medical and biological sciences

UNIWERSYTET MIKOŁAJA KOPERNIKA w TORUNIU COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA W BYDGOSZCZY

MEDICAL AND BIOLOGICAL SCIENCES

(dawniej

ANNALES ACADEMIAE MEDICAE BYDGOSTIENSIS)

TOM XXVI/1

styczeń – marzec

ROCZNIK 2012

REDAKTOR NACZELNY Editor-in-Chief Grażyna Odrowąż-Sypniewska

ZASTĘPCA

REDAKTORA NACZELNEGO Co-editor Jacek Manitius

SEKRETARZ REDAKCJI Secretary Beata Augustyńska

REDAKTORZY DZIAŁÓW Associate Editors Mieczysława Czerwionka-Szaflarska, Stanisław Betlejewski, Roman Junik, Józef Kałużny, Jacek Kubica, Wiesław Szymański

KOMITET REDAKCYJNY Editorial Board Aleksander Araszkiewicz, Beata Augustyńska, Michał Caputa, Stanisław Dąbrowiecki, Gerard Drewa, Eugenia Gospodarek, Bronisław Grzegorzewski, Waldemar Halota, Olga Haus, Marek Jackowski, Henryk Kaźmierczak, Alicja Kędzia, Michał Komoszyński, Wiesław Kozak, Konrad Misiura, Ryszard Oliński, Danuta Rość, Karol Śliwka, Eugenia Tęgowska, Bogdana Wilczyńska, Zbigniew Wolski, Zdzisława Wrzosek, Mariusz Wysocki

KOMITET DORADCZY Advisory Board Gerd Buntkowsky (Berlin, Germany), Giovanni Gambaro (Padova, Italy), Edward Johns (Cork, Ireland), Massimo Morandi (Chicago, USA), Vladimir Palička (Praha, Czech Republic)

Adres redakcji Address of Editorial Office Redakcja Medical and Biological Sciences ul. Powstańców Wielkopolskich 44/22, 85-090 Bydgoszcz Polska – Poland e-mail: [email protected], [email protected] tel. 52 585-3326 www.medical.cm.umk.pl Informacje w sprawie prenumeraty: tel. 52 585-33 26 e-mail: [email protected], [email protected]

ISSN 1734-591X

UNIWERSYTET MIKOŁAJA KOPERNIKA W TORUNIU COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA

BYDGOSZCZ 2012

Medical and Biological Sciences, 2012, 26/1

CONTENT

p.

REVIEW Monika Kuczma, Katarzyna Matuszak, Waldemar Kuczma, Wojciech H a g n e r , B a r b a r a K s i ą ż k i e w i c z – Treatment and rehabilitation of patients with scoliosis at the turn of the century . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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ORIGINAL ARTICLES M a ł g o r z a t a D a b k o w s k a , T a d e u s z P r a c k i , D a r i a P r a c k a – The objective measurement of movement vs. the intensification of ADHD symptoms in assessment of parents and doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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J e r z y E k s t e r o w i c z , M a r e k N a p i e r a ł a – Morphological parameters of physical education students in the years 2006-2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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M a r i u s z K l i m c z y k – Somatic build vs sports results of pole vault contestants aged 16-17 . . . . . .

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Alicja Rzepka, Kornelia Kędziora-Kornatowska, Marlena Jakubczyk, Ł u k a s z S i e l s k i , K r z y s z t o f K u s z a – Assessment of the needs and expectations of elderly patients regarding physiotherapeutical care in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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CASE REPORTS Małgorzata Łukowicz, Magdalena Mackiewicz-Milewska, Sabina L a c h - I n s z c z a k , I w o n a S z y m k u ć , W o j c i e c h H a g n e r – Transpedicular stabilization complications in thoracic region of the spine after SCI – three casus report and literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Edyta Sutkowska, Anna Kotłowska, Krzysztof Mastej, Rajmund A d a m i e c – Tuberous sclerosis, lated diagnosis: a case analysis . . . . . . . . . . . . . . . . . . . . . . . . .

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SPIS TREŚCI str. PRACA POGLĄDOWA Monika Kuczma, Katarzyna Matuszak, Waldemar Kuczma, Wojciech H a g n e r , B a r b a r a K s i ą ż k i e w i c z – Leczenie i rehabilitacja pacjentów ze skoliozą na przełomie wieków . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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PRACE ORYGINALNE M a ł g o r z a t a D a b k o w s k a , T a d e u s z P r a c k i , D a r i a P r a c k a – Obiektywny pomiar ruchu a nasilenie objawów ADHD w ocenie rodziców i lekarza . . . . . . . . . . . . . . . . . . . . . .

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J e r z y E k s t e r o w i c z , M a r e k N a p i e r a ł a – Parametry morfologiczne studentów wychowania fizycznego w latach 2006-2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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M a r i u s z K l i m c z y k – Budowa somatyczna vs wyniki sportowe zawodników skaczących o tyczce w wieku 16-17 lat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Alicja Rzepka, Kornelia Kędziora-Kornatowska, Marlena Jakubczyk, Ł u k a s z S i e l s k i , K r z y s z t o f K u s z a – Ocena zapotrzebowania i oczekiwań pacjentów w starszym wieku w odniesieniu do opieki fizjoterapeutycznej w Polsce . . . . . . . . . . . . . . . . . . . . .

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PRACE KAZUISTYCZNE Małgorzata Łukowicz, Magdalena Mackiewicz-Milewska, Sabina L a c h - I n s z c z a k , I w o n a S z y m k u ć , W o j c i e c h H a g n e r – Powikłania po stabilizacji transpedikularnej odcinka piersiowego kręgosłupa u pacjentów po urazie rdzenia kręgowego – opis trzech przypadków i przegląd literatury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Edyta Sutkowska, Anna Kotłowska, Krzysztof Mastej, Rajmund A d a m i e c – Stwardnienie guzowate, późne rozpoznanie: opis przypadku . . . . . . . . . . . . . . . . . .

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Regulamin ogłaszania prac w Medical and Biological Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Medical and Biological Sciences, 2012, 26/1, 5-9

REVIEW / PRACA POGLĄDOWA

Monika Kuczma¹,², Katarzyna Matuszak¹, Waldemar Kuczma¹, Wojciech Hagner¹, Barbara Książkiewicz²

TREATMENT AND REHABILITATION OF PATIENTS WITH SCOLIOSIS AT THE TURN OF THE CENTURY LECZENIE I REHABILITACJA PACJENTÓW ZE SKOLIOZĄ NA PRZEŁOMIE WIEKÓW

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Institute and University Department of Rehabilitation Nicolaus Copernicus University Collegium Medicum in Bydgoszcz Head: dr hab. Wojciech Hagner, prof. UMK 2 Institute and University Department of Neurology Nicolaus Copernicus University Collegium Medicum in Bydgoszcz Head: dr hab. Barbara Książkiewicz, prof. UMK

Summary Idiopathic scoliosis is an illness commonly occurring in children and teenagers. During its development threedimensional deformities can be observed: in frontal plane – primary, lateral curvature, in sagittal plane - deepening or flattening of the natural curvature of the spine and in transversal, horizontal plane - rotation and torsion of the vertebrae Scoliosis treatment and rehabilitation have been an important and complex issue since the ancient times.

The early methods, however, were very painful and hardly effective. At the turn of XVI - XVII centuries a fast development of scoliosis research and the first rehabilitation attempts were observed. In the following the use of corsets became a popular way of treatment. In Poland, scoliosis treatment and patients’ rehabilitation gained new meaning at the turn of XVII-XIX centuries, when new, fast developing rehabilitation/treatment centers in Krakow, Poznań and Warsaw were opened.

Streszczenie Skolioza idiopatyczna jest chorobą dzieci i młodzieży. W trakcie jej rozwoju można obserwować u pacjenta zmiany zachodzące w trzech płaszczyznach. W płaszczyźnie czołowej występuje wyboczenie, w płaszczyźnie strzałkowej pogłębienie lub spłycenie krzywizn fizjologicznych, a w płaszczyźnie poprzecznej notuje się rotację i torsję kręgów. Leczeniem i rehabilitacją pacjentów ze skoliozą zajmowali się uczeni już w czasach starożytnych. Początkowo były to Key words: scoliosis, treatment, rehabilitation Słowa kluczowe: skolioza, leczenie, rehabilitacja

metody bardzo bolesne i mało skuteczne. Duży rozwój technik leczenia jak i początki rehabilitacji pacjentów ze skoliozą nastąpił na przełomie XVI-XVII w. W kolejnych latach rozkwitły metody leczenia poprzez gorset. W Polsce duży rozwój technik leczenia i rehabilitacji pacjentów ze skoliozą datuje się na przełom XVIII-XIX w. kiedy to powstały prężne ośrodki rehabiltacyjno-lecznicze w Krakowie, Poznaniu i Warszawie.

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Monika Kuczma et. al.

INTRODUCTION Idiopathic scoliosis is a typical, three-dimensional illness of growing children and teenagers. During its development the deformities can be observed in the frontal plane, lateral or thoracic plane (in most cases deepened chest kyphosis is also present) and horizontal plane with rotational deformity [1, 2, 3, 4].

Another great physician, considered the father of orthopedic surgery in the United States, Lewis Albert Sayre treated scoliosis using a hoist (Picture 1)[6].

WORLD HISTORY OF SCOLIOSIS TREATMENT Idiopathic scoliosis has been of interest of the greatest scientists of our times, among others Hyppocrates or Galen, for a long time. Hippocrates of Kos (460-377 BC), considered the father of Western medicine, presented a number of various pioneer theories and descriptions, including lateral curve, in a collection of medical works called: Hippocrates Corpus (‘Corpus Hippocraticum’). One of these was noticing the dependence between the level of spine deformity and the age of the patient when the curve became visible. However, it was a prominent Roman doctor - Galen (129-199) who introduced the term ‘scoliosis’ into the world of medicine. In his great work ‘Ars Parva’ this scientist of Greek ethnicity presented a handmade woodcut showing spine traction and slide. Unfortunately, these early methods of deformities treatment were not only extremely cruel and painful but also hardly effective [4]. Avicenna (Persian physician and philosopher) in his work entitled ‘Qanun’ completed in 1000 AD described and pictured spine positioning. His treatment methods were widely applied until 1700s. The first clinical description of the lateral curve appeared in the sixteenth century works published by a French surgeon Ambroise Paré (1510-1590). This great scientist did not only serve the French kings, treating them and describing various diseases, but also presented clinical descriptions of idiopathic scoliosis and its treatment using a metal corset [4,5]. Francis Glisson (1599-1677), a British scientist and physician, was another doctor treating scoliosis using innovative methods. In his work ‘Rachitis’ Glisson published several theories and methods of scoliosis treatment, nowadays considered the basis of handling with this illness. What is more, he was the inventor of the rehabilitation loop, known as ‘the Glisson’s loop’ which has been widely used in rehabilitation ever since. Its main aim is to stretch the muscles and ligaments along the spine and shoulders.

Pic. 1. Spine traction in scoliosis treatment Ryc. 1. Trakcja kręgosłupa w leczeniu skoliozy

Pic. 2. Posture while learning. Date unknown Ryc. 2. Postawa ciała podczas nauki. Data nieznana

Nicolas Andry de Bois-Regard, a French physician and writer, who played a significant role in the early history of orthopedics, was the inventor of the name ‘posture hygiene’, first used in his great work ‘Orthopédie’ (the name orthopedics derived from it). In his discourse on biomechanics of scoliosis, Andry pointed out that the muscles changes may be the etiological factor of the illness. He underlined the importance of teaching the patients how to maintain the correct posture habits. His approach was the

Treatment and rehabilitation of patients with scoliosis at the turn of the century

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beginning of postural reeducation, nowadays being the basis of posture defects treatment (Picture 2) [6].

Pic. 3. Prototype of orthesis used in scoliosis correction [7] Ryc. 3. Pierwowzór ortezy do korekcji skoliozy [7]

Fast development of idiopathic scoliosis diagnostics and treatment occurred between 1780 and 1880s. The first rehabilitation centers were opened in Florence, Bologna, Paris, Montpelier, Lozanne and Birmingham using innovative treatment methods as well as various tools, equipment and corsets for posture correction (Pictere 3) [7]. It was then, in 1772, that the prototype of Milwaukee corset was designed in Paris by Lavarcher. A few years later, in 1780 a book entitled ‘La gymnastique médicale et chirurgicale’ describing various methods of physical exercises for children with spine deformities, applied in surgery and orthopedics was published by Tissot. In the XIX century a publication of the first catalogues with a variety of corsets appeared (Picture 4,5) [7].

Pic. 4. Various corsets presented by F.W. Braun and co. in 1903 [7] Ryc. 4. Różne modele gorsetów zaprezentowane przez F.W. Braun i spółkę w 1903 [7]

Pic. 5. ‘Corsets for sale’, published by Sears, Roebuck Company Incorporated in 1800s [7] Ryc. 5. „Gorsety na sprzedaż”, wydane przez Sears, Roebuck Company Incorporated w latach 1800-tych [7]

In 1894 corsets done up with laces were presented. (Picture 6,7) [7].

Pic. 6. Corset, 1894, manufactured in Detroit Pharmaceutical Company Ryc. 6. Gorset, 1894, zmontowany w Detroit Pharmacal Company

Pic. 7. Corsets presented by E.H. Bradford and E.G. Brackett in 1880 Ryc. 7. Gorsety przedstawione w 1880 r przez E.H. Bradford and E.G. Brackett

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Monika Kuczma et. al.

The flourish of corset production was at the turn of XVIII and XIX centuries. A true supporter of a passive method of spine correction was Z.B. Adams who designed the first laced corset (Picture 8) [7].

Pic. 8. Corset designed in 1910 by Z. A. Adams as an alternative to metal corsets. [7] Ryc. 8. Gorset zaprojektowany przez Z. A. Adamsa w 1910 r. Jako alternatywa dla gorsetów metalowych [7]

One of the leading opponents of passive correction of spine deformities was Shaw, who believed that exercises were the only effective method of treatment. In his book ‘Curvature of the Spine’ (London, 1825) Shaw described a whole series of exercises correcting spine’s posture as well as hips and ribs’ placement. According to him, these exercises were to show therapeutic properties, improving the overall posture (spine, ribs and limbs) and had to be followed by a series of exercises strengthening the muscles of the back. Another French surgeon, Jacque Mathieu Delpech in his book ‘Orthomorphie’ (1829) advocated the importance of the asymmetric growth of the spine and its influence on the curvature, and promoted using a disc placed between the vertebra as a successful treatment method. His ideas were the first attempts of creating a theory explaining the source of scoliosis. In his treatment Delpech supported both passive and active methods of posture correction, using various equipment in order to relieve the pressure on spine when in horizontal position. He also recommended

swimming as a successful method of treatment and set up a rehabilitation centre for patients with scoliosis. In 1874 Sayre applied plaster cast in horizontal curve correction. His approach was further developed by Bradford and Brackett, who put the cast on when the patient was lying on a special table, using the horizontal hoist at the same time. Swedish school of scoliosis treatment and rehabilitation, led by Henry Ling (1776-1839) developed concurrently. The source of posture deformities was searched for in the muscles structure dysfunction, therefore numerous dynamic exercises, aimed at proper symmetry reinforcement, were introduced. Even though they did not bring the expected results, they surely played a significant role in scoliosis treatment, being one of the first of the preventive measures undertaken to ensure correct posture habits. In 1886 Lorentz realized that in order to successfully treat scoliosis, maximum muscles’ strength had to be achieved, whereas regaining proper spine line in the frontal layer and Swedish exercises were significant only as preventive measures. The beginning of the XX century and the years between the World Wars were dominated by the use of various equipment in posture deformities’ correction. In 1911 Abbot designed a method of hunchback correction by a de-rotation using a frame. This method was further developed by Cortel and then Risser (the father of the so-called ‘Risser’s frame’) in the post war years. In 1946 Boston orthesis and Milwaukee-Blount corsets appeared and were soon popularized. POLISH HISTORY One of the leading Polish scientists, a personal doctor of Stefan Batory, Wojciech Oczko (1537-1599) based his theories of scoliosis treatment on Galen’s. In the XIX century a fast development of rehabilitation centers in Krakow, Poznań and Warsaw started, with gymnastic and orthopedic wards where rehabilitation of posture deformities was widely practiced. Henry Ling’s methods found a number of followers in Poland, among others Helena Kuczalska, who in 1892 set up the therapeutic and gymnastic center which developed into therapeutic and gymnastic and massage school 14 years later, training leading future Polish therapists and instructors.

Treatment and rehabilitation of patients with scoliosis at the turn of the century

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Wiktor Dega, a pioneer in Polish orthopedics and rehabilitation of children was the first person to organize therapeutic and gymnastic classes for pupils in 1930. Seven years later the first department of therapeutic rehabilitation was opened in Bydgoszcz [8]. During 1990s further development of national rehabilitation centers treating posture deformities took place (e.g. ‘Konstancin’ managed by professor Marian Weiss [4].

Address for correspondence: mgr Monika Kuczma Institute and University Department of Rehabilitation Nicolaus Copernicus University Collegium Medicum in Bydgoszcz ul. M. Curie Skłodowskiej 9, 85-094 Bydgoszcz tel. (52) 585-43-30, tel./fax (52) 585-40-42 e-mail: [email protected]

BIBLIOGRAPHY

Received: 18.05.2011 Accepted for publication: 13.02.2012

1. 2.

3. 4. 5. 6.

8. 9.

Kasperczyk T.: Wady postawy ciała, leczenie i diagnostyka. Kraków 2001: 50-51. Nowakowski A., Łabaziewicz L.: Skolioza idiopatyczna – epidemiologia i etiologia. Chir Narzadow Ruchu Ortop Pol 1998; 63(4): 317-320. Kwolek A.: Rehabilitacja medyczna, tom2. Wrocław 2003: 250-256. Wilczyński J. Korekcja wad postawy człowieka. Starachowice 2001: 196-225. Milanowska K., Dega W.: Rehabilitacja medyczna. Warszawa 1999: 228-272. The Pediatric Spine: Principles and Practice New York 1994: 556-557.Farrell-Beck J.: Medical and Commercial Supports for Scoliotic Patients; 1819-1935. Studies in Anatomy and Technology; 1995 11(3): 142-163. Dega W., Marciniak W.: Wiktora Degi ortopedia i rehabilitacja, tom 2. Warszawa 2004: 66-68.


ORIGINAL ARTICLE / PRACA ORYGINALNA

Małgorzata Dabkowska¹, Tadeusz Pracki², Daria Pracka²

THE OBJECTIVE MEASUREMENT OF MOVEMENT VS THE INTENSIFICATION OF ADHD SYMPTOMS IN ASSESSMENT OF PARENTS AND DOCTORS OBIEKTYWNY POMIAR RUCHU A NASILENIE OBJAWÓW ADHD W OCENIE RODZICÓW I LEKARZA

¹Departament of Psychiatry Nicolaus Copernicus University in Torun Collegium Medium in Bydgoszcz Head: Prof. dr hab. Aleksander Araszkiewicz ²Department of Physiology, Nicolaus Copernicus University in Torun Collegium Medium in Bydgoszcz Head: prof. dr hab. n. med. Małgorzata Tafil-Klawe Summary The purpose of this work was the objective actigraphic evaluation of movement at children with ADHD (Attention Deficit Hyperactivity Disorder) in relation to the evaluation of symptom intensification according to their parents (ADHD-RS IV) and a medical qualification to a subtype of ADHD (DSM IV TR). The motor activity of a child was evaluated by means of an actigraph - Actiwatch 4 produced by Cambridge Neurotechnology Ltd. The investigated group consisted of 37 children (32 boys, 5 girls). Results: there were no differences in the activity between the group of

children with recognized ADHD combined subtype and the group of children with recognized ADHD predominantly inattentive subtype observed. More serious attention disorders occur in case of children, who in later hours of the day have the maximum activity intensity. The scores of items evaluating the hyperactivity and impulsiveness did not correlate with the results of activity measurement. The results of actigraphic measurement did not correlate with the evaluation of the activity intensification according to parents.

Streszczenie Celem pracy była obiektywna aktograficzna ocena ruchu u dzieci z rozpoznaniem ADHD w stosunku do oceny nasilenia objawów według rodziców i kwalifikacji lekarskiej do podtypu ADHD. Diagnozę ADHD postawiono zgodnie z kryteriami badawczymi DSM IV TR. Nasilenie poszczególnych objawów ADHD opiekunowie oceniali za pomocą kwestionariusza ADHD Rating Scale-IV wersji dla rodziców. Aktywność ruchową dziecka oceniano za pomocą aktografu Actiwatch 4 firmy Cambridge Neurotechnology Ltd. Grupę badaną stanowiło 37 dzieci (32 chłopców, 5

dziewcząt) w wieku od 7 do 14 lat, średnia wieku 10 lat (SD=2,3). Wyniki: Nie obserwowano różnicy w aktywności między grupą dzieci z rozpoznaniem ADHD podtypu mieszanego a grupą dzieci z rozpoznaniem ADHD podtypu z przewagą deficytu uwagi. Większe zaburzenia uwagi występują u dzieci, które w późniejszych godzinach doby mają maksymalne nasilenie aktywności. Wyniki pomiaru aktograficznego nie korelowały z oceną nasilenia ruchliwości według rodziców.

Key words: Attention Deficit Hyperactivity Disorder, actigraphy, motor activity, parent ratings Słowa kluczowe: zaburzenie hiperkinetyczne, aktograf, aktywność ruchowa, ocena rodziców

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INTRODUCTION Attention Deficit Hyperactivity Disorder (ADHD) is a multi-factor based disorder [1]. In children with ADHD an increase of right hemisphere activation in response to both kinds of questions contrary to health controls was observed [2]. In children with ADHD the dysfunctions of the frontal lobe were diagnosed [3]. Motor hyperactivity is one of the core symptoms of ADHD [4]. Pathophysiologically, it can be understood as a result of an abnormal motor facilitation or inhibition within cortical and subcortical motor circuits. These children have serious problems with the control of their moves, adjustment of the move strength to the situation, limitation of moves in the social situations that require calm behavior. The utterances of people with ADHD are accompanied by numerous hand gestures. The hyperactivity is particularly visible in case of younger patients, but the increased motor readiness still remains in adult life, negatively influencing social functioning. In patients with ADHD some deviations in the movement pattern in response to electro-stimulation were observed [5]. The pathophysiological basis of the motor disorders in patients with ADHD can be deviations of the dopaminergic frontal-striatum circuit. The results prove that ADHD symptoms are significantly connected with neurophysiologic factors. Kids with ADHA have dysfunctions in the brain areas connected with body motor activity – in the temporal lobe, cerebellum, area of sub-cortex [6]. In children with ADHD some deviations in motor functions the basis of which is brain immaturity are observed [7]. The intensification of motor disorders in ADHD was evaluated by the evaluation of the presence of soft neurological symptoms and general physical fitness [8]. In children with ADHD higher intensity of syndrome symptoms is connected with the weakening of the motor fitness. Motor dysfunctions are a significant factor of the risk of more serious or complicated ADHD and higher negative influence on social functioning. Irregularities in the motor activity can be considered factors responsible for interactions between the biological aspect of the disorder and the level of social and family functioning of those children [6]. Sensor integration disorders occur much more often among the patients with ADHD (84.3 %) than in the population of school children (10.3 %) [9, 10]. Patients with ADHD have weakened vestibular functions,

worse performance of activities and movement planning [11]. In children with ADHD, with the help of objective tests evaluating balance, the worse possibilities of keeping the balance of the body were confirmed [12]. Hampering the activity and attention deficit visible in ADHD can be the results of disorders in the frontal-motor connections of the cortex [13]. The Fourth Edition of the Diagnostic and Statistical Manual (DSM-IV) recognizes three subtypes of ADHD: the predominantly inattentive subtype, the predominantly hyperactive/impulsive subtype, and the combined subtype [14]. A recent study suggested that deficits in response inhibition may be related to inattentiveness rather than hyperactive and impulsive behavior, suggesting a differential neuropsychological profile associated with subtypes of ADHD [15]. The purpose of this work was the objective actigraphic evaluation of movement of children with recognized ADHD in relation to the evaluation of the intensification of symptoms according to parents and medical qualification to the sub-type of ADHD. METHODS I. Evaluation of presence and intensity of ADHD ADHD was diagnosed by a child and youth psychiatrics specialist in agreement with the DSM IV TR research criteria [16]. The parents evaluated the intensity of particular symptoms of the Attention Deficit Hyperactivity Disorder by means of the ADHD Rating Scale questionnaire – IV version for parents [17]. The questionnaire for parents - ADHD Rating Scale-IV (ADHD-RS) was filled up during the parents’ visits, most frequently mothers’ visits, at children and youth psychiatrist. ADHD Rating Scale-IV questionnaire (ADHD-RS) version for parents is devoted to the evaluation of problems resulting from ADHD symptoms at children and youth at the age from 4 do 20. It evaluates the ADHD symptoms from the period of last 6 months. It consists of 18 items describing behaviors resulting from the presence of ADHD symptoms. Each item is evaluated in a 4-grade scale describing the frequency of a given behavior – never, rarely, sometimes, often, very often (respectively from 0 to 3 points). The scale is divided into 2 sub-scales concerning separately the attention deficit symptoms and the hyperactivity and

The objective measurement of movement vs the intensification of ADHD symptoms in assessment of parents and doctors

impulsiveness symptoms, and the sum of points of the subscales constitutes the ADHD RS-IV questionnaire result. The scale has a good reliability - test-retest assessed in big groups of children in the United States [17]. The scale norms are adjusted to boys and girls separately and to the age groups (5-7, 8-10, 11-13, 1418) [18]. The interpretation of the results depends on the type and number of symptoms and the intensity of problems. The percentile table serves the interpretation – separately for boys and girls, with the division into age groups and the division into the symptoms of attention deficit and hyperactivity and impulsiveness as well as total score. The values equal to and over the 90 percentile mean the high probability of ADHD diagnosis. In the works of Korean researchers, in which the ADHD RS-IV score was equal to 90 percentile and above, they qualified the patient to ADHD diagnosis. DuPaul suggests that the score between 80 and 90 percentile shows the possibility of ADHD diagnosis, while the score between 93 and 98 percentile indicates ADHD diagnosis [18]. In the Korean researches, in case of using both versions of ADHDRS-IV – for parents and for teachers, the point on 90 percentile had a high value confirming clinical diagnosis of ADHD [19]. According to DSM IV-TR criteria, there were four ADHD subtypes (the combined subtype, the predominantly inattentive subtype, the predominantly hyperactive/impulsive subtype and unspecified subtype) classified in the examined group. II. Motor activeness measurement The motor activity of children was assessed with the help of actigraph. For 72 hours all the examined children wore digital recorders of the motor activity on their wrists - Actiwatch 4 actigraph produced by Cambridge Neurotechnology Ltd. The motor activity was calculated from 72 hours, from 2-minute consecutive measurement periods typical of chronobiological examinations. The times of daily and night activity were isolated. The peak time (an hour out of twenty-four hours) - maximum motor activity (cosine peak) was determined. The first miniature electronic digital actigraph in Poland was constructed in 1987 by the co-author of the research - Tadeusz Pracki [20]. III. Study group The examined group was composed of 37 children at the age from 7 to 14, the average age in the group

13

was 10 years (SD=2.3). The majority of children were boys -32 and there were only 5 girls. The children were outpatients. Almost all children lived in a city with 400000 inhabitants. In most cases the reasons for coming with a child to the Clinic were teachers’ suggestions about the need of diagnosing the difficulties in school functioning. All children had a confirmed intellectual norm. The children from a given group were at the moment of diagnosing, parents’ and teachers’ psycho-education, and before including into therapeutic groups and possible pharmacotherapy. Among 37 children, the diagnosis of the combined subtype ADHD was the most frequent (86 %), while there was only 14 % of the predominantly inattentive subtype. IV. Statistical analysis The test results were subject to statistic evaluation. There was a packet of statistic tests - SPSS for Windows, version 13.0 used. Test for independent variables: t-test and Pearson’s correlation coefficient was used. RESULTS According to DSM IV TR, all examined children met the diagnostic ADHD criteria. The total scoring of the ADHD RS-IV scale above the 90 percentile (93 and 98), which shows undoubted ADHD diagnosis, was noted in case of 72 % children, and equal to the 90 percentile or above the 80 percentile in case of 28 %. In 80.5 % of children the scoring of the subscale concerning the attention deficit was over the 90 percentile. The score of the subscale of hyperactivity/impulsiveness in 66.6 % of the group corresponded to 93 or 98 percentiles. The average intensity of scoring in the ADHD-RS questionnaire form for parents was 37.3 points (SD= 10.6), minimum 18 points, and the maximum scoring amounted to 53 points. The average intensity of the sum of the item scorings concerning the attention deficit symptoms in the group was 22 points (SD= 8.0), and the average intensity of items concerning hyperactivity and impulsiveness amounted to19.9 points (SD= 9.1). The average intensity of scoring in the ADHD RS-IV questionnaire form was significantly higher in the group of children with the combined subtype of ADHD than in the group of children with the majority of attention deficit symptoms (table I). The average intensity of ADHD symptoms was similar in the group


14

of younger children (below 10) in comparison to the group of older children (table I). There was no difference in the intensity of average scoring of the ADHD RS-IV scale at boys in comparison to girls observed (table I). Table I. Intensification of ADHD symptoms depending on the sub-type of the disorder, sex and age ADHD RS-IV points Mean SD Subtype Combined Inattentive Age 10 years Boys Girls

39.6

9.1

22.6 38.3 36.7 36.8 40.8

8.4 8.3 12.1 11.1 6.3

t

df

P

3.93

35

0.000*

35

0.651

35

0.446

0.457 0.771

Table II. Average results of activity measurement by means of actigraph at children with ADHD diagnosis taking into account the ADHD sub-type Whole group SD 98.3 148.5 9.8 17.4 1.4

ADHD subtype Inattentive Mean SD 139.2 124.0 203.6 185.5 11.7 5.6 21.2 13.7 12.9 1.6

Boys Mean 146.6 206.9 12.6 25.5 13.7

SD 102 154.4 10.4 17.9 1.4

Girls Mean 138.4 203.4 8.5 29.1 14.2

SD 78.5 117.8 4.6 15.1 1.1

Difference P 0.866 0.961 0.396 0.675 0.462

Independent samples t-test

Average intensity of attention deficit was similar in case of boys (22.1points) and girls (21 points) (P=0.764); the intensity of hyperactivity and impulsiveness in case of boys (19.8 points) and girls (19.8)(P=0.446; independent - sample test) was also similar. No difference in the activity measured by means of hand moves measurement was observed between the group of children with recognized ADHD of combined sub-type and the group of children with recognized ADHD predominantly inattentive (table II). Between the ADHD sub-types there were no differences in the results of average 3-day activity, daily and night activity and in the relation of daily to night activity and cosine peak activity.

Mean 145.5 206.5 12.0 25.9 13.9

Measurement by actigraph activity average daily night daily/night cosine peak

Difference

Independent samples t-test, *- significant difference

Actigraphic measurement activity average daily night daily/night cosine peak

Table III. Average results of activity measurement depending on sex

ADHD subtype Combined Mean SD 152.2 96.3 214.2 146.0 12.2 11.1 28.1 18.5 14.1 1.3

Difference P 0.767 0.874 0.911 0.371 0.075

Independent samples t test

Average results of the boys’ and the girls’ activity measurement did not differ (table III). No differences between the intensity of average activity, daily activity and night activity were noticed in the group of younger children in comparison to the group of older children (below and over 10)(table IV).

Table IV. Average values of activity in the group of younger and older children Measurement Age with actigraph < 10 years Activity Mean SD Average 170.5 122 Daily 249.7 178 Night 11.9 11.2 Daily/night 28.3 14.5 Cosine peak 14.0 0.88 Independent samples t-test

Age >= 10 years Mean SD 127.6 75 175.6 117 12.1 9.0 24.3 19.4 13.7 1.7

Difference P 0.201 0.142 0.946 0.507 0.566

Also the results of the objective measurement of the 24-hour motor activity (P= 0.499), daily activity (P= 0.329) and night activity (P= 0.659) did not considerably correlate with age (Pearson correlation). A The intensification of the total score of the ADHD RS-IV questionnaire for parents did not correlate with the intensification of hand moves measured by actigraph (table V). The considerable positive correlation was observed between the intensification of attention deficits evaluated in the middle of the ADHD RS-IV questionnaire for parents and the increase in the value of cosine peak (table V). The cosine peak value in the actigraphic measurement shows the time of twenty-four hour peak activity. The scorings of items evaluating hyperactivity and impulsiveness did not correlate with the results of hand moves during three days of daily and night activity or the measurement of cosine peak (table V). The correlations between the intensification of particular symptoms evaluated in 18 items of the ADHD RS-IV questionnaire and the average twentyfour hour, daily, and night activity, the relation of the daily activity to night-time activity and cosine peak activity were studied. No significant correlation between the results of the activity measurement and the intensity of particular ADHD symptoms was found. No significant correlation between the results of objective movement measurement and items concerning hyperactivity in relation to the symptoms of attention disorders was noted (table VI).


No difference in average measurements of 24-hour activity, daily activity or night activity at children having the total scores gained in ADHD RS-IV scale over the 93 percentile, or in sub-scale concerning attention deficit as well as in the subscale describing hyperactivity was noted (table VII). The intensification of symptoms in ADHD RS-IV scale over 93 percentile is connected with a reliable disorder diagnosis. Table V. The correlation between activity and the intensification of all ADHD symptoms, symptoms of hyperactivity and symptoms of attention disorders

Actigraphic measurement average activity daily night daily.night cosine peak

ADHD RS ADHD RS Attention deficit Hyperactivity/impulsiveness items items r P r P -0.052 0.765 0.210 0.220 -0.091 0.596 0.192 0.261 0.158 0.359 0.119 0.491 -0.144 0.402 -0.021 0.902 0.349 0.057* 0.211 0.216

ADHD RS-IV r -0.075 -0.120 0.071 -0.087 0.311

P 0.665 0.487 0.681 0.616 0.065

Pearson correlation test; r- correlation coefficient; * relevance on the 0.05 level

Table VI. The correlation between the intensity of particular symptoms of ADHD and the results of movement measurement by actigraph Number of Item ADHD RS-IV 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

average 72-hour activity r -0.080 -0.12 0.020 -0.081 -0.031 -0.101 -0.120 -0.287 -0.157 -0.142 -0.060 -0.001 -0.031 -0.080 -0.120 0.119 -0.024

P 0.643 0.487 0.909 0.637 0.858 0.560 0.487 0.090 0.361 0.409 0.727 0.997 0.856 0.642 0.487 0.488 0.890

daily activity r -0.119 -0.086 0.071 -0.017 -0.086 -0.136 -0.160 0.310 -0.117 -0.164 -0.098 -0.048 -0.030 -0.080 -0.112 0.079 -0.054

P 0.491 0.617 0.682 0.498 0.619 0.428 0.350 0.066 0.498 0.340 0.571 0.783 0.862 0.642 0.514 0.646 0.756

night activity r 0.014 -0.220 -0.090 -0.024 0.020 -0.115 -0.068 -0.266 -0.145 -0.192 0.065 0.042 0.029 0.121 -0.074 0.066 -0.076

P 0.937 0.197 0.601 0.889 0.906 0.504 0.696 0.116 0.398 0.261 0.707 0.807 0.867 0.481 0.669 0.704 0.661

Pearson correlation test; r- correlation coefficient; uneven items concern attention deficit, even items concern the symptoms of hyperactivity/impulsiveness

15

Table VII. The average result of activity measurement in the group of children with the intensity of scoring over and below 93 percentile Total score Mean activity

24 hours Daily Night Light/dark

Inattention

Hyperactivity/Impulsivity

=93rd =93rd %ile %ile P %ile %ile P Mean Mean Mean Mean (SD) (SD) (SD) (SD) 125.2 153.2 0.452 145.6 145.4 0.996

=93rd %ile Mean (SD) 158.4

(105.7) (96.2)

(98.9)

(97.4)

215.3

183.4

(146.8)

(158)

10.04

12.8

(6.4)

(10.9)

25.6

26.1

(18.6)

(17.ł)

Cosine

13.1

14.1

peak

(1.7)

(1.1)

(114.1) (96.3) 0.571 0.456 0.945 0.129

213.8

204.7

(170.2)

(146)

11.11

12.2

(5.8)

(10.6)

20.7

27.2

(10.5)

(18.6)

13.1

14.0

(1.5)

(1.3)

0.887 0.785 0.336 0.167

174.1

(222.6

(147)

(149.3)

12.1

11,9

(6.5)

(11.3)

19.7

29.07

(14.8)

(18.1)

13.5

14.0

(1.9)

(1.0)

P 0.269 0.363 0.964 0.134 0.425

Independent samples t-test

DISCUSSION Average scoring in the ADHD RS-IV questionnaire was significantly higher in the group of children with the mixed subtype of ADHD than in the group of children with the majority of attention deficit symptoms. No difference in the activity evaluated with the help of hand moves measurement between the group of children with recognized ADHD combined type and the group of children with recognized ADHD predominantly inattentive was observed. Dane’s et al. compared subtypes of ADHD on an objective measure of activity level (actigraphy) and noted that there were no significant group differences in activity level in the morning session. During the afternoon session, children with ADHD were significantly more active than controls, but there were no differences between ADHD subtypes [21]. The results of the measurement of the boys’ and the girls’ activity did not differ. Due to a gender unbalance in the study group (a very limited number of females) it was impossible to determine differences in severity of activity in girls and boys. According to some authors, sex may not correlate with an ADHD subtype [22]. In the actigraphic measurement no difference in the intensity of physical activity in the group of younger children in comparison to older kids was observed. In some works any no correlation of ADHD symptoms with age or motor dysfunctions was observed [6]. A significant positive correlation was observed between the intensification of attention deficit evaluated in the middle of the ADHD RS-IV questionnaire for parents and the increase of the cosine peak value, i.e. the time

16


of maximum activity during the measurement. The later time of the peak of 24-hour activity was, the bigger the attention deficit was. The ADHD subtype can have bigger influence on the course of illness and co-morbidity than the sex or age of a child [22]. The evaluation of ADHD subtypes is based on the impression of surroundings (parents, teachers, doctor). The people evaluating the patient can see problems resulting more from the attention deficit or hyperactivity. The objective actigraphic measurement shows that the intensification of hand moves is similar in both subtypes - in children in whom attention disorders dominate and in those who above all show motor disturbances. The actigraph evaluates hand gesticulation which in the examined group is similar in both subtypes, similar among boys and girls (males dominated in the group), similarly in younger and older children. The literature proves that hyperactivity decreases with age, however the gesticulation remains on the similar level in case of children at different ages in the examined group. The excessive gesticulation can disturb the performance of complex activities (such as for example driving a car). CONCLUSIONS The results of the actigraphic measurement did not correlate with the evaluation of activity intensity according to parents. In the studied group no differences in the movement intensity between the combined sub-type and the attention deficit sub-type of ADHD were observed. More serious attention disorders occurred in children who in later hours (of 24-hours) had the maximum activity intensity.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

REFERENCES 1. Dabkowska M (2002) Risk factors in attention deficit hyperactivity disorder. Psychiatria i Psychologia Kliniczna 2:102-114. 2. Dabkowska M, Borkowska A (2000a) Hemispheric activation in children with ADHD (in Polish). In: Zaburzenia psychiczne dzieci i młodzieży: wybrane zagadnienia (Namysłowska I, ed). Biblioteka Psychiatrii Polskiej, Kraków, Poland, 35-39. 3. Dabkowska M, Borkowska A (2000b) Neuropsychological assessment of frontal dysfunction in child and adolescent with ADHD (in Polish). In: Zaburzenia psychiczne dzieci i młodzieży: wybrane

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zagadnienia (Namysłowska I, ed). Biblioteka Psychiatrii Polskiej, Krakow, 41-46. Biederman J (2005) Attention-deficit/hyperactivity disorder: a selectiveoverview. Biol Psychiatry 57:1215– 1220. Ben-Pazi H, Gross-Tsur V, Bergman H, Shalev RS (2003) Abnormal rhythmic motor response in children with attention-deficit–hyperactivity disorder. Dev Med Child Neurol 45:743-745. Gustafsson P (2008) Bio-social aspects of Attention Deficit Hyperactivity Disorder (ADHD): Neurophysiology, maturity, motor function and how symptoms relate to family interaction. Lund University. Gustafsson P, Thernlund G, Besjakov J, Karlsson M, Ericsson I, Svedin CG (2008) ADHD symptoms and maturity – a study in primary school children. Acta Paediatr 97: 233-238. Ericsson I (2008) Motor skills, attention and academic achievements - an intervention study in school year 1-3. Br Educ Res J 34:301-313. Guo P，Guo H，Yang CH, et al. (1999) Sensory Integra-tion Therapyon Attention Deficit HyperactivityDis-order.Chinese J Behav Med Sci 8:306306. Ren GY, Wang YF, Gu BM, et al.(1995) Investigation on prevalence of sensory integration dysfunction in1994 school children in a Beijing urban area. Chinese J Ment Health 9:70-73. Mulligan S (1996) An analysis of score patterns of children with attention disorders on the Sensory Integration and Praxis Tests. Am J Occup Ther 50:647654. Zang Y, Bomei Gu, Qian Q, Wang Y (2002) Objective Measurement of the Balance Dysfunction in Attention Deficit Hyperactivity Disorder Children. Chin J Clin Rehabil 6: 1372-1374. Niedermeyer E, Naidu SB (1997) Attention-deficit hyper-activity disorder (ADHD) and frontal-motor cortex disconnection. Clin Electroencephalogr 28:130-136. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edition (DSMIV) Washington DC. Chhabildas N, Pennington BF, Willcutt EG (2001) A comparison of the neuropsychological profiles of the DSM-IV subtypes of ADHD. J Abnorm Child Psychol 29:529 –540. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders: DSM-IV-TR Fourth Edition Text Revision. DuPaul GJ, Anastopoulos AD, Power TJ, Reid R, McGoey MJ, McGoey KE (1998a) Parent Ratings of Attention-Deficit/Hyperactivity Disorder Symptoms: Factor Structure and Normative Data. J Psychopathol Behav Assess 20:83-102. DuPaul GJ (1991) Parent and teacher ratings of ADHD symptoms: psychometric properties in a community based sample. J Clin Child Psychol 20:245-53. Kim JW, Park KH, Cheon KA, Kim BN, Cho SC, Hong KEM (2005) The Child Behavior Checklist Together


With the ADHD Rating Scale Can Diagnose ADHD in Korean Community-Based Samples. Can J Psychiatry 50: 802–805. 20. Pracki T, Jurek K, Pracka D (1989) Aktograf - rejestrator aktywności ruchowej. Probl Techn Med. 20:93–98. 21. Dane AV, Schachar RJ, Tannock R (2000) Does Actigraphy Differentiate ADHD Subtypes in a Clinical Research Setting? JAACA 39:752-760. 22. Byun H, Yang J, Lee M, Jang W, Yang JW, Kim JH, Hong SD, Joung YS (2006) Comorbidity in Korean Children and Adolescents with Attention-Deficit Hyperactivity Disorder: Psychopathology According to Subtype. Yonsei Med J 28:113–121.

Address for correspondence: [email protected] tel.: 48 (52) 5854270 fax: 48 52 5853766


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ORIGINAL ARTICLE / PRACA ORYGINALNA

Jerzy Eksterowicz, Marek Napierała

MORPHOLOGICAL PARAMETERS OF PHYSICAL EDUCATION STUDENTS IN THE YEARS 2006-2010 PARAMETRY MORFOLOGICZNE STUDENTÓW WYCHOWANIA FIZYCZNEGO W LATACH 2006-2010

The Institute of Physical Education, Kazimierz Wielki University in Bydgoszcz Head: dr hab. Mariusz Zasada, prof. nadzw. UKW

Summary The body construction of an adult person depends on a variety of factors. First of all, it is determined genetically – at the moment of conception every human organism receives a set of an equal amount of chromosomes from the father and the mother with genes that convey "instructions" about the developmental features of the system. The human growth is not a uniform process. It is characterised by a great diversity in terms of qualitative and quantitative changes and the intensity level of the processes in time. Ontogenetic development of a man is an ordered system of some specific developmental changes leading to the formation of human beings adapted to living in particular conditions and able to

extend the existence of mankind. The direction of these processes is determined by inherited factors, surrounding environment and so-called behaviourism, which can be described as the behaviour of an individual in particular conditions. The aim of this study was to determine the selected body parameters of 279 first-year students (179 men and 100 women) of physical education (stationary studies) at the Kazimierz Wielki University in Bydgoszcz. The research of morphological characteristics was conducted in the period of 2006-2010 and its results were presented in tables. They document the changes in morphological construction.

Streszczenie Budowa ciała dorosłego człowieka zależy od wielu czynników. Przede wszystkim uwarunkowana jest genetycznie, gdyż organizm w momencie poczęcia otrzymuje w równym stopniu od ojca i matki zestaw chromosomów, w których rozmieszczone są geny zawierające „instrukcje” o właściwościach rozwojowych ustroju. Rozwój konstytucjonalny człowieka nie jest procesem jednostajnym. Charakteryzuje go duża różnorodność pod względem zmian ilościowych i jakościowych oraz stopnia natężenia zachodzących procesów w czasie. Ontogenetyczny rozwój człowieka polega na uporządkowanym systemie przebiegu pewnych specyficznych zmian rozwojowych zmierzających do ukształtowania się osobników przystosowanych do życia

w danych warunkach i zdolnych do przedłużenia istnienia gatunku. Kierunek tych procesów jest określony czynnikami dziedziczonymi, warunkami otaczającego środowiska oraz tzw. behawioryzmem czyli postępowaniem, zachowaniem się samego osobnika w danych warunkach. Celem niniejszych badań było określenie wybranych parametrów ciała 279 studentów I roku (179 mężczyzn i 100 kobiet) z kierunku wychowania fizycznego studiów stacjonarnych Uniwersytetu Kazimierza Wielkiego w Bydgoszczy. Badania cech morfologicznych przeprowadzono od 2006-2010 roku, a wyniki przedstawiono tabelarycznie. Dokumentują one zmiany budowy morfologicznej.

Key words: morphological construction, physical education students Słowa kluczowe: budowa morfologiczna, studenci wychowania fizycznego

20


INTRODUCTION The body construction of an adult person depends on a variety of factors. First of all, it is determined genetically – at the moment of conception every human organism receives a set of an equal amount of chromosomes from the father and the mother with genes that convey "instructions" about the development features of the system. The contained information shapes the growth of an individual; the genetic factors and environmental conditions influence the development in a comparable degree – initially, in the prenatal life, when the external environment for the developing embryo (and then foetus) is the uterus of the mother, and then during the post prenatal life as widely understood environmental conditions. Moreover, there is a third factor affecting the development of an individual, which is called behaviourism – it can be described as a widely understood behaviour of an individual. Its importance for the organism development grows over time, as well as with acquired experiences and knowledge. In the opinion of many researchers, these three factors shape all somatic, functional and mental features of people (Eksterowicz, Napierała 2007; Wolański 2006; Malinowski 1994). Looking at the sizes of selected morphological features among physical education students; both retardation and excessive development of certain morphological values in comparison with the average values in the population can be observed. The knowledge obtained from these researches allows selecting appropriate didactic resources to support students efforts aimed at maintaining good health, as well as specifying risky areas in the somatic construction from the perspective of maintaining good health of an individual and the whole population (obesity, lipohyperplasia, proneness to anorexia, etc.). The aim of this research was to specify the size of selected morphological features and body composition of physical education students at the Kazimierz Wielki University in Bydgoszcz in the period of last five years, separately for each year, and to compare these parameters both in a one-year and a five-year scale. MATERIAL AND METHODS The researches were carried out among 279 stationary students of physical education (179 men and 100 women) aged 19 - 26 years at the Kazimierz Wielki University in Bydgoszcz in the period from

2006 to 2010. There was one research per year, carried out in July during the summer sports camp. All students were examined according to the following anthropometric measurements (cm): body height (V B), arm length (a - r), forearm length (r - sty), upper limb length (a - da III), leg length (tro - B), foot length (ap - pte), shoulder width (a - a), hip width (ic - ic), pelvis width (is - is), arm width (mm - mu), hand width (mr - mu), foot width (mtt - mtf). Moreover, the circumferences of the following body parts were measured (cm): chest at full inspiration and expiration, waist, flexed and unflexed arm, thigh and calf. The proper body mass was specified as well (kg). In addition to that, the thickness of three skinfolds were measured (mm), which are located: over the triceps muscle (TSF) (triceps skinfold), vertical skinfold, under the lower angle of the shoulder blades (SCSF) (subscapular skinfold), horizontal skinfold, and over the iliac crest (SISF) (suprailiac skinfold), oblique skinfold. Based on those measurements, the following indicators were calculated: BMI (Body Mass Index, kg/m2), AMC (Arm Muscle Circumference), WHR (Waist to Hip Ratio), body fat mass (FM) (kg), percent body fat (FM) (%) and lean body mass in kilograms and percentage (FFM) (kg), (FFM) (%) (Drozdowski 1998, 2002). For the indices interpretation the following elements were calculated: - BMI (for women and men): below 19.0 – body mass deficit; between 19.0 and 25.0 – proper body mass; from 25.1 to 29.9 – overweight; over 30.0 – obesity; - it was assumed that the border value of the WHR index, over which the obesity is observed, is: 0.95 for men and 0.85 for women; - the criteria of AMC evaluation: the degree of aluminous nutrition was calculated according to the formula: arm circumference – (3.14 x the thickness of the dermal-aliphatic skinfold over the triceps), the following values were assumed: good aluminous nutrition – men > 22.8, women > 20.9; slight malnutrition – men: 22.7-20.2, women: 20.8-18.6; moderate malnutrition – men: 20,1-17,7, women: 18,516,2; heavy malnutrition – men < 17.7, women < 16.2; - the Rohrer index, specifying it with the Curtis Key and the Kretschmer characteristics: x – 1.27 leptosomatic type, 1.28 - 1.49 athletic type and 1.50 – x pyknic type; - the Pignet rate and the index values were ranked on the basis of Polish materials and sources from the

Morphological parameters of physical education students in the years 2006-2010

researches of candidates to the physical education studies (Drozdowski 2002, p. 118). The calculations were carried out according to the formula: I = the body height – (mass + chest circumference). The following criteria were assumed: Criteria (Kryteria) Very strong construction (Budowa bardzo mocna) Strong construction (Budowa mocna) Medium construction (Budowa średnia) Weak construction (Budowa słaba) Very weak construction (Budowa bardzo słaba)

men (mężczyźni)

women (kobiety)

x - 7.7

x - 18.8

7.8 - 12.5

18.9 - 22.5

12.6 - 22.1

22.6 - 30.0

22.2 - 26,9

30.1 - 33.8

27 – x

33.9 - x

- torso index: I = (torso length : body height) x body height Criteria (Kryteria) Long torso (Długi tułów) Medium torso (Średni tułów) Short torso (Krótki tułów)

men (mężczyźni) 31.3 - x 29.6 - 31.2 x - 29.5

women (kobiety) 30.8 – x 29.5 - 30.7 x . 29.4

- shoulder index: I = (shoulder width : torso length) x 100 Criteria (Kryteria) Narrow shoulders (Barki wąskie) Medium shoulders (Barki średnioszerokie) Broad shoulders (Barki szerokie)

men (mężczyźni) x - 70.1

women (kobiety) x - 72.6

70.2 - 76.5

72.7 - 77.2

76.6 - x

77.3 - x

- pelvic index: I = (pelvis width : shoulders width) x 100 Criteria (Kryteria) Narrow pelvis (Miednica wąska) Medium pelvis (Miednica średnioszeroka) Broad pelvis (Miednica szeroka)

men (mężczyźni) x - 71.5

women (kobiety) x - 79.3

71.6 - 76.1

79.4 - 84.5

76.2 - x

84.6 - x

- arm musculature index: I = (circumference : length) x 100 – Men: slender arm > 77.1, stocky arm < 77.2, women: slender arm > 76.0, stocky arm < 76.1 (Drozdowski 1998, 2002).

The measurements were made using the portable medical scale – model: TANITA BF 662M and the anthropometric tool-kit (anthropometer, anthropometric tape, skinfolds meter) produced by a Swiss company – Siber Hegner & Co. Ltd. (Drozdowski 1998, 2002). From these measurements the mean values and standard deviations were calculated and the statistical inference was conducted by comparing the tested parameters. TEST RESULTS ANALYSIS This paper is of diagnostic nature, so the researches were focusing on solving problems on the example of specified population and in the particular time horizon. Hence, no research hypothesis was formulated that would go beyond the factual materials. The assumptions about the relative somatic homogeneity of respondents were made, which allows interpreting possible developmental differences in the light of the environmental variety.

Table

21

I.

Comparison of values of morphological measurements in men between 2006 and 2010 Tabela I. Charakterystyka somatyczna (wielkości średnie i odchylenia standardowe) studentów (mężczyzn) na przestrzeni lat 2006=2010 Tested feature

2006 N=41

X Body height (Wysokość ciała) (cm) Body mass (Masa ciała) (kg) Subscapular skinfold (Fałd pod łopatką) (mm) Skinfold over triceps (Fałd nad tricepsem) (mm) Suprailiac skinfold (Fałd nad biodrem) (mm) Skinfolds in total (Suma fałdów) (mm) Arm length (Dł. ramienia) (a-r) Forearm length (Dł. przedramienia) (r-sty) Upper limb length (Dł. kończyny górnej) (a-daIII) Leg length (Dł. kończyny dolnej) (tro-B) Foot length (Dł. stopy) (pte-ap) Shoulders width (Szer. barków) (aa) Hips width (Szer. bioder) (ic-ic) Pelvis width (Szer. miednicy) (is-is) Arm width (Szer. ręki) (mm-mu) Palm width (Szer. dłoni) (mr-mu) Foot width (Szer. stopy) (mtt-mtf) Chest circumference (inspiration) (Ob. klatki piersiowej wdech) (cm) Chest circumference (expiration) (Ob. klatki piersiowej wydech) (cm) Waist circumference (Ob. pasa) (cm) Hips circumference (Ob. bioder) (cm) Arm circumference (flexed) (Ob. ramienia napiętego) (cm) Arm circumference (unflexed) (Ob. ramienia bez napięcia) (cm) Thigh circumference (Ob. uda) Calf circumference (Ob. łydki) Torso length (Dł. tułowia) (tro-a)

2007 N=37 S

X

S

2008 N=32

X

S

2009 N=43

X

2010 N=26 S

X

S

180.58 6.07 180.5 7.79 181.0 8.01 `180,0 5,0 181.4 6.01 76,31 8.10 76.3 8.43 76.7 9.70 77.6

9.6 76.7 7.91

9,91 2.51 10.38 2.08 10.81 2.61 10.50 2.60 10.41 1.91 6.51 2.92 8.08 2.77 9.0 2.01 10.3

2.7 8.62 2.32

8.41 3.02 9.37 4.08 10.5 3.3

10.7

2.9 9.11 2.32

27.5 6.10 27.83 5.34 30.3 6.70 31.5

7.6 28.01 5.34

30.48 2.87 30.10 3.13 32.51 2.51 32.40 2.78 32.52 1.63 25.85 1.62 26.75 2.05 27.43 1.86 25.86 2.49 27.84 2.33 79.25 3.04 81.20 5.76 79.45 3.95 79.17 4.72 80.18 3.86 90.86 3.88 96.00 5.68 91.88 3.89 91.08 4.72 90.77 4.69 26.85 2.78 27.02 3.05 27.15 1.51 26.46 1.18 26.81 1.34 40.40 2.26 43.15 2.05 43.07 1.89 43.19 2.48 42.43 2.14 29.05 1.34 30.95 1.88 30.59 2.19 31.08 2.32 29.78 1.94 23.36 1.59 24.87 1.41 24.23 2.29 24.88 1.96 24.02 1.41 10.77 0.99 10.92 1.12 10.93 0.64 10.75 0.64 11.14 0.63 8.77 0.54 8.86 0.61 8.78 0.64 8.57 0.55 8.62 0.42 10.17 0.39 10.32 0.42 10.14 0.67 10.43 0.50 10.44 0.67 101.9 5.82 96.5 5.92 97.31 4.99 100.61 6.31 97.04 4.30

94.08 5.33 90.55 6.02 91.82 5.53 93.62 3.03 91.15 3.90

80.96 3.54 81.2 5.76 78.02 5.32 82.69 6.78 79.35 4.62 93.37 6.03 96.0 5.68 95.53 6.15 96.14 4.79 93.85 5.70 34.04 2.63 30.1 3.13 32.78 2.28 33.74 3.28 33.40 1.95

30.04 1.61 29.05 0.65 29.93 2.67 29.85 2.83 29.74 1.70 55.60 3.63 54.80 3.05 52.93 3.77 56.21 3.83 55.57 3.60 37.42 2.11 36.95 3.08 36.78 2.82 38.22 2.45 37.30 2.45 56.02 3.36 56.39 3.57 56.71 3.12 57.01 3.33 57.10 2.97

N – numbers, X – average value, S – standard variation (source: own study) (źródło: opracowanie własne)

This assumption is a reasonable condition due to the similar sizes of the researched individuals that occur both within a one-year and a five-year scale.


22

Table II. Comparison of values of morphological measurements in women between 2006 and 2010 Tabela II. Charakterystyka somatyczna (wielkości średnie i odchylenia standardowe) studentek (kobiet) na przestrzeni lat 2006 – 2010 Tested feature

2006 N=25

X

Body height (Wysokość 169.83 ciała) (cm) Body mass (Masa ciała) 63.82 (kg) Subscapular skinfold (Fałd 12.10 pod łopatką) (mm) Skinfold over triceps (Fałd nad tricepsem) 11.80 (mm) Suprailiac skinfold (Fałd 12.40 nad biodrem) (mm) Skinfolds in total (Suma 37.30 fałdów) (mm) Arm length (Dł. ramienia) 28.25 (a-r) Forearm length (Dł. przedramienia) 26.00 (r-sty) Upper limb length (Dł. kończyny 71.38 górnej) (adaIII) Leg length (Dł. kończyny 82.98 dolnej) (tro-B) Foot length (Dł. stopy) 24.68 (pte-ap) Shoulders width (Szer. 36.49 barków) (a-a) Hips width (Szer. bioder) 29.39 (ic-ic) Pelvis width (Szer. miednicy) (is- 23.78 is) Arm width (Szer. ręki) 9.65 (mm-mu) Palm width (Szer. dłoni) 7.94 (mr-mu) Foot width (Szer. stopy) 9.32 (mtt-mtf) Chest circumference (inspiration) 90.44 (Ob. klatki piersiowej – wdech) (cm) Chest circumference (expiration) 89.02 (Ob. klatki piersiowej – wydech) (cm) Waist circumference 72.59 (Ob. pasa) (cm) Hips circumference 95.60 (Ob. bioder) (cm) Arm circumference (flexed) (Ob. 28.61 ramienia napiętego) (cm) Arm circumference (unflexed) (Ob. 26.06 ramienia bez napięcia) (cm) Thigh circumference 56.38 (Ob. uda) Calf circumference 38.71 (Ob. łydki) Torso length (Dł. tułowia) 52.01 (tro-a)

S

2007 N=18 S

X

2008 N=18

X

S

2009 N=21 S

X

2010 N=18 S

X

4.80 170.0 4.97 170.01 7.02 169.0 6.0 167.4 8.02 7.40 63.7 6.66 64.3 6.36 63.0 7.97 65.72 6.52 4.00 12.78 4.33 14.20 5.55 13.75 6.1 11.81 2.95 2.90 14.34 4.28 12.9 3.72 15.1 2.76 12.32 2.99 3.30 13.71 4.45 10.21 2.71 12.0 2.82 12.31 3.19 3.50 40.83 5.01 34.21 8.01 39.70 6.11 36.50 7.80 2.25 26.0 2.27 29.04 1.65 32.09 3.47 30.82 2.62 1.30 26.05 1.23 25.65 1.78 23.81 1.99 24.69 1.96

3.95 74.30 4.02 72.48 3.64 74.13 4.24 72.79 3.99 4.75 86.10 5.15 86.85 6.23 85.85 4.94 83.73 6.87 1.20 24.70 1.18 25.19 1.30 24.45 1.37 24.23 1.37 1.33 37.55 1.98 39.61 1.56 38.86 2.65 37.44 2.53 1.75 31.80 2.88 32.62 3.32 30.51 1.95 30.56 1.96 1.74 23.77 1.67 23.97 2.36 24.77 1.92 24.11 1.55 0.81 9.87 0.77 9.59 0.35 9.78 0.49 9.75 0.48 0.19 7.78 0.30 7.79 0.28 7.80 0.37 7.91 0.48 0.20 9.36 0.35 9.35 0.52 9.30 0.45 9.31 0.50

4.59 93.80 4.93 91.81 5.22 93.38 5.17 94.73 4.23

4.24 88.90 4.98 87.66 4.62 88.65 5.78 90.84 4.33

5.23 75.2 6.64 71.57 3.45 76.03 6.50 74.89 6.04 4.45 96.30 5.04 97.11 5.43 94.47 5.82 95.28 4.57

2.15 28.01 1.90 28.35 1.71 28.49 2.31 28.11 1.70

2.03 26.40 1.35 26.76 1.69 26.20 2.39 25.87 1.38 3.74 55.10 4.08 54.70 3.04 53.05 3.66 53.02 2.36 2.08 37.12 2.05 36.68 1.72 36.83 2.73 36.09 1.72 3.22 52.36 3.63 52.45 2.89 52.32 2.77 51.44 2.64

N – numbers, X – average value, S – standard variation (source: own study) (źródło: opracowanie własne)

The average results of many somatic factors that were studied in different years do not differ too much from each other. It may result from the specific uniformity of the researched group whose members practise sports from their early childhood and as students of physical education they still continue to participate actively in physical activities. Such a lifestyle causes that they have slim and well-built bodies, which are desirable in sport (mass or professional). The following tables present the somatic characteristics of the students who took part in the research. These results may be a material for comparison for all people who deal with anthropology. The presented research results in men showed that the average BMI for all collated years was within limits for proper body mass. Also the average WHR demonstrated that there was no example of obesity in those years. The criteria of AMC evaluation indicated the medium/good nutrition. The average scores of body slenderness ratio defined by Rohrer index and Kretschmer characteristics were within 1.28 - 1.33, which indicates the athletic types. The Pignet index values proved that in 2006, 2008 and 2009 men had strong body construction, while in 2007 and 2001 it was medium (Table III). In the years 2006 and 2007, the torso index demonstrated a medium body length, while in the remaining years it showed high body length among the students. The researched group of students had medium shoulders in 2006, 2007 and 2010, and broad shoulders in 2008 - 2009. When reading the calculated average pelvis width, it can be concluded that in all those years the students had narrow pelvis. In all researched years the students had stocky arms (Table III). Table III. Numerical characteristics of selected somatic indices of men (source: own study Tabela III. Charakterystyka liczbowa wybranych wskaźników somatycznych mężczyzn) (źródło: opracowanie własne) Year of BMI WHRAMC Pigneta Rohrera Torso Shoulder Pelvic Arm study (Rok index index index Index index muscle badań) (Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik index Pigneta) Rohrera) tułowia) barków) miednicy) (Wskaźnik umięśnienia ramienia) 2006 23.3 2007 23.41 2008 23.40 2009 24.0 2010 23.6 All 23.54 (Wszystkie)

0.85 0.84 0.82 0.86 0.84

27.20 27.50 27.11 26.61 29.46

10.19 13.65 12.48 8.78 13.55

1.30 1.30 1.28 1.33 1.31

31.02 31.24 31.33 31.56 31.70

72.12 76.50 77.48 76.04 74.20

57.82 57.63 56.26 57.61 56.61

98.56 96.51 92.06 92.13 91.40

0.84 27.58

11.73

1.30

31.37

75.27

57.19

94.13


The BMI values showed that during the research women had proper body mass. There was also only a small number of obese women and this is demonstrated by the WHR. When it comes to the AMC index, all researched women had it over 20.9, which indicates good protein nutrition. When determining the average values of the slenderness ratio, it can be stated that in all researched years both women and men represented the athletic type. During the whole research, women were characterized by a very strong body construction (specified by the Pignet index). In the years 2007, 2008 and 2009 the body length index demonstrated that the researched women had long torso, while in the remaining years of the research they had medium body length. Narrow shoulders were observed among the researched women in 2006 and 2007, while in the remaining years of the research they were medium. In all observations, the researched women had narrow pelvises (pelvic index) and stocky arms (Table IV). Table IV. Numerical characteristics of selected somatic indices of women (source: own study) Tabela IV. Charakterystyki liczbowe wybranych wskaźników somatycznych kobiet (źródło: opracowanie własne) Year of study (Rok badań)

was observed in 2007 – 74.60%. The recommended average value of FFM is 75% (Table VI). Table V. The selected morphological body sizes of men (source: own study) Tabela V. Wybrane wielkości morfologiczne ciała mężczyzn (źródło: opracowanie własne) Year of study (Rok badań)

The average values Body fat Lean body mass and standard deviation (Tkanka tłuszczowa) (Beztłuszczowa masa ciała) (Wartości średnie (kg) (%) (kg) (%) i odchylenie standardowe)

2006

X

9.21

12.79

67.10

s

2.58

3.79

6.66

3.79

2007

X

10.64

13.7

63.02

85.6

s

2.87

2.72

5.46

2.99

2008

X

12.23

15.73

64.48

84.27

s

3.62

3.14

7.17

3.14

2009

X

12.76

16.26

64.63

83.74

2010 All (Wszystkie)

22.90 21.50 22.81 21.45 25.43

16.99 17.43 18.04 17.35 10.84

1.30 1.30 1.31 1.31 1.40

30.62 30.80 30.85 30.96 30.73

70.16 71.69 75.5 74.26 72.78

65.17 63.30 60.52 63.74 64.39

ramienia) 92.25 101.53 92.15 81.64 83.93

0.77 22.82

16.13

1.32

30.79

72.88

63.42

90.3

0.76 0.78 0.74 0.81 0.78

The presented average test results among men, including in particular the body mass, body fat and lean body mass in kilograms and percentages prove that these values were within the recommended limits, e.g. body fat (BF) from 12.79% in 2006 to 16.26% in 2009. Similar observation was made concerning the lean body mass (FFM), which average value was the lowest in 2009 – 83.74% and the highest in 2006, 87.20% (Table V). The researches carried out among women proved that the smallest average value of body fat (BF) was noted in 2007 – 25.41%, while the highest in 2009 – 30.49%. The latter parameters slightly exceed the normative and recommended standards of body fat for women (25%). Lean body mass (FFM) was on average the lowest in 2009 amounting to 69.51%, while the highest FFM

87.20

s

4.09

3.13

6.05

3.13

X

11.41

14.74

65.27

85.26

s

2.89

2.60

5.85

2.60

X

11.25

14.65

64.90

85.21

s

3.21

3.08

6.24

3.13

Table VI. The selected morphological body sizes of women (source: own study) Tabela VI. Wybrane wielkości morfologiczne ciała kobiet (źródło: opracowanie własne)

The average values and Year of standard BMI WHR AMC Pigneta Rohrera Torso Shoulder Pelvic Arm study (Rok deviation index index index Index index muscle badań) (Wartości średnie (Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik index i odchylenie Pigneta) Rohrera) tułowia) barków) miednicy) (Wskaźnik standardowe) umięśnienia

2006 21.32 2007 22.0 2008 22.3 2009 22.2 2010 23.9 All 22.34 (Wszystkie)

23

Body fat (Tkanka tłuszczowa)

Lean body mass Beztłuszczowa masa ciała)

(kg)

(%)

(kg)

(%)

19.21 3.94 16.30

29.45 3.44 25.41

44.6 4.08 47.44

70.55 3.43 74.60

2006

X

2007

X σ

3.44

3.50

4.28

3.52

2008

X

2009

X

18.34 3.25 19.30

28.38 2.80 30.49

45.93 3.66 43.63

71.62 2.80 69.51

σ

3.27

1.96

5.0

1.96

2010

X

All (Wszystkie)

X

19.23 3.01 18.48 3.38

29.23 3.08 28.59 2.96

46.46 4.78 45.61 4.36

70.77 3.08 71.41 2.96

σ

σ

σ σ

CONCLUSIONS The morphological construction differs and is unique for individuals. We can talk about the differentiation of body constitution. In the literature, there are divergent views on the characteristics of the human body (Roy, Shephard 1987; Andreasi and others 2010). Drozdowski (2002) points out that even the terminology is not sufficiently uniform, because we talk about a somatic, morphological and morfofunctional body construction or the body constitution of a man. The typology of the human body

24


could be understood as all characteristics of an organism that are closely related to each other, interacting and conditioning its structural and functional unity (Drozdowski 2002, p. 94). The phenomenon of human diversification in terms of size and proportions of various body parts as well as the types of reaction to environmental factors has been known for a long time (Wolański 2006). The differences between human forms appeared in relatively early stages of their evolution. Various groups of people who occupied particular areas lived probably in very diverse environments causing the morfofunctional characteristics to adopt to the surrounding environmental conditions. It can be observed that the construction of the human body is an expression of adaptation to diverse natural environment. Numerous studies show the diversity between human groups, which can be divided for the intercontinental and the intracontinental ones, is associated with the formation of human races. The papers of many scientists point out that the formation process of various populations is influenced by their geographical location (Napierała 1999, 2008). Regional and environmental differences in terms of body composition can be observed also on the territory of Poland, although it is an area inhabited by a very homogeneous society. One of the very distinctive characteristics of the human body is its height. It is of polygenic nature (shaped by multiple genes), therefore the offspring may deviate in various directions from the value of particular characteristics of their parents. The final values for these characteristic show a high dependence on environmental conditions, especially on the quality of nutrition during the progressive development (Malinowski 1994). The researches carried out in Poland also demonstrate differences in height, depending on the education and social position. Similar results were observed in longitudinal studies in the Bydgoszcz area (Napierała, 1999). The results presented in this paper concerning the basic morphological characteristics of physical education students during a 5-year period do not show significant changes in the given body constitution elements. The specificity of this particular field of interest gathers at the physical education studies a number of young people with past or present interest in sports. People practising sport differ from those who do not exercise at all in terms of their constitutional body construction as it is influenced by systematic physical exercises, the selection of sport disciplines

and maintaining a desired and well-muscled athletic body. The research results bring the following conclusions: 1. The research carried out among women and men showed that the average BMI in all collated years is within limits of proper body mass. 2. The WHR demonstrated that there was no obesity in any year among the researched students; the AMC evaluation criteria showed good nutrition. 3. The average results of the body slenderness among men and women defined by the Rohrer index and the Kretschmer characteristics indicated the athletic types. 4. The Pignet index defined the body composition as medium and strong in men, and as very strong in women in all researched years. 5. The researched students (men and women) had medium or long torso. The shoulders were medium and wide in men, and medium and narrow in women. In all years of the research both groups had narrow types of pelvis and stout arms. REFERENCES 1. 2. 3.

4.

5.

6.

7. 8.

Drozdowski Z. (1998), Antropometria w wychowaniu fizycznym, Podręczniki AWF, Poznań nr 24 Drozdowski Z. (2002), Antropologia dla nauczycieli wychowania fizycznego, AWF, Poznań Malinowski A. (1994), Wstęp do antropologii i ekologii człowieka, Wydawnictwo Uniwersytetu Łódzkiego Napierała M. (2008), Środowiskowe uwarunkowania somatyczne i motoryczne a wiek rozwojowy dzieci i młodzieży (na przykładzie województwa kujawsko – pomorskiego), Bydgoszcz, Wydawnictwo Uniwersytetu Kazimierza Wielkiego w Bydgoszczy Napierała M. (1999), Rozwój fizyczny i motoryczny dzieci wiejskich i miejskich w województwie kujawsko – pomorskim, [w:] Uwarunkowania rozwoju fizycznego dzieci i młodzieży wiejskiej, (red.) J. Zagórski i in., Instytut Wychowania Fizycznego i Sportu, Biała Podlaska, Rocznik Naukowy Tom VI Suplement nr 1 Eksterowicz J., Napierała M., (2007), Zmiany morfologiczne studentów z kierunku wychowania fizycznego w trakcie letniego obozu sportowego, Medical and Biological Sciences, Tom21/3, Bydgoszcz, pp. 49-52. Roy J., Shephard M. D., (1987), Exercise physiology. BC Decker INC, Toronto, Philadelphia. Andreasi V, Michelin E, Rinaldi AE, Burini RC, (2010), Physical fitness and associations with anthropometric measurements in 7 to 15-year-older


9.

school children. Jornal De Pediatria [J Pediatr (Rio J)], Nov-Dec; Vol. 86 (6), pp. 497-502. Wolański N. (2006), Rozwój biologiczny człowieka, PZWL, Warszawa.

Address for correspondence: Jerzy Eksterowicz Uniwersytet Kazimierza Wielkiego w Bydgoszczy Instytut Kultury Fizycznej Bydgoszcz ul. Ogińskiego 16 tel.: 601 63 91 81 e-mail: [email protected]


25


Mariusz Klimczyk

SOMATIC BUILD VS SPORTS RESULTS OF POLE VAULT CONTESTANTS AGED 16-17 BUDOWA SOMATYCZNA VS WYNIKI SPORTOWE ZAWODNIKÓW SKACZĄCYCH O TYCZCE W WIEKU 16-17 LAT

Institute of Physical Culture, Kazimierz Wielki University in Bydgoszcz Headmaster Senior Doctor Mariusz Zasada

Summary Experimental researches conducted between 2005 and 2009 included 20 sportsmen aged 16-17 pole vaulting at the sports club ‘Zawisza’ Bydgoszcz, TS ‘Olimpia’ Poznań, pole vault centre Gdańsk, ‘Gwardia’ Piła, ‘Śląsk’ Wrocaław. The aim of the thesis was to define the relation between somatic parameters and sports results of pole vaulters of junior category (aged 16-17). The following methods and research tools were used in the thesis: evaluation of physical development, testing physical dexterity, recording sports results and statistical description.

The analysis of the research showed great diversity of somatic features and physical dexterity results of particular athletes. The relation which occurs between sports result of the pole vault and the body height (0.66), the length of upper limb and lower limb (0.64, 0.54, respectively) are interesting. On the basis of the above analysis with regard to, among many, small number of the examined, it is not possible to draw far-reaching conclusions concerning the relation which occurs between somatic build and physical dexterity attempts and pole vault result.

Streszczenie Badania eksperymentalne prowadzono w latach 20052009, którymi objęto 20 sportowców w wieku 16-17 lat uprawiających skok o tyczce w klubie sportowym „Zawisza” Bydgoszcz, TS „Olimpia” Poznań, Ośrodek skoku o tyczce Gdańsk, „Gwardia” Piła, „Śląsk” Wrocław. Celem pracy było określenie zależności między parametrami somatycznymi, a wynikiem sportowym w skoku o tyczce, tyczkarzy w kategorii junior młodszy (16-17 lat). W pracy wykorzystano następujące metody i narzędzia badań: ocena rozwoju fizycznego, testowanie sprawności fizycznej, rejestracja wyników sportowych i metody statystycznego opracowania. Key words: somatic features, sports result, correlation Słowa kluczowe: cechy somatyczne, wynik sportowy, korelacja

Analiza badań wykazała duże zróżnicowanie cech somatycznych i wyników sprawności fizycznej u poszczególnych ćwiczących. Interesująco przedstawia się zależność, jaka występuje pomiędzy wynikiem sportowym skoku o tyczce, a wysokością ciała (0,66), długością kończyny górnej i dolnej (odpowiednio 0,64, 0,54). Na podstawie powyżej przeprowadzonej analizy ze względu na między innymi małą liczbę badanych nie można wysunąć daleko idące wnioski dotyczące relacji, jaka zachodzi pomiędzy budową somatyczną, a próbami sprawności fizycznej i wynikiem w skoku o tyczce.

28

Mariusz Klimczyk

INTRODUCTION

METHODS OF RESEARCH

The history of men's pole vault shows that the biggest sports achievements of this spectacular and complex athletic sports event are achieved by the contestants of diverse somatic build [1]. The achievement of the best results by the contestant depends, among many, on: level, physical dexterity, somatic build, technical skills and other conditions [2]. Numerous publications describe research results which show that the body type of every human being is their biological, to a high degree, determined genetically feature, i.e. the feature with a great immutability in the period of life [3, 4, 5, 6]. That is why an accurate choice in the aspect of children's body build to the proper sports events contributes to beneficial prognosis that these individuals will meet, in the future, the somatic requirements making sports competition on the highest world level reachable for them. The external manifestation of the development of a particular person is their body build and the predispositions to execute particular physical activity. Because of that, somatic build and, most of all, some of its proportions which have their own development course, are of great importance in the pole vault [4, 7]. So far we have not been able to clearly state which of the parameters of somatic build are an exponent or rather a criterion for particular age categories of pole vault contestants. The aim of the thesis was to define the relation between the somatic parameters and sports results of the pole vault jumpers of junior category (16 – 17).

The following methods and research tools were used in the thesis: •evaluation of physical development, •testing physical dexterity, •recording sports results, •methods of statistical description. In order to conduct the evaluation of physical development, somatic build measurements including the following indexes were used. •body height (basis-vertex), •weight, •torso length (suprasternale-symphysiom), •lower limb length (basis-symphysion), •upper limb length (acromion-daktylion III), •shoulder width (acromion-acromion), •pelvis width (iliocristale-iriocristale), •thigh circumference, •shank circumference, •arm circumference, •volume of the chest during inhalation, •volume of the chest during exhalation, •chest breadth (the difference of the chest volume during inhalation and exhalation). Using the above parameters, somatic build index according to Rohrer was calculated using the following relation:

MATERIALS AND METHODS

During the research a pair of large bow compasses, scales and measuring tape were used. During the construction of physical dexterity attempts the system of control indexes suitable for competition requirements of pole vault was taken into account [8]: •running speed for 30-m distance - high start position (s), •running speed for 15-m distance with a 20-meter runup, •running speed for 15-m distance with a 20-meter runup with a pole (s), •running speed for 15-m distance with a 20-meter runup with setting a pole (s), •strength – measured by the long jump with a 20-meter run-up (cm),

Cognitive tests were conducted between 2005 and 2009 and they included 20 sportsmen aged 16 – 17 pole vaulting at the sports club ‘Zawisza’ Bydgoszcz, TS ‘Olimpia’ Poznań, pole vault centre Gdańsk, ‘Gwardia’ Piła, ‘Śląsk’ Wrocław. The contestants participated in training classes at the club 4-6 times a week. The training unit lasts for 60-90 min., while at school they were following Physical Education programme in the amount of 3-4 45-minute units a week, with the emphasis on education of general physical dexterity.

Body weight (g) x 100 _________________ Body height (cm) 3

Somatic build vs sports results of pole vault contestants aged 16-17

•explosive strength – measured by the long jump with a 20-meter run-up, •strength of back muscles and shoulder girdle – measured by lifting feet to the horizontal bar from straight arm overhang 5 times (time measured) (s), •strength of back muscles and shoulder girdle – measured by lifting feet to the horizontal bar from straight arm overhang (quantity), •strength of shoulder girdle and shoulders' muscles – measured by climbing 3-meter rope (s), •strength of shoulder girdle and shoulders' muscles, horizontal pull-ups (quantity), •strength of shoulder girdle and shoulders' muscles, 5 horizontal pull-ups (time measured) (s), •pole vault test (cm), •coordination and explosive strength measured by “flying” over the crossbeam from back somersault through a handstand (from the mattress) (cm), •strength – measured by 4-kg shot put thrown back over the head (m). The execution of the planned attempts was preceded by a detailed instruction on a way of their execution and before their performance the coach conducted a 15-minute warm-up. To conduct the analysis of sports results the official competition protocols were included. The collected material was analysed statistically using the minimum, maximum and average value, the variations of the examined parameters and Pearson’s correlation factors were considered as statistically significant for p 100k zamieszkania/ Do 50tys.< 50k Place of Wieś/Rural area residence Stan cywilny/ Zamężny/Married Marital status Wdowiec/Widowed

Na lepsze/ For the better 25(50%) 10(20%) 9(18%)

Na Brak Brak Razem/Total gorsze/ zmian/No opinii/ For the change No worse opinion 5(10%) 1(2%) 0(0%) 31 (62%) 5(10%) 4(8%) 0(0%) 19 (38%) 0(0%) 12(24%) 5(10%) 26(52%)

9(18%) 2(4%)

1(2%)

3(6%)

15 (30%)

4(8%)

3(6%)

1(2%)

0(0%)

8 (16%)

0(0%)

0(0%)

1(2%)

0(0%)

1 (2%)

7(14%) 1(2%) 4(8%) 0(0%) 11(22%) 2(4%) 10(20%) 5(10%) 3(6%) 0(0%) 0(0%) 2(4%)

17(34%) 28(56%) 5(10%)

12(24%) 2(4%)

0(0%)

7(14%)

36(76%)

5(10%) 2(4%)

0(0%)

3(6%)

10(20%)

1(2%) 0(0%) 2(4%)

0(0%) 0(0%) 3(60%)

2(4%) 0(0%) 0(0%)

5(10%) 2 (4%) 5(10%)

0(0%) 2(4%) 3(6%)

5(10%) 3(6%) 5(10%) 5(10%) 2(4%) 2(4%)

12(24%) 16(32%) 17(34%)

Wolny/Single 2(4%) Rozwiedziony/Divorced 2(4%) Wykształcenie/ Podstawowy/Primary 0(0%) Education Zawodowy/Vocational 4(8%) Średnie/Secondary 4(8%) Wyższe/ Higher 10(20%)

When analysing the opinion regarding the trends in physiotherapeutic care in Poland for the next 10 years in relation to age subgroup; 9 (18%) patients from subgroup I, 9 (18%) patients from subgroup II and 4 (8%) patients from subgroup III think that the situation will improve. 2 patients from subgroup II (4%) and 3 from subgroup III (6%) predict changes for worse. No changes are predicted by 12 (24%) respondents from subgroup I, 1 (2%) from subgroup II, 1 (2%) from subgroup III and 1 (2%) from subgroup IV. 5 (10%) patients from subgroup I and 3 (6%) from subgroup II gave no opinion [Fig 4, Table II ].

Fig 4. Changes in the Polish physiotherapeutic care proposed by the elderly for the next 10 years - in relation to age Ryc. 4. Proponowane zmiany w polskiej opiece fizjoterapeutycznej na przestrzeni najbliższej dekady zgodnie z wiekiem

Analysing the opinion regarding the trends in physiotherapeutic care in Poland for the next decade in relation to the place of residence showed that

according to 7 (14%) patients from cities with more than 100 000 residents, 11 (22%) from cities below 50 000 and 3 (6%) from rural areas believe that this care will develop. to 1 (2) patient from a city with more than 100 000 residents and 2 (5%) from cities below 50 000 believe that it will degrade. Respectively, 4 (8%) and 10 (20%) think it will not change. No opinion was voiced by 5 (10%) patients from cities with less than 50 000 residents and 2 (4) from rural areas [Table II]. An analysis of the trends in physiotherapeutic care in Poland for the next decade in relation to marital status showed that 12 (24%) married, 5 (10%) widowed, 2 (4%) single and 2 (4%) divorced patients believe that the changes will be for the better. Changes for the worse are predicted by 2 (4%) married, 2 (4%) widowed and 1 (2%) single patients. 7 (14%) married, 3 (6%) widowed and 2 (4%) single patients did not state any opinion on this matter [Table II]. Opinions regarding changes in geriatric care for the next decade were compared in relation to education. Changes for the better are predicted by 4 (8%) patients with vocational education, 4 (8%) with secondary education and 10 (20%) with higher education. Changes for the worst are expected by 2 (4%) patients with primary education, 2 (4%) with secondary education and 3 (6%) with higher education. According to 3 (6%) patients with primary education, 5 (10%) with vocational, 5 (10%) with secondary and 2 (4%) with higher education no changes will happen. No opinion regarding this topic was stated by 3 (25%) patients with vocational education, 5 (31%) with secondary education and 2 (4%) with higher education [ Table II]. Methods for improving the aforementioned care could be: advertising the need for physiotherapeutic health care (25 patients, 50%), education in one’s own social group (city, region) (11 patients, 22%) and more funds (1 patient, 2%). 13 (26%) patients expressed no faith in any positive changes. Opinions on the methods for improving physiotherapeutic care in relation to sex, age, place of residence, marital status and education are shown in table III. The respondents were asked about what changes they would like to see in the next 10 years. The answers were: shorter waiting time for physiotherapeutic treatment (42%, n=21), more physiotherapeutic centres for the elderly (50%, n=25) and an improvement in the qualification of the physiotherapeutic staff (8%, n=4).

Assesment of the needs and expectations of elderly patients regarding physiotherapeutical care in Poland

When analyzing the results based on the respondents’ sex, 16 (32%) women and 9 (18%) men voted for an increase in the number of physiotherapeutic centres for the elderly. Shorter waiting time was pointed out by 16 (32%) women and 8 (16%) men. 2 women (4%) and 2 men (4%) wanted better qualified staff [Table IV]

39

physiotherapy centres for the elderly. For 5 (10%) patients from cities above 100 000 residents and 9 (18%) from cities below 50 000 residents the most important issue is the shortening of waiting times. Physiotherapeutic staff with higher qualification is a priority for 1 (2%) person from a city above 100 000 residents and 9 patients (18%) from cities below 50000 residents [Table IV].

Table III. Methods for improving physiotherapeutic care given by the elderly in relation to the given characteristic Tabela III. Sposoby poprawienia opieki fizjoterapeutycznej wśród osób starszych w zależności od danej cechy Cecha/ Characteristic

Płeć/Sex

Kobiety/Women Mężczyźni/Men Wiek/ PodgrupaI/ Age Subgroup I PodgrupaII/ Subgroup II PodgrupaIII/Subgroup III PodgrupaIV/ Subgroup IV Miejsce Pow.100 tys.> 100k zamieszkania/ Do 50tys. < 50k Place of Wieś/ Rural area residence Stan Zamężny/Married cywilny/Marital Wdowiec/Widowed status Wolny/ Single Rozwiedziony/ Divorced

Nagłośnienie Edukacja Większe konieczności społeczeństwa/ fundusze/ opieki Educating the More zdrowotnej society funds wśród pacjentów w starszym wieku/ Promoting the need for healthcare for the elderly 14 (28%) 7 (14%) 11 (22%) 3 (6%) 1 (2%) 20 (40%) 5 (10%) 1(2%)

Brak wiary w jakiekolwiek zmiany/ Lack of faith in any changes

Razem/Total

10 (20%) 4 (8%)

31 (62%) 19 (38%) 26(52%)

8 (16%)

4 (8%)

3 (6%)

15 (30%)

5 (10%)

2 (4%)

1 (2%)

8 (16%)

1 (2%)

1 (2%)

8 (16%) 18 (36%) 3 (6%)

5 (10%) 2 (4%) 2 (4%)

20 (40%) 7 (14%)

5 (10%) 2 (4%)

2 (4%) 1 (2%)

2 (4%)

Analysing the opinion regarding the expected changes in physiotherapeutic care in Poland for the next decade in relation to age subgroups showed that 14 patients (28%) from subgroup I, 8 (16%) from subgroup II and 4 (8%) from subgroup III wanted the number of physiotherapeutic centres to increase. A shorter waiting time was chosen by 1 (2%) person from subgroup I , 5 (10%) from subgroup II , and 4 (8%) from subgroup III. 1 patient (2%) from subgroup I, 2 (4%) from subgroup II, none from subgroup III and 1(2%) from subgroup IV wanted the staff to be better qualified [Table IV]. When analysing the expectations regarding physiotherapeutic care for the next decade in relation to the place of residence it has been observed that 11 (22%) respondents from cities above 100 000 residents, 10 (20%) from cities below 50 000 residents and 5 (10%) from rural areas wanted more

1(2%)

1(2%)

4 (8%) 7 (14%)

17(34%) 28(56%) 5(10%)

11 (22%) 1 (2%)

36(76%) 10(20%)

1 (2%)

5(10%) 2 (4%)

An analysis of the patients' expectations for physiotherapeutic care in the next decade in comparison to marital status showed the following results. 18 (35%) married, 5 (10%) widowed, 3 (6%) divorced and 1 (2%) single patient wanted more physiotherapeutic care centres for the elderly. Shorter waiting times were expected by 15 (30%) married and 5 (10%) widowed patients). 3 (6%) married patients wanted the physiotherapeutic staff to become more qualified [Table IV]. When analysing the expectations regarding physiotherapeutic care for the next decade in relation to education it has been observed that 2 (4%) patients with primary education, 6 (12%) with vocational education, 8 (16%) with secondary education and 9 (18%) with higher education wanted more physiotherapeutic centres for the elderly.

40

Alicja Rzepka et. al.

caused by worries regarding their own health and the fact that they will have to start using physiotherapeutic services Cecha/ Characteristic Więcej Krótszy czas Bardziej Razem/Total due to disability growing ośrodków oczekiwania na wykwalifikowany fizjoterapeutycznych/ zabiegi/Shorter personel/Better with age. This is More physiotherapeutic waiting times qualified staff centres corroborated by Płeć/Sex Kobiety/Women 16(32%) 13(26%) 2(4%) 31(62%) Bogowolska at al. study Mężczyźni/Men 9(18%) 8(16%) 2(4%) 19(38%) Wiek/ Age Podgrupa I/Subgroup I 14(28%) 11(22%) 1(2%) 26(52%) entitled ‘Life conditions of PodgrupaII/Subgroup II 8(16%) 5(10%) 2(4%) 15(30%) PodgrupaIII/Subgroup III 4(8%) 4(8%) 0(0%) 8(16%) the elderly from Lower PodgrupaIV/Subgroup IV 0(0%) 0(0%) 1(2%) 1(2%) Silesia’ which shows that Miejsce Pow.100tys./> 100k 11(22%) 5(10%) 1(2%) 17(34%) zamieszkania/ Do 50tys./< 50k 10(20%) 9(18%) 9(18%) 28(56%) 21.3% of patients aged Place Wieś/Rural area 5(10%) 0(0%) 0(0%) 5(10%) of residence from 60-64 use Stan cywilny/ Zamężny/Married 18(36%) 15(30%) 3(6%) 36(72%) rehabilitation services Marital status Wdowiec/Widowed 5(10%) 5(10%) 0(0%) 10(20%) Wolny/Single 3(6%) 0(0%) 0(0%) 3(6%) this percentage grows to Rozwiedziony/Divorced 1(2%) 0(0%) 0(0%) 1(2%) Wykształcenie/ Podstawowe/Primary 2(4%) 1(2%) 2(4%) 5(10%) 24.26 in the 65-69 age Education Zawodowe/Vocational 6(12%) 6(12%) 0(0%) 12(24%) group. It drastically drops Średnie/Secondary 8(16%) 9(18%) 0(0%) 17(34%) Wyższe/Higher 9(18%) 5(10%) 2(4%) 16(32%) for even older patients but not due to a lack for this treatment but because of the impossibility to make use Shorter waiting times are a priority for 1 (2%) of of it. This study shows the need for physiotherapeutic the respondents with primary education, 6 (12%) with care and its current maladjustment to the elderly [10]. vocation education, 9 (18%) with secondary education The need is greatest amongst people living in and 5 (10%) with higher education. 2 (4%) patients cities with a population below 50 000. This may be with primary education and 2 (4%) with higher connected with a small number of physiotherapeutic education would wish for more qualified staff [Table facilities – this causes longer waiting times. What is IV]. more, more than one fifth of the elderly from Lower Silesia complain about a lack of a health care centre in DISCUSSION their place of residence and this means no chance for any physiotherapeutic care [10, 11]. Bień confirms According to Kostka, the elderly are the largest there results. According to her, health state as well as social group benefiting from rehabilitation services. the access to healthcare is much worse on rural areas This is caused by a higher frequency of chronic when compared to cities. This applies to using medical, diseases, a decrease of functional fitness and growing dentist and rehabilitation facilities [12]. Moscovice et dependency on others [5]. Despite these data the Polish al. share this view – according to them healthcare in national health fund was planning to spend only one the rural areas of the USA is different from the one in billion PLN more on healthcare in 2011 than the year the cities. People face many challenges when it comes before. Only 4% of this amount will be spent on health to accessing healthcare services [13]. These services resort care (a part of physiotherapeutic care) for the can be improved by developing cost-effective and elderly. These amounts are about 3 times smaller than practical standards for the healthcare centres. This is a in case of German and French healthcare. task for the monitoring agencies, service providers and According to Kornatowska et al. physiotherapeutic people buying medical insurance [13]. care for the elderly was neglected in the 20th century. Majority of married people voted for a need for an This was connected with constant degradation of the improvement of physiotherapeutic care. It must be said vital energy of a person [9]. Patients from the that this was the most numerous group. This need is Department and Clinic of Geriatrics of the University probably connected with the fact that a patient cares for Hospital No. 1 in Bydgoszcz voice a need for his/her health as well as the spouse’s health. improvements in the field of Polish physiotherapeutic Kalpakjian et al. say that marriage leads to improved care. They were mostly from the first age subgroup welfare and the dissolution of marriage to (between 60 and 70 years of age). This was probably Table IV. Changes in the Polish physiotherapeutic care proposed by the elderly for the next 10 years in relation to the given characteristic Tabela IV. Proponowane zmiany na najbliższą dekadę w opiece fizjoterapeutycznej w opinii osób starszych w zależności od cechy

Assesment of the needs and expectations of elderly patients regarding physiotherapeutical care in Poland

impoverishment. What is more, patients who suffer from spinal cord injuries and who are at the same time marred, have a better frame of mind and are less prone to depression than divorced, single or widowed patients. This study is also interesting as it shows that women after divorce are more satisfied with life and judge their health better than divorced men [14]. This is corroborated by DeVivo et al. According to them, people after such injuries rather stay married and divorce more rarely. Increased divorce risk is true only for the young, Afro-American and without children [15]. Most people with secondary education wanted physiotherapeutic care to improve. This was the most populous group. Oztürk believes this to be otherwise. According to his study, there is no statistically significant difference between education, sex, marital status and the appearance of chronic diseases and their type amongst the elderly [16]. According to most women, people from the first and second age subgroup, residents of cities below 50 000, married people and people with higher education Polish physiotherapeutic care will improve in the coming decade. This may be connected with the fact that these groups are the most numerous and the youngest – and consequently the most optimistic and having a stabilised personal life. The issues which should be addressed first in the coming years are long waiting times for physiotherapy, not enough physiotherapy centres and an improvement of the qualification of the physiotherapy staff. According to the 2009 report, the Mazovian Centre of Social Policies spent over 7 million PLN on physiotherapeutic care. The money was spent on rehabilitation facilities, as well as and modernising the existing social help centres [17]. We have a similar situation in the Greater Poland voivodeship where the Family, Social Issues and Public Healthcare Commission of the Poznan City Council spent 600 000 PLN for rehabilitation services for Poznan citizens older than 60. The aim of this initiative was to ensure the elderly access to rehabilitation (underfinanced by the National Health Fund) and, in consequence, to improve their health and stop further disabilities. However, this is only a small part of the physiotherapeutic need of the elderly in Poland [18].

41

CONCLUSIONS Elderly patients in Poland expect physiotherapeutic care to improve. This is irrespective of age, sex, marital status, place of residence and education. REFERENCES 1. 2.

3. 4.

5.

6. 7.

8.

9. 10.

11. 12. 13.

Zembaty A. Kinezyterapia tom1 . Kraków 2002. Wydawnictwo Kasper S.p. z.o. o str. 9-14. Kędziora-Kornatowska K, Muszalik M. Kompendium pielęgnowania pacjentów w starszym wieku. Wydawnictwo Czelej Lublin 2007 str 79-88 Prognoza ludności na lata 2008-2035, GUS Warszawa 2009 tab. A6 str 204 Wieczorowska-Tobis K, Kostka T, Borowicz A.M. Fizjoterapia w geriatrii, Wydawnictwo Lekarskie PZWL. Warszawa 2011. Kostka T, Koziarska- Rościszewska M. Choroby wieku podeszłego. Wydawnictwo Lekarskie PZWL. Warszawa 2009: 164 Rosławski A. Wybrane zagadnienia z geriatrii. AWF Wrocław 2008: 9-11 Wieczorowska-Tobis K., Talarska D. Geriatria i pielęgniarstwo geriatryczne. PZWL Warszawa 2008: 335-341 Uprawnienia kombatantów do korzystania ze świadczeń zdrowotnych bez kolejki [Narodowy Fundusz Zdrowia] Adres: http:// www.nfzwarszawa.pl/index/pacjent/kom_11082010 Kondycja życiowa dolnośląskich seniorów Raport z badań. Część II. Analiza wyników badań. http://www.dops.wroc.pl/publikacje.php Kondycja życiowa dolnośląskich seniorów. Raport z badań. Część I http://www.dops.wroc.pl/publikacje.php Bień B. Health care services for the elderly living in the rural area of Poland Przegl Lek. 2002, 59(4-5): 211-215

Address for correspondence: mgr Alicja Rzepka Departament and Clinic of Geriatrics of the Nicolaus Copernicus University in Toruń Collegium Medicum in Bydgoszcz 85-094 Bydgoszcz, M. Curie-Skłodowskiej 9 Street tel/fax (052) 585-49-00 e-mail: [email protected]



CASE REPORT / PRACA KAZUISTYCZNA

Małgorzata Łukowicz1, Magdalena Mackiewicz-Milewska2, Sabina Lach-Inszczak2, Iwona Szymkuć2, Wojciech Hagner2

TRANSPEDICULAR STABILIZATION COMPLICATIONS IN THORACIC REGION OF THE SPINE AFTER SCI - THREE CASES REPORT AND LITERATURE REVIEW POWIKŁANIA PO STABILIZACJI TRANSPEDIKULARNEJ ODCINKA PIERSIOWEGO KRĘGOSŁUPA U PACJENTÓW PO URAZIE RDZENIA KRĘGOWEGO – OPIS TRZECH PRZYPADKÓW I PRZEGLĄD LITERATURY

1

The Lasetherapy and Physical Therapy Department, Nicolaus Copernicus University in Toruń Collegium Medicum in Bydgoszcz Head: dr n. med. Małgorzata Łukowicz 2 The Department of Rehabilitation, University Hospital in Bydgoszcz Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz Head: prof. dr hab. Wojciech Hagner

Summary A case report of three cases of complications after transpedicular stabilization in thoracic part of the spine. O b j e c t i v e s . The aim of the study was to report the complications after surgical stabilization in thoracic level of the spine that could be very dangerous and cause many symptoms. All patients were treated in The Department of Rehabilitation, University Hospital in Bydgoszcz, Collegium Medicum of Nicolaus Copernicus University in Bydgoszcz, Poland C a s e r e p o r t 1 . The case of 24 year old patient after spinal fracture within T9 as well as T12 level was introduced. The patient was subjected to transpedicular stabilization within the levels of T8-T10 and T11-L2. In ASIA classification A, the lack of any sensation in sacral segments, no anal sphincter motor activity was noticed. Complications manifested by dislocation of screws as well as postoperative wound infection occurred, what caused the necessity for the stabilizer removal. These complications exerted harmful effect on early rehabilitation process. The patient underwent three surgical procedures resulted from dislocation of screws. C a s e r e p o r t 2 . 31 year old male patient after SCI in T6 region of the spine. He was treated with transpedicular

stabilization within the levels of T5-T6. The complication was screw translocation in vertebral body T5 and connecting aortic aneurysm. He was successfully operated by thoracic surgeons. C a s e r e p o r t 3 . 26 year old male patient after fracture of T5 and T6 vertebra column. He was operated with transpedicular stabilization. He had fever and respiratory tract infection symptoms; after radiological examination the diagnosis of pleuritis was stated and a dislocation of screw in T3 and T4 vertebral body. He was treated conventionally without operation. Conclusions Complications prolong as well as disturb rehabilitation treatment. The control radiographic examinations need to be performed directly after operative treatment to evaluate the stabilization system during walking and assuming the erect position. Increased pain ailments within spinal cord segment that was subjected to surgical procedure may signify the possible dislocation of screws. Such dislocation, noticed within thoracic region, can be life-threatening, because of the nearness of the significant anatomical structures.

44

Małgorzata Łukowicz et. al.

Streszczenie Opisano trzy przypadki pacjentów, u których wystąpiły powikłania po stabilizacji transpedikularnej odcinka piersiowego kręgosłupa. C e l e m p r a c y było opisanie powikłań po stabilizacji odcinka piersiowego kręgosłupa, które mogą być niebezpieczne dla zdrowia i życia chorych oraz są przyczyną wystąpienia wielu dolegliwości. 1 o p i s p r z y p a d k u . 24-letnia chora po złamaniu kręgosłupa z uszkodzeniem rdzenia kręgowego na poziomie T9 i T12. Została zakwalifikowana do wykonania stabilizacji transpedikularnej na wysokości od T8 do T10 oraz od T11 do T12. W klasyfikacji ASIA A, bez czucia oddawania moczu i stolca oraz czynności zwieraczy odbytu i cewki moczowej. Powikłaniem po stabilizacji było nieprawidłowe umieszczenie śruby transpedikularnej oraz zakażenie rany pooperacyjnej. Wskutek tych powikłań konieczne było usunięcie całej stabilizacji transpedikularnej. Zdarzenia te znacznie spowolniły i ograniczyły cały proces rehabilitacji. Pacjentka łącznie została poddana trzem operacjom neurochirurgicznym wskutek nieprawidłowego umieszczenia śrub transpedikularnych. 2 o p i s p r z y p a d k u . 31-letni mężczyzna po urazie rdzenia kręgowego na wysokości T6. Wykonano stabilizacje transpedikularną na poziomach od T5-T6. Powikłaniem było nieprawidłowe umieszczenie w trzonie kręgu T5 śruby

transpedikularnej, co spowodowało powstanie tętniaka aorty. Ostatecznie chory ponownie był operowany przez zespół neurochirurgów i chirurgów naczyniowych z dobrym rezultatem. 3 o p i s p r z y p a d k u . 26-letni mężczyzna po złamaniu kręgosłupa i uszkodzeniu rdzenia kręgowego na wysokości T5 i T6. Po wykonaniu stabilizacji transpedikularnej wzrosły parametry stanu zapalnego tj. gorączka oraz cechy zapalenia dróg oddechowych. Wykonano zdjęcie radiologiczne płuc, które wykazało zapalenie opłucnej oraz nieprawidłowe położenie śrub transpedikularnych w trzonach T3 i T4. Chorego leczono zachowawczo. W n i o s k i . Powikłania opóźniają oraz zaburzają cały proces rehabilitacji pacjenta. Kontrola radiologiczna po wykonaniu stabilizacji transpedikularnej powinna być wykonywana również po zabiegu operacyjnym, aby zapewnić choremu bezpieczną pionizację oraz naukę chodu. Wystąpienie dolegliwości bólowych wzdłuż dermatomów odpowiadających poziomom wykonanej stabilizacji transpedikularnej może wskazywać na nieprawidłowe położenie śrub transpedikularnych. W odcinku piersiowym takie powikłanie może być groźne dla życia chorych, z powodu bliskiego położenia ważnych struktur anatomicznych.

Key words: spinal cord injury, thoracic injury, paraplegia, transpedicular stabilization Słowa kluczowe: uraz rdzenia kręgowego, urazy odcinka piersiowego kręgosłupa, stabilizacja transpedikularna

INTRODUCTION It was estimated during the International Spinal Cord Society Conference in 2001 that approximately 17.2 people per million of the population in Europe suffer from traumatic SCI (spinal cord injury) every year. [1] Young people with average age of 40 years old suffer from these injuries. More often these are men than women; it is approximately 5-6 times more. The cause of the spinal cord injuries are usually communication accidents. Looking at the incidence of levels of the injury it is estimated that approximately 52% of cases are in cervical region, 46% in thoracic, lumbar and sacral region, remaining percentage is unrecorded. In complete paraplegia there was the evidence of recovery from flaccid muscle to antigravity grade in 86% of the muscles, but if there was no activity, only 26% of muscles can improve their activity to antigravity grade. The presence of sensation in the sacral region or voluntary anal sphincter motor activity is a good prognostic factor for neurological recovery and whole rehabilitation process. [2]

There are a lot of therapeutic indications to neurosurgery interventions after spinal cord injury. Without any doubts the most serious and obvious is instability of the spine or/and neurovascular structures compression. Immediate those structures decompression decreased the risk of neurological deficits progression. The treatment of choice presents transpedicular stabilization performed within the first twenty-four hours following injury and then – intensive rehabilitation. This procedure gives patients a chance to improve their quality of life and achieve maximum progress in rehabilitation process and treatment. The postoperative complications are very seldom. However, the most common are both general postoperative wound infections, especially the postoperative wound infection, as well as extravertebral localization of transpedicular screws. Dislocation of the screws are the cause of vascular or/and neurological structures damage. However, for example thoracic aorta aneurysm is a rare complication after transpedicular stabilization because of spinal cord injury.

Transpedicular stabilization complications in thoracic region of the spine after SCI - three cases report and literature review

CASE 1

system was removed since the improvement had not been noticed.

History data. Patient (female) sustained the fraction of T9 and L1 vertebral bodies along with spinal cord injury within this level. Moreover, there were haemothorax as well as bilateral rib fracture noticed. The transpedicular stabilization was applied at the day of accident, at the level of T8 – L1. Twenty days after surgical procedure, the patient was subjected to another – the correction of localization (decompression of spinal cord, removal of osteal fragments from dural sac, replacement of stabilization, introduction of titan plates). Examination. During the admission to a hospital, the patient notified intense pain ailments – root pain type. The examination revealed decreased muscle tone of lower limbs, decreased tendon and periosteal reflexes, lack of active movements within lower limbs and trace movement in hip joint. Fecal and urinary incontinence were observed. Evaluation: ‐ ASIA (A) ‐

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WISCI II 7- The patient adapted to active wheelchair

Course of treatment. Girdle pain ailments within the thorax intensified while tilting the patient to erect position and limited significantly the breathing exercises. That is why the imaging examination, which revealed incorrect localization of stabilization system of T8-T10 – direct neighborhood of screw with aorta at the left side, within T8 level (Fig. 1), as well as infringement of vertebral body, was carried out. Another surgical procedure was carried out – repositioning of T11 screw, at the left side and T8, at the same surface, due to excessive mobility and also limited location. The control CT examination revealed position of T11 screw; T8 screw localized in a direct contact with vertebral canal but not clashing with vertebral column structures. There were antibiotics introduced into the therapy. Persistent pain ailments, notified by the patient within the thorax, receded immediately after the procedure. At the beginning the healing process of postoperative wound proceeded successfully, but then, the wound started dripping. The inoculation was performed. Unfortunately, the infection (MethicillinSensitive Staphylococcus Aureus) covered the whole stabilization region. The attempt of a treatment with guided antibiotic was taken. The whole stabilizing

Fig. 1. NMR examination of the spinal column – the screw modulates the abdominal aorta

CASE 2

History data. 31 year old patient (male) was admitted to the University Hospital in Bydgoszcz with deep tetraparesis. Six weeks before admission, the patient sustained multiorgan injury (ski accident), including cranial trauma (brain and brain stem contusion, secondary subarachnoid bleeding) as well as the thoracic spinal cord injury. NMR examination revealed: compression fracture of T6 vertebral body along with angular position of spinal column, intervertebral stenosis between T5-T6 and T6-T7, some part of chondroosseous structures translocated into the central canal, exerting pressure on spinal cord at the distance of about 15 mm. The neurosurgical procedure for thoracic spinal cord stabilization was delayed up to the fifth day, due to the serious general condition (3 GCS). Transpedicular screws were introduced within the level of T5-T7, using X-ray monitor. There was decompression laminectomy applied at the T6 level. The existing compression syndrome evoked by fragments of fractured bone from vertebral body was noticed within the dural sac. The posterior spinal arthrodesis was carried out by means of OMEGA instrumentarium what made decompression within the level of fracture possible. Examination. Patient admitted to the rehabilitation department within 6 weeks after the injury. Patient was conscious, without verbal contact; serious paresis of lower limbs was observed, without arbitrary movement

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of lower limbs, upper limbs paresis, more significant at the right side, paresis in regression, without dysesthesia. Evaluation: GCS 13 ASIA B WISCI II 0 (at admission) and 7 (after therapy) Course of treatment. The arbitrary movement of lower limbs, flexion within hip, knee joints as well as feet movement appeared in a course of hospitalization. Upper limbs paresis subsided completely. Because of pain ailments within thoracic cord intensification, there was guided X-ray imaging of T5-T7 carried out which disclosed extravertebral location of T5 screw (Fig. 2). Guided CT examination of T3-T8 thoracic cord level was performed and revealed posttraumatic-state of T6 vertebral body fracture and postoperative state of stabilization within T5-T7 level. The screws incorporated at the level of T5 and T7, at the left side laterally situated from the vertebral pedicles and bodies, and their extremities were localized within direct neighbourhood of descending aorta.

Fig. 3. The aorta aneurysm in angio-CT examination

A group of physicians consisting of neurosurgeon, vascular surgeon as well as cardiosurgeon decided to remove dislocated screw. The procedure was accompanied by vascular surgeons because of the serious risk of surgical intervention. Postoperative course was uncomplicated. As a result of stabilization removal from T5 region and non-union of fragments of T6 vertebra, patient was equipped with orthesis stabilizing thoracic cord, anticipated for the period of three months. CT control examination of aorta that was carried out directly after the procedure, 6 and 12 months after it, revealed aneurysmal bulge of descending aorta at the distance of 7mm and diameter of 5 mm. The patient stays under regular supervision of vascular surgeon. Nowadays, the patient reveals satisfactory neurological state (ASIA C), walks independently, with crutches at long distances (WISCI), went back to work. CASE 3

Fig. 2. CT scan of T5 screw extravertebral location

Another, CT angiography examination revealed aneurysmal bulge of thoracic aorta within a distance of about 5 mm and T5 screw extremity adhered to it. The screw applied to T7 vertebra at the left side modulated thoracic aorta from medial side (Fig 3.).

History data. 26 year old patient admitted to the rehabilitation department with serious paraparesis, two weeks after surgical operation of spinal fracture. He sustained the fracture of T5 and T6 vertebral bodies along with the spinal cord injury, located at the same level, as a result of traffic accident. The transpedicular stabilization within the level of T3-T8 was carried out. There were screws applied to T3, T4, T6, T7 as well as T8 vertebral bodies.


Examination. Patient suffering from paraparesis, none muscle tone, deep reflexes, superficial sensibility, deep pain and temperature sensitivity below T6 level. Fecal and urinary incontinence was observed. Evaluation: ASIA A WISCI II 0 (at admission), 1 (after therapy) Course of treatment. Patient demonstrated subfebrile states, gradual increase of temperature as well as inflammatory state indexes (CRP 163 mg/l, WBC 14 x 103/ul), at the beginning the pleural rub over lung fields, then vesicular murmur lowered. There were X-ray examination of lungs and CT scan of spinal column carried out within the region of stabilization to find the source of inflammation. Dislocation of screw within T3 and T4 vertebral column was disclosed – it protruded about 9mm in front of T3 and 6mm in front of T4 vertebral body (Fig.4).

Fig. 4. CT scan of T3 and T4 screw extravertebral location

Inflammatory atelectasis connected with pleural exudates. The pleurisy was diagnosed. After consultation with neurosurgeon and thoracosurgeon, it was decided to abandon the operative treatment and apply conservative therapy. Patient discharged from hospital with improvement, tilted up. DISCUSSION The application of spinal column stabilization increased in frequency during the last few decades. It is connected with development of knowledge concerning spinal column injuries, operative techniques as well as application of more and more advanced instruments [7].

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The precursor of currently applied transpedicular stabilization technique was King which introduced the method in 1948. Roy-Camille improved it and spread within the 70’s. Unfortunately, along with increased amount of the transpedicular stabilization procedures, the problems connected with damages like: fractures or dislocations of screws appear more often. In accordance with Vanichkachorm, the value amounts to 3-19% and 4-8% - according to McAfee [7, 8]. The diameter of spinal canal is of great significance in thoracic spine fractures. The canal diameter of the thoracic spine is narrower than that of the cervical and lumbar spine. At the T6 level, the long axis of the spinal canal is approximately 16 mm in diameter, whereas in the middle of cervical and lumbar spine, the long axis is 23 mm and 26 mm, respectively. The smaller diameter may make fixation techniques such as sublaminar wire fixation more difficult. Dislocation of screws may damage partially or completely the spinal cord, roots, liquorrhoea as well as may cause the injury of main vessels [10, 11, 12]. There was compression on spinal roots noticed, correlated with pain ailments of thorax, escalated during the motion. In case of the third patient, dislocated screw at the level of T3 and T4 vertebral bodies, modulated the pleura, what caused inflammatory reaction. In the second case, incorrect location of transpedicular screw caused aneurysmal bulge of thoracic aorta at a distance of about 5 mm, where Th5 screw extremity adhered to it. The anatomical nearness of thoracic cord and the aorta presents increased danger of injury during the procedure [13]. Most of described injures of aorta, resulting from complication after transpedicular stabilization, were caused by the damage of wall due to interaction of vascular wall and metal instruments. Metal causes erosion of vascular walls and finally the aortoclasia, which may be deadly [12, 13, 14]. Another reason for damage of aorta is dislocation of transpedicular screws, what causes direct tremor of vascular wall. This dislocation caused formation of thoracic aorta false aneurysm in the first case report. Minor described similar case [14]; dislocation of screw within T5 segment caused aortic wall injury and it was discovered within the routine CT examination. Dislocation of transpedicular screws, described in our cases as well as by Minor, had place despite the

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fact that the procedures were enhanced by X-ray imaging. Such control presents a standard [8]. Nearness of thoracic spinal cord as well as aorta run the risk of vascular injury resulted from the procedure of screws removal [14, 16]. In the second case, the procedure of screw removal was carried out by posterior-access surgical procedure, in a presence of vascular surgeon and the operating room was prepared for the possible thoracotomy. Minor assumed the similar pattern of procedure [14]. Vanichkachorn describes difficulties of broken screw removal within T12 segment, which translocated during the procedure and had direct contact with aorta [7]. The possibility of aorta injury resulting from application of transpedicular stabilization in thoracic region of the spine is caused by nearness of these structures. Especially, the anterior-access procedures bring a risk of complications [12, 13, 16]. Iatrogenic false aneurysm of thoracic segments occurs during the invasive cardiologic procedures or after some time, as a postoperative complication (e.g. intraaortic counterpulsation) [13] or as a result of cardiosurgical procedures (after coarctation of the aorta, direct vascular wall injury, aortic valve replacement and others) [16, 17, 18]. Transpedicular stabilization presents rarely described etiology of such aneurysms. It seems, the correctly performed supervision of patients after transpedicular stabilization located within thoracic region, allows early detection of the possible complications. In accordance with many authors, the control should take place after 2, 8, 12, 26 and 52 weeks [8, 11, 14, 19, 21]. There is no standard regarding the imaging method (X-ray or CT scan). Computer tomography examination seems to be indicated at least in case of the first supervision. The back pain can not be disregarded in case of patients subjected to procedures of spinal cord injuries, which may stay irrelevant; however, it can result from dislocation of stabilization instruments, the presence of aortic aneurysm or irritation of other structures that are located within direct neighbourhood [22, 23, 24, 25, 26, 27, 28, 29]. CONCLUSIONS Complications prolong as well as disturb rehabilitation treatment. The control radiographic examinations need to be performed directly after operative treatment to evaluate

the stabilization system during walking and assuming of erect position. Increased pain ailments within spinal cord segment that was subjected to surgical procedure may signify the possible dislocation of screws. Such dislocation, noticed within thoracic region, can be lifethreatening, because of the nearness of the significant anatomical structures. REFERENCES 1. Paddison S, Middleton F. Spinal Cord Injury. (in) Stoces M. Physical Management in Neurological Rehabilitation. Edinburgh 2004: 125-152. 2. Walters R.L., Adkins R.H., Yakura J.S. et al. Motor and sensory recovery following incomplete paraplegia. Arch Phys Med Rehab 1994a, 75:67-72. 3. Collins W. Surgery in the acute treatment of spinal cord injury: a review of the past forty years. J Spinal Cord Med 1995, 18:3-8. 4. American Spinal Injuries Association (ASIA) International Standards for Neurological and Functional Classification of Spinal Cord Injury. Chicago: ASIA; 1992. 5. Ditunno J.F., Young W., Donovan W.H. The International Standards booklet for neurological and functional classification of spinal cord injury. Paraplegia 1994, 32; 70-80. 6. Ditunno J.F., Ditunno P.L., Graziani V. et al. Walking Index for Spinal cord injury (WISCI). An international multi centre validity and reliability study, Spinal Cord 2000, 38: 234-243. Revision: (WISCI II) Spinal Cord 2001, 39:654-656. 7. J.S. Vanichkachorn, A.R. Vaccaro, C.M. Cotler. Potential large vessel injury during thoracolumbar pedicle removal: a case report. Spine 1997, 22 (1); 110-113. 8. J. Yue, A. Sossan, C. Selgrath, S.L. Deutsch, K. Wilkens, M. Testaiuti, P.J.Gabriel. The treatment of unstable thoracic spine fractures with transpedicular screw instrumentation: a 3 year consecutive series. Spine 2002, 27 (24), 15; 2782-2787. 9. Leahy M. Thoracic Spine Fractures and Dislocations. www.emedicine.com/orthoped/topic567.htm 10. R. A. Dickson Spinal cord injuries. Early surgical treatment. Paraplegia 1992; 30: 43-45. 11. A. Vaccaro, S. Rizzolo, R.A. Balderston, T.J. Allardyce, S. R. Garfin, C. Dolinskas, H. S. Howard. Placement of pedicle screws in the thoracic spine. The Journal of Bone and Joint Surgery 1995, 77, 8; 1200-1206. 12. Tsutomu Ohnishi, Masashi Neo, Mutsumi Matsushita, Masashi Komeda, Tadaaki Koyama, Takashi Nakamura. Delayed aortic rupture caused by implanted anterior spinal device. The Journal of Neurosurgery (Spine 2) 95 2001; 253-256. 13. W Roy-Smythe, JP Carpenter. Upper abdominal aortic injury during spinal surgery. The Journal of Vascular Surgery 1997, 25; 774-777.


14. M.E. Minor, N.J. Morrissey, R. Peress, A. Carroccio, S. Ellozy, G Agarwal, V. Teodorescu, L. Hollier, M.L. Marin. Endovascular treatment of an iatrogenic thoracic aortic injury after spinal instrumentation: case report. The Journal of Vascular Surgery 2004, 39, 4; 893-897. 15. W.C Sternbergh , Gonze M.D, C.L Garrard , S.R. Money . Abdominal and thoracoabdominal aortic aneurysm. Surg Clin North Am 1998;78:827-43. 16. D W. Polly,J R.Orchowski, R G.Ellenbogen. Revision pedicle screws: bigger,larger shims-what is best? Spine 1998, 239 (12); 1374-1379. 17. Mandak J, Lonsky V, Dominik J, Zacek P. Vascular complications of the intra-aortic ballon counterpulsation. Angiology 2005; 70:69-74. 18. Ince H, Petzsch M, Rehders T, Kische S, Korber T, Weber F, et al. Percutaneous endovascular repair of aneurysm after previous coarctation surgery. Circulation 2004; 108 : 2967-70. 19. R.F. Mclain, JK Burkus, D.R. Benson. Segmental instrumentation for thoracic and thoracolumbar fractures: prospective analysis of construct survival and five year follow-up. The Spine Journal 2000, 1; 310-323. 20. Milas Z. L, Dodson T. F, Ricketts R. R. Pediatric blunt trauma resulting in major arterial injuries. The American Surgeon 2004; 70: 443-447. 21. Cook S. D., Salkeld S. L., Whitecloud T. S., Barbera J. Biomechanical testing and clinical experience with the OMEGA-21 spinal fixation system. The American Journal of Orthopedics. 2001; 30 (5): 387-94 22. Jendrisak M. Spontaneous abdominal aortic rupture from erosion by lumbar spine fixation device: A case report. Surgery 1986, 99, 5; 631-633 23. Heini P., Scholl E. Fatal cardiac tamponade associated with posterior spinal instrumentation. A case report. Spine 1998; 23(20): 2226-30 24. Finkelmeier A., Mentzler R. M. Chronic traumatic thoracic aneurysm: report of two cases with the question of timing for surgical intervention. The Journal of Cardiovascular Surgery; 1982, 84: 257-266 25. Bacharach J. M., Garratt K. N., Rooke T. W. Chronic traumatic thoracic aneurysm: report of two cases with the question of timing for surgical intervention. The Journal of Vascular Surgery 1993; 17: 780-3 26. Coselli J. S., LeMaire S. A. Surgical techniques. Thoracoabdominal aorta. Cardiol Clin 1999; 17: 751-65 27. Schnee Ch.L., Ansell L.W. Selection criteria and outcome of operative approaches for thoracolumbar burst fracture. The Journal of Neurosurgery 1997; 86: 48-56 28. Donovan W.H. Operative and nonoperative management of spinal cord injury. A review. Paraplegia 1994; 32: 375-388 29. Alho A. Operative treatment as a part of the comprehensive care for patients with injuries of thoracolumbar spine. Paraplegia. 1994; 32: 509-516

Address for correspondence: [email protected] Received: 8.03.2011 Accepted for publication: 5.07.2011

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CASE REPORT / PRACA KAZUISTYCZNA

Edyta Sutkowska1, Anna Kołtowska2, Krzysztof Mastej3, Rajmund Adamiec3

TUBEROUS SCLEROSIS, LATE DIAGNOSIS: A CASE ANALYSIS STWARDNIENIE GUZOWATE, PÓŹNE ROZPOZNANIE: OPIS PRZYPADKU

1

Department and Clinic of Orthopaedic and Traumatologic Surgery- Division of Rehabilitation Head of the Department: Prof Szymon Dragan Head of the Division of Rehabilitation: Prof Zdzisława Wrzosek 2 General Radiology, Interventional Radiology and Neuroradiology Clinic of Wroclaw Medical University3Department of Angiology, Hypertension and Diabetology of Wroclaw Medical University Summary Tuberous sclerosis (TS) is an uncommon, congenital disease, usually diagnosed during childhood. It is rare to find undiagnosed adult patient. The fundamental feature of TS is the presence of multifocal malignant tumors. In this study we present a case of a 50-year-old woman with multiple tumors.

The characteristic features e.g. on the brain and abdomen CT helped us diagnose this rare disease despite patient’s age. We aimed at stressing the importance of careful medical examination because of oligosymptomatic patients with TS.

Streszczenie Stwardnienie guzowate jest rzadką chorobą wrodzoną, zazwyczaj diagnozowaną już w dzieciństwie. Wyjątkiem są osoby dorosłe, u których diagnoza zapada w życiu dojrzałym. Typowo w tym schorzeniu występują liczne guzy, o bardzo różnej lokalizacji. W poniższym opracowaniu prezentujemy przypadek 50-letniej kobiety z późno zdiagnozowanymi, licznymi zmianami guzowatymi w narządach. Ze względu, jak wspomniano, na nietypowy dla rozpoznania stwardnienia

guzowatego, wiek pacjentki dopiero charakterystyczne zmiany w tomografii komputerowej głowy i jamy brzusznej pozwoliły na postawienie diagnozy. Opisany przykład podkreśla wagę dokładnych badań, także dodatkowych, u chorych z niejasnymi zmianami i konieczność uwzględnienia także nietypowych dla wieku, rzadko występujących chorób wrodzonych.

Key words: tuberous sclerosis, mutation, hamartoma, congenital disease Słowa kluczowe: stwardnienie guzowate, mutacja, hamartoma, choroba wrodzona

INTRODUCTION Tuberous sclerosis complex (TSC) is an uncommon, autosomal dominant disorder characterized by multifocal tumors. The prevalence of TSC is 1:8 000 to 1: 30 000 [1]. Disease is caused by mutations in the TSC1 and TSC2 tumor suppressor genes on chromosomes 9q34 and 16p13.3, respectively [2]. These mutations result in uncontrolled cell growth and tumourigenesis.

The main changes in TSC include hamartomas, hamartias, hamartoblastomas, or choriostomas [3]. In TSC a number of organs are affected, including the skin (prevalence depends on the type of disturbances), eyes (approximately 40%) [4], heart (rare in adults) and liver (40%-50%) [5], lungs (26%39%) [6,7], while the kidneys (75T-85%) [8] and brain

52

Edyta Sutkowska et. al.

(80%-95%) [9] are the two most frequently involved organs [10]. Tuberous sclerosis (TS) is a disorder with a variable clinical presentation usually diagnosed during childhood. Mental retardation and seizures are the most frequent clinical problems that are manifested during infancy or childhood. The diagnosis is based on clinical criteria - a combination of signs classified as major or minor [11], is required to establish a clinical diagnosis.

very small fatty tissue component); however, malignancy was not excluded. TSC was suggested.

CASE REPORT The study was approved by Commission of Bioethics of Wroclaw Medical University. A 50year-old lady with left calf pain, originally diagnosed as a symptom of deep venous thrombosis (DVT), was admitted to the hospital. The laboratory test results, including D-dimer, were within norms except for a slight increase in triglycerides and a slight decrease in the magnesium level. She denied any chronic diseases. She had 3 healthy, adult children and a 52-year-old healthy sister. Her mother died at 77 years of age from colon cancer and her father died at 57 years of age from a stroke. The physical examination showed a large, supple tumour in the left popliteal space-there was no swelling of the leg. An enlarged, heterogenic thyroid gland and multiple, yellow-red papules on her nose and cheeks were noted. She confirmed that she had been diagnosed and treated for acne since the age of 5. . The remainder of the physical examination was normal. The history included several years of recurrent abdominal pain. The pain was independent of the menstrual cycle, bowel movements, or meals. An ultrasound study did not show venous thrombosis, but revealed a large (5x10 cm) Baker’s cyst in the left popliteal space. A number of irregularities were detected on abdominal echography, so a CT scan was ordered. The abdominal tomography showed a few cysts within both lobes of the liver up to 3 cm in diameter, multiple nodular lesions within both kidneys with heterogeneous densities and heterogeneous contrast enhancement with small calcifications ( Fig.1, Fig.2). There was an enlarged lymph node, measuring 1.5 cm in the short axis, within the retroperitoneal space. The diagnosis suggested multiple benign tumours within the kidneys, most likely atypical angiomyolipomas (with or without a

Fig. 1. Right renal tumour-abdomen CT no 1 Ryc. 1. Guz prawej nerki-tomografia komputerowa jamy brzusznej nr 1

Fig. 2. Right renal tumour-abdomen CT no 2 Ryc. 2. Guz prawej nerki- tomografia komputerowa jamy brzusznej nr 2

There were inhomogenous and normoechogenic nodules in the ultrasound study of the thyroid. There were no changes on the chest x-ray and ECG. A CT scan of the head (Fig.3, Fig.4) showed several tiny calcified nodules bilaterally along the cauodothalamic grooves in the caudate nuclei areas and one adjoining to the body of the right ventricle. There were several further cortical and subcortical white matter calcified tubers in both the frontal and temporal lobes. The appearance was classified as compatible with TS. A dermatologic consultation described the skin changes as a high probability of angiofibromas.

Tuberous sclerosis, late diagnosis: a case analysis

Fig. 3. Brain CT no 1 Ryc. 3. Zmiany w tomografii komputerowej głowy- zdjęcie nr 1

53

tumours. Epithelioid angiomyolipomas can also be found [14]. For the brain, the most characteristic findings are subependymal and cortical and subcortical tubers. The prevalence of subependymal giant cell ependymomas (SEGAs) in patients with TSC is 6%-14% [15]. In such cases we found few important features characteristic of TSC, including facial angiofibromas, cortical tubers, subependymal nodules, 11 renal angiomyolipomas, and liver cysts. Our patient did not agree to further examination, or for psychological testing. It was a very awkward situation because of the possibility of renal cancer. Two things could influence the patient decision. Firstly, the patient’s mental status seemed to be slightly deficient and limited the comprehension of the problem and risk. Secondly, the course of the disease was nearly asymptomatic. We offered patient diagnostic tests and treatment wherever she decided for such care and informed her about obligatory control. As we presented, even for adult patients, we should consider the presence of rare congenital diseases. It is important especially if the patient’s clinical picture is not consistent with our findings (e.g. ultrasound). The brain characteristic image can be helpful for TSC detection even if there are no clear signs from nervous system. We aimed at stressing the importance of careful medical examination because of such kind oligosymptomatic patients. REFERENCES

Fig. 4. Brain CT no 2 Ryc. 4. Zmiany w tomografii komputerowej głowy- zdjęcie nr 2

The patient was referred to an urologist who recommended surgery for probable renal carcinoma. The patient did not consent to surgery or any other diagnostic tests (e.g., thyroid biopsy, skin biopsy, colonoscopy, or genetic tests). She was informed of the risk and was discharged from the hospital with an information card. CONCLUSIONS Renal lesions associated with TS are serious, as they are the second common cause of death after lesions of the nervous system [12]. The most common findings are polycystic kidney disease, renal lipomata, or renal cancer [13], as a result of many benign

1. Hong CH, Darling TN, Lee CH. Prevalence of Tuberous Sclerosis Complex in Taiwan: A National PopulationBased Study. Neuroepidemiology 2009; 33:335-341. 2. van Slegtenhorst M, de Hoogt R, Hermans C et al. Identification of the tuberous sclerosis gene TSC1 on chromosome 9q34. Science 1997; 277.5327:805-808. 3. Napolioni V, Curatolo P. Genetics and molecular biology of tuberous sclerosis complex. Curr Genomics 2008; 9:475-487. 4. Rowley SA, O’Callaghan FJ, Osborne JP. Ophthalmic manifestations of tuberous sclerosis: a population based study. Br J Ophthalmol 2001; 85:420-423. 5. Jozwiak S, Michalowicz R, Pedich M et al. Hepatic hamartoma in tuberous sclerosis. Lancet 1992; 339:180. 6. Franz DN, Brody A, Meyer C et al. Mutational and radiographic analysis of pulmonary disease consistent with lymphangioleiomyoma-tosis and micronodular pneumocyte hyperplasia in women with tuberous sclerosis. Am J respire Crit Care Med 2001; 164:661668. 7. Costello LC, Hartman TE, Ryu JH. High frequency of pulmonary lymphangioleiomyomatosis in women with

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8.

9.

10.

11.

12.

13. 14.

15.

Edyta Sutkowska et. al. tuberous sclerosis complex. Mayo Clin Proc 2000; 75:591-594. Roach ES, Sparagana SPJ. Diagnosis of tuberous sclerosis complex. Child Neurol 2004; 19:643-649; Review. Shepherd CW, Hoser OW, Gomez M. MR findings in tuberous sclerosis complex and correlation with seizure development and mental impairment. Am J Neuroradiol 1995; 16:149-155. Dumitrescu D, Georgescu EF, Niculescu M et al. Tuberous sclerosis complex: report of two intrafamilial cases, both in mother and daughter. Rom J Morphol Embryol 2009; 50:119-124. Roach ES, Gomez MR, Northrup H. Tuberous sclerosis complex consensus conference: revised clinical diagnostic criteria. J Child Neurol 1998; 13:624-628. Sague LJ, Borrego PL, Salas CR et al. Urological conservative management of a patient with tuberous sclerosis complex (Bourneville disease). Arch Esp Urol 2009; 62:596-599. Bonsib SM. Renal cystic disease and renal neoplasms: a mini-review. Clin J Am Soc Nephrol 2009; 4:1998-2007. D’Antonio A, Caleo A, Caleo O et al. Monotypic epithelioid angiomyolipoma of the adrenal gland: an unusual site for a rare extrarenal tumor. Ann Diagn Pathol 2009; 13:347-350. Adriaensen ME, Schaefer-Prokop CM, Stijnen T et al. Prevalence of subependymal giant cell tumors in patients with tuberous sclerosis and a review of the literature. Eur J Neurol 2009; 16:691-696.

Address for correspondence: tel.: 48 71 734 32 20; 48/503077016 fax:48 71 734 32 09; e-mail: [email protected] Received: 10.01.2011 Accepted for publication: 13.02.2012

Selected articles presented during the 2nd International Conference „Europejski Wymiar Nauk o Zdrowiu” organized on the occasion of the XVth Anniversary of Faculty of Health Sciences at Collegium Medicum, Nicolaus Copernicus University BYDGOSZCZ, March 19-20, 2012

GUEST EDITOR: PROFESSOR ZBIGNIEW BARTUZI


CONTENT

p.

Ewa Barczykowska, Anna Burczyk, Iwona Sadowska-Krawczenko, M a r t a G r a b i n s k a , A n d r z e j K u r y l a k – Quality of life in children, adolescents and young adults suffering from cystic fibrosis and in their parents . . . . . . . . . . . . . . . . . . . . . . . . .

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G r a ż y n a B ą c z e k , E w a D m o c h - G a j z l e r s k a – Independent midwifery practice in Poland – legal considerations versus reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Bernadeta Cegła, Małgorzata Filanowicz, Aneta Dowbór-Dzwonka, E w a S z y n k i e w i c z – Does the character of hypertension and mode of therapy determine changes in the quality of life? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Kamila Faleńczyk, Agnieszka Pluta, Wiesława Kujawa, Halina Basińska, M a r i a B u d n i k - S z y m o n i u k , A l i c j a M a r z e c – Analysis of problems and their determinants among family caregivers taking care of chronically ill people . . . . . . . . . . . . . . . . . . .

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M i r o s ł a w a F e l s m a n n , A g a t a K o s o b u c k a – The influence of external, internal and artificial environment upon the occurrence of breast cancer and coping with this disease. The verification of the systemic theory of Betty Neumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Mirosława Felsmann, Barbara Futyma, Mariusz Zbigniew Felsmann, M a r z e n a A n n a H u m a ń s k a , B e a t a H a o r – Quality of life in children with epilepsy, evaluated by the parents on the basis of QOLCE questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Grażyna Franek, Marta Ćmiel-Giergielewicz, Zofia Nowak-Kapusta, M a r z e n a Z m y s ł o - R o g o z i k – Awareness of risk factors assessment among individuals with ischemic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Małgorzata Graczyk, Michał Przybyszewski, Jacek Tlappa, Jacek Mućka, Andrzej Kuźmiński, Magdalena Żbikowska-Gotz, Ewa Szynkiewicz, Katarzyna Napiórkowska, Joanna Kołodziejczyk, Robert Zacniewski, A n n a R ó ż a l s k a , Z b i g n i e w B a r t u z i – Determination of ECP concentration in patients with allergic type of food hypersensitivity and in subjects with dyspeptic symptoms not associated with food allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Anna Grzanka-Tykwińska, Alicja Rzepka, Katarzyna Porzych, Krzysztof K u s z a , K o r n e l i a K ę d z i o r a - K o r n a t o w s k a – The quality of life of patients over 60 including demographic and environmental factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Beata Haor, Kamila Korniluk , Mirosława Felsmann, Marzena Humańska – Tasks of a nurse in seniors’ preparation for self-care in the course of type 2 diabetes . . . . . . . . . .

125

Judyta Kutowska, Małgorzata Gierszewska, Estera Mieczkowska, G r a ż y n a G e b u z a , M a r z e n a K a ź m i e r c z a k – Quality of life among women with gestational diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

133

M a g d a l e n a M i ń k o , D o r o t a S i w c z y ń s k a – Breast cancer prevention as a part of health policy activities in Lublin province . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

139


Agnieszka Pluta, Magdalena Skrzeszewska, Halina Basińska, M a r i a B u d n i k - S z y m o n i u k , K a m i l a F a l e ń c z y k – The functional efficiency in elderly patients treated with hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

143

Iwona Sadowska-Krawczenko, Agata Staśkiewicz, Andrzej Kurylak, B a r c z y k o w s k a E w a , A l d o n a K a t a r z y n a J a n k o w s k a – The knowledge of nurses working in pediatric wards of assessment and treatment of pain in children . . . . . . . . . . .

149

P a w e ł S z c z u d ł o , M a r t a H r e ń c z u k – Variability of drugs with narrow therapeutic window in transplantology – potential costs and clinical consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

155

Monika Zawadka, Paweł Zalewski, Jacek J. Klawe, Małgorzata Tafil-Klawe, Joanna Pawlak, Krzysztof Kunikowski, Anna Bitner – Cardiovascular autonomic regulation in response to orthostatic stress with Parkinson’s disease – case report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

161

A n e t a Z r e d a - P i k i e s , A n d r z e j K u r y l a k – Evaluation of the quality of life of children who have completed acute lymphoblastic leukemia treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

169


SPIS TREŚCI str. Ewa Barczykowska, Anna Burczyk, Iwona Sadowska-Krawczenko, M a r t a G r a b i n s k a , A n d r z e j K u r y l a k – Jakość życia dzieci, młodzieży i młodych dorosłych chorych na mukowiscydozę oraz ich rodziców . . . . . . . . . . . . . . . . . . . . . . . . .

61

G r a ż y n a B ą c z e k , E w a D m o c h - G a j z l e r s k a – Samodzielna praktyka położnej w Polsce – uwarunkowania prawne a rzeczywistość . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

69

Bernadeta Cegła, Małgorzata Filanowicz, Aneta Dowbór-Dzwonka, E w a S z y n k i e w i c z – Czy specyfika choroby nadciśnieniowej i sposób przyjmowania leków w zastosowanej terapii są determinantami zmian w jakości życia chorych? . . . . . . . . . . . . . . . . . . .

77

Kamila Faleńczyk, Agnieszka Pluta, Wiesława Kujawa, Halina Basińska, M a r i a B u d n i k - S z y m o n i u k , A l i c j a M a r z e c – Analiza problemów opiekunów rodzinnych osób przewlekle chorych oraz czynników wpływających na ich występowanie . . . . . .

85

M i r o s ł a w a F e l s m a n n , A g a t a K o s o b u c k a – Wpływ środowiska zewnętrznego, wewnętrznego i wykreowanego na występowanie raka piersi i radzenie sobie z chorobą. Weryfikacja teorii systemowej Betty Neumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

93

Mirosława Felsmann, Barbara Futyma, Mariusz Zbigniew Felsmann, M a r z e n a A n n a H u m a ń s k a , B e a t a H a o r – Jakość życia dzieci z padaczką w ocenie rodziców na podstawie kwestionariusza QOLCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

99

Grażyna Franek, Marta Ćmiel-Giergielewicz, Zofia Nowak-Kapusta, M a r z e n a Z m y s ł o - R o g o z i k – Ocena stanu wiedzy na temat czynników ryzyka wśród chorych z niedokrwienną chorobą serca . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

107

Małgorzata Graczyk, Michał Przybyszewski, Jacek Tlappa, Jacek Mućka, Andrzej Kuźmiński, Magdalena Żbikowska-Gotz, Ewa Szynkiewicz, Katarzyna Napiórkowska, Joanna Kołodziejczyk, Robert Zacniewski, A n n a R ó ż a l s k a , Z b i g n i e w B a r t u z i – Ocena stężenia ECP u pacjentów z nadwrażliwością pokarmową typu alergicznego i u pacjentów z objawami dyspeptycznymi bez alergii pokarmowej . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

113

Anna Grzanka-Tykwińska, Alicja Rzepka, Katarzyna Porzych, Krzysztof K u s z a , K o r n e l i a K ę d z i o r a - K o r n a t o w s k a – Jakość życia pacjentów powyżej 60 roku życia z uwzględnieniem czynników demograficzno-środowiskowych . . . . . . . . . . . . . . . . .

119

Beata Haor, Kamila Korniluk , Mirosława Felsmann, Marzena Humańska – Zadania pielęgniarki w przygotowaniu do samoopieki seniorów w przebiegu cukrzycy typu 2 . .

125

Judyta Kutowska, Małgorzata Gierszewska, Estera Mieczkowska, G r a ż y n a G e b u z a , M a r z e n a K a ź m i e r c z a k – Jakość życia kobiet z cukrzycą ciążową . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

133


M a g d a l e n a M i ń k o , D o r o t a S i w c z y ń s k a – Profilaktyka raka piersi jako element działań z zakresu polityki zdrowotnej w województwie lubelskim . . . . . . . . . . . . . . . . . . . . . . . . . .

139

Agnieszka Pluta, Magdalena Skrzeszewska, Halina Basińska, M a r i a B u d n i k - S z y m o n i u k , K a m i l a F a l e ń c z y k – Sprawność funkcjonalna u pacjentów w wieku podeszłym leczonych hemodializą . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

143

Iwona Sadowska-Krawczenko, Agata Staśkiewicz, Andrzej Kurylak, B a r c z y k o w s k a E w a , A l d o n a K a t a r z y n a J a n k o w s k a – Wiedza pielęgniarek pracujących w oddziałach pediatrycznych w zakresie oceny i leczenia doznań bólowych u dzieci . .

149

P a w e ł S z c z u d ł o , M a r t a H r e ń c z u k – Zmienność leków o wąskim oknie terapeutycznym w transplantologii – potencjalne koszty I konsekwencje kliniczne . . . . . . . . . . . . . . . . . . . . . . . . . .

155

Monika Zawadka, Paweł Zalewski, Jacek J. Klawe, Małgorzata Tafil-Klawe, Joanna Pawlak, Krzysztof Kunikowski, Anna Bitner – Autonomiczna regulacja sercowo-naczyniowa w odpowiedzi na pionizację u pacjentów z chorobą Parkinsona – studium przypadku . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

161

A n e t a Z r e d a - P i k i e s , A n d r z e j K u r y l a k – Ocena jakości życia dzieci po zakończonym leczeniu ostrej białaczki limfoblastycznej . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

169


Ewa Barczykowska1, Anna Burczyk2, Iwona Sadowska-Krawczenko1, Marta Grabinska3, Andrzej Kurylak1

QUALITY OF LIFE OF CHILDREN, ADOLESCENTS AND YOUNG ADULTS SUFFERING FROM CYSTIC FIBROSIS AND OF THEIR PARENTS JAKOŚĆ ŻYCIA DZIECI, MŁODZIEŻY I MŁODYCH DOROSŁYCH CHORYCH NA MUKOWISCYDOZĘ ORAZ ICH RODZICÓW

1

Paediatric Nursing Research Institute Nicolaus Copernicus University in Toruń Collegium Medicum in Bydgoszcz

2

Graduate from nursing, second level degree studies at , Nicolaus Copernicus University in Toruń Collegium Medicum in Bydgoszcz, operating theatre ward at A. Jurasz University Hospital no. 1. in Bydgoszcz.

3

Students' Paediatric Nursing Research Society, student of nursing research, first level degree full-time studies at Nicolaus Copernicus University in Toruń Collegium Medicum in Bydgoszcz

Summary A i m . Assessment of quality of life of children, adolescents and adults suffering from cystic fibrosis and of their parents. Met h o d s . Examination involved 23 persons (16 patients and 7 parents). Questionnaires CDQ-12-13, CFQ-14 and CFQ-6-13 were used as research tools. R e s u l t s . Children between 12 and 13 years old, as well as young adults and adolescents ranked their physical aptitude and their food-related behaviours as highest, and the appearance of their bodies as lowest. Parents, on the other hand, assessed eating as a difficult effort for their children. A

decisive majority of the parents claimed, that everyday therapy was time-consuming, yet fulfilling the therapy recommendations was not intensely difficult for the child. Also for adolescents and young adults, only minimally do the limitations resulting from a prolonged systematic therapy obstruct everyday life. C o n c l u s i o n . The assessment of quality of life of children suffering from cystic fibrosis is varied. The highest patients' quality of life assessment is found in schoolchildren aged 12 to 13. Patients assess their body image as very poor.

Streszczenie C e l . Ocena jakości życia wśród dzieci, młodzieży i dorosłych chorych na mukowiscydozę oraz ich rodziców. M e t o d y . Badaniu poddano 23 osoby (16 chorych i 7 rodziców). Jako narzędzia badawcze wykorzystano kwestionariusze CFQ-12-13, CFQ-14 + oraz CFQ- 6-13. W y n i k i . Dzieci w wieku 12-13 lat oraz młodzi dorośli i młodzież powyżej 14 lat najwyżej ocenili funkcjonowanie fizyczne oraz zachowania związane z jedzeniem a najniżej wygląd własnego ciała. Natomiast rodzice najwyżej ocenili stan emocjonalny, a najniżej zakres dotyczący masy ciała chorego dziecka. Wśród chorych na

mukowiscydozę problemy związane z jedzeniem występują sporadycznie. Natomiast większość rodziców chorych dzieci ocenia, że jedzenie jest dla dzieci trudne. Zdecydowana większość rodziców stwierdza, że codzienna terapia jest czasochłonna, jednak stosowanie się do zaleceń terapeutycznych nie sprawia dziecku dużych trudności. Także dla młodzieży i młodych dorosłych ograniczenia związane z przewlekłym i systematycznym leczeniem w niewielkim stopniu utrudniają życie codzienne. Wnioski. Ocena jakości życia dzieci z mukowiscydozą jest zróżnicowana. Najwyższa ogólna ocena

62

Ewa Barczykowska et. al.

jakości życia wśród chorych występuje w grupie dzieci szkolnych w wieku 12-13 lat. Chorzy bardzo nisko oceniają

wygląd własnego ciała.

Key words: quality of life, children, cystic fibrosis Słowa kluczowe: jakość życia, dzieci, mukowiscydoza

INTRODUCTION Cystic fibrosis (CF) is a genetically conditioned, multi-organ systemic disease [1, 2, 3]. The disease is caused by mutation of a gene coding protein synthesis, CFTR (Cystic Fibrosis Transmembrane Regulator), which regulates transportation of ions within the cell membrane. Due to disturbances in the transportation of chloride ions, re-absorption of sodium ions and water is increased, while mucus rises in density and viscosity. As a result, an irreversible and gradual depletion of respiratory system occurs [1, 2, 4].Chronic infections of respiratory tracts, as well as bronchitis, lead to a gradual respiratory failure [5]. In 85-90% of cases exocrine pancreatic insufficiency and gastrointestinal problems occur. The clinical picture is conditioned by the patient's age [1]. Standard therapy in cystic fibrosis is multidirectional and includes antibiotic therapy, chest physiotherapy, bronchi-expanding and antiinflammatory medicines, oxygen therapy and treatment of late after-effects of the disease and its complications [6, 7, 8]. All patients receive pancreas enzyme preparations before each meal, pharmaceuticals decreasing hydrochloric acid secretion, preparations of vitamin A, D, E and K. An intensive consumption of calories (130% of norm) is necessary [2, 9]. An early beginning of treatment leads to progression of changes and is a key to increasing quality of life in CF patients [10]. Progress in medicine over the years led to extension of cystic fibrosis patients' lifespan [2, 6, 7]. Average lifespan of these patients increased from 31 to 37 years over the last decade (30 years in 1999) [11, 12]. Average lifespan for children born in the 21st century is estimated as 50 years [13]. A well managed therapy effects in a satisfactory quality of life for most adult patients [7]. The disease and its treatment have a considerable impact on patient's everyday life [2, 9, 14]. Therefore, examining the influence of the disease on patient's quality of life has become very popular in recent years. Such examination aims, among other goals, at determining the impact of treatment on patient's functioning, assessing benefits and losses ensuing from introduction of new forms of therapy, facilitating clinical decision making [15, 16, 17].

First results of cystic fibrosis patients' quality of life examination were published in 1989. The research concentrated on assessing the physical mobility and social limitations in the context of respiratory system's functioning and exercise-stress capacity [18, 19]. Later research involved measuring the effect of different therapies, including lungs transplantation [20, 21]. Valuable research compared cystic fibrosis patients' quality of life to the quality of life of patients suffering from other chronic diseases of the respiratory system [22, 23]. AIM OF THE RESEARCH The research aimed at assessing the quality of life in cystic fibrosis patients, including physical activity, roles played by the patient, vitality, social and emotional activity, perception of patient's own condition, body image, digestion disturbances, Treatment Constrains, symptoms within the respiratory and digestive systems. Research problems were formed into the following questions: 1. Which of the areas covered by the examination were ranked highest and lowest by adolescents and adults, by schoolchildren and parents of children aged 6 to 13? 2. What is the general quality of life rating in cystic fibrosis patients in a group of adolescents and adults, schoolchildren and parents of children aged 6 to 13? 3. How do cystic fibrosis patients perceive their own bodies? 4. What was the rating of digestive behaviours in adolescents and adults, schoolchildren and parents of children aged 6 to 13? 5. How do patients perceive constrains related to their treatment? PATIENTS AND METHODS Research involved examining 23 persons: parents of children aged 6-13, adolescents and young adults suffering from cystic fibrosis, who were patients of

Quality of life of children, adolescents and young adults suffering from cystic fibrosis and of their parents

Paediatrics, Pneumologic and Alergologic Ward with Infant Subward and of cystic fibrosis out-patient clinic at Children's Regional Hospital in Bydgoszcz. In the research conducted among parents, a decisive majority of their children were aged between 12 and 13 (42.9% and 28.6%). There were also two younger children, aged 8 and 10 (14.3%). Questionnaires were filled by mothers only (100%). The mothers were aged between 33-35 (42.9%) and 36-47 (57.1%). A decisive majority of children came from married parents; one child had parents living in concubinage. 42.9% of the women were graduates of high schools and the same percentage graduated from vocational schools. Questioned about current occupation, 57% of the mothers answered: „housekeeping”, while 28.6% worked full-time or part-time. Most children (71.4%) studied in schools. In case of questionnaire CFQ-14+, 61.5% respondents were persons between 14 and 17 years, while 38.5% are persons between 20 and 28 years. A decisive majority of the respondents, 10 persons, were women (76.9%), while 3 were men (23.1%). Questioned about school and work, 53.8% of the respondents answered, they kept going to school as usual. 4 persons (30.8%) answered, they restrained from going to school or work because of health problems. Among 13 respondents, only 1 was married, and 92.3% were single. Questioned about education, 61.5% respondents confessed they graduated from a high school. Only 1 person had achieved a high school finals diploma (7.7%), the same number completed a junior college, 23.1% graduated from a vocational school. Answering the question about educational or occupational situation, 38.5% responded they attended classes at school, while 30.8% learned at home. 1 person (7.7%) worked full- or part-time, the same number was searching for a job. Only 1 person admitted they did not go to school or work because of their health condition. Questionnaire CFQ-12-13 was filled by 3 persons only. 66.7% were children aged 12, and 33.3% were children aged 13. Majority of the group consisted of girls (66.7%), boys forming 33.3%. 2 children (66.7%) attended classes at school as usual, the same number were 5th grade primary school pupils. Only 1 person had an individual mode of education. Research was done using a polish version of Quality of Life Questionnaire adapted for children and adults with cystic fibrosis, as well as for their parents

63

(CFQ-R). The Questionnaire consisted of three versions: - adolescents and parents (age 14 and older) - CFQ14+, - older schoolchildren (age 12-13) - CFQ-12-13, - parents of children aged 6 to 13 - CFQ-6-13. The original version of the questionnaire was assembled in France and became adapted in Germany, Netherlands, Brazil and United States. The Polish version of the questionnaire originated from an international research and is adapted from the American test. The questionnaires were adjusted to Polish conditions by D. Sands, Ph.D., and U. Borawska-Kowalczyk, MA at Mother and Child Institute in Warsaw [24]. The aim of the statistic analysis was to determine quality of life in groups of patients for each domain, and to compare general quality of life levels in these groups. Parametric and non-parametric significance tests were used to verify hypotheses proposed. Respondents filled the questionnaires answering questions they contained. Questions demanded answering with grades according to Likert's scale, from 1 to 4. In several cases, grades in the questionnaire demanded an inversion, following the formula: grade= 5-X, where X was a grade to be inverted. Standardized quality of life ratings (QoLR) of each patient in a given domain were calculated according to the formula: sum of points − minimum possible sum of points QoLR= ───────────────────────────── x 100 maximum possible sum of points - minimum possible sum of points All QoLR values are situated within the range of 0 to 100, a higher rating signifies a better quality of life. RESULTS In the analysis and discussion of the results, a system resulting from specific research problems of this paper was used. 1. Areas ranked highest and lowest by adolescents and young adults, schoolchildren and parents of children aged 6 to 13.


7

81.5 93.3 80.0 50.0 55.6 77.8 77.8 66.7 77.8 88.9 88.9

M

70.9 74.3 64.8 61.9 52.4 57.1 58.7 33.3 63.5 71.4 66.7

SD

17.3 15.1 12.0 35.6 17.8 32.3 24.6 27.2 28.5 24.1 29.4

Digestive behaviours

Treatment Constrains

Respiratory system functioning

33.3

M

79.6 73.6 77.8 48.1

55.6

74.1

75.0

66.7

29.4

17.0

16.7

33.3

7.3

28.0

Group 2. Children aged 12 and 13. The examined group included 3 children at this age. Highest results were achieved in scales measuring physical functioning (M=79.6) and social limitations (M=77.8). Lowest were the ratings related to body image (M=48.1) and digestive behaviours (M=55.6). Group 3. Adolescents and adults (patients aged over 14). (table 3). Table III. Means and standard deviations for respective areas of the CFQ-14+ test Areas

1 100 83.3 86.7 100 100 100 77.8 88.9 100 100 100

100

2 37.5 33.3 6.7 66.7 44.4 33.3 50.0 33.3 25.0 66.7 55.6 88.9 3 50.0 83.3 66.777.8 66.7 88.9 83.3 66.7 75.0 100 94.4 100.0 4 33.3 33.3 53.333.3 33.3 44.4 50.0 55.6 58.3 33.3 0.0

22.2

5 79.2 33.3 6.7 77.8 88.9 55.6 55.6 0.0 66.7 33.3 83.3 66.7 6

Highest results were achieved in the areas related to the emotional state (M=74.3) and functioning of the respiratory system (M=71.4), while the lowest result was achieved in the area of body mass (M=33.3). (table 2).

Emotional condition

SD 21.0 13.4

Digestive sytem functioning

Body image

58.3

Social limiations

88.9

Physical functioning

33.3

Respiratory system functioning Digestive sytem functioning

70.4 86.7 60.0 100.0 77.8 100.0 44.4 66.7 66.7 77.8 88.9

94.4 83.3 85.7 77.8

Body mass

6

3

Role limitations

88.9 73.3 60.0 50.0 44.4 55.6 77.8 33.3 77.8 55.6 44.4

66.7

Body image

40.7 66.7 66.7 83.3 22.2 33.3 33.3 33.3 11.1 66.7 77.8

5

100

91.7

Social limiations

4

75.0

55.6

Health perception

74.1 73.3 80.0 50.0 66.7 66.7 77.8 33.3 66.7 83.3 100

77.8

44.4


85.2 46.7 46.7 00.0 55.6 00.0 22.2 00.0 44.4 100.0 22.2

3

88.9

88.9 58.3 71.4 22.2


55.6 80.0 60.0 100.0 44.4 66.7 77.8 00.0 100 27.8 44.4

2

55.6 79.2 76.2 44.4

2

Emotional condition

1

1

Vitality

Respiratory system functioning

Body mass

School performance

Body image

Social limiations

Health perception



Emotional condition

Vitality


Respondents

Areas

Areas


Table I. Means and standard deviations for respective areas of the CFQ-6-13 test

Table II. Means and standard deviations for respective areas of the CFQ-12-13 test

Respondents

2. General CF patients' quality of life rating in the group of adolescents and young adults, schoolchildren and parents of children aged 6 to 13. 3. Body appearance rating. 4. Digestive behaviours in adolescents and young adults, schoolchildren and parents of children aged 6 to 13. 5. Treatment Constrains. 1. Areas ranked highest and lowest by adolescents and young adults, schoolchildren and parents of children aged 6 to 13. Group 1. Parents/ legal guardians of children aged 6 to 13. The following table contains quality of life ratings for each of the 7 respondents in respective domains, calculated according to the foregoing formula, as well as mean values (M) and standard deviations (SD) in each domain. (table1)

Respondents

64

4.2 50.0 46.766.7 33.3 22.2 44.4 33.3 50.0 0.0 61.1 77.8

7 66.7 25.0 100 100 55.6 77.8 66.7 100 58.3 100 27.8 66.7 8 70.8 66.7 86.7 100 44.4 77.8 77.8 55.6 66.7 66.7 44.4 88.9 9 91.7 66.7 100 100 88.9 77.8 88.9 100 83.3 100 88.9 88.9 10 70.8 33.3 46.788.9 66.7 44.4 61.1 0.0 50.0 33.3 72.2 44.4 11 62.5 58.3 66.7 100 33.3 66.7 55.6 66.7 50.0 0.0 22.2 66.7 12 66.7 83.3 100 100 66.7 88.9 66.7 11.1 100 0.0 72.2 88.9 13 79.2 75.0 86.7 100 66.7 44.4 88.9 33.3 83.3 66.7 50.0 88.9 M 62.5 55.8 65.685.5 60.7 63.2 66.7 49.6 66.7 53.8 59.4 76.1 SD 25.9 22.1 32.520.5 22.5 24.2 15.4 34.7 21.5 39.8 30.1 22.6


The test for persona over 14 revealed highest results in the scale for digestive behaviours (M=85.5) and functioning of the digestive system (M=76.1), and the lowest results in the area related to body image (M49.6) and body mass (M=53.8). 2. quality of life rating among cystic fibrosis patients, in the group of adolescents and adults, schoolchildren and parents of children aged 6-13. The following table presents mean values and standard deviations for quality of life ratings in the three compared groups, as well as the result of testing distribution normality in group 2 numbering less than 50. ( table 4) Table IV. Mean values and standard deviations for quality of life ratings

W

Group 1 77 61.4 25.8 -

Group 2 24 68.8 21.5 0.940

Group 3 156 63.8 27.5 -

Wkr

-

0.914

-

normality

n/a

yes

n/a

n* Mean SD ShapiroWilk's test for normality

Among the three groups the highest quality of life was found in children aged 12 and 13. Shapiro-Wilk's test for normality did not reject a hypothesis that the distribution of quality of life ratings in group 2 did not significantly differ from a normal distribution. To compare mean values, a z-test was used, based on a normal distribution and Student's t test. Z-test is used to compare mean values in two large (>50) groups, in this case groups 1 and 3. It was proved, that the distribution of quality of life ratings in group 2 did not significantly differ from the normal. Snedecor's F test also did not detect significant differences between variances in groups 1-2 and 2-3 (values of calculated F-statistics are lower than critical values). This allowed using the Student's parametric t test to compare mean values in these groups. To compare groups 1-3 the z-test was used. No significant difference between mean quality of life ratings in the compared groups was detected. All values received through statistic calculations are lower than critical values collected from respective tables at significance level p=0.05. 3. Perception of body image. Body image received the lowest grade among all domains ranked by the respondents. In one of the

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groups it received a mean value M of 48.1, while in the other, 49.6. Questions about body mass appeared in two versions of the test only, and also this domain was not ranked high among CF patients and their parents. The parents graded this domain very poor (M=33.3). 4. Digestion-related behaviours among adolescents and adults, schoolchildren and parents of children aged 6-13. Rating digestion-related behaviours, patients with cystic fibrosis and their parents ranked high compared to other domains. Adolescents and adults suffering from cystic fibrosis received a high result in this domain (M=85.5). Questioned about difficulties related to eating, most parents agreed, that eating was difficult for their children. Over a half of adolescent and adult respondents (69.2%) claimed they always ate with pleasure. Ranking an answer about forcing themselves to eat, 84.6% claimed it was untrue. Difficulties with eating appeared occasionally or never in 92.3% of respondents. 5. Limitations related to treatment. Answering questions about treatment-related limitations, 85.7% of parents of children aged 6 to 13 answered, that to follow therapy instructions daily causes child little difficulty. Moreover, a large number of parents (71.4%) claimed, that treatment did not obstruct child's everyday activities. A majority of parents though, namely 85.8%, confirmed that medical procedures take a considerable amount of time every day. 84.6% of adolescents and adults answering questions about treatment-related limitations claimed that treatment caused little or some difficulties for their everyday life. Questioned about perception of everyday treatment, 61.6% claimed, that treatment had caused them little or no difficulty. DISCUSSION As research reveals, the age of the examined patient is one of the factors determining perception of quality of life [19, 25]. Results of research undertaken by Sands and Borawska-Kowalczyk on 128 persons (91 cystic fibrosis patients and 37 parents) show, that children aged 12-13 achieved the most points in scales measuring emotional state (M=72.91) and functioning of the respiratory system (M=72.12), while the least

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points were achieved in the areas related to body image (M=65.38) and limitations associated with digestion (M=65.81) [24]. In our independent research, the highest results for the same age group were achieved in the scales measuring physical functioning and social limitations, while the lowest were achieved in areas related to body image and digestive limitations. In instances, body image as well as digestive limitations was ranked poorest. In the test by Sands and Borawska-Kowalczyk for persons aged over 14, digestion-related behaviours ranked highest (M=84.23) and body mass perception ranked lowest (M=55.91) [24]. These results agree with the results of our research. Subject literature suggests differences between quality of life perception by child patients [25] and their parents. In the parents' questionnaire Sands and Borawska-Kowalczyk received the highest ranks in the area related to functioning of the digestive system (M=81.68), while the lowest ranks appeared in the area related to body mass (M=48.65) [24]. Our research does not confirm this as for the highest ranks. Parent respondents indicated the area related to emotional stress and functioning of the respiratory system. However, we recorded agreement of the results in the lowest range, which is the child patient's body mass. Cystic fibrosis patients perceive their digestive problems as intermittent. Nevertheless, Polish research on CF child patients' nutrition conducted by Brudziński and focusing on biological indicators, revealed deficient body mass in relation to height in 35% of children. L. Majek's research showed underweight in 64% of respondents [26]. Analysis of our independent research's results indicates that a decisive majority of cystic fibrosis patients are aware of the fact, that they experience problems with body mass and body image as compared to their healthy peers. A majority of child patients' parents define eating as difficult for children. A decisive majority of the parents claim, that everyday therapy takes time, nevertheless following therapy recommendations does not cause significant difficulties for the child. Hegarty notes, that “treatment burden” is perceived as less significant by child patients aged 6 to 13, than by their parents [25]. Global quality of life factor achieved by respondents varies between (M=61.4) and (M=68.8). In the research conducted by Sands and BorawskaKowalczyk quality of life factor is higher than in our research, and amounted to (M=70.21) in children aged

12-13, (M=65.2) in parents, and (M=70.4) in patients aged over 14 [24]. Belgian research reveals that beginning education or work by CF patients is closely connected with health condition. Decision to stop attending classes at school or quit work, is difficult and has impact on personal, social and financial quality of life [27]. In Majek's research, the number of CF patients engaging in marriages or employment is low. 36% had never worked professionally, and 16% lived in formal or informal relationships. One can notice a high percentage of persons with high school education (about 88% of respondents graduated from a primary school) [26]. Every chronic disease evokes strong negative emotions. Many authors emphasise not only somatic symptoms on patient's functioning, but also mental burden as well [28, 29]. In Staab's research special attention was focused on the demand to mentally support the patient with their adaptation and everyday functioning with a chronic disease like cystic fibrosis, and not only delivering medical service [30]. CONCLUSION 1. Quality of life assessment for children with cystic fibrosis is varied. 2. Highest general ranking of quality of life among patients appears in a group of schoolchildren aged 1213. 3. Patients rank their body image very poor. BIBLIOGRAPHY 1. Davies JC, Alton EW, Bush A, Cystic fibrosis. BMJ 2007 Dec 15; 335(7632):1255-9. 2. Ernst MM, MC Johnson, Stark LJ, Developmental and psychosocial issues in cystic fibrosis. Child Adolesc Psychiatr Clin N Am 2010 Apr; 19(2): 263-83. 3. Program Badań Przesiewowych w Polsce na lata 20092014, www.mz.gov.pl [02.03.2011]. 4. Narasimhan M, Cohen R, New and investigational treatments in cystic fibrosis. Rher Ady Respir Dis 2011 Mar 3 [PubMed 7.05.2011] 5. Zemanick ET, Sagel SD, Harris JK, The airway microbione in cystic fibrosis and implications for treatment. Curr Opin Pediatr 2011 Apr 13 [PubMed7.05.2011] 6. O’Sullivan BP, Flume P, The clinical approach to lung disease in patients with cystic fibrosis. Semin Respir Crit Care Med 2009 Oct; 30(5): 505-13.


7. Dalcin T, Abreu e Silva, Cystic fibrosis in adults: diagnostic and therapeutic aspects. J Bras Pneumol 2008 Feb; 34(2):107-17. 8. Pressler T, Targeting airway inflammation in cystic fibrosis children: past, present, and future. Peadiatr Drugs 2011 Jun 1; 13(3): 141-7. 9. Jelalian E, Stark LJ, Reynolds L, et al., Nutrition intervention for weight gain in cystic fibrosis: a meta analysis. J Pediatr 1998 Mar; 132(3Pt1): 486-92. 10. McKay KO, Cystic fibrosis: benefis and clinical outcome. J Inherit Metab Dis 2007 Aug; 30(4): 544-55. 11. Elborn JS, Hodson M, Bertram C, Implementation of European standards of care for cystic fibrosis — provision of care, Journal of Cystic Fibrosis 8(2009): 348-355. 12. O’Sullivan BP, Freedman SD; Cystic fibrosis. Lancet. 2009 May 30; 373(9678): 1891-904. 13. Dodge JA, Lewis PA, Stanton M, Wilsher J, Cystic fibrosis mortality and survival in the UK: 1947-2003. Eur Respir J 2007; 29: 522-6. 14. Pizzignacco TM, de Mello DF, de Lima RA, Stigma and cystic fibrosis. Rey Lat Am Enfermagem 2010 Jan-Feb; 18(1): 139-42. 15. Kochman D, Wybrane aspekty jakości życia dzieci i młodzieży. Pielęgniarstwo Polskie 2006; 2,22: 112-114. 16. Uchmanowicz I, Łoboz-Grudzień K, Jakość życiadefinicje i narzędzia badawcze- przegląd literatury, Family Medicine & Primary Care Review 2008; 10,2: 245-252 17. Abbott J, Health-related quality of life measurement in cystic fibrosis: advances and limitations. Chron Respir Dis 2009; 6(1): 31-41. 18. Orenstein D, The Quality of Well-Being In Cystic Fibrosis, Chest 1989;95:344-347. 19. Cohen MA, Ribeiro MA, Ribeiro AF, Ribeiro JD, Morcillo AM; Quality of life assessment in patients with cystic fibrosis by means of the Cystic Fibrosis Questionnaire. J Bras Pneumol 2011 Apr; 37(2): 184192. 20. Jankaskas JR, Mallory GB, Lung transplantation in cystic fibrosis, Chest 1998; 113, 217- 226. 21. Gomez C, Revnaud-Gaubert M; Long-term outcome of lung transplantation. Rev Pneumol Clin 2010 Feb; 67(1): 64-73. 22. Basa A, Pawlaczyk B (promotor), Jakość życia dzieci z mukowiscydozą i chorobą trzewną: praca doktorska, Akademia Medyczna im. Karola Marcinkowskiego Katedra Pielęgniarstwa Pediatrycznego w Poznaniu, 2004, GBL: 45/22725. 23. Ziaian T, Sawyer M, Reynolds K, Carbone J., Clark J, Baghurst P, et al, Treatment burden and health-related quality of life of children with diabetes, cystic fibrosis and asthma. J Paediatr Child Health. 2006 Oct;42(10):596-600. 24. Sands D, Borawska-Kowalczyk U, Polska adaptacja Kwestionariusza Jakości Życia przeznaczonego dla dzieci i dorosłych chorych na mukowiscydozę oraz ich rodziców (CFQ-R), Pediatria Polska 2009, 84,2, 165-172.

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25. Hegarty M, Macdonald J, Watter P, Wilson C, Quality of live young people with cystic fibrosis: effects of hospitalization, age and gender, and differences in parent/child perceptions, Child Care Health Dey 2009 Jul; 35(4): 462-8. 26. Dębska G, Jakość życia chorych na mukowiscydozę, Acta Pneumonologia et Allergologica Pediatrica 2003; 6,3:39-42. 27. Havermans T., Colpaert K., Vanharen L., Dupont L.J.; Health related quality of life in cystic fibrosis: To work or not to work?; Journal of Cystic Fibrosis 8 (2009), 218223 28. Kaplan SH, Greenfield S, Ware JE Jr, Assessing the Effects of Physician-Patient Interactions on the Outcomes of Chronic Disease, Med Care. 1989 Mar;27(3 Suppl):S110-S127. 29. Eiser C, Psychological Effects of Chronic Disease, J. Child Psychol Psychiatry, 1990 Jan; 31(1): 85-98. 30. Staaba D, Wenningera K, Geberta N, Ruppratha K, Bissonb S, Trettinc M, et al, Quality of life in patients with cystic fibrosis and their parents: what is important besides disease severity, Thorax 1998;53:727-731.

Address for correspondence: Ewa Barczykowska UMK w Toruniu Collegium Medicum im. L. Rydygiera ul. Techników 3 85-801 Bydgoszcz tel: 52 585 21 93 e-mail: [email protected]



Grażyna Bączek, Ewa Dmoch-Gajzlerska

INDEPENDENT MIDWIFERY PRACTICE IN POLAND – LEGAL CONSIDERATIONS VERSUS REALITY SAMODZIELNA PRAKTYKA POŁOŻNEJ W POLSCE – UWARUNKOWANIA PRAWNE A RZECZYWISTOŚĆ

Department of Gynecologic and Obstetrical Didactics, Warsaw Medical University, 00-424 Warsaw, Poland Zakład Dydaktyki Ginekologiczno-Położniczej Kierownik: prof. dr hab. Ewa Dmoch-Gajzlerska, Wydział Nauki o Zdrowiu, Warszawski Uniwersytet Medyczny

Summary O b j e c t i v e . To assess the readiness of midwives in regards to carrying out complex independent care for expecting families during physiological pregnancy, delivery and puerperium; to evaluate the role of midwifery practice during individual preparation of a woman (and her spouse) for childbirth; to define the elements of health education included in preparation for childbirth. M a t e r i a l a n d m e t h o d . Design - questionnaire survey. Setting - eight types of hospitals located in and outside of Warsaw. Participants - 291 practicing midwives with current or past practice in the delivery room. F i n d i n g s . The majority of midwives (232; 80%) declared their readiness to provide complex care to expecting families and offered individual preparation of women (and their spouses) for delivery. Most state obstacle is the lack of practice, the need to improve skills and prevent system. The majority of midwives practice individual preparation of women for childbirth (172; 59%).

Midwives complementary education for masters, much less frequently (72; 47%) operate this type of care than the other (76; 71%) - p = 0.001. This form of practice is implemented by the midwives hot properties (25; 83%) - p = 0.017. The most frequent components of prenatal health education included: biological aspects of pregnancy, delivery and puerperium, followed by psychological aspects, hygiene, diet, physical activity and prenatal communication with the child. Conclusions and implications for p r a c t i c e . Independent midwifery practice is not limited by Polish law. The obstacles faced by independent midwives are associated rather with the healthcare system and the mentality of its workers. The profession of midwifery should be strengthened by extensive media campaigns promoting the competency of this professional group, along with the completion of graduate and postgraduate education curricula in aspects useful for running independent practice.

Streszczenie C e l e m p r a c y jest próba odpowiedzi na pytanie czy położne mają możliwość podejmowania, gwarantowanej przez ustawodawstwo, indywidualnej i samodzielnej praktyki w opiece nad zdrową kobietą oczekującą dziecka. M a t e r i a ł i m e t o d a . Badania przeprowadzono metodą sondażu diagnostycznego. Narzędziem badawczym był samodzielnie skonstruowany dla celów pracy kwestionariusz ankiety. Zbadano grupę 291 położnych praktykujących obecnie lub w przeszłości w sali porodowej, zatrudnionych w ośmiu szpitalach warszawskich i poza Warszawą.

W y n i k i . Większość badanych (232, 80%) uznała, że położne są przygotowane do objęcia całościową i samodzielną opieką rodziny oczekującej dziecka. Najczęściej wymienianą przeszkodą jest brak praktyki, konieczność podnoszenia kwalifikacji oraz przeszkody systemowe. Większość położnych praktykuje indywidualne przygotowanie kobiety do porodu (172, 59%). Położne uzupełniające wykształcenie na studiach magisterskich znacznie rzadziej (72, 47%) świadczą ten rodzaj opieki niż pozostałe (76, 71%) – istotność statystyczna p = 0,001. Znamiennie częściej ta forma praktyki realizowana jest przez

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położne specjalistki (25, 83%) - istotność statystyczna wynosi p = 0,017. Najczęściej realizowane elementy edukacji zdrowotnej w przygotowaniu do porodu dotyczyły: biologicznych aspektów ciąży, porodu, połogu, higieny, psychologicznych aspektów ciąży, porodu, połogu i diety, ruchu oraz komunikacji z dzieckiem. W n i o s k i . Prawodawstwo nie ogranicza samodzielnej praktyki położnej w Polsce. Badane położne w większości

uznały, że są gotowe do objęcia całościową opieką zdrowej rodziny oczekującej dziecka. Większość badanych praktykuje indywidualne przygotowanie kobiety do porodu edukując swe podopieczne najczęściej w zakresie biologicznych i psychologicznych aspektów ciąży, porodu, połogu. Konieczne jest wzmocnienie zawodu położnej oraz uzupełnienie treści kształcenia przeddyplomowego i podyplomowego w elementy samodzielnej praktyki.

Key words: midwife, independent practice, legal aspects Słowa kluczowe: położna, samodzielna praktyka, uwarunkowania prawne

INTRODUCTION The internationally accepted definition of midwifery states: „A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. The midwife is recognized as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. The midwife has an important task in health counseling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care. A midwife may practice in any setting including the home, community, hospitals, clinics or health units.” [1] The majority of Polish midwives belong to the Polish Midwives Association, a member organization of the International Confederation of Midwives. As such, the aforementioned definition also encompasses the role of midwifery practice in Poland. Poland, as a member state of the European Union, is obliged to follow EU directives regulating various aspects of life. Midwifery practice is regulated by Directive 80/155/EWG, particularly by article 4. According to this article: „Member States shall ensure that midwives are at least entitled to take up and pursue the following

activities: 1) to provide sound family planning information and advice; 2) to diagnose pregnancies and monitor normal pregnancies; to carry out the examinations necessary for the monitoring of the development of normal pregnancies; 3) to prescribe or advise on the examinations necessary for the earliest possible diagnosis of pregnancies at risk; 4) to provide a program of parenthood preparation and a complete preparation for childbirth including advice on hygiene and nutrition; 5) to care for and assist the mother during labor and to monitor the condition of the fetus in utero by the appropriate clinical and technical means; 6) to conduct spontaneous deliveries including where required an episiotomy and in urgent cases a breech delivery; 7) to recognize the warning signs of abnormality in the mother or infant which necessitate referral to a doctor and to assist the latter where appropriate; to take the necessary emergency measures in the doctor's absence, in particular the manual removal of the placenta, possibly followed by manual examination of the uterus; 8) to examine and care for the new-born infant; to take all initiatives which are necessary in case of need and to carry out where necessary immediate resuscitation; 9) to care for and monitor the progress of the mother in the post-natal period and to give all necessary advice to the mother on infant care to enable her to ensure the optimum progress of the new-born infant; 10) to carry out the treatment prescribed by a doctor; 11) to maintain all necessary records.” [2] “The law on nurse and midwife profession” is a legally binding act in Poland. Specific considerations regarding the practice of midwifery are included in article 5 of this act: „1) The profession of midwifery is practiced by a person with the required qualifications, being confirmed by proper documents, and includes providing healthcare services, particularly nursing, preventive, diagnostic, therapeutic and rehabilitative services as well as health promotion to women, including pregnant women, delivering women and women in puerperium as well as the neonates. 2) These

Independent midwifery practice in Poland - legal considerations versus reality

aforementioned services are mostly provided by means of: a) education in terms of preparation for parenthood, methods of family planning and protection of maternity and paternity, b) pregnancy detection, providing care to pregnant women during physiologic pregnancy and performing tests necessary in normal pregnancy monitoring, c) referral to examinations necessary for the earliest possible detection of high-risk pregnancies, d) conducting spontaneous deliveries and monitoring of fetal welfare with the aid of medical devices, e) conducting spontaneous deliveries including perineal incisions and suturing, f) undertaking necessary actions in emergency situations in the physician’s absence, conducting breech deliveries and manual removal of the placenta, g) care for future mothers and monitoring of them during the prenatal period, h) examination and care of neonates, i) execution of physician’s orders during diagnostics, treatment and rehabilitation, j) independent, preventive, diagnostic, therapeutic and rehabilitative services to a limited extent, and k) prevention of gynecologic diseases and obstetrical pathologies.” [3] These aforementioned documents, along with ongoing discussions within the Polish midwifery community, prompt detailed competence analysis of particular members of the therapeutic team responsible for taking care of women during normal pregnancies, during physiological deliveries, and in puerperium. The hereby presented results constitute part of this analysis and in our opinion, will provide the basis for future discussion. The aim of this study was to verify if midwives have real possibilities for providing individual and independent care to healthy expecting women, as is guaranteed to this profession by the aforementioned laws. The detailed objectives of this study were: 1) to assess the readiness of midwives in regards to complex and independent care giving for expecting families during physiological pregnancy, delivery and puerperium, 2) to evaluate the role of midwifery practice during individual preparation of woman (and her spouse) for childbirth, and 3) to define the elements of health education included in preparations for childbirth. MATERIAL AND METHOD The diagnostic survey was completed by 291 practicing midwives. The inclusion criterion for this study was current or past practice in the delivery room.

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The study included midwives employed at eight types of hospitals located in and outside of Warsaw. Moreover, the study group included students of weekend and complementary courses in midwifery at Warsaw Medical University. All participants were asked to complete the questionnaire prepared by the authors for the purpose of this study. Grouping variables for further analysis included: participant’s age, place of residence, education level, current educational status, place of work, and work experience. The distributions of answers (in percentages) in the groups distinguished based on these variables were compared using the chisquare test. Calculations were performed using Statistica 7 (StatSoft®, Poland) software, with statistical significance defined as p≤0.05. FINDINGS The first problem that was analyzed in this study was the readiness of midwives to provide complex independent care for expecting families during physiologic pregnancy, delivery and puerperium (Table I). Most of the study participants (n=232; 80%) declared their readiness for this type of caregiving. Twenty-seven out of 59 participants who answered this question with a “no” gave their reasons for this answer. The most frequently declared reasons were: lack of sufficient experience (n=14; 46%), need to improve qualifications (n=7; 23%), and systemic obstacles (n=5; 17%). Positive answers were observed most frequently (n=14; 88%) amongst midwives older than 50 years of age. A relationship was observed between the age of participants and the distribution of their answers – the younger the age of respondents, the lower the fraction of declared readiness for complex independent caregiving to healthy women during pregnancy, delivery and puerperium. This finding is undoubtedly related to the lack of sufficient experience in younger midwives. Another association was observed between answer distributions and the place of residence. Nearly all respondents living in mediumsized towns (n=34; 92%) declared that they were ready to provide complex independent care – contrary to participants living in Warsaw (n=129; 75%) or in the countryside (n=69; 83%). This finding is probably related to the fact that midwives working in mediumsized town hospitals have more freedom and are more independent than their colleagues employed at clinical hospitals in Warsaw. An interesting association was

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observed between answer distributions and the education levels of participants. Table I. Readiness of midwives in regards to complex and independent care giving for expecting families during physiological pregnancy, delivery and puerperium Tabela I. Gotowość położnych do świadczenia kompleksowej i samodzielnej opieki w zakresie fizjologicznej ciąży, porodu i połogu Grouping variable/ Yes/ Tak No/ Nie Grupa zmiennych Total (n=291) 232 (80%) 59 (20%) Age/ Wiek ≤30 years / lat 39 (76%) 12 (24%) (n=51) 31-50 years/ lat 179 (80%) 45 (20%) (n=224) >50 years/ lat (n=16) 14 (88%) 2 (12%) Place of residence/ Miejsce zamieszkania Big city/ Duże 129 (75%) 42 (25%) miasto (n=171) Medium-sized 34 (92%) 3 (8%) towns/ Średnie miasto (n=37) Countryside / Wieś 69 (83%) 14 (17%) (n=83) Education/ Wykształcenie Secondary/ 186 (81%) 44 (19%) Zawodowe (n=230) Higher/ Wyższe 46 (75%) 15 (25%) (n=61) Studies/ Osoby aktualnie studiujące Yes/ Tak (n=153) 115 (75%) 38 (25%) No/ Nie (n=107) 92 (86%) 15 (14%) Specialization/ Specializacja Yes/ Tak (n=30) 28 (93%) 2 (7%) No/ Nie (n=261) 204 (78%) 57 (22%) Place of work/ Miejsce pracy Clinical hospital/ 32 (74%) 11 (26%) Szpital kliniczny (n=43) Institute/ Instytut 28 (88%) 4 (12%) (n=32) City hospital/ 69 (81%) 16 (19%) Szpital miejski (n=85) Obstetric30 (64%) 17 (36%) gynecologic hospital/ Szpital położniczo ginekologiczny (n=47) Outpatient clinic/ 14 (78%) 4 (22%) Ambulatorium (n=18) Specialist hospital/ 17 (81%) 4 (19%) Szpital specjalistyczny (n=21) Voivodeship 21 (88%) 3 (12%) hospital/ Szpital wojewódzki (n=24) Professional experience/ Staż pracy 21 years/ lat (n=61) 53 (87%) 8 (13%) *chi-square test

p value* 0.626

0.052

0.893

0.033

0.08

0.08

0.272

Midwives with secondary education gave positive answers more frequently (n=186, 81%) than their colleagues with higher education (n=46, 75%). Presumably, the opinions of midwives with higher education are more consciously and carefully formulated. The aforementioned relationship was confirmed when answer distributions were compared in relation to the current educational status of participants: midwives who were completing their education at the time of this survey gave positive answers less frequently (n=115; 75%) than their colleagues (n=92; 86%; p=0.033). An opposite relationship, however, was observed in the group of specialized midwives. Therefore, it may be assumed that specialization provides more useful skills than university education. No significant association was observed between the type of hospital the study participants were employed at and their answer distributions. Autonomy was most frequently declared by nurses who worked at voivodeship hospitals or institutes (n=21; 88% and n=28; 88%, respectively). Negative answers were in turn most frequently observed amongst workers of specialist obstetric-gynecologic hospitals (n=17; 36%). Midwives from voivodeship hospitals declared organizational obstacles as their most frequent limitation in providing independent care. Midwives working for 20 years or longer (n=53; 87%) declared the highest readiness for complex and independent care when the duration of professional experience was included in the analysis. Another analyzed question pertained to the readiness of midwives for the individual preparation of women (and their spouses) for delivery (Table II). More than half of the study participants (n=173; 59%) declared that they execute this task in their everyday practice. Again, positive answers were most frequent amongst midwives older than 50 years of age (n=11; 69%). Another association was observed in relation to the participants’ place of residence. Most respondents from medium-sized towns (n=29; 78%) declared their readiness for this type of care – contrary to midwives practicing in Warsaw (n=101; 59%) or in the countryside (n=42; 51%). Again, a higher degree of freedom and independence amongst midwives from medium-sized town hospitals may be the potential reason for this finding. Surprisingly, midwives who were continuing their education at the time of this survey declared providing this type of care less


frequently (n=72; 47%) than their colleagues (n=76; 71%, p=0.001). Table II. Readiness of midwives in regards to individual preparation of woman (and her spouse) for childbirth Tabela II. Gotowość położnych do świadczenia indywidualnego przygotowania kobiety (i jej małżonka) do porodu Grouping variable/ Yes/ Tak No/ Nie Grupa zmiennych Total (n=291) 173 (59%) 118 (41%) Age/ Wiek ≤30 years/ lat (n=51) 28 (55%) 23 (45%) 31-50 years/ lat 134 (60%) 90 (40%) (n=224) >50 years/ lat (n=16) 11 (69%) 5 (31%) Place of residence/ Miejsce zamieszkania Big city/ Duże 101 (59%) 69 (41%) miasto (n=170) Medium sized 29 (78%) 8 (22%) towns/ Średnie miasto (n=37) Countryside/ Wieś 42 (51%) 41 (49%) (n=83) Studies/ Osoby aktualnie studiujące Yes/ Tak (n=152) 72 (47%) 80 (53%) No/ Nie (n=107) 76 (71%) 31 (29%) Specialization/ Specjalizacja Yes/ Tak (n=30) 25 (83%) 5 (17%) No/ Nie (n=260) 147 (57%) 113 (43%) Place of work/ Miejsce pracy Clinical hospital/ 19 (44%) 24 (56%) Szpital kliniczny (n=43) Institute/ Instytut 25 (78%) 7 (22%) (n=32) City hospital/ 47 (55%) 38 (45%) Szpital miejski (n=85) Obstetric30 (65%) 16 (35%) gynecologic hospital/ Szpital położniczo ginekologiczny (n=46) Outpatient clinic/ 8 (44%) 10 (56%) Ambulatorium (n=18) Specialist hospital/ 15 (71%) 6 (29%) Szpital specjalistyczny (n=21) Voivodeship 16 (67%) 8 (33%) hospital/ Szpital wojewódzki (n=24) Professional experience/ Staż pracy 21 years/ lat (n=60) 39 (65%) 21 (35%) *chi-square test

p value* 0.859

0.063

0.001

0.017

0.23

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type of care more frequently than the other respondents (n=25, 83%; p=0.017). Considering the participants’ place of work, individual preparation for delivery was most frequently provided by the midwives who worked at institutes (n=25; 78%) or specialist hospitals (n=15, 71%). This form of care was declared least frequently amongst employees of academic hospitals (n=19,; 44%) and outpatient clinics (n=8; 44%). Readiness for individual preparation for delivery increased proportionally along with the participants’ professional experience. This form of care was most frequently declared by nurses whose professional experience was greater than 20 years (n=39; 65%). Describing the aspects of health education provided for the preparation of expecting parents was the third objective of this study. The most frequently declared aspects were: biological aspects of pregnancy, delivery and puerperium (n=150; 19%), followed by hygiene (n=145; 18%), psychological aspects of pregnancy, delivery and puerperium, and proper nutrition (each n=131; 16%), physical activity (n=127; 16%), and prenatal communication with the child (n=106; 13%). Some respondents (n=14) proposed their own elements in regards to the health education provided to parents during prenatal education. The most frequent answers in this category were: breastfeeding (n=8; 44%), preparation for the parental role, and childcare (each n=4; 22%). DISCUSSION

0.19

One reason for this discrepancy might be that respondents currently studying had less time, due to studying, to provide this type of care. An opposite relationship, however, was observed in the subgroup of specialized midwives who declared readiness for this

The question of providing complex and independent midwifery care to healthy expecting women and women at the time of delivery or during puerperium is strongly associated with the continuity of healthcare. The selection of a midwife who will accompany women on their way to maternity is of crucial importance. Analysis by Green et al. (2000) confirmed that women who experienced continuous care during their pregnancies and deliveries were more satisfied than those who did not experience this type of care. Consequently, these authors suggest organizing centers of perinatal care in such a way as to ensure that continuous care would be standard. Such an attitude would follow patients’ expectations and strengthen the role of midwives amongst healthcare professionals. [4] Polish law in regards to the profession of midwifery does not prohibit practicing outpatient

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midwifery. Still, there is no room for such independent practice in the Polish healthcare system. However, there is a group of independent midwives who provide care for pregnant women during physiologic pregnancies, conduct deliveries at homes, and take care of mothers and their neonates. Their services, however, are not refunded by the public healthcare system. A study by Pollard (2010) [5] gives an interesting insight into midwifery practice in Great Britain. The aim of the study was to analyze if, and in what way, midwifery practices influenced maternity care and issues regarding the medicalization of childbirth. The author was also interested in inter-relationships present between the medical authority, gender, and the degree of midwife professionalism. Qualitative methods were used, including interviews and observations taken in neutral environments. The study revealed that midwives are often inconsistent and that systemic obstacles force them to perform activities different from what they declare. Consequently, midwife professionalism and a degree of delivery “medicalization” are mostly considered traditionally. These findings confirm the complexity of the situation faced by midwives and the challenges faced by this professional group. Our analysis revealed a wider context to this problem, identifying the reasons which inhibit midwives from providing complex care to pregnant women, women during delivery, or in puerperium. One-fifth of our respondents declared that they were not ready to provide this type of care due to the lack of experience and qualifications. Another declared reason was systemic obstacles faced during independent midwifery practice. These aforementioned obstacles suggest the need for the integration of therapeutic team members and a mutual appreciation of competence. This hypothesis was confirmed by Schmied et al. (2010) [6] who analyzed the role of integrated perinatal care. The authors highlighted the importance of cooperation between midwives, nurses and primary care physicians. They also emphasized the role of an integrated healthcare model for pregnant women, neonates and their families. The efficiency of this integrated care depends mostly on the quality of communication within therapeutic teams along with mutual appreciation of competence. The appreciation of competence is still problematic in Poland. Even though laws pertaining to the

profession of midwifery state that these professionals are competent to independently conduct spontaneous deliveries, in most cases, such deliveries are still conducted by physicians. An interesting example of midwifery care was presented by Johnson et al. (2003). [7] Their model of care was geared towards women in low-risk pregnancies. Among numerous factors studied, the authors analyzed practical considerations, elements of continuity and patient satisfaction. The study included patients subjected to standard hospital care and women who received primary health care from midwives. The quality and continuity of care experienced by women subjected to midwifery care was better, resulting in better satisfaction when compared to hospitalized patients. Our study revealed that more than half of the respondents (59%) provide future parents with individual preparations for delivery. It should be noted, however, that this form of practice is only a parasystemic (not refunded by the social insurance) element of perinatal care. Nonetheless, it is a substitute of aforementioned primary health midwifery care. Therefore, although not respected by the Polish healthcare system, this type of activity constitutes proper direction of Polish midwifery development. According to Polish professional law, midwives are allowed to administer some drugs and may carry out individual practice. Unfortunately, there are no regulations in regards to the purchasing of prescription drugs necessary for the practice of midwifery (e.g. during childbirth at home or in a labor house). Therefore, Polish law paradoxically allows and simultaneously disables carrying out individual practice. In the curriculum of birthing schools in Poland, particular attention is paid to the promotion of breastfeeding. Questions pertaining to this aspect of perinatal education were not included in our questionnaire on purpose, since breastfeeding is a compulsory subject in Polish birthing school curricula. Interesting research on the importance of breastfeeding promotion and public health was carried out by Agampodi and Agampodi (2008) [8]. They analyzed breastfeeding in a group of 336 mothers and observed that the efficiency of breastfeeding increased from 19% to 70% in women who participated in health promotion programs, Moreover, this study confirmed the positive impact of educational intervention on the duration of breastfeeding (up to six months of life).


In our study, none of the participants declared the use of aromatherapy during preparations for delivery or during delivery itself. However, we know from unpublished information that this type of assistance is used by some midwives in Poland. Aromatherapy is a medical practice based on the use of plant oils. It has been used for ages in female healthcare. The proper composition of different plant-derived oils attenuates the woman’s feelings during delivery and puerperium. [9] Therefore, further research is needed on the use of aromatherapy by Polish midwives. Birthing schools have for years been established areas for independent midwifery practice. Our study confirmed that this type of education is complex and includes both physical, mental, and social aspects of health. A separate problem pertains to the question of female education in terms of decision making and participation in the delivery process. A Dutch study analyzed the opinions of midwives in regards to decision making by pregnant and delivering women. [10] Interestingly, decision making was more frequent amongst younger patients (below 29 years of age). In the author’s opinion, the increased “medicalization” of deliveries results from a conflict between the attitudes of midwives to delivery care and the freedom of choice of pregnant women. Problems in the implementation of independent midwifery practices in Poland suggest the necessity for detailed analysis of the forms and extent of services provided by midwives. Standardized tools, enabling comparison between our own results and results from other centers, allow for detailed evaluation of midwifery practices. An example of such studies was published by Murphy and Fullerton (2001). [11] According to these authors, studies on the effectiveness of midwifery care are complicated due to the lack of proper investigative tools. Therefore, they described their observations with the use of an existing tool (Optimality Index-US) during the evaluation of midwifery practices in the United States. The results of preliminary studies suggest that this tool could be used in the assessment of perinatal care. Other results of midwifery practice assessments (in terms of optimal care) were published by Cragin and Kennedy (2006). [12] They analyzed a group of 375 patients along with 179 physicians and 196 midwives to compare the quality of care provided by the two latter medical professions. After adjustment for actual risk, the optimal model of care (low intervention and

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“medicalization” rates) was more frequently offered to patients who were subjected to midwifery care. The results of our study constitute a kind of diagnosis pertaining to the readiness of Polish midwives for independent professional care of childexpecting women. These findings provide the basis for the implementation of further proper procedures and tools. CONCLUSIONS Independent midwifery practice is not limited by Polish law. The obstacles faced by independent midwives are associated rather with the healthcare system and the mentality of its workers, who often do not appreciate the competence of midwives. The majority of midwives (80%) declare their readiness in providing complex care for expecting families. Additionally, most of the participants (59%) offer the individual preparation of women (and their spouses) for delivery, even though this service is not refunded by social insurance. The biological aspects of pregnancy, delivery and puerperium are the most frequent components of prenatal health education, followed by psychological aspects, hygiene, diet, physical activity and prenatal communication with the child. The role of the midwife should be strengthened by extensive media campaigns promoting the competence of this professional group, along with the completion of graduate and postgraduate education curricula in aspects useful for running independent practice. Perinatal care models and the methods of their evaluation in different centers inspire Polish midwives to search for ways to establish their professional autonomy. REFERENCES 1. Confederation of Midwives Council Meeting. 19 July 2005, Brisbane, Australia. http://www. internationalmidwives.org. Accessed: 6.07.2006. 2. Council Directive of 21 January 1980 concerning the coordination of provisions laid down by law, regulation or administrative action relating to the taking up and pursuit of the activities of midwives (80/155/EEC) 3. The law on nurse and midwife profession, 1996 (Dz. U. Nr 91, poz. 410) http://www.portalmed.pl/xml/prawo/medycyna/medycyn a/r2005/051461u,18.04.2009

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4. Green J.M., Renfrew M.J., Curtis P.A.,. Continuity of career: what matters to women? A review of the evidence. Midwifery 2000,16, 186-196. 5. Pollard K.C., How midwives' discursive practices contribute to the maintenance of the status quo in English maternity care. Midwifery 2010, 6 [Epub ahead of print] 6. Schmied V., Mills A., Kruske S., at all.,. The nature and impact of collaboration and integrated service delivery for pregnant women, children and families. Journal of Clinical Nursing 2010, 19, 3516-3526. 7. Johnson M., Stewart H., Langdon R. at all. Womencentred care and caseload models of midwifery. Collegian 2003, 10, 30-34. 8. Agampodi, S.B., Agampodi T.C., Effect of low cost public health staff training on exclusive breastfeeding. Indian Journal of Pediatrics 2008, 75, 1115-1119. 9. Tillett J., Ames D., The uses of aromatherapy in women's health. Journal of Perinatal & Neonatal Nursing 2010, 24, 238-245. 10. van der Hulst L.A., van Teijlingen E.R., Bonsel G.J. at all. Dutch women's decision-making in pregnancy and labour as seen through the eyes of their midwives. Midwifery 2007, 23, 279-286. 11. Murphy P.A., Fullerton J.T., Measuring outcomes of midwifery care: development of an instrument to assess optimality. Journal of Midwifery & Women’s Health 2001, 46, 274-284. 12. Cragin L., Kennedy H.P., Linking obstetric and midwifery practice with optimal outcomes. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2006, 35,779-785.

Address for correspondence: Grażyna Bączek PhD Department of Gynecologic and Obstetrical Didactics Warsaw Medical University ul. Solec 57 00-424 Warsaw, Poland. Tel./fax +48 22 621 14 15; e-mail: [email protected] tel. 603 500 337



Bernadeta Cegła, Małgorzata Filanowicz, Aneta Dowbór-Dzwonka, Ewa Szynkiewicz

DOES THE CHARACTER OF HYPERTENSION AND MODE OF THERAPY DETERMINE CHANGES IN THE QUALITY OF LIFE? CZY SPECYFIKA CHOROBY NADCIŚNIENIOWEJ I SPOSÓB PRZYJMOWANIA LEKÓW W ZASTOSOWANEJ TERAPII SĄ DETERMINANTAMI ZMIAN W JAKOŚCI ŻYCIA CHORYCH?

Department of Health Sciences Division of Nursing in Internal Diseases The Nicolaus Copernicus University in Toruń Collegium Medicum named after Ludwik Rydygier in Bydgoszcz

Summary I n t r o d u c t i o n . The study of factors which determine changes of life quality in patients with arterial hypertension is crucial to relevancy and effectiveness of secondary activities which are implemented for patients’ care. Does the character of hypertension and mode of therapy determine changes in the quality of life? For many years, the improvement in quality of life has been taken into account. Apart from activities eliminating the symptoms of disease and prolonging the duration of patient’s life, it is essential to improve the quality of life. Conducting research aiming at determining factors allows taking proper preventive and reparative steps. T h e a i m o f t h e s t u d y is to determine: - what the level of quality of life in patients with arterial hypertension is, - if duration of illness influences changes in the quality of life, - if differences in quality of life reflect severity of hypertension, - if the type of leading symptom and its intensity change the quality of life. M a t e r i a l s a n d m e t h o d s . The studied group comprised of 185 patients with arterial hypertension. The mean age of patients was 55.6±14.2 years. Diagnostics

survey was applied as the analysis method. The selfdeveloped ‘Quality of Life Questionnaire’ and ‘Interview Questionnaire’ were exploited. The study was performed in the area of city of Bydgoszcz. T h e r e s u l t s showed that mean Quality of Life [QoL] in patients was 0.58, where 0 represented the lowest and 1.0 the highest level of QoL. The lowest level of QoL (0.54) was demonstrated by patients with long history of hypertension. In patients with short duration of disease the Quality of Life was 0.69. The level of hypertension had the most important influence on the Quality of Life. The dependence between the leading symptom and the quality of life was not demonstrated. The level of intensity of the leading symptom of the disease revealed to be the most strongly influencing factor. C o n c l u s i o n s . 1. The quality of life in patients with arterial hypertension is significantly low. 2. The duration of the disease influences the patients’ quality of life. 3. The mode of therapy is not a relevant factor causing changes of life quality. 4. The intensity of the leading symptom determines the quality of life in patients.

Streszczenie W s t ę p . Badanie czynników determinujących zmiany jakości życia chorych na nadciśnienie tętnicze jest istotne z punktu widzenia trafności i skuteczności wtórnych działań wdrażanych do opieki nad pacjentem. Od wielu lat w leczeniu uwzględnia się poprawę jakości życia. Oprócz działań likwidujących objawy choroby i przedłużania życia chorego istotna jest poprawa jego jakości. Prowadzenie badań mających na celu poznanie czynników

determinujących pogarszanie jakości życia pozwala podejmować celowe działania prewencyjne i naprawcze. Cel badań - jaki jest poziom jakości życia chorych z nadciśnieniem tętniczym, - czy długość chorowania wpływa na zmiany w jakości życia,

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- czy różnice w poziomie jakości życia związane są z ciężkością nadciśnienia, - czy rodzaj wiodącego objawu i jego nasilenie powodują zmiany jakości życia. Materiał i metody. Grupę badaną stanowiło 185 osób chorych na nadciśnienie tętnicze. Średni wiek pacjentów wynosił 55,6±14,2 lat. Do gromadzenia danych wykorzystano metodę sondażu diagnostycznego. Posłużono się Kwestionariuszem Jakości Życia i Kwestionariuszem Wywiadu konstrukcji własnej. Badania przeprowadzono na terenie miasta Bydgoszczy. W y n i k i b a d a ń wykazały, że średnia JŻ (jakość życia) chorych wynosi 0.58, przy czym 0 stanowi najniższą a 1.0 najwyższą JŻ. Najniższą JŻ, 0.54 wykazywali pacjenci,

chorujący długo na nadciśnienie. U pacjentów chorujących krótko JŻ była na poziomie 0.69. Czynnikiem najsilniej wpływającym na JŻ był stopień ciężkości nadciśnienia. Nie stwierdzono wpływu rodzaju, wiodącego w nadciśnieniu objawu, na JŻ pacjentów. Zdecydowanie najsilniej wpływającym na zmiany jakości życia czynnikiem okazał się stopień nasilenia głównego objawu choroby. Wnioski. 1. Jakość życia pacjentów z nadciśnieniem tętniczym jest znacznie obniżona. 2. Czas trwania choroby wpływa na jakość życia chorych. 3. Sposób przyjmowania leków nie jest istotnym czynnikiem powodującym zmiany jakości życia. 4.Stopień nasilenia wiodącego objawu choroby determinuje jakość życia chorych.

Key words: hypertension, therapy, quality of life Słowa kluczowe: nadciśnienie tętnicze, terapia, jakość życia

INTRODUCTION Nine million Poles have been suffering from arterial hypertension while the number of Americans with the disease reached 50 millions [1]. Among all of them, about 15% in Poland and 50% in the U.S. have been effectively treated meaning not only the dose or type of the prescribed medication but also granting priority to such factors as proper life style, adequate self-control, regularity and scrupulosity of drug administration. Arterial hypertension belongs to the diseases which symptoms significantly burden everyday functions and decrease patients’ comfort [2, 3]. Pain, vertigo and blurred vision worsen concentration. The necessity of regular and continuous drug administration, diet adjustment and quitting bad habits imply limitations which often result in frustration, discouragement and returning to negative and hazardous behavior. On the other hand, the disease can be easily (in majority of cases) managed and controlled providing comfort and function on a satisfactory level. The above mentioned change of life style, adequate self-control and diet are elements determining improved Quality of Life and decreasing hypertension level. For example, a reduction in body weight of 5.1kg on average is related to a mean decrease of systolic pressure by 4.4 mm Hg and diastolic pressure by 3.6 mm Hg [4]. It is obvious that beside elimination of disease symptoms and life prolongation of patients, an improvement in Quality of Life plays an essential role and has been included in the management of patients with hypertension for many years now. Without diagnosing specific reasons for worsening life quality, areas of better quality and determinants of changes, undertaken measures cannot

lead to desired goals. The importance of exploration and confirmation of existing relations is essential as a basis and reference for recommended changes. This type of study is required when considering pertinence and effectiveness of prospective activities which will be implemented in patients care to help reaching good preventive and reparative targets. The aim The aim of this study was determining: - what a quality of life in patients with arterial hypertension is, - if duration of diseases influence changes life quality, - if differences in quality of life reflect severity of hypertension, - if type of the leading symptom and its intensity change the quality of life. MATERIAL AND METHODS The studied group comprised 185 patients with arterial hypertension. Among them 104 were women and 81 - men aged from 21 to 84 years. The mean age of patients was 55.6±14.2 years. Patients diagnosed with arterial hypertension, patients hospitalized due to various reasons in whom hypertension was a concomitant disease and patients treated for hypertension under control of out-patient clinic were enrolled into the study. The consent for participation in the study was given by signing a consent form after getting information about the study. The detailed characteristic of the studied group is presented in Table I.

Does the character of hypertension and mode of therapy determine changes in the quality of life?

Table I. The characteristics of the studied group Tabela I. Charakterystyka grupy badanej Marital status Stan cywilny

Education Wykształcenie

Single Married Elementary Professional College Wolny Żonaty/Zamężna Podstawowe Zawodowe Średnie n 48 137 30 % 26% 74% 16.2% Mean height średni wzrost Mean weight średnia waga BMI

43 23.2%

Residence Zamieszkanie University Rural Urban Wyższe Wieś Miasto

80 32 36 149 43.2% 17.3% 19.5% 80.5% 168.2 ±9.2 cm 81.5 ±17.8 kg 28.7 ±5.4 kg/m2

The study was performed in university departments, wards and out-patient clinics in the area of Bydgoszcz. In order to conduct the study, authors obtained the approval of the Bioethics Board of the Nicolaus Copernicus University Collegium Medicum in Bydgoszcz, (No. KB/44/2008). For the analysis the method of diagnostic survey was used. The selfdeveloped Quality of Life questionnaire for Patients with Arterial Hypertension and Interview and Activity Assessment questionnaire were exploited. For gathering personal, physical activity and life style data the Interview and Activity Assessment questionnaire was applied. In statistical analysis, as relevant p=0.05 level of significance was assumed, for which critical values are given in the tables. RESULTS Hereby presented results are a part of a more comprehensive study which analyzed influence of various life areas and modes of patient functioning on the quality of life and the change determinants in observed quality of life. The presented results comprise selected topics and concentrate on factors which are specific to disease and patient’s self-control. The gathered data were subject to a quantitative and statistical analysis. Firstly, data concerning patients with arterial hypertension were analyzed. The analysis of data revealed the level of Quality of Life in particular patients. For normalization of values in 0-1 scale the linear conversion was applied; in result each patient received Quality of Life result in normalized 01 scale, where the worst possible Quality of Life was represented by 0, while the best one by 1. The mean value of Quality of Life in the studied group was calculated as 0.58 which is slightly higher than mean value of 0.5. The result allows concluding that Quality of Life in patients with arterial hypertension is significantly decreased by the disease and its consequences. The discussed results are presented in Table II.

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Table II. The quality of life in patients with arterial hypertension Tabela II. Poziom jakości życia chorych z nadciśnieniem tętniczym Parameters Parametry Min Max Median Mean SD

Quality of life level Poziom jakości życia 0.04 0.99 0.60 0.58 0.21

Subsequently, the relation between Quality of Life and duration of illness was assessed. The levels of observed Quality of Life were compared in a subgroup between patients with a recently diagnosed hypertension (six months ago) and those with a longer history of hypertension (diagnosed ten years ago). Both subgroups had been treated since the diagnosis was made. The analysis revealed decreasing Quality of Life along with the duration of the disease. Patients with the longest history of disease had the lowest Quality of Life. An interesting result appeared in Quality of Life among patients who have been treated for a year in comparison to a group of patients with a recently diagnosed hypertension (six months ago). It could be concluded that significantly worsened Quality of Life does not improve instantly with introducing treatment, whereas the longer the disease duration is, the more the Quality of Life decreases. The differences between marginal values of Quality of Life are statistically significant. It could be stated for certain that duration of disease determines Quality of Life in patients. The results suggest that this state is caused by patients’ condition worsening along with disease duration or healthy life style becoming neglected. The detailed data on the subject are presented in Table III. Table III. The duration of disease and quality of life in patients with arterial hypertension Tabela III. Długość trwania choroby a poziom jakości życia chorych z nadciśnieniem tętniczym

Quality of life Jakość Życia

ANOVA test (Fkr=2.42)

Parame ters Parametry n mean SD F p

Duration of disease (in years) Długość trwania choroby (w latach) 0.5

1

15 0.58 0.20

15 0.69 0.15

3 36 0.64 0.23 2.83