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Articles 31 - 60 of 61

Full-Text Articles in Alternative and Complementary Medicine

Effects Of Mindfulness And Stress Management On Neurocardiovascular And Psychological Outcomes, Aditi P. Vyas Jan 2022

Effects Of Mindfulness And Stress Management On Neurocardiovascular And Psychological Outcomes, Aditi P. Vyas

Dissertations, Master's Theses and Master's Reports

There has been a higher prevalence of developing anxiety due to frequent episodes of stress among adults in recent years. Chronic anxiety can contribute to the prevalence of elevated blood pressure and hypertension. High anxiety and stress also contribute to overactivation of the sympathetic nervous system which can be quantified by increased muscle sympathetic nerve activity (MSNA). Sympathetic overactivation can lead to vasoconstriction and loss of arterial elasticity. Anxiety, MSNA, blood pressure, and arterial stiffness are all interconnected, thus studying these relationships is crucial to understand the underlying mechanisms for prevention and treatment of cardiovascular disease (CVD). Non-pharmacological and mind-body …


A Comparison Of The Magnitude Of The Mental Health Benefits Of Exercising Outdoors Vs Exercising Indoors: A Review, Greta M. Rueschmann Jan 2022

A Comparison Of The Magnitude Of The Mental Health Benefits Of Exercising Outdoors Vs Exercising Indoors: A Review, Greta M. Rueschmann

Graduate Theses/Dissertations

Many people in the United States suffer from poor mental health which can lead to suicide, self-harm, or negative effects on job performance and relationships. Not everyone can afford traditional therapy nor feels comfortable with it. With a greater emphasis placed on taking care of one’s mental health during the COVID-19 pandemic, there should also be a greater emphasis placed on finding alternative types of therapy that can be matched to individuals based on their personalities and preferences. One such alternative is outdoor exercise. This review was conducted to examine whether exercising or performing physical activity outdoors results in greater …


Mindfulness-Based Interventions For Prenatal Stress, Anxiety, And Depression, Fiona Kate Rice May 2021

Mindfulness-Based Interventions For Prenatal Stress, Anxiety, And Depression, Fiona Kate Rice

Expressive Therapies Capstone Theses

Pregnant people in the United States (US) face myriad barriers to resource accessibility when seeking support, including financial gatekeeping, discrimination, and cis-gendering of the process. Commodification of prenatal support is exhaustive and contributes to a growing exclusivity of traditionally accessible interventions designed to reduce stress, anxiety, and depression, and to promote positive fetal outcomes and parent-child bond. Mindfulness-based interventions are particularly appropriate for reducing stress, anxiety, and depression in pregnancy. Mindfulness-based interventions are intersectional, accessible means of pregnancy and childbirth support with evidence-based outcomes of positive birth experiences and results. Mindfulness is defined as nonjudgmental awareness of the present moment. …


Exploring The Usefulness Of Mindfulness Practices Through Zoom Meetings In Reducing Anxiety And/Or Stress Of Adults With Learning And Developmental Disabilities During The Covid-19 Pandemic, Thatiane Abra May 2021

Exploring The Usefulness Of Mindfulness Practices Through Zoom Meetings In Reducing Anxiety And/Or Stress Of Adults With Learning And Developmental Disabilities During The Covid-19 Pandemic, Thatiane Abra

Expressive Therapies Capstone Theses

This thesis explored which mindfulness meditations or mindfulness practices could be beneficial in the online sessions, the extent to which adults with learning and developmental disabilities could learn the practices remotely, and how stress and anxiety disorders could be reduced through online mindfulness interventions. Furthermore, it was also necessary to address the online sessions as the only mental health treatment possibility during the Coronavirus pandemic for the clients observed and the benefits and limitations of these interventions. Additionally, the importance of structure and routine for this population, the multi-modal structure of the interventions, and how attunement plays an important role …


Using Mindfulness To Decrease Stress In College Students, Saska Pavlovic May 2021

Using Mindfulness To Decrease Stress In College Students, Saska Pavlovic

Evidence-Based Practice Project Reports

The prevalence of stress is increasing in colleges, where students are experiencing anxiety at an alarming rate, with anxiety being the topic most discussed in university counseling centers. The purpose of this evidence-based practice project was to determine the effect of mindfulness exercises on college students’ perceived stress. The Stetler Model guided the project development and implementation. The literature search revealed that best practice included mindfulness exercises through a combination of face-to-face instruction and remote online audio meditation for a duration of eight weeks. For this project, 56 undergraduate students (health care-leadership, health-science, and nursing majors) enrolled in a health …


Complementary And Alternative Medicine: The Effects Of Aromatherapy On New And Expectant Mothers, Heather Tran May 2021

Complementary And Alternative Medicine: The Effects Of Aromatherapy On New And Expectant Mothers, Heather Tran

Nursing | Senior Theses

Complementary and alternative medicine (CAM) is vastly expanding and is now being used in the clinical setting as an effective management of various symptoms. Pregnancy, labor, and the postpartum period can be beautiful yet overwhelming moments in a woman’s life. The symptoms that are usually accompanied along this journey include nausea, vomiting, anxiety, pain, fatigue, stress and more. Aromatherapy has been proven to be a safe and natural, non-pharmacological method in reducing these symptoms that may make it harder for the mother to enjoy her pregnancy. This holistic approach to treatment is inexpensive, noninvasive, does not require a prescription from …


The Influence Of Prenatal Yoga On Mental Health In Pregnancy During The Covid-19 Pandemic, Cathryn Duchette Apr 2021

The Influence Of Prenatal Yoga On Mental Health In Pregnancy During The Covid-19 Pandemic, Cathryn Duchette

Masters Theses & Specialist Projects

The COVID-19 pandemic poses risks to the mental health of expecting mothers as studies have demonstrated increased levels of stress and anxiety for new and expectant mothers during the pandemic. Prenatal yoga has been shown to be effective for improving mental health during pregnancy, but no research has been done to determine its effect on mental health during a pandemic. The purpose of this study was to determine the influence of a 10-week prenatal yoga intervention on the mental health of pregnant women during the COVID-19 pandemic. Baseline levels of anxiety and depression were high, with an average depression score …


Addressing Psychosocial Outcomes Of Social Isolation In Older Adults, Megan Friesen, Madeline M. Christensen Feb 2021

Addressing Psychosocial Outcomes Of Social Isolation In Older Adults, Megan Friesen, Madeline M. Christensen

Nursing DNP Projects

Purpose and Rationale

The aim of the evidence-based practice (EBP) project is to improve psychological outcomes for socially isolated older adults enrolled in a Homebound Program (HP) through the implementation of an EBP intervention. Social isolation has a multitude of negative consequences, including impacting the psychological health (e.g. depression, loneliness, anxiety) of the older adult population.

Synthesis of Evidence

Meta-analyses, systematic reviews, and randomized controlled trials addressing the clinical problem of social isolation were identified. Through critical appraisal of the evidence, physical activity, psychotherapy, and socialization interventions have shown to decrease depression and loneliness in older adults. There were mixed …


The Effect Of Physical Activity On The Mental Health Of Pre-Nursing Students And Undergraduate Student Nurses, Larinda J. Fandrich Jan 2021

The Effect Of Physical Activity On The Mental Health Of Pre-Nursing Students And Undergraduate Student Nurses, Larinda J. Fandrich

DNP Research Projects

Abstract

Mental health concerns are on the rise among the college-aged student. College students face a great deal of stress, which can lead to depression and anxiety. Nursing students, as a sub-group of college students, are under even greater stress related to rigorous course work and the responsibility of caring for other people, which can lead to greater depression and anxiety. This study aimed to determine what effect, if any, physical activity has on depression and anxiety scores using the PHQ-9 and GAD-7 instruments in pre-nursing and nursing students. In this study, physical activity is defined as is “any bodily …


The Green Rx: An Intervention In Nurse Anxiety And Depression, Melissa Dawley Jan 2021

The Green Rx: An Intervention In Nurse Anxiety And Depression, Melissa Dawley

DNP Research Projects

No abstract provided.


A Retrospective Analysis Of Integrative Group Medical Visits For Low-Income Patients With Anxiety Disorders In Primary Care, Annamma Udaya Thomas Jan 2021

A Retrospective Analysis Of Integrative Group Medical Visits For Low-Income Patients With Anxiety Disorders In Primary Care, Annamma Udaya Thomas

Walden Dissertations and Doctoral Studies

High utilization of the emergency department (ED) by patients with anxiety symptoms has brought attention to mental health access disparities among low-income racially/ethnically diverse populations. The health system in this study attempted to increase access to mental health care with integrative group medical visits (IGMVs), a nonpharmacological intervention with biomedical care consultation, health education, and peer support. The purpose of this retrospective comparative analysis, guided by integrative health equity in primary care framework, was to determine whether patients with diagnoses of anxiety who attended four or more IGMVs had reduced nonemergent ED utilization, reduced prescribed doses of benzodiazepine (BZD), and …


Move For A Healthy Mind: A Program Of Peer-Led Physical Activity For Adolescents With Depression And Anxiety, Emily Edwards Dec 2020

Move For A Healthy Mind: A Program Of Peer-Led Physical Activity For Adolescents With Depression And Anxiety, Emily Edwards

Master's Projects and Capstones

The following discusses adolescent depression and anxiety and the utilization of physical activity as an intervention or coping mechanism. Adolescents have been experiencing increased rates of anxiety or depression diagnoses over the past roughly two decades. Adolescence is, physiologically, a formative period in the developmental stage from childhood to adulthood. Current barriers to achieving optimal mental health among the adolescent population include the stigmatization of mental health issues, lack of education, socioeconomic status and healthcare access. Further, physical activity has been studied and identified to be an effective treatment for individuals experiencing depression and anxiety. In an effort to treat …


Effectiveness Of Ashtanga And Vinyasa Yoga: Combating Anxiety, Depression, Stress And Sleep Quality., Kati Street Jul 2020

Effectiveness Of Ashtanga And Vinyasa Yoga: Combating Anxiety, Depression, Stress And Sleep Quality., Kati Street

Graduate Theses and Dissertations

Purpose: This lack of rigor in yoga research methodology hinders the understanding of yoga components and best practices. This study implements two yoga interventions with recommended adequate structure, one more physically demanding (Ashtanga Vinyasa) and a less physically demanding (slow flow vinyasa). The instructor, who is also the lead researcher, developed a slow flow vinyasa sequence and modified the set sequence of Ashtanga Vinyasa for beginners. Both yoga interventions cover domains suggested by Sherman (2012) for meticulous methods in yoga research.

Methods: This study implements two styles of yoga with university students over the course of eight weeks, meeting twice …


Treatment Of Anxiety Using Massage Therapy In A Neurorehabilitation Program, Jennifer Gordon Feb 2020

Treatment Of Anxiety Using Massage Therapy In A Neurorehabilitation Program, Jennifer Gordon

Graduate Theses, Dissertations, and Capstones

Abstract

Traumatic brain injury (TBI) has been considered a silent epidemic. The symptoms post-injury can be pervasive and impact individuals physically, emotionally, and socially. It also creates a financial burden on the individual and society. Finally, it can be challenging to the family and caregivers of these individuals because navigating the healthcare needs can be problematic. An enriched neurorehabilitation program may improve the quality of life and outcomes of the individual with TBI. The diagnosis of anxiety has been found to be a major factor that influences the prognosis. Cognitive behavior therapy (CBT) and pharmacology can assist in the management …


A Feasibility Study Of Lavender Aromatherapy In An Awake Craniotomy Environment, Kailah Cathey, Nichole Gunyon, Nancy Chung, Nancy Conway, Diane Ames, Maharaj Singh, Amin B. Kassam, Richard A. Rovin Jan 2020

A Feasibility Study Of Lavender Aromatherapy In An Awake Craniotomy Environment, Kailah Cathey, Nichole Gunyon, Nancy Chung, Nancy Conway, Diane Ames, Maharaj Singh, Amin B. Kassam, Richard A. Rovin

Journal of Patient-Centered Research and Reviews

Purpose: Integrative medicine interventions are needed for awake craniotomies, as many patients experience anxiety. Lavender aromatherapy significantly reduces anxiety or pain in a variety of surgical procedures. This feasibility study used lavender aromatherapy during awake craniotomies to determine the number of patients who would consent and complete the study, the technicality of lavender aromatherapy use, and acceptance by operating room (OR) staff.

Methods: We approached 40 consecutive patients (≥18 years old). Exclusion criteria were pulmonary issues or sensitivity to lavender. Outcome measures in consented patients were enrollment and completion rates, anxiety and pain as measured by the Visual Analog Scale …


A Qualitative Investigation Into The Influence Of A Mental Health Physical Activity Intervention On University Students, Heather M. Tunks Jan 2020

A Qualitative Investigation Into The Influence Of A Mental Health Physical Activity Intervention On University Students, Heather M. Tunks

Theses and Dissertations (Comprehensive)

Objective

Among the university student population, mental illnesses are highly prevalent. Adults aged 20-30 years have the highest rates of mood and anxiety disorders than any other age group, with approximately 12.0% diagnosed with an anxiety disorder and 7.0 to 9.0% experiencing clinical depression (Nunes et al., 2014; Pedrelli, Nyer, Yeung, Zulauf, & Wilens, 2015). Reducing or preventing the effects of mental illness among this population may have lifelong implications including improvements in coping and management of mental illness throughout the lifespan(Jaworska, DeSomma, Fonseka, Heck, & MacQueen, 2016). This research examines the lived experiences of volunteers and participants in a …


Flowers Or Flora?: Understanding The Effects Of Probiotics On Depression, Nicole Collopy Dec 2019

Flowers Or Flora?: Understanding The Effects Of Probiotics On Depression, Nicole Collopy

Senior Theses

The human gut is populated with hundreds of types of bacteria and fungi. In North America, both intestinal and mood disorders are prevalent, presenting health problems that challenge health care professionals and patients alike. A scholarly literature review was conducted to explore this important relationship.

The investigation of the literature revealed that there is an association between gut health disorders and mood disorders, mainly anxiety and depression. This is due to bi-directionality between the brain-gut pathways, meaning that gastrointestinal health may have an effect on mental health and vice versa.

This connection between gut and mood can have substantial implications …


Increasing Utilization Of Cognitive Behavioral Therapy To Reduce Morbid Obesity In A Primary Care Setting, Erin J. Mccue Apr 2019

Increasing Utilization Of Cognitive Behavioral Therapy To Reduce Morbid Obesity In A Primary Care Setting, Erin J. Mccue

Doctoral Projects

Background: Obesity among adults is characterized by a body mass index (BMI) of 30 or higher. The impairment and disability resulting from obesity indicates a significant health problem that is often seen in primary care settings. Research indicates that cognitive behavioral therapy (CBT) is an underutilized, but extremely beneficial intervention that may support individuals in achieving weight loss. Adults suffering from obesity with or without comorbid conditions such as psychiatric disorders (e.g. anxiety and depression) have benefitted from CBT.

Purpose: To implement the increased utilization of CBT in the adult population with obesity and depression or anxiety in a primary …


Effectiveness Of Yoga Therapy On Pain And Related Depression, Anxiety, Perceived Stress, And Quality Of Life, Karen Romani Jan 2019

Effectiveness Of Yoga Therapy On Pain And Related Depression, Anxiety, Perceived Stress, And Quality Of Life, Karen Romani

Walden Dissertations and Doctoral Studies

Individuals are becoming more dependent on medication for conditions such as chronic-pain, anxiety, and depression. It is reported that patients are often overprescribed medication while health outcomes do not improve. The medicalization of society is distracting attention from the possibility of other therapies such as complementary or alternative medicine (CAMs) that can improve health outcomes if they were as supported as pharmacological research and better received by the medical community. Yoga and meditation, the components of Mindfulness Based Stress Reduction (MBSR) and yoga therapy, have been shown as effective CAMs for cases of anxiety and depression related to chronic illness …


Music Heals: Therapeutic Music To Reduce Pain And Anxiety In Adult Icu Patients, Kathleen Sowada Jan 2018

Music Heals: Therapeutic Music To Reduce Pain And Anxiety In Adult Icu Patients, Kathleen Sowada

Nursing Posters

To decrease pain and anxiety in adult intensive care unit patients through the use of therapeutic music as compared to no music intervention.


The Psychological And Physiological Effect Of Performing The Primal Reflex Release Technique On Female, Division I Collegiate Athletes, Erika K. Vichcales Jan 2018

The Psychological And Physiological Effect Of Performing The Primal Reflex Release Technique On Female, Division I Collegiate Athletes, Erika K. Vichcales

Graduate Student Theses, Dissertations, & Professional Papers

Anxiety is a cognitive, behavioral, and physiological reaction to stress, and athletes have an increased risk being in a high-stress environment. One of the effects of increased stress on the body is a condition known as central sensitization (CS) where the central nervous system amplifies sensory input across many organ systems causing a pain response in normally non-painful areas or hypersensitivity to stimuli. The Primal Reflex Release Technique (PRRT) is a manual-therapy approach for evaluating and relieving musculoskeletal pain in patients, and is meant to facilitate a “neural reboot” of a hyper-aroused nervous system. The purpose of this study is …


Healing Touch: Enhancing Quality Of Life, Julia Mccann-Khludenev May 2017

Healing Touch: Enhancing Quality Of Life, Julia Mccann-Khludenev

Evidence-Based Practice Project Reports

Healing touch (HT) is a non-invasive energy therapy used in the management of symptoms of various health conditions. HT utilization has demonstrated enhanced comfort and relief of symptoms such as chronic pain, post-traumatic-stress, depression, and anxiety. The purpose of this evidence-based practice (EBP) project was to promote awareness and appointment compliance rate of HT amongst veterans, and also to determine effectiveness of HT intervention on symptom relief and well-being. The PICO question was: “For Veterans, what is the effect of HT education material and mail notification on appointment compliance rate, and HT delivery on symptom relief and well-being as compared …


Utilization Of Traditional, Complementary And Alternative Medicine And Mental Health Among Patients With Chronic Diseases In Primary Health Care Settings In Cambodia, Siyan Yi, Chanrith Ngin, Sovannary Tuot, Pheak Chhoun, Tyler Fleming, Carinne M. Brody Jan 2017

Utilization Of Traditional, Complementary And Alternative Medicine And Mental Health Among Patients With Chronic Diseases In Primary Health Care Settings In Cambodia, Siyan Yi, Chanrith Ngin, Sovannary Tuot, Pheak Chhoun, Tyler Fleming, Carinne M. Brody


Background: Coping with chronic illnesses often involves major lifestyle changes that may lead to poor mental health. Furthermore, in order to treat the chronic conditions, many sufferers in Asia turn to traditional, complementary and alternative medicines (TCAM). This study explores prevalence of TCAM use and factors associated with anxiety and depressive symptoms among patients with chronic diseases in Cambodia.

Methods: In 2015, this cross-sectional study was conducted with outpatients receiving treatment and care for chronic diseases in two urban and two rural primary health centers. Every eligible patient was randomly selected at the health centers using a systematic sampling procedure. …


Is L-Theanine An Effective Treatment For Reducing Anxiety In Patients Ages 18-25?, Nicole Bubes Jan 2017

Is L-Theanine An Effective Treatment For Reducing Anxiety In Patients Ages 18-25?, Nicole Bubes

PCOM Physician Assistant Studies Student Scholarship

Objective: The objective of this selective EBM review is to determine whether or not L-theanine, an amino acid analogue found in green tea leaves, is an effective treatment for reducing anxiety in patients ages 18-25.

Study design: Review of two double-blind, randomized controlled studies and one single-blind, randomized controlled study published in 2007, 2012 and 2013 respectively.

Data sources: PubMed

Outcome(s) measured: Each study measured L-theanine’s ability to reduce acute anxiety with a series of self-report measures assessing acute anxiety and stress, including the Profile of Mood States (POMS), the visual analogue scales (VAS), State-Trait Anxiety …


Mind And Body Training To Improve Functioning And Coping With Chronic Pain: A Pilot Study, Olga Valieva, Leah M. Welsh, Betty Amuzu, Niraj Nijhawan, Jessica J.F. Kram Nov 2016

Mind And Body Training To Improve Functioning And Coping With Chronic Pain: A Pilot Study, Olga Valieva, Leah M. Welsh, Betty Amuzu, Niraj Nijhawan, Jessica J.F. Kram

Journal of Patient-Centered Research and Reviews

Background: Patients with chronic pain are often crippled by psychological distress, depression and fear. These patients also can develop altered pain perception, with enhanced brain activity in pain-responsive regions and those associated with anxiety/depression. Exercise and meditation can impact pain-reducing brain areas and positively influence pain characteristics.

Purpose: To alter pain center activity by reducing the activation of the higher brain and deactivation of the lower brain with somatocognitive and meditative practices, with secondary aim of reducing anxiety/depression and improve overall quality of life.

Methods: We conducted a pilot study on mentally competent adult women with stable chronic pain who …


Understanding Physicians’ And Non-Physician Practitioners’ Recommending Practices, Knowledge, Attitudes, Beliefs And Expectations Regarding Music As A Cost-Effective Complementary And Alternative Medicine Approach, Paul F. Franco Mar 2016

Understanding Physicians’ And Non-Physician Practitioners’ Recommending Practices, Knowledge, Attitudes, Beliefs And Expectations Regarding Music As A Cost-Effective Complementary And Alternative Medicine Approach, Paul F. Franco

Seton Hall University Dissertations and Theses (ETDs)

Background and Purpose of the Study: With the rise in healthcare costs, partly due to an aging demographic (of whom these care-receivers and their informal family member/friend caregivers are experiencing high stress and anxiety levels resulting in an increase in nursing home placement), a need exists for a cost-effective alternative to the traditional medical approach. Specifically, Music Therapy, a form of Complementary and Alternative Medicine (CAM) has been shown to decrease the severity of the problem by alleviating symptoms of an illness and improving overall well-being. The purpose of this study was to create a valid tool entitled “The Global …


Attitudes Toward Complementary And Alternative Medicine, Miranda Lea Cobb Jan 2016

Attitudes Toward Complementary And Alternative Medicine, Miranda Lea Cobb

Theses, Dissertations and Capstones

Complementary and alternative medicine (CAM) usage has increased throughout the years, as many people are becoming interested in using less conventional interventions for common illnesses. As a whole, CAM encompasses any practice used to treat an illness or disorder that does not fall under the category of traditional medicine. CAM interventions not only treat the physical aspects of health, but as clinicians are beginning to realize, these interventions may also be effective in treating psychological problems, most notably anxiety and depression. This research focused on attitudes toward CAM for psychological disorders. I examined participants’ attitudes about the use of CAM …


Mindfulness: Being Present In The Moment, Stephanie Ann Stathas, Christine Frazer Apr 2015

Mindfulness: Being Present In The Moment, Stephanie Ann Stathas, Christine Frazer

Walden Faculty and Staff Publications

This article serves to enlighten childbirth educators’ knowledge about mindfulness and the mother-baby benefits associated with incorporating mindfulness- based interventions into practice. Jon Kabat-Zinn, who developed the Mindfulness Based Stress Reduction program, brought the concept of mindfulness into the world of healthcare and mainstream society. Mindfulness is the practice of bringing awareness to the here and now using a variety of methods. Nancy Bardacke has taken the practice of mindfulness further and developed a program for expecting mothers, known as Mindfulness Based Childbirth and Parenting. This program has been shown to reduce stress responses that may be harmful to a …


The Effect Of Tea And Its Constituent L-Theanine On Anxiety: A Review Of The Literature, Christine Gilbert Dec 2014

The Effect Of Tea And Its Constituent L-Theanine On Anxiety: A Review Of The Literature, Christine Gilbert

Food Science and Nutrition

Mental health disorders are a universal issue and affect millions of individuals every day. Anxiety is the most common type of mental disorder, affecting social, physical, and cognitive health. Although clinicians usually suggest prescriptive medications, they carry side effects, are expensive, and only acutely alleviate symptoms. As a result, recent interest has been directed towards nonconventional dietary therapies, including tea and its constituent L-theanine, for anxiolytic effects. Tea is the most prevalent beverage consumed after water; it is historically and globally accepted. The purpose of this literature review is to explore whether tea and its constituent L-theanine carry anxiolytic effects. …


Reducing Anxiety In Pediatric Bone Marrow Transplant Patients Using Reiki, Robyn Ait Ali Jan 2014

Reducing Anxiety In Pediatric Bone Marrow Transplant Patients Using Reiki, Robyn Ait Ali

Theses and Graduate Projects

Reiki, meaning universal life force energy, facilitates the flow of energy that travels naturally in and around the body. Blockages in energy flow create disease and or pain in the body; the Reiki practitioner facilitates the removal of blockages which allows for healing and restoration of balance. Anxiety in children undergoing Bone Marrow Transplant (BMT) manifests itself across all body systems and effects the care they receive during hospitalization. Children are open to the concept of energetic healing therefore, the use of Reiki for children undergoing BMT to reduce anxiety, facilitate relaxation, and ease pain makes sense. The introduction of …