medical and biological sciences

Transkrypt

UNIWERSYTET MIKOŁAJA KOPERNIKA w TORUNIU
COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA
W BYDGOSZCZY
MEDICAL
AND BIOLOGICAL
SCIENCES
(dawniej
ANNALES ACADEMIAE MEDICAE BYDGOSTIENSIS)
TOM XXV/3
lipiec – wrzesień
ROCZNIK 2011
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
BYDGOSZCZ 2011
Medical and Biological Sciences, 2011, 25/3
CONTENTS
p.
REVIEWS
D a n u t a G e r y k , M a c i e j D z i e r ż a n o w s k i – Back pain in everyday life . . . . . . . . . . . . . . . . .
5
A n n a J a w o r s k a - P o s a d z y , J a n S t y c z y ń s k i , M a ł g o r z a t a K u b i c k a – Minimal
redisudal disease in childhood acute lymphoblastic leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
Z u z a n n a P u j a n e k – Operations of paranasal sinuses – review of operational techniques . . . . . . . .
21
ORIGINAL ARTICLES
A n n a B e d n a r e k , A n d r z e j E m e r y k – The analysis of parents’ knowledge about preventive
vaccination programme in the group of healthy and allergic children . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
W a l d e m a r C i e m n o c z o ł o w s k i , P i o t r J u r k o w s k i , A n n a P i ą t k o w s k a – Profile
of candidate for the first-cycle program at the Faculty of Health Sciences of the Ludwik Rydygier
Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, in the academic
year 2008/2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35
A g n i e s z k a M a r i a D z i e w a , A n n a K s y k i e w i c z - D o r o t a – Validation of research
tool for assessment of quality of nursing care with respect to prophylaxis of hospital-acquired
infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
Anna Grabowska-Gaweł, Donata Gacka, Danuta Dobosz, Beata Augustyńska
– The impact of shift work on psychosomatic health of nurses employed in the intensive care unit . . .
45
Wiktor Mishchenko, Stanisław Ławczyn, Mariusz Zasada, Agnieszka
C y b u l s k a – Effects of the resistance training of inspiratory muscles during the health related
program of exercises on aerobic working capacity in young women . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51
Michał Szpinda, Monika Paruszewska-Achtel, Mariusz Baumgart,
A d r i a n n a S o b o l e w s k a , G a b r i e l a E l m i n o w s k a - W e n d a – Quantitative growth
of the human deltoid muscle in human foetuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
59
CASE REPORT
Marcin Gierach, Joanna Gierach, Marta Spychalska, Maciej Papierski,
R o m a n J u n i k – Sheenan’s syndrome – case report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
65
SPIS TREŚCI
str.
PRACE POGLĄDOWE
D a n u t a G e r y k , M a c i e j D z i e r ż a n o w s k i – Bóle kręgosłupa w życiu codziennym . . . . . . . . .
5
A n n a J a w o r s k a - P o s a d z y , J a n S t y c z y ń s k i , M a ł g o r z a t a K u b i c k a – Minimalna
choroba resztkowa w ostrych białaczkach limfoblastycznych u dzieci . . . . . . . . . . . . . . . . . . . . . . .
13
Z u z a n n a P u j a n e k – Operacje zatok obocznych nosa – przegląd technik operacyjnych . . . . . . . . . .
21
PRACE ORYGINALNE
A n n a B e d n a r e k , A n d r z e j E m e r y k – Ocena wiedzy rodziców na temat programu szczepień
ochronnych w grupie dzieci zdrowych i z chorobą alergiczną . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
W a l d e m a r C i e m n o c z o ł o w s k i , P i o t r J u r k o w s k i , A n n a P i ą t k o w s k a – Profil
kandydata na studia pierwszego stopnia na Wydziale Nauk o Zdrowiu Collegium Medicum
im. L. Rydygiera w Bydgoszczy UMK w Toruniu w roku akademickim 2008/2009 . . . . . . . . . . . . . . .
35
A g n i e s z k a M a r i a D z i e w a , A n n a K s y k i e w i c z - D o r o t a – Walidacja narzędzia
badawczego dla oceny jakości opieki pielęgniarskiej w zakresie profilaktyki zakażeń szpitalnych . . . .
41
Anna Grabowska-Gaweł, Donata Gacka, Danuta Dobosz, Beata Augustyńska
– Wpływ pracy zmianowej na sferę psychosomatyczną pielęgniarek zatrudnionych w oddziale
intensywnej terapii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45
Wiktor Mishchenko, Stanisław Ławczyn, Mariusz Zasada, Agnieszka
C y b u l s k a – Wpływ oporowego treningu mięśni wdechowych na wydolność tlenową młodych
kobiet uprawiających fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51
Michał Szpinda, Monika Paruszewska-Achtel, Mariusz Baumgart,
A d r i a n n a S o b o l e w s k a , G a b r i e l a E l m i n o w s k a - W e n d a – Wzrost ilościowy
mięśnia naramiennego u płodów człowieka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
59
PRACA KAZUISTYCZNA
Marcin Gierach, Joanna Gierach, Marta Spychalska, Maciej Papierski,
R o m a n J u n i k – Zespół Sheehana – opis przypadku . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
65
Regulamin ogłaszania prac w Medical and Biological Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
Medical and Biological Sciences, 2011, 25/3, 5-12
REWIEV / PRACA POGLĄDOWA
Danuta Geryk, Maciej Dzierżanowski1
BACK PAIN IN EVERYDAY LIFE
BÓLE KRĘGOSŁUPA W ŻYCIU CODZIENNYM
1
Department of Manual Therapy Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz
Head: Maciej Dzierżanowski, MD, PhD
Summary
The vertebral column is constantly overloaded. To
properly maintain its function it is crucial to change everyday
life activities, starting with sleeping habits, through getting up,
walking, sitting and finishing with home leisure activities. One
cannot forget about physical exercises either.
Streszczenie
Kręgosłup ulega stałym przeciążeniom. W dbałości
o niego, należy zmodyfikować czynności dnia codziennego –
od snu, poprzez wstawanie z łóżka, chód, pozycję siedzącą, aż
po pozycję przyjmowaną podczas pracy oraz w trakcie domo-
wego wypoczynku. Nie należy jednocześnie zapominać
o ćwiczeniach fizycznych.
Key words: spine, preventive medicine, pain
Słowa kluczowe: kręgosłup, profilaktyka, dolegliwości bólowe
INTRODUCTION
Nowadays, back pain affects 20-30% of adults,
while about 90% of them have had at least a single
pain accident [1]. In interpreting the current reports, it
may be fair to say that these pains have become
a problem of civilization. This problem is not only
difficult to diagnose but also delivers treatment doubts,
making it a severe medical problem. Because of the
high costs of diagnosis and treatment, they also
constitute a social problem. Back pains are also
a sociological issue, because they can contribute to the
disorganization of professional and private life.
Moreover, increasing spine pain is often accompanied
by depression. Recent reports suggest that 30-40% of
patients seeking medical help (beyond the psychiatrist)
suffer from depression. Increasingly, it is masked
depression, running without a clearly degraded mood,
where the mask are somatic symptoms, especially pain
(19% of patients) [2, 3, 4, 5, 6].
According to many authors, low back pain is just
a consequence of the development of civilization, and
a result of overtaking evolutionary development. The
reason for this is a decline in physical activity of
a man. Current times create the conditions for the
absence of dynamic muscle work and overload postural
muscles.
The development of civilization has contributed to
the ‘laziness’ of people by creating more and better
means of transport. Modern technologies increase the
number of employees in a sitting position. They have
also changed the form of leisure which relates mostly
to the sitting position. The most common form of
recreation is sitting in front of a computer or TV.
6
Danuta Geryk, Maciej Dzierżanowski
A man sits practically everywhere and at every
opportunity. It is not surprising because from an early
age we are used to sit in stillness for a long time, that is
why it is so hard for us to switch to the dynamic sit.
According to many research, sitting position causes
a significant overload of the spine, exhausting
abdominal, chest and diaphragm muscles, even further
increasing the pressure on it is structures. All these
factors show that the continuous development of
civilization causes overload of the spine, which is
above its physiological capabilities. Biomechanical
properties of the spine are not able to meet the
demands of civilization.
Our spine is constantly loaded. Each activity
performed by us affects the structure of the spine in
a different degree [1,7]:
- Lying on back = 30 kg load LS spine
- Walking = 85 kg
- Standing = 100 kg
- Jumping= 110 kg
- Supported sitting = 140 kg
- Leaning stand = 150 kg
- Sitting without support = 180 kg
- Lifting 50 kilogram weight = 800 kg
From an early age a man spends time in a seated
position. Preschool age children spend 5 to 6 hours
a day seated. This time increases with age, and the first
or second grade pupils spend at their desks at school
from 8 to 9.5 hours.
Leisure time is also mostly spent in a sitting
position, whether in front of the TV or the computer,
and doing homework.
In adulthood, most people work while staying
seated for 8 hours a day. Unfortunately most of these
choose a passive way of relaxing after work.
Lack of physical activity from an early age leads to
the increasing prevalence of pathologic posture. Sitting
is the worst position for the spine and results in:
- Flaccidity and shortening of the abdominal, chest and
hip flexor muscles,
- Overstretch of back muscles, resulting in a “round
back”
- Increased pressure in the abdominal cavity, causing
compression of its organs,
- Overload of the spine which exceeds its
biomechanical capabilities
- Headache
- Forming of varices through additional load on blood
vessels,
- Impaired concentration,
- Fatigue.
DYNAMIC SIT
According to many authors, it is sitting technique,
in which the pelvis is maintained in balance on the
ischial tubers. The spine is in a physiologically straight
position and the trunk is rotated around the vertical
axis of the body [11]. Leans are performed by moves in
the hip joints and not by vertebral column flexions.
The dynamic position of legs is also important.
Through the position of the feet and legs, we can act to
stabilize the whole body, acquiring directed load and
move of proper feet zones making concentration easier
(Tietze 1990). Conclusion – the position of feet should
be changed every 5 minutes. According to many
authors, the most effective feet position which grants
concentration is in 56% crossing them.
The dynamic sit forces the muscles to work,
resulting in even distribution of load in intervertebral
discs and nutrition improvement through varying load
changes.
According to many authors, it is hard for us to
switch to dynamic sit, because from an early age
through school, university, and work we are
accustomed to sitting quietly in stillness for a long
time.
Learning a dynamic sitting position
According to many authors, it should start with
taking a seat on a chair and doing the following
exercises [11]:
- Altering buttock load,
- Circulation of the pelvis,
- Delicate circulation of the trunk around the axis of
the body.
We must remember that the fewer parts of our body
have support, the more muscle tension they need,
therefore:
- Put elbows on the thighs,
- Pull with hands on the tabletop, desk, or inverted rear
of the chair.
Learning dynamic sitting position:
We sit on the front edge of the chair, then deploy
legs, so that they are on the width of the hips. Feet
should rest on the floor. Thigh and lower leg should
form a 90 degree angle and lay with the foot the lower
limbs. This position allows even distribution of load on
these joints. The seat should be carefully chosen so that
knees are not above the hips.
The next step is to find the physiological sitting
position. In search of it, lean the pelvis front and then
Back pain in everyday life
back to the pressure on ischial tubers. Then, push the
chest forward, lean the torso slightly forward, look
straight ahead, relax the shoulders.
All exercises should be done sitting in front of
a mirror to observe and correct your position.
SELECTION OF THE SEAT
According to many authors, dynamic sit helps us to
choose the right chair. Such seat shall have the option
to regulate lean back and forth. Tilt forward lean is
helpful for the muscles when the pelvis leans and this
makes physiological sitting position easier. Adjusting
the tilt angle allows to keep buttocks on the rear
surface of the seat. The front edge of the chair should
be rounded, thereby preventing too high pressure on
the popliteal area, back of the lower leg and thigh.
Back of the chair should be shaped to provide support
for the physiological curvatures of the spine and the
largest area of the back, thus taking the weight of the
torso. Relief of the lumbar spine can be acquired
through a 2 - 5 cm bulge in the L5 - S1 area of the back
of the chair. The chair should also have support for the
upper edge of the pelvis, which prevents the elevation
of the pelvis. The upper edge of the seat should extend
to the scapula and give the possibility of leaning
towards the rear. Relief for the shoulder muscles is the
support for elbows and shoulders, which is also a great
help in getting up and sitting down.
HOW TO PROPERLY SIT DOWN AND GET UP?
According to many authors, starting to learn the
correct standing and sitting, you must repeat these
steps several times to observe what happens to the
pelvis in the course of these movements.
In this exercise, we should observe that during the
sit pelvis and lumbar spine is rotated back up to the
contact between the body and back of the chair. To
compensate this flexion in the upper lumbar spine,
thoracic and cervical spine flex to the front.
To prevent this phenomenon, sitting down and
getting up must be practiced. To do this, start by
shifting the center of gravity. An exercise that will help
with this: we are facing a chair, bend your knees
slightly so that they touch the edge of the chair and
slowly lower the buttocks. Then repeat the movement
with the front elevation of the arms or front lean of the
torso [11].
7
According to many authors, by going from standing
to sitting position, slowly lower your buttocks
downwards until you touch the surface of the seat. This
movement is performed by flexing the hip, knee, ankle
joints.
Make sure that the pelvis is not rotating back.
When changing position from sitting to standing,
exactly opposite movements need to be made. Forward
leaning of the trunk will move forward the center of
gravity. So that it’s over the feet. Be sure to get up and
sit up slowly, without making sudden movements,
because they can cause unnecessary loads on the lower
spine.
ERGONOMIC STANDING POSITION
According to many authors, the position of standing is
the most beneficial, because the spine is arranged here
in the form of a double letter S. In addition, in this
position spinal muscles work in the most ergonomic
way and intervertebral discs load is intermediate. The
body is in a "labile balance state”. This is a stable
supported stance and set balance point of gravity
vertically over your feet. Maintaining a straight posture
is possible through the activity of muscles and tendons.
The most important muscles are:
- Triceps surae,
- Group of the front thigh muscles,
- Gluteus muscles,
- Back muscles,
- Abdominal muscles.
Important elements necessary to maintain a straight
posture are proprioreceptors present in the joints,
muscles and tendons and the labyrinth of the ear, and
eye.
Upright posture can be maintained in two ways:
Actively-by-muscle strength,
- Passive-suspending the body in the ligaments.
Passive form of maintaining an upright posture is more
convenient, but unfortunately more aggravating for
musculoskeletal structures leading to:
- Drawing of the muscles,
- Atrophy of muscles,
- Intervertebral discs and vertebral joints are
overburdened, resulting in their degeneration.
Wanting to avoid the occurrence of persistent spinal
pain, or reduce the feeling of already existing, one
should use the active standing position, as a preventative measure.
8
The effects of prolonged exposure in the standing
position are:
- Fatigue,
- Increase in hydrostatic pressure in the veins of the
lower limbs,
- Retention of tissue fluid [11].
To avoid the negative effects of prolonged
standing, support materials, should be used such as
orthopedic insoles and above all, every now and then
change in the position of the body. Furthermore, the
muscles should be systematically enhanced through
posture exercise, avoiding lack of coordination and
dysfunction is systems controlling statics and balance.
WALKING AND THE VERTEBRAL COLUMN
According to many authors, walking is a mix of
conscious, automatic and semi-automatic movements,
which results in the movement in the upright posture
from one place to another without loss of balance, with
relatively little effort in energy. During this activity
symmetric pendulous moves to the left and to the right
take place. These movements strengthen the back
muscles, as well as support pumping mechanism.
Studies suggest the rhythmic and dynamic gait used to
treat patients with intervertebral disc problems creates
stimuli throughout both active and passive elements of
the musculo-skeletal system.
During walking, each leg must maintain our body
weight until the dragging of the other leg. In addition,
when walking we often encounter obstacles such as
stairs. To overcome this, legs must be able to flex, in
other words they need well-functioning flexors of
greater joints and muscles which lift the pelvis.
During the rolling gait phase reflection at the end of
the standing phase is possible through the action of
triceps surae. Acceleration phase is begun by the
activity of toe extensors. Running is possible through
the work of triceps surae, knee and hip extensors
muscles.
Walking is also the reflection of our temperament
and mood.
Lifting objects from the floor-how to do this
without burdening the spine?
According to many authors, the load of the spine
when lifting objects is dependent on the lean of the
body, namely, the burden is smaller, the closer over the
center of the surface we’re standing on, lays the point
of weigh of the body and the lifted object, the trunk
being less leaned, the vector of the load shorter [Eight,
1911].
THE CORRECT POSITION WHEN LIFTING
WEIGHTS
According to many authors, the items should be
lifted with straight back, the lean of the pelvis and
spine immobilization with a slight lordosis. This
position is accessible through the work of back, hip
flexors and abdominal muscles. By lifting objects in
such a position, we reduce the burden on intervertebral
discs, which allows us to:
- Considerable length of the arm-strength,
- Intervertebral disc is then in the center,
- Point of muscle attachment is better,
- Tilted pelvis forms part of the arm of gravity,
- Spine is stabilized by the muscles,
- The load is spread evenly over the intervertebral
discs.
The most important rules you need for lifting heavy
objects:
- Get as close to the lifted object
- Space out feet for a minimum width of the hips,
- Place whole surface of the foot on the ground,
- Spine erected,
- Flex the knee to a maximum of 90 degrees,
- Lean the straight trunk to the front and the pelvis
back until gripping with extended arms the lifted
object,
- Lift the object using leg muscles work (raise the
sternum upwards and to the front, straighten the hip,
knee and ankle joints),
- Do not perform this operation on the apnea, and
support this action by conscious inhalation and
exhalation,
- Lifting weight, remember to keep object possibly
close to your body,
- If the weigh is large, you should ask someone for
help.
Lifting weight:
- Use a cart or wheelbarrow to transport the objects,
- If you decide to move it yourself, keep the body
upright,
- Keep the object close to your body,
- Distribute the weight symmetrically,
- Take frequent breaks,
- Do not cover the face with the transferred object,
reducing the visibility,
- If you move an object in a few people, raising it, do it
on command.
HOW TO MOVE A HEAVY OBJECT
IN A STANDING POSITION
- Stand close to the object, then,
- Bend your knees,
- Lean erected trunk, next grab the object
- Stabilize the trunk through muscle tension,
- Lift the object through the work of the legs,
- Putting the object down, align it on your risen and
flexed thigh, then grab it underneath, straighten your
legs and leave it,
- If you suffer from a degenerative knee joints, perform
this operation from kneeling.
HOW TO RAISE A HEAVY OBJECT IN A SITTING
POSITION
- Sit on the front edge of the chair,
- Lean the straight trunk to the front,
- Grab the object with both arms
- Rise the object upwards by moving the sternum to the
front and up, straighten your knees and hips.
HOW TO GET UP NOT OVERLOADING
THE SPINE?
According to many authors, getting up and lying down
in spite of being simple movements creates many
problems. The vast majority of people perform these
activities too quickly.
HOW TO GET OUT OF BED?
Lying on back move to the edge of the bed and turn to
the side by knees bent. The hand nearer the bed is bent
at the elbow; the other hand is straight and holds the
edge of the bed. Bent in knees legs should be dropped
off the bed, then rise from the elbow and using the
other hand continue to a lateral sit, then extending the
elbow bent arm finish in straight sit.
KINESITHERAPY – MOTION EXERCISES
Kinesitherapy is an essential part of preventing
lumbar spine pain [12].
The positive impact of Exercise:
- Acceleration of repair processes,
9
- Accelerate the replacement process in the motor
system and internal organs,
- Counteracts the cardiopulmonary complications,
- Enhances the performance of the body,
- Prevents defective compensation,
- Prevents secondary changes in the skeletal, articular,
muscular and ligament systems.
Kinesitherapy’s aim is to break the vicious circle of
pain, which is obtained by reducing the reflex of
increased tension of vertebral muscles and increasing
in the stability of lumbar spine by increased the
abdominal press and restoring muscles balance to
prevent recurrence of pain.
For greater stability of the lumbar spine, care must
be taken to increase the pressure in the abdomen. In
order to achieve this, abdominal muscle strength must
be increased through regular physical exercises. The
importance of abdominal pressure is particularly
highlighted considering its protection on the lumbar
spine during lifting heavy objects.
Strengthening your abdominal muscles is the core
of lower back pain prevention [12].
Another very important group of muscles are the
muscles of the torso. This group of muscles is in
ceaseless activity, even during sleep. Loss of strength
and endurance of these muscles is a predictor of spinal
pain.
In kinesitherapy it is essential to utilize techniques
of lumbar spine stabilization during intentional
movement, which aims to create proper conditions for
dynamic muscle control and protection against harmful
overloads.
The stabilization of the spine is achieved by
applying the synergic activation of trunk and spine
muscles in the middle of the amplitude of movement.
Pressure and loads, should be gradually increased
through the motions of the upper limbs and lower
limbs.
A well-designed exercise program allows you to
painlessly create a muscular corset for the spine, thus
reducing the burden on intervertebral discs.
The effectiveness of kinesitherapy depends on the
selection of exercises - that is their nature and
sequence. Another very important element is the
dosage understood as the duration of the exercise and
the number of repetitions. The third very important
component is a selection of an appropriate starting
position for the exercises (on the back, on the side, in
a supported kneeling).
10
According to Dziak the safest for the lumbar spine
position during exercise is set between flexion and
extension.
THE MAIN PRINCIPLES OF EXERCISE
BY DZIAK [8, 12]
1. The best effect is obtained by the daily preventive
exercises
2. Exercises with resistance should be used only to the
limit of pain
3. In the prevention of lumbar spine pain generally
improving exercises are effective.
4. Exercises are recommended in the full range of
movements, performed in the morning, due to daily
changes in the hydration of the intervertebral disc, and
thus the load of the spine.
5. The guiding principle is to perform a large number
of repetitions with a small load, which protects the
spine against microinjuries.
6. When selecting exercises it is better to concentrate
on endurance improving exercises rather than exercises
that increase muscle strength.
7. Exercises should be chosen individually.
BASIC GUIDELINES FOR EXERCISE
ACCORDING TO KEMPF [11]
1. Exercises should be performed slowly in
concentration.
2. An important element is the adoption of the correct
starting position, which provides safe and effective
implementation of this exercise.
3. Regularity is the key.
4. Load should be adjusted to the possibility of the
patient.
5. Do not exercise on apnea.
6. Prior to exercise pressure should be checked.
7. Motion exercises should begin with a warm-up
exercises and stretching.
8. Shortened muscles, you should extend at least
3 times a week, when doing this, hold the stretch for
15-20 seconds.
9. By doing strengthening exercises, should be
maintained tension for 10-15 seconds.
10. In dynamic exercises, repeat the movement 10-15
times.
11. The exercises must not be practiced if they cause
severe pain.
12. Spasm during exercise, is a sign to stop the
exercise.
TAKING THE CORRECT POSTURE
WHILE WORKING
Many authors make suggestions for the adoption of
proper posture while working. These postures are to
reduce pain in the lumbar spine.
Especially for prevention, it is recommended that at
work:
a) standing - with a relatively fixed body position, bend
one leg, by basing it on a low stool. Periodically
change the leg. Do not stand with outstretched legs!
b) seated - we select the appropriate seating, on which
the knee area of thighs is slightly higher than the chairs
edge (but the feet are still on the floor). The supporting
back of the chair should reach the lower part of
thoracical spine and have shape that allows lumbar
spine to keep its lordosis [13, 14].
PROPER IMPLEMENTATION OF THE WORK
AND ACTIVITIES OF DAILY LIVING
Positions and methods of performing these activities
have an enormous impact on spine pain discomfort.
Many authors have said that you should not do
housework leaning your torso forward, but by moving
through the hip joints. Flexing the lumbar spine is also
not beneficial. The upright sitting position is best for
performing everyday activities and working [13, 15,
16].
Adjusting kitchen furniture according to our high is
also an important element in preventing lumbar spine
pain:
- If a table is too low, it should be raised, thereby
preventing flexure posture while working on it,
- Choosing an appropriate chair to allows the adoption
of proper posture for example, during ironing.
THE MOST EFFECTIVE POSITIONS DURING
REST AND SLEEP
Daily rest and sleep are very important elements of
the circadian rhythm, because it accounts for the
largest percentage of our entire lives, which is why it is
so important to accept the most effective position.
While relaxing, take such positions at which you
feel the slightest pain. During the rest after work lay on
your back with the stool under shank [17, 18].
According to many authors, it is important to rest
and sleep on an appropriately chosen hard mattress.
Too soft mattress causes distortion of the physiological
curvature of the spine, which can lead to overloads.
In selecting the most advantageous position for the
spine during sleep, we consider all of the possible [19]:
1. 'On the abdomen.'
For those who are not pregnant it is a good position for
the lumbar spine, because it causes the creation of
physiological lordosis. In a pregnant woman is not
a proper position – it is uncomfortable, especially
during second and third trimester because of a growing
fetus. This position is not good for the cervical spine,
because it interferes with the proper anatomical
relations of this section, contributing to the abnormal
arterial blood flow to the brain.
2. "On the side"
This creates a natural physiological curvature of the
spine, but causes abnormal lateral flexure. Also
exposes to large overloads the sterno-clavicular joints.
3. "On the back"
Once you get adequate support you acquire correct
physiological curvatures of spine, even during sleep.
Support concerns: the lumbar-sacrum (small roll) and
cervical (individually matched pillow or roll under the
neck, filling the empty space in this area). According to
many authors, it creates the best conditions for the
spine and prevents the pain in the lumbar section.
For the purposes of prevention, when rising from lower
position we should remember not to execute a sudden
and violent movements. We should do it gradually and
slowly without burdening the spine.
The right way of getting up from bed should begin
from straitening and then turning on the back, bending
knees and hips, tensing abdominal muscles to rotating
to one side, with straight back. Supporting on the
elbow of the arm lying on the mattress and hand of the
other arm move to the sitting position by straighting
both arms while lowering the legs. Lean the torso
forward and straighten the legs in the knee and hip
joints and continue to the standing position [20].
Positions which decrease the load on the spine are (by
many authors):
1. Lying on the side, legs flexed at knee joints.
2. Lying on the back, legs flexed, feet based on the
surface.
3. Lying on the back, legs flexed at the knee joints at
90 degrees, lower legs on the stool.
11
CONCLUSION
In everyday life, one must be remember that every
carried out activity has an impact on the spine.
Through the development of civilization and
convenient lifestyle we tend to take less care about our
health (and especially the vertebral column) often not
truly realizing it. Taking care of the spine requires
a change in certain habits and huge self-discipline that
is so important, because prevention of back pain should
be systematic. Back pain relates to an increasing group
of people, it can also affect you. Take care of your own
spine, before pain will force you to it. Remember,
prevention is better than curing.
BIBLIOGRAPHY
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problem cywilizacyjny. Family Medicine & Primary
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neurologa. Badanie DEPEND. Neurol. Neurochir. Pol.,
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5. Pużyński S.: Depresje I zaburzenia afektywne. PZWL,
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6. Simon G.E., von Korff M.: Recognition, management,
and outcomes of depression in primary care. Arch. Fam.
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problem? Kilka uwag praktycznych dla pielęgniarki
i rehabilitanta jak troszczyć się o swój kręgosłup. Pielęgniarstwo chirurgiczne i Angiologiczne, 2008, 4.
8. Dziak A.: Bolesny krzyż. Wyd. Medicina Sportova,
Kraków, 2003.
9. Stodolny J.: Choroba przeciążeniowa kręgosłupa. Wyd.
ZL. NATURA, Kielce, 2003.
10. A Andersson G.B.J.: Biomechanies of the lumbag spine.
Kirhadly- Willis W.H., Burton CoV (eds) Managing low
back pain., Wyd. New York, NY: Churchill
Livingstonep, 1992, 27-28.
11. Kempf H-D.: Ćwiczenia kręgosłupa. Wyd. Interspar,
1995.
12. Dziak A.: Bóle i dysfunkcje kręgosłupa. Wyd. Medicina
Sportova, Kraków, 2007.
12
13. Duchnowska A.: Szkoła pleców – szkołą zdrowia. Med.
Fiz. Zdr., 2001,48(3): 7-10.
14. Fijałkowski W.: Ruch a zdrowie kobiety. Wyd. Lekarskie
PZWL, Warszawa, 1985, 17-22.
15. Krawczak M.: Dobowy system ochrony kręgosłupa.
Wychow. Fiz. Zdr., 2003,50: 11-16.
16. Centrum prasowe PAI, Materiały prasowe: Ruch na rzecz
zdrowych pleców. Med. Rodz., Warszawa, 10 września
2002, 5(5): 199-204.
17. Rudzik J.: Jak uniknąć nawracających bólów pleców?
Med. Dydakt. Wychow., 2001, 33 (1-2): 73-76.
18. Rudzik J.: Człowiek-muzyka-medycyna. Med.Dydakt.
Wychow., 2000, 32 (3/4): 119-123.
19. Niedzielski W.: Pozycja podczas snu jako wiodący
element profilaktyki dolegliwości kręgosłupopochodnych. Med. Man., 2005,9 (3/4): 12-14.
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Address for correspondence:
ul. Kilińskiego nr 6
06-400 Ciechanów
[email protected]
tel. 798363973
Received: 23.11.2010
Accepted for publication: 8.03.2011
REVIEW / PRACA POGLĄDOWA
Anna Jaworska-Posadzy, Jan Styczyński, Małgorzata Kubicka
MINIMAL RESIDUAL DISEASE IN CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA
MINIMALNA CHOROBA RESZTKOWA W OSTRYCH BIAŁACZKACH LIMFOBLASTYCZNYCH
U DZIECI
Department of Pediatric Hematology and Oncology, Laboratory of Clinical and Experimental Oncology
Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz
Head: Prof. Mariusz Wysocki, MD
Summary
I n t r o d u c t i o n . At the time of achieving clinical
remission, patients with acute lymphoblastic leukemia (ALL)
may harbour up to 1010 residual leukemic blasts, known as
minimal residual disease (MRD).
Techniques
and
targets
for
MRD
m o n i t o r i n g i n A L L . Presence of MRD can be
assessed
by
(i)
multiparameter
flow-cytometric
immunophenotyping based on the occurrence of leukemiaassociated immunophenotypes or by (ii) polymerase chain
reaction (PCR) analysis of the: (iii) rearrangements of Ig or
T-cell receptor (TCR) gene segments or (iv) breakpoint
fusion regions of chromosome aberrations.
Clinical
significance
of
MRD
monitoring in hematopoietic malignant
d i s e a s e s . MRD detection has acquired a significant
position in treatment protocols for ALL patients, on the basis
of its prognostic value for predicting outcome and the
possibilities for implementation of MRD diagnostics in
treatment stratification.
C o n c l u s i o n s . : Monitoring of MRD in ALL children
and adult is an independent risk factor of high clinical
relevance, both in the novo and relapsed ALL, as well as in
ALL patients undergoing stem cell transplantation.
Streszczenie
W s t ę p . W momencie osiągnięcia remisji klinicznej
w organizmie pacjentów z ostrą białaczką limfoblastyczną
(Acute Lymphoblastic Leukemia, ALL) może pozostać do
1010 przetrwałych komórek nowotworowych, określanych
minimalną chorobą resztkową (Minimal Residual Disease,
MRD).
Metody
wykorzystywane
do
monit o r o w a n i a M R D u p a c j e n t ó w z A L L . Do
wykrywania obecności MRD u pacjentów z ostrą białaczką
limfoblastyczną stosuje się dwie najbardziej obiecujące
techniki – molekularną i cytometryczną. Cytometryczna
ocena (flow cytometry, FC) MRD polega na analizie izmunofenotypów charakterystycznych dla komórek Biadaczkowych. Do monitorowania MRD przy pomocy techniki
polimerazowej reakcji łańcuchowej (Polymerase Chain
Reaction, PCR) wykorzystuje się klonalne rearanżacje genów
antygenu-receptora i/lub strukturalne aberracje chromosomalne (charakterystyczne miejsca złamań chromosomów
prowadzące do powstania genów fuzyjnych).
Wartość prognostyczna monitorowania
MRD
w
leczeniu
nowotworów
u k ł a d u k r w i o t w ó r c z e g o . Poziom MRD po terapii
indukcji uważany jest aktualnie za jeden z najważniejszych
czynników rokowniczych, ściśle korelujący z przeżywalnością. Procedura diagnostyczna monitorowania minimalnej
choroby resztkowej zyskała znaczącą pozycję w protokołach
leczenia, co udoskonaliło aktualne kryteria stratyfikacji
pacjentów z ostrą białaczką limfoblastyczną.
W n i o s k i . Monitorowanie MRD u dzieci oraz
u dorosłych pacjentów z ALL dostarcza znamiennej infor-
Anna Jaworska-Posadzy et al.
14
macji prognostycznej, nadrzędnej w stosunku do wszystkich
klasycznych czynników rokowniczych, zarówno w pierwszym
rozpoznaniu ALL oraz wznowy, jak również u pacjentów po
zabiegu transplantacji szpiku kostnego.
Key words: minimal residual disease, MRD; acute lymphoblastic leukemia; children
Słowa kluczowe: minimalna choroba resztkowa, MRD; ostra białaczka limfoblastyczna; dzieci
INTRODUCTION
Contemporary treatment protocols lead to complete
remission in a high proportion of patients with acute
leukemia, but many of them relapse [1, 2]. Due to
developments in diagnostic tests for hematopoietic
malignancies during the past two decades, it is known
that not all clonogenic malignant cells are killed,
although the patients are classified as being in
complete remission according to clinical and
morphological criteria [3, 4, 5].
At the time of achieving clinical remission, patients
with acute lymphoblastic leukemia (ALL) may harbor
up to 1010 residual leukemic blasts [6, 7]. This cell
detection is beyond the sensitivity level of classical
cytomorphologic methods (1-5%); they represent
Minimal Residual Disease (MRD) [5, 6].
Numerous methods of monitoring MRD in acute
leukemia have been developed. Most of the following
techniques: conventional cytogenetics, fluorescent in
situ hybridization, Southern blotting and cell- culture
systems, are not suitable for clinical MRD detection,
because of limited sensitivity. The most promising
techniques applied for MRD detection in almost all
pediatric patients with ALL (up to 95%) are: flow
cytometric (FC) detection of aberrant immunophenotypes and polymerase chain reaction analysis of
clonal antigen-receptor gene rearrangements [3, 7].
Several studies have demonstrated that the results
of MRD monitoring in patients provide useful
information on the biology of acute leukemia and its
responsiveness to treatment which significantly
correlate with clinical outcome. This has resulted in
MRD-based stratification of ALL treatment protocols
[2, 6, 8].
TECHNIQUES AND
MONITORING IN ALL
TARGETS
FOR
MRD
Acute leukemias are malignant proliferations of
haematopoietic precursor cells arrested at very
immature differentiation stages. Therefore, the
techniques used for monitoring of MRD must be able
to distinguish leukemic blasts form normal marrow or
blood cells, without false-positive results [1, 4]. For
acute leukemia, there is usually 1-log difference
between bone marrow (BM) and peripheral blood (PB)
analysis, with the highest MRD level in BM.
Therefore, studies of blood might be less informative
about the patient remission status than those in
marrow. Although PB based MRD studies are
relatively noninvasive, they could be used only as an
indicator for timing of BM samples and confirmation
of any minor changes. BM samples should be tested at
regular intervals [7, 9].
Because of the fact that MRD targets are lost
during the course of disease the most important feature
for assays to detect residual cells is to choose stable
leukemia-specific markers and it should not give falsenegative results. ALL cells can be recognized by their
leukemia-associated immunophenotypes and clonal
rearrangement of immunoglobulin and T-cell receptor
genes, expression of gene fusions [1].
Reliable tools to detect MRD should have
sensitivity of at least 10-3 but higher sensitivity is
preferred. Assays based on polymerase chain reaction
or flow cytometry can detect one ALL cell among 10
000 to 100 000 normal cells in clinical samples [3, 4, 8,
10]. Additionally, for the MRD tests to be incorporated
into the large-scale clinical trials and to obtain
multicentre treatment protocols, what is the most
essential, it requires reproducibility between
laboratories, simple, quick and easy to perform [3, 8,
10, 11].
FLOW CYTOMETRIC MRD DETECTION
The first idea that MRD could be detected by using
the increasingly versatile and specific capacities of FC
appeared as early as the late 80s. FC technique has
developed gradually over the last 20 years, with
advances in technology and software making
increasingly accessible for MRD detection, such that it
is now becoming an essential tool for monitoring
neoplastic cells [7, 12, 13, 14].
Although most ALL cells have immunophenotypes
comparable to normal immature leukocytes, MRD
detection is possible because hematopoietic
malignancies display aberrant or unusual antigen
expression or clonal patterns of immunoglobulin (Ig)
or TCR protein expression. This immunophenotypic
alterations (qualitative, quantitative, or both) have been
referred to as leukemia-associated immunophenotypic
patterns (LAIP) and are the result of cross lineage
Minimal residual disease in childhood acute lymphoblastic leukemia
15
antigen expression, or ectopic antigen expression,
maturational asynchronous expression of antigens,
antigen overexpression, and/or the absence of antigen
expression (Fig. 1A, 2A)[5, 7, 15, 16].
Cross-lineage antigen expression occurs when
typical myeloid antigens are expressed on lymphoid
cells (Fig. 1D, 2D) or vice versa and B-lineage
antigens on T-lineage cells or vice versa (Fig. 1C, 2C).
In asynchronous antigen expression two or more
antigens not present at the same time during normal
differentiation are coexpressed (Fig. 1B, 2B). As far as
ectopic antigen expression is concerned particular
antigens are presented on cells outside their normal
sites of production or homing areas or antigen that are
normally expressed only on non-hematopoietic cells
untypically appears [3, 12, 15, 16].
Fig. 2. Flow cytometric analysis of MRD in four B-ALL
patients at day 15. B-ALL cells showed immunophenotype changes with reference to immunophenotype at diagnosis in fig. 1
Ryc. 2. Cytometryczna analiza MRD u czterech pacjentów
z B-ALL w 15 dniu terapii. Widoczne zmiany
immunofenotypów białaczkowych limfocytów B
w porównaniu do immunofenotypów obecnych na
tych komórkach w dniu rozpoznania przedstawionych na ryc. 1
Fig. 1. Flow cytometric MRD monitoring showing examples
of unusual antigen expression patterns in four B-ALL
patients at diagnosis. (A) Overexpression of CD10
and CD19 in a subset of B-ALL blasts; (B)
Asynchronous expression of the stem cell marker
CD34 on CD20-positive mature B lymphocytes; (C)
Cross-lineage expression of the T lineage marker
CD2 on CD19-positive B lineage lymphoblasts; (D)
Cross-lineage expression of the myeloid lineage
marker CD13 on CD19-positive B lineage
lymphoblasts
Ryc. 1. Cytometryczna analiza MRD u czterech pacjentów
z B-ALL w dniu rozpoznania. Przykłady charakterystycznych immunofenotypów białaczkowych. (A)
Nadekspresja antygenów CD10 i CD19 na
komórkach blastycznych B-ALL; (B) Immunofenotyp
asynchroniczny. Obecność antygenu komórek macierzystych CD34 na dojrzałych CD20+ limfocytach
B; (C) Koekspresja antygenu CD2, charakterystycznego dla limfocytów T, na komórkach B-ALL
CD19+; (D) Koekspresja antygenu komórek
mieloidalnych CD13 na komórkach B-ALL CD19+
Since ALL blasts frequently reveal complex
aberrant immunophenotypic features, they fall into socalled "empty spaces" outside the multiparameter flow
cytometric dot plot templates of normal lymphoid cells
in normal BM and PB. LAIPs must be identified at
diagnosis in each case by comparing the cell marker
profile of leukemic blasts to that of reference bone
marrow samples, including those from patients
receiving or recovering from chemotherapy. There is
a challenge in FC detection of MRD to separate
residual malignant cells from normal cells, especially
at stages when regenerating BM may contain more
early maturation forms than normal samples at a steady
stage of hematopoiesis [1, 7, 15].
Current immunophenotyping strategies for
diagnosing ALL and MRD monitoring are based on
staining with combinations of monoclonal antibodies
(mAbs) conjugated to different fluorochromes.
Double- ,triple-, or quadruple-color staining panels can
include B lineage markers (e.g. CD19, CD10, CD20,
CD22), T lineage markers (e.g. TdT, CD3, CD4, CD8,
CD2, CD5, CD7), myeloid lineage markers (e.g.
CD13, CD33, CD15, CD14), and/or stem cell markers
(CD34, CD117) [10, 16, 17]. The selection of the
appropriate markers used to monitoring of MRD
depends on immunophenotypic features of the patient's
16
leukemic cells at the time of diagnosis [5, 15, 17]. If
the immunophenotype was not known, one would have
to apply the full range of potentially useful marker,
what is expensive and time-consuming option that
might still fail to identify residual disease.
Nevertheless, for FC MRD monitoring, it is preferred
to use at least two leukemia-associated antigen
combinations per patient, in order to prevent falsenegative results [5, 6, 10].
Although, flow cytometric MRD detection can
frequently reach sensitivities of 10-3-10-4, which is
slightly below the sensitivity of molecular methods, it
is cost effective, rapid, available to most of centers and
applicable to most patients in contrast to PCR assays
[1, 4, 5, 12]. After the sample is taken, results can be
obtained within a few hours [17].
Table I. Main characteristics of commonly used assays to
monitor minimal residual disease in acute
lymphoblastic leukemia
Tabela I. Charakterystyka najczęściej stosowanych metod
w monitorowaniu minimalnej choroby resztkowej
u pacjentów z ostrą białaczką limfoblastyczną
Method of MRD detection
in All
Technika stosowana w
monitorowaniu MRD
u pacjentów z ALL
Percentage
of patients
that can be
monitored
Sensitivity
Czułość
Advantages
Zalety
Disadvantages
Wady
Odsetek
pacjentów,
u których
można
zastosować
metodę do
monitorowania
MRD
PCR-based
techniques
of
Metody
oparte na
reakcji PCR
PCR analysis of
antigen-receptor
gene
rearrangements
Analiza rearanżacji
genów antygenureceptora
90%
0.01%0.001%
- high
sensitivity
wysoka czułość
- accurate
quantification
when RQ-PCR
is used
możliwa
precyzyjna
ocena ilościowa
przy
zastosowaniu
metody RQPCR
- requirement
for more
than one target
reduces
applicability
ograniczone
zastosowanie z
uwagi na potrzebę
analizy więcej niż
jednego markera
- clonal evolution
(false-negative
results)
klonalna ewolucja
(fałszywie
ujemne wyniki)
PCR analysis of
chromosome
aberrations
(fusion
transcripts, break
point fusion
genes)
Analiza aberracji
chromosomalnych
(transkryptów
genów fuzyjnych,
miejsca pęknięć
chromosomów)
40%
0.01%0.001%
- high
sensitivity
wysoka czułość
- stable
leukemia
targets
throughout
therapy
stałe markery w
trakcie leczenia
- accurate
quantification
when RQ-PCR
is used
możliwa
precyzyjna
ocena ilościowa
przy
zastosowaniu
metody RQPCR
- RNA instability
(false-negative
results)
niestabilność
RNA (fałszywie
ujemne wyniki)
- risk of crosscontamination
(falsepositive results)
ryzyko
zanieczyszczenia
badanych
sekwencji
(fałszywie
pozytywne
wyniki)
95%
0.01%
- widely
applicable
możliwa do
wykonania w
wielu
laboratoriach
- rapid
wynik
uzyskiwany w
krótkim czasie
- cost effective
mniej
kosztowna niż
metody
genetyczne
- accurate
quantification
możliwa
precyzyjna
ocena ilościowa
- lack of
expertise in
sample
processing and
data
interpretation
(false-positive
and falsenegative results)
brak
doświadczenia w
analizie i
interpretacji
wyników
(fałszywie
pozytywne i
negatywne
wyniki)
- phenotypic
shifts
zmiany
immunofenotypu
PCR-BASED TECHNIQUES OF MRD DETECTION
IN ALL
Presence of residual disease can be assessed by
polymerase chain reaction (PCR) of (i) rearrangements
of Ig or T-cell receptor (TCR) gene segments or (ii)
breakpoint fusion regions of chromosome aberrations
[1, 3, 18-20]. From a strictly technological point of
view PCR-based techniques can be used for the
detection of short segments of DNA (break point
fusion sequences at the DNA level) or for the detection
of RNA expression, RT-PCR (tumour-specific fusion
genes transcribed into fusion-gene mRNA) [3, 7, 18].
Whereas immunophenotyping gives direct quantitative
information, MRD quantification by PCR analysis is a
complex process. However, one method has become
available and highly suitable, real-time quantitative
PCR (RQ-PCR), which permits accurate quantification
during the exponential phase of PCR amplification [8,
11, 21].
FC and PCR analysis yield remarkably similar
measurements, if MRD is present at a 0.01% level.
Thus, we regard these methods as complementary,
each with specific strengths and potential weaknesses
(Table I).
PCR techniques may be preferable for analysis at
the end of therapy, when the higher sensitivity of PCR
might reveal MRD undetectable by flow cytometry
which is better for studies at early time points during
therapy, e.g. day 15 [12, 17].
Flow cytometric MRD
detection
Analiza cytometryczna
PCR ANALYSIS OF ANTIGEN-RECEPTOR GENE
REARRANGEMENTS
Clonal rearrangement of Ig and TCR genes can be
found in the majority of cases of ALL, but in less than
10% of acute myeloid leukemia (AML) cases. Each
lymphocyte, during early differentiation, gets a specific
combination of V(D)J segments that codes for the
variable domains of Ig or TCR molecules (Fig. 3). The
random insertion and deletion of nucleotides at the
junction site of V, (D), and J gene segments make the
junctional regions of Ig and TCR genes into
fingerprint-like sequences [1, 4, 7, 18]. These specific
features probably differ in each lymphocyte and thus
also in each malignant lymphoid disease. In order to
detect cells with such rearrangements, a real-time PCR
is preferred because it allows a precise quantification
of the PCR product, hence MRD [22]. The high
sensitivity of this method makes it possible to detect
one leukemia cell among 104-105 normal cells [8, 23].
The main disadvantage of using Ig/TCR
rearrangements as MRD target in ALL is the
occurrence of clonal evolution during treatment which
can result in the loss of the particular target with falsenegative PCR result. Thus, a minor clone at diagnosis
may become predominant during the course of the
disease and remain undetected because only a major
clone present at diagnosis is being monitored [18, 22].
To prevent this potential problem, it is advisable either
to use sets of probes matching two or more different
rearrangements or to use two independent MRD
methods (e.g., PCR and flow cytometry) [4, 23].
17
aberrations has few advantages. One of them is the
strong association between the molecular abnormality
and the leukemic clone, regardless of the presence of
intraclonal differentiation and cellular changes caused
by therapy. Although chromosome aberrations are
ideal leukemia specific targets, which remain stable
during the disease course as they are directly involved
in leukemogenesis, many haemopoietic malignant
disease do not have such specific markers that can be
detected by PCR [1, 4].
The most frequently occurring fusion transcripts,
such as BCR-ABL, MLL-AF4, E2A-PBX1, and TELAML1 in ALL, and AML1-ETO, CBFβ-MYH11 and
PML-RARA in AML can be used as target for
amplification [5, 7, 19]. In order to measure the level
of such fusion gen transcripts a real-time PCR can be
used. Depending on the type of chromosome
aberration, sensitivities of 10-3 to 10-4 can be reached
with PCR [3].
MRD monitoring by using fusion transcripts as
targets has some difficulties with precise quantitation
of malignant cells because of the fact that the number
of transcripts per leukemic cell may vary from patient
to patient with the same genetic leukemia subtype and
among different cells within the leukemic clone, and
might be affected by therapy [4, 11].
CLINICAL SIGNIFICANCE OF MRD
MONITORING IN HEMATOPOIETIC
MALIGNANT DISEASES
Fig. 3. TCRδ gene recombination in ALL. Two main types of
rearrangement are found in ALL. The Vδ1-DJδ1
recombination is predominant in T-ALL, whereas the
Vδ2-Dδ3 is usually found in B-lineage ALL. Arrows
indicate the position of the primers that can be used to
amplify the recombination sites by PCR [2, 27]
Ryc. 3. Dwa główne typy rearanżacji genu TCRδ w ALL.
Rearanżacja Vδ1-DJδ1 jest charakterystyczna
w przypadku T-ALL, natomiast rearanżacja Vδ2Dδ3 zachodzi zazwyczaj w B-ALL. Strzałki na
rycinie wskazują sekwencje, do których można
zaprojektować specyficzne startery w celu amplifikacji miejsca rearanżacji w reakcji PCR [2, 27]
PCR ANALYSIS OF CHROMOSOME
ABERRATIONS
PCR amplification of chromosomal breakpoints
and fusion transcripts can also be used to track MRD
but only in a minority of patients with ALL or AML
[1, 3, 19]. MRD detection by targeting chromosome
MRD detection has acquired a significant position
in treatment protocols for ALL patients [8]. The
prognostic value for predicting outcome and the
possibilities for implementation of MRD diagnostics in
treatment stratification, including treatment reduction,
have been proved by many researches [2, 3]. The need
for treatment deintensification is particularly pressing
in developing countries, where modern therapies for
childhood ALL may have unacceptably high toxicities
[4, 24].
Several reports have been published dedicated to
the role of MRD detection in order to predict of
treatment outcome in childhood ALL. Constant-Smith
et al. found that patients who had MRD of 0.01% or
higher in bone marrow at any of the time point during
treatment had a significantly higher relapse hazard [6].
Patients with MRD 1% or higher at the end of
remission induction treatment and those with MRD
18
0,1% or higher during continuation therapy had an
extremely high risk of relapse [6].
In addition to MRD-based stratification in modern
treatment protocols, MRD diagnostics have several
other applications in the clinical management of
childhood ALL. For example, it can uncover
impending relapse, thus giving a head start in the
planning of salvage therapy and/or hematopoietic stem
cell transplantation (HSCT). MRD assays also can be
used to help selecting the optimal post-remission
treatment in children who relapse and achieve a second
remission, i.e. chemotherapy versus HSCT [3, 9, 21,
25].
The optimal timing and method of MRD
assessment are a matter of debate [1, 3, 9, 10, 26].
Recently, several reports have been published
dedicated to the comparison of results obtained by FC
to those obtained by PCR [20].
Basso et al demonstrated the powerful prognostic
impact of early marrow disease estimation in childhood
ALL. They showed that MRD levels <0.1% measured
by FC on day 15 of remission induction therapy was an
important prognostic factor that retained independent
significance in a model including MRD levels
determined by PCR amplification of antigen-receptor
genes on days 33 and 78 from the start of remission
induction [17].
Kerst et al. have demonstrated that two the most
powerful techniques used in monitoring of MRD, FC
and PCR, can detect leukemic cells with a sensitivity
of 0.01% (one leukemic cell among 10 000 nucleated
bone marrow cells). The combined use of these
methods allowed MRD monitoring in all 45 patients
with highly concordance. Importantly, this approach
was also used in regenerating BM samples what
indicate that it should enable MRD detection in
practically all patients and prevent false-negative
results due to phenotypic shifts of clonal evolution.
However, for future MRD trials, the decision to choose
either one method or the concurrent use of both
methods may be determined by cost or by limited
applicability [26].
the leukemic clone, what is associated with an
excellent overall outcome. Consequently, MRD
diagnostics is currently incorporated in treatment
protocols as a tool for stratification. Standardization of
methodologies (molecular assays or FC) and definition
of common MRD terms has become important in order
to comparing of MRD results between different
laboratories or even in different treatment protocols.
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mgr Anna Jaworska-Posadzy
Katedra i Klinika Pediatrii, Hematologii i Onkologii
Uniwersytet im. Mikołaja Kopernika
Collegium Medicum im. Ludwika Rydygiera
ul. Curie-Skłodowskiej 9
85-094 Bydgoszcz
tel. 52 585 4349
faks 52 585 4867
e-mail: [email protected]
REWIEV / PRACA POGLĄDOWA
Zuzanna Pujanek
OPERATIONS OF PARANASAL SINUSES – REVIEW OF OPERATIONAL TECHNIQUES
OPERACJE ZATOK OBOCZNYCH NOSA – PRZEGLĄD TECHNIK OPERACYJNYCH
Chair and Department of Otolaryngology and Laryngological Oncology Nicolaus Copernicus University in Toruń,
Collegium Medicum in Bydgoszcz
Head: Henryk Kaźmierczak, MD, PhD, professor of medicine
Summary
Diseases of paranasal sinuses constituted the therapeutic
problem for many centuries. Anatomy and physiology of
sinuses were unknown what made diagnosing and curing
almost impossible. Over the time, thanks to the development
of medicine and the technique, but first of all thanks to
constructing more and more precise surgical instruments,
a knowledge about sinuses and the possibility of curing their
diseases was being expanded. Beginnings of operating curing
are being dated on 17th century, however conducting and
describing classical operational technique on the maxillary
sinus, today named Caldwell-Luca operation, was the first real
turning point. For the following years intense progress
concerning operation techniques on sinuses took place, which
through intranasal operations, with using the operating
microscope led to the still lasting era of endoscopy- at first
from the outside approach, at present most often carried out
FESS type procedures. Operating rhynology is still developing
and attempts to use more and more advanced surgical
instruments and navigational systems are being made. At this
work a review of operation techniques and the figures who
contributed to their development was described from historical
beginnings to the present day.
Streszczenie
Choroby zatok przynosowych przez wiele stuleci
stanowiły problem terapeutyczny. Nieznana była anatomia
i fizjologia zatok, co uniemożliwiało właściwe diagnozowanie
i leczenie. Z czasem, dzięki rozwojowi medycyny i techniki,
a przede wszystkim dzięki konstruowaniu coraz bardziej
precyzyjnych narzędzi chirurgicznych, poszerzano wiedzę na
temat zatok i możliwości leczenia ich schorzeń. Początki
operacyjnego leczenia datowane są na XVII w., jednakże
pierwszym prawdziwym przełomem było przeprowadzenie
i opisanie operacji klasycznej zatoki szczękowej, dziś
nazywanej zabiegiem Caldwella-Luca. W ciągu następnych lat
nastąpił ogromny postęp technik operacyjnych zatok
obocznych nosa, który poprzez operacje wewnątrznosowe,
z użyciem mikroskopu operacyjnego doprowadził do trwającej
obecnie ery endoskopii- początkowo zabiegi z dojścia
zewnętrznego, współcześnie najczęściej wykonywane zabiegi
typu FESS. Rynologia operacyjna nadal się rozwija
i podejmowane są próby używania coraz bardziej
zaawansowanych narzędzi chirurgicznych oraz systemów
nawigacyjnych. W pracy tej przedstawiono przegląd technik
operacyjnych od ich historycznych początków do dnia
dzisiejszego oraz lekarzy- naukowców, którzy przyczynili się
do ich rozwoju.
Key words: parana sal sinuses, methods of treatment, endoskopy, history
Słowa kluczowe: zatoki przynosowe, techniki operacyjne, endoskopia, historia
22
Zuzanna Pujanek
For ages diseases of paranasal sinuses have been a
cause of significant ailments in patients and have
created a therapeutic challenge for doctors. Initially,
the close anatomy and physiology of sinuses were not
developed. Preventive measures, chosen more or less
accurately according to the therapeutist’s knowledge
and intuition, were the only remedy. In the course of
time, thanks to the persistence and inquisitiveness of
doctors, the knowledge of paranasal sinuses has been
broadened. The first attempts of medical procedure
treatment, that also appeared, were initially very
incompetent and did not bring the intended result.
Following years brought new knowledge and
experience. New techniques of operating paranasal
sinuses were developed and were more and more
progressive and precise on one hand and less traumatic
on the other. The development of operational
techniques in Polish otolaryngology has been
influenced by the crucial role of PTORL rhinology
section established in the 1980’ by professor (Ph.D.) S.
Betlejewski [1, 2]. This article shows stages in the
development of sinuses operations from their historical
beginnings to the methods applied in the 21st century.
First attempts of opening the sinuses were made in
the 17th century: in 1675 Molinetti described the
approach to maxillary sinus through the chin; in 1798
Desault through the canine fossa; in 1892 Robertson
through the front wall. More dynamic development in
operational techniques had not taken place until the
1860’, when Lichwitz, Krause and Mikulicz started to
use the puncture of maxillary sinus through the inferior
meatus. In 1893 ‘New York Medical Journal’
magazine published an article describing the technique
of opening the maxillary sinus through the canine fossa
in the atrium of the oral cavity with the following
complete removal of the mucous membrane and
linking the sinus with the inferior meatus. The author
of this article was George W. Caldwell – an
otolaryngologist from New York. An identical
technique was presented four years later in Europe by
a French otolaryngologist Henry P. Luc. This
operation, today called the Caldwell – Luc procedure is
known to be a classical operational technique on the
maxillary sinus. Initially, while introducing this
method into the operating rooms, chronic rhinosinusitis
was the only indication to perform it. Along with the
development and increasing popularity of this
technique the list of conditions which qualified patients
to the operation performed in classical way was
extended. This tendency had maintained for centuries
until the era of endoscopy, when the figures underwent
an essential reduction. In 1990’ the indications to
perform an operation were following: the advanced
polyposis of the nose and sinuses, injuries, foreign
bodies, myxoma, empyema, retention or odontogenic
cyst, creating approach to the fossa pterygopalatina.
Along with the change in indications, the operational
technique itself has also changed. The Caldwell-Luc
Procedure is also defined as the radical operation
because of the complete removal of the mucous
membrane from the sinus. However, in some
pathological states (for example in the presence of the
foreign body) the approach and opening of the sinus
were the only procedures needed, without the necessity
to remove the membrane – this modification of the
Caldwell-Luc Procedure, is, so called, preservative
operation. Today the classical operation is performed
seldom and the indications are the cases of an
ineffective endoscopic treatment, antrochoanal polyp
and the fungal paranasal sinusitis [3, 4, 5].
Along with the increased operational approach to
the maxillary sinus different possibilities of procedural
treatment of other sinuses have been researched. The
radical operation of the frontal sinus has been
developed – the Jansen, Ritter and Riedel operation.
First of them is conducted in case of fronto-basal
fracture,
intracranial
complications
of
the
inflammatory and traumatic conditions and in order to
remove cancer tumors. The second operation is
conducted extremely seldom, in case of fronto-basal
fractures with a complete destruction of the front wall
and the fundus of the sinus, when it is impossible to
open these walls or during the operation of the mucous
cyst if the destruction of the osseous walls of the sinus
is very extensive [6]. A technique of a radical
operation of the
ethmoid sinus has also been
implemented – when the approach is conducted to its
ostium from the medial angle of the orbit. The
indications for the procedure are frontobasal fractures,
inflammation of the ethmoid cells with the orbital
complications, the transition of inflammation process
of the osseous walls, removal of some tumors of the
ethmoid bone, especially those originating in the area
of the frontal sinus ostium, or tumors developing in the
medial part of the orbit. Finding an approach to the
sphenoid sinus because of its location has been an
essential challenge for otolaryngologists. Three
operations have been described and implemented on
the basis of their access/approach:
Operation of paranasal sinuses - review of operational techniques
1) From the sublabial incision with the eversion
of the face covers.
2) From the through – septum approach
3) By the lateral rhinotomy (which lately has
been vastly criticized)[7].
Currently the external approach is held by the
pituitary surgery.
Classical, radical operations are connected with a
long process of healing, because removing the mucous
membrane from the sinuses severely deteriorates their
functions in the future, and with putting on large nasal
dressings and with long hospitalization [8]. Despite
these inconveniences and the reduction of indications
together with the dynamic development of the
endoscopic surgery, they are still applied in
contemporary otolaryngology.
The next step in the development of the sinus
surgery was the advancement of operational techniques
from the intranasal approach. It became possible
thanks to learning the detailed anatomy of the nasal
cavity and localizing the natural sinuses ostia. The
maxillary sinus is operated with the use of methods
developed by Claoue, Ruttin and Sturmann. In the first
two methods the maxillary sinus ostium is approached
by cutting off (Claoue) or pressing (Ruttin) the middle
nasal turbinate, and the third method by smashing the
edge of the piriform aperture. There are three groups of
indications for the intranasal operations:
1) Chronic sinusitis with the hyperplasia and
polyp changes in the mucous membrane.
2) Insufficient ventilation and drainage of the
sinus after the treatment of the endoscopic
antrostomy of the natural sinus ostium.
3) Lack of improvement on the way of multiple
punctures or a permanent drainage of an
ostium [9].
The intranasal opening of the frontal sinus is made
with the use of Halle’s method. The indications are:
1) Chronic frontal sinusitis.
2) Chronic frontal sinuses empyema.
3) Inflammation condition of the sinus with
headaches, while the negative pressure
emerges in the sinus.
4) Purulent or mucous cyst [9].
There are three ways of the intranasal opening of
the ethmoid sinus. The cutting off the middle nasal
turbinate is conducted in the Mosher’s method;
breaking and dislocating the middle nasal turbinate
towards the septum and opening the ethmoid sinuses
appears in the Halle’s method. A numerous group of
23
indications has been distinguished for these types of
procedure, namely:
1) Acute inflammation of the ethmoid cells of a
septic character.
2) Subacute or chronic ethmoid sinusitis.
3) Chronic sinusitis with polyp-changes.
4) Retrobulbar optic neuritis caused by the
inflammation of ethmoid cells.
5) Small benign tumors and purulent-mucous
cysts [9].
Though rarely conducted, there are procedures of
the intranasal opening of the sphenoid sinus, too. The
methods used are Hajek’s, Hirsch-Seagury’s and the
most popular method of sublabial and transseptal
opening of the sphenoid sinuses. There are two groups
of indications distinguished for these operations:
1) Injuries of the cranium base,
2) Operations on the pituitary [9].
Creating the possibility of intranasal operations on
sinuses resulted in the increase of post-operational
comfort in patients because it is not connected with
leaving scars on skin and it also decreases the
traumatization of tissues covering the sinuses.
Intranasal operations became a starting point for the
functional microsurgery.
Initially, before the endoscopes were invented and
used, there had been attempts to use the accessible
apparatus to expose the mucous membrane of the
sinuses. Microscope became an appropriate tool and it
was used for the first time in 1958 by Heermann [7].
The method of exposing the mucous membrane by the
use of microscope was widely accepted and soon
started to be used around the world. Along with its use
the validity of using different tools, that could replace
microscope and enable even more detailed examination
of sinuses, were discussed. The tool that fulfilled all
the conditions mentioned above was the endoscope.
The endoscopy of paranasal sinuses gained an essential
development in the 1960’, however first attempts of
such approach appeared earlier. First of them took
place in 1901 when Hirschmann modified the
cystoscope invented by Nitze in 1879, in a way to use
it in order to see the inside of the maxillary sinus [8].
There were numerous attempts for the next 70 years to
use endoscopy to treat sinus diseases around the world.
Endoscope was inducted into the maxillary sinus
through the fossa canina and later through the inferior
nasal meatus. The examination of the frontal sinus was
conducted by a 6 mm opening drilled in the sinus
frontal wall. Because of the location, the most difficult
24
Zuzanna Pujanek
approach for the surgeon appeared for the sphenoid
sinus. A long trocar was used as a conductor for the
endoscope.
For 70 years the endoscopic surgery has struggled
with many problems but the essential one was the
technical lack in equipment. The endoscope itself was
imperfect at that time, the lighting came from light
bulbs attached in a special way and because of that it
was often too bright or too dark. The reflections were
another obstacle. It was also difficult to match the right
diameter of the endoscope to expose an operational
field of an appropriate range. All those conditions
caused the endoscopic technique to be very difficult;
procedures were time consuming and often did not
bring the intended results. 1970’ were a breakthrough
in endoscopic technique, when Messerklinger proved
that the transport of the mucus in the sinuses, thanks to
the cilia covering the mucous membrane, leads from
the natural sinus ostium located under the middle and
superior turbinate of the nasal cavity, and every
disturbance of this transport leads to the state of
sinusitis [10]. Thanks to his discovery and to thin 30and 70-degree Hopkins’s endoscopes, of implementtation of the operational technique of the approach
from the natural sinus ostium under the middle nasal
turbinate with the possibility of documentation in the
form of colorful photographs was successfully
introduced. In 1986 this technique was developed and
described as a sinus drainage and ventilation procedure
limited to the opening of her natural ostium by
Stamberger who was a student of Messerklinger. Since
that time medical nomenclature has forever adopted the
name FESS – functional endoscopic surgery of
paranasal sinuses [11]. Currently, the functional
sinuses surgery is the basic method in the treatment of
chronic sinusitis. Regardless of optical appliances used
(microscope or endoscope) its essence comes to the
creation of conditions for regenerating the inflamed
mucous membrane by unblocking the paranasal sinuses
ostia. Along with familiarizing with and using FESS,
the number of indications for such procedures has
increased. Contemporarily, apart from chronic
sinusitis, we add to them orbital complications,
developing mucocelae and pyocelle and benign tumors
[8]. Significant evolution also concerns the apparatus
used during the procedure. Cutting forceps started to be
used and that enabled more precise removal of
pathologically
mutated
mucous
membrane.
Subsequently, the forceps were joined to the suction
system thanks to which it became possible to remove
mutations alongside with sucking off the blood from
the operational field. It contributed to the improvement
of visibility causing the increase in precision and
decrease in the number of complications. The latest
invention is a shaver, which is a connection of rotating
micro-knife with a sucking-rinsing system thanks to
which pathologically mutated tissues are cut and
sucked alongside with rinsing the operational field [7].
There are also attempts to use a laser in endoscopic
surgery, but regarding high costs and insufficient
results, it is not frequently used. In order to be more
precise and safe, the support of optical and
electromagnetic neuronavigation is implemented,
which leads to positive results [12]. The effects of
using FESS are very promising. From previous
research it appears that more than 80% of patients say
that the ailments have totally receded or significantly
decreased. The benefits of microsurgery are also
confirmed by objective researches indicating that in
endoscopic evaluation more than 50% of patients
reported the complete or significant regression of
pathological mutations [2]. What is also significant for
the benefits resulting from this method, is the fact that
complications after procedures are seldom and come
up only to a few percent. They include the perforation
of the nasal septum, epidural hematoma, orbital
emphysema and rhinorrhea. Apart from a small
percentage of complications, there are other benefits
for patients from using FESS. It was proved that using
endoscopic surgery in comparison to classical
operations leads to a less blood loss and the procedure
and the hospitalization of the patient takes less time
[13].
The Balloon Catheterisation of Sinuses may
become a new therapeutic option. It means putting a
flexible guide wire in the sinus ostium, on the track of
which a catherer with a balloon is guided to the sinus
lumen. After dosing the contrast liquid, the balloon that
is under pressure decompresses and widens the
narrowed sinus ostium. This method will certainly not
replace functional endoscopic sinus surgery but it may
create a valuable alternative in specific patients [14].
CONCLUSIONS
The sinus surgery has been developing for a few
centuries. The aim has been to invent a technique that
is the least invasive. Thanks to the thorough study of
the nasal cavity anatomy, the functions of the sinus
mucous membrane and by localizing their natural ostia,
Operation of paranasal sinuses - review of operational techniques
it became possible to use endoscopes in such a way to
save the nearest tissues as much as possible in the
treatment of the pathological conditions of sinuses.
More and more new tools are introduced which
facilitates and simplifies the work of their operators.
Contemporary rhinology is overcome by
endoscopic procedures; however it is impossible to
forget that there is still a group of indications to use the
techniques of classical surgery and their significance is
undisputed today.
BIBLIOGRAPHY
1. Betlejewski S., Znaczenie aerodynamiki dla fizjologii
oddychania przez nos, Otolaryngologia Polska, 1995, vol
21, str. 5-8.
2. Betlejewski S., Konchotomia podśluzówkowa dolna
wskazania i technika, Otolaryngologia Polska, 1995, vol
21, str. 119-121.
3. Krzeski A., Janczewski G. Choroby nosa i zatok
przynosowych, Sanmedia, Warszawa 1997.
4. Lund V. The evolution of surgery on the maxillary sinus
for chronic rhinosinusitis. Laryngoscope, 2002, vol 112,
415-419.
5. Misiołek M, Stankiewicz Cz. „Miejsce operacji
Caldwella-Luca we współczesnej rynologii”. Magazyn
Otorynolaryngologiczny, X-XII, 2006, vol. V, issue 4, no
20.
6. Boenninghaus H.G. Otorynolaryngologia, Springer
PWN, Warszawa 1997.
7. Janczewski
G.
Otorynolaryngologia
praktyczna
podręcznik dla studentów i lekarzy, vol. I, Via Medica,
Gdańsk 2007.
8. Szyfter W., Mielcarek-Kuchta D., Leszczyńska M.
“9-letnie doświadczenia Kliniki Poznańskiej w chirurgii
czynnościowej zatok przynosowych- od mikroskopu
operacyjnego do techniki czterech rąk”. Otolartngologia
Polska, 2008, 62 (2): 165-169.
9. Latkowski B. „Technika zabiegów i operacji w otolaryngologii”, Wydawnictwo lekarskie PZWL, Warszawa.
2000.
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10. Nayak S.R., Kirtane M.V., Ingle M.V.. “Functional
endoscopic sinus surgery (Anatomy, diagnosis,
evaluation and technique)”. Journal of Postgraduate
Medicine, 1991, vol. 37: 26-30.
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A., “Clinical and performance results of functional
endoscopic sinus surgery”. Acta Otorrinolaryngol Esp,
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12. Sieśkiewicz A., Łysoń T., Mariak Z.,
“Chirurgia
endoskopowa zatok przynosowych i podstawy czaszki ze
wspomaganiem neuronawigacją: porównanie systemów
optycznych i elektromagnetycznych”. Otolaryngologia
Polska, 2009, vol. 63 (3): 256-260.
13. Ikeda, K. Hirano, T. Oshima, A. Shimomura,
“Comparision of Complications between Endoscopic
Sinus Surgery and Caldwell- Luc Operation”. Tohoku J.
Exp. Med., 1996, vol. 180: 27-31.
14. Jurkiewicz D., Szczygielski K., Brzozowski K.
“Cewnikowanie endoskopowe zatok- ewolucja czy
rewolucja w leczeniu zapaleń zatok przynosowych?
Doświadczenie
własne
i
przegląd
literatury”.
Otolaryngologia Polska, 2009, vol. 63 (2): 113-117.
Chair and Department of Otolaryngology and
Laryngological Oncology
Nicolaus Copernicus University in Toruń
Collegium Medicum in Bydgoszcz
Skłodowskiej-Curie 9
85-094 Bydgoszcz, Poland
ORIGINAL ARTICLE / PRACA ORYGINALNA
Anna Bednarek1, Andrzej Emeryk2
THE ANALYSIS OF PARENTS’ KNOWLEDGE ABOUT PREVENTIVE VACCINATION
PROGRAMME IN THE GROUP OF HEALTHY AND ALLERGIC CHILDREN
OCENA WIEDZY RODZICÓW NA TEMAT PROGRAMU SZCZEPIEŃ OCHRONNYCH
W GRUPIE DZIECI ZDROWYCH I Z CHOROBĄ ALERGICZNĄ
1
Head of Chair and Department of Paediatric Nursing, Faculty of Nursing, Medical University of Lublin
2
Head of Department of Pulmonary Diseases and Rheumatology of the Medical University of Lublin
Summary
I n t r o d u c t i o n . In properly developing modern
society the idea of active prophylactic intervention in
managing infectious diseases becomes widely accepted, both
in immunoprophylactics of healthy children and of children
with chronic diseases, including allergic diseases.
T h e a i m o f t h e s t u d y was to identify the
knowledge of healthy and allergic children’s parents on
preventive vaccinations and the analysis of the use of
conjugate vaccines in the realization of obligatory and
optional Preventive Vaccination Programme.
M a t e r i a l a n d m e t h o d . : A group of 50 parents
of healthy children and a group of 50 parents of children with
allergy were examined. The diagnostic survey was carried
out among parents of children aged 2 months old up to 19
years old in two vaccination centres of Lublin, in 2008 and
2009. Quantitative details about the frequency of using
recommended vaccines were obtained with analysis method
of the documentation of the medical District Sanitaryepidemiological Station in Lublin.
R e s u l t s . Straight majority of parents of children with
allergy (91.0 %) and 80.0 % of parents of healthy children
agrees with the idea of completion of preventive vaccinations
in the current, compulsory form. Examined parents above all
have information concerning the preventive effect of the
WZW B vaccine (95.0 % of parents of children with allergy
and 100.0 % of parents of healthy children p < 0.001), next
BCG, Poliomyelitis and DTP. The least popular, in the aspect
of the immunogenicity, is a vaccine known to respondents a
monovalent vaccine HIB (for 72.0 % of parents of children
with allergy and only 38.0 % parents of healthy children, p <
0,001). Majority of examined parents of children with
allergosis - 70.0 %, p < 0,001 and 71.0 % regards taking
associated vaccines with high prices. Amongst healthy
children, parents have more rarely applied recommended
vaccination. However, a flu vaccination was recommended
preparation most often applied in both analyzed groups of
vaccinated children.
Conclusions
1. The level of parents’ knowledge on the preventive
vaccinations affects the frequency of used
conjugated preparations and realization of
recommended vaccinations.
2. Observation of the growing interest of parents in
conjugated
vaccines
and
recommended
preparations, mainly in allergic children but also in
the healthy ones, is a positive phenomenon of
growing in social awareness of infectious diseases
prophylactics.
28
Anna Bednarek, Andrzej Emeryk
Streszczenie
W s t ę p . W prawidłowo rozwijającym się nowoczesnym społeczeństwie idea czynnej interwencji profilaktycznej
w postępowaniu z chorobami zakaźnymi staje się szeroko
akceptowaną, zarówno w immunoprofilaktyce dzieci zdrowych, jak również z chorobami przewlekłymi, w tym
alergicznymi.
C e l p r a c y . Identyfikacja wiedzy rodziców dzieci
zdrowych i z chorobą alergiczną na temat szczepień
ochronnych oraz ocena zastosowania przez rodziców
szczepionek skojarzonych w realizacji Programu Szczepień
Ochronnych obowiązkowych i zalecanych u własnego
dziecka.
M a t e r i a ł i m e t o d a . Metodą sondażu diagnostycznego objęto badaniami 50. osobową grupę rodziców
dzieci zdrowych oraz 50. osobową grupę rodziców dzieci
z alergią, w wieku od 2 miesiąca życia do 19 roku życia,
w dwóch punktach szczepień Lublina, w roku 2008 i 2009.
Dane ilościowe o częstości zastosowania szczepionek
zalecanych pozyskano metodą analizy dokumentacji
medycznej Powiatowej Stacji Sanitarno-Epidemiologicznej
w Lublinie.
W y n i k i . Zdecydowana większość rodziców dzieci
z alergią (91,0%) oraz 80,0% rodziców dzieci zdrowych
opowiada się za realizacją szczepień ochronnych w obecnej,
obowiązkowej formie. Badani rodzice przede wszystkim
posiadają informacje dotyczące zapobiegawczego działania
szczepionki WZW B (95,0% rodziców dzieci z alergią
i 100,0% rodziców dzieci zdrowych p<0,001), następnie
BCG, Poliomyelitis i DTP. Najmniej znaną dla ankietowanych szczepionką, w aspekcie immunogenności, jest
monowalentna szczepionka HIB (dla 72,0% rodziców dzieci
z alergią i tylko 38,0% rodziców dzieci zdrowych, p<0,001).
Większość badanych rodziców dzieci z chorobą alergiczną –
70,0%, p<0,001 i 71,0% rodziców dzieci zdrowych uważa,
że stosowanie szczepionek skojarzonych wiąże się ze zbyt
wysokim kosztem ich zakupu. Wśród dzieci zdrowych
rodzice rzadziej stosowali szczepienia zalecane. Natomiast
w obu analizowanych grupach zaszczepionych dzieci
najczęściej stosowanym preparatem zalecanym było
szczepienie przeciwko grypie.
Wnioski
1. Poziom wiedzy rodziców na temat szczepień
ochronnych wpływa na częstość stosowanych preparatów skojarzonych i realizację szczepień zalecanych.
2. Obserwacja rosnącego zainteresowania rodziców
szczepionkami skojarzonymi i preparatami zalecanymi, przede wszystkim w grupie dzieci z chorobą
alergiczną, ale też i zdrowych stanowi pozytywne
zjawisko wzrostu świadomości społecznej w zakresie
profilaktyki chorób zakaźnych.
Key words: preventive vaccination programme, allergic children
Słowa kluczowe: realizacja szczepień ochronnych u dzieci, wiedza rodziców na temat szczepień
INTRODUCTION
Preventive vaccinations are the most effective
intervention in public health, both in industrialized and
in developing countries.
The immunization process realized with the support
of WHO has contributed to international cooperation in
order to maximize the proportion of immunised
persons, monitor epidemiological situation of many
infectious diseases and systematic launch of new
vaccines. It should be considered a significant success
of contemporary vaccinology [1, 2].
The initiated in Poland in 1950s realization of
commonly
accessible
obligatory
preventive
vaccinations in children and adult population,
contributed to elimination of many serious infectious
diseases, such as: poliomyelitis, tetanus, measles,
diphtheria and considerably limited development of
tuberculosis and hepatitis type B [3].
Recently, almost every year the Ministry of Health
publishes a new program of preventive vaccinations
covering both obligatory and optional vaccinations.
The need for realization of that programme results
from current epidemiological needs of our country [4].
In spite of unquestionable successes of infectious
diseases in immunoprophylactics, the realization of the
programme of preventive vaccination in Poland
considerably differs from the one in EU countries and
the latest WHO recommendations in this field.
Economic situation of our country with low cost of
immunoprophylactics realization in central budget
leads to the use of too small number of
multicomponent vaccines in Polish Programme of
Preventive Vaccinations (PPV). DTP (preventing
against diphtheria, tetanus and pertusis) and MMR II
(against measles, mumps and rubella) are the only, so
called, conjugated vaccines and reimbursed by
National Health Fund preparations in Polish PPV.
However, the easier in use, five- and six-component
modern conjugated vaccines, which during single
vaccination provide effective prophylactics of
diphtheria,
tetanus,
pertusis,
poliomyelitis,
Heamophilus influenzae type B and hepatitis type B,
are realized in our country for additional fee. The
program of obligatory, i.e. free vaccinations involves
three separate injections of infants during the same
The analysis of parents' knowledge about preventive vaccination programme in the group of healthy and allergic children
appointment. Children up to 2 years old get 16
injections, and if realization of PPV made use of
conjugated vaccines, this number would be reduced by
half [5, 6, 7].
This fact worries those parents for whom the
problem of comfort and no stress during realization of
vaccination programme (in spite of using local
anaesthesia) plays an important role. Moreover,
multicomponent vaccines generate high immunogenity
and are safer in use as they include less preservative
substances. They release less general post-vaccine
reactions, causing only bigger reaction at the place of
injection, which disappears by itself after several days
[8, 9, 10].
Since 2007 WHO has been realizing a new
programme of preventive vaccinations - GAVI-Global
Alliance for Vaccines and Immunisation, the goal of
which is to use all accessible vaccines in the preventive
vaccination programme and to increase the number of
vaccinated subjects. Only in 2006 Poland was the last
country in EU where the obligatory for all children
vaccination against haemophilus influenzae type B was
introduced. However, the pneumococcal vaccine is
accessible since 2008 only for children in special risk
groups, i.e. children with confirmed immunodeficiency
and broncho-pulmonary dysplasia [11, 12, 13, 14].
In Poland the vaccinations against meningococccus,
chicken-pox, rotavirus diarrhoea
are still not
reimbursed. Only in some places in our country a
program of free of charge vaccinations against HPV
has been launched and covered by the local
administration, while in the USA, Canada and
Germany, vaccination is free of charge. In France,
Ministry of Health reimburses 65% of the costs spent
on vaccinations. However the vaccine against
rotaviruses is orally administered in liquid form, and it
prevents the child from stress connected with injection
and does not collide with realization of PPV [15, 16].
A great progress in common access and realisation
of preventive vaccinations in 1970s and 1980s was
stopped during last decade and contributed to the
return of many serious child-related diseases.
Realisation of preventive vaccinations in Developing
Countries(Nigeria, India, Afghanistan, Pakistan) is a
specific problem, where the Heine-Medina disease is
still reported and caused by poliomyelitis virus; infant
tetanus, diphtheria, pertussis, yellow fever, in spite of
accessibility of effective vaccines [17, 18].
In industrialized countries unofficial movement
against vaccination (also being present in Poland),
29
which originated in the USA and has been propagating
not scientifically documented reports on the harmful
effects of some preventive vaccines, is serious cause
for the reduction in the number of realized preventive
vaccinations in children.
According to the information of this pressure
group, vaccinations can result in bronchial asthma and
other allergic diseases, autism, and inflammatory
condition of large intestine. Following the false
information, there is a tendency of reduction in the
number of vaccinated children, below 80%, which is
a threat of epidemic return of many infectious diseases.
At the end of 1990s following terrified parents’ panics
in Great Britain concerning the particular harm of
MMR vaccine, a considerable part of them resigned
from the vaccination against measles, mumps and
rubella, causing the increase of measles epidemic focus
in many regions of the country. For several years in the
USA the number of parents who do not vaccinate their
children also due to some religious reasons, has been
growing [19, 20].
Children with primary immunodeficiency which is
usually hereditary, as well as children with secondary,
inherited immunodeficiency due to chronic disease or
its therapy, are special problem to vaccinology.
Therapy with glicocorticosteroids administered for
some time in big doses [21, 22] is the example of that
secondary immunodeficiency.
Constantly increasing incidence of allergic diseases
is closely related with the disorders in functioning of
humoral and cellular defensive mechanisms as well as
the need of prolonged pharmacotherapy. Systematic
realization of preventive vaccinations in the group of
children with chronic diseases, including allergic
diseases, is extremely important as infectious diseases
in these children develop more frequently and the
course of disease is more severe. Moreover, the
performed preventive vaccinations at the time of
impaired resistance may decrease the effectiveness of
immunotherapy, therefore sometimes it is necessary to
apply the vaccine only after reaching the improvement
of immunologic condition of the ill child. Also due to
decreased ability of producing correct resistance
reaction, allergic children belong to the group of
increased risk of undesired post-vaccine reactions
development,
particularly
after
administering
attenuated preparations [23, 24].
Particular conditioning of preventive vaccinations
realization in allergic children requires continuous
upgrading of parents’ knowledge on preventive
30
vaccinations, which simultaneously affects the
frequency of applied conjugated preparations and
realization
of
recommended
immunisations.
Application of modern vaccines is the example of
parents’ alternative behaviour in caring about their
child’s health and the quality and safety of preventive
vaccinations.
THE OBJECTIVE
The objective of the study is an identification of
knowledge of healthy and allergic children’s parents
on preventive vaccinations and assessment of
application of preventive vaccines by parents in
realization of PPV of obligatory and recommended
vaccines in their children.
The present study is a continuation of initiated in
2006 research on realization of preventive vaccinations
in allergic children.
MATERIAL AND METHOD
The study covered 50 parents of healthy children
and 50 parents of allergic children in the age range
from 2 months to19 years from 2 vaccination units in
Lublin in 2007 and 2008.
The empirical material was obtained on the basis of
research tool which was a questionnaire designed
especially for the purpose of the study. The questions
included in the questionnaire concerned parents’
knowledge and approval of preventive vaccines
realized in their children and the reasons for using or
not using conjugated vaccines as well as realization of
recommended vaccinations.
The quantitative data on the frequency of
recommended vaccines application in non-allergic
children were also obtained by analyzing medical
documents of the District Sanitary-Epidemiological
Station in Lublin.
The statistical software SPSS 14.0PL with the use
of numbers, percentage calculations, test chi square of
compliance and test chi square of independence, were
used.
RESULTS
The studied group of allergic children’s parents
comprised young people aged 29-34 years (38%).
Similarly among the healthy children’s parents the age
25-31 was dominating (41%). A considerable majority
were women (90.0% in allergic children’s parents
group and 92.0% in healthy children’s parents group).
The majority of parents had secondary and higher
education (48.0% and 45.0% in the group of allergic
children’s parents and 44.0% and 41.0% in the group
of healthy children’s parents). The smallest number in
both surveyed groups comprised people with
vocational education, i.e. 6.0% of parents of allergic
children and 12.0% among parents of healthy children.
The average frequency of appointments with the family
doctor or allergologist, according to the studied parents
of allergic children, was 16-18 times, and in the group
of parents of healthy children only 3-4 times.
A significant prerequisite for proper realization of
PPV by parents in their children is first of all the
approval of vaccines. The analysis of the study implies
that all of the responding parents of allergic children
have a positive attitude towards preventive
vaccinations suggested in the vaccination calendar and
consider them a positive element of infectious diseases
prophylaxis. However, in the group of healthy
children’s parents, four of them, i.e. 8.0% (all with
higher education) think that healthy children correctly
developing and living in optimal social conditions, do
not need to be vaccinated. A considerable majority of
allergic children’s parents (91.0%) and 80.0% of
parents of healthy children is for preventive
vaccinations in the present obligatory form. Only 8.0%
allergic children’s parents and 20.0% of health
children’s parents are for voluntary realization of
preventive vaccination (Fig. 1).
100%
80%
60%
obli gato ry
40%
vo luntary
20%
0%
allergi c chil dren
healthy chil dren
Fig. 1. The opinion of studied parents concerning the present
form of preventive vaccination realization (obligatory,
voluntary)
Knowledge of the studied parents on prophylactic
activity of certain vaccines in a healthy child and in the
course of chronic diseases is a necessary condition for
their systematic realization. First of all the studied
parents (Fig. 2) have information concerning
preventive activity of hepatitis type B (95.0% of
parents of allergic children and 100.0% of healthy
children’s parents, p<0.001), then BCG, Poliomyelitis
and DTP. The least known for the parents vaccine in
terms of immunogenicity is a monovalent vaccine HIB
(for 72.0% of parents with allergic children and only
for 38.0% of parents with healthy children, p<0.001).
31
appointments at the doctor (30.0% of allergic
children’s parents, p<0.001 and 31.0% of healthy
children’s parents, p<0.001).
60%
100%
40%
80%
20%
60%
0%
allergic children
healthy children
40%
20%
frequent deterioration of alergic disease
child's disease
0%
allergic children
lack of time
healthy children
forgetting
DTP
WZW B
BCG
HJB
POLIOMYELITIS
MMR
Fig. 2. Knowledge of parents on preventive activity of
monovalent and conjugated vaccines
The basic sources of knowledge about prophylactic
activity of certain vaccines – monovalent and
conjugated- realized in PPV, considered by the studied
parents (Fig. 3) were: the nurse form vaccination unit
(81.0% of allergic children’s parents and 61.0% of
healthy children’s parents, p<0.001), then the primary
health care physician (63.0% of allergic children’s
parents and 21.0 health children’s parents, p<0.001) as
well as publications in the vaccination unit (48.0% of
allergic children’s parents and 62.0% of healthy
children’s parents, p<0.001).
Fig. 4. The most important advantages of conjugated vaccine
according to the respondents
Majority of allergic children’s parents [70.0%,
p<0.001 and 71.0% of healthy children’s parents,
p<0.001 (Fig. 5)] think that using conjugated vaccines
is connected with a high cost. At the same time,
a considerable part of them stated that they have too
little information on the accessible conjugated vaccines
(22.0% of allergic children’s parents, p<0.001 and
31.0% of healthy children’s parents, p<0.001).
80%
70%
60%
50%
40%
30%
100%
20%
80%
10%
60%
0%
allergic children
40%
20%
too high cost of vaccine
0%
allergic children
nurse in v accination unit
healthy children
Primary health care physician
publications
Fig. 3. Sources of information for parents on prophylactic
activity of monovalent and conjugated vaccines
The most important advantage of conjugated
vaccine according to the respondents (Fig.4) was the
possibility of simultaneous immunization against
several infectious diseases (64.0% of allergic
children’s parents, p<0.001 and 38.0% of healthy
children’s parents, p<0.001). It is also important for the
studied subjects that using of this biological
preparation reduces the number of injections and
healthy children
too little information in this field
Fig. 5. Factors preventing parents from using conjugated
vaccines
A statistically significant cause of not keeping the
terms of realization of preventive vaccines by allergic
children’ parents (52.0%, p<0.001) is frequent
deterioration of allergic disease in a child (Fig. 6).
However, in healthy children’s parents it is a condition
of child’s infection (23.0%, p<0.001) and lack of time
(11.0%, p<0.001) as well as forgetting (7.0%,
p<0.001).
32
60%
50%
40%
30%
20%
10%
0%
allergic children
healthy children
frequent deterioraton of allergic disease
child's infection
lack of time
forgetting
Fig. 6. The reasons for not keeping the terms of obligatory
vaccinations
On the basis of MZ-54 report on using the vaccines
in 2007 in healthy children and information obtained
from allergic children’s parents, it was stated that
among healthy children parents less frequently used
recommended vaccines. However, in both analysed
groups of vaccinated children the most frequent
recommended vaccine was that against flu (Fig. 7).
Smallpox
45
40
35
Tick-borne
encephalitis
30
Hepatitis type A
25
20
Streptococcus
pneumoniae
15
Flu
10
Neisseria
meningitidis
5
0
healthy children
allergic children
Diarhoea
Fig. 7. Kind and number of used recommended vaccines in
2007 in healthy and allergic children in the analysed
vaccination units in Lublin (per 358 children)
DISCUSSION
Constant development of vaccinology generates
better possibilities of obtaining highly immunogenic,
conjugated and safe vaccine preparations against many
infectious diseases. These vaccines considerably
facilitate realization of PPV both in healthy and
allergic children. At the same time they favour
providing of optimal epidemiologic situation by
exposing a high proportion of children population to
preventive vaccinations. Therefore, it is an important
element of health policy of each country to make
efforts focused on possibility of their common use also
as the most beneficial activities for health [1,19].
The necessity of providing parents with reliable
information on obligatory and recommended vaccines
and the accessible conjugated vaccines is a valid
requirement, particularly for medical personnel dealing
with vaccinations. However, broadening this
knowledge should result from personal motivation of
parents for ensuring their child optimal and safe
prophylactics. It is especially important for allergic
children in terms of periodical contraindications for
realization of preventive vaccinations resulting from
the course of therapy [11,13,14].
The analysis of knowledge of parents on the
prophylactic activity of monovalent and conjugated
vaccines implies that it is clearly differentiated by the
health condition of the interrogated parents’ children.
The correct answers in this field were more frequently
given by allergic children’s parents, whose great
interest in preventive vaccination resulted from both
frequent visits in medical settings and the related better
accessibility to information on vaccine preparations
from the health care personnel and exposition of
publications.
Seeking of information about preventive
vaccination by allergic children’s parents resulted also
from the concern about child’s health and systematic
identification of factors determining it. At the same
time, all of the respondents lived in Lublin and this fact
generated favorable conditions for obtaining reliable
information on preventive vaccination. Similar results
were obtained by the authors of earlier research. Also
Pokorska et al.[25] stated that the place of residence
and
education
differentiates
knowledge
on
recommended vaccines most.
The analysis of the information of the assembled
company from the surveyed parents about the
immunization carried out at children shows that their
duty resulting from the Polish legislation is a form
accepted by the straight majority of parents of children
with allergy, as well as of parents of healthy children.
A fact of the possibility of the influence of some
immunisation often arouses anxieties of the survey
parents for appearing or triggering tightening
allergoses, or increased, undesirable postvaccinal
manifestations. None of the currently being carried
Henderson and co. [21], Nilssona publications and co.
[26] and observation of Taiwanese Authors [27]
confirms the connection of the completion of the
immunisation with appearing of allergoses or
sharpening them, or increased, general serum
sicknesses.
Peculiarly modern associated vaccines constitute
safe, about the high clinical effectiveness immunogenic
preparations for allergic children. Applying associated
vaccines is more and more often a method accepted
and backed up, both through the medical staff, as well
as parents. However, a fact is stirring up controversy,
too modern necessities of the individual payment
preparations vaccines what in case of children with
allergosis is playing a significant role by virtue and so
often of heavy costs of applied curing essential illness.
In the group of healthy children permanent
monitoring is a crucial condition for the effective
vaccination programme. However, in the group of
children with allergoses an evaluation of the real
effectiveness of the significant immunoprophylactics
and in some cases, establishing the individual calendar
of basic and recommended vaccination are needed.
Also, modern possibilities of financing of vaccines
associated and recommended in the group of allergic
children.
CONCLUSIONS
1. All parents of children with allergosis have a
positive attitude towards the completion of the
immunisation and they apply both associated, as well
as recommended vaccines.
2. Parents of healthy children demonstrated lower
knowledge of the preventive effect of associated and
recommended vaccines, as well as their limited
application.
3. With main obstacle in the PSO realization for
parents is an economic factor 4. Impediments in the
PSO realization among allergic children resulted above
all from frequent of tightening symptoms for her at the
child.
4. With recommended vaccine most often chosen
by parents among both allergic as well as healthy
children, there was an influenza vaccine.
5. Observation of the growing interest of parents in
the
associated
vaccines
and
recommended
preparations, in both examined groups of parents,
constitutes a positive phenomenon of the growth of the
social awareness in the prevention of infectious
diseases.
33
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[email protected]
tel. do Katedry i Zakładu Pielęgniarstwa
Pediatrycznego: 81 718 53 75
tel. kom. 607 607 115
Waldemar Ciemnoczołowski1, Piotr Jurkowski1, Anna Piątkowska2
PROFILE OF A CANDIDATE FOR THE FIRST-CYCLE PROGRAM
AT THE FACULTY OF HEALTH SCIENCES OF THE LUDWIK RYDIGIER
COLLEGIUM MEDICUM IN BYDGOSZCZ,
NICOLAUS COPERNICUS UNIVERSITY IN TORUN, IN THE ACADEMIC YEAR 2008/2009
PROFIL KANDYDATA NA STUDIA PIERWSZEGO STOPNIA NA WYDZIALE NAUK
O ZDROWIU COLLEGIUM MEDICUM IM. L. RYDYGIERA W BYDGOSZCZY UMK
W TORUNIU W ROKU AKADEMICKIM 2008/2009
1
Department of Computer Science and Methodology of Scientific Research, Nicolaus Copernicus University
in Toruń, Collegium Medicum in Bydgoszcz
Head: Assoc. Prof. Piotr Jurkowski, MD
2
Department of Radiology and Organ Diagnostics, J. Biziel University Hospital No. 2 in Bydgoszcz
Head: Elżbieta Sokólska, MD
Summary
The purpose of the study, conducted at the Faculty of
Health Sciences of the Ludwik Rydygier Collegium Medicum
in Bydgoszcz in the academic year 2008/2009, was an attempt
to define the profile of people applying for the first-cycle
studies at the above mentioned faculty. Overall the survey
questionnaire was completed by 203 candidates for
undergraduate studies in the academic year 2008/2009: 157
women (77.3%) and 46 men (22.7%). The mode of study
chosen by the candidates was related to their age, i.e. full-time
students were younger than the part-time students. Applicants
for admission to part-time courses were normally employed
and financially independent. Candidates for studies usually
lived in the Kujawsko-Pomorskie province. In addition to its
convenient location, the most important criterion for the
selection of the Faculty of Health Sciences as a place of study
was its good reputation.
Streszczenie
Celem badań, przeprowadzonych na Wydziale Nauk
o Zdrowiu Collegium Medicum w Bydgoszczy w roku
akademickim 2008/2009, była próba zdefiniowania profilu
osób podejmujących naukę na tym Wydziale na studiach
pierwszego stopnia. Ogółem kwestionariusz ankiety wypełniło
203 kandydatów na studia pierwszego stopnia w roku
akademickim 2008/2009, w tym: 157 kobiet (77,3%) i 46
mężczyzn (22,7%). Tryb studiów wybieranych przez
kandydatów pozostaje w związku z ich wiekiem tzn. na
Key words: profile of candidate for study, the student profile
Słowa kluczowe: profil kandydata na studia, profil studenta
studiach stacjonarnych są osoby młodsze niż na studiach
niestacjonarnych. Osoby ubiegające się o przyjęcie na studia
niestacjonarne zwykle pracują zawodowo i są niezależne
finansowo. Kandydaci na studia zwykle pochodzą z województwa kujawsko-pomorskiego. Poza dogodnym położeniem
najważniejszym kryterium wyboru Wydziału Nauk o Zdrowiu,
jako miejsca odbywania studiów, jest renoma, jaką cieszy się
ten wydział.
Waldemar Ciemnoczołowski et al.
36
INTRODUCTION
The purpose of the study, conducted at the Faculty
of Health Sciences Medical College in the academic
year 2008/2009, was an attempt to define the profile of
people taking science at the Faculty for an
undergraduate degree. Such a profile may assist in the
optimization of operations which the university
undertakes in terms of increasing quality of education,
enhancing the candidate’s satisfaction in choosing their
field of study, as well as in all marketing activities.
MATERIAL AND METHODS
The survey covered people who came forward to
the Faculty of Health Sciences and registered in the
College Student Service System (CSSS). Through the
Academic Information Centre, each candidate received
an anonymous electronic survey with a cover letter and
full instructions for completion. After completing the
forms, the candidates sent the questionnaire to
a dedicated e-mail account on the server of the Medical
College in Bydgoszcz. Overall the survey
questionnaire was completed by 203 candidates for
undergraduate studies in the academic year 2008/2009:
157 women (77.3%) and 46 men (22.7%). Statistical
analysis of the data was done with the use of the
statistical tools package: SPSS 14.0 PL.
Out of the people surveyed, 156 (76.8%) intended
to pursue studies in full-time mode, and 47 (23.2%) in
part-time mode. The median age of candidates for fulltime studies was 19 years (minimum = 18, maximum =
25), and part-time 21.5 years (minimum = 19,
maximum 51). As a measure of central tendency the
median was used as the age distribution of candidates
in both groups was inconsistent with the normal
distribution (the value of statistics from the
Kolmogorov-Smirnov test is appropriate for candidates
for full-time: Z = 4.24, and part-time: Z = 2.11; p
<001). Based on the data collected, it was found that
the differences in the age of respondents, depending on
their mode of study, are statistically significant (Z =
3.969, p <001). The observed relationship between the
subjects' age and their choice of mode for study is of
moderate strength (η = 0.489).
The vast majority of respondents, i.e. 161 persons
(94.7%), are graduates of secondary schools, who
attended classes with profiles including humanistic,
economic, sports, mathematics and physics, and
general. The largest group, however, consisting of as
many as 75 persons (44.1%), are candidates who
completed classes with a biology-chemistry profile.
Although the schools of the respondents were spread
across several provinces, most of them were within the
Kujawsko-Pomorskie province.
RESULTS
At the Faculty of Health Sciences in the Ludwik
Rydygier Collegium Medicum in Bydgoszcz,
candidates have the opportunity to train in various
fields and specialties in full-time and part-time modes
of study. The survey respondents applied for admission
to the degree courses listed below:
Table II. Location of candidates’ previous schools
Tabela II. Lokalizacja szkół średnich kandydatów
Mode of study
Tryb studiów
Kujawsko-pomorskie
Full-time
Stacjonarne
Table I. The fields of study chosen by the candidates
Tabela I. Kierunek studiów wybrany przez kandydatów
Field of study / specialization
Kierunek studiów / specjalność
37
18.2
Physiotherapy / Fizjoterapia
23
11.3
Nursing / Pielęgniarstwo
37
18.2
Obstetrics / Położnictwo
7
3.4
Medical Rescue / Ratownictwo medyczne
39
19.2
Public Health / organization and management
Zdrowie Publiczne / organizacja i zarządzanie
27
13.3
Public Health / electroradiology
Zdrowie Publiczne / elektroradiologia
33
16.3
Overall / Ogółem
203
100.0
Part-time
Niestacjonarne
Frequency
Częstość
Percent
Procent
114
73.1
Lubuskie
1
0.6
Łódzkie
3
1.9
Mazowieckie
10
6.4
Opole
1
0.6
Pomorskie
12
7.7
Warmińsko-mazurskie
4
2.6
Wielkopolskie
8
5.1
Zachodniopomorskie
Frequency Percent
Częstość Procent
Dietetics / Dietetyka
Province
Województwo
3
1.9
Overall
Ogółem
156
100.0
Kujawsko-pomorskie
32
69.6
Mazowieckie
3
6.5
Pomorskie
3
6.5
Warmińsko-mazurskie
3
6.5
Wielkopolskie
5
10.9
Overall
Ogółem
46
100.0
In the group of candidates for full-time mode,
graduates finishing high school in the year of the
Candidate profile for the study of first degree, faculty of healt sciences, L. Rydygiera College, Bydgoszcz...
conducted survey accounted for 69.8%, and 28.9%
part-time. It is worth noting that 22 (14.1%) of
candidates for full-time studies and three (6. 5%) of the
candidates for part-time studies had been already
studying in another field of studies.
As regards the place of residence, 215 (77.9%) of
the respondents live in the city, and 61 (22.1%) in rural
areas. Interestingly, considering the groups separated
on the basis of the chosen mode of study, the
proportions of the candidates in different places of
residence are very similar.
Table III. The place of residence, correlated with the mode of
study
Tabela III. Miejsce zamieszkania w zależności od wybranego
trybu studiów
Mode of study
Tryb studiów
Full-time
Stacjonarne
Part-time
Niestacjonarne
Place of residence
Miejsce zamieszkania
Frequency
Częstość
Percent
Procent
Urban
Miasto
152
79.2
Rural
Wieś
40
20.8
Overall
Ogółem
192
100.0
Urban
Miasto
63
75.0
Rural
Wieś
21
25.0
Overall
Ogółem
84
100.0
Candidates in full-time study
Kandydaci na studia stacjonarne
14
Candidates in part-time study
Kandydaci na studia niestacjonar
12
were dependent on someone, 30.4% were partially
dependent on others, and as much as 41.3% were selfsupporting. A test of independence between variables
Chi 2 (Chi 2 = 69.548, p <0.001) confirms the existence
of a relationship between the degree of financial
independence of the respondents and their choice of
study mode.
Analysis of the personal situation of the
respondents indicated that the vast majority of
candidates for study were single, i.e. 176 respondents
(88%), of which the proportion of single people on
full-time programs amounted to 93.3% and 72.3% on
part-time programs. Of all people surveyed, only 12%
were in relationships, and people with children were
restricted to the part-time group, making up 25.5% of
the total.
As regards the place of residence during the time of
study, 46.3% of the people would not benefit from any
form of accommodation in the place of learning,
because each would commute to class from home. The
remaining 53.7% of those surveyed would make use of
different forms of accommodation during the academic
year, with majority intending to rent an apartment.
Table IV. Students’ accommodation during the academic
year
Tabela IV. Miejsce zamieszkania studentów w trakcie roku
akademickiego
Mode of study
Tryb studiów
Number
Liczebność
10
8
Full-time
Stacjonarne
6
4
2
0
Financially
independent
Osoby w pełni
niezależne finansowo
Partially financially
independent
Osoby częściowo
niezależne finansowo
Financially
dependent on others
Osoby będące na
czyimś utrzymaniu
Fig. 1. The financial independence of the respondents
Ryc. 1. Niezależność ankietowanych pod względem finansowym
Of those participating in the survey, in the group of
full-time candidates 11.8% worked, and among the
part-time candidates - 67.9%. This state of affairs is
reflected in the degree of financial independence of the
respondents. Among the full-time candidates as many
as 79.2% were financially dependent on someone,
19.5% were partially dependent on others, and only
1.3% was self-supporting. As regards the part-time
candidates, the proportions are reversed, i.e. 28.3%
37
Part-time
Niestacjonarne
Place of residence
Miejsce zamieszkania
Frequency
Częstość
Percent
Procent
Dormitory / Dom studencki
32
33.7
Hotel / motel
1
1.1
With family / friends
U rodziny / znajomych
2
2.1
Rented accommodation
Wynajęte mieszkanie
53
55.8
Own flat
Własne mieszkanie
4
4.2
Other / Inne
3
3.2
Overall / Ogółem
95
100.0
Dormitory / Dom studencki
6
42.9
With family / friends
U rodziny / znajomych
3
21.4
Rented accommodation
Wynajęte mieszkanie
5
35.7
Overall / Ogółem
14
100.0
In the group of subjects of the study, the most
important reasons for choosing the Faculty of Health
Sciences of Ludwik Rydygier Collegium Medicum in
Bydgoszcz as a place of study were: the convenient
location of the university, the university’s reputation,
and the possibility of obtaining a place on a course in
their chosen field. It is worth noting that, according to
the respondents, the Faculty of Health Sciences has a
Waldemar Ciemnoczołowski et al.
38
high reputation (on a scale from 1 to 5: mean = 4.05;
Standard deviation = 0.69).
Table V. Most important selection criteria for Faculty of
Health Sciences Collegium Medicum in Bydgoszcz
Tabela V. Najważniejsze kryterium wyboru WNoZ CM
w Bydgoszczy
Criterion
Kryterium
Frequency Percent
Częstość Procent
Convenient location of the university
Dogodne położenie uczelni
61
24.5
Reputation of Faculty of Health Sciences of Ludwik
Rydygier Collegium Medicum Renoma WNoZ
59
23.7
Possibility of obtaining course in chosen field
Możliwość dostania się na wybrany kierunek
52
20.9
Cost of living (residence) in Bydgoszcz
Koszty utrzymania (pobytu) w Bydgoszczy
15
6.0
Absence of required degree program in other universities
Na innych uczelniach nie ma tego kierunku studiów
13
5.2
State of scientific and educational base
Stan bazy naukowo-dydaktycznej
11
4.4
Type of activities provided for in the plan in this field
Rodzaj zajęć przewidzianych w planie na tym kierunku
8
3.2
Relatives, friends and acquaintances study here
Fakt, że studiują tutaj znajomi, bliscy
6
2.4
Rother / Inne
24
9.7
Overall / Ogółem
249
100.0
located in the province of Kujawsko-Pomorskie, and
graduates of secondary schools wish to continue
learning in a higher education in the same region [1].
Another aspect that has been raised in the study was
the source of income, and the degree of candidates’
financial independence. In contrast to applicants for
admission to the part-time courses, only a small
proportion of full-time students is fully financially
independent. The results obtained do not differ from
other reports on this subject [4, 9]. Due to the territory
the above people come from, most of them declare that
each time they will commute to classes from their
family homes. The rest of them, in principle, will use
the student hostels or rent an apartment. Similar
regularity can be found in the literature [4]. In
choosing the Faculty of Health Sciences as a place of
study, the decisive role play such factors as the
convenient location of the university, the reputation
and the possibility of reaching a required field of study.
It should be noted that also in this regard, the attitude
of candidates corresponds to the attitudes of students of
other faculties / departments [4].
DISCUSSION
CONCLUSIONS
The available literature and findings relating to
people starting or continuing their education, usually
concern one very specific aspect, for example
motivation, attitudes or living conditions [1, 2, 3, 5, 7,
9, 10]. This study also focuses on specific sociodemographic topics. One of them is the age of people
entering the higher education. It is true that the median
age of the study group does not differ from the median
age of respondents in comparable scientific studies,
however, this time there are people much older than
elsewhere, i.e. over 36 years of age [3, 5]. The
distribution of respondents by gender clearly weighs in
favor of women. There are almost four times more
women than men. The number of various fields offered
at the Faculty of Health Sciences plays here a
fundamental role. In fact, nursing, obstetrics,
physiotherapy and dietetics are primarily the domain of
women. It is worth noting that in other scientific
reports it has been also found that among those
studying at public universities, there are more women
than men [3], and Central Statistical Office shows that
in 2008 the female sex accounted for more than 66% of
the population of students at public universities [9 ].
Among the subjects, the percentage of general
secondary schools graduates was higher than in other
scientific studies, i.e. 94.7% [3, 4]. It should be noted
that the majority of candidates’ secondary schools were
1. The mode of study chosen by the candidates is
related to their age, i.e. full-time students are
younger than the part-time students.
2. Candidates live in the Kujawsko-Pomorskie
province and those adjacent to it. Candidates
graduated from high school – mostly in classes
with a biology-chemistry profile.
3. Just over half the respondents intended to find
accommodation near the place of learning, the
majority of whom intended to live in rented
accommodation.
4. Applicants for admission to part-time courses were
normally
employed,
and
are
financially
independent, as opposed to people applying for
full-time studies, of whom very few work and most
are dependent on others, for example their parents.
5. A full-time candidate is generally a single person
without children, and among people applying to
study part-time, one in four lives in a relationship
and have children.
6. In addition to its convenient location, the most
important criterion for the selection of the Faculty
of Health Sciences as a place of study is its good
reputation.
Candidate profile for the study of first degree, faculty of healt sciences, L. Rydygiera College, Bydgoszcz...
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które zostały sfinansowane przez Uniwersytet Mikołaja
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32/2008
mgr Waldemar Ciemnoczołowski
Zakład Informatyki i Metodologii Pracy Naukowej
UMK w Toruniu
ul. Techników 3
85-801 Bydgoszcz
tel. 52 585 21 94
Received: 7.12.2010
Agnieszka Maria Dziewa1, Anna Ksykiewicz-Dorota2
VALIDATION OF RESEARCH TOOL FOR ASSESSMENT
OF QUALITY OF NURSING CARE WITH RESPECT TO PROPHYLAXIS
OF HOSPITAL-ACQUIRED INFECTIONS
WALIDACJA NARZĘDZIA BADAWCZEGO DLA OCENY JAKOŚCI OPIEKI PIELĘGNIARSKIEJ
W ZAKRESIE PROFILAKTYKI ZAKAŻEŃ SZPITALNYCH
1
Chair and Department of Management in Nursing, Faculty of Nursing and Health Sciences,
Medical University, Lublin
Agnieszka Dziewa, pre-doctoral fellowship
2
Chair and Department of Management in Nursing, Faculty of Nursing and Health Sciences
Medical University, Lublin
Head: Prof. Anna Ksykiewicz-Dorota
Summary
I n t r o d u c t i o n : The assessment of the quality of
nursing care is performed by means of various methods and
research instruments. Most frequently, the major criteria for
assessment of the quality of nursing care refer to the
following: the provision of physical safety of a patient;
protection against infections; hotel conditions and
satisfaction of existential needs; informing a patient;
preparation for self-care; performance of therapeutic-nursing
procedure; efficient organization of care and its
documentation (BOHIPSZO method). Limiting this scope of
issues to a single problem of the quality of care – prophylaxis
of hospital-acquired infections – requires development of
more comprehensive detailed criteria, which would be
adequate for the nursing activity within the above-mentioned
area.
O b j e c t i v e : The objective of the study was validation
of a self-designed instrument for the assessment of the
quality of nursing care with respect to the prophylaxis of
hospital infections.
M a t e r i a l a n d m e t h o d s : The work of nurses
was evaluated in the Independent Public Health Care Facility
in Kraśnik, with respect to the observance of aseptic
procedures, by performing 60 observations with the use of
the research instrument. For the needs of evaluation of
interrater reliability of the research instrument, Kendall’s
coefficient of concordance W was applied. This coefficient
was calculated for each criterion specified in the evaluation
form.
R e s u l t s : For each criterion, all coefficients of
concordance W among judges were high and statistically
significant, their values ranging from 0.842–0.959.
Conclusions: The results obtained allow the presumption that
the research instrument assessed enables the obtaining of
reliable results, and may be applied for the evaluation of the
quality of nursing care in the area of prevention of hospitalacquired infections.
Streszczenie
W s t ę p . Oceny jakości opieki pielęgniarskiej dokonuje
się za pomocą różnych metod i narzędzi badawczych.
Najczęściej kryteria główne oceny jakości pielęgniarskiej
odnoszą się do: zapewnienia bezpieczeństwa fizycznego
pacjenta; ochrony przed zakażeniami; warunków hotelowych
oraz zaspokojenia potrzeb egzystencjalnych; informowania
pacjenta; przygotowania do samo pielęgnacji; wykonywania
zabiegów leczniczo-pielęgnacyjnych; sprawnego organizowa-
42
Agnieszka Maria Dziewa, Anna Ksykiewicz-Dorota
nia opieki i jej dokumentowania (Metoda BOHIPSZO). Zawężenie tego zagadnienia do jednego obszaru jakości opieki profilaktyki zakażeń szpitalnych wymaga rozszerzenia i opracowania bardziej szczegółowych kryteriów, adekwatnych do
działalności pielęgniarskiej w wyżej wymienionym zakresie.
C e l e m była walidacja własnego narzędzia do oceny
jakości opieki pielęgniarskiej w zakresie profilaktyki zakażeń
szpitalnych.
M a t e r i a ł i m e t o d y . W SP ZOZ w Kraśniku
dokonano oceny pracy pielęgniarek w zakresie przestrzegania
procedur aseptycznych przeprowadzając 60 obserwacji przy
wykorzystaniu narzędzia badawczego. Dla potrzeb walidacji
narzędzia badawczego do analizy statystycznej kryteriów
zawartych w arkuszu zastosowano współczynnik zgodności W
Kendalla i test zgodności Chi-kwadrat.
W y n i k i . Dla każdego z kryteriów wszystkie
współczynniki zgodności sędziów W były wysokie i statystycznie istotne. Wartości te wahały się w granicach 0,842–
0,959.
W n i o s k i . Uzyskane wyniki pozwalają stwierdzić, że
oceniane narzędzie badawcze
umożliwia osiągnięcie
rzetelnych wyników i może być zastosowane do oceny jakości
opieki pielęgniarskiej w płaszczyźnie zapobiegania
zakażeniom szpitalnym.
Key words: infections, nursing care, Kendall’s coefficient, validation of research instrument
Słowa kluczowe: zakażenia, opieka pielęgniarska, współczynnik W Kendalla, walidacja narzędzia badawczego
INTRODUCTION
The concept of the quality of health care specifies
the capability of an institution and its staff for the
performance of the duties assigned to them, biased
towards the fulfillment of the health needs of society.
This also strives for such a level of health care that
would allow obtaining of the best results possible and
the reduction in the number of undesirable events,
according to the present state of medical knowledge.
Modern control of infections in a hospital should
result from the recognition of the scale of the
phenomenon, i.e. infections, detection of their causes,
and determination of their frequency, implementation
of efficient procedures and standards of prevention, as
well as supervision of their performance. The actions
are based on the listed guidelines, procedures and
standards for the control of infections, concerning all
diagnostic, therapeutic and care activities, during
which an infection may occur [1].
The quality of the entire, complex process of
hospital infections cannot be measured directly;
therefore, alternatively, indicators are implemented as
a measurable insight into the course of the process.
Most often, these indicators are short, important and
frequently performed procedures selected from among
the entire therapeutic-care procedure, e.g. frequency of
infections, frequency of patient catheterization, amount
of time required for the isolation of the endemic focus,
frequency and quality of washing hands [2].
The study was conducted at the Independent Public
Health Care Facility in Kraśnik, in the anesthesiology
and intensive care unit, as well as the internal diseases
ward, and the neurology and surgical wards, and
covered 12 nurses (3 nurses from each of the abovementioned wards). The evaluation of agreement
between the performance of nursing tasks and
procedures was carried out by 5 competent judges.
These were charge nurses employed in the wards
different from those where the study was conducted.
With the method of competent judges, the researcher
appoints a number of raters who individually assess the
observation material submitted to them. A greater
number of votes decides about the qualification of the
material. A competent judge may be anyone who had
been informed about how to define the phenomenon
assessed, and what were the criteria for its evaluation.
The characteristic of observation is its systematicity,
which consists in the collection of information in
a continuous way, or by the method of time trials [3].
The total number of 60 assessments of the quality
of nursing care was carried out with respect to the
prophylaxis of hospital-acquired infections, based on a
research instrument designed by the authors. The study
was conducted in October 2010.
The research instrument was an evaluation form of
nursing care quality in the prophylaxis of hospitalacquired infections, which consisted of 9 main criteria
concerning the prevention of occurrence of hospitalacquired infections with respect to the following: 1 –
observance of aseptic procedures; 2 – prophylaxis of
vascular line infections; 3 – observance of hygienic
procedures; 4 – prophylaxis of surgical wound
infection; 5 – prophylaxis of infections of the urinary
system; 6 – prophylaxis of hospital-acquired
pneumonia; 7 – control of disinfection and sterilization
procedures; 8 – principles of isolation; and 9 –
documentation of hospital-acquired infections. The
OBJECTIVE
The objective of the study was validation of the
instrument designed by the author for assessment of
the quality of nursing care with respect to the
prophylaxis of hospital infections.
Validation of research instrument for assessment of quality of nursing care with respect to prophylaxis...
major criteria were supplemented with detailed criteria,
which consisted of 83 indicators pertaining to the
nursing activities in the area of the prophylaxis of
infections. Individual criteria were ascribed an
adequate score value according to a 5-score scale,
where ‘5’ was the highest satisfaction of the
requirements, and ‘1’ – the lowest fulfillment of the
requirements. It was assumed that the nursing activities
specified in the instrument, aimed at the prevention of
hospital-acquired infections, would not require their
performance with respect to each ward and each
patient. Hence, additional cells were contained in the
evaluation form describing the actual status, i.e. :
‘Yes’, ‘No’, and ‘Not applicable’. The cell ‘Yes’
served the description of agreement between reality
and a given criterion, and the assessment placed in this
cell reflected the level of satisfaction of the criterion.
In the cell ‘No’, the weight of each criterion was
written down when the lack of agreement was
recognized. The cell ‘Not applicable’ contained the
weight of the criterion, which did not refer to an
individual ward or patient. In the situation where only
a part of the criterion was performed there was a
possibility to divide the score value ascribed to this
criterion between the cells ‘Yes’ and ‘No’. While
developing the scoring system, the ‘Evaluation form
for nursing care quality in the prophylaxis of hospitalacquired infections’ was patterned on the instrument
for the assessment of quality of nursing care by
Lenartowicz, called by the author BOHIPSZO [4].
The validation of the instrument was carried out by
the method of competent judges. Each of the judges, at
the same time, during participant observation,
independently
evaluated
individual
activities
performed by the same nurse employed in one of the
above-mentioned wards. The judges did not
communicate between each other and did not negotiate
the score values. Each rater, in the assessment form,
ascribed the nurse a specified score value for the task
performed.
In the statistical analysis, interrater reliability of the
research instrument was evaluated with the use of
Kendall’s coefficient of concordance (W). This
coefficient should be applied for investigating
agreement between ratings originating from many
sources, e.g. evaluations of the same thing coming
from various raters. Its values remain within the
interval from 0 (no agreement) to 1 (complete
agreement). Kendall’s coefficient of concordance is
frequently used for evaluating agreement among
competent judges [3]. The significance of Kendall’s –
W was tested by chi-square statistic.
43
RESULTS
The analysis performed shows that the Kendall’s W
coefficient of concordance for individual main criteria
was very high (in range from W = 0.842 to W = 959).
Table 1. Kendall’s W coefficients of concordance for total
ratings by 5 judges and 12 nurses with respect to 9
criteria of nursing care
Tabela I. Współczynniki zgodności sędziów W Kendalla dla
sumarycznych ocen pięciu sędziów oceniających
i 12 pielęgniarek w odniesieniu do 9 kryteriów
opieki pielęgniarskiej
Criterion
W
Chi-square
significance
0.928
Percentage
of
explaining
variance
80%
Criterion 1
Observance of aseptic procedures
Criterion 2
Prophylaxis of vascular lines infections
Criterion 3
Observance of hygienic procedures
Criterion 4
Prophylaxis of surgical wounds infections
Criterion 5
Prophylaxis of urinary system infections
Criterion 6
Prophylaxis of hospital-acquired pneumonia
Criterion 7
Control of disinfection and sterilization processes
Criterion 8
Isolation principles
Criterion 9
Documentation of hospital infections
0.920
77%
0.000001
0.930
80%
0.000001
0.908
74%
0.000005
0.923
78%
0.000001
0.842
58%
0.000003
0.923
78%
0.000001
0.959
88%
0.000021
0.856
61%
0.000002
0.000001
For each criterion, its coefficient of concordance
was high and statistically significant. The same
understanding of the criteria evaluated, reflected by the
value of W coefficient, explained from 88% - 80% of
variability of ratings of observance of isolation
principles, as well as aseptic and hygienic. The
remaining ratings (not more than 20%) depended on
individual differences between judges with respect to
the method of evaluation. Concordance, as understood
by the subsequent three criteria: control of disinfection
and sterilization processes, prophylaxis of vascular
lines infections, and prophylaxis of surgical wound
infection, explained from 74% - 78% ratings of the
judges. Relatively the lowest percentages of common
understanding of the criteria were obtained with
respect to: assessment of the application of principles
of prophylaxis of hospital-acquired infections (58%)
and documentation of hospital-acquired infections
(61%).
The highest coefficient of concordance was
obtained for a detailed criterion: ‘Transport of patients
isolated within the ward and hospital is limited to
a minimum’, within Criterion 8, and was 1 (complete
agreement). Coefficients close to complete agreement
were also obtained for the following criteria: ‘ Shaving
is performed on the day of surgery, before the
44
Agnieszka Maria Dziewa, Anna Ksykiewicz-Dorota
operation” (0.950; Criterion 4), ‘Medical equipment is
protected against dust with a slipcover or serviette’
(0.926; Criterion 3), ‘Prior to the use of sterilized
equipment, the test inside the kit is checked’ (0.921;
Criterion 7), ‘Urine sacks are replaced with the
frequency recommended by the manufacturer’ (0.920;
Criterion 5), ‘Open drops, ointments, and ampoules are
used within 48 hours’ (0.918; Criterion 1), ‘Used
single-use equipment is disposed in infections waste’
(0.915; Criterion 3), ‘Open drops, ointments and
ampoules with medicinal products are described,
giving the date, hour of beginning of use, and protected
by a gauze’ (0.907: Criterion 2), ‘Cannula is removed
as quickly as possible’ (0.901; Criterion 2), From
among 83 detailed criteria, 31 (37.3%) obtained the
concordance coefficient higher than 0.800, while
coefficients of 0.500 and lower were registered for 32
criteria, i.e. 38.55% of the tasks performed. In 3 cases
(3.6%), the calculation of Kendall’s coefficient of
concordance was not possible.
The lowest level of concordance was obtained for
the following criteria: ‘Respirators’ drainage lines and
tubes, filters are exchanged not less often than every 24
hours’ – 0.00 (Criterion 6), ‘Shaving of the surgical
area is performed in a patient’ – 0.100 (Criterion 4),
‘Potentially infected and contagiously ill patients are
isolated in accordance with the sanitary regime’ –
0.133 (Criterion 8), ‘Sterile dressing material readymade obtained from a pharmacy or sterilized from the
Sterilization Centre is used for dressings’ – 0.144
(Criterion 4), ‘After the removal of a cannula or its
exchange a new dressing is placed’ – 0.150 (Criterion
2), ‘Surgical instruments are sterilized in the
Sterilization Centre according to the rules’ – 0.160
(Criterion 7), ‘ Most frequently, port catheters are
applied for collecting specimens of urine without
disconnecting the system’ – 0.169 (Criterion 5), ‘The
dressing at the insertion site is exchanged once daily,
or as needed’ – 0.179 (Criterion 2), ‘A nurse takes care
that the drain is not occluded or bent, and the container
overflow does not occur’ – 0.181 (Criterion 5),
‘Suction tube containers are exchanged in a patient
every time’ – 0.186 (Criterion 6).
DISCUSSION
The objective of the presented study was validation
of the research instrument for evaluation of the quality
of nursing care with respect to the prophylaxis of
hospital-acquired infections. The objective of the study
was to investigate whether the raters evaluating the
interrater reliability of criteria within the research
instrument, and the satisfaction of quality requirements
by nurses determine, in a similar way, the quality
requirements reflecting the activities on behalf of
prophylaxis of hospital-acquired infections. These
requirements were handled into criteria describing
nursing activities, which exert an effect on the
development or lack of infections [3]. By means of the
analysis conducted, a high agreement was noted
between individual raters, despite the lack of
contacting one another and negotiating the score value
for activities performed by the same nurses observed.
High agreement is evidenced by high values of
Kendall’s W coefficient for individual main criteria, as
well as for the majority of detailed criteria.
The results obtained allow the presumption that the
evaluation instrument, which is ‘The evaluation form
for quality of nursing care in prophylaxis of hospitalacquired infections’ is adequate for performing
evaluation of the level of quality in nursing care with
respect to the development of infections in health care
facilities.
CONCLUSIONS
1. The evaluation form for the quality of nursing care
in prophylaxis of hospital-acquired infections
allows obtaining high agreement of the results
obtained by the raters.
2. The investigated instrument for the evaluation of
the quality of nursing care in the prevention of
hospital-acquired infections may be successfully
applied by practitioners in hospital wards.
REFERENCES
1. Fleischer M., Bober-Gheek B.: Essentials of
epidemiological nursing. Urban & Partner Medical
Publishers, Wrocław 2006
2. Heczko P., Wójkowska–Mach J. (ed.): Hospital-acquired
infections. Polish Medical Publishers, Warsaw 2009
3. Brzeziński J.: Methodology of psychological studies.
State Scientific Publisher, Warsaw 1987
4. Lenartowicz H.: Quality management in nursing.
Medical Education Centre, Warsaw 1998
5. Pieter J.: General methodology of scientific work.
Ossolineum, Wrocław 1967
Agnieszka Dziewa
Polichna III, 21
23-225 Szastarka
tel. 604 152 793
fax.081 884-32-09
Anna Grabowska-Gaweł1, Donata Gacka1, Danuta Dobosz1, Beata Augustyńska2
THE IMPACT OF SHIFT WORK ON PSYCHOSOMATIC HEALTH OF NURSES EMPLOYED
IN THE INTENSIVE CARE UNIT
WPŁYW PRACY ZMIANOWEJ NA SFERĘ PSYCHOSOMATYCZNĄ PIELĘGNIAREK
ZATRUDNIONYCH W ODDZIALE INTENSYWNEJ TERAPII
1
Intensive Care Nursing Department of the Collegium Medicum in Bydgoszcz
Nicolaus Copernicus University of Toruń
Head: Anna Grabowska-Gaweł, MD, PhD
2
Psychiatry Department and Clinic of the Collegium Medicum in Bydgoszcz
Nicolaus Copernicus University of Toruń
Head: Prof. Aleksander Araszkiewicz, MD
Summary
I n t r o d u c t i o n . The necessity of employing health
care workers in continuous system leads to the change of
their biological rhythm. After certain time, it can result in
many changes in functioning of the worker’s body. Certain
changes are compensated after rest and do not pose a direct
threat to the worker and patient’s health. Others cause
irreversible health problems, which result in increased
absence, malpractice risk and incorrect usage of medical
equipment.
Aim od the thesis
1. Determination whether shift work has a significant
impact on psychosomatic health of nursing personnel
employed in the Intensive Care Unit.
2. Determination which factors related to shift work have
the most negative impact on individual aspects of life of the
worker.
Material
and
m e t h o d . The study was
performed among 50 people from nursing personnel (45
women and 5 men) aged between 23 and 50 (aver. 35 years)
employed in the Intensive Care Units. The study
encompassed the use of our own questionnaire containing 26
questions, including 10 questions regarding sociodemographic data and 16 questions covering the following
issues: most strenuous factors accompanying shift work, their
influence on psychosomatic health, applied forms of
relaxation, substances used to feel better, and influence of
shift work on individual aspects of life. In order to determine
a hierarchy of importance of individual factors a five-level
scale was used, where “0” stands for lack of influence and
“5” – very high influence.
R e s u l t s . 75% of respondents expressed an opinion
that the most strenuous is work during night hours (72%),
work during holidays (38%), and diversification of the range
of duties performed during a shift (32%). The most frequent
somatic disorders include back pain (82%) and lower limb
pain (44%); among mental complaints - chronic fatigue
(40%).
C o n c l u s i o n s . 1. According to 75% of respondents
the most tiresome work is during a night shift and holidays.
2. From among somatic ailments, respondents mention
mainly back pain and lower limb pain, whereas from among
mental complaints – the sense of neglecting family duties and
limitation of participation in social life. 3. Deficits of
emotional nature affect to a lesser extent the group of women
aged between 41 and 50, working shifts for 16 up to 20 years,
which is most likely related to the fact that their children
have become independent and a better financial situation,
allowing taking advantage of various forms of recreation. 4.
Despite declaring a negative impact of shift work on
psychosomatic health, only 26% of respondents are involved
in active recreation, whereas 64% reach for substances and
calming agents in order to de-stress.
46
Anna Grabowska-Gaweł et. al.
Streszczenie
W s t ę p . Konieczność zatrudniania pracowników
lecznictwa w systemie ciągłym powoduje zmianę ich rytmów
biologicznych, co prowadzić może po pewnym czasie do
wielu zmian w funkcjonowaniu organizmu pracownika.
Pewne zmiany ulegają kompensacji po odpowiednim
odpoczynku i nie stanowią bezpośredniego zagrożenia dla
pracownika i chorego. Inne zaś z czasem powodują
nieodwracalne zmiany zdrowotne prowadzące do zwiększonej absencji, ryzyka popełnianych pomyłek i błędnego
użytkowania sprzętu.
Cele pracy
1. Określenie, czy praca zmianowa wywiera negatywny
wpływ na zdrowie psychosomatyczne personelu pielęniarskiego zatrudnionego w oddziale intensywnej terapii.
2. Jakie czynniki związane z wykonywaniem pracy
zmianowej wywierają najbardziej niekorzystny wpływ na
poszczególne sfery życia pracownika.
M a t e r i a ł i m e t o d a . Badaniami objęto 50 osób
spośród personelu pielęgniarskiego (45 kobiet i 5 mężczyzn)
w wieku od 23 do 50 lat (śr. 35 lat) zatrudnionych
w oddziale intensywnej terapii. Do badań zastosowano
kwestionariusz ankiety własnej konstrukcji (autorstwa)
składający się z 26 pytań, z czego 10 pierwszych pytań
dotyczyło danych socjodemograficznych, a kolejnych 16
pytań następujących zagadnień: uciążliwych czynników
towarzyszących pracy zmianowej, ich wpływu na sfere
psychosomatyczną, stosowanych form relaksu, stosowanych
używek poprawiających nastrój oraz wpływowi pracy na
poszczególne sfery życia. W określeniu hierarchii ważności
poszczególnych czynników zastosowano pięciostopniową
skalę, gdzie ‘0” oznacza brak wpływu a „5” bardzo duży
wpływ.
W y n i k i 75% respondentów prezentuje pogląd, iż
najbardziej uciążliwa jest praca w porze nocnej (72%), w dni
powszechnie wolne od pracy (38%) oraz zróżnicowanie
zakresu obowiązków przypadających na zmianę (32%).
Najczęściej podawanymi dolegliwościami somatycznymi jest
zespół bólowy kręgosłupa ( 82 % ), i bóle kończyn dolnych (
44%). Spośród zaś dolegliwości psychicznych przewlekle
zmęczenie (40%).
W n i o s k i . 1. 75 % respondentów prezentuje pogląd,
iż najbardziej uciążliwa jest praca w porze nocnej i w dni
ustawowo wolne od pracy. 2. Spośród dolegliwości
somatycznych najbardziej doskwierają im bóle kręgosłupa i
kończyn dolnych , zaś spośród sfery psychicznej poczucie
zaniedbywania sfery rodzinnej oraz ograniczenie udziału w
życiu towarzyskim. 3. deficyty natury emocjonalnej są
najmniej odczuwane przez kobiety w wieku 41-50 lat
i pracujące w systemie od 16 do 20 lat, co prawdopodobnie
związane jest ze zmniejszeniem zakresu obowiązków
rodzinnych tej grupy badanych wynikających z usamodzielnienia się dzieci oraz polepszenia sytuacji materialnej
pozwalającej korzystanie z różnych form wypoczynku. 4.
Pomimo deklarowania przez ankietowanych negatywnego
wpływu pracy zmianowej na zdrowie psychosomatyczne,
tylko 26 % badanych uprawia czynną formę odpoczynku, zaś
64 % w celu rozładowania emocji i zmęczenia sięga po
używki i leki uspakajające i nasenne.
Key words: shift work, psychosomatic health, nurses
Słowa kluczowe: praca zmianowa, zdrowie psychosomatyczne, pielęgniarki
INTRODUCTION
AIM OF THE THESIS
In today’s world we can notice a trend for hiring
workers in the shift system, which is aimed to
continuation of production and reduction of losses
resulting from stoppage. It applies to many industries
and services, including health care, for which work
during night hours and holidays is of the highest
importance. It should be remembered, however, that
shift work and related to it inversion of physiological
rhythm leads, after a certain time, to many changes in
functioning of the worker’s body. Certain changes are
compensated after rest and do not pose a direct threat
to the worker’s health, whereas others cause
irreversible health problems, which result in increased
absence, malpractice risk and incorrect usage of
medical equipment.
Therefore, the aim of the thesis is:
1. To determine whether if shift work has a
significant impact on psychosomatic health of
nursing personnel employed in the Intensive
Care Unit and
2. What factors related to shift work have the
most negative impact on health and
fulfillment of professional duties.
MATERIAL AND METHOD
The study was performed among 50 people from
nursing personnel (45 women and 5 men) aged
between 23 and 50 (aver. 35 years) employed in the
Intensive Care Units at hospitals of Bydgoszcz.
The study encompassed the use of our own
questionnaire containing 26 closed-ended questions,
including 10 questions concerning socio-demographic
The impact of shift work on psychosomatic health of nurses employed in the Intensive Care Unit
data such as age, gender, marital status, children, place
of residence, seniority in the Intensive Care Unit, shift
work system, number of years in shift work system,
number of work hours in a month, form of employment
and 16 questions covering the following issues:
1. most strenuous factors accompanying shift work
- hours on duty
- diversification of duties at a shift
- work at in night
- work during holidays
- I do not notice arduousness of shift work
2. negative psychiatric aspects accompanying shift
work
- oversensitivity
- sleeplessness, excessive drowsiness
- chronic fatigue
- bad mood
3. somatic disorders
- lower limb pain
- back pain
- stomach – intestine disorders (diarrhea,
constipation)
- excessive appetite
- lack of appetite
- menstrual disorders
4. applied forms of relaxation
- participation in social meetings
- watching television, Internet browsing
- active recreation
- nap
- reading
- cinema
- listening to music
- shopping in supermarkets
- lack of time to relax
5. substances used to feel better
- cigarettes
- coffee
- alcohol
- sedatives and sleeping pills
- other
6. influence of shift work on individual aspects of life
- partner relations
- parental duties
- household activities
- social life
- recreation
- pro-health activities
- eating habits
In order to determine a hierarchy of importance of
the problems presented above, related to performance
of shift work and its impact on individual aspects of
life, a five-level scale was used, where ‘0’ stood for
lack of influence and ‘5’ – very high influence.
47
RESULTS
Among responders, 95% were women aged
between 23 and 50 (aver. 33.5 years). People in steady
relationships accounted for 58%; 64% of them had
children; 70% of respondents lived in Bydgoszcz,
whereas the remaining 30% in nearby small towns and
villages. The biggest group (36%) comprised people
working in shift system in a period ranging between 16
and 20 years, whereas people working between 11 and
15 years accounted for 30%. Respondents working
based on long-term employment contract comprise
76%; 22% were employed based on a civil-legal
agreement (contract), whereas the remaining 2% were
freelance employees.
74% of respondents expressed an opinion that the
most strenuous factor in shift work system is work
during night hours (72%), work during holidays (38%),
excessive duties performed during shift (32%) and a
number of hours per one shift (28%). The remaining
26% of those surveyed believed that shift work is a
favorable form of employment, since it allows
avoiding direct contact with the management staff,
reduces cost of commuting, makes taking another job
or change of duty possible, and provides more time for
fulfillment of family duties and pursuit of interests.
Negative effects of shift work on the aspect of
private life, according to their hierarchy of importance,
determined in the 0-5 scale, are presented in Table I.
Tables II and III show the impact of shift work on
psychosomatic disorders, which, according to
respondents, are related to shift work.
Table I. Psychosomatic disorders related to shift work
Ailments and
disorders
MENTAL
SOMATIC
Seniority
Ailments
Seniority
0-5 6-10 11- 16- Sum and
0-5 6-10 11- 16- Sum
disorders years years 15
years years 15
20
20
years years
years years
8% 12% 14% 6% 40% Back pain 12% 34% 22% 14% 82%
Chronic
fatigue
Oversensitivity 8%
10% 14% 4%
Drowsiness
10% 8%
10% 8%
Sleeplessness
0%
Mood
disorders
Lack of
symptoms
2%
4%
6%
2%
2%
2%
2%
2%
14% 4%
2%
36% Lower
limb pain
36% Stomachintestine
disorders
20% Appetite
disorders
14% Menstrual
disorders
8% Lack of
appetite
Lack of
symptoms
10% 12% 12% 10% 44%
2%
8%
8%
6%
24%
4%
10% 2%
6%
22%
4%
4%
2%
2%
12%
0%
0%
2%
2%
4%
2%
2%
0%
2%
6%
Anna Grabowska-Gaweł et. al.
48
Table II. Negative and positive factors accompanying shift
work
1
2
3
4
5
6
Positive factors
Factor
% responses
More free time
66%
Saving of leave
50%
Negative factors
Factor
% responses
Shift work
72%
Interference with the
46%
biological rhythm
Working weekdays free
38%
1
2
Possibility of duty
conversion
Take extra work
44%
3
34%
4
Reducing the costs
of commuting
Avoiding Executive
34%
5
32%
6
Differentiation of
responsibilities attaching to
change
Intensification of work on
the individual duty
Length of duty
32%
22%
18%
Table III. The negative impact of shift work on individual
areas of life
SOME AREAS OF
LIFE
Area
Home
activities
Further
training
Caring for
health
Caring for
nutrition
Hobby
FORMS OF REST
%
active
responses
67%
Social
meetings
67%
Sport
%
passive
12% Short sleep
METHODS OF
REDUCING MENTAL
TENSION
% Method
%
responses
20% Cigarettes
32%
8%
Music
18% Alcohol
12%
Cinema
4%
Television
18% Sedatives
2%
59%
Walking
2%
Reading
18% Hypnotics
50%
Sum
: 26%
59%
Social life
49%
Rest
46%
Sum
74%
0%
Antidepressants
0%
None of the
above drugs
42%
Passive rest is a form of relaxation for 74% of
respondents. In order to reduce mental tension, 46% of
respondents reach for substances (cigarettes, alcohol)
and sedatives. Results of tests are presented in Table 3.
The majority of respondents (84%) expressed the need
of psychological counseling; however, they did not
specify what they expect from such visit and how
frequently they should attend such counseling sessions.
DISCUSSION
Repeatability of phenomena taking place in nature
has a crucial impact on life of all live organisms. It
determines the length of vegetation period of plants,
their blooming and fading. Thanks to it, animals
hibernate and wake up, whereas birds migrate in order
to find a more favorable climate.
Humans are also subject to biological cycles;
however, as the highest forms of evolution, they have
possibilities of adjustment to the changing conditions
such as change of day and night, change of lighting,
ambient temperature and working during the time they
should sleep. Unfortunately, despite adjustment skills
possessed by humans, sooner or later people working
shifts, particularly during nighttime, have their
biological rhythm disturbed [2, 4].
Shift work and related to it inversion of
physiological rhythm leads to many changes in
functioning of the worker’s organism. Certain changes
are compensated after a proper rest, whereas disorders
disappear after a short time, causing no significant
problem. However, frequently health disorders do not
disappear and lead to irreversible psychosomatic
changes, occurring in the form of sleeplessness,
chronic fatigue, reduced immunity to infections,
depression, digestive ailments, and back pain [1, 3].
This study makes an attempt to evaluate the impact
of shift work on the psychosomatic aspect of nursing
personnel employed in the Intensive Care Unit.
Selection of the group of respondents was not
accidental and was determined by the specificity of
work performed by nurses in the Intensive Care Unit, a
group burdened with particular professional duties
resulting from constant contact with unconscious
patients, under intensive care and tended continuously.
The achieved results confirm unambiguously the
negative effect of shift work on psychosomatic health
of respondents. The most frequent somatic disorders
given in responses include back pain, reported by 82%
of respondents, lower limb pain (44%), stomach –
intestine disorders in the form of diarrhea and
constipation (24%), and appetite disorders (22%). Just
like back pain and lower limb pain result undoubtedly
from physical overstrain, which affects other
professions, digestive and appetite disorders are
undeniably caused by irregularity and impossibility of
eating regular meals.
The work of nursing team in the Intensive Care
Unit takes place in a continuous rhythm, which results
from the necessity of constant presence with the
patient. Shortage of nursing personnel working in the
Intensive Care Units contributes to the fact that they
have no possibility of taking their meal breaks, to
which they are entitled. As a result, employees eat their
meals during random breaks, when work allows,
between their nursing duties. It is usually a cold meal
or a hot cup of soup, which they eat while standing up.
Continuity and range of patient care performed by
nurses do not release employer from adherence to the
basic principles of labor [5, 6].
Opinions expressed by respondents also indicated
other significant disorders resulting primarily from
their work during night shift. They included chronic
fatigue (40%), mainly in the form of reluctance to
active recreation, oversensitivity (36%) and
The impact of shift work on psychosomatic health of nurses employed in the Intensive Care Unit
dysfunction of the organism related to alertness and
sleep (drowsiness 36% and sleeplessness 20%).
In addition, respondents have a feeling of
neglecting primarily parental and partner-related
duties. They are also bothered by a limited
participation in social life and lack of time for pursuit
interests.
The mentioned deficits related to the mental aspect
are determined by age, gender and the number of work
years in shift system, affecting to a lesser extent the
group of women aged between 41 and 50, working
shifts between 16 and 20 years. Therefore, it can be
deduced that this professional group is burdened by
fewer family duties, resulting most likely from the fact
that their children become independent and a better
financial situation, allowing taking advantage of
various forms of relaxation.
Considering the strategy preventing negative
effects of shift work, it cannot burden exclusively the
employer, since employees themselves play an
important role in it [7, 8]. Unfortunately, the alarming
results of research obtained in this study confirm that
respondents, besides reporting negative consequences
of shift work, do nothing to prevent them. It can be
acknowledged by the fact that as much as 74% of
respondents recognize passive rest as the only form of
relaxation, whereas 64% reach for cigarettes and
alcohol to de-stress.
CONCLUSIONS
1.
2.
3.
According to 74% of respondents the most
tiresome work is during night shift, for 38%
work during holidays, whereas for 32% and
28%, respectively, diversification of the range
of duties during shift and the number of hours
per shift.
From among somatic ailments, respondents
mention mainly back pain (82%) and lower
limb pain (44%), whereas from among mental
complaints – primarily sleep disorders (56%)
and chronic fatigue (40%).
Respondents have a sense of neglecting
primarily parental and partner-related duties;
they are also bothered by a limited
participation in social life, although these
deficits affect to a lesser extent the group of
women aged between 41 and 50, working
shifts between 16 and 20 years. It most likely
results from their children becoming
4.
49
independent and a better financial situation,
allowing taking advantage of various forms of
recreation.
Despite declaring a negative impact of shift
work
on
psychosomatic
health
by
respondents, only 26% of them are involved
in active recreation, whereas 64% reach for
substances and calming agents.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
Chien-Ming Yang., Spielmann A.J., Yu-Shu Huang.:
Bezsenność. Medycyna po Dyplomie. 2007; 1.
Gaweł G.: Rytmy biologiczne i ich wpływ na
aktywność fizyczną i umysłową. [W:] Zarządzanie w
pielęgniarstwie. Czelej, Lublin 2004.
Iskra-Golec I.: Stres pracy zmianowej – przyczyny,
skutki, strategie działania.[ W: ]
Zarządzanie
w pielęgniarstwie. Wydaw. Czelej, Lublin 2004.
Kmak S.: Rytmy biologiczne. PWN, Warszawa 1996.
Krzemińska S.: Pamiętać o potrzebach. Magazyn
Pielęgniarki i Położnej. 2004; 4
Ksykiewicz-Dorota A.: Organizacja pracy pielęniarskiej. Wydaw. Czelej, Lublin 2004.
Makowiec-Dąbrowska T.: Elementy pracy i ergonomii.
PZWL, Łódż, 1992.
Marcinkowski T.: Higiena, profilaktyka i organizacja
w zawodach medycznych. PZWL, Warszawa 2003.
dr n. med. Anna Grabowska-Gaweł
Zakład Pielęgniarstwa
w Intensywnej Opiece Medycznej
UMK w Toruniu
ul. Techników 3
85-801 Bydgoszcz
tel. (52) 585-21-94 w. 244
Wiktor Mishchenko1, Stanisław Sawczyn1, Mariusz Zasada2, Agnieszka Cybulska1
EFFECTS OF THE RESISTANCE TRAINING OF INSPIRATORY MUSCLES
DURING THE HEALTH RELATED PROGRAM OF EXERCISES
ON AEROBIC WORKING CAPACITY IN YOUNG WOMEN
WPŁYW OPOROWEGO TRENINGU MIĘŚNI WDECHOWYCH
NA WYDOLNOŚĆ TLENOWĄ MŁODYCH KOBIET UPRAWIAJĄCYCH FITNESS
1
Sniadecki University School of Physical Education and Sport in Gdańsk
Head: Assoc. Prof. Stanisław Sawczyn, SUSPES
2
Institute of Physical Education, Kazimierz Wielki University in Bydgoszcz
Head: Assoc. Prof. Mariusz Zasada, KWU
Summary
Physical activities usually comprehensively influence
many-sided improvement of human functional abilities, but
they can also act selectively on some of them. In recent years
the devices for inspiratory muscles training have been
popularised. Their application in aerobic fitness training,
characterised by inspiratory muscle training, can constitute
one of the additional means supporting the circulatoryrespiratory system of an athlete. The aim of the study was to
determine the effects of inspiratory muscles resistance
training included in the fitness program (spinning) on lung
ventilation capacities and the changes of aerobic working
capacity in 20-25 years old females.
The research covered 42 female students between 20 and
25 years old, who do not train any sports discipline. For
experimental purposes, three research groups of 14 students
were formed, two of which were experimental groups and
one was a control group. All the groups realised four weeks
health related training program on stationary bikes – spinning
(3 training units a week, 60 min each). The first experimental
group carried out 2 series (2 min resting intervals) of 30
inspirations-expirations with the increased resistance of
inspiration (PowerBreathe devise) before and after the each
training session. In the second experimental group, during the
whole training session, the elastic belts with regulated
tension on the lower part of the chest (tightened with the
force of 2.5 kg) were used. The main parts of the sessions
were realised in the high area of exercise intensity (HR 160179 BPM). At the beginning and at the end of the four-week
experiment the gradual cycle ergometric test of maximal
oxygen intake, PWC170, as well as the measurements of
respiratory volume and the lung ventilation were conducted.
The spirometric measurements - forced inspiration and
expiration and the maximal voluntary ventilation were also
conducted (K4b2 Cosmed).
The results showed significant increase in the aerobic
power (maximal oxygen intake), PWC170 and respiratory
system capabilities in both experimental groups using
inspiratory muscles training program by means of
PowerBreathe device and elastic belts.
Streszczenie
Aktywność fizyczna zazwyczaj kompleksowo wpływa na
poprawę wielu aspektów możliwości funkcjonalnych
człowieka, ale może też działać wybiórczo na niektóre
z nich. W ostatnich latach rozpowszechnione zostały
urządzenia dla treningu mięśni oddechowych. Zastosowania
ich w aerobowych zajęciach fitness o charakterze treningu
mięśni wdechowych może stanowić jeden z dodatkowych
środków wspomagających wydolność układu krążeniowooddechowego ćwiczących. Celem podjętych badań było
określenie wpływu oporowego treningu mięśni wdechowych
52
Wiktor Mishchenko et al.
włączonego do programu zajęć fitness (spinning) na
możliwości wentylacyjne, zmiany wydolności tlenowej
u kobiet w wieku 20-25 lat.
Badaniami objęto 42 studentki w wieku 20-25 lat nie
trenujące żadnej dyscypliny sportowej. Dla celów
eksperymentalnych stworzono trzy 14-to osobowe grupy
badawcze, z czego dwie stanowiły grupy eksperymentalne
i jedna grupę kontrolną. Wszystkie grupy realizowały
czterotygodniowy program zajęć fitness na rowerach
stacjonarnych – spinning (3 jednostki treningowe w ciągu
tygodnia, każda po 60 min). Pierwsza grupa eksperymentalna
przed i po zajęciach wykonywała 2 serie po 30 wdechówwydechów przy zwiększonym oporze na wdechu i 2-minutowym interwałem wypoczynkowym (PowerBreathe).
W drugiej grupie eksperymentalnej w trakcie realizacji całej
jednostki treningowej używano elastyczne pasy z regulowa-
nym naprężeniem na dolną część klatki piersiowej (zaciśnięte
z siła 2,5 kg). Część główna zajęć realizowana była w
wysokiej strefie intensywności wysiłku (HR 160-179
skr/min). Na początku i końcu czterotygodniowego
eksperymentu przeprowadzono stopniowy test maksymanego poboru tlenu na rowerze, PWC170, pomiary objętości
oddechowej, wentylacji minutowej płuc (Quark b2 Cosmed).
Dokonano również pomiarów spirometrycznych –
natężonego wdechu-wydechu oraz maksymalnej wentylacji
dowolnej ( K4b2 Cosmed).
W wyniku realizacji specjalnego programu treningowego
mięśni wdechowych za pomocą urządzenia PowerBreathe
oraz elastycznych pasów, w obu grupach eksperymentalnych
odnotowano istotny wzrost możliwości układu krążeniowooddechowego, wydolności tlenowej (maksymalnego poboru
tlenu) i PWC170.
Key words: inspiratory muscles training, physical exercise, aerobic capacities, young women
Słowa kluczowe: fitness, trening mięśni wdechowych, układ krążeniowo-oddechowy
INTRODUCTION
It does not raise any doubts, that there is an
increasing demand for scientific justification of an
optimized physical training in order to lower the health
risk. It is known, that the aim of physical activity
recreation program is to satisfy the need of motor
necessary for health, to keep the physical condition and
circulatory-respiratory fitness of the body [1]. The
dynamic development of various forms of physical
activity of recreational character promotes the
possibility to adjust them to the people’s specific needs
and capabilities. Today, the organised group forms of
physical fitness, the main aim of which is to improve
the physical condition and aerobic capacities for a
person’s health, are described as ‘fitness’. The fitness
is the most typical form of physical activity for
women. The selection and realisation of the exercises
depend mostly on the question if the aim is to increase
aerobic capacities, to decrease the body mass, or to
increase the muscle strength [2]. In spite of the
constantly introduced different and varied content of
the programs, still the most popular ones include
aerobic exercises which are characterised as “aerobic”
[1]. Such an activity is mainly oriented to circulatoryrespiratory system capabilities. As many data indicate,
the efficiency of the most popular fitness classes of
such type often turns out to be insufficient [1,2,3]. The
existing fitness technologies are to some extent limited
by their specificity of training effect and the final,
determined direction towards lowering concrete health
risk., The effects are usually obtained only at the first
stages of such training [2]. This is why the use of
typical forms of fitness classes do not usually provide
the essential, long-term training effect. It was stated
that after 3-5 months of the training, the typical fitness
classes among young and middle-aged women do not
bring the essential increase in physical condition and
the improvement in reaction of circulatory-respiratory
system [1,4]. Therefore, we can assume that in order to
obtain the sufficient training stimuli and preserved
effect, it would be necessary to increase the intensity or
frequency and durance of the training sessions, which
practically is hard to realise.
The physical activity usually comprehensively
influences the improvement of many aspects of human
functional abilities, but it can also act selectively on
some of them. In order to increase the effectiveness of
such selected impacts, one can use special technical
devices, which additionally stimulate an increase in
different functional components of the body. It also
applies to respiratory muscles training. Systematic
exercises improving the respiratory muscles are often
described as respiratory muscle training (RMT). At
present, the use of such untraditional means of physical
training refers mainly to the area of preparing athletes.
In recent years, the devices for inspiratory muscles
training, such as PowerBreathe and elastic belts put on
the lower part of the chest, have been popularised
[5,6,7]. Their application among athletes leads to
increasing the level of physical efficiency, improving
the functional mechanisms of the diaphragm and the
venous return of the blood to the heart [8,9]. At the
present stage of scientific research concerning the
influence of RMT among athletes, the following
Effects of the resistance training of inspiratory muscles during the helath realted program of exercises...
changes have been observed: an increase in the
strength of the respiratory muscle and ventilation
efficiency, as well as a decrease in respiratory muscle
fatigue, the feeling of effort dyspnoea and effort
heaviness, the oxygen intake by the respiratory
muscles at the expense of other skeletal muscles and
increased exercise working capacities.
It is estimated, that some of the indicated effects
can be used for health-related purposes. The basis for
such activity can be the physiological estimation of
a determined direction, the range and the specificity of
the obtained effects. The researches concerning the use
the inspiratory muscle training in order to increase the
circulatory-respiratory system efficiency can be the
basis to use the mentioned training as one of the
additional means, supporting the aerobic effect of
fitness training. There is the need to develop the
criteria for the choice of means of RMT, its dosage and
influence.
The aim of the study was to determine the effects of
inspiratory muscles resistance training included in the
fitness program (spinning) on lung ventilation
capacities and the changes of aerobic working capacity
in 20-25 years old females.
MATERIAL AND METHOD
The research covered 42 female students between
20 and 25 years old, who do not train any sports
discipline. For experimental purposes, three research
groups of 14 students were formed, two of which were
experimental groups and one was a control group. All
the groups realised four weeks health related training
program on stationary bikes – spinning (3 training
units a week, 60 min each). The first experimental
group, before and after the each training session,
carried out 2 series (2 min resting intervals) of 30
inspirations-expirations with the increased resistance of
inspiration (PowerBreathe devise). In the second
experimental group, during the whole training session,
the elastic belts with regulated tension on the lower
part of the chest (tightened with the force of 2.5 kg)
were used. The determination of intensiveness of
fitness session training and their monitoring were
realised by the measurements of heart rate contraction
among all the examined by Team Tester Polar device
(Polar Precision Performance SW 3.0).
The main parts of the sessions were realised in the
high area of exercise intensity (HR 160-179 BPM). At
the beginning (study 1) and after four weeks (study 2)
53
the incremental cycle ergometric test of maximal
oxygen uptake (VO max) was conducted, PWC170, as well
as the measurements of respiratory volume (VT), the
lung ventilation (VE) and the index VE/ VO (Quark b2
Cosmed). The spirometric measurements of forced
inspiration and expiration (FVC) and the maximal
voluntary ventilation – MVV (K4b2 Cosmed) were also
conducted. The changes of values of certain indexes
were statistically analysed with the use of t-Student test
(for dependant samples) assuming that p=0.05*.
2
2
RESULT
The study results showed the essential increase in
the values of maximal oxygen uptake and the PWC170
index among the groups using respiratory muscle
training with the use of PowerBreathe device and the
elastic belts (Table I).
Table I. The changes of maximal oxygen uptake and PWC170
under the influence of the inspiratory muscle
training among the examined groups
Tabela I. Zmiany maksymalnego poboru tlenu oraz PWC170
pod wpływem treningu
mięśni wdechowych w
obrębie badanych grup
The research
groups
Grupa
badawcza
Characteristics
Wskaźnik
PWC170
The
(W)
PowerBreathe
PWC170 (W/kg)
group
VO2max
Grupa
PowerBreathe (ml/min)
VO2max
(n=14)
(ml/kg/min)
PWC170
The elastic belts (W)
group
PWC170 (W/kg)
Grupa
VO2max
elastyczne pasy (ml/min)
(n=14)
VO2max
(ml/kg/min)
PWC170
(W)
The control
PWC170 (W/kg)
group
Grupa kontrolna VO2max
(ml/min)
(n=14)
VO2max
(ml/kg/min)
Study 1 (Before)
Badanie1
M
Study 2
(After)
Badanie 2
SD
M
133.1
18.5
147.5*
2.1
0.32
2.4*
2415.1
220.7
2636.1*
39.3
4.6
133.8
2.1
.SD
Significance of
differences
Wartości
t
p
22.8
3.387
0.004*
0,42
2.912
0.012*
227,2
4.056
0.001*
42.2*
4,5
3.577
0.003*
14.0
144.6*
14,9
4.513
0.000*
0.2
2.3*
0,3
5.434
0.000*
2420.0
197.4
2603.6*
142,5
-5.269
0.000*
39.7
5.2
42.4*
3,9
-4.631
0.000*
134.6
10.5
136.1
16,3
-0.669
0.516
2.13
0.3
2.17
0,3
-0.862
0.405
2460.2
423.2
2505.4
433,5
-2.162
0.051
39.7
6.6
40.3
6,2
-2.084
0.059
* the differences statistically significant (with the assumed level of
significance p=0.05)
* różnice istotne statystycznie (przy założonym poziomie istotności
p=0,05)
However, no essential changes in VO2max (Fig. 1)
and PWC170 (Fig. 2) were notice in the control group.
When comparing the results of maximal oxygen
uptake, one can conclude that a special RMT included
in the fitness program on the stationary bikes increases
the effectiveness of the realized exercises and
essentially influences the increase in aerobic working
capacities.
54
VO2max (ml . kg -1 . min -1) - 125 W
result of the comparative analyses in the case of lung
ventilation (VE l/min) and the index VE/ VO2 (Fig. 4,
5).
Table II. The changes of circulatory-respiratory characteristics at the submaximal load (125W) under the
influence of the training among the examined
groups
Tabela II. Zmiany wybranych wskaźników krążeniowooddechowych przy obciążeniu submaksymalnym
(125W) pod wpływem treningu w obrębie
badanych grup
Characteristics
Wskaźnik
Fig. 1. The comparative characteristic of the changes of the
value in VO2max (ml . kg -1 . min -1) under the
influence of the inspiratory muscle training
Ryc. 1. Charakterystyka porównawcza zmiana wartości
wskaźnika VO2max (ml . kg-1 . min-1) pod wpływem
treningu mięśni wdechowych
.
-1
PWC170 (W kg ) - 125 W
VT ( l )
Significance of
difference
Wartości
SD
M
SD
t
p
The PowerBreathe group
Grupa (PowerBreathe)
0.35
1.747
0.23
0.027
0.978
Study 1 (Before)
Badania 1
M
1.745
Study 2 (After)
Badania 2
VE (l/min)
51.1
5.64
46.1*
4.57
3.898
0.001*
VE/VO2
28.7
1.63
24.3*
1.89
7.623
0.000*
VO2/HR (ml/bt)
10.8
1.43
13.5*
1.23
6.341
0.000*
1918.7
82.6
1820.8*
102.9
6.214
0.000*
The elastic belts group
Grupa (elastyczne pasy)
0.23
1.759
0.19
0.563
5.18
45.0
4.00
4.253
2.09
25.1
1.95
8.567
0.77
12.0
1.02 -7.523
0.582
0.000*
0.000*
0.000*
2.147
0.051*
VO2 (ml/min)
VT ( l )
VE (l/min)
VE/VO2
VO2/HR (ml/bt)
VO2 (ml/min)
1.732
50.3
30.1
10.3
1819.3
91.1
1710.8
232.3
The control group
Grupa kontrolna
VT ( l )
1.736
0.20
1.733
0.20
0.060
0.953
0.720*
VE (l/min)
46.8
4.60
46.2
6.73
0.366
VE/VO2
25.1
2.43
25.3
2.65
-0.270
0.792*
0.967*
VO2/HR (ml/bt)
VO2 (ml/min)
11.7
1.91
11.9
1.31
-0.041
1916.8
96.2
1816.8
96.2
0.535
0.602*
VO2 (ml. min -1) -125 W
Fig. 2. The comparative characteristic of the changes in the
value PWC170 (W . kg - 1) under the influence of the
inspiratory muscle training
wskaźnika PWC170 (W . kg - 1) pod wpływem
treningu mięśni wdechowych
The comparison of the data from tables II shows
statistically significant increase in the values of
circulatory and respiratory indexes, measured during
5-minutes standard submaximal load (125 W). In the
women’s group, using the special RMT with the use of
PowerBreathe device and the elastic belts during
standard load, the significantly decreased value of
minute oxygen uptake, compared to the women in the
control group, was noticed (Fig. 3). There is a similar
index value VO2 (ml . min-1) at standard load (125W)
under the influence of the inspiratory muscle training
wskaźnika VO2 (ml . min-1) podczas standardowego
wysiłku (125 W) pod wpływem treningu mięśni
wdechowych
VE (l . min-1) - 125 W
Fig. 4. The comparative characteristic of the changes in the
value of VE (l . min-1) at standard load (125W) under
the influence of the inspiratory muscle training
wskaźnika VE (l . min-1) podcza standardowego
wysiłku (125 W) pod wpływem treningu mięśni
wdechowych
VE/VO2 - 125 W
55
voluntary ventilation of the lungs (MVV l/min)
increased the most.
Table III. The change of the characteristics of respiratory
system capabilities by means of forced inspirationexpiration and the maximal lung voluntary
ventilation (BTPS) under the influence of the
health-related training in examined groups
Tabela III. Zmiany wybranych wskaźników możliwości
oddechowych w warunkach natężonego wdechuwydechu i maksymalnej dowolnej wentylacji
płuc (BTPS) pod wpływem treningu w obrębie
poszczególnych grup
FVC. l
4.07
Significance of
differences
Wartości
SD
M
SD
t
p
The PowerBreathe group
Grupa PowerBreathe
0.40
4.68
0.49 -4.225 0.00099*
FEV1. l
3.16
0.62
Characteristics
Wskaźnik
PEF. l/s
MVV. l/min
FVC. l
FEV1. l
PEF. l/s
MVV. l/min
Study 1
Badania 1
M
Study 2
Badania 2
3.71
0.47
-2.988
0.01049*
0.00604*
0.00027*
5.20
1.27
6.06
1.25
-3.274
121.80
20.53
144.15
19.32
-4.945
4.16
3.44
5.00
134.89
The elastic belts group
Grupa elastyczne pasy
0.35
4.67
0.49 -5.237
0.30
3.95
0.49 -3.398
1.19
6.48
1.25 -5.885
22.56 160.98 21.48 -11.533
0.000*
0.005*
0.000*
0.000*
The control group
Grupa kontrolna
FVC. l
4.16
0.49
4.36
0.48
-1.913
0.082
FEV1. l
3.44
0.37
3.60
0.41
-1.524
0.155
0.003
0.004
PEF. l/s
MVV. l/min
index value VE/VO2 at standard load (125W) under
the influence of the inspiratory muscle training
wskaźnika VE/VO2 podcza standardowego wysiłku
(125 W) pod wpływem treningu mięśni wdechowych
The data presented indicate a better economy of
body work; in order to do the same work, the athlete
who undergoes RMT needs less energy. It also shows
in the reactions of circulatory and respiratory systems,
measured during 5-minutes standard submaximal load.
And what is more, it seems that lower lung ventilation,
which is the result of RMT, is the index of more
economical work of the respiratory system. In the
group which used respiratory muscles training with the
use of PowerBreathe device (Table III), the 1-second
Forced Expiratory Volume (FEV1), the peak
expiratory flow (PEF 1/s) and the Forced Vital
Capacity (FVC) significantly increased. The maximum
5.89
1.02
6.64
1.08
-3.753
136.58
14.60
150.80
18.69
-3.597
Under the influence of respiratory muscle training
with the use the elastic belts with regulated tension on
the lower part of the chest (tightened with the force of
2.5 kg) (Table III), the maximal lung voluntary
ventilation, 1-second forced expiratory volume and
forced volume capacity significantly increased. The
peak expiratory flow increased the most.
In the control group, an increase in maximal lung
voluntary ventilation, forced vital capacity, 1-second
forced expiratory volume, and significantly the greatest
increase in peak expiratory flow was observed (Table
III).
The indexes increased insignificantly as opposed to
the group using the elastic belt and the PowerBreathe
device (Fig. 6,7).
Based on the analyses of the spirometric
measurements, it was stated that after the four-week
experiment, among both experimental groups
a significant increase in the indexes described above
56
could be observed. The effect of the training in both
experimental groups was similar.
MVV (l·min¯¹)
Fig. 6. The comparative characteristic of the changes in
value of MVV (l·min¯¹) under the influence of the
wskaźnika MVV (l·min¯¹) pod wpływem treningu
mięśni wdechowych
FVC (l . BTPS)
Fig. 7. The comparative characteristic of the changes in
value of FVC (l . BTPS) under the influence of the
wskaźnika FVC (l . BTPS) pod wpływem treningu
mięśni wdechowych
DISCUSSION
We came to the assumption, that a special
respiratory muscle training (RMT) can be a factor of
increasing the function of oxygen transport in the body
including the aerobic work capacity of young women.
The spinning type of fitness belongs to simple and safe
forms of aerobic training on stationary bikes.
It can be assumed, that four weeks period of
systematic aerobic fitness sessions combined with the
resistance training of inspiratory muscles causes the
improvement of aerobic capacities and the functioning
of respiratory system to a greater extent than without
RMT. The importance of the data is connected with the
need to increase the efficiency of a health-related
training, and providing such means, which can help to
obtain its individual efficiency within optimal amount
of time [1,2]. It becomes obvious, that with the use of
traditional means of fitness technology, it is necessary
to intensify and differentiate the training stimuli. The
respiratory muscle training can constitute one of the
crucial elements in this aspect. It is obviously because
there are a lot of technical devices being developed in
sports, which allow deepening the training effects
oriented for the physical working capacities of the
body [6,7,8,10]. Among the professional devices
described in literature used for the RMT, one can find
devices such as the PowerBreathe and the elastic belts
with regulated tension on the lower part of the chest,
which duringphysical exercises are additional
resistance for working inspiratory muscle [6,7]. The
activities of PowerBreathe were, above all, oriented to
an increase in the power of inspiratory muscles, and
the influence of the RMT with the use of the elastic
belts was oriented to an increase of the respiratory
muscles endurance [11].
The respiratory muscles are characterised by
coordinated work, providing overcoming of the inertial
resistance, and also result from the mechanical
properties of the respiratory system – the elastic
resistance created by the elastic structures of the walls
of chest and lungs, as well as the inelastic resistance
occurring in respiratory pathways. [12,13]. During high
intensity physical exercises, the oxygen uptake by
respiratory muscles significantly increases and equals
approximately 10-15% of the overall oxygen
consumption by the body [7]. The increased demand
for oxygen of the excessively used respiratory muscles,
analogically to other skeletal muscles, can lead to their
fatigue [14,15]. The feeling of fatigue during physical
load to great extent comes from the respiratory muscles
[16]. One of the direct indicators of fatigue of the
respiratory muscles is the change of the ways of
breathing, which are characterised by the depth of
breath in and out and the rate of breathing [14]. The
increase in breathing rate as an indicator of respiratory
fatigue is confirmed by the scientific researches, owing
to which there are reasons to assume that respiratory
muscles limit the general ability of physical training in
case of exceptionally intensive loads [16].
The effort capabilities of respiratory muscles
constitute one of more significant factors which decide
about physical endurance of the body. In many
publications the authors presented the positive
influence of RMT among patients with the diseases of
the respiratory system, such as bronchial asthma,
chronic obstructive pulmonary disease (COPD) as well
as pulmonary emphysema. It was proved that such
training, as rehabilitation, can influence an increase in
the respiratory muscle strength and the improvement of
the function of the respiratory system causing
a decrease in dyspnoea among the examined patients
and the ability of making greater physical working
capacities [17]. With reference to the researches in
sports, it was stated, that after three week’s RMT (with
the use of the PowerBreathe device and the elastic
belts) in high performance rowers, the effort tolerance
of the respiratory muscles changed positively. While
using different areas of exercise intensiveness, the
possibility of diversity of RMT was indicated [6]. The
connection between the increase in respiratory muscles
capacity and special working capacities in athletes was
also noticed (the increase in the tidal volume during
physical load). After introducing inspiratory muscles
training with the use of PowerBreathe device into the
training process of female rowers and athletes training
other endurance disciplines, an increase in the
resistance of the inspiratory muscles to fatigue and
a decrease in the feeling of dyspnoea (lack of breath)
during work were indicated [9,18].
A significantly positive influence was also noticed
with the use of the inspiratory and expiratory muscle
training among healthy, not training men. [5,7]. The
training of such kind was realised in the form of
systematic respiratory exercises, oriented to the
development of strength and endurance of respiratory
muscles. As showed Boutellier [18] special exercises
oriented to the development of respiratory muscles
increase their working capacities more than
conventional physical training. In the training people,
the breaths frequency decreases and they become
deeper, the respiratory muscles better eliminate the
lactate, and the fatigue occurs later than among people
who do not use special respiratory muscle training
[15]. It was also observed, that the athletes who did not
use the special respiratory exercises, stopped the
physical exercise due to fatigue of the lower limbs.
The effectiveness of RMT realised during 8 weeks
among women of 60-69 years old was shown [19]. The
strength and endurance of respiratory muscles
increased as well as many other spirometric indexes
and physical endurance.
57
It was shown in the present study that under the
influence of RMT there was a tendency of significantly
better oxygen uptake and PWC170 index among the
groups of young women practising inspiratory muscle
training with the use of PowerBreathe device and the
elastic belts. It seems possible, that the respiratory
muscles covered their own oxygen consumption at the
expense of working muscles of the lower limbs. One
can come here to the conclusion, that decreased lungs
ventilation at PWC170, which is the consequence of the
respiratory muscle training, indicates more economical
work of the respiratory system. It can give evidence,
that on the basis of improvement of the strength of the
respiratory muscles, among healthy people, especially
women, the lung capacity reserve increases. That is
why, not only among older but also among young
women, the maximal voluntary lung ventilation, the
forced vital capacity, 1-second forced expiratory
volume and relatively the greatest increase in the peak
expiratory flow, were observed.
We assume that the respiratory muscle training can
be the factor which extends the time of sustaining the
maximal oxygen uptake, as well as it can be the factor
which positively influences sustaining of the heart
systolic volume.
The results shown on this study indicate the
effectiveness of the respiratory muscle training
included in the stationary bike fitness program for
young women. The effect of its realisation is an
increase in aerobic capacities and the efficiency of the
respiratory system.
It may be concluded that the inspiratory muscle
training with the use of PowerBreathe and the elastic
belts included in the program health related training,
increased the training stimulus and caused positive
changes of some particular indexes of the respiratory
system capabilities: the forced vital capacity, 1-second
forced expiratory volume, and the peak expiratory
flow. The positive changes of the described indexes
indicate an increase in the inspiratory flow reflecting
the potency of the bronchi, indirectly indicate an
increase in the strength of respiratory muscles, and
confirmed the increased aerobic working ability. The
inspiratory muscles training caused a significant
increase in the maximal oxygen uptake and an increase
in the relation of oxygen uptake and heart rate.
With the assumption mentioned above, it must be
stated, that the most current task of further research in
this direction, is to create the system of health-related
impacts, with taking into account the specificity of
58
women’s body reaction to RMT. The use of such
untraditional means of influence can be an important
part of fitness exercises, which increases the possibility
of optimize of the physiological adaptation of the body.
In the next stages of researches, there is the need to
determine the criteria of the choice of the means of the
respiratory muscle training, its dosage and high
specific effects.
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Pneumonol. Alergol. Pol., 1996, tom 64, nr. 9-10, 697709.
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dr hab. Mariusz Zasada, prof. UKW
Uniwersytet Kazimierza Wielkiego w Bydgoszczy
Instytut Kultury Fizycznej
Mariusz Zasada
ul. Zelwerowicza 25
85-183 Bydgoszcz
kom. 506 052 877
[email protected]
Received: 7.12.2010
Michał Szpinda, Monika Paruszewska-Achtel, Mariusz Baumgart, Adrianna Sobolewska,
Gabriela Elminowska-Wenda
QUANTITATIVE GROWTH OF THE HUMAN DELTOID MUSCLE IN HUMAN FOETUSES
WZROST ILOŚCIOWY MIĘŚNIA NARAMIENNEGO U PŁODÓW CZŁOWIEKA
Department of Normal Anatomy Ludwik Rydygier Collegium Medicum in Bydgoszcz
Head: Assoc. Prof. Michał Szpinda, MD
Summary
I n t r o d u c t i o n : The present study was performed to
provide the missing data concerning the morphometric
growth of the deltoid muscle in human foetuses.
M a t e r i a l a n d M e t h o d s : Using anatomical dissection,
digital image analysis (Multiscan v.14.02) and statistical
analysis (STATISTICA 9.1) both the length (mm) of the tree
proximal attachments, and the surface area (mm2) of the
scapular, acromial and clavicular parts in 30 spontaneously
aborted fetuses aged 17-30 weeks were analysed. No visible
anomalies were observed.
R e s u l t s : No significant laterality and gender differences
between all the parameters measured on both sides were
found. Both the attachment length (mm) and surface area
(mm2) of the scapular part of the deltoid muscle were found
to be statistically (P<0.01) largest (10.92 mm; 186.27 mm2)
when compared to its acromial (8.65mm; 163.96 mm2) or
clavicular (8.38mm; 148.08 mm2) parts. The following linear
models with P<0.01 were generated: y = -0.9406+0.3948x (r
= 0.62), y = 1.3074+0.3105x (r = 0.70), y =
-0.7468+0.04936x. Consequently, their surface areas were
following: y = -150.543+12.6357x (r = 0.76), y =
-199.1859+15.3659x (r = 0.77), y = -190.8514+15.9571x
(r = 0.70).
Conclusions:
1. There are no significant deltoid’s laterality and
gender differences.
2. The scapular part is the biggest, whereas the
clavicular one is the smallest.
3. The developmental dynamic of the deltoid muscle
follows a linear regression.
Streszczenie
W s t ę p : Badania te przeprowadzono celem dostarczenia
brakujących danych z zakresu wzrostu morfometrycznego
mięśnia naramiennego u płodów człowieka.
M a t e r i a ł i m e t o d y : U 30 płodów człowieka w wieku
17-30 tygodni, pochodzących z poronień samoistnych, przy
zastosowaniu dysekcji anatomicznej, cyfrowej analizy obrazu
(Multiscan v. 14.02) i analizy statystycznej (STATISTICA
9.1) zbadano długość trzech przyczepów początkowych
i pola powierzchni części łopatkowej, barkowej i obojczykkowej mięśnia naramiennego. Nie zaobserwowano żadnych
widocznych anomalii.
W y n i k i : Nie stwierdzono istotnych różnic wartości
parametrów w odniesieniu do płci i strony ciała. Zarówno
długość przyczepu, jak i pola powierzchni części łopatkowej
(10,92 mm; 186,27 mm2) były największe, w porównaniu z
częścią barkową (8,65 mm; 163,96 mm2) i obojczykową
(8,38 mm; 148,08 mm2). Wygenerowano następujące modele
liniowe z P <0,01 : y = -0,9406+0,3948 x (r = 0,62), y =
1,3074 +0,3105 x (r = 0,70), y = -0,7468 +0,04936 x.
Konsekwentnie wzrosły również pola powierzchni: y =
-150,543 +12,6357 x (r = 0,76), y = -199,1859 +15,3659 x
(r = 0,77), y = -190,8514 +15,9571 x (r = 0,70).
60
Michał Szpinda et al.
Wnioski:
1. Nie obserwuje się różnic bilateralnych i płciowych w
odniesieniu do mięśnia naramiennego.
2. Część łopatkowa jest największa, natomiast część
obojczykowa jest najmniejsza.
3. Dynamika rozwoju mięśnia naramiennego następuje
zgodnie z funkcją liniową.
Key words: deltoid muscle, measurements, attachment length, surface area, regression analysis
Słowa kluczowe: mięsień naramienny, długości przyczepu, pole powierzchni, analiza regresji badawczego
INTRODUCTION
The deltoid muscle, named after its triangular
appearance, superficially envelops the ball-and-socket
shoulder joint. Although some authors have
distinguished as many as seven its functional
components [1, 2], the deltoid is commonly considered
as a three-part muscle, consisting of anterior or
clavicular, middle or acromial, and posterior or
scapular parts. Among the six rotator cuff muscles, the
deltoid is biggest and the only one, the fibres of which
attach from the lateral third of the clavicle, the
acromion, and the lower edge of the scapular spine to
be differentiated into three subsequently parts, and
finally to form a short, substantial tendon which is
inserted to the deltoid tubercle on the lateral aspect of
the midshaft of the humerus [3-5].
Despite its important both functional and clinical
jobs, little information is known about deltoid’s
dimensions in humans.
The aim of the present study was to examine the
growth of the deltoid by measuring the attachment
length and surface area of each of the three parts in
human foetuses.
-
the length (mm) of the tree proximal attachments,
the surface area (mm2) of the scapular, acromial
and clavicular parts.
The digital method allows us to estimate precisely
all the measurements with accuracy of 0.1 mm. The
parameters obtained were correlated to foetal age in
order to establish their growth. The values obtained
were statistically analysed using the STATISTICA 9.1
programme. Regression analysis was used to derive the
line of best fit for the plot for each morphometric
feature against gestational age.
RESULTS
The deltoid muscle in all the foetuses has typically
arisen forming the three parts: clavicular, acromial and
scapular. The mean values obtained are presented in
Table I. The mean widths of both the clavicular and
acromial deltoid’s attachments were comparable,
whereas the scapular part was significantly longer than
the two above mentioned parts. Consequently, the
former had the greater mean surface areas than that of
the latter.
The examinations were carried out on 30
spontaneously aborted human foetuses of both sexes
(14 males, 16 females). The present study was
approved by the University Research Ethic Committee
(KB 191/2011). Gestational ages of the foetuses were
determined by the crown-rump length (CRL) [6] and
ranged from 17 to 30 weeks. Specimens were
preserved in 10 % neutral formalin solution, then the
skin and subcutaneous tissues were removed out to
expose the deltoid muscle. In each foetus, the three
origins of the deltoid muscle were placed with
millimetre scale and then recorded using a Canon EOS
550D camera. With the use of the MultiScan
v 14.02 programme, all the digitalized deltoid’s images
were measured in relation to the six following
parameters on both sides:
Table I. Length of the three attachments and the surface area
of the deltoid muscle
Tabela I. Długość trzech przyczepów początkowych mięśnia
naramiennego i pole powierzchni równoimiennych
części mięśnia
Attachment
attachment length (mm)
part
długość przyczepu (mm)
Część
SD
x
przyczepu
clavicular part
/ część
8.39A
2.07
obojczykowa
acromial part
część barkowa
8.65 A
1.46
surface area (mm2)
pole powierzchni (mm2)
SD
x
148.08 A
54.46
163.96 A,B
65.02
scapular part
część
10.92 B
2.39
186.27 B
74.37
łopatkowa
The means in columns that differ significantly are determined by
different letters: A and B, P <0.001
Średnie w kolumnach, które różnią się istotnie, oznaczono różnymi
literami: A i B, przy P<0.001
Quantitative growth of the human deltoid muscle in human foetuses
61
Table II. Individual deltoid’s morphometric results
Tabela II. Wyniki indywidualne parametrów m. naramiennego
age
(weeks)
wiek
(tygodnie)
attachment lenght (mm)
długość przyczepu początkowego (mm)
clavicular part
acromial part
scapular part
cz. obojczykowa
cz. barkowa
cz. łopatkowa
left
mean
right
left
mean
right
left
mean
right
lewa
średnia prawa lewa
średnia prawa lewa
średnia prawa
clavicular part
cz. obojczykowa
left
mean
right
lewa
średnia prawa
surface area (mm2)
pole powierzchni (mm2)
acromial part
cz. barkowa
left
mean
right
lewa
średnia prawa
scapular part
cz. łopatkowa
left
mean
right
lewa
średnia prawa
17
5.41
5.46
5.50
4.94
6.04
7.14
7.07
7.86
8.65
52.48
58.19
63.89
74.86
72.07
69.28
56.59
67.17
77.74
18
19
5.06
4.00
4.71
4.96
4.36
5.92
6.17
7.64
6.62
6.89
7.07
6.14
7.38
5.67
7.60
6.80
7.82
7.93
50.89
54.01
53.33
58.50
55.77
62.99
63.21
90.10
65.81
79.60
68.40
69.09
92.07
82.57
77.10
79.73
62.12
76.88
19
7.33
7.30
7.26
9.18
8.44
7.70
7.23
9.85
12.47
111.50
107.69
103.9
186.90
160.69
134.53
122.90
132.69
142.47
20
21
4.92
6.85
5.23
6.46
5.54
6.07
5.98
6.83
6.14
7.34
6.30
7.84
8.78
9.8
8.68
8.95
8.57
8.10
65.84
90.78
61.62
89.25
57.39
87.71
44.13
55.50
44.78
70.74
45.43
85.97
90.14
105.90
68.45
104.63
46.76
103.35
22
8.58
8.39
8.20
11.21
9.51
7.81
10.57
12.8
15.02
166.70
149.26
131.82
135.00
136.08
137.12
119.19
182.43
245.67
22
8.25
8.53
8.80
7.88
7.66
7.43
8.74
9.51
10.27
115.00
130.44
145.88
119.10
114.32
109.50
212.88
178.14
143.40
22
22
5.52
6.86
6.89
7.29
8.25
7.72
6.45
6.04
6.09
6.80
5.73
7.56
7.51
9.74
7.83
9.42
8.14
9.10
112.50
113.90
104.82
99.65
97.10
85.39
96.24
95.49
81.07
99.92
65.89
104.35
119.31
134.63
125.92
145.70
132.52
156.76
23
10.65
10.01
9.37
10.33
8.81
7.28
8.76
9.83
10.9
232.40
193.50
154.60
225.10
209.86
194.64
152.88
179.13
205.37
23
23
8.61
8.03
8.41
8.18
8.20
8.32
8.82
8.89
8.48
8.38
8.13
7.87
12.54
10.72
11.93
10.82
11.32
10.92
123.30
139.30
130.05
126.58
136.84
113.84
186.30
124.20
178.24
110.63
170.14
97.02
278.99
145.21
300.92
128.69
322.84
112.17
24
8.46
10.38
12.29
8.60
8.95
9.30
10.91
12.92
14.92
153.00
178.09
203.22
185.20
185.45
185.67
212.67
237.56
262.45
24
24
7.13
8.46
8.81
8.24
10.49
8.02
9.87
10.55
8.81
9.45
7.75
8.34
8.89
11.31
9.78
14.33
10.67
17.35
137.00
166.80
176.06
190.78
215.11
214.79
208.70
266.50
191.18
203.71
173.7
140.96
253.87
201.32
292.87
233.17
331.87
265.01
24
8.07
8.14
8.21
11.64
10.06
8.47
9.56
10.64
11.72
139.60
162.71
185.81
251.30
197.64
144.03
195.32
188.79
182.26
24
9.71
8.70
7.69
8.54
9.83
11.11
11.01
11.18
11.34
211.10
164.89
118.67
154.10
187.71
221.3
137.35
155.32
173.28
24
24
8.79
7.50
8.76
8.15
8.73
8.79
7.09
7.95
8.94
8.69
10.79
9.43
9.40
10.63
9.98
11.14
10.56
11.65
209.00
160.80
204.21
155.06
199.43
149.29
174.80
170.70
203.57
144.45
232.32
118.24
214.55
147.49
206.95
131.02
199.35
114.54
24
9.08
7.99
6.89
9.24
9.11
8.98
10.35
8.88
7.40
168.60
143.85
119.09
154.60
153.30
152.01
163.43
134.13
104.82
24
11.56
15.11
18.66
12.23
11.22
10.20
15.06
12.70
10.33
215.20
200.90
186.64
277.20
246.15
215.14
321.32
291.61
261.90
24
26
6.53
8.98
8.13
9.56
9.73
10.13
6.68
11.59
7.48
10.60
8.28
9.61
11.57
12.90
11.50
14.93
11.43
16.96
103.20
178.90
124.38
198.65
145.54
218.36
94.53
305.50
136.65
271.00
178.77
236.55
170.10
332.64
188.17
291.41
206.24
250.17
27
7.28
9.14
10.99
12.73
11.11
9.48
10.44
11.31
12.18
115.80
182.62
249.49
320.40
271.45
222.51
160.64
214.12
267.60
28
9.93
10.32
10.71
10.61
10.31
10.01
13.40
14.82
16.24
204.00
234.18
264.41
233.20
214.87
196.51
322.95
314.83
306.70
29
29
7.77
9.48
8.05
10.43
8.32
11.37
8.54
10.42
8.92
9.85
9.29
9.28
10.16
15.54
9.47
14.74
8.78
13.93
126.00
231.80
129.62
253.09
133.26
274.42
217.30
184.90
184.42
226.25
151.53
267.61
112.43
261.36
170.99
262.72
229.54
264.07
29
9.51
11.39
13.26
11.09
9.15
7.21
15.03
15.9
16.76
188.40
236.74
285.09
291.30
243.22
195.13
258.56
242.96
227.35
30
9.61
8.63
7.65
11.89
9.73
7.56
14.66
11.48
8.30
193.70
143.79
93.83
223.10
234.09
245.06
269.14
260.80
252.46
The statistical analysis revealed neither gender nor
laterality differences (P<0.01), hence the results were
presented irrespective of sex and side. The values of all
the parameters studied appeared to be linearly related
to advanced foetal age.
Clavicular part
In the material under examination the values for
the clavicular part (Fig. 1, 4 ) ranged from 4.71 to
15.11 mm, according to the linear model: y = 0.9406+0.3948x (r = 0.62, P<0.01). Its surface area
(Fig. 7) ranged from 53.33 to 253.09 mm2 to generate
the linear model: y = -150.543+12.6357x (r = 0.76,
P<0.01).
Acromial part
The values for the length (Fig. 2, 5) ranged from
6.04 to 11.11 mm, following the linear model: y =
1.3074+0.3105x (r = 0.70, P<0.01). The values for its
surface area (Fig. 8) ranged from 44.78 to 271.45 mm2
to
create
the
linear
regression:
y
=
-199.1859+15.3659x (r = 0.77, P<0.01).
Fig. 1. The clavicular part ( 1 ) of the deltoid muscle
62
Fig. 4. Regression line for the length [y] of the clavicular
attachment versus foetal age [x]: y = - 0.9406 +
0.3948x
Ryc. 4. Krzywa regresji dla długości przyczepu początkowego części obojczykowej [y] w porównaniu z
wiekiem płodu [x]: y = - 0,9406 + 0,3948x
Fig. 2. The acromial part ( 2 ) of the deltoid muscle
Fig. 5. Regression line for the length [y] of the acromial
attachment versus foetal age [x]: y = 1.3074 +
0.3105x
Ryc. 5. Krzywa regresji dla długości przyczepu
początkowego części barkowej [y] w porównaniu
z wiekiem płodu [x]: y = 1,3074 + 0,3105x
Fig. 3. The scapular part ( 3 ) of the deltoid muscle
Scapular part
In relation to the length of the scapular attachment
(Fig. 3) the values ranged (Fig. 6) proportionally from
6.80 to 15.90 mm as the function: y = 0.7468+0.04936x (r = 0.68, P<0.01). The values for its
surface area (Fig. 9) ranged from 67.17 to 314.83 mm2
to be modelled as the linear function: y =
-190.8514+15.9571x (r = 0.70, P<0.01).
Fig. 6. Regression line for the length [y] of the scapular
attachment versus foetal age [x]: y = - 0.7468 +
0.4936x
Ryc. 6. Krzywa regresji dla długości przyczepu początkowego części łopatkowej [y] w porównaniu z
wiekiem płodu [x]: y = - 0,7468 + 0,4936x
Quantitative growth of the human deltoid muscle in human foetuses
63
DISCUSSION
Fig. 7. Regression line for the surface area [y] of the
clavicular part versus foetal age [x]: y = - 150.543
+ 12.6357x
Ryc. 7. Linia regresji dla pola powierzchni części
obojczykowej [y] w porównaniu z wiekiem płodu
[x]: y = - 150,543 + 12,6357x
acromial part versus foetal age [x]: y = - 199.1859
+ 15.3659x
Ryc. 8. Krzywa regresji dla pola powierzchni części
barkowej [y] w porównaniu z wiekiem płodu [x]:
y = - 199,1859 + 15,3659x
scapular part versus foetal age [x]: y = - 190.8514 +
15.9571x
Ryc. 9. Krzywa regresji dla pola powierzchni części
łopatkowej [y] w porównaniu z wiekiem płodu
[x]: y = - 190,8514 + 15,9571x
The deltoid muscle appears to develop as several
muscle bundles in distinctly separated but
interconnected septal segments [1], which are
responsible for the number of deltoid’s parts
characterized by different functions, and thereby clinical importance. As an anterior stabilizer, the
deltoid muscle prevents the shoulder from dislocating
forwards. The deltoid is reported [7] to be potentially
the most capable of translating the humeral head
superiorly towards the glenoid cavity, the shoulder
socket. As a prime mover, the acromial deltoid with the
supraspinatus is important throughout glenohumeral
abduction, especially in mid- and late abduction after
50 degrees [8]. Since its physiological cross-sectional
area is more than twice as large as the supraspinatus, it
can generate a large torque to abduct the arm even in
the initiation phase of abduction. Except for internal
rotation and flexion, the clavicular deltoid was found
to have a large abduction moment after 15 degree
elevation. Besides external rotation and extension [8,
9], the posterior deltoid acts as an antagonist during
abduction gradually losing this function at higher
abduction angles.
From a surgical point of view, the deltoid is
involved both in rotator cuff surgery [10-12] and in
transposition to the triceps tendon for restoration of
elbow extension in the paralyzed upper limbs [13].
Having reviewed the professional literature on the
deltoid muscle, we did not manage to find any
morphometric parameters. The statistical analysis of
the values obtained showed neither gender nor
laterality differences. This fact appears to harmonize
with results of Pande and Singh [14], who found no
laterality differences in human foetal deltoid’s weight.
We realize that the present study suffers from the
inherent limitations since the age of foetuses is not
representative of the whole gestation, and the number
of the specimens studied is relatively small, as well.
However, the regression analysis used in this study
partially compensates for some of these limitations,
demonstrating the theoretical linear growth of the
parameters during prenatal life.
Both the attachment length and surface area of all
the three deltoid’s parts rose proportionally during
gestation, thereby generating specific linear models. In
relation to the attachment length we received the
following functions: y = -0.9406+0.3948x, y =
1.3074+0.3105x, and y = -0.7468+0.04936x for the
64
clavicular, acromial and scapular parts, respectively.
Their surface areas increased proportionally as follows:
y = -150.543+12.6357x, y = -199.1859+15.3659x, and
y = -190.8514+15.9571x. The linear models under
discussion are completely new, thereby filling the gap
in the expertise concerning the quantitative growth of
the deltoid muscle. To summarize, the scapular
deltoid’s attachment length and the surface area (mm2)
of the scapular deltoid’s part were found to be
statistically largest (10.92 mm; 186.27 mm2) when
compared to its acromial (8.65mm; 163.96 mm2) or
clavicular (8.38 mm; 148.08 mm2) parts.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
Audenaert E., Barbaix E.: Separate segments within the
deltoid muscle: Anatomical variants or wishful
thinking? Int. J. Shoulder Surg., 2008; 2: 69-70.
Bergman R.A., Thompson S.A., Afifi A.K., et al.:
Compendium of human anatomic variation. Baltimore:
Urban and Schwarzenberg, 1988.
Kumar V.P., Satku K., Liu J., et al.: The anatomy of
the anterior origin of the deltoid. J. Bone Joint Surg.,
1997; 79:680-683.
Herzberg G., Urien J.P., Dimnet J.: Potential excursion
and relative tension of muscles in the shoulder girdle:
relevance to tendon transfers. J. Shoul. Elb. Surg.,
1999; 8:430-437.
Zhao X., Hung L.K., Zhang G.M., et al.: Applied
anatomy of the axillary nerve for selective
neurotization of the deltoid muscle. Clin. Orthop.
Relat. Res. 2001; 390:244-251.
Iffy L., Lavenhar M., Kaminetzky H., et al.: The effect
of maternal age, parity, fetal sex and season upon early
intrauterine development. In J. Gynecol. Obstet., 1978;
16: 210-215.
Halder A.M., Halder C.G., Zhao K.D., et al.: Dynamic
inferior stabilizers of the shoulder joint. Clin.
Biomech., 2001; 16:138-143.
Ackland D.C., Pak P., Richardson M., Pandy M.G.:
Moment arms of the muscles crossing the anatomical
shoulder. J. Anat., 2008; 4:383-390.
9.
10.
11.
12.
13.
14.
Liu J M.D., Hughes R.E., Smutz W.P., et al.: Roles of
deltoid and rotator cuff muscles in shoulder elevation.
Clin. Biomech., 1997; 12:32-38.
Sher J.S., Iannotti J.P., Warner J.J., et al.: Surgical
treatment of postoperative deltoid origin disruption.
Clin. Orthop. Relat. Res., 1997; 343:93-98.
Jeon I.H., Koorevaar R., Neumann L., et al.:
Reconstruction of the deltoid and acromion after failed
acromionectomy. Clin. Orthop. Relat. Res., 2005;
430:100-107.
McCallister W.V., Parsons I.M., Titelman R.M., et al.:
3rd Open rotator cuff repair without acromioplasty. J.
Bone Joint Surg. Am., 2005; 87:1278-1283.
Ejeskar A.: Elbow extension. Hand Clin., 2002;
18:449-459.
Pande B.S., Sing I.: One-sided dominance in the upper
limbs of human fetuses as evidenced by asymmetry in
muscle and bone weight. J. Anat., 1971; 109:457-459.
Department of Normal Anatomy
Ludwik Rydygier Collegium Medicum in Bydgoszcz,
Dr hab. med. Michał Szpinda
Karłowicza 24 Street
PL-85-092 Bydgoszcz
CASE REPORT / PRACA KAZUISTYCZNA
Marcin Gierach1, Joanna Gierach1, Marta Spychalska2 , Maciej Papierski2, Roman Junik1
SHEEHAN’S SYNDROME – CASE REPORT
ZESPÓŁ SHEEHANA – OPIS PRZYPADKU
¹Chair of Endocrynology and Diabetology of Nicolaus Copernicus University Ludwik Rydygier Collegium
Medicum in Bydgoszcz
Head: Prof. Roman Junik, MD
2
Students’ Scientific Society of Chair of Endocrynology and Diabetology of Nicolaus Copernicus University
Ludwik Rydygier Collegium Medicum in Bydgoszcz
Head: Marcin Gierach, MD, PhD
Summary
Sheehan’s syndrome is a rare complication of pregnancy
that was already described in 1937. During pregnancy,
a twofold enlargement of an anterior pituitary lobe appears,
which, in the case of an excessive blood loss in the perinatal
period, can lead to its necrosis. As a result, pituitary hormone
deficiency is caused.
We present a case of 57 years old patient, admitted to the
Department of Endocrinology and Diabetology, Collegium
Medicum in Bydgoszcz, for a purpose of an assessment of
endocrine system metabolism, after the implementation of
substitution treatment, because of a Sheehan’s syndrome,
diagnosed in 1944.
The diagnosis of Sheehan’s syndrome may cause certain
difficulties, since individual hormone deficiency can give
various clinical signs. The basis of the diagnosis is an
affirmation of pituitary hormones deficiency (prolactin above
all- postpartum agalactosis) and a positive history of bleeding
during childbirth. We believe that despite its rarity,
Sheehan’s syndrome should be taken into consideration in
differential diagnosis in all women with perinatal
hemorrhage in their medical history and the symptoms of
hypopituitarism.
Streszczenie
Zespół Sheehana stanowi obecnie rzadkie powikłanie
porodu, które zostało opisane już w 1937 roku. Podczas ciąży
dochodzi do dwukrotnego powiększenia przedniego płata
przysadki, co, w przypadku nasilonego krwawienia w okresie
okołoporodowym, może prowadzić do jego martwicy,
w wyniku czego dochodzi do niedoboru hormonów tego
gruczołu.
Przedstawiamy
przypadek
57-letniej
pacjentki
hospitalizowanej w Klinice Endokrynologii i Diabetologii
Collegium Medicum UMK w Bydgoszczy celem oceny
gospodarki
hormonalnej
po
wdrożonym
leczeniu
substytutcyjnym z powodu rozpoznanego w 1994 roku
zespołu Sheehana.
Key words: Sheehan’s syndrome
Słowa kluczowe: zespół Sheehana
Rozpoznanie zespołu Sheehana może sprawiać pewne
trudności, ponieważ niedobory poszczególnych hormonów
mogą dawać rozmaite objawy kliniczne. Podstawą rozpoznania jest stwierdzenie niedoborów hormonów wydzielanych
przez przysadkę (przede wszystkim prolaktyny – brak laktacji) oraz dodatni wywiad w kierunku krwawienia podczas
porodu.
Uważamy, że pomimo rzadkiego występowania, zespół
Sheehana powinien być brany pod uwagę w diagnostyce różnicowej u wszystkich kobiet z krwawieniem okołoporodowym w wywiadzie oraz objawami niedoczynności przysadki.
66
Marcin Gierach et al.
INTRODUCTION
Sheehan’s
syndrome
(postpartum
pituitary
necrosis) is a rare complication of pregnancy that was
already described in 1937 [1, 2, 7, 8, 11]. During
pregnancy, a twofold enlargement of an anterior
pituitary lobe appears, which, in the case of an
excessive blood loss in the perinatal period, can lead to
its necrosis. As a result, pituitary hormone deficiency
is caused. Taking into account, that individual hormone
deficiency can give various clinical signs, the diagnosis
of Sheehan’s syndrome may cause certain difficulties.
CASE REPORT
Serum cortisol and ACTH in a circadian rhythm,
GH and TSH, fT3 and fT4 were within normal limits.
During the hospitalization in the department of
Endocrinology and Diabetology, the pharmacological
treatment of the patient was modified: dosage of
hydrocortisone was increased (30 mg --> 40 mg) and
following were applied: fludrocortisone 0.1 mg 3 times
a week, L-thyroxine 1 x 50 ug a day, estradiol 1 x 1,
acetylsalicylic acid 1 x 75 mg, piracetam 1.2 g 1 – 1 –
0. On discharge, a continuation of the initiated
treatment was recommended to the patient.
DISCUSSION
57 years old patient (K.T.) was admitted to the
Department of Endocrinology and Diabetology,
Collegium Medicum in Bydgoszcz, for an assessment
of endocrine system metabolism, after the
implementation of substitution treatment, because of
a Sheehan’s syndrome, diagnosed in 1944.
In a patient, during her sixth childbirth (8th
pregnancy, 2 miscarriages) in 1982, because of
complications in the form of postpartum uterine atony
and severe bleeding, a hysterectomy without removal
of the adnexa was performed. Since that time, the
patient has had certain abnormal symptoms, such as:
lack of lactation after the childbirth, pubic hair loss,
secondary hair loss (head, eyebrows), secondary
amenorrhea, physical weakness and difficulty in
concentration.
In 1994, after performing series of hormonal tests
(ACTH, cortisol, TSH, FSH, LH) and magnetic
resonance imaging of hypophysis (feature of empty
saddle syndrome), a diagnosis of Sheehan’s syndrome
was established. It was then, when substitution
treatment (hydrocortisone, fludrocortisone, L-thyroxine, estradiol), because of recognition of secondary
hypoadrenalism, hypothyroidism and hypogonadism,
was administered to the patient.
Currently, the patient is additionally treated
because of a stable angina pectoris, hypertension,
osteoarthritis of the cervical and lumbar-sacral spine
and a chronic posterior cerebral circulation
insufficiency.
During the physical examination on the day of
admission to the Department, from abnormalities, only
the lack of armpit and pubic hair was found. The
abnormalities discovered in additional studies are
shown in a table 1.
The Sheehan’s syndrome is a rare complication of a
childbirth [1-5]. Isolated case reports with the
symptoms of this disease appeared already in 1913
(L.K. Gliński) and 1914 (M. Simmonds) [6, 7].
However, the symptoms of postpartum pituitary
necrosis were fully described in 1937 by an English
pathologist Harold Leeming Sheehan [1].
During the pregnancy, as a consequence of
lactotropic hyperplasia, a twofold enlargement of an
anterior pituitary lobe appears what may lead to its
relative hypoxia[8]. The hypophysis is supplied by a
low-pressure network of capillaries and it causes an
increased risk of ischemia. In the case of bleeding and
hypovolemic shock occurring in the perinatal period, it
may come to necrosis of the pituitary, resulting in
shortage of hormones secreted by it. The Sheehan’s
syndrome occurs when approximately 70-75% of the
pituitary mass is destroyed. Additionally, a release of
thromboplastic tissue that favours the disseminated
intravascular coagulation (DIC) during childbirth, may
be the factor that favours the incidence of Sheehan’s
syndrome. Later, the anterior pituitary lobe is being
replaced with a fibrous tissue. The changes are usually
irreversible.
The diagnosis of Sheehan’s syndrome may cause
certain difficulties, since individual hormone
deficiency can give various clinical signs. The basis of
the diagnosis is an affirmation of pituitary hormones
deficiency (mainly prolactin - postpartum agalactosis)
and a positive history of bleeding during childbirth [2].
Cortisol deficiency can cause a general physical
weakness, nausea and hypoglycemia. An inadequate
secretion of gonadotropins leads to lack of or quick
recovery from lactation, breast atrophy, atrophic
changes within the reproductive organs, secondary
amenorrhea and decreased libido. An absence or
deficiency of growth hormone secretion is associated
with a decrease in muscle mass, decline in quality of
Sheehan's syndrome - case report
life and fatigue. Furthermore, symptoms associated
with pituitary hormone deficiency are: a decrease in
hemoglobin
levels,
lower
basal
metabolic,
hyponatremia, and symptoms of heart failure [2, 3, 4,
9, 10]. In the available literature there are also single
case reports of postpartum pituitary necrosis
manifested by headaches and double vision or the
occurrence of severe hyponatremia with accompanying
hypoglycemia [4, 9]. Among others, in the study of
Foppiani et al., in 15 patients with hypopituitarism,
dyslipidaemias (73%), anemia (20%) and hyponatremia (13%) were discovered [11]. Wang and colleagues
present a case of Sheehan’s syndrome, where a heart
failure and symptoms associated with it, which
appeared as a result of heavy bleeding after childbirth
were the main cause of hospitalization in patient [3].
Our patient also had heart failure symptoms
manifesting in stable angina pectoris.
The severity of symptoms of hypopituitarism, as
well as the rate of their occurrence depends on the
extent of damage to the pituitary gland. Due to the fact
that the gland has a large secretory reserve, only after
the destruction of more than 75% of cells, clinical
symptoms manifest. Most patients with Sheehan’s
syndrome have a slow progression of hormonal
disorders associated with postpartum hypopituitarism,
and that is why clinical symptoms, characteristic for
this syndrome, grow slowly and diagnosis takes several
years, usually more than 5 [5, 12, 13].
In the presented case, we experienced the typical
symptoms of Sheehan’s syndrome, such as the lack of
lactation after birth (1982), hair loss, general weakness
and difficulty in concentration. The Sheehan’s
syndrome was diagnosed in the patient only after 12
years since her last childbirth, during which heavy
vaginal bleeding occurred.
An absence of pituitary hormones in the blood,
occurring in the Sheehan’s syndrome, requires
substitution therapy. An appropriate hormone therapy
in hypopituitarism may significantly improve quality
of life and reduce morbidity and mortality.
In our patient, after the diagnosis of postpartum
hypopituitarism, an initial dose of hydrocortisone
30mg/a day [20-10-0], fludrocortisone (Cortineff) 0.1
mg 3 times per week and L-thyroxine (Letrox 50
ug/day) were administered.
In conclusion, we believe that despite its rarity,
Sheehan’s syndrome should be considered in the
differential diagnosis in all women with a history of
perinatal bleeding and hypopituitarism.
67
LITERATURE
1. Sheehan HL. Postpartum necrosis of the anterior
pituitary. J Path Bacteriol 1937; 45: 189-214.
2. Schrager S, Sabo L. Sheehan Syndrome: a rare
complication of postpartum hemorrhage. J Am Board
Fam Pract 2001; 14(5): 389-391.
3. Wang SY, Hsu SR, Su SL, Tu ST. Sheehan’s syndrome
presenting with early postpartum congestive heart failure.
J Chin Med Assoc. 2005; 68: 386-391.
4. Bunch TJ, Dunn WF, Basu A, Gosman RI. Hyponatremia
and hypoglycemia in acute Sheehan’s syndrome.
Gynecol Endocrinol. 2002; 16: 419-423.
5. Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta
N. Pituitary autoimmunity in patients with Sheehan’s
syndrome. J Clin Endocrinol Metab. 2002; 87: 41374141.
6. Simmonds M. Uber hypophysisschwund mit todlichem
Ausgang. Dtsch. Med. Wschr. 1914; 40: 322-323.
7. Gliński L.K.: Z kazuistyki zmian anatomopatologicznych
w przysadce mózgowej. Przegląd Lekarski, Kraków 52,
13-14 (1913).
8. Karaca Z, Tanriverdi F, Unluhizarci K, Kelestimur F.
Pregnancy and pituitary disorders. Eur J Endocrinol.
2010; 162: 453-475.
9. Vaphiades MS, Simmons D, Archer RL, Stringer W.
Sheehan syndrome: a splinter of the mind. Surv
Ophtalmol. 2003; 48: 230-233.
10. Kageyama Y, Hirose S, Terahi K, Nakayama S,
Komatsuzaki O, Fukuda H. A case of postpartum
hypopituitarism (Sheehan’s syndrome) associated with
severe hiponatremia and congestive heart failure. Jpn J
Med. 1988; 27: 337-341.
11. Foppiani L, Ruelle A, Bandelloni R, Quilici P, Del
Monte P. Hypopituitarism in the elderly: multifaceted
clinical and biochemical presentation. Curr Aging Sci
2008; 1: 42-50.
12. Anfuso S, Patrelli TS, Soncini E, Chiodera P, Fadda
GM, Nardelli GB. A case report of Sheehan’s syndrome
with acute onset, hyponatremia and severe anemia. Acta
Biomed. 2009; 80: 73-76.
13. Aron D., Findling J., Tyrrell B. Podwzgórze i przysadka.
W: Endokrynologia ogólna i kliniczna. Pod red.
Greenspan F, Gardner D. Lublin 2004, 109-177
Marcin Gierach
Katedra Endokrynologii i Diabetologii
UMK w Toruniu
ul. M. Skłodowskiej-Curie 9
85-094 Bydgoszcz POLAND
tel./fax (+48)(052) 585 42 40
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