Nerve Express

APPENDIX A Theoretical Review of the Nerve-Express System with Sample Cases

The Nerve-Express System Overview

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The Nerve-Express Method What is the Nerve-Express Method? The Nerve-Express Advantage Heart Rate Variability Analysis Recognition and Classification of ANS States Physiological Interpretation of ANS States Nerve-Express Test Modalities Orthotest Sample Cases Valsalva Maneuver combined with Deep Breathing Sample Cases Monitor Test PC-ECG Device

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The Health-Express Method What is the Health-Express Method? The Health-Express Advantage Orthotest as the Health-Express Test Modality Health-Express applications

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Theoretical Review of the Nerve-Express System with Sample Cases By Alexander Riftine, Ph.D

The Nerve-Express System Overview Nerve-Express is a fully automatic, non-invasive computer-based system designed for quantitative assessment of the Autonomic Nervous System (ANS)1 and general state of health based on Heart Rate Variability (HRV) analysis. It is the first and only such system available today for practitioners and researchers in the field. The Nerve-Express System uses two methods of assessment of the body's vital functions, based on different types of HRV analysis: Nerve-Express and Health-Express: 1. Nerve-Express is a method of quantitative assessment of the Autonomic Nervous System (ANS) hence, the term Nerve-Express. The Nerve-Express uses 3 test modalities for the ANS assessment: Orthostatic test (Orthotest), where the patient changes the position from the Supine to Upright; Valsalva Maneuver combined with Deep Breathing; Real-time long term continuous monitoring of a patient.

2. Health-Express is a method of assessment of the general state of health, i.e., the levels of Physical Fitness, Wellness and Functional Capacity. The assessment is based on the Orthostatic test as a test modality. Health-Express takes into account the Transition Period of the test, while Nerve-Express does not.

Our system includes both methods, but since the NE method is more common for use in medical offices and offers a wider variety of test modalities, the whole system became traditionally known under the name Nerve-Express.

1 The Autonomic Nervous System (ANS) is the portion of the peripheral nervous system that functions independently (autonomously) and continuously, without conscious effort. This system controls visceral activities by regulating the actions of smooth muscles, cardiac muscles, and various glands. It is concerned with regulating heart rate, blood pressure, breathing rate, body temperature, and other visceral activities. ANS has two divisions: the Sympathetic Nervous System (SNS), primarily concerned with regulation under stressful conditions, and the Parasympathetic Nervous System (PSNS), primarily concerned with regulation under restful conditions.

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Nerve-Express - the Express Method for Quantitative Assessment of the Autonomic Nervous System (ANS) What is the Nerve-Express Method?

Nerve-Express is a method for quantitative assessment of the Autonomic Nervous System (ANS) based on Heart Rate Variability (HRV) analysis. Prior to the application of HRV to ANS assessment, the Autonomic function could only be approximately assessed by the following three parameters: - Autonomic Balance (Vegetative Homeostasis) - Sympathetic Prevalence - Parasympathetic Prevalence. Traditionally, the criteria used for evaluating these three parameters were clinical and laboratory findings. Assessment of the Autonomic function was thus labor intensive and not always feasible. The introduction of HRV analysis - especially, the identification of the power of low-frequency band of 2 HRV spectral function with the activity of Sympathetic Nervous System (SNS) and the power of its high2 frequency band with the activity of Parasympathetic Nervous System (PSNS) - opened up new theoretical opportunities for ANS assessment. But to make practical use of this important scientific discovery one had to solve the problem of deriving some form of quantitative relationship between SNS and PSNS from the spectral function. HRV analysis is based on measuring variability in heart rate; specifically, variability in intervals between R waves - “RR intervals” (cf. Fig. 1). These RR intervals are then analyzed by spectral (as in NerveExpress) or some other form of mathematical analysis (e.g., chaos, wavelet theories). Such mathematical analysis generates multiple parameters; typically 20-30. The problem of SNS-PSNS quantification, which has remained for many years the principal dilemma of HRV analysis, is specifically in reducing all possible variations of these multiple parameters to a quantitative relationship between only two parameters: SNS and PSNS. Nerve-Express is the first and only system to solve the problem of SNS-PSNS quantification. This technological breakthrough is achieved by using proprietary algorithms and a new approach based on one of the leading theories of Artificial Intelligence - Marvin Minsky's Frame Theory3. Nerve-Express objectively and reliably evaluates the state of ANS during rest (up to 24 hours) as well as during Orthostatic test and Valsalva maneuver combined with Deep Breathing. Due to its highly sophisticated HRV analysis, Nerve-Express is the only method that enables precise recognition and classification of 74 ANS states with a corresponding qualitative description for each one.

2 3

cf. SNS and PSNS definitions in footnote 1, page 66. M. Minsky. Structures for Knowledge Representation. Machine Vision Psychology. Mir, 1978.

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The algorithms used by Nerve-Express have been developed and tested for over twenty years in studies involving more than twenty thousand patients. Nerve-Express was then subjected to an independent review by the leading authority on HRV - J. Thomas Bigger, Jr., M.D., Head of Research Holter Laboratory, Professor of Medicine and Pharmacology of the Cardiology Division, Department of Medicine at Columbia University. In a preamble to his review Dr. Bigger states: "The purpose of this evaluation was to compare the Nerve Express algorithms with the "gold standard" CHRONOS algorithms to test the reliability of the Nerve Express algorithms for power spectral analysis of RR intervals. The CHRONOS algorithms have been shown to predict death in coronary heart disease and to quantify physical fitness, but they are accessed via Holter technology and are not packaged as a stand-alone office instrument. The Nerve Express algorithms are conveniently packaged for office use. If they are equivalent to CHRONOS, they would constitute a reliable office system useful for many purposes: assessment of risk in cardiovascular disorders; assessment of physical fitness; documentation of benefit for cardiac, chiropractic, or orthopedic rehabilitation; and quantification of drug effects on the autonomic nervous system."5 In his final conclusion for both phases of evaluation, Dr. Bigger states: "The results of our comparison of the Nerve Express algorithms with the CHRONOS algorithms indicate that the values obtained with the 6 two algorithms show excellent agreement…" Until the development of Nerve-Express there was no practical way to use ANS assessment technology outside of a research laboratory as automatic reproducibility proved to be unattainable by any other HRV analysis system available to date. Another distinctive advantage of Nerve-Express is that, in addition to a quantitative interpretation of HRV spectral function, it provides a qualitative analysis of the resulting parameters.

5

Research Holter Lab. Validation Study Reports. A Comparison of Nerve Express and ChronosAlgorithms. A. Statement of Study Purpose, p.2 Ibid. Report of Phase 2A: Comparison of Nerve Express and Chronos Data Acquisition and Power Spectral Algorithms in Healthy Volunteers. E. Conclusion, p.10 and Report of Phase 2B: Comparison of Nerve Express and Chronos Data Acquisition and Power Spectral Algorithms in Patients with Heart Disease. E. Conclusion, p.15. 6

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The Nerve-Express Advantage The Nerve-Express advantage is threefold: Ÿ

High degree of sophistication and reliability in detecting the early signs of pathological developments or functional disorders, which may not be revealed in the course of an ordinary physical examination. Thus, Nerve-Express becomes an objective probing tool for early detection and early intervention by a physician regardless of the patient's complaints.

Ÿ

High degree of flexibility and robustness in effectiveness assessment for any type of therapy, medication or activity. Thus, Nerve-Express becomes an objective assessment and research tool for both professional and personal use.

Ÿ

High degree of versatility and customization in identifying and refining the optimal protocols for medical and self-improvement. Thus, Nerve-Express becomes a perfect health and personal productivity tool for both medical and mass markets.

Heart Rate Variability Analysis in the Nerve-Express Assessment It is well known that autonomic response is the first human response to any intervention or to any physical, physiological, or psycho-emotional activity. Likewise, any pathological process will immediately provoke an ANS response. And the main regulatory mechanism in Heart Rate Variability (HRV) is autonomic regulation. Therefore, HRV method is unique in its ability to assess the impact of any intervention or activity and to detect the early signs of pathological developments or functional disorders, which may not be revealed by routine physical examination. To perform Heart Rate Variability analysis, Nerve-Express uses an effective and transparent visual representation, known as the Method of Rhythmography7, which reflects HRV wave structure and serves as a “fingerprint” of autonomic regulatory mechanisms. The method is based on drawing the time

Fig. 1 7

developed in 1967 by Dr. Zhemaitite of Lithuania, one of the leading Soviet authorities on cardiology automation; cf. D. I. Zhemaitite. The methodology for automatic analysis of rhythmograms and its clinical applications. The Doctoral Dissertation (Doctor of Medical Science). Kaunas, Lithuania, 1972.

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intervals between consecutive heartbeats as straight vertical lines. The longer the interval between two heartbeats (RR), the longer the corresponding vertical line (Fig. 1). When these lines are graphed sequentially, they form a Rhythmogram - a curve-specific wave portrait of RR Intervals Variability (Fig. 2a). Rhythmographic representation allows a great deal of information to be compressed in a simple picture. The wave portrait in Fig. 2a is composed of 448 RR intervals of the ECG. A spectral analysis of this wave “portrait” allows Nerve-Express to identify two main spectral components (Fig. 2b):

· .Low frequency: 0.04 - 0.15Hz · High frequency: 0.15 - 0.5Hz

Fig. 2a

Fig. 2b

A high degree of correlation has been established between the power of high-frequency band of the spectral function and the activity of Parasympathetic Nervous System (PSNS). A similar correlation has been demonstrated between the power of low-frequency band and the activity of Sympathetic Nervous System (SNS). These findings have been well documented in a number of medical and scientific publications and in conference reports from the American College of Cardiology, The American Heart Association, and others. Nerve Express' proprietary algorithm analyzes the power of both high and low-frequency bands as well as their peak amplitudes and pre-and-post autonomic intervention shifting. It then graphs the relationship between SNS and PSNS activities. Nerve-Express uses a principally new classification of ANS states, i.e., Sympathetic/Parasympathetic levels of activity, arranged into nine categories.

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Recognition and Classificaion of ANS States Nerve-Express automatically recognizes 74 ANS states that represent different relationships between SNS and PSNS activities and variations in their balance. Nerve-Express then graphs the Parasympathetic activity on the horizontal or X-axis and the Sympathetic activity on the vertical or Y-axis (Fig. 3a). The intersection point of the Sympathetic and Parasympathetic axes is the point of Autonomic Balance. To the right of and above this balance point, Nerve-Express displays an area of increased Parasympathetic and Sympathetic activities in 4 gradations. Decreases in PSNS and SNS activities are shown to the left and below the balance point. 74 ANS states are subdivided into nine categories (circled in red in Fig. 3a, with corresponding numbers marking each category - e.g., 1, 2):

Category 1

PSNS prevalence with the average level of SNS activity is illustrated by 4 points: Point 1 represents a slight PSNS prevalence Point 2 represents a moderate PSNS prevalence Point 3 represents a significant PSNS prevalence Point 4 represents a sharp PSNS prevalence

Category 2

A simultaneous increase in both PSNS and SNS activities, with different variations, is illustrated by 16 points

Category 3

SNS prevalence is illustrated by 4 points (slight, moderate, significant, and sharp)

Category 4

PSNS decrease with an SNS increase is illustrated by 16 points

Category 5

PSNS decrease with the average level of SNS activity is illustrated by 4 points (slight, moderate, significant, and sharp)

Category 6

A general decrease in both SNS and PSNS activities is illustrated by 16 points

Category 7

A point at zero value on the coordinate system indicates ANS balance

Category 8

SNS decrease with average level of PSNS is illustrated by 4 points (slight, moderate, significant, and sharp)

Category 9

Increase in PSNS with a decrease in SNS is illustrated by 9 points

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Fig. 3a Nine categories of the Autonomic Nervous System's conditions

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by Alexander Riftine, Ph.D

New Classification of the Autonomic System’s conditions Autonomic Nervous System’s conditions

Physiological Interpretation of ANS States The main physiological meaning of the Sympathetic Nervous System is that it could be viewed as a “mobilizing” or “energy-boosting” division of ANS. SNS is concerned primarily with preparing the body for energy-expending, stressful or emergency situations. It controls the “fight or flight” reaction, increasing blood pressure, heart rate, and blood flow to the muscles. SNS is also a biological marker of age. Conversely, the main physiological meaning of the Parasympathetic Nervous System is that it could be viewed as a “restful” or “energy-conserving” division of ANS. PSNS is most active under ordinary, restful conditions. It also counterbalances the effects of the sympathetic division, and restores the body to a resting state following a stressful experience. In response to various internal and external processes and stimuli, an individual experiences a continuous interplay of these two main ANS forces, constantly trying to balance each other. For example, during an emergency, the sympathetic division will cause the heart and breathing rates to increase; following the emergency, the parasympathetic division will decrease these activities. In the Cartesian system of SNS/PSNS axes, the basic guiding principle is that parameters displayed at or to the right of the point of Autonomic Balance (PSNS > or = 0) represent basically healthy people (area colored green in Fig. 3a), while those to the left (PSNS < 0) mostly represent temporarily dysfunctional or chronically sick people (area colored yellow in Fig. 3a). Notice the difference between Rhythmograms and Spectral Function Graphs corresponding to different ANS categories and their segments. Specifically, notice the sharply fluctuating and regular Rhythmogram patterns of the green ("healthy") areas (PSNS > or = 0) vs. the flat and chaotic patterns of the yellow ("problem") areas (PSNS < 0). The basic principle in reading a Rhythmogram is: the sharper and more regular the fluctuation pattern, the healthier the person it belongs to. The nine ANS categories are now considered in more detail (cf. Fig. 3b). 1. PSNS prevalence with the average level of SNS activity: This category represents PSNS dominance. It is usually observed when a patient is resting or during the first stage of sleep (specifically, dreamless sleep). In the second stage of sleep, SNS activity is generally increased, at times markedly so. This category is further subdivided into four subcategories, depending on the state of PSNS (slight, moderate, significant, sharp prevalence - cf. Category 1 on p. 5). This category is somewhat limited, since it can only be observed in patients with strictly median values of SNS activity. 2. Increase in PSNS and SNS activities: This category is subdivided into sixteen different combinations of PSNS/SNS activity. It is characteristic of mostly healthy subjects. One distinctive area in this category represents what might be called the “high sympatho-adrenergic” state corresponding to a significant increase in SNS (points [3.1], [3.2], [3.3], [3.4], [4.1], [4.2], [4.3], [4.4], marked with /// shading in Fig. 3b). A person reaches this state when he/she experiences a major energy boost (i.e., a sharp SNS increase). The “high sympatho-adrenergic” state is characterized by a sudden adrenalin surge similar to what an athlete feels before a competition or a tiger before a jump. 73

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Fig. 3b Nine categories of the Autonomic Nervous System's conditions

ANS degeneration zone (e.g., age > 80; serious pathology like cancer, degenerative joint disease)

old age, temporary or chronic sickness

possible chronic pathology (median SNS = no stress; depression of PSNS receptors)

chronic or temporary dysfunction (e.g., exhaustion, intoxication, infection, nervous tension)

acute state or "distress" zone

by Alexander Riftine, Ph.D

Physiological Interpretation of ANS States

NOTE: There is an interesting correlation between our results and the popular "Theory of Stress" by Selye. According to this theory, stress could be subdivided into 2 categories: 1). stress as a positive idea, and 2). distress as a negative idea. Categories 1 through 3 represent basically healthy persons, but we have to keep in mind that healthy people may have two different physiological states. One state has a low level of sympathetic activity and the other has a significant increase in sympathetic activity. Both states are distinguished by an increase in parasympathetic activity. In Selye's stress theory, an increase in PSNS and a significant increase in SNS reflect “positive” stress while a decrease in PSNS and a significant increase in SNS reflect distress. Condition of a healthy person with a significant increase in SNS and an increase in PSNS (our “high sympatho-adrenergic” state) thus corresponds to Selye's idea of “positive” stress. 3. SNS Prevalence: This category represents an increase in SNS combined with a median value of PSNS. From the physiological standpoint, this category represents a transitional stage between the second and fourth categories. 4. PSNS decrease with SNS increase: This category can apply to both clinically sick and clinically healthy individuals (defined as those not requiring medical intervention). However, the use of the term "healthy" is not always appropriate since functional imbalance from stress, physical exhaustion, nervous tension, infection, intoxication (including drugs and alcohol), exacerbation of chronic conditions, and many other causes may still be present. In such cases a decrease in PSNS due to depressed PSNS nerve centers can be observed, along with a simultaneous Sympathetic activation, which is triggered by the struggle of the nervous system to balance itself. When Sympathetic activation is high (points: [-3.2], [-3.3], [-3.4], [-4.2], [4.3] [-4.4], marked with \\\\ shading in Fig. 3b), a person reaches an "acute" state characteristic of an acute illness or extreme stress/dysfunction. NOTE: The "acute" section of Category 4 with a decrease in PSNS and a significant increase in SNS clearly corresponds to Selye's idea of distress as a “negative stress” (see NOTE to Category 2 above). 5. PSNS decrease with average level of SNS: This category, like the third, is transitional. Everything that pertains to the fourth category can be related to it, but here, SNS activity is within median values. This means that stress, or nervous overload is unlikely. This category may often reflect a depression in the receptor system of PSNS, indicating the possibility of chronic pathology. 6. SNS and PSNS decrease: The sixth category, especially beyond the point -3 on either axis, reflects a general involuntary degeneration of both SNS and PSNS nervous centers (“ANS Degeneration” area, marked with ||| shading in Fig. 3b). The majority of cases found in this category are either very old patients or those with diseases causing a significant decrease in the sensitivity of the entire receptor system along with partial degeneration of nervous centers. Examples are the elderly people, patients suffering from cancer or any other disease causing similar depression of ANS centers.

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NOTE 1:

Point [-1.-1] of this category is an exception to this. It represents an insignificant, general decrease in ANS and approximates the point of Autonomic Balance. It can be interpreted as a border line value of Autonomic Balance.

NOTE 2:

Points [-1.-2], [-1.-3], [-1.-4] are usually, though not exclusively, found in patients with hyperkalemia or excessive levels of potassium ions, which alter the usual polarized state of the cardiac muscle fibers leading to a decrease in the rate and force of contractions. In fact, if potassium ion concentration is very high, the transmission of cardiac impulses may be blocked and the heart activity may suddenly stop (cardiac arrest). This “Hyperkalemia” section of Category 6 is marked with XXX shading in Fig. 3b.

7. Autonomic Balance. It is a category, even though formally it is only a point, and all other points in its vicinity that belong to the other eight categories can be interpreted as borderline values of the Autonomic Balance. The central point is circled in red; the extended “Autonomic Balance” area is marked with a red dotted line in Fig. 3b. 8. SNS decrease with average level of PSNS: This category, like the third and fifth, is transitional. Everything that pertains to the six and nine categories can be related to it, but here, PSNS activity is within median values. 9. Increase in PSNS with decrease in SNS: The ninth category is rather unusual because normally an increase in PSNS is accompanied by an increase in SNS. This rare condition is found in water polo athletes, long-distance runners, navy seals and persons with special heart training for deep-sea diving.

Nerve-Express' Methods for Evaluating the State of ANS Nerve-Express implements a battery of three tests as the most comprehensive and informative combination of tests for ANS purposes: 1. Orthostatic test as the initial method for ANS provocation; 2. Valsalva maneuver combined with Deep Breathing as the optimal method for revealing the hidden abilities of the Autonomic function and distinguishing between chronic and temporary abnormalities; 3. Real-time Nerve-Monitor test as the ultimate method for ANS assessment in long-term therapy, continuous monitoring (especially, under anesthesia/intensive care), research and experimentation. All three tests may be conducted on a single patient as well as on two patients simultaneously for comparative purposes (with a special cable).

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Orthotest as a Method of ANS Assessment A proper evaluation requires measurements of a patient under at least two different conditions. The method used here is to examine a patient both at rest and during physical activity. This can be accomplished by having a patient engage in some activity where the general response of a healthy person is known. Based on the patient's reaction, a more accurate assessment of ANS is possible. Nerve-Express uses a very popular method of ANS provocation - the Orthostatic Test, which is simply a transition from a supine to a standing position. Any physical or mental dysfunction will be exhibited as an inadequate ANS response during this test. Nerve-Express graphs the ANS State and its reaction using SNS and PSNS activities as, respectively, the vertical or "Y" and the horizontal or "X" axis. IMPORTANT NOTE. The most important group of points among the 74 recognizable possibilities is the group along the line bisecting the [0,0] coordinates as shown in Fig. 4. This line contains 9 points (including [0,0]) with numerically equal coordinates. Formally these points may be considered points of Autonomic Balance due to their characteristic parity of PSNS and SNS activity. Thus the point [0,0] may be interpreted as a point of balance in the general activity of PSNS and SNS which correlates with the accepted notion of "vegetative homeostasis". It is important to realize that a slight increase [1, 1] or a slight decrease [-1.-1] still reflects a normal average level of the traditional notion of "vegetative homeostasis", but any deviation outside of these parameters, though mathematically still balanced, must not be interpreted as a clinical homeostasis. Children, however, will typically show a moderately to sharply increased balance.

Fig. 4

The general approach is to balance ANS or restore it to homeostasis. However, you can and should develop your own methods, based on the needs of specific cases. Evaluating a patient's ANS State using Nerve-Express' Orthotest before and after any treatment can provide an accurate and reliable evaluation of treatment effectiveness. For example, in cardiology, it is very important to optimize the therapeutic strategy for the assessment of beta-blockers' effectiveness. Or, in clinical pharmacology, one of the important tasks is to assess the influence of some particular medicine on Autonomic function.

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How to interpret Orthotest:

ANS RESPONSES during ORTHOTEST with ILLUSTRATIONS and PHYSIOLOGICAL IMPLICATIONS

Types of ANS Responses during Orthotest

By Direction: Adequate SNS increased, PSNS decreased

By Absolute Value

Normal for both SNS & PSNS

U SS -3 -2

-1 0

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SNS (S) < 0 Sympathetic Disbalance*

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if PSNS>0 in supine; PSNS<0 in upright 85% of cases have GI problems

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Paradoxical for both PSNS & SNS Double Paradoxical Response “Double Switch”

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SAMPLE CASES Evaluating a patient's ANS state by Nerve-Express' Orthotest before and after any treatment can provide an accurate and reliable evaluation of treatment effectiveness. Figures 5 - 7 provide useful examples. The measurements in Figures 5a and 5b are typical for a healthy, fit person. This can be further appreciated from Fig. 5b, which represents the HRV spectral function graph. It is noteworthy that in the Supine and Upright positions the spectral functions in Fig. 5b have two dominant peaks: one in the Lowfrequency range and the other, a Middle frequency peak (MF) on the borderline between the High and Low frequencies, which reflects the sensitivity of baroreceptors system.

Fig. 5a

Fig. 5b 80

Another example can be seen in Figures 6a and 6b. It represents a patient's ANS state pre-and-post upper cervical manipulation. In Figure 10a the Orthostatic test result seems normal. This example is interesting as it shows a strong stimulating effect of treatment mostly on SNS, which is reflected in a sharp increase in amplitude of the Low frequency range (Smax (LF)) in the upright position (Fig. 6b).

Fig. 6a Before upper cervical manipulation

Fig. 6b After upper cervical manipulation 81

When using Nerve-Express it is necessary to realize that any expected ANS reaction is not only dependent on the type or intensity of the impacting factor, but is also determined by the functional state of ANS itself, and its ability to react. For example, in the case of involuntary degeneration of ANS nervous centers (i.e., in a geriatric patient or a patient with a degenerative cardiovascular disorder or a weakened receptor sensitivity), it is impossible to expect an adequate ANS reaction (for example, see a cardiovascular patient in Fig. 7a and 7b).

Fig. 7a Ischemic heart disease patient

Fig. 7b Ischemic heart disease patient 82

Valsalva maneuvre combined with Deep Breathing

While Orthostatic Test is used for initial ANS assessment, the Valsalva maneuver combined with Deep Breathing is the second-tier, more in-depth test, which primary purpose is threefold: 1. revealing the hidden abilities of the Autonomic function; 2. indirect assessment of the sensitivity of baroreceptors; 3. distinguishing between chronic and temporary abnormalities. We recommend the Valsalva maneuver only as a follow-up to Orthotest and only if it shows negative parasympathetic results, i.e., if the midpoint between the Supine and Upright positions, marked by a red dot, has a negative PSNS value. Valsalva maneuver is explicitly NOT recommended if the stress level is too high, i.e., SNS = 3 or 4.

How to interpret Valsalva: Valsalva results with illustrations and physiological implications Valsalva main results are: 1. Calculation of Valsalva Index; 2. Comparative analysis of the Autonomic status of Normal vs. Deep Breathing. The latter result is by far more reliable and informative. We recommend the Valsalva maneuver as a short preparation for performing such a comparative analysis. Based on our long-term research, we have established that the Transitional Process in Valsalva is practically impossible to standardize since Valsalva maneuver is an act of will and, therefore, determined by many subjective factors due to variations in individual physiology and psycho-emotional makeup (e.g., people with underwater training are more adaptable to Valsalva maneuver). A classical Transition Process during Valsalva, which serves as a basis for calculating the Valsalva Index, does exist, but in real life it is observed in about 10% of all cases as it applies only to highly trained and healthy people. Therefore, automatic calculation of the Valsalva Index does not always reflect the real picture, while the Autonomic assessment is always reliable for Deep Breathing.

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We recommend paying attention to a comparison between Normal and Deep Breathing. A certain Parasympathetic improvement (i.e., negative PSNS turning positive under Deep Breathing) means that the patient's problem is temporary or could be physiologically compensated, as such improvement is an indirect indication of the sensitivity of baroreceptors and autonomic receptors. Thus, we can assess the gravity of the problem (temporary/compensable vs. chronic) by the extent of Parasympathetic improvement under Deep Breathing. Let’s consider most typical cases:

I. PSNS improvement (no change in SNS) A). Significant increase in PSNS (cf. Fig. 8a) with comparative spectral function

Fig. 8a 84

B). Slight increase in PSNS (cf. Fig. 8b)

Fig. 8b C). No increase in PSNS (cf. Fig. 8c)

Fig. 8c 85

II.

Mixed improvement (in both PSNS and SNS): A). Significant increase in PSNS, moderate increase in SNS (cf. Fig. 9a)

Fig. 9a B). Slight increase in both PSNS and SNS (cf. Fig. 9b)

Fig. 9b 86

C). Moderate increase in PSNS, significant increase in SNS (cf. Fig. 9c)

Fig. 9c

HRI's unique Nerve-Monitor test for Real-time Long-term Experimentation in Research and Clinical Practice Nerve-Monitor enables ANS assessment in a "real-time" mode, which means that data is analyzed as it is put in. Results can thus be produced with certain periodicity (the period of data renewal corresponds to the time of "standard stage" which is 192 RR intervals). 192 RR intervals may last from 2 to 4 minutes, depending on heart rate. Calculations, therefore, can be done every 2 to 4 minutes. Additional information, such as heart rate, tension index (TI) and analysis of extrasystolic beats, can be obtained simultaneously with the autonomic tone analysis at every stage. In spite of some simplicity of a "real-time" mode, it is essentially universal, since it enables the autonomic response assessment during different kinds of long-term therapy, long-term tests like the Stress test (cf. Figures 10a-c) or during any kind of experiments aimed at therapeutic strategy optimization. Some of the most important applications are intensive-care and anesthesia monitoring. Also of great interest are experiments with allergic agents identification, as in the case of asthma. This list of practical applications can be extended, but specialists at each clinic can find their own uses for the system. Nerve Monitor was specifically designed to include the possibility of interrupting data input during therapeutic intervention, using the “Pause" option. For example, clicking on “Pause" at the time of injection eliminates irrelevant ANS response to pain and leaves only ANS response to treatment.

87

Figures 10 a-c show a sample printout during a stress test. Here ANS reaction is typical of most cases. At the onset of the exercise, the Parasympathetic response decreases and the Sympathetic response increases. With the increase of the workout the process is intensified. At the end of the exercise (recovery period) we can observe the restoration of the autonomic tone to its initial level. In Figures 10 a - c you can see: Stage 1 - rest; Stage 2 - onset of exercise (adaptation period); Stages 3-6 - workout; Stage 7 - first period of recovery (fast recovery); Stages 8 -12 - second period of recovery (slow recovery). Figure 10a includes the results of calculations for each stage. Fig. 10b shows separate responses of Sympathetic and Parasympathetic Tone, stage by stage. Figure 10c depicts the 3D spectral analysis for all stages. Figures 10 a-c show many extrasystoles before and after the stress test. In such cases it is important to realize that there is a critical mass of extrasystoles beyond which the correct analysis of ANS state is impossible.

1 2 3 4 5 6 7 8 9 10 11 12

67 97 104 105 106 106 81 73 73 72 71 71

25 28 29 29 30 29 27 27 27 27 26 27

21 21 30 30 30 30 28 29 26 26 25 26

28 18 26 29 29 29 28 30 30 30 30 29

0 3 3 3 3 3 2 1 1 1 1 1

-1 -2 -3 -4 -4 -4 -2 -2 -2 -2 -2 -2

Tigeminy. Multiple Extrasystolia. Single extrasystoles. Extrasystoles not recogmized Extrasystoles not recogmized Extrasystoles not recogmized Extrasystoles not recogmized Tigeminy. Multiple Extrasystolia. Tigeminy. Multiple Extrasystolia. Tigeminy. Multiple Extrasystolia. Tigeminy. Multiple Extrasystolia. Tigeminy. Multiple Extrasystolia. Tigeminy. Multiple Extrasystolia.

Fig. 10a 88

May be wrong Autonomic Assessment

May be wrong Autonomic Assessment May be wrong Autonomic Assessment May be wrong Autonomic Assessment May be wrong Autonomic Assessment May be wrong Autonomic Assessment

Fig. 10b

Fig. 10c 89

Neve-Express testby using PC ECG input device By using PC ECG device (QRS-Card) as input device for RR intervals we can see real ECG on a screen as shown in Fig. 11. It is important to recognize the type of extrasystoles in such cases. In Figure 12 a ventricular ectopic beat is identified. We can use PC ECG inpup device for all Nerve-Express test modalities.

Fig. 11

Fig. 12 90

HEALTH-EXPRESS - the Express Method for Quantitative Health Assessment What is the Health-Express Method? 8

Nerve-Express uses a certain type of Heart Rate Variability (HRV) analysis for automatic assessment of 9 the Autonomic Nervous System (ANS) - hence, the term Nerve-Express. Health-Express uses a somewhat different type of HRV analysis for automatic assessment of the general state of health, i.e., the levels of Physical Fitness, Wellness and Functional Capacity. The main difference is that Health-Express analysis takes into account the Transition Period of the Orthotest10 Rhythmogram11 , while Nerve-Express does not. The Transition period (RR intervals from 192 to 256), shown as part of Orthotest Rhythmogram in Fig. 13a and as an isolated segment in Fig. 13b, corresponds to a transitional process between a Supine and an Upright positions in Orthotest. Its main characteristics are its "min" (the shortest RR interval, corresponding to the highest heart rate or Max HR, as the person undergoing Orthotest is changing positions from a Supine to an Upright) and its "max" (the longest RR interval, corresponding to the lowest heart rate or Min HR , as the heart is stabilizing in an Upright position).

Fig. 13a

Fig. 13b

8

cf. section Heart Rate Variability Analysis, page 69 cf. footnote 1, page 66 10 cf. section Orthotest, page 77 11 cf. pages 69-70 for a definition and a discussion

9

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Adding the Transition Period to our analysis opens up new possibilities for general health assessment, such as assessment of Physical Fitness, Wellness and Functional Capacity. The basic rule is that the steeper and deeper the "Transitional Curve", the healthier and more fit the person it belongs to and the better the functioning of his/her physiological processes. Specifically, the steeper and deeper the curve "on the way down", the healthier the heart (i.e., the sooner it reacts by beating faster and the greater is the degree to which it beats faster). The heart's reaction is measured by one of the main parameters of the Transition Period - the Chronotropic Myocardial Reaction (ChMR). By the same token, the steeper and higher the curve "on the way up", the healthier the peripheral vascular system (i.e., the sooner it compensates by slowing the heart rate back to its previous level in a Supine position and the closer it brings it to that level). The vascular reaction is measured by another important parameter of the Transition Period - the Vascular Compensation (VC). The normal range for ChMR is 0.59-0.63. The smaller the value of the Chronotropic parameter, the better the state of one's cardiovascular system. The normal range for VC is within the ChMR range or slightly higher. The value of HRV analysis is not limited to cardiovascular reaction; HRV is the best indicator of the functional integrity of all physiological processes in a human body. It is also the best indicator of one’s general wellbeing. Thus a Rhythmogram like the one in Fig. 13a represents a specific wave "portrait" of our functional integrity. Health-Express is the first and only fully automated computer-based system that allows one to interpret this "portrait" and provides quantitative assessments of human physiological condition and fitness level based on HRV analysis. The system's assessment is based on an understanding of HRV wave pattern as a unique key to the deciphering of all fluctuating neural, autonomic, hormonal and other processes that occur in a human body. In addition to a Rhythmogram, the level of physical fitness or functional capacity can be recorded in a special chart - Fitnogram, marked by 91 points (cf. Fig. 14a and 14 b)

Fig. 14a

Fig. 14b 92

The vertical axis of a Fitnogram consists of 7 Levels of Adaptation Reserve, from the highest (first) to the lowest (seventh). They represent the levels of cardiovascular adaptability calculated on the basis of the Transition Period parameters. The horizontal axis represents different Levels of Functioning of Physiological Systems, with #1 being the highest or best state and #13 being the lowest. The calculation of these levels is based on parameters derived from both the Supine and Upright segments of Orthotest Rhythmogram. The red square in a Fitnogram represents the patient's current state. Whereas a Rhythmogram (cf. Fig. 13a) represents a full and complex "wave portrait" of one's functional integrity, a Fitnogram (cf. Fig. 14 a-b) is like its "instant snapshot", immediately and directly demonstrating one's fitness or functional rating. Health-Express provides 2 printable versions of a Fitnogram screen: one intended for a patient/athlete/fitness fan, with more color and less medical data (cf. Fig. 14a); the other intended for a doctor, with less color and more medical data (cf. Fig. 14b). To make a Fitnogram even more transparent and easier to understand, the patient’s/athlete’s version has its 3 main zones marked with color: blue (top fitness zone - professional athletes), green (normal fitness zone), and red (below normal fitness zone). Figures 15 a-b show test results for an athlete and a heart disease patient. Notice the difference in the wave pattern of respective Rhythmograms (spiky and regular for an athlete vs. flat and irregular for a patient), in the Transition Period (steep and deep for an athlete vs. flat and shallow for a patient), and in the red square position (close to top left for an athlete vs. close to bottom right for a patient). As can be seen from the charts, the best state occurs when the red square is situated at top left. Thus, an athlete's Fitnogram indicates a score of 1 for the heart's Adaptation Reserve and 3 for the Level of the Functioning of Physiological systems, combined into an almost perfect score of 1.3.

Heart disease patient

Professional athlete

Transition

1 2 3 4 5 6 7 8 9 10 11 12 13 Levels of Functioning of the Physiological systems

1 2 3 4 5 6 7

Levels of Adaptation Reserve

1 2 3 4 5 6 7

1 2 3 4 5 6 7 8 9 10 11 12 13

Levels of Adaptation Reserve

Transition

Levels of Functioning of the Physiological systems

Levels of Functioning of the Physiological systems

Fig. 15b

Fig. 15a

All points in a Fitnogram chart are based on evaluating people in diverse physical condition, varying from professional athletes to seniors or people suffering from exhaustion. Thus, if one's result is low, it does not mean that the person is ill, but only that his/her general state of health is at its lowest level. Notice also that the topmost left area of the Fitnogram applies only to people who are physically very fit (i.e., professional athletes). 93

The main value of using Health-Express is not in one-time assessment, but in being able to determine and consistently monitor the changes in one's wellbeing over time, as well as determine the nature of one's body responses to various stimuli. It is useful to record the physical condition of the body before and after a particular physical or physiological activity, keeping in mind that one's body requires time for regeneration after a physical/physiological task. Therefore, to accurately measure the effects of any activity, one needs to administer the test not only immediately after the activity, but also at different time intervals (next morning, or after training for a week). Predictably, if measurements are made immediately before and after physical or mental stress, the physiological condition and adaptation reserve will undoubtedly be lower. But if one keeps comparing next morning's measurements to those of previous mornings, he/she can then see a real change. Thus, we now have the ultimate tool for quantitative assessment of any factor affecting our health (e.g., sleep, work, exercise, sports training, alcohol, coffee, cigarettes, sex, etc.). Included in test results is a written conclusion that is phrased in special physiological terminology. The Health-Express system automatically defines a human body's Functional State by Orthostatic test results. The Functional State of a human body is the ability to perform habitual functions. The main components that determine a Functional State are: - Heredity; - Degree of physical fitness; - Current psychological and emotional state; - Destabilizing factors at the time of test. The destabilizing factors may include illness, emotional and physical stress, alcoholic and other kinds of intoxication.

The Health-Express Advantage The Health-Express advantage is threefold: · Health-Express is a unique tool for measuring, monitoring and improving Fitness for the broadest range of consumers: from the sick and the elderly, trying to regain or preserve their health and vigor, to amateur sports/fitness fans, trying to stay in shape, to professional athletes seeking to improve their training and performance in pursuit of world records. Health-Express is used by professional trainers and athletes themselves to optimize their training, resting and dietary protocols while achieving the critical competitive edge, top preparedness and performance. · Health-Express is an ideal tool for Wellness assessment and improvement. It is used by wellness practitioners to optimize their own and their clients' nutrition, energy, vitality, and general physical and emotional wellbeing. · Health-Express is a unique Personal Productivity Tool, enabling ANY individual to continuously identify, monitor, customize and optimize ANY internal or external factor effecting his/her life (e.g., physical/mental dysfunction, medication, stress, environmental impact), ANY aspect of his/her activity (e.g., sleeping, dietary, working, exercise patterns) ANYTIME, ANYWHERE. The result for anyone, no matter how young or old, sick or healthy, perfect or imperfect to start with, is a life-long achievement of one's ultimate personal productivity, continuous self-improvement and lifestyle optimization.

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Orthotest as Health-Express Method for Evaluating PhysicalFitness/Wellness/FunctionalCapacity

Orthotest is selected as the principal test in Health-Express primarily for the same reasons as in Nerve Express (cf. page 11). But unlike Nerve-Express, Health-Express takes into account the Transitional Period of Orthotest, which provides the cardiovascular response measurements, critical to general health evaluation (i.e., physical fitness, wellness, functional capacity).

THE MAIN TECHNICAL PARAMETERS Fig. 16 is a snapshot of a Health-Express screen, showing a generic Rhythmogram in the top window, data specific to Health-Express below, and a Fitnogram in the bottom right corner.

Fig 16

95

Two tables under a Rhythmogram include the testing parameters of the supine (left) and upright (right) positions as follows: - HR: - MSSD: - TI: - SC1, SC2, SC3: - SC1: - SC2: - SC3:

Heart rate per minute; Mean successive square deviation; Tension index. Change limits TI= {10- 10,000}; TI index determines the tension of HRV regulating mechanisms. It is an integral index of decrease in variability; Indexes correspond to three main spectral components of the Rhythmogram; Index of the "respiration" component of HRV, which corresponds to waves of 2-8 seconds in length; Index of baroreflex influences on HRV, which corresponds to TraubeGaering waves of 8-18 seconds in length; Slow wave component activity index corresponding to Mayer waves of 80-90 seconds in length.

# I 2 3 4 5 6 7 8 9

TI gradations

VALUES

Normal TI Close to normal TI Slightly increased TI Close to moderately increased TI Moderately increased TI Close to significantly increased TI Significantly increased TI Close to sharply increased TI Sharply increased TI

10 80 80 - 120 120 - 150 150 - 200 200 - 400 400 - 600 600 - 900 900 - 1,200 > 1,200

Table 1.

At the center of a Rhythmogram there is a "Transition Period" segment representing a transitional process between a Supine and an Upright positions (R-R intervals from 192 to 256). This segment differs from the rest of the Rhythmogram by its characteristic "dip" or "curve". The main goal here is to correctly define the “min" and "max" of the transitional process which allows a higher degree of accuracy in determining the levels of Chronotropic Myocardial Reaction (ChMR), characterizing the downward portion of the curve and Vascular Compensation (VC), characterizing the upward portion of the curve. The transitional parameters table (to the right of the transitional Rhythmogram segment) includes the following: - ChMR:

Chronotropic Myocardial Reaction index, which is the basis for evaluating the level of cardiac adaptation reserves;

- VC:

Vascular Compensatory (Recovery) Reaction;

- IOT:

Integral evaluation of the transitional process.

96

#

ChMR gradations

VALUES

I High chronotropic reaction 2 Normal chronotropic reaction 3 Close to normal chronotropic reaction 4 Slightly decreased chronotropic reaction 5 Moderately decreased chronotropic reaction 6 Significantly decreased chronotropic reaction 7 Sharply decreased chronotropic reaction

< 0.53 0.53 - 0.58 0.59 - 0.63 0.64 - 0.69 0.70 - 0.75 0.76 - 0.81 > 0.81

Table 2.

The text under the transitional Rhythmogram strip is an assessment of the character of the transition process obtained by analyzing the above indexes. There are five classes of such assessments (cf. Fig.17).

CLASSIFICATION OF TRANSITION PERIOD ASSESSMENTS 1. Normal transition: Ÿ Ÿ

Transition is within normal parameters. Transition is close to normal parameters.

2. General reaction decreases: Ÿ Ÿ Ÿ Ÿ

General reaction decreases slightly General reaction decreases moderately General reaction decreases significantly General reaction decreases sharply

3. Recovery (Compensatory) reaction decreases while Chronotropic reaction is normal or close normal: Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ

to

Recovery reaction decreases slightly while Chronotropic reaction is within normal parameters. Recovery reaction decreases slightly while Chronotropic reaction is close to normal. Recovery reaction decreases moderately while Chronotropic reaction is within normal parameters. Recovery reaction decreases moderately while Chronotropic reaction is close to normal. Recovery reaction decreases significantly while Chronotropic reaction is within normal parameters. Recovery reaction decreases significantly while Chronotropic reaction is close to normal. Recovery reaction decreases sharply while Chronotropic reaction is within normal parameters. Recovery reaction decreases sharply while Chronotropic reaction is close to normal.

97

98

Fig. 17

Classification of transitions during orthostatic test

4. Chronotropic reaction decreases while Recovery (Compensatory) reaction is absent: Ÿ Ÿ Ÿ Ÿ

Chronotropic reaction decreases slightly while Recovery reaction is absent. Chronotropic reaction decreases moderately while Recovery reaction is absent. Chronotropic reaction decreases significantly while Recovery reaction is absent. Chronotropic reaction decreases sharply while Recovery reaction is absent.

5. "Mixed" decreases in Chronotropic and Recovery (Compensatory) reactions: Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ

Chronotropic reaction decreases slightly while Recovery reaction decreases slightly. Chronotropic reaction decreases slightly while Recovery reaction decreases moderately. Chronotropic reaction decreases slightly while Recovery reaction decreases significantly. Chronotropic reaction decreases slightly while Recovery reaction decreases sharply. Chronotropic reaction decreases moderately while Recovery reaction decreases slightly. Chronotropic reaction decreases moderately while Recovery reaction decreases moderately. Chronotropic reaction decreases moderately while Recovery reaction decreases significantly. Chronotropic reaction decreases moderately while Recovery reaction decreases sharply. Chronotropic reaction decreases significantly while Recovery reaction decreases slightly. Chronotropic reaction decreases significantly while Recovery reaction decreases moderately. Chronotropic reaction decreases significantly while Recovery reaction decreases significantly. Chronotropic reaction decreases significantly while Recovery reaction decreases sharply. Chronotropic reaction decreases sharply while Recovery reaction decreases slightly. Chronotropic reaction decreases sharply while Recovery reaction decreases moderately. Chronotropic reaction decreases sharply while Recovery reaction decreases significantly. Chronotropic reaction decreases sharply while Recovery reaction decreases sharply.

The first group represents a high level of reaction parameters. The second group reflects a generally decreased reaction to Orthotest, which happens when Chronotropic and Recovery (Compensatory) reactions are equally decreased. The third group reflects different grades of Recovery (Compensatory) reaction decreases and normal or close to normal Chronotropic reaction. The fourth group represents the absence of Recovery (Compensatory) reaction and different grades of Chronotropic reaction decreases. The fifth group reflects different combinations of Recovery (Compensatory) and Chronotropic reaction decreases. NOTE 1:

While analyzing the above statements one has to bear in mind that these reactions occur only in response to Orthotest.

NOTE 2:

The assessment of the Chronotropic reaction level is made on the basis of a comprehensive analysis of all three indexes of the transitional process.

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OTHER TECHNICAL PARAMETERS At bottom left of the Health-Express screen depicted in Figure 20 is a list of special parameters “Parameters of Optimal Variability” (POV): POV (supine) POV (upright) POV is a parameter of Optimal HRV wave structure: it shows quantitatively the approximation of the ideal value by an individual wave structure. POV defines the deviation of an individual heart rate variability from the ideal heart rate variability. NOTE: POV is calculated through analysis of SC1, SC2, SC3 indexes and a number of additional parameters obtained during spectral analysis. The range of POV values is from 1 to 38. Certain correlation of SC1, SC2, SC3 indexes corresponds to an optimal value of POV The range of SC1, SC2, SC3 values is from 1 to 15, where 1 corresponds to the highest activity and 15 to the lowest activity. # 1 2 3 4 5 6

POV gradations

VALUE

Optimal POV value 34 - 38 Close to optimal POV value 30 - 33 Slight deviation from the optimal 24 - 29 Moderate deviation from the optimal 17 - 23 Significant deviation from the optimal 8 -16 Sharp deviation from the optimal 0-7 Table 3

INDEX of DISCREPANCY (ID): ID provides a quantitative valuation of HRV discrepancy after a transitional period (i.e., the deviation of post-transitional from pre-transitional HRV). ID may also be called an equilibrium parameter, as it permits the valuation of HRV wave structure recovery after any impact. The range of ID index values is from -3 to 35.

# 1 2 3 4 5 6

ID gradations

RANGE

State of equilibrium State close to equilibrium Slight deviation from equilibrium Moderate deviation from equilibrium Significant deviation from equilibrium Sharp deviation from equilibrium

(-3) - (-1) 0- 1 2- 4 5- 9 10 - 21 22 - 39

Table 4.

The right side of Health-Express screen output contains a written (Conclusion) and a graphical (Fitnogram) summary assessments of the Level of Physical Fitness. A Fitnogram is described above in section What is Health-Express on pages 89-91.

100

CONCLUSIONS REACHED BY HEALTH EXPRESS METHOD The conclusions are based on two factors: 1) The Level of functioning of physiological systems (13 gradatios along the X axis). 2) The heart’s adaptation reserves (7 gradations along the Y axis).

LEVELS OF FUNCTIONING OF PHYSIOLOGICAL SYSTEMS 1. Highest Level functioning of physiological systems 2. Close to Highest Level functioning of physiological systems 3. The physiological systems are functioning at a Sharply Increased Level 4. The physiological systems are functioning at a Significantly Increased Level 5. The physiological systems are functioning at a Moderately Increased Level 6. The physiological systems are functioning at a Slightly Increased Level 7. The physiological systems are functioning at an Average Level 8. The physiological systems are functioning at a Significantly Reduced Level 9. The physiological systems are functioning at a Moderately Reduced Level 10. The physiological systems are functioning at a Significantly Reduced Level 11. The physiological systems are functioning at a Sharply Reduced Level 12. Close to Very Low Level functioning of physiological systems 13. Very Low Level functioning of physiological systems

LEVELS OF ADAPTATION RESERVE 1. 2. 3. 4. 5. 6. 7.

The adaptation reserve is at the Highest Level The adaptation reserve is Close to the Highest Level The adaptation reserve is at a Normal Level The adaptation reserve is at a Significantly Reduced Level The adaptation reserve is at a Moderately Reduced Level The adaptation reserve is at a Significantly Reduced Level The adaptation reserve is at a Low Level

NOTE: Chronotropic Myocardial Reaction, which is defined by the ChMR index, provides estimates for Adaptation reserves. 70 possible combinations of adaptation reserve and physiological functioning levels define the body's physiological state. The following two conclusions represent the top most feasible levels of physiological functioning that may be achieved by athletically trained individuals. 1. “THE HIGHEST LEVEL OF PHYSICAL FITNESS” - the highest level of functioning of physiological systems with the highest adaptation reserve (point 1.1). 2. “PHYSICAL FITNESS IS CLOSE TO THE HIGHEST LEVEL” - the functioning of physiological systems is close to the highest level with the highest adaptation reserve (point 2.1).

101

The conclusions for the rest of 66 points will include separate assessments of physiological condition and adaptation reserve. The line “Additional Information" may include some specific information about the patient's psychoemotional state such as sensitivity to outside stimuli or introversion. The individual’s psychoemotional state is one of the key factors determining his/her functional condition. The influence of psychoemotional factors on people with excitable nervous system may be definitive in some situations. This should be taken into consideration in any analysis of functional state data, especially in cases when an individual’s functional condition is particularly weak. The Health-Express method reveals the symptoms of introversion by analysis of the post-transitional changes in HRV wave structure . Figure 18 shows a rhythmographic strip of a woman awaiting a cataract surgery (one hour before surgery). An assumption about her sensitive psychoemotional state is based, in this case, on an inadequate change in HRV wave structure: the wave structure registered in "upright" position is better than in "supine" position.

SUPINE

UPRIGHT Fig. 18

It should be noted that Health-Express only registers the symptoms. It is up to a psychologist to make specific findings about the patient's psychoemotional status.

Health-Express' Major Markets and Applications The Health-Express system has four major markets: A. B. C. D.

Fitness; Wellness; Personal Productivity/Self-improvement/Lifestyle optimization; Personnel Management.

A. Fitness Health-Express is a unique tool for measuring, monitoring and improving fitness for the broadest range of consumers: from the sick and the elderly, trying to regain or preserve their health and vigor, to amateur sports/fitness fans, trying to stay in top shape, to professional athletes seeking to improve their training and performance in pursuit of world records.

102

Health-Express PC is recommended for Health Clubs, Fitness Centers, Gyms, and Rehabilitation Centers. Professional trainers and coaches use the system to optimize their athletes' training, resting and dietary protocols, giving them the critical competitive edge, top preparedness and performance. Currently Health-Express is being used for training the elite athletes in several countries, including World and Olympic champions. Health-Express PDA is recommended for individual use by anyone involved in sports or fitness, whether professional or amateur, at the top or at the bottom of their physical condition and skill level. One can start practically at any age, any shape, any level of training, and continuously monitor oneself to achieve continuous fitness improvement.

B. Wellness Health-Express is an ideal tool for the Wellness market, where it can be used for the needs assessment, treatment effectiveness assessment, nutritional/exercise protocol selection and monitoring, etc. Health-Express PC is recommended for Wellness Centers, and Health Spas. Naturopathic doctors, dentists, nurses, dieticians, chiropractors and other health practitioners at these centers use the system to optimize their clients' nutrition, energy, vitality, and general physical and emotional wellbeing. Health-Express PDA is recommended for individual use by anyone interested in improving their health and general wellness through continuous monitoring, usually under the supervision of a health care professional.

C. Personal Productivity/Self-improvement/Lifestyle Optimization Health-Express can be viewed as a unique Personal Productivity Tool, enabling ANY individual to continuously identify, monitor, customize and optimize ANY internal or external factor effecting his/her life (e.g., physical/mental dysfunction, medication, stress, environmental impact), ANY aspect of his/her activity (e.g., sleeping, dietary, working, exercise patterns) ANYTIME, ANYWHERE. The result for anyone, no matter how young or old, sick or healthy, perfect or imperfect to start with, is a life-long achievement of one's ultimate personal productivity, continuous self-improvement and lifestyle optimization.

D. Personnel Management Two main applications in this market are: 1. Personnel selection and monitoring; 2. Personnel testing Safety Assurance testing in Safety-critical professions.

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1. PERSONNEL SELECTION AND MONITORING Health-Express' proprietary method of personnel selection and monitoring is based on its unique capacity for revealing an individual's functional ability or dysfunction. Thus, an individual's “functional state”, marked by red dots on the chart, can range from “Top Achiever” in the top left corner (Fig. 19a) to “Lowest Achiever” in the bottom right corner (Fig. 19b), with “Average Achiever” in the middle (Fig. 19c).

- Current Physical Fitness 1 2 3 4 5 6 7

7 levels of the Adaptation Reserve

1 2 3 4 5 6 7 8 9 10 11 12 13

13 Levels of the functioning of the physiological system 1.1 - The best possible 13.7 - The worst possible functional state functional state Additional Information

Fig. 19a

- Current Physical Fitness 1 2 3 4 5 6 7

7 levels of the Adaptation Reserve

1 2 3 4 5 6 7 8 9 10 11 12 13

13 Levels of the functioning of the physiological system 1.1 - The best possible functional state

13.7 - The worst possible functional state

Additional Information

Fig. 19b 104

- Current Physical Fitness 1 2 3 4 5 6 7

7 levels of the Adaptation Reserve

1 2 3 4 5 6 7 8 9 10 11 12 13

13 Levels of the functioning of the physiological system 1.1 - The best possible functional state

13.7 - The worst possible functional state

Additional Information

Fig. 19c It is clear from the chart that the “Top Achiever” marker is determined largely by the Adaptation Reserve parameter (Y-axis), as selecting an individual with great functional potential depends largely on such reserves. On the other hand, slight, close to moderate and moderate reduction of the level of functioning (levels 5, 6, and 7) is allowed in this marker. The top 1.1 functional state is very rare and reflects not only physiological possibilities, but also one's psycho-emotional state. The “Lowest Achiever” marker consists of points that can only be measured in individuals suffering from severe conditions that greatly reduce their functional state. The most common cause placing individuals in this marker is the so-called "acute state" which may be caused by different factors, including: - extreme overexertion; - psycho-emotional stress; - rapidly developing infections and intoxications. The acute state may be caused by some other factors too, but all of them create a roughly identical HRV “wave portrait”. An example of an acute state caused by alcoholic intoxication is shown in Figures 21a and 21b. NOTE: The Health-Express system is not a substitute for traditional functional diagnostics and laboratory examination methods; it complements them with new critically important comprehensive information about the functional state of a human body.

105

2. PERSONNEL TESTING - Safety Assurance Testing in Safety-critical Professions Nerve-Express opens new possibilities for safety assurance in professions where public safety is of primary concern. These include pilots, subway train operators, railroad engineers, nuclear power plant operators, air traffic controllers, and military personnel. Much higher standards of safety assurance are achieved by Nerve-Express' testing of “critical” personnel prior to “critical task” performance. Such testing is highly sensitive in detecting intoxication, tiredness, infection or any other deviation from the “norm”. What is even more important, such testing cannot be misled by any human trick as it measures objective physiological parameters that are beyond conscious human control. In order for the testing to be accurate, it is necessary to first establish an individual "norm" for each person by testing him or her with the Health-Express system three to five times on different days. The best result should be considered his/her "normal" Functional state. These tests will also show permissible deviations from an individual's norm. For example, the individual norm was defined as a score of 7.3 on the diagram in Figure 20. In this Figure, the X-axis shows 13 gradations of the level of functioning of physiological system, whereas the Y-axis shows seven levels of an individual's adaptation reserves, with the top level considered the best.

Fig. 20 All deviations from the individual norm are shown as red dots on the diagram, defining the range of possible functional states of an individual before the beginning of his working shift. A trained professional who knows the medical and psycho-emotional condition of employees should supervise all tests. All subsequent tests will monitor the individual's functional state. Once the range of the individual's deviations from the norm is established, special attention should be paid to all scores that lie outside the range. An example of a significant deviation from the norm, eight hours after the ingestion of alcoholic beverages, is shown in Figure 21a (before alcohol) and Figure 21b (after alcohol). Different factors, such as strong emotional stress, physical strain, infection, intoxication, and many others, both endogenous and exogenous, may cause this deviation. A trained professional is needed to define the cause and provide the test administrator with objective information.

106

C

NERV

XPRESS Physical Fitness evaluation based on analysis of Heart Rate Variability analysis Electrocardiographic Rhythm Strip

R-R intervals (sec) 2

Current Physical Fitness - 4,3 1 1 2

0 1

Supine

192

256

Heart beats Upright

3

448

4

7 levels of the Adaptation

5

HR MSSD TI SC1 SC2

61 0.11 23 3

SC3

3

13

Transition

HR MSSD TI SC1

SC2 SC3

75 0.07 71 8

10

6

9

Reserve

7

max 1

Transition Parameters ECTOPIC BEATS ANALYSIS

ChMR VC 0.60

Extrasystoles not recognized

0.66

2

3

4

5

6

7

8

9

10

11

12

13

13 Levels of Functioning of the Physiological systems

Iot

Point (1.1 The best possible Physical Fitness

1.22

Point (13.7) The worst possible Physical Fitness

Additional info:

min

Transition is decreases slightly in response to orthotest Parameters o f O ptimal V ariability

CONCLUSION

D iscrepancy o f H RV ( s) a nd H RV ( up)

POV (Supine) = 34 POV (upright) = 27

FUNCTIONING OF THE PHYSIOLOGICAL SYSTEMS IS CLOSE TO THE NORMAL LEVEL, WHILE THE ADAPTATION RESERVE IS CLOSE TO NORMAL LEVEL

Index of discrepancy = 12

Fig. 21a Before alcohol (300 ml)

C

NERV

XPRESS Physical Fitness evaluation based on analysis of Heart Rate Variability analysis Electrocardiographic Rhythm Strip

R-R intervals (sec) 2

Current Physical Fitness - 11,6 1 1 2

0 1

Supine

192

256

7 levels

Heart beats Upright

3

448

of the

4

HR MSSD TI SC1 SC2 SC3

99 0.03 492 14 14

4

Transition

HR MSSD TI SC1 SC2

SC3

121 0.04 253 14 14

2

5

Adaptation

6

Reserve

7

max 1

Transition Parameters ECTOPIC BEATS ANALYSIS

Extrasystoles not recognized

ChMR VC 079

0.83

POV (Supine) = 26 POV (upright) = 0

3

4

5

6

Point (1.1 The best possible Physical Fitness

1.22

7

8

9

10

11

12

13

Point (13.7) The worst possible Physical Fitness

Additional info:

min Chronotropic Reaction decreases sharply in response to orthotest while Vascular Compensation is absent. Parameters o f O ptimal Variability

2

13 Levels of Functioning of the Physiological systems

Iot

CONCLUSION

D iscrepancy o f H RV ( s) a nd H RV ( up)

THE FUNCTIONING OF THE PHYSIOLOGICAL SYSTEMS IS ON THE FIRST LOW LEVEL, WHILE THE ADAPTATION RESERVE IS SIGNIFICANTLY REDUCSD

Index of discrepancy = -1

Fig. 21b After alcohol (300 ml.) 107