APPENDIX A

Theoretical Review of the Nerve-Express System with Sample Cases

The Nerve-Express System Overview 66

The Nerve-Express Method

What is the Nerve-Express Method? 67

The Nerve-Express Advantage 69
Heart Rate Variability Analysis 69
Recognition and Classification of ANS States 71
Physiological Interpretation of ANS States 73
Nerve-Express Test Modalities 76
Orthotest 77
Sample Cases 80
Valsalva Maneuver combined with Deep Breathing 83
Sample Cases 84
Monitor Test 87
PC-ECG Device 90

The Health-Express Method

What is the Health-Express Method? 91

The Health-Express Advantage 94
Orthotest as the Health-Express Test Modality 95
Health-Express applications 103
 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.

66
 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 high-
2
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 Nerve-
Express) 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
cf. SNS and PSNS definitions in footnote 1, page 66.
3
M. Minsky. Structures for Knowledge Representation. Machine Vision Psychology. Mir, 1978.

67
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
6
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.

68
 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.
69
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.

70
 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

71
 New Classification of the Autonomic System’s conditions
Autonomic Nervous System’s conditions
by Alexander Riftine, Ph.D

Borderline Values
of Autonomic
Balance
SNS
3
x x x x 4 x x x x x

4 x x x x 3 x x x x x 2
4
x x x x 2 x x x x x

x x x x 1 x x x x x

5 x x
7 x x
1
x x x x

72
x PSNS
-4 -3 -2 -1 1 2 3 4
x x x x -1 x x x x x

x x x x -2 x x x x x

6 x x x x -3 x x 9
x x x x -4 x

8
1

Fig. 3a Nine categories of the 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
 Physiological Interpretation of ANS States
by Alexander Riftine, Ph.D

acute state or "distress" zone “high sympatho-adrenergic” state or “positive” stress zone
SNS
3
x x x x 4 x x x x x

4 x x x x 3 x x x x x 2 normal healthy condition

chronic or temporary dysfunction 4
(e.g., exhaustion, intoxication, x x x x 2 x x x x x
infection, nervous tension) condition close to special physiology/training
x x x x 1 x x x x x

5 x x
7 x x
1
x x x x x PSNS
-4 -3 -2 -1 2 3 4

74
1
possible chronic pathology x x x x -1 x x x x x
(median SNS = no stress; special physiology /special training
depression of PSNS receptors) x x x x x x x x x
-2
6 x x x x -3 x x
Autonomic Balance point
9
old age, temporary or chronic sickness x x x x -4 x Borderline Values of Autonomic Balance
Autonomic Balance zone
8
1

ANS degeneration zone Hyperkalemia zone Borderline values between special physiology and Hyperkalemia cases
(e.g., age > 80; serious pathology (50% probability) - category 8
like cancer, degenerative joint disease)

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

 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.

75
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).

76
 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.

77
 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 Normal for PSNS, Abnormal for SNS Normal for SNS, Abnormal for PSNS,

SNS same or increased SNS increased by > 1 level PSNS decreased by 2 or 3 levels PSNS decreased by > 3 levels
by 1 level; and PSNS <0
PSNS same or decreased
by 1 level

Normal ANS reaction* SNS (S) >or = 0 SNS (S) < 0 Parasympathetic if PSNS>0 in supine;
Sympathetic Dominance: Sympathetic Disbalance* PSNS<0 in upright
temporary problem/ Disbalance* 85% of cases
illness (e.g., Intoxication, have GI problems
flu)

SNS SNS
SNS U 4 4 PSNS SNS SNS

3 3 3 3 3
2 2 2 2 2
U U U U
1 1 U 1 1 1
U SS S S S S
-3 -2 -1 0 1 2 3 -3 -2 -1 0 1 2 3 -1 0 1 -3 -2 -1 0 1 2 3 -3 -2 -1 0 1 2 3
-1 PSNS -1 -1 -1 PSNS -1 PSNS
PSNS
S -2
-2 -2 -2 -2
-3 -3 -3 -3 -3
-4 -4

* Healthy or unhealthy condition depends on the zone (cf. Fig. 3a-3b)

78
 By Direction: Inadequate or Paradoxical

Paradoxical for PSNS Paradoxical for both

Simple Paradoxical PSNS & SNS
Response Double Paradoxical Response
“Simple Switch" “Double Switch”

PSNS increased > or = 2 levels PSNS increased, SNS decreased

Possible indication of Stronger marker

introversion,subject to of inroversion
further testing by a
psychologist

3 3
2 S 2
U U
1 1
S
-3 -2 -1 0 1 2 3 -3 -2 -1 0 1 2 3
-1 -1
-2 -2
-3 -3

79
 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 Low-
frequency 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.

83
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 67 25 21 28 0 -1 Tigeminy. Multiple Extrasystolia. May be wrong Autonomic Assessment

2 97 28 21 18 3 -2 Single extrasystoles.
3 104 29 30 26 3 -3 Extrasystoles not recogmized
4 105 29 30 29 3 -4 Extrasystoles not recogmized
5 106 30 30 29 3 -4 Extrasystoles not recogmized
6 106 29 30 29 3 -4 Extrasystoles not recogmized
7 81 27 28 28 2 -2 Tigeminy. Multiple Extrasystolia.
8 73 27 29 30 1 -2 Tigeminy. Multiple Extrasystolia. May be wrong Autonomic Assessment
9 73 27 26 30 1 -2 Tigeminy. Multiple Extrasystolia. May be wrong Autonomic Assessment
10 72 27 26 30 1 -2 Tigeminy. Multiple Extrasystolia. May be wrong Autonomic Assessment
11 71 26 25 30 1 -2 Tigeminy. Multiple Extrasystolia. May be wrong Autonomic Assessment
12 71 27 26 29 1 -2 Tigeminy. Multiple Extrasystolia. May be wrong Autonomic Assessment

Fig. 10a

88
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
9
cf. footnote 1, page 66
10
cf. section Orthotest, page 77
11
cf. pages 69-70 for a definition and a discussion

91
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.

Professional athlete Heart disease patient

Transition Transition

Levels of Adaptation Reserve

1 1
Levels of Adaptation Reserve

2 2
3 3
4 4
5 5
6 6
7 7

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

Fig. 15a Fig. 15b

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.

94
 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: Heart rate per minute;

- MSSD: Mean successive square deviation;
- TI: 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;
- SC1, SC2,
SC3: Indexes correspond to three main spectral components of the
Rhythmogram;
- SC1: Index of the "respiration" component of HRV, which corresponds to
waves of 2-8 seconds in length;
- SC2: Index of baroreflex influences on HRV, which corresponds to Traube-
Gaering waves of 8-18 seconds in length;
- SC3: Slow wave component activity index corresponding to Mayer waves of
80-90 seconds in length.

# TI gradations VALUES

I Normal TI 10 - 80
2 Close to normal TI 80 - 120
3 Slightly increased TI 120 - 150
4 Close to moderately increased TI 150 - 200
5 Moderately increased TI 200 - 400
6 Close to significantly increased TI 400 - 600
7 Significantly increased TI 600 - 900
8 Close to sharply increased TI 900 - 1,200
9 Sharply increased TI > 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 < 0.53

2 Normal chronotropic reaction 0.53 - 0.58
3 Close to normal chronotropic reaction 0.59 - 0.63
4 Slightly decreased chronotropic reaction 0.64 - 0.69
5 Moderately decreased chronotropic reaction 0.70 - 0.75
6 Significantly decreased chronotropic reaction 0.76 - 0.81
7 Sharply decreased chronotropic reaction > 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 Transition is within normal parameters.

Ÿ Transition is close to normal parameters.

2. General reaction decreases:

Ÿ General reaction decreases slightly

Ÿ General reaction decreases moderately
Ÿ General reaction decreases significantly
Ÿ General reaction decreases sharply

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

normal:

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

97
 Classification of transitions during orthostatic test

98
Fig. 17
4. Chronotropic reaction decreases while Recovery (Compensatory) reaction is absent:

Ÿ Chronotropic reaction decreases slightly while Recovery reaction is absent.

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

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

Ÿ Chronotropic reaction decreases slightly while Recovery reaction decreases slightly.

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

99
 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.

# POV gradations VALUE

1 Optimal POV value 34 - 38

2 Close to optimal POV value 30 - 33
3 Slight deviation from the optimal 24 - 29
4 Moderate deviation from the optimal 17 - 23
5 Significant deviation from the optimal 8 -16
6 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.

# ID gradations RANGE

1 State of equilibrium (-3) - (-1)

2 State close to equilibrium 0- 1
3 Slight deviation from equilibrium 2- 4
4 Moderate deviation from equilibrium 5- 9
5 Significant deviation from equilibrium 10 - 21
6 Sharp deviation from equilibrium 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. The adaptation reserve is at the Highest Level

2. The adaptation reserve is Close to the Highest Level
3. The adaptation reserve is at a Normal Level
4. The adaptation reserve is at a Significantly Reduced Level
5. The adaptation reserve is at a Moderately Reduced Level
6. The adaptation reserve is at a Significantly Reduced Level
7. 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. Fitness;
B. Wellness;
C. Personal Productivity/Self-improvement/Lifestyle optimization;
D. 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.

103
 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 7 levels
3 of the
4
5
Adaptation
6 Reserve
7

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 7 levels
3
4 of the
5 Adaptation
6 Reserve
7

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. 19b

104
 - Current Physical Fitness

1
2 7 levels
3
4
of the
5 Adaptation
6 Reserve
7

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. 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.

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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.

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 C

NERV XPRESS

Physical Fitness evaluation based on analysis of Heart Rate Variability analysis

Electrocardiographic Rhythm Strip

R-R intervals (sec)

Current Physical Fitness - 4,3

1

2 7 levels
0
Heart beats 3
1 Supine 192 256 Upright 448 of the
4
Adaptation
5
HR MSSD TI SC1 SC2 SC3 HR MSSD TI SC1 SC2 SC3 Reserve
6
Transition
61 0.11 23 3 3 13 75 0.07 71 8 10 9
7
max
1 2 3 4 5 6 7 8 9 10 11 12 13
Transition Parameters
ECTOPIC BEATS ANALYSIS
ChMR VC Iot 13 Levels of Functioning of the Physiological systems
Point (1.1 The best possible Point (13.7) The worst possible
Extrasystoles not recognized 0.60 0.66 1.22 Physical Fitness Physical Fitness

Additional info:
min
Transition is decreases slightly in response to orthotest

CONCLUSION
Parameters o f O ptimal V ariability D iscrepancy o f H RV ( s) a nd H RV ( up)
FUNCTIONING OF THE PHYSIOLOGICAL SYSTEMS IS CLOSE
POV (Supine) = 34 TO THE NORMAL LEVEL, WHILE THE ADAPTATION RESERVE IS
POV (upright) = 27 Index of discrepancy = 12 CLOSE TO NORMAL LEVEL

Fig. 21a Before alcohol (300 ml)

NERV XPRESS
Physical Fitness evaluation based on analysis of Heart Rate Variability analysis

Electrocardiographic Rhythm Strip

R-R intervals (sec)

Current Physical Fitness - 11,6

1

2
0 7 levels
Heart beats
1 Supine 192 256 Upright 448 3
of the
4

5 Adaptation
HR MSSD TI SC1 SC2 SC3 HR MSSD TI SC1 SC2 SC3
Transition 6 Reserve
99 0.03 492 14 14 4 121 0.04 253 14 14 2
7
max
1 2 3 4 5 6 7 8 9 10 11 12 13
Transition Parameters
ECTOPIC BEATS ANALYSIS 13 Levels of Functioning of the Physiological systems
ChMR VC Iot
Point (1.1 The best possible Point (13.7) The worst possible
Extrasystoles not recognized 079 0.83 1.22 Physical Fitness Physical Fitness

Additional info:
min
Chronotropic Reaction decreases sharply in response to orthotest
while Vascular Compensation is absent.
CONCLUSION
Parameters o f O ptimal Variability D iscrepancy o f H RV ( s) a nd H RV ( up)
THE FUNCTIONING OF THE PHYSIOLOGICAL SYSTEMS IS ON THE
POV (Supine) = 26 FIRST LOW LEVEL, WHILE THE ADAPTATION RESERVE IS
POV (upright) = 0 Index of discrepancy = -1 SIGNIFICANTLY REDUCSD

Fig. 21b After alcohol (300 ml.)

107