistance of glued-laminated timber (glulam) beams is usually determined by calculation models or by tests. The evaluation of the fire resistance tests is accompanied by an uncertainty with regard to the timber material properties, which is, however, important to know when comparing the test results to the effective cross-section method according to EN 1995-1-2. The present paper presents therefore for the first time the results of six fire resistance tests with glulam beams with specific local mechanical material properties, such as exact position and dimension of knots, weak sections and finger joints, densities and strength properties of small cells. The tested glulam beams had an approximate height of 250 mm and reached a fire resistance of up to 68 min. The performed fire tests allowed the determination of the zero-strength layer with a higher certainty than investigations performed in the past. Additionally, reference tests at ambient temperature were considered in the evaluation. The determined zero-strength layer was in the range of 7 mm, as given in the current version of EN 1995-1-2 for beams in bending.

Functional classification of grasp strategies used by hemiplegic patients.

This study aimed to identify and qualify grasp-types used by patients with stroke and determine the clinical parameters that could explain the use of each grasp. Thirty-eight patients with chronic stroke-related hemiparesis and a range of motor and functional capacities (17 females and 21 males, aged 25–78), and 10 healthy subjects were included. Four objects were used (tissue packet, teaspoon, bottle and tennis ball). Participants were instructed to “grasp the object as if you are going to use it”. Three trials were video-recorded for each object. A total of 456 grasps were analysed and rated using a custom-designed Functional Grasp Scale. Eight grasp-types were identified from the analysis: healthy subjects used Multi-pulpar, Pluri-digital, Lateral-pinch and Palmar grasps (Standard Grasps). Patients used the same grasps with in addition Digito-palmar, Raking, Ulnar and Interdigital grasps (Alternative Grasps). Only patients with a moderate or relatively good functional ability used Standard grasps. The correlation and regression analyses showed this was conditioned by sufficient finger and elbow extensor strength (Pluri-digital grasp); thumb extensor and wrist flexor strength (Lateral pinch) or in forearm supinator strength (Palmar grasp). By contrast, the patients who had severe impairment used Alternative grasps that did not involve the thumb. These strategies likely compensate specific impairments. Regression and correlation analyses suggested that weakness had a greater influence over grasp strategy than spasticity. This would imply that treatment should focus on improving hand strength and control although reducing spasticity may be useful in some cases.

The Combined Effects of Adaptive Control and Virtual Reality on Robot-Assisted Fine Hand Motion Rehabilitation in Chronic Stroke Patients: A Case Study

Robot-assisted therapy is regarded as an effective and reliable method for the delivery of highly repetitive training that is needed to trigger neuroplasticity following a stroke. However, the lack of fully adaptive assist-as-needed control of the robotic devices and an inadequate immersive virtual environment that can promote active participation during training are obstacles hindering the achievement of better training results with fewer training sessions required. This study thus focuses on these research gaps by combining these 2 key components into a rehabilitation system, with special attention on the rehabilitation of fine hand motion skills. The effectiveness of the proposed system is tested by conducting clinical trials on a chronic stroke patient and verified through clinical evaluation methods by measuring the key kinematic features such as active range of motion (ROM), finger strength, and velocity. By comparing the pretraining and post-training results, the study demonstrates that the proposed method can further enhance the effectiveness of fine hand motion rehabilitation training by improving finger ROM, strength, and coordination.

The role of physique, strength and endurance in the achievements of elite climbers.

PurposeThe primary aim of this study is to determine the principal somatic and motor determinants for elite climbers.MethodsTwenty climbers were examined [age: 28.5±6.1 years].The runners were divided into two groups based on their climbing level, according to the International Rock Climbing Research Association (IRCRA). Elite climbers represented a 8b-8c Rotpunkt (RP) climbing level (n = 6), and advanced climbers represented an 7c+-8a RP level (n = 14). The following measurements were assessed: height, weight, lean body mass, upper limb length, arm span, and forearm, arm, thigh and calf circumference. The BMI, Rohrer ratio, and Ape Index were also measured. The following motor tests were assessed: a specific test for finger strength, an arm strength test, and a test of muscle endurance (hanging from 2.5 and 4 cm ledges). In addition, pull ups were used to measure muscle resistance to fatigue.ResultsElite climbers recorded significantly higher values for finger strength than advanced climbers (129.08 vs. 111.54 kg; t(18) = 2.35, p = 0.03) and arm endurance (33.17 vs. 25.75 pull ups; t(18) = 2.54, p = 0.02). In addition, the calf circumference was significantly lower in elite climbers than that in advanced climbers (34.75 vs. 36.93 cm; t(18) = 3.50, p = 0.003).ConclusionThe results suggest that elite climbers have greater finger strength and arm endurance than advanced climbers.

Square or oblong?

In these activities two-year-olds investigate the properties of rectangles while practising fine motor skills. The emphasis is on developing hand and finger strength, hand eye co-ordination and object manipulation.

Bone setting manipulative reduction for the treatment of children's distal radioulnar fracture and dorsal dislocation

To observe the effect of different manipulative reduction for children's distal radioulnar fracture and dorsal dislocation. From June 2013 to June 2014, 80 children with distal radioulnar fracture and dorsal dislocation were treated by bone setting manipulative reduction including 51 males and 29 females with an average age of 6.5 years old ranging from 3 to 14 years old. Time from injury to treatment was 1 h to 6 d, 31 cases were on the right, 49 cases were on the left. Among them, 45 cases were type I of overlapping displacement, 35 cases were type II. The displacement of the fracture was observed by clinical manifestations and X-ray examination. Under fluoroscopy, different techniques were used for reduction and fixation. After 3 weeks of over wrist fixation, the splints were overturned and fixed again for 1 to 2 weeks, then were removed. The wrist joint function was evaluated based on Dienst criteria. Eighty cases of fracture were successfully operated one time, all reached anatomic reduction or near anatomic reduction. Eighty children were followed up for 3 months to 1 year. All the fractures healed, and the healing time was 4 to 5 weeks with an average of 4.6 weeks. All patients removed the splint 3 months later, the results were excellent in 72 cases, good in 7 cases and fair in 1 case, the excellent and good rate was 98.75%. Bone setting manipulation for children's distal radioulnar fracture and dorsal dislocation can get good reduction. At 1 month after the removal of the splint, wrist function and finger strength gradually recovered and returned to normal after 3 months.

Climb Hard, Train Harder: Supplemental Training Techniques for Improved Rock Climbing Performance

Climbing is an increasingly popular recreational activity that has attracted interest from a wide variety of populations, likely because of the increasing availability and challenge of climbing. Many children and adolescents are introduced to rock climbing in adventure programming units in their schools. Through physical education, children are able to try new activities that can spark a new interest such as climbing. Because of the versatility of climbing, it can develop into a lifelong activity. Although individuals of all ages and skill levels can enjoy climbing, it is important to understand that individuals who seek to climb challenging heights should be particularly fit and experienced. This article examines three supplemental training techniques that are often overlooked by climbers: (1) forearm and finger strength, (2) footwork and leg strength, and (3) cardiovascular conditioning. These training techniques enable climbers of any level to grow stronger, prevent injury, increase technical proficiency, and improve more quickly.

Design of adaptive control and virtual reality-based fine hand motion rehabilitation system and its effects in subacute stroke patients

ABSTRACTRobot-assisted therapy is regarded as an effective and reliable method for the delivery of highly repetitive training that is needed to trigger neuroplasticity following a stroke. This study focuses on the pre-defined research gaps by combining adaptive assist-as-needed control and immersive virtual environment (VE) into a rehabilitation system, with special attention on the rehabilitation of fine hand motion skills. The virtual reality-based integrated rehabilitation system using Oculus Rift DK2 head mounted display, featuring rehabilitation gaming system with rendering immersive VE is proposed to strengthen activities of daily living and task-oriented kinematic features such as force, range of motion (ROM) and finger coordination. The effectiveness of the system is examined by conducting clinical trials on a group of 8 subacute stroke patients for a period of six weeks with 18 training sessions. The results are verified through clinical evaluation methods and key kinematic features such as active ROM and finger strength. By comparing the pre- and post-training results, the study demonstrates that the proposed method can enhance the efficiency of fine hand motion rehabilitation training by 35% on average in the patients who participated in the experimental work.