medical and biological sciences

Transcription

UNIWERSYTET MIKOŁAJA KOPERNIKA w TORUNIU
COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA
W BYDGOSZCZY
MEDICAL
AND BIOLOGICAL
SCIENCES
(dawniej
ANNALES ACADEMIAE MEDICAE BYDGOSTIENSIS)
TOM XXVI/1
styczeń – marzec
ROCZNIK 2012
REDAKTOR NACZELNY
Editor-in-Chief
Grażyna Odrowąż-Sypniewska
ZASTĘPCA
REDAKTORA NACZELNEGO
Co-editor
Jacek Manitius
SEKRETARZ REDAKCJI
Secretary
Beata Augustyńska
REDAKTORZY DZIAŁÓW
Associate Editors
Mieczysława Czerwionka-Szaflarska, Stanisław Betlejewski,
Roman Junik, Józef Kałużny, Jacek Kubica, Wiesław Szymański
KOMITET REDAKCYJNY
Editorial Board
Aleksander Araszkiewicz, Beata Augustyńska, Michał Caputa, Stanisław Dąbrowiecki, Gerard Drewa, Eugenia Gospodarek,
Bronisław Grzegorzewski, Waldemar Halota, Olga Haus, Marek Jackowski, Henryk Kaźmierczak, Alicja Kędzia,
Michał Komoszyński, Wiesław Kozak, Konrad Misiura, Ryszard Oliński, Danuta Rość, Karol Śliwka, Eugenia Tęgowska,
Bogdana Wilczyńska, Zbigniew Wolski, Zdzisława Wrzosek, Mariusz Wysocki
KOMITET DORADCZY
Advisory Board
Gerd Buntkowsky (Berlin, Germany), Giovanni Gambaro (Padova, Italy), Edward Johns (Cork, Ireland),
Massimo Morandi (Chicago, USA), Vladimir Palička (Praha, Czech Republic)
Adres redakcji
Address of Editorial Office
Redakcja Medical and Biological Sciences
ul. Powstańców Wielkopolskich 44/22, 85-090 Bydgoszcz
Polska – Poland
e-mail: [email protected], [email protected]
tel. 52 585-3326
www.medical.cm.umk.pl
Informacje w sprawie prenumeraty: tel. 52 585-33 26
e-mail: [email protected], [email protected]
ISSN 1734-591X
UNIWERSYTET MIKOŁAJA KOPERNIKA W TORUNIU
BYDGOSZCZ 2012
Medical and Biological Sciences, 2012, 26/1
CONTENT
p.
REVIEW
Monika Kuczma, Katarzyna Matuszak, Waldemar Kuczma, Wojciech
H a g n e r , B a r b a r a K s i ą ż k i e w i c z – Treatment and rehabilitation of patients
with scoliosis at the turn of the century . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
ORIGINAL ARTICLES
M a ł g o r z a t a D a b k o w s k a , T a d e u s z P r a c k i , D a r i a P r a c k a – The objective
measurement of movement vs. the intensification of ADHD symptoms in assessment of parents
and doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
J e r z y E k s t e r o w i c z , M a r e k N a p i e r a ł a – Morphological parameters of physical education
students in the years 2006-2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
M a r i u s z K l i m c z y k – Somatic build vs sports results of pole vault contestants aged 16-17 . . . . . .
27
Alicja Rzepka, Kornelia Kędziora-Kornatowska, Marlena Jakubczyk,
Ł u k a s z S i e l s k i , K r z y s z t o f K u s z a – Assessment of the needs and expectations
of elderly patients regarding physiotherapeutical care in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35
CASE REPORTS
Małgorzata Łukowicz, Magdalena Mackiewicz-Milewska, Sabina
L a c h - I n s z c z a k , I w o n a S z y m k u ć , W o j c i e c h H a g n e r – Transpedicular
stabilization complications in thoracic region of the spine after SCI – three casus report and
literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43
Edyta Sutkowska, Anna Kotłowska, Krzysztof Mastej, Rajmund
A d a m i e c – Tuberous sclerosis, lated diagnosis: a case analysis . . . . . . . . . . . . . . . . . . . . . . . . .
51
SPIS TREŚCI
str.
PRACA POGLĄDOWA
Monika Kuczma, Katarzyna Matuszak, Waldemar Kuczma, Wojciech
H a g n e r , B a r b a r a K s i ą ż k i e w i c z – Leczenie i rehabilitacja pacjentów ze skoliozą
na przełomie wieków . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
PRACE ORYGINALNE
M a ł g o r z a t a D a b k o w s k a , T a d e u s z P r a c k i , D a r i a P r a c k a – Obiektywny
pomiar ruchu a nasilenie objawów ADHD w ocenie rodziców i lekarza . . . . . . . . . . . . . . . . . . . . . .
11
J e r z y E k s t e r o w i c z , M a r e k N a p i e r a ł a – Parametry morfologiczne studentów
wychowania fizycznego w latach 2006-2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
M a r i u s z K l i m c z y k – Budowa somatyczna vs wyniki sportowe zawodników skaczących o tyczce
w wieku 16-17 lat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
Alicja Rzepka, Kornelia Kędziora-Kornatowska, Marlena Jakubczyk,
Ł u k a s z S i e l s k i , K r z y s z t o f K u s z a – Ocena zapotrzebowania i oczekiwań pacjentów
w starszym wieku w odniesieniu do opieki fizjoterapeutycznej w Polsce . . . . . . . . . . . . . . . . . . . . .
35
PRACE KAZUISTYCZNE
Małgorzata Łukowicz, Magdalena Mackiewicz-Milewska, Sabina
L a c h - I n s z c z a k , I w o n a S z y m k u ć , W o j c i e c h H a g n e r – Powikłania
po stabilizacji transpedikularnej odcinka piersiowego kręgosłupa u pacjentów po urazie rdzenia
kręgowego – opis trzech przypadków i przegląd literatury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43
Edyta Sutkowska, Anna Kotłowska, Krzysztof Mastej, Rajmund
A d a m i e c – Stwardnienie guzowate, późne rozpoznanie: opis przypadku . . . . . . . . . . . . . . . . . .
51
Regulamin ogłaszania prac w Medical and Biological Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
177
Medical and Biological Sciences, 2012, 26/1, 5-9
REVIEW / PRACA POGLĄDOWA
Monika Kuczma¹,², Katarzyna Matuszak¹, Waldemar Kuczma¹, Wojciech Hagner¹, Barbara Książkiewicz²
TREATMENT AND REHABILITATION OF PATIENTS WITH SCOLIOSIS
AT THE TURN OF THE CENTURY
LECZENIE I REHABILITACJA PACJENTÓW ZE SKOLIOZĄ NA PRZEŁOMIE WIEKÓW
1
Institute and University Department of Rehabilitation
Nicolaus Copernicus University Collegium Medicum in Bydgoszcz
Head: dr hab. Wojciech Hagner, prof. UMK
2
Institute and University Department of Neurology
Nicolaus Copernicus University Collegium Medicum in Bydgoszcz
Head: dr hab. Barbara Książkiewicz, prof. UMK
Summary
Idiopathic scoliosis is an illness commonly occurring in
children and teenagers. During its development threedimensional deformities can be observed: in frontal plane –
primary, lateral curvature, in sagittal plane - deepening or
flattening of the natural curvature of the spine and in
transversal, horizontal plane - rotation and torsion of the
vertebrae
Scoliosis treatment and rehabilitation have been an
important and complex issue since the ancient times.
The early methods, however, were very painful and
hardly effective. At the turn of XVI - XVII centuries a fast
development of scoliosis research and the first rehabilitation
attempts were observed. In the following the use of corsets
became a popular way of treatment. In Poland, scoliosis
treatment and patients’ rehabilitation gained new meaning at
the turn of XVII-XIX centuries, when new, fast developing
rehabilitation/treatment centers in Krakow, Poznań and
Warsaw were opened.
Streszczenie
Skolioza idiopatyczna jest chorobą dzieci i młodzieży.
W trakcie jej rozwoju można obserwować u pacjenta zmiany
zachodzące w trzech płaszczyznach. W płaszczyźnie
czołowej występuje wyboczenie, w płaszczyźnie strzałkowej
pogłębienie lub spłycenie krzywizn fizjologicznych, a w
płaszczyźnie poprzecznej notuje się rotację i torsję kręgów.
Leczeniem i rehabilitacją pacjentów ze skoliozą zajmowali
się uczeni już w czasach starożytnych. Początkowo były to
Key words: scoliosis, treatment, rehabilitation
Słowa kluczowe: skolioza, leczenie, rehabilitacja
metody bardzo bolesne i mało skuteczne. Duży rozwój
technik leczenia jak i początki rehabilitacji pacjentów ze
skoliozą nastąpił na przełomie XVI-XVII w. W kolejnych
latach rozkwitły metody leczenia poprzez gorset. W Polsce
duży rozwój technik leczenia i rehabilitacji pacjentów ze
skoliozą datuje się na przełom XVIII-XIX w. kiedy to
powstały prężne ośrodki rehabiltacyjno-lecznicze w
Krakowie, Poznaniu i Warszawie.
6
Monika Kuczma et. al.
INTRODUCTION
Idiopathic scoliosis is a typical, three-dimensional
illness of growing children and teenagers. During its
development the deformities can be observed in the
frontal plane, lateral or thoracic plane (in most cases
deepened chest kyphosis is also present) and horizontal
plane with rotational deformity [1, 2, 3, 4].
Another great physician, considered the father of
orthopedic surgery in the United States, Lewis Albert
Sayre treated scoliosis using a hoist (Picture 1)[6].
WORLD HISTORY OF SCOLIOSIS TREATMENT
Idiopathic scoliosis has been of interest of the
greatest scientists of our times, among others
Hyppocrates or Galen, for a long time.
Hippocrates of Kos (460-377 BC), considered the
father of Western medicine, presented a number of
various pioneer theories and descriptions, including
lateral curve, in a collection of medical works called:
Hippocrates Corpus (‘Corpus Hippocraticum’). One of
these was noticing the dependence between the level of
spine deformity and the age of the patient when the
curve became visible. However, it was a prominent
Roman doctor - Galen (129-199) who introduced the
term ‘scoliosis’ into the world of medicine. In his great
work ‘Ars Parva’ this scientist of Greek ethnicity
presented a handmade woodcut showing spine traction
and slide. Unfortunately, these early methods of
deformities treatment were not only extremely cruel
and painful but also hardly effective [4].
Avicenna (Persian physician and philosopher) in
his work entitled ‘Qanun’ completed in 1000 AD
described and pictured spine positioning. His treatment
methods were widely applied until 1700s.
The first clinical description of the lateral curve
appeared in the sixteenth century works published by a
French surgeon Ambroise Paré (1510-1590). This great
scientist did not only serve the French kings, treating
them and describing various diseases, but also
presented clinical descriptions of idiopathic scoliosis
and its treatment using a metal corset [4,5].
Francis Glisson (1599-1677), a British scientist
and physician, was another doctor treating scoliosis
using innovative methods. In his work ‘Rachitis’
Glisson published several theories and methods of
scoliosis treatment, nowadays considered the basis of
handling with this illness. What is more, he was the
inventor of the rehabilitation loop, known as ‘the
Glisson’s loop’ which has been widely used in
rehabilitation ever since. Its main aim is to stretch the
muscles and ligaments along the spine and shoulders.
Pic. 1. Spine traction in scoliosis treatment
Ryc. 1. Trakcja kręgosłupa w leczeniu skoliozy
Pic. 2. Posture while learning. Date unknown
Ryc. 2. Postawa ciała podczas nauki. Data nieznana
Nicolas Andry de Bois-Regard, a French
physician and writer, who played a significant role in
the early history of orthopedics, was the inventor of
the name ‘posture hygiene’, first used in his great
work ‘Orthopédie’ (the name orthopedics derived
from it). In his discourse on biomechanics of scoliosis,
Andry pointed out that the muscles changes may be
the etiological factor of the illness. He underlined the
importance of teaching the patients how to maintain
the correct posture habits. His approach was the
Treatment and rehabilitation of patients with scoliosis at the turn of the century
7
beginning of postural reeducation, nowadays being the
basis of posture defects treatment (Picture 2) [6].
Pic. 3. Prototype of orthesis used in scoliosis correction [7]
Ryc. 3. Pierwowzór ortezy do korekcji skoliozy [7]
Fast development of idiopathic scoliosis
diagnostics and treatment occurred between 1780 and
1880s. The first rehabilitation centers were opened in
Florence, Bologna, Paris, Montpelier, Lozanne and
Birmingham using innovative treatment methods as
well as various tools, equipment and corsets for posture
correction (Pictere 3) [7].
It was then, in 1772, that the prototype of
Milwaukee corset was designed in Paris by Lavarcher.
A few years later, in 1780 a book entitled
‘La gymnastique médicale et chirurgicale’ describing
various methods of physical exercises for children with
spine deformities, applied in surgery and orthopedics
was published by Tissot.
In the XIX century a publication of the first
catalogues with a variety of corsets appeared (Picture
4,5) [7].
Pic. 4. Various corsets presented by F.W. Braun and co. in
1903 [7]
Ryc. 4. Różne modele gorsetów zaprezentowane przez F.W.
Braun i spółkę w 1903 [7]
Pic. 5. ‘Corsets for sale’, published by Sears, Roebuck
Company Incorporated in 1800s [7]
Ryc. 5. „Gorsety na sprzedaż”, wydane przez Sears, Roebuck
Company Incorporated w latach 1800-tych [7]
In 1894 corsets done up with laces were presented.
(Picture 6,7) [7].
Pic. 6. Corset, 1894, manufactured in Detroit Pharmaceutical Company
Ryc. 6. Gorset, 1894, zmontowany w Detroit Pharmacal
Company
Pic. 7. Corsets presented by E.H. Bradford and E.G.
Brackett in 1880
Ryc. 7. Gorsety przedstawione w 1880 r przez E.H.
Bradford and E.G. Brackett
8
Monika Kuczma et. al.
The flourish of corset production was at the turn of
XVIII and XIX centuries. A true supporter of a
passive method of spine correction was Z.B. Adams
who designed the first laced corset (Picture 8) [7].
Pic. 8. Corset designed in 1910 by Z. A. Adams as an
alternative to metal corsets. [7]
Ryc. 8. Gorset zaprojektowany przez Z. A. Adamsa w 1910 r.
Jako alternatywa dla gorsetów metalowych [7]
One of the leading opponents of passive correction
of spine deformities was Shaw, who believed that
exercises were the only effective method of treatment.
In his book ‘Curvature of the Spine’ (London, 1825)
Shaw described a whole series of exercises correcting
spine’s posture as well as hips and ribs’ placement.
According to him, these exercises were to show
therapeutic properties, improving the overall posture
(spine, ribs and limbs) and had to be followed by a
series of exercises strengthening the muscles of the
back.
Another French surgeon, Jacque Mathieu Delpech
in his book ‘Orthomorphie’ (1829) advocated the
importance of the asymmetric growth of the spine and
its influence on the curvature, and promoted using a
disc placed between the vertebra as a successful
treatment method. His ideas were the first attempts of
creating a theory explaining the source of scoliosis. In
his treatment Delpech supported both passive and
active methods of posture correction, using various
equipment in order to relieve the pressure on spine
when in horizontal position. He also recommended
swimming as a successful method of treatment and set
up a rehabilitation centre for patients with scoliosis.
In 1874 Sayre applied plaster cast in horizontal
curve correction. His approach was further developed
by Bradford and Brackett, who put the cast on when
the patient was lying on a special table, using the
horizontal hoist at the same time.
Swedish school of scoliosis treatment and
rehabilitation, led by Henry Ling (1776-1839)
developed concurrently. The source of posture
deformities was searched for in the muscles structure
dysfunction, therefore numerous dynamic exercises,
aimed at proper symmetry reinforcement, were
introduced. Even though they did not bring the
expected results, they surely played a significant role in
scoliosis treatment, being one of the first of the
preventive measures undertaken to ensure correct
posture habits.
In 1886 Lorentz realized that in order to
successfully treat scoliosis, maximum muscles’
strength had to be achieved, whereas regaining proper
spine line in the frontal layer and Swedish exercises
were significant only as preventive measures.
The beginning of the XX century and the years
between the World Wars were dominated by the use of
various equipment in posture deformities’ correction.
In 1911 Abbot designed a method of hunchback
correction by a de-rotation using a frame. This method
was further developed by Cortel and then Risser (the
father of the so-called ‘Risser’s frame’) in the post war
years.
In 1946 Boston orthesis and Milwaukee-Blount
corsets appeared and were soon popularized.
POLISH HISTORY
One of the leading Polish scientists, a personal
doctor of Stefan Batory, Wojciech Oczko (1537-1599)
based his theories of scoliosis treatment on Galen’s.
In the XIX century a fast development of
rehabilitation centers in Krakow, Poznań and Warsaw
started, with gymnastic and orthopedic wards where
rehabilitation of posture deformities was widely
practiced. Henry Ling’s methods found a number of
followers in Poland, among others Helena Kuczalska,
who in 1892 set up the therapeutic and gymnastic
center which developed into therapeutic and gymnastic
and massage school 14 years later, training leading
future Polish therapists and instructors.
Treatment and rehabilitation of patients with scoliosis at the turn of the century
9
Wiktor Dega, a pioneer in Polish orthopedics and
rehabilitation of children was the first person to
organize therapeutic and gymnastic classes for pupils
in 1930. Seven years later the first department of
therapeutic rehabilitation was opened in Bydgoszcz
[8].
During 1990s further development of national
rehabilitation centers treating posture deformities took
place (e.g. ‘Konstancin’ managed by professor Marian
Weiss [4].
Address for correspondence:
mgr Monika Kuczma
Institute and University Department of Rehabilitation
Nicolaus Copernicus University Collegium Medicum
in Bydgoszcz
ul. M. Curie Skłodowskiej 9,
85-094 Bydgoszcz
tel. (52) 585-43-30, tel./fax (52) 585-40-42
e-mail: [email protected]
BIBLIOGRAPHY
Received: 18.05.2011
Accepted for publication: 13.02.2012
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2.
3.
4.
5.
6.
8.
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Kasperczyk T.: Wady postawy ciała, leczenie i
diagnostyka. Kraków 2001: 50-51.
Nowakowski
A.,
Łabaziewicz
L.:
Skolioza
idiopatyczna – epidemiologia i etiologia. Chir
Narzadow Ruchu Ortop Pol 1998; 63(4): 317-320.
Kwolek A.: Rehabilitacja medyczna, tom2. Wrocław
2003: 250-256.
Wilczyński J. Korekcja wad postawy człowieka.
Starachowice 2001: 196-225.
Milanowska K., Dega W.: Rehabilitacja medyczna.
Warszawa 1999: 228-272.
The Pediatric Spine: Principles and Practice New York
1994: 556-557.Farrell-Beck J.: Medical and
Commercial Supports for Scoliotic Patients;
1819-1935. Studies in Anatomy and Technology; 1995
11(3): 142-163.
Dega W., Marciniak W.: Wiktora Degi ortopedia i
rehabilitacja, tom 2. Warszawa 2004: 66-68.
ORIGINAL ARTICLE / PRACA ORYGINALNA
Małgorzata Dabkowska¹, Tadeusz Pracki², Daria Pracka²
THE OBJECTIVE MEASUREMENT OF MOVEMENT
VS THE INTENSIFICATION OF ADHD SYMPTOMS
IN ASSESSMENT OF PARENTS AND DOCTORS
OBIEKTYWNY POMIAR RUCHU A NASILENIE OBJAWÓW ADHD
W OCENIE RODZICÓW I LEKARZA
¹Departament of Psychiatry Nicolaus Copernicus University in Torun
Collegium Medium in Bydgoszcz
Head: Prof. dr hab. Aleksander Araszkiewicz
²Department of Physiology, Nicolaus Copernicus University in Torun
Collegium Medium in Bydgoszcz
Head: prof. dr hab. n. med. Małgorzata Tafil-Klawe
Summary
The purpose of this work was the objective actigraphic
evaluation of movement at children with ADHD (Attention
Deficit Hyperactivity Disorder) in relation to the evaluation
of symptom intensification according to their parents
(ADHD-RS IV) and a medical qualification to a subtype of
ADHD (DSM IV TR). The motor activity of a child was
evaluated by means of an actigraph - Actiwatch 4 produced
by Cambridge Neurotechnology Ltd. The investigated group
consisted of 37 children (32 boys, 5 girls). Results: there
were no differences in the activity between the group of
children with recognized ADHD combined subtype and the
group of children with recognized ADHD predominantly
inattentive subtype observed. More serious attention
disorders occur in case of children, who in later hours of the
day have the maximum activity intensity. The scores of items
evaluating the hyperactivity and impulsiveness did not
correlate with the results of activity measurement. The results
of actigraphic measurement did not correlate with the
evaluation of the activity intensification according to parents.
Streszczenie
Celem pracy była obiektywna aktograficzna ocena ruchu
u dzieci z rozpoznaniem ADHD w stosunku do oceny
nasilenia objawów według rodziców i kwalifikacji lekarskiej
do podtypu ADHD. Diagnozę ADHD postawiono zgodnie z
kryteriami badawczymi DSM IV TR. Nasilenie
poszczególnych objawów ADHD opiekunowie oceniali za
pomocą kwestionariusza ADHD Rating Scale-IV wersji dla
rodziców. Aktywność ruchową dziecka oceniano za pomocą
aktografu Actiwatch 4 firmy Cambridge Neurotechnology
Ltd. Grupę badaną stanowiło 37 dzieci (32 chłopców, 5
dziewcząt) w wieku od 7 do 14 lat, średnia wieku 10 lat
(SD=2,3). Wyniki: Nie obserwowano różnicy w aktywności
między grupą dzieci z rozpoznaniem ADHD podtypu
mieszanego a grupą dzieci z rozpoznaniem ADHD podtypu z
przewagą deficytu uwagi. Większe zaburzenia uwagi
występują u dzieci, które w późniejszych godzinach doby
mają maksymalne nasilenie aktywności. Wyniki pomiaru
aktograficznego nie korelowały z oceną nasilenia ruchliwości
według rodziców.
Key words: Attention Deficit Hyperactivity Disorder, actigraphy, motor activity, parent ratings
Słowa kluczowe: zaburzenie hiperkinetyczne, aktograf, aktywność ruchowa, ocena rodziców
12
Małgorzata Dabkowska et. al.
INTRODUCTION
Attention Deficit Hyperactivity Disorder (ADHD)
is a multi-factor based disorder [1]. In children with
ADHD an increase of right hemisphere activation in
response to both kinds of questions contrary to health
controls was observed [2]. In children with ADHD the
dysfunctions of the frontal lobe were diagnosed [3].
Motor hyperactivity is one of the core symptoms of
ADHD [4]. Pathophysiologically, it can be understood
as a result of an abnormal motor facilitation or
inhibition within cortical and subcortical motor
circuits.
These children have serious problems with the
control of their moves, adjustment of the move strength
to the situation, limitation of moves in the social
situations that require calm behavior. The utterances of
people with ADHD are accompanied by numerous
hand gestures. The hyperactivity is particularly visible
in case of younger patients, but the increased motor
readiness still remains in adult life, negatively
influencing social functioning. In patients with ADHD
some deviations in the movement pattern in response
to electro-stimulation were observed [5].
The
pathophysiological basis of the motor disorders in
patients with ADHD can be deviations of the
dopaminergic frontal-striatum circuit. The results prove
that ADHD symptoms are significantly connected with
neurophysiologic factors. Kids with ADHA have
dysfunctions in the brain areas connected with body
motor activity – in the temporal lobe, cerebellum, area
of sub-cortex [6]. In children with ADHD some
deviations in motor functions the basis of which is
brain immaturity are observed [7]. The intensification
of motor disorders in ADHD was evaluated by the
evaluation of the presence of soft neurological
symptoms and general physical fitness [8]. In children
with ADHD higher intensity of syndrome symptoms is
connected with the weakening of the motor fitness.
Motor dysfunctions are a significant factor of the risk
of more serious or complicated ADHD and higher
negative influence on social functioning.
Irregularities in the motor activity can be
considered factors responsible for interactions between
the biological aspect of the disorder and the level of
social and family functioning of those children [6].
Sensor integration disorders occur much more often
among the patients with ADHD (84.3 %) than in the
population of school children (10.3 %) [9, 10]. Patients
with ADHD have weakened vestibular functions,
worse performance of activities and movement
planning [11]. In children with ADHD, with the help of
objective tests evaluating balance, the worse
possibilities of keeping the balance of the body were
confirmed [12]. Hampering the activity and attention
deficit visible in ADHD can be the results of disorders
in the frontal-motor connections of the cortex [13].
The Fourth Edition of the Diagnostic and Statistical
Manual (DSM-IV) recognizes three subtypes of
ADHD: the predominantly inattentive subtype, the
predominantly hyperactive/impulsive subtype, and the
combined subtype [14].
A recent study suggested that deficits in response
inhibition may be related to inattentiveness rather than
hyperactive and impulsive behavior, suggesting a
differential neuropsychological profile associated with
subtypes of ADHD [15].
The purpose of this work was the objective
actigraphic evaluation of movement of children with
recognized ADHD in relation to the evaluation of the
intensification of symptoms according to parents and
medical qualification to the sub-type of ADHD.
METHODS
I. Evaluation of presence and intensity of ADHD
ADHD was diagnosed by a child and youth
psychiatrics specialist in agreement with the DSM IV
TR research criteria [16]. The parents evaluated the
intensity of particular symptoms of the Attention
Deficit Hyperactivity Disorder by means of the ADHD
Rating Scale questionnaire – IV version for parents
[17]. The questionnaire for parents - ADHD Rating
Scale-IV (ADHD-RS) was filled up during the parents’
visits, most frequently mothers’ visits, at children and
youth psychiatrist. ADHD Rating Scale-IV
questionnaire (ADHD-RS) version for parents is
devoted to the evaluation of problems resulting from
ADHD symptoms at children and youth at the age from
4 do 20. It evaluates the ADHD symptoms from the
period of last 6 months. It consists of 18 items
describing behaviors resulting from the presence of
ADHD symptoms. Each item is evaluated in a 4-grade
scale describing the frequency of a given behavior –
never, rarely, sometimes, often, very often
(respectively from 0 to 3 points). The scale is divided
into 2 sub-scales concerning separately the attention
deficit symptoms and the hyperactivity and
The objective measurement of movement vs the intensification of ADHD symptoms in assessment of parents and doctors
impulsiveness symptoms, and the sum of points of the
subscales constitutes the ADHD RS-IV questionnaire
result. The scale has a good reliability - test-retest
assessed in big groups of children in the United States
[17]. The scale norms are adjusted to boys and girls
separately and to the age groups (5-7, 8-10, 11-13, 1418) [18]. The interpretation of the results depends on
the type and number of symptoms and the intensity of
problems. The percentile table serves the interpretation
– separately for boys and girls, with the division into
age groups and the division into the symptoms of
attention deficit and hyperactivity and impulsiveness as
well as total score. The values equal to and over the 90
percentile mean the high probability of ADHD
diagnosis. In the works of Korean researchers, in
which the ADHD RS-IV score was equal to 90
percentile and above, they qualified the patient to
ADHD diagnosis. DuPaul suggests that the score
between 80 and 90 percentile shows the possibility of
ADHD diagnosis, while the score between 93 and 98
percentile indicates ADHD diagnosis [18]. In the
Korean researches, in case of using both versions of
ADHDRS-IV – for parents and for teachers, the point
on 90 percentile had a high value confirming clinical
diagnosis of ADHD [19].
According to DSM IV-TR criteria, there were four
ADHD subtypes (the combined subtype, the
predominantly inattentive subtype, the predominantly
hyperactive/impulsive subtype and unspecified
subtype) classified in the examined group.
II. Motor activeness measurement
The motor activity of children was assessed with
the help of actigraph. For 72 hours all the examined
children wore digital recorders of the motor activity on
their wrists - Actiwatch 4 actigraph produced by
Cambridge Neurotechnology Ltd. The motor activity
was calculated from 72 hours, from 2-minute
consecutive measurement periods typical of
chronobiological examinations. The times of daily and
night activity were isolated. The peak time (an hour out
of twenty-four hours) - maximum motor activity
(cosine peak) was determined. The first miniature
electronic digital actigraph in Poland was constructed
in 1987 by the co-author of the research - Tadeusz
Pracki [20].
III. Study group
The examined group was composed of 37 children
at the age from 7 to 14, the average age in the group
13
was 10 years (SD=2.3). The majority of children were
boys -32 and there were only 5 girls. The children were
outpatients. Almost all children lived in a city with
400000 inhabitants. In most cases the reasons for
coming with a child to the Clinic were teachers’
suggestions about the need of diagnosing the
difficulties in school functioning. All children had a
confirmed intellectual norm. The children from a given
group were at the moment of diagnosing, parents’ and
teachers’ psycho-education, and before including into
therapeutic groups and possible pharmacotherapy.
Among 37 children, the diagnosis of the combined
subtype ADHD was the most frequent (86 %), while
there was only 14 % of the predominantly inattentive
subtype.
IV. Statistical analysis
The test results were subject to statistic evaluation.
There was a packet of statistic tests - SPSS for
Windows, version 13.0 used. Test for independent
variables: t-test and Pearson’s correlation coefficient
was used.
RESULTS
According to DSM IV TR, all examined children
met the diagnostic ADHD criteria. The total scoring of
the ADHD RS-IV scale above the 90 percentile (93
and 98), which shows undoubted ADHD diagnosis,
was noted in case of 72 % children, and equal to the
90 percentile or above the 80 percentile in case of 28
%. In 80.5 % of children the scoring of the subscale
concerning the attention deficit was over the 90
percentile. The score of the subscale of
hyperactivity/impulsiveness in 66.6 % of the group
corresponded to 93 or 98 percentiles. The average
intensity of scoring in the ADHD-RS questionnaire
form for parents was 37.3 points (SD= 10.6), minimum
18 points, and the maximum scoring amounted to 53
points. The average intensity of the sum of the item
scorings concerning the attention deficit symptoms in
the group was 22 points (SD= 8.0), and the average
intensity of items concerning hyperactivity and
impulsiveness amounted to19.9 points (SD= 9.1). The
average intensity of scoring in the ADHD RS-IV
questionnaire form was significantly higher in the
group of children with the combined subtype of ADHD
than in the group of children with the majority of
attention deficit symptoms (table I). The average
intensity of ADHD symptoms was similar in the group
14
of younger children (below 10) in comparison to the
group of older children (table I). There was no
difference in the intensity of average scoring of the
ADHD RS-IV scale at boys in comparison to girls
observed (table I).
Table I. Intensification of ADHD symptoms depending on the
sub-type of the disorder, sex and age
ADHD RS-IV
points
Mean
SD
Subtype
Combined
Inattentive
Age <10 years
Age >10 years
Boys
Girls
39.6
9.1
22.6
38.3
36.7
36.8
40.8
8.4
8.3
12.1
11.1
6.3
t
df
P
3.93
35
0.000*
35
0.651
35
0.446
0.457
0.771
Table II. Average results of activity measurement by means
of actigraph at children with ADHD diagnosis
taking into account the ADHD sub-type
Whole group
SD
98.3
148.5
9.8
17.4
1.4
ADHD subtype
Inattentive
Mean
SD
139.2
124.0
203.6
185.5
11.7
5.6
21.2
13.7
12.9
1.6
Boys
Mean
146.6
206.9
12.6
25.5
13.7
SD
102
154.4
10.4
17.9
1.4
Girls
Mean
138.4
203.4
8.5
29.1
14.2
SD
78.5
117.8
4.6
15.1
1.1
Difference
P
0.866
0.961
0.396
0.675
0.462
Independent samples t-test
Average intensity of attention deficit was similar in
case of boys (22.1points) and girls (21 points)
(P=0.764); the intensity of hyperactivity and
impulsiveness in case of boys (19.8 points) and girls
(19.8)(P=0.446; independent - sample test) was also
similar.
No difference in the activity measured by means of
hand moves measurement was observed between the
group of children with recognized ADHD of combined
sub-type and the group of children with recognized
ADHD predominantly inattentive (table II). Between
the ADHD sub-types there were no differences in the
results of average 3-day activity, daily and night
activity and in the relation of daily to night activity and
cosine peak activity.
Mean
145.5
206.5
12.0
25.9
13.9
Measurement
by actigraph
activity
average
daily
night
daily/night
cosine peak
Difference
Independent samples t-test, *- significant difference
Actigraphic
measurement
activity
average
daily
night
daily/night
cosine peak
Table III. Average results of activity measurement depending
on sex
ADHD subtype
Combined
Mean
SD
152.2
96.3
214.2
146.0
12.2
11.1
28.1
18.5
14.1
1.3
Difference
P
0.767
0.874
0.911
0.371
0.075
Independent samples t test
Average results of the boys’ and the girls’ activity
measurement did not differ (table III).
No differences between the intensity of average
activity, daily activity and night activity were noticed
in the group of younger children in comparison to the
group of older children (below and over 10)(table IV).
Table IV. Average values of activity in the group of younger
and older children
Measurement
Age
with actigraph
< 10 years
Activity
Mean
SD
Average
170.5
122
Daily
249.7
178
Night
11.9
11.2
Daily/night
28.3
14.5
Cosine peak
14.0
0.88
Age
>= 10 years
Mean
SD
127.6
75
175.6
117
12.1
9.0
24.3
19.4
13.7
1.7
Difference
P
0.201
0.142
0.946
0.507
0.566
Also the results of the objective measurement of the
24-hour motor activity (P= 0.499), daily activity (P=
0.329) and night activity (P= 0.659) did not
considerably correlate with age (Pearson correlation).
A The intensification of the total score of the ADHD
RS-IV questionnaire for parents did not correlate with
the intensification of hand moves measured by
actigraph (table V). The considerable positive
correlation was observed between the intensification of
attention deficits evaluated in the middle of the ADHD
RS-IV questionnaire for parents and the increase in the
value of cosine peak (table V). The cosine peak value
in the actigraphic measurement shows the time of
twenty-four hour peak activity.
The scorings of items evaluating hyperactivity and
impulsiveness did not correlate with the results of hand
moves during three days of daily and night activity or
the measurement of cosine peak (table V).
The correlations between the intensification of
particular symptoms evaluated in 18 items of the
ADHD RS-IV questionnaire and the average twentyfour hour, daily, and night activity, the relation of the
daily activity to night-time activity and cosine peak
activity were studied. No significant correlation
between the results of the activity measurement and the
intensity of particular ADHD symptoms was found.
No significant correlation between the results of
objective movement measurement and items
concerning hyperactivity in relation to the symptoms of
attention disorders was noted (table VI).
No difference in average measurements of 24-hour
activity, daily activity or night activity at children
having the total scores gained in ADHD RS-IV scale
over the 93 percentile, or in sub-scale concerning
attention deficit as well as in the subscale describing
hyperactivity was noted (table VII). The intensification
of symptoms in ADHD RS-IV scale over 93 percentile
is connected with a reliable disorder diagnosis.
Table V. The correlation between activity and the
intensification of all ADHD symptoms, symptoms
of hyperactivity and symptoms of attention
disorders
Actigraphic
measurement
average activity
daily
night
daily.night
cosine peak
ADHD RS
ADHD RS
Attention deficit Hyperactivity/impulsiveness
items
items
r
P
r
P
-0.052
0.765
0.210
0.220
-0.091
0.596
0.192
0.261
0.158
0.359
0.119
0.491
-0.144
0.402
-0.021
0.902
0.349
0.057*
0.211
0.216
ADHD RS-IV
r
-0.075
-0.120
0.071
-0.087
0.311
P
0.665
0.487
0.681
0.616
0.065
Pearson correlation test; r- correlation coefficient; * relevance on the
0.05 level
Table VI. The correlation between the intensity of particular
symptoms of ADHD and the results of movement
measurement by actigraph
Number
of Item
ADHD
RS-IV
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
average
72-hour activity
r
-0.080
-0.12
0.020
-0.081
-0.031
-0.101
-0.120
-0.287
-0.157
-0.142
-0.060
-0.001
-0.031
-0.080
-0.120
0.119
-0.024
P
0.643
0.487
0.909
0.637
0.858
0.560
0.487
0.090
0.361
0.409
0.727
0.997
0.856
0.642
0.487
0.488
0.890
daily activity
r
-0.119
-0.086
0.071
-0.017
-0.086
-0.136
-0.160
0.310
-0.117
-0.164
-0.098
-0.048
-0.030
-0.080
-0.112
0.079
-0.054
P
0.491
0.617
0.682
0.498
0.619
0.428
0.350
0.066
0.498
0.340
0.571
0.783
0.862
0.642
0.514
0.646
0.756
night activity
r
0.014
-0.220
-0.090
-0.024
0.020
-0.115
-0.068
-0.266
-0.145
-0.192
0.065
0.042
0.029
0.121
-0.074
0.066
-0.076
P
0.937
0.197
0.601
0.889
0.906
0.504
0.696
0.116
0.398
0.261
0.707
0.807
0.867
0.481
0.669
0.704
0.661
Pearson correlation test; r- correlation coefficient; uneven
items concern attention deficit, even items concern the
symptoms of hyperactivity/impulsiveness
15
Table VII. The average result of activity measurement in the
group of children with the intensity of scoring
over and below 93 percentile
Total score
Mean
activity
24 hours
Daily
Night
Light/dark
Inattention
Hyperactivity/Impulsivity
<93rd >=93rd
<93rd >=93rd
%ile
%ile
P
%ile
%ile
P
Mean Mean
Mean Mean
(SD)
(SD)
(SD)
(SD)
125.2 153.2 0.452 145.6 145.4 0.996
<93rd
%ile
Mean
(SD)
119.5
>=93rd
%ile
Mean
(SD)
158.4
(105.7) (96.2)
(98.9)
(97.4)
215.3
183.4
(146.8)
(158)
10.04
12.8
(6.4)
(10.9)
25.6
26.1
(18.6)
(17.ł)
Cosine
13.1
14.1
peak
(1.7)
(1.1)
(114.1) (96.3)
0.571
0.456
0.945
0.129
213.8
204.7
(170.2)
(146)
11.11
12.2
(5.8)
(10.6)
20.7
27.2
(10.5)
(18.6)
13.1
14.0
(1.5)
(1.3)
0.887
0.785
0.336
0.167
174.1
(222.6
(147)
(149.3)
12.1
11,9
(6.5)
(11.3)
19.7
29.07
(14.8)
(18.1)
13.5
14.0
(1.9)
(1.0)
P
0.269
0.363
0.964
0.134
0.425
DISCUSSION
Average scoring in the ADHD RS-IV questionnaire
was significantly higher in the group of children with
the mixed subtype of ADHD than in the group of
children with the majority of attention deficit
symptoms. No difference in the activity evaluated with
the help of hand moves measurement between the
group of children with recognized ADHD combined
type and the group of children with recognized ADHD
predominantly inattentive was observed. Dane’s et al.
compared subtypes of ADHD on an objective measure
of activity level (actigraphy) and noted that there were
no significant group differences in activity level in the
morning session. During the afternoon session,
children with ADHD were significantly more active
than controls, but there were no differences between
ADHD subtypes [21].
The results of the measurement of the boys’ and the
girls’ activity did not differ. Due to a gender unbalance
in the study group (a very limited number of females)
it was impossible to determine differences in severity
of activity in girls and boys. According to some
authors, sex may not correlate with an ADHD subtype
[22].
In the actigraphic measurement no difference in the
intensity of physical activity in the group of younger
children in comparison to older kids was observed. In
some works any no correlation of ADHD symptoms
with age or motor dysfunctions was observed [6]. A
significant positive correlation was observed between
the intensification of attention deficit evaluated in the
middle of the ADHD RS-IV questionnaire for parents
and the increase of the cosine peak value, i.e. the time
16
of maximum activity during the measurement. The
later time of the peak of 24-hour activity was, the
bigger the attention deficit was.
The ADHD subtype can have bigger influence on
the course of illness and co-morbidity than the sex or
age of a child [22]. The evaluation of ADHD subtypes
is based on the impression of surroundings (parents,
teachers, doctor). The people evaluating the patient can
see problems resulting more from the attention deficit
or
hyperactivity.
The
objective
actigraphic
measurement shows that the intensification of hand
moves is similar in both subtypes - in children in
whom attention disorders dominate and in those who
above all show motor disturbances. The actigraph
evaluates hand gesticulation which in the examined
group is similar in both subtypes, similar among boys
and girls (males dominated in the group), similarly in
younger and older children. The literature proves that
hyperactivity decreases with age, however the
gesticulation remains on the similar level in case of
children at different ages in the examined group. The
excessive gesticulation can disturb the performance of
complex activities (such as for example driving a car).
CONCLUSIONS
The results of the actigraphic measurement did not
correlate with the evaluation of activity intensity
according to parents.
In the studied group no differences in the
movement intensity between the combined sub-type
and the attention deficit sub-type of ADHD were
observed.
More serious attention disorders occurred in
children who in later hours (of 24-hours) had the
maximum activity intensity.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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[email protected]
tel.: 48 (52) 5854270
fax: 48 52 5853766
17
Jerzy Eksterowicz, Marek Napierała
MORPHOLOGICAL PARAMETERS OF PHYSICAL EDUCATION STUDENTS
IN THE YEARS 2006-2010
PARAMETRY MORFOLOGICZNE STUDENTÓW WYCHOWANIA FIZYCZNEGO
W LATACH 2006-2010
The Institute of Physical Education, Kazimierz Wielki University in Bydgoszcz
Head: dr hab. Mariusz Zasada, prof. nadzw. UKW
Summary
The body construction of an adult person depends on a
variety of factors. First of all, it is determined genetically – at
the moment of conception every human organism receives a
set of an equal amount of chromosomes from the father and
the mother with genes that convey "instructions" about the
developmental features of the system. The human growth is
not a uniform process. It is characterised by a great diversity
in terms of qualitative and quantitative changes and the
intensity level of the processes in time. Ontogenetic
development of a man is an ordered system of some specific
developmental changes leading to the formation of human
beings adapted to living in particular conditions and able to
extend the existence of mankind. The direction of these
processes is determined by inherited factors, surrounding
environment and so-called behaviourism, which can be
described as the behaviour of an individual in particular
conditions.
The aim of this study was to determine the selected body
parameters of 279 first-year students (179 men and 100
women) of physical education (stationary studies) at the
Kazimierz Wielki University in Bydgoszcz. The research of
morphological characteristics was conducted in the period of
2006-2010 and its results were presented in tables. They
document the changes in morphological construction.
Streszczenie
Budowa ciała dorosłego człowieka zależy od wielu
czynników. Przede wszystkim uwarunkowana jest
genetycznie, gdyż organizm w momencie poczęcia otrzymuje
w równym stopniu od ojca i matki zestaw chromosomów, w
których rozmieszczone są geny zawierające „instrukcje” o
właściwościach rozwojowych ustroju. Rozwój konstytucjonalny człowieka nie jest procesem jednostajnym.
Charakteryzuje go duża różnorodność pod względem zmian
ilościowych i jakościowych oraz stopnia natężenia
zachodzących procesów w czasie. Ontogenetyczny rozwój
człowieka polega na uporządkowanym systemie przebiegu
pewnych specyficznych zmian rozwojowych zmierzających
do ukształtowania się osobników przystosowanych do życia
w danych warunkach i zdolnych do przedłużenia istnienia
gatunku. Kierunek tych procesów jest określony czynnikami
dziedziczonymi, warunkami otaczającego środowiska oraz
tzw. behawioryzmem czyli postępowaniem, zachowaniem się
samego osobnika w danych warunkach.
Celem niniejszych badań było określenie wybranych
parametrów ciała 279 studentów I roku (179 mężczyzn i 100
kobiet) z kierunku wychowania fizycznego studiów
stacjonarnych Uniwersytetu Kazimierza Wielkiego w
Bydgoszczy. Badania cech morfologicznych przeprowadzono od 2006-2010 roku, a wyniki przedstawiono
tabelarycznie.
Dokumentują
one
zmiany
budowy
morfologicznej.
Key words: morphological construction, physical education students
Słowa kluczowe: budowa morfologiczna, studenci wychowania fizycznego
20
INTRODUCTION
The body construction of an adult person depends
on a variety of factors. First of all, it is determined
genetically – at the moment of conception every
human organism receives a set of an equal amount of
chromosomes from the father and the mother with
genes that convey "instructions" about the
development features of the system. The contained
information shapes the growth of an individual; the
genetic factors and environmental conditions influence
the development in a comparable degree – initially, in
the prenatal life, when the external environment for the
developing embryo (and then foetus) is the uterus of
the mother, and then during the post prenatal life as
widely understood environmental conditions.
Moreover, there is a third factor affecting the
development of an individual, which is called
behaviourism – it can be described as a widely
understood behaviour of an individual. Its importance
for the organism development grows over time, as well
as with acquired experiences and knowledge. In the
opinion of many researchers, these three factors shape
all somatic, functional and mental features of people
(Eksterowicz, Napierała 2007; Wolański 2006;
Malinowski 1994).
Looking at the sizes of selected morphological
features among physical education students; both
retardation and excessive development of certain
morphological values in comparison with the average
values in the population can be observed. The
knowledge obtained from these researches allows
selecting appropriate didactic resources to support
students efforts aimed at maintaining good health, as
well as specifying risky areas in the somatic
construction from the perspective of maintaining good
health of an individual and the whole population
(obesity, lipohyperplasia, proneness to anorexia, etc.).
The aim of this research was to specify the size of
selected morphological features and body composition
of physical education students at the Kazimierz Wielki
University in Bydgoszcz in the period of last five
years, separately for each year, and to compare these
parameters both in a one-year and a five-year scale.
MATERIAL AND METHODS
The researches were carried out among 279
stationary students of physical education (179 men and
100 women) aged 19 - 26 years at the Kazimierz
Wielki University in Bydgoszcz in the period from
2006 to 2010. There was one research per year, carried
out in July during the summer sports camp. All
students were examined according to the following
anthropometric measurements (cm): body height (V B), arm length (a - r), forearm length (r - sty), upper
limb length (a - da III), leg length (tro - B), foot length
(ap - pte), shoulder width (a - a), hip width (ic - ic),
pelvis width (is - is), arm width (mm - mu), hand width
(mr - mu), foot width (mtt - mtf). Moreover, the
circumferences of the following body parts were
measured (cm): chest at full inspiration and expiration,
waist, flexed and unflexed arm, thigh and calf. The
proper body mass was specified as well (kg). In
addition to that, the thickness of three skinfolds were
measured (mm), which are located: over the triceps
muscle (TSF) (triceps skinfold), vertical skinfold,
under the lower angle of the shoulder blades (SCSF)
(subscapular skinfold), horizontal skinfold, and over
the iliac crest (SISF) (suprailiac skinfold), oblique
skinfold. Based on those measurements, the following
indicators were calculated: BMI (Body Mass Index,
kg/m2), AMC (Arm Muscle Circumference), WHR
(Waist to Hip Ratio), body fat mass (FM) (kg), percent
body fat (FM) (%) and lean body mass in kilograms
and percentage (FFM) (kg), (FFM) (%) (Drozdowski
1998, 2002).
For the indices interpretation the following
elements were calculated:
- BMI (for women and men): below 19.0 – body mass
deficit; between 19.0 and 25.0 – proper body mass;
from 25.1 to 29.9 – overweight; over 30.0 – obesity;
- it was assumed that the border value of the WHR
index, over which the obesity is observed, is: 0.95 for
men and 0.85 for women;
- the criteria of AMC evaluation: the degree of
aluminous nutrition was calculated according to the
formula: arm circumference – (3.14 x the thickness of
the dermal-aliphatic skinfold over the triceps), the
following values were assumed: good aluminous
nutrition – men > 22.8, women > 20.9; slight
malnutrition – men: 22.7-20.2, women: 20.8-18.6;
moderate malnutrition – men: 20,1-17,7, women: 18,516,2; heavy malnutrition – men < 17.7, women < 16.2;
- the Rohrer index, specifying it with the Curtis Key
and the Kretschmer characteristics: x – 1.27
leptosomatic type, 1.28 - 1.49 athletic type and 1.50 –
x pyknic type;
- the Pignet rate and the index values were ranked on
the basis of Polish materials and sources from the
Morphological parameters of physical education students in the years 2006-2010
researches of candidates to the physical education
studies (Drozdowski 2002, p. 118).
The calculations were carried out according to the
formula: I = the body height – (mass + chest
circumference). The following criteria were assumed:
Criteria (Kryteria)
Very strong construction (Budowa
bardzo mocna)
Strong construction (Budowa mocna)
Medium construction (Budowa
średnia)
Weak construction (Budowa słaba)
Very weak construction (Budowa
bardzo słaba)
men
(mężczyźni)
women
(kobiety)
x - 7.7
x - 18.8
7.8 - 12.5
18.9 - 22.5
12.6 - 22.1
22.6 - 30.0
22.2 - 26,9
30.1 - 33.8
27 – x
33.9 - x
- torso index: I = (torso length : body height) x body height
Criteria (Kryteria)
Long torso (Długi tułów)
Medium torso (Średni tułów)
Short torso (Krótki tułów)
men
(mężczyźni)
31.3 - x
29.6 - 31.2
x - 29.5
women
(kobiety)
30.8 – x
29.5 - 30.7
x . 29.4
- shoulder index: I = (shoulder width : torso length) x 100
Criteria (Kryteria)
Narrow shoulders (Barki wąskie)
Medium shoulders (Barki
średnioszerokie)
Broad shoulders (Barki szerokie)
men
(mężczyźni)
x - 70.1
women
(kobiety)
x - 72.6
70.2 - 76.5
72.7 - 77.2
76.6 - x
77.3 - x
- pelvic index: I = (pelvis width : shoulders width) x 100
Criteria (Kryteria)
Narrow pelvis (Miednica wąska)
Medium pelvis (Miednica
średnioszeroka)
Broad pelvis (Miednica szeroka)
men
(mężczyźni)
x - 71.5
women
(kobiety)
x - 79.3
71.6 - 76.1
79.4 - 84.5
76.2 - x
84.6 - x
- arm musculature index: I = (circumference : length) x 100 –
Men: slender arm > 77.1, stocky arm < 77.2, women: slender
arm > 76.0, stocky arm < 76.1 (Drozdowski 1998, 2002).
The measurements were made using the portable
medical scale – model: TANITA BF 662M and the
anthropometric
tool-kit
(anthropometer,
anthropometric tape, skinfolds meter) produced by a
Swiss company – Siber Hegner & Co. Ltd.
(Drozdowski 1998, 2002).
From these measurements the mean values and
standard deviations were calculated and the statistical
inference was conducted by comparing the tested
parameters.
TEST RESULTS ANALYSIS
This paper is of diagnostic nature, so the researches
were focusing on solving problems on the example of
specified population and in the particular time horizon.
Hence, no research hypothesis was formulated that
would go beyond the factual materials. The
assumptions about the relative somatic homogeneity of
respondents were made, which allows interpreting
possible developmental differences in the light of the
environmental variety.
Table
21
I.
Comparison of values of morphological
measurements in men between 2006 and 2010
Tabela I. Charakterystyka somatyczna (wielkości średnie i
odchylenia standardowe) studentów (mężczyzn)
na przestrzeni lat 2006=2010
Tested feature
2006
N=41
X
Body height
(Wysokość ciała)
(cm)
Body mass (Masa
ciała) (kg)
Subscapular
skinfold (Fałd pod
łopatką) (mm)
Skinfold over
triceps (Fałd nad
tricepsem) (mm)
Suprailiac skinfold
(Fałd nad biodrem)
(mm)
Skinfolds in total
(Suma fałdów)
(mm)
Arm length (Dł.
ramienia) (a-r)
Forearm length
(Dł. przedramienia)
(r-sty)
Upper limb length
(Dł. kończyny
górnej) (a-daIII)
Leg length (Dł.
kończyny dolnej)
(tro-B)
Foot length (Dł.
stopy) (pte-ap)
Shoulders width
(Szer. barków) (aa)
Hips width (Szer.
bioder) (ic-ic)
Pelvis width (Szer.
miednicy) (is-is)
Arm width (Szer.
ręki) (mm-mu)
Palm width (Szer.
dłoni) (mr-mu)
Foot width (Szer.
stopy) (mtt-mtf)
Chest
circumference
(inspiration) (Ob.
klatki piersiowej
wdech) (cm)
Chest
circumference
(expiration) (Ob.
klatki piersiowej
wydech) (cm)
Waist
circumference (Ob.
pasa) (cm)
Hips circumference
(Ob. bioder) (cm)
Arm circumference
(flexed) (Ob.
ramienia
napiętego) (cm)
Arm circumference
(unflexed) (Ob.
ramienia bez
napięcia) (cm)
Thigh
circumference (Ob.
uda)
Calf circumference
(Ob. łydki)
Torso length (Dł.
tułowia) (tro-a)
2007
N=37
S
X
S
2008
N=32
X
S
2009
N=43
X
2010
N=26
S
X
S
180.58 6.07 180.5 7.79 181.0 8.01 `180,0 5,0 181.4 6.01
76,31 8.10 76.3 8.43 76.7 9.70 77.6
9.6 76.7 7.91
9,91 2.51 10.38 2.08 10.81 2.61 10.50 2.60 10.41 1.91
6.51 2.92 8.08 2.77 9.0 2.01 10.3
2.7 8.62 2.32
8.41 3.02 9.37 4.08 10.5 3.3
10.7
2.9 9.11 2.32
27.5 6.10 27.83 5.34 30.3 6.70 31.5
7.6 28.01 5.34
30.48 2.87 30.10 3.13 32.51 2.51 32.40 2.78 32.52 1.63
25.85 1.62 26.75 2.05 27.43 1.86 25.86 2.49 27.84 2.33
79.25 3.04 81.20 5.76 79.45 3.95 79.17 4.72 80.18 3.86
90.86 3.88 96.00 5.68 91.88 3.89 91.08 4.72 90.77 4.69
26.85 2.78 27.02 3.05 27.15 1.51 26.46 1.18 26.81 1.34
40.40 2.26 43.15 2.05 43.07 1.89 43.19 2.48 42.43 2.14
29.05 1.34 30.95 1.88 30.59 2.19 31.08 2.32 29.78 1.94
23.36 1.59 24.87 1.41 24.23 2.29 24.88 1.96 24.02 1.41
10.77 0.99 10.92 1.12 10.93 0.64 10.75 0.64 11.14 0.63
8.77 0.54 8.86 0.61 8.78 0.64 8.57 0.55 8.62 0.42
10.17 0.39 10.32 0.42 10.14 0.67 10.43 0.50 10.44 0.67
101.9 5.82 96.5 5.92 97.31 4.99 100.61 6.31 97.04 4.30
94.08 5.33 90.55 6.02 91.82 5.53 93.62 3.03 91.15 3.90
80.96 3.54 81.2 5.76 78.02 5.32 82.69 6.78 79.35 4.62
93.37 6.03 96.0 5.68 95.53 6.15 96.14 4.79 93.85 5.70
34.04 2.63 30.1 3.13 32.78 2.28 33.74 3.28 33.40 1.95
30.04 1.61 29.05 0.65 29.93 2.67 29.85 2.83 29.74 1.70
55.60 3.63 54.80 3.05 52.93 3.77 56.21 3.83 55.57 3.60
37.42 2.11 36.95 3.08 36.78 2.82 38.22 2.45 37.30 2.45
56.02 3.36 56.39 3.57 56.71 3.12 57.01 3.33 57.10 2.97
N – numbers, X – average value, S – standard variation
(source: own study) (źródło: opracowanie własne)
This assumption is a reasonable condition due to
the similar sizes of the researched individuals that
occur both within a one-year and a five-year scale.
22
Table II. Comparison of values of morphological measurements in women between 2006 and 2010
Tabela II. Charakterystyka somatyczna (wielkości średnie i
odchylenia standardowe) studentek (kobiet) na
przestrzeni lat 2006 – 2010
Tested feature
2006
N=25
X
Body height
(Wysokość
169.83
ciała) (cm)
Body mass
(Masa ciała)
63.82
(kg)
Subscapular
skinfold (Fałd 12.10
pod łopatką)
(mm)
Skinfold over
triceps (Fałd
nad tricepsem) 11.80
(mm)
Suprailiac
skinfold (Fałd 12.40
nad biodrem)
(mm)
Skinfolds in
total (Suma
37.30
fałdów) (mm)
Arm length
(Dł. ramienia) 28.25
(a-r)
Forearm length
(Dł.
przedramienia) 26.00
(r-sty)
Upper limb
length (Dł.
kończyny
71.38
górnej) (adaIII)
Leg length (Dł.
kończyny
82.98
dolnej) (tro-B)
Foot length
(Dł. stopy)
24.68
(pte-ap)
Shoulders
width (Szer.
36.49
barków) (a-a)
Hips width
(Szer. bioder) 29.39
(ic-ic)
Pelvis width
(Szer.
miednicy) (is- 23.78
is)
Arm width
(Szer. ręki)
9.65
(mm-mu)
Palm width
(Szer. dłoni)
7.94
(mr-mu)
Foot width
(Szer. stopy)
9.32
(mtt-mtf)
Chest
circumference
(inspiration)
90.44
(Ob. klatki
piersiowej –
wdech) (cm)
Chest
circumference
(expiration)
89.02
(Ob. klatki
piersiowej –
wydech) (cm)
Waist
circumference 72.59
(Ob. pasa) (cm)
Hips
circumference 95.60
(Ob. bioder)
(cm)
Arm
circumference
(flexed) (Ob.
28.61
ramienia
napiętego)
(cm)
Arm
circumference
(unflexed) (Ob. 26.06
ramienia bez
napięcia) (cm)
Thigh
circumference 56.38
(Ob. uda)
Calf
circumference 38.71
(Ob. łydki)
Torso length
(Dł. tułowia)
52.01
(tro-a)
S
2007
N=18
S
X
2008
N=18
X
S
2009
N=21
S
X
2010
N=18
S
X
4.80 170.0 4.97 170.01 7.02 169.0 6.0 167.4 8.02
7.40 63.7 6.66 64.3 6.36 63.0 7.97 65.72 6.52
4.00 12.78 4.33 14.20 5.55 13.75 6.1 11.81 2.95
2.90 14.34 4.28 12.9 3.72 15.1 2.76 12.32 2.99
3.30 13.71 4.45 10.21 2.71 12.0 2.82 12.31 3.19
3.50 40.83 5.01 34.21 8.01 39.70 6.11 36.50 7.80
2.25 26.0 2.27 29.04 1.65 32.09 3.47 30.82 2.62
1.30 26.05 1.23 25.65 1.78 23.81 1.99 24.69 1.96
3.95 74.30 4.02 72.48 3.64 74.13 4.24 72.79 3.99
4.75 86.10 5.15 86.85 6.23 85.85 4.94 83.73 6.87
1.20 24.70 1.18 25.19 1.30 24.45 1.37 24.23 1.37
1.33 37.55 1.98 39.61 1.56 38.86 2.65 37.44 2.53
1.75 31.80 2.88 32.62 3.32 30.51 1.95 30.56 1.96
1.74 23.77 1.67 23.97 2.36 24.77 1.92 24.11 1.55
0.81 9.87 0.77 9.59 0.35 9.78 0.49 9.75 0.48
0.19 7.78 0.30 7.79 0.28 7.80 0.37 7.91 0.48
0.20 9.36 0.35 9.35 0.52 9.30 0.45 9.31 0.50
4.59 93.80 4.93 91.81 5.22 93.38 5.17 94.73 4.23
4.24 88.90 4.98 87.66 4.62 88.65 5.78 90.84 4.33
5.23 75.2 6.64 71.57 3.45 76.03 6.50 74.89 6.04
4.45 96.30 5.04 97.11 5.43 94.47 5.82 95.28 4.57
2.15 28.01 1.90 28.35 1.71 28.49 2.31 28.11 1.70
2.03 26.40 1.35 26.76 1.69 26.20 2.39 25.87 1.38
3.74 55.10 4.08 54.70 3.04 53.05 3.66 53.02 2.36
2.08 37.12 2.05 36.68 1.72 36.83 2.73 36.09 1.72
3.22 52.36 3.63 52.45 2.89 52.32 2.77 51.44 2.64
N – numbers, X – average value, S – standard variation
(source: own study) (źródło: opracowanie własne)
The average results of many somatic factors that
were studied in different years do not differ too much
from each other. It may result from the specific
uniformity of the researched group whose members
practise sports from their early childhood and as
students of physical education they still continue to
participate actively in physical activities. Such a
lifestyle causes that they have slim and well-built
bodies, which are desirable in sport (mass or
professional).
The following tables present the somatic
characteristics of the students who took part in the
research. These results may be a material for
comparison for all people who deal with anthropology.
The presented research results in men showed that
the average BMI for all collated years was within
limits for proper body mass. Also the average WHR
demonstrated that there was no example of obesity in
those years. The criteria of AMC evaluation indicated
the medium/good nutrition. The average scores of body
slenderness ratio defined by Rohrer index and
Kretschmer characteristics were within 1.28 - 1.33,
which indicates the athletic types. The Pignet index
values proved that in 2006, 2008 and 2009 men had
strong body construction, while in 2007 and 2001 it
was medium (Table III).
In the years 2006 and 2007, the torso index
demonstrated a medium body length, while in the
remaining years it showed high body length among the
students. The researched group of students had
medium shoulders in 2006, 2007 and 2010, and broad
shoulders in 2008 - 2009. When reading the calculated
average pelvis width, it can be concluded that in all
those years the students had narrow pelvis. In all
researched years the students had stocky arms (Table
III).
Table III. Numerical characteristics of selected somatic
indices of men (source: own study
Tabela III. Charakterystyka liczbowa wybranych wskaźników
somatycznych mężczyzn) (źródło: opracowanie
własne)
Year of BMI WHRAMC Pigneta Rohrera
Torso Shoulder Pelvic
Arm
study (Rok
index
index
index
Index
index
muscle
badań)
(Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik index
Pigneta) Rohrera) tułowia) barków) miednicy) (Wskaźnik
umięśnienia
ramienia)
2006
23.3
2007
23.41
2008
23.40
2009
24.0
2010
23.6
All
23.54
(Wszystkie)
0.85
0.84
0.82
0.86
0.84
27.20
27.50
27.11
26.61
29.46
10.19
13.65
12.48
8.78
13.55
1.30
1.30
1.28
1.33
1.31
31.02
31.24
31.33
31.56
31.70
72.12
76.50
77.48
76.04
74.20
57.82
57.63
56.26
57.61
56.61
98.56
96.51
92.06
92.13
91.40
0.84 27.58
11.73
1.30
31.37
75.27
57.19
94.13
The BMI values showed that during the research
women had proper body mass. There was also only a
small number of obese women and this is demonstrated
by the WHR. When it comes to the AMC index, all
researched women had it over 20.9, which indicates
good protein nutrition. When determining the average
values of the slenderness ratio, it can be stated that in
all researched years both women and men represented
the athletic type. During the whole research, women
were characterized by a very strong body construction
(specified by the Pignet index). In the years 2007, 2008
and 2009 the body length index demonstrated that the
researched women had long torso, while in the
remaining years of the research they had medium body
length. Narrow shoulders were observed among the
researched women in 2006 and 2007, while in the
remaining years of the research they were medium. In
all observations, the researched women had narrow
pelvises (pelvic index) and stocky arms (Table IV).
Table IV. Numerical characteristics of selected somatic
indices of women (source: own study)
Tabela IV. Charakterystyki liczbowe wybranych wskaźników
somatycznych kobiet (źródło: opracowanie
własne)
Year of
study
(Rok
badań)
was observed in 2007 – 74.60%. The recommended
average value of FFM is 75% (Table VI).
Table V. The selected morphological body sizes of men
(source: own study)
Tabela V. Wybrane wielkości morfologiczne ciała mężczyzn
(źródło: opracowanie własne)
Year of
study
(Rok
badań)
The average values
Body fat
Lean body mass
and standard deviation
(Tkanka tłuszczowa) (Beztłuszczowa masa ciała)
(Wartości średnie
(kg)
(%)
(kg)
(%)
i odchylenie standardowe)
2006
X
9.21
12.79
67.10
s
2.58
3.79
6.66
3.79
2007
X
10.64
13.7
63.02
85.6
s
2.87
2.72
5.46
2.99
2008
X
12.23
15.73
64.48
84.27
s
3.62
3.14
7.17
3.14
2009
X
12.76
16.26
64.63
83.74
2010
All
(Wszystkie)
22.90
21.50
22.81
21.45
25.43
16.99
17.43
18.04
17.35
10.84
1.30
1.30
1.31
1.31
1.40
30.62
30.80
30.85
30.96
30.73
70.16
71.69
75.5
74.26
72.78
65.17
63.30
60.52
63.74
64.39
ramienia)
92.25
101.53
92.15
81.64
83.93
0.77 22.82
16.13
1.32
30.79
72.88
63.42
90.3
0.76
0.78
0.74
0.81
0.78
The presented average test results among men,
including in particular the body mass, body fat and
lean body mass in kilograms and percentages prove
that these values were within the recommended limits,
e.g. body fat (BF) from 12.79% in 2006 to 16.26% in
2009. Similar observation was made concerning the
lean body mass (FFM), which average value was the
lowest in 2009 – 83.74% and the highest in 2006,
87.20% (Table V).
The researches carried out among women proved
that the smallest average value of body fat (BF) was
noted in 2007 – 25.41%, while the highest in 2009 –
30.49%. The latter parameters slightly exceed the
normative and recommended standards of body fat for
women (25%).
Lean body mass (FFM) was on average the lowest
in 2009 amounting to 69.51%, while the highest FFM
87.20
s
4.09
3.13
6.05
3.13
X
11.41
14.74
65.27
85.26
s
2.89
2.60
5.85
2.60
X
11.25
14.65
64.90
85.21
s
3.21
3.08
6.24
3.13
Table VI. The selected morphological body sizes of women
(source: own study)
Tabela VI. Wybrane wielkości morfologiczne ciała kobiet
(źródło: opracowanie własne)
The average
values and
Year of
standard
BMI WHR AMC Pigneta Rohrera
Torso Shoulder Pelvic
Arm
study (Rok
deviation
index
index
index
Index
index
muscle
badań)
(Wartości średnie
(Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik index
i odchylenie
Pigneta) Rohrera) tułowia) barków) miednicy) (Wskaźnik
standardowe)
umięśnienia
2006
21.32
2007
22.0
2008
22.3
2009
22.2
2010
23.9
All
22.34
(Wszystkie)
23
Body fat
(Tkanka
tłuszczowa)
Lean body mass
Beztłuszczowa masa ciała)
(kg)
(%)
(kg)
(%)
19.21
3.94
16.30
29.45
3.44
25.41
44.6
4.08
47.44
70.55
3.43
74.60
2006
X
2007
X
σ
3.44
3.50
4.28
3.52
2008
X
2009
X
18.34
3.25
19.30
28.38
2.80
30.49
45.93
3.66
43.63
71.62
2.80
69.51
σ
3.27
1.96
5.0
1.96
2010
X
All
(Wszystkie)
X
19.23
3.01
18.48
3.38
29.23
3.08
28.59
2.96
46.46
4.78
45.61
4.36
70.77
3.08
71.41
2.96
σ
σ
σ
σ
CONCLUSIONS
The morphological construction differs and is
unique for individuals. We can talk about the
differentiation of body constitution. In the literature,
there are divergent views on the characteristics of the
human body (Roy, Shephard 1987; Andreasi and
others 2010). Drozdowski (2002) points out that even
the terminology is not sufficiently uniform, because we
talk about a somatic, morphological and
morfofunctional body construction or the body
constitution of a man. The typology of the human body
24
could be understood as all characteristics of an
organism that are closely related to each other,
interacting and conditioning its structural and
functional unity (Drozdowski 2002, p. 94).
The phenomenon of human diversification in terms
of size and proportions of various body parts as well as
the types of reaction to environmental factors has been
known for a long time (Wolański 2006).
The differences between human forms appeared in
relatively early stages of their evolution. Various
groups of people who occupied particular areas lived
probably in very diverse environments causing the
morfofunctional characteristics to adopt to the
surrounding environmental conditions. It can be
observed that the construction of the human body is an
expression of adaptation to diverse natural
environment. Numerous studies show the diversity
between human groups, which can be divided for the
intercontinental and the intracontinental ones, is
associated with the formation of human races. The
papers of many scientists point out that the formation
process of various populations is influenced by their
geographical location (Napierała 1999, 2008).
Regional and environmental differences in terms of
body composition can be observed also on the territory
of Poland, although it is an area inhabited by a very
homogeneous society. One of the very distinctive
characteristics of the human body is its height. It is of
polygenic nature (shaped by multiple genes), therefore
the offspring may deviate in various directions from
the value of particular characteristics of their parents.
The final values for these characteristic show a high
dependence on environmental conditions, especially on
the quality of nutrition during the progressive
development (Malinowski 1994). The researches
carried out in Poland also demonstrate differences in
height, depending on the education and social position.
Similar results were observed in longitudinal studies in
the Bydgoszcz area (Napierała, 1999).
The results presented in this paper concerning the
basic morphological characteristics of physical
education students during a 5-year period do not show
significant changes in the given body constitution
elements. The specificity of this particular field of
interest gathers at the physical education studies a
number of young people with past or present interest in
sports. People practising sport differ from those who
do not exercise at all in terms of their constitutional
body construction as it is influenced by systematic
physical exercises, the selection of sport disciplines
and maintaining a desired and well-muscled athletic
body.
The research results bring the following
conclusions:
1. The research carried out among women and men
showed that the average BMI in all collated years is
within limits of proper body mass.
2. The WHR demonstrated that there was no obesity
in any year among the researched students; the
AMC evaluation criteria showed good nutrition.
3. The average results of the body slenderness among
men and women defined by the Rohrer index and
the Kretschmer characteristics indicated the athletic
types.
4. The Pignet index defined the body composition as
medium and strong in men, and as very strong in
women in all researched years.
5. The researched students (men and women) had
medium or long torso. The shoulders were medium
and wide in men, and medium and narrow in
women. In all years of the research both groups had
narrow types of pelvis and stout arms.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
Drozdowski Z. (1998), Antropometria w wychowaniu
fizycznym, Podręczniki AWF, Poznań nr 24
Drozdowski Z. (2002), Antropologia dla nauczycieli
wychowania fizycznego, AWF, Poznań
Malinowski A. (1994), Wstęp do antropologii i
ekologii człowieka, Wydawnictwo Uniwersytetu
Łódzkiego
Napierała M. (2008), Środowiskowe uwarunkowania
somatyczne i motoryczne a wiek rozwojowy dzieci i
młodzieży (na przykładzie województwa kujawsko –
pomorskiego),
Bydgoszcz,
Wydawnictwo
Uniwersytetu Kazimierza Wielkiego w Bydgoszczy
Napierała M. (1999), Rozwój fizyczny i motoryczny
dzieci wiejskich i miejskich w województwie kujawsko
– pomorskim, [w:] Uwarunkowania rozwoju
fizycznego dzieci i młodzieży wiejskiej, (red.) J.
Zagórski i in., Instytut Wychowania Fizycznego i
Sportu, Biała Podlaska, Rocznik Naukowy Tom VI
Suplement nr 1
Eksterowicz J., Napierała M., (2007), Zmiany
morfologiczne studentów z kierunku wychowania
fizycznego w trakcie letniego obozu sportowego,
Medical and Biological Sciences, Tom21/3,
Bydgoszcz, pp. 49-52.
Roy J., Shephard M. D., (1987), Exercise physiology.
BC Decker INC, Toronto, Philadelphia.
Andreasi V, Michelin E, Rinaldi AE, Burini RC,
(2010), Physical fitness and associations with
anthropometric measurements in 7 to 15-year-older
9.
school children. Jornal De Pediatria [J Pediatr (Rio J)],
Nov-Dec; Vol. 86 (6), pp. 497-502.
Wolański N. (2006), Rozwój biologiczny człowieka,
PZWL, Warszawa.
Jerzy Eksterowicz
Uniwersytet Kazimierza Wielkiego w Bydgoszczy
Instytut Kultury Fizycznej
Bydgoszcz ul. Ogińskiego 16
tel.: 601 63 91 81
25
Mariusz Klimczyk
SOMATIC BUILD VS SPORTS RESULTS OF POLE VAULT CONTESTANTS AGED 16-17
BUDOWA SOMATYCZNA VS WYNIKI SPORTOWE ZAWODNIKÓW SKACZĄCYCH O TYCZCE
W WIEKU 16-17 LAT
Institute of Physical Culture, Kazimierz Wielki University in Bydgoszcz
Headmaster Senior Doctor Mariusz Zasada
Summary
Experimental researches conducted between 2005 and
2009 included 20 sportsmen aged 16-17 pole vaulting at the
sports club ‘Zawisza’ Bydgoszcz, TS ‘Olimpia’ Poznań, pole
vault centre Gdańsk, ‘Gwardia’ Piła, ‘Śląsk’ Wrocaław.
The aim of the thesis was to define the relation between
somatic parameters and sports results of pole vaulters of
junior category (aged 16-17).
The following methods and research tools were used in
the thesis: evaluation of physical development, testing
physical dexterity, recording sports results and statistical
description.
The analysis of the research showed great diversity of
somatic features and physical dexterity results of particular
athletes.
The relation which occurs between sports result of the
pole vault and the body height (0.66), the length of upper
limb and lower limb (0.64, 0.54, respectively) are interesting.
On the basis of the above analysis with regard to, among
many, small number of the examined, it is not possible to draw
far-reaching conclusions concerning the relation which occurs
between somatic build and physical dexterity attempts and
pole vault result.
Streszczenie
Badania eksperymentalne prowadzono w latach 20052009, którymi objęto 20 sportowców w wieku 16-17 lat
uprawiających skok o tyczce w klubie sportowym „Zawisza”
Bydgoszcz, TS „Olimpia” Poznań, Ośrodek skoku o tyczce
Gdańsk, „Gwardia” Piła, „Śląsk” Wrocław.
Celem pracy było określenie zależności między
parametrami somatycznymi, a wynikiem sportowym w skoku
o tyczce, tyczkarzy w kategorii junior młodszy (16-17 lat).
W pracy wykorzystano następujące metody i narzędzia
badań: ocena rozwoju fizycznego, testowanie sprawności
fizycznej, rejestracja wyników sportowych i metody
statystycznego opracowania.
Key words: somatic features, sports result, correlation
Słowa kluczowe: cechy somatyczne, wynik sportowy, korelacja
Analiza badań wykazała duże zróżnicowanie cech
somatycznych i wyników sprawności fizycznej u
poszczególnych ćwiczących.
Interesująco przedstawia się zależność, jaka występuje
pomiędzy wynikiem sportowym skoku o tyczce, a
wysokością ciała (0,66), długością kończyny górnej i dolnej
(odpowiednio 0,64, 0,54).
Na podstawie powyżej przeprowadzonej analizy ze
względu na między innymi małą liczbę badanych nie można
wysunąć daleko idące wnioski dotyczące relacji, jaka
zachodzi pomiędzy budową somatyczną, a próbami
sprawności fizycznej i wynikiem w skoku o tyczce.
28
Mariusz Klimczyk
INTRODUCTION
METHODS OF RESEARCH
The history of men's pole vault shows that the
biggest sports achievements of this spectacular and
complex athletic sports event are achieved by the
contestants of diverse somatic build [1]. The
achievement of the best results by the contestant
depends, among many, on: level, physical dexterity,
somatic build, technical skills and other conditions [2].
Numerous publications describe research results which
show that the body type of every human being is their
biological, to a high degree, determined genetically
feature, i.e. the feature with a great immutability in the
period of life [3, 4, 5, 6]. That is why an accurate
choice in the aspect of children's body build to the
proper sports events contributes to beneficial prognosis
that these individuals will meet, in the future, the
somatic requirements making sports competition on the
highest world level reachable for them.
The external manifestation of the development of a
particular person is their body build and the
predispositions to execute particular physical activity.
Because of that, somatic build and, most of all, some of
its proportions which have their own development
course, are of great importance in the pole vault [4, 7].
So far we have not been able to clearly state which of
the parameters of somatic build are an exponent or
rather a criterion for particular age categories of pole
vault contestants.
The aim of the thesis was to define the relation
between the somatic parameters and sports results of
the pole vault jumpers of junior category (16 – 17).
The following methods and research tools were
used in the thesis:
•evaluation of physical development,
•testing physical dexterity,
•recording sports results,
•methods of statistical description.
In order to conduct the evaluation of physical
development, somatic build measurements including
the following indexes were used.
•body height (basis-vertex),
•weight,
•torso length (suprasternale-symphysiom),
•lower limb length (basis-symphysion),
•upper limb length (acromion-daktylion III),
•shoulder width (acromion-acromion),
•pelvis width (iliocristale-iriocristale),
•thigh circumference,
•shank circumference,
•arm circumference,
•volume of the chest during inhalation,
•volume of the chest during exhalation,
•chest breadth (the difference of the chest volume
during inhalation and exhalation).
Using the above parameters, somatic build index
according to Rohrer was calculated using the following
relation:
MATERIALS AND METHODS
During the research a pair of large bow compasses,
scales and measuring tape were used.
During the construction of physical dexterity
attempts the system of control indexes suitable for
competition requirements of pole vault was taken into
account [8]:
•running speed for 30-m distance - high start position
(s),
•running speed for 15-m distance with a 20-meter runup,
•running speed for 15-m distance with a 20-meter runup with a pole (s),
•running speed for 15-m distance with a 20-meter runup with setting a pole (s),
•strength – measured by the long jump with a 20-meter
run-up (cm),
Cognitive tests were conducted between 2005 and
2009 and they included 20 sportsmen aged 16 – 17
pole vaulting at the sports club ‘Zawisza’ Bydgoszcz,
TS ‘Olimpia’ Poznań, pole vault centre Gdańsk,
‘Gwardia’ Piła, ‘Śląsk’ Wrocław.
The contestants participated in training classes at
the club 4-6 times a week. The training unit lasts for
60-90 min., while at school they were following
Physical Education programme in the amount of 3-4
45-minute units a week, with the emphasis on
education of general physical dexterity.
Body weight (g) x 100
_________________
Body height (cm) 3
Somatic build vs sports results of pole vault contestants aged 16-17
•explosive strength – measured by the long jump with
a 20-meter run-up,
•strength of back muscles and shoulder girdle –
measured by lifting feet to the horizontal bar from
straight arm overhang 5 times (time measured) (s),
•strength of back muscles and shoulder girdle –
measured by lifting feet to the horizontal bar from
straight arm overhang (quantity),
•strength of shoulder girdle and shoulders' muscles –
measured by climbing 3-meter rope (s),
•strength of shoulder girdle and shoulders' muscles,
horizontal pull-ups (quantity),
•strength of shoulder girdle and shoulders' muscles, 5
horizontal pull-ups (time measured) (s),
•pole vault test (cm),
•coordination and explosive strength measured by
“flying” over the crossbeam from back somersault
through a handstand (from the mattress) (cm),
•strength – measured by 4-kg shot put thrown back
over the head (m).
The execution of the planned attempts was
preceded by a detailed instruction on a way of their
execution and before their performance the coach
conducted a 15-minute warm-up.
To conduct the analysis of sports results the official
competition protocols were included. The collected
material was analysed statistically using the minimum,
maximum and average value, the variations of the
examined parameters and Pearson’s correlation factors
were considered as statistically significant for p<0.05.
THE ANALYSIS OF TEST RESULTS
The conducted analysis of physical development of
pole vault jumpers showed that the value of the
standard deviation of particular parameters oscillates
from 1.27 (pelvis width) to 6.24 (weight) (table 1). The
average body height of the contestants aged 16-17 was
181.3 cm - the tallest contestant was 190 cm high and
the shortest contestant was 174 cm high. We could
observe clear diversity in the sportsmen’s weight (min.
53.5, max. 78 kg). The average values of shoulder and
pelvis width were 38.91 cm, 28.95 cm, respectively.
The average values of upper and lower limb length
were 91.78cm, 78.54 cm and the difference between
their minimum and maximum values was equal 12.5
cm (lower limb) and 12.2 cm (upper limb). The
measurement of thigh, shank and arm circumference
were equally interesting. The average value of these
features was 48.15 cm, 35.56 cm and 26.82 cm,
29
respectively. Relatively big diversity can be observed
between the maximum and minimum value of thigh
circumference (15.5). The measurement of the chest
volume during inhalation and exhalation indicated the
average value on the level of 93.38 cm, 85.73 cm,
respectively, and for the average value of chest breadth
- on the level of 7.6 cm. The average value of torso
length was 53.9 cm while the minimum value was 50
cm and the maximum value was 57.1 cm.
Table 1. The results of somatic development of the
contestants of the junior category (aged 16-17)
Tabela 1. Wyniki badań rozwoju somatycznego 16-17 letnich
skoczków o tyczce
No
1.
Ex am ined
param et res
body
hei ght
(cm )
2.
body
w ei ght
(k g)
3.
shoul der
w idt h
(cm )
4.
pelv i s
w idt h
(cm )
5.
l ow er
lim b
l engt h
(cm )
upper
lim b
l engt h
(cm )
t high
ci rcum f erence
(cm )
6.
7.
8.
shank
ci rcum f erence
(cm )
9.
arm
ci rcum f erence
(cm )
10.
v ol um e of
t he chest
i nspi rat i on
(cm )
v ol um e of
t he chest
ex hal at i on
(cm )
chest
breadt h
(cm )
11.
12.
13.
t orso
l engt h
(cm )
St at i st ical
v alues
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
Av erage
SD
Mi n
Max
16-17 y ears
ol d (n-20)
181,30
4,62
174,00
190,00
67,86
6,24
53,50
78,00
38,91
2,09
36,00
43,90
28,95
1,27
27,20
32,50
91,78
3,29
84,00
96,50
78,54
3,34
72,00
84,20
48,15
4,19
42,50
58,00
35,56
2,29
32,50
40,00
26,82
2,10
23,50
32,00
93,38
4,65
86,00
101,50
85,73
4,13
79,00
93,50
7,60
1,37
4,50
10,00
53,90
2,04
50,00
57,10
Mariusz Klimczyk
30
Comparing the body height of the examined pole
vault jumpers to the tests' results of M. Napierała
(2008), who conducted researches within kujawskopomorskie province, shows that the examined pole
vault jumpers are taller than their peers (M. Napierała:
16.5 years old – 175.64 cm). The relation between the
body height of the examined contestants and the body
height of the boys in Polish national tests of R.
Przewęda and J. Dobosz (2003) looks similar: (16.5
years old – 176.49 cm).
Comparing the body weight of pole vault jumpers
with the tests' results of M. Napierała (2008) within
kujawsko-pomorskie province and Polish national tests
of R. Przewęda and J. Dobosz (2003) it is shown that
the examined pole vault jumpers have greater average
body weight. In the research of M. Napierała (2008)
and R. Przewęda, J. Dobosz (2003)the results are
following: M. Napierała 16,5 years old – 65,27 kg; R.
Przewęda, J. Dobosz 16,5 years old – 66,49 kg.
The conducted analysis of biological development
of pole vault jumpers contributed to showing the
relations resulting from their above natural
development and, most of all, from the process of
organism's adaptation occurring because of
implemented training factors used in their athletic
sports discipline.
In table 1 the parameters of somatic build of pole
vault jumpers of the junior category (aged 16-17) are
presented.
The analysis of body slenderness, defined by
Rohrer index showed, on the basis of comparison of
tests' results of the above index with the author's
previous tests of the younger contestants doing the pole
vault [11], the tendency of growth. It can be an
evidence of growth of their muscle mass caused by
training loads and the period of biological development
of the examined sportsmen, as well as shoulder width
and smaller dynamic of body height. The above index
achieved value of 1.14 (table 2)
Table 2. Index of body built by Rohrer
Tabela 2. Wskaźnik budowy ciała wg. Rohrera
No
Rohrer index
Age
16-17
1.
1,14
The conducted analysis of physical dexterity tests'
results showed significant fluctuation of standard
deviation from 0.03 (first /0-5m/ and second /5-10m/
stage of the run for 15-m distance with setting a pole)
to 49.48 in the pole vault in particular attempts. In the
run for 30-m distance the average value was 4.05 s, the
minimum value 3.71 s and the maximum value 4.31 s.
In the run for 15-m distance, for 15-m distance with a
pole and for 15-m distance with setting a pole the
average values of 1.79 s, 1.85 s and 1.95 s,
respectively, were noted. The results of the long jump
at state and with a run-up are interesting. In both
attempts there is a great diversity of results (standard
deviation 25.92 and 31.63). The average of results of
the long jump at state and with a run-up was 265.5 cm
and 577.35 cm. The shortest long jump was 162 cm
and the longest was 292 cm. In the long jump with a
run-up the worst score was 528 cm and the best 631
cm. The pole vault results present a greatest diversity
and the difference between the worst and the best one 150 cm. The rest of the results of physical dexterity
attempts are presented in Table 3.
Correlative analysis of particular physical dexterity
tests' results and somatic build of pole vault jumpers
aged 16-17 showed numerous statistically significant
relations (table 4). Body height has statistically
significant relation with seven physical dexterity
attempts; run for 15-m distance (0.46), climbing a rope
(0.48), lifting feet to the horizontal bar 5 times (0.79),
5 pull-ups on the horizontal bar (0.57), “flying” over
the crossbeam from back somersault (0.64), 4-kg shot
put thrown back over the head (058) and pole vault
(0.66). Statistically significant relations occur between
body weight and run for 15-m distance (0.52), first
stage (0-5m), run for 15 m distance with setting a pole
(0.49), climbing a rope (0.47) and lifting feet to the
horizontal bar 5 times (0.60). There is at least one
statistically significant relation between shoulder
width, pelvis width (adequately with lifting feet to the
horizontal bar 5 times /0.52/ and the last stage /1015m/ of the run for 15-m distance with setting a pole
/0.45/). Interesting statistically significant relations
occur between the length of lower and upper limb and
lifting feet to the horizontal bar 5 times (0.68 and 0.72
respectively), ‘flying’ over the crossbeam, 4-kg shot
put throw back over the head and pole vault (0.60,
0.52, 0.64 and 0.64 and 0.52, 0.54) and climbing a rope
(0.52 and 0.52). We also found the relation between
thigh circumference and 4-kg shot put thrown back
over the head (0.59) and run for 15-m distance, shank
circumference (0.52).
Table 3. The results of physical dexterity of pole vault
jumpers aged 16-17
Tabela 3. Wyniki sprawności fizycznej 16-17 letnich
skoczków o tyczce
1
Dext erit y
t est s
run for 30 m (s)
2
run for 15 m (s)
3
ru n for 1 5 m w it h a
pole (s)
4
run for 1 5 m w it h
set t ing a pole (s)
5
0 - 5 m (s)
6
5 - 1 0 m (s)
7
10 - 1 5 m (s)
8
long jum p at st at e
(cm )
9
long jum p wit h a
Run-u p (cm )
10
clim bing 3-m rope
(s)
11
Pull-up s on t h e
horizont al bar
(qu ant it y)
12
lift ing feet t o t he
crossbeam t raining st im ulat or
(qu ant it y)
lift ing feet t o t he
horizont al bar
5 t im es in good
t im e (s)
5 pull-u ps on t he
horizont al bar
in good t im e (s)
No
13
14
15 „ flyin g” over t he crossbeam
from back som ersault
t hrough a handst and
from t he m at t ress (cm )
4-kg shot pu t
16
t hrown back over
t he h ead (m )
17
pole vault result
(cm )
St at ist ical
values
Average
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Averge
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Aerage
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Average
SD
m in
m ax
Age
16-17 (n-2 0)
4,05
0,16
3,71
4,31
1,79
0,07
1,67
1,98
1,85
0,11
1,69
2,05
1,98
0,09
1,81
2,18
0,64
0,03
0,59
0,73
0,65
0,03
0,60
0,72
0,70
0,04
0,62
0,77
2 65,50
25,92
1 62,00
2 92,00
5 77,35
31,63
5 28,00
6 31,00
5,84
1,19
3,31
8,02
12,00
3,08
7,00
17,00
4,70
2,13
1,00
10,00
6,20
0,93
4,42
7,51
6,11
1,01
4,22
7,54
70,40
25,74
35,00
1 20,00
14,73
1,06
12,89
16,25
3 86,30
49,48
3 30,00
4 80,00
31
Also many statistically significant relations occur
between arm circumference, volume of the chest
during inhalation and exhalation and torso length and
some physical dexterity tests. The most interesting
relation occurs between arm circumference and
climbing a rope, lifting feet to the horizontal bar 5
times and 5 pull-ups on the horizontal bar (0.51, 0.63,
0.60, respectively). Statistically significant relations of
torso length and particular physical dexterity tests are
on the level from 0.49 and 0.67. The chest breadth does
not enter into statistically significant relations with any
physical dexterity test. It is necessary to emphasise that
most relations occur on the average and small level of
significance.
In table 5 the relations of particular somatic
features with pole vault result are presented.
Statistically significant correlation occurs between five
out of 13 somatic build features. The relations between
sports result and body height (0.66), upper and lower
limb length (0.64, 0.54 respectively) are also of
interest. Interesting is that statistically significant
relation of pole vault occurs with the chest volume
during inhalation and exhalation (0.45, 0.46).
However, the relations of low and average relation are
the most common (table 5).
Mariusz Klimczyk
32
Table 4. Values of correlative analysis of the results of particular physical dexterity tests and somatic build of pole vault
jumpers aged 16-17
Tabela 4. Wartości analizy korelacyjnej wyników poszczególnych testów sprawności fizycznej i budowy somatycznej 16-17
letnich skoczków o tyczce
Exa m ine d f e a t ure s – som a t ic m e a sure m e nt s
Body Body Shoulder Pelv is Low er Upper Thigh Shank
Arm
Chest
Chest
Chest Torso
lim b circum . circum . circum . v olum e
height w eight
w dt h
w idt h lim b
v olum e breadt h lengt h
(k g)
(k g)
(cm )
(cm ) lengt h lengt h (cm )
(cm )
(cm ) inspiration ex halation (cm )
(cm )
(cm ) (cm )
(cm )
(cm )
Exa m ine d pa ra m e t e rs
Re sult s of physica l de xt e rit y a t t e m pt s
ru n for 3 0 m (s)
ru n for 1 5 m (s)
ru n for 1 5 m w it h a p ole (s)
ru n for 1 5 m w it h set t in g a p ole (s)
0 - 5 m (s)
5 - 1 0 m (s)
1 0 - 1 5 m (s)
lon g ju m p at st at e (cm )
lon g ju m p w it h a ru n -u p (cm )
clim b in g 3 -m rop e (s)
Pu ll-u p s on h orizon t al b ar (q u an t it y)
Lift in g -st im u lat or-feet t o t h e crossb eam (q u an t it y)
lift in g feet 5 t im es t o t h e h orizon t al b ar in g ood t im e (s)
5 p u ll-u p s on t h e h orizon t al b ar in g ood t im e (s)
„ flyin g ” over t h e crossb eam from b ack som ersau lt
4 -kg sh ot p u t t h row n b ack over t h e h ead (m )
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
A
0 ,1 6
-0 , 4 6
-0 ,3 0
-0 ,3 5
-0 ,4 2
-0 ,4 1
-0 ,4 1
0 ,3 3
0 ,0 9
-0 , 4 8
0 ,4 1
0 ,2 2
-0 , 7 9
-0 , 5 7
0,64
0,58
B
-0 ,1 1
-0 , 5 2
-0 ,2 2
-0 ,3 0
-0 , 4 9
-0 ,3 7
-0 ,2 1
0 ,2 6
0 ,0 1
-0 , 4 7
0 ,3 9
0 ,0 2
-0 , 6 0
-0 ,3 5
0 ,2 6
0 ,2 8
C
0 ,0 8
-0 ,3 4
-0 ,3 6
-0 ,2 7
-0 ,2 6
-0 ,3 7
-0 ,0 7
-0 ,1 0
-0 ,4 1
-0 ,2 5
0 ,3 4
0 ,1 1
-0 , 5 2
-0 ,4 3
0 ,2 7
0 ,2 9
D
0 ,2 0
0 ,2 4
0 ,1 9
0 ,2 5
0 ,3 5
0 ,2 1
0,45
0 ,0 7
-0 ,3 5
0 ,2 9
-0 ,1 7
-0 ,0 6
0 ,1 0
0 ,1 0
0 ,0 5
0 ,1 6
E
0 ,2 8
-0 ,3 3
-0 ,2 2
-0 ,2 5
-0 , 4 7
-0 ,2 4
-0 ,3 7
0 ,1 2
0 ,2 1
-0 , 5 2
0 ,1 9
0 ,1 5
-0 , 6 8
-0 ,3 8
0,60
0,52
F
0,50
-0 ,2 3
-0 , 5 4
-0 ,3 9
-0 ,4 1
-0 ,4 3
-0 ,3 0
0 ,0 0
-0 ,0 6
-0 , 5 2
0 ,1 5
0 ,3 4
-0 , 7 2
-0 , 4 9
0,64
0,52
G
0 ,0 2
-0 ,4 1
-0 ,2 2
-0 ,3 6
-0 ,0 8
-0 ,3 6
-0 ,1 8
0 ,1 0
-0 ,3 1
-0 ,0 4
0 ,3 6
0 ,1 2
-0 ,4 2
-0 , 4 5
0 ,3 9
0,59
H
-0 ,2 0
-0 , 5 2
-0 ,1 3
-0 ,2 5
-0 ,3 4
-0 ,2 4
-0 ,1 9
0 ,1 5
-0 ,0 1
-0 ,1 8
0 ,2 5
-0 ,0 1
-0 ,2 9
-0 ,2 1
0 ,0 9
0 ,3 2
I
0 ,1 5
-0 , 4 7
-0 , 5 7
-0 ,3 4
-0 ,2 6
-0 , 4 8
-0 ,0 9
0 ,0 9
-0 ,0 1
-0 , 5 1
0 ,3 4
0 ,2 5
-0 , 6 3
-0 , 6 0
0 ,2 2
0,52
J
0 ,2 9
-0 ,3 1
-0 ,4 4
-0 ,2 9
-0 ,3 1
-0 ,3 9
-0 ,1 7
0 ,0 9
-0 ,1 2
-0 , 4 7
0 ,2 8
0 ,2 7
-0 , 7 0
-0 , 5 4
0,56
0,49
K
0 ,3 0
-0 ,3 5
-0 , 4 5
-0 ,2 8
-0 ,4 2
-0 ,3 9
-0 ,2 0
0 ,0 8
-0 ,1 0
-0 , 5 5
0 ,2 4
0 ,2 1
-0 , 7 6
-0 , 5 1
0,54
0,45
L
0 ,0 9
-0 ,1 9
-0 ,3 0
-0 ,1 0
-0 ,0 4
-0 ,2 9
0 ,0 3
-0 ,0 1
-0 ,2 2
-0 ,1 6
-0 ,1 4
-0 ,0 5
-0 ,2 2
-0 ,1 3
-0 ,1 2
0 ,0 3
Ł
-0 ,2 8
-0 , 5 9
-0 ,3 4
-0 , 4 9
-0 ,0 7
-0 , 5 4
-0 ,3 2
0 ,3 1
0 ,1 8
-0 ,3 3
0,63
0 ,3 3
-0 , 5 0
-0 , 6 7
0 ,3 0
0,58
p<0,05 bold
Table 5. The results of correlative analysis of somatic
features with pole vault result of the jumpers aged
16-17
Tabela 5. Rezultaty analizy korelacyjnej cech somatycznych z
wynikiem w skoku o tyczce 16-17 letnich tyczkarzy
No
1
2
3
4
5
6
7
8
9
10
11
12
13
Ex am in ed feat u res
Bod y h eig h t ( cm )
Bod y w eig h t ( k g )
Sh ou ld er w id t h (cm )
Pelv is w d t h (cm )
Low er lim b len g t h ( cm )
Up p er lim b len g t h ( cm )
Th ig h circu m fer en ce (cm )
Sh an k cir cu m feren ce ( cm )
Ar m cir cu m fer en ce ( cm )
Ch est v olu m e in sp ir at ion ( cm )
Ch est v olu m e ex h alat ion ( cm )
Ch est b read t h ( cm )
Torso len g t h (cm )
Ag e
1 6 -1 7
0,66
0 ,2 2
0 ,1 5
0 ,0 9
0,64
0,54
0 ,2 4
0 ,0 6
0 ,0 8
0,45
0,46
-0 ,2 1
0 ,2 0
p<0.05 bold
CONCLUSIONS
Analyzing the correlation of particular somatic
feature with any parameter describing motor dexterity
contributes to the presentation of the differences which
occur in the examined group and also between
particular sportsmen. In the opinion of prominent
experts, this subject is extremely complex. The
specialists take a position which excludes explicitness
of the successive relations [12.13].
The value of the standard deviation (of somatic
features) oscillating from 1.27 (pelvis width) to 6.24
(body weight) proves the diversity of the examined
sportsmen in relation to somatic build.
Rohrer index defined the body slenderness of the
group on the level of 1.14 confirming that the
examined sportsmen at the age of 16-17 experience
greater growth of muscle tissue and smaller growth of
their body.
The analysis of the results of physical dexterity
attempts showed their great diversity, the standard
deviation oscillates from 0.03 to 49.48. The biggest
one relates to the pole vault. In this attempt the
difference between the worst and the best score was
45.45%.
The analysis of correlation of the examined pole
vault jumpers' results with their particular
measurements of somatic features showed some
interesting relations. For example, body height is
subject to statistically significant correlation with
seven physical dexterity attempts ( e. g. with ‘flying’
over the crossbeam from back somersault /0.64). The
relation between shank circumference and 4-kg shot
put thrown back over the head (0.59) is also
interesting.
Sports results have statistically significant
correlation with five somatic features. The relation
which occurs between pole vault sports result and body
height (0.66), the length of upper and lower limb (0.64
and 0.54, respectively) is also interesting.
However, on the basis of the above analysis with
regard to (among many) a small number of the
examined sportsmen, it is not possible to draw farreaching conclusions concerning the relation which
occurs between somatic build and physical dexterity
attempts and pole vault result.
BIBLIOGRAPHY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Kowalczuk G.I,, Wasniew I.A., Diagnostyka uzdolnień
skoczków o tyczce. W: Fiziczeskaja Kultura –
Naukowo-Metodyczny Żurnal no 4. Moskwa
[Moscow], 2002.
Ważny Z., Współczesny system szkolenia w sporcie
wyczynowym. SiT, Warszawa [Warsaw], 1981.
Drozdowski S., Dynamika przyrastania dzieci
obciążonych różnym wysiłkiem fizycznym. W:
Materiały. Konferencja – Biologia populacji ludzkich
współczesnych pradziejowych. AWF, Poznań, 1993.
Drozdowski Z., Antropologia sportowa. Morfologiczne
podstawy wychowania fizycznego i sportu. Seria:
Podręczniki nr 12. AWF, Poznań, 1984.
Łaska-Mierzejewska T., Antropologia w sporcie i
wychowaniu fizycznym. Biblioteka Trenera, COS,
Warszawa [Warsaw], 1999.
6. Sawczyn S., Kochanowicz K., Kruczkowski D.,
Dancewicz T., Cechy prognostyczne w budowie
somatycznej w doborze do gimnastyki sportowej. W:
Trening, Kwartalnik Metodyczno Szkoleniowy nr 3
PTNKF, Warszawa [Warsaw], 1997.
Bril M. S., Princypy i mietodiczeskije osnowy
aktiwnogo obora szkolnikow dla sportiwnogo
sowierszenstwowanija. Praca habilitacyjna. GCFK,
Moskwa [Moscow], 1986.
Klimczyk M. Special fitness and a sport result in 19year-old pole vault jumpers. Medical and Biological
Sciences 2009, 23/3, p 61-67.
Napierała M. (2008), Środowiskowe uwarunkowania
somatyczne i motoryczne a wiek rozwojowy dzieci i
młodzieży na przykładzie województwa kujawskopomorskiego. Wydawnictwo Uniwersytetu Kazimierza
Wielkiego, Bydgoszcz.
1Przewęda R., J. Dobosz (2003), Kondycja fizyczna
polskiej młodzieży, Studia i Monografie nr 98, AWF,
Warszawa [Warsaw].
Klimczyk M. Kierowanie i kontrola szkolenia
sportowego tyczkarzy na etapach wstępnym i
podstawowym.
Bydgoszcz
Wydawnictwo
Uniwersytetu Kazimierza Wielkiego, 2008.
Drozdowski
Z.
(1994): Filogenetyczny rozwój
motoryczności
człowieka. W: Motoryczność
człowieka
–
jak
struktura,
zmienność
i
uwarunkowania. Red. W. Osiński. Monografie,
Podręczniki, Skrypty AWF, Poznań, no. 310.
Osiński W. (2003): Antropomotoryka. AWF, Poznań. p
367.
Institute of Physical Culture, Kazimierz Wielki
University in Bydgoszcz
Headmaster Senior Doctor Mariusz Zasada
ul. Ogińskiego 16
85-092 Bydgoszczy
tel./fax: 663089733, 52 37 67 910
33
Alicja Rzepka1,2, Kornelia Kędziora-Kornatowska1, Marlena Jakubczyk2, Łukasz Sielski2, Krzysztof Kusza2,3
ASSESSMENT OF THE NEEDS AND EXPECTATIONS OF ELDERLY PATIENTS
REGARDING PHYSIOTHERAPEUTICAL CARE IN POLAND
OCENA ZAPOTRZEBOWANIA I OCZEKIWAŃ PACJENTÓW W STARSZYM WIEKU
W ODNIESIENIU DO OPIEKI FIZJOTERAPEUTYCZNEJ W POLSCE
1
Department and Clinic of Geriatrics of the Nicolaus Copernicus University in Toruń
Collegium Medicum in Bydgoszcz
Head: Prof. Kornelia Kędziora –Kornatowska, PhD., M.D.
2
Department and Clinic of Anesthesiology and Intensive Care of the Nicolaus Copernicus University in Toruń
Head: Prof of UMK Krzysztof Kusza, PhD., M.D.
3
Department and Clinic of Anesthesiology and Intensive Care and a Pain Treatment of the Medical University
in Poznań
Head: Prof. Leon Drobnik, PhD., M.D.
Summary
I n t r o d u c t i o n . The physiotherapeutic care is a
sensitive subject for the medical society, the elderly patients
and their carers.
A i m . An assessment of the needs and expectation of
elderly patients in relation to physiotherapeutic care in
Poland.
M a t e r i a l s a n d m e t h o d s . 50 patients, aged
61-91, under the care of the Department and Clinic of
Geriatrics of the University Hospital were qualified for the
study. The study was based on a self-created anonymous
survey. The questions concerned the needs and expectations
of the elderly regarding physiotherapeutic care. The results
were analyzed in relation to sex, age, place of residence,
marital status and education.
R e s u l t s . (80%, n=40) of the patients pointed to the
need for improvement in the field of physiotherapeutic care.
20% did not have an opinion on this topic. The need to adjust
the therapeutic services was equally voiced by men and
women. Methods for improvement of this care would be
advertising the need for medical care in the field of
physiotherapy (50%, n=25), education (22%, n=11) and more
funds (2%, n=1). 26% (n=13) do not believe any change is
possible while 70% (n=30) believe that in the coming 10
years the state of physiotherapeutic care in Poland will
improve, 20% (n=10) - degrade and 10% (n=5) that it will
not change. The subjects expect that in the coming years the
waiting time for medical procedures will be shorter (42%,
n=21), that there will be more physiotherapy centres (50%,
n=25) and the qualification of the physiotherapeutic staff will
improve (8%, n=4).
C o n c l u s i o n s . Elderly patients voice a need for
physiotherapeutic care and its improvement, regardless of
sex, age, marital status, place of residence and education.
Streszczenie
W s t ę p : Opieka fizjoterapeutyczna w Polsce stanowi
problem dla środowiska medycznego, starzejących się
pacjentów oraz ich opiekunów.
Celem
p r a c y była ocena zapotrzebowania
i oczekiwań pacjentów w starszym wieku w odniesieniu do
opieki fizjoterapeutycznej w Polsce.
36
Alicja Rzepka et. al.
Materiał
i
metody.
Do
badania
zakwalifikowano 50 pacjentów w wieku 61-91 lat będących
pod opieką Kliniki Geriatrii oraz Poradni Geriatrycznej
Szpitala Uniwersyteckiego im. dr A. Jurasza. Badania
przeprowadzono na podstawie anonimowej ankiety
własnego autorstwa. Pytania dotyczyły oczekiwań oraz
zapotrzebowania na opiekę fizjoterapeutyczną u pacjentów w
starszym wieku. Wyniki przeanalizowano w zależności od
płci, wieku, miejsca zamieszkania, stanu cywilnego oraz
wykształcenia.
W y n i k i . Spośród 50 pacjentów
(20%, n=40)
opowiedziało się
za koniecznością poprawy
opieki
fizjoterapeutycznej (20%, n=10) nie miało na powyższy
temat zdania. Potrzebę dostosowania usług terapeutycznych
w równym stopniu zgłaszali zarówno mężczyźni, jak i
kobiety. Sposobami na poprawę w/w opieki byłoby
nagłośnienie/rozreklamowanie
konieczności
opieki
zdrowotnej w zakresie fizjoterapii (50%, n=25), edukacja
środowiska (22%, n=11) oraz większe fundusze na ten cel
(2%, n=1). Brak wiary w zmiany przewiduje (26%, n=13).
Stan polskiej opieki fizjoterapeutycznej w najbliższych 10
latach stanie się lepszy(70%, n=35) , gorszy (20%, n=10) ,
nie zmieni się (10%, n=5). Badani oczekują w przeciągu 10
lat
skrócenia
czasu
oczekiwania
na
zabiegi
fizjoterapeutyczne (42%, n=21), zwiększenia liczby
ośrodków fizjoterapeutycznych (50%, n=25) oraz
zwiększenia kwalifikacji personelu fizjoterapeutycznego
(8%, n=4).
W n i o s k i . Pacjenci w starszym wieku opowiadają
się za koniecznością poprawy oraz zapotrzebowaniem na
opiekę fizjoterapeutyczną niezależnie od płci, wieku, stanu
cywilnego, miejsca zamieszkania i wykształcenia.
Key words: care, physiotherapy, needs, elderly patients, survey questionnaire
Słowa kluczowe: opieka, fizjoterapia, zapotrzebowanie, pacjenci w starszym wieku, badanie ankietowe
INTRODUCTION
Physiotherapy in Poland has been developing
rapidly for the last couple of years, taking care of
patients with locomotor organs’ ailments, neurological
ailments and patients after injuries [1]. However, there
is a lack of specialist physiotherapeutic care designed
for geriatric patients. Elderly patients are often under
the care of many specialists due to many organ
dysfunctions, often with complications arising from
many years of treatment and problems related with
aging – anal incontinence, psychopathological
disorders, locomotion and balance dysfunction, falls,
failing senses [2]. The need for physiotherapeutic care
catered for geriatric patients is steadily increasing due
to the growing number of people older than 60. This is
confirmed by the studies of the Central Statistical
Office (Polish: GUS) which predicts that in 2030 there
will be 9.5% more people of 65 years of age, 12.9% 70 and up to 17.3% - 80 years old [3]. Developments in
the field of medicine as well as social care caused life
expectancy to increase by 5 years for men and 4.6
years for women in the years 1999-2006 [3, 4]. That is
why it is necessary to adjust physiotherapeutic care to
the needs of this group of patients. This care should be
planned individually and aim at the primary ailment of
a patient [5]. On the other hand, it should also prevent
physical disability and dependency on family and
carers [5].
50 patients over 60 years of age, under the care of
the Department and Clinic of Geriatrics of the A.
Jurasz University Hospital were qualified for the study.
The group consisted of 19 men (38%) and 31 women
(63%) aged 61-91. A detailed characteristic of the
group is shown in table 2. The study was based on a
self-created, anonymous survey. The questions
concerned the needs and expectations of the elderly
regarding physiotherapeutic care. The results were
analyzed in relation to sex, age, place of residence,
marital status and education. The study was approved
by the Bioethical Committee.
The data was analysed using Excel 2007 and
Statistica for Windows 8.0 (created by StatSoft)
software. A p<0.05 significance coefficient was taken
as statistically significant. The significance of
differences between the study parameters was tested
using the Chi2 test for categorised qualitative
variables.
AIM OF THE STUDY
The aim of the study was to assess the needs and
expectation of the elderly patients in relation to
physiotherapeutic care in Poland.
RESULTS
The need to adjust the therapeutic services was
equally voiced by men (17, 34%) and women (17,
34%). 14 women (28%) and 2 men (4%) did not have
an opinion on this topic [Fig 1].
Among 50 patients, 21 (42%) from subgroup I, 12
(24%) from subgroup II and 8 (16%) from subgroup III
expressed a need for an adjustment of
physiotherapeutic care. None of the patients was
against further care improvements. 5 patients form
Assesment of the needs and expectations of elderly patients regarding physiotherapeutical care in Poland
Liczba pacj/Number of patients
(%)
subgroup I (10%), 3 from subgroup II (6%) and 1 from
subgroup IV (2) had no opinion on this topic [Fig 2].
80
Kobiety/Women
60
Mężczyzni/Men
40
20
0
Tak/Yes
Nie/No
Nie wiem/Do
not know
Potrzeba dostosowania opieki do osób starszych/A need to adjust
physiotherapy to the needs of the elderly
Fig 1. The need for an improvement of physiotherapeutic
care for the elderly - in relation to sex
Ryc. 1. Konieczność poprawy opieki fizjoterapeutycznej
wśród osób starszych w zależności od płci
In relation to the place of residence, 14 patients
(28%) from cities with more than 100 000 residents, 23
(46%) from cities below 50 000 residents and 3 (6%)
from rural areas were for improving physiotherapeutic
care for the elderly. No resident of a city below 50 000
residents nor rural area was against physiotherapeutic
care improvements. 3 patients from cities above
100 000 residents (6%), 5 from cities below 50 000
residents (10%) and 2 from rural areas (4%) did not
voice any opinion on this topic [Table I].
Table I. The opinions of the elderly regarding the
improvement of physiotherapeutic care in
relation to the given characteristic
Tabela I Opinie osób starszych odnośnie poprawy opieki
fizjoterapeutycznej wśród osób w starszym wieku w
zależności od danej cechy
Cecha/ Characteristic
Tak/Yes
Nie/No
Płeć /Sex
Kobiety/Women
Mężczyźni/ Men
Wiek /Age
Podgrupa I/Subgroup I
Podgr.II/Subgroup II
Podgr.III/Subgroup III
Podgr.IV/Subgroup IV
Pow.100tys./> 100k
Do 50tys./< 50k
17(34%)
17
(34%)
21(42%)
12(24%)
8(16%)
0(0%)
14(28%)
23(46%)
Miejsce
zamieszkania/
Place
of
residence
Stan cywilny/
Marital status
Wykształcenie/
Education
0(0%)
0(0%)
Nie
wiem/Do
not
know
14(28%)
2(4%)
Razem/Sum
31(62%)
19(38%)
0(0%)
0(0%)
0(0%)
0(0%)
0(0%)
0(0%)
5(10%)
3(6%)
0(0%)
1(2%)
3(6%)
5(10%)
26(52%)
15(30%)
8(16%)
1(2%)
17(34%)
28(56%)
Wieś/Rural area
3(6%)
0(0%)
2(4%)
5(10%)
Zamężny/Married
Wdowiec/Widowed
Wolny/Single
Rozwiedziony/Divorced
Podstawowe/Primary
Zawodowe/Vocational
Średnie/Secondary
Wyższe/ Higher
33(66%)
6(12%)
3(6%)
1(2%)
4(8%)
10(20%)
14(28%)
12(24%)
0(0%)
0(0%)
0(0%)
0(0%)
0(0%)
0(0%)
0(0%)
0(0%)
3(6%)
4(8%)
0(0%)
0(0%)
1(2%)
2(4%)
3(6%)
4(8%)
36(72%)
10(20%)
3(6%)
1(2%)
5(10%)
12(24%)
17(34%)
16(32%)
When analysing the need for physiotherapeutic
care improvement in relation to marital status it was
observed that 33 (66%) married patients, 6 widowed
patients (12%), 3 single patients (6%) and 1 divorced
patient (2%) were for the improvements. None of the
respondents were against improving physiotherapeutic
care of the elderly. 3 married patients (6%) and 4
37
widowed patients (8%) had no opinion in this regard
[Table I].
When analysing the need for physiotherapeutic
care improvement in relation to education 12 (24%)
patients with higher education, 14 (28%) with
secondary education, 10 (20%) with vocational
education and 2 (8%) with primary education support
improving physiotherapeutic care. No one was against
the need for this development. No opinion was given
by 4 (8%) patients with higher education, 3 (6%) with
secondary education, 2 (4%) with vocational education
and 1 (2%) with primary education [ Table I].
Fig. 2. The need for an improvement of physiotherapeutic
care for the elderly - in relation to age
Ryc. 2. Konieczność poprawy opieki fizjoterapeutycznej
u osób starszych w zależności od wieku
When analysing the opinion regarding the trends
in physiotherapeutic care in Poland for the next 10
years in relation to sex it was observed that 25 (50%)
women and 10 (20%) men believed that the changes
would be for the better. Changes for the worst were
predicted by 5 (10%) women and 5 men (10%). No
changes were foreseen by 1 (2%) woman and 4 (8%)
men [Fig 3; Table II].
Fig 3. Changes in the Polish physiotherapeutic care
proposed by the elderly for the next 10 years - in
relation to sex
Ryc. 3. Proponowane zmiany w polskiej opiece
fizjoterapeutycznej na najbliższą dekadę w opinii
osób starszych zgodnie z płcią
38
Table
II.
Predictions of the elderly regarding
physiotherapeutic care in the next 10 years in
relation to the given characteristic
Tabela II. Prognozy na najbliższe 10 lat w opiece
fizjoterapeutycznej w zależności od danej cechy
Cecha/Characteristic
Płeć/Sex
Wiek/Age
Kobiety/Women
Mężczyźni/Men
PodgrupaI/ SubgroupI
PodgrupaII/
SubgroupII
PodgrupaIII/
SubgroupIII
PodgrupaIV/ Subgroup
IV
Miejsce
Pow.100tys.> 100k
zamieszkania/ Do 50tys.< 50k
Place
of Wieś/Rural area
residence
Stan cywilny/ Zamężny/Married
Marital status
Wdowiec/Widowed
Na
lepsze/
For the
better
25(50%)
10(20%)
9(18%)
Na
Brak
Brak Razem/Total
gorsze/ zmian/No opinii/
For the change
No
worse
opinion
5(10%) 1(2%) 0(0%) 31 (62%)
5(10%) 4(8%) 0(0%) 19 (38%)
0(0%) 12(24%) 5(10%) 26(52%)
9(18%) 2(4%)
1(2%)
3(6%)
15 (30%)
4(8%)
3(6%)
1(2%)
0(0%)
8 (16%)
0(0%)
0(0%)
1(2%)
0(0%)
1 (2%)
7(14%) 1(2%) 4(8%) 0(0%)
11(22%) 2(4%) 10(20%) 5(10%)
3(6%) 0(0%) 0(0%) 2(4%)
17(34%)
28(56%)
5(10%)
12(24%) 2(4%)
0(0%)
7(14%)
36(76%)
5(10%) 2(4%)
0(0%)
3(6%)
10(20%)
1(2%)
0(0%)
2(4%)
0(0%)
0(0%)
3(60%)
2(4%)
0(0%)
0(0%)
5(10%)
2 (4%)
5(10%)
0(0%)
2(4%)
3(6%)
5(10%) 3(6%)
5(10%) 5(10%)
2(4%) 2(4%)
12(24%)
16(32%)
17(34%)
Wolny/Single
2(4%)
Rozwiedziony/Divorced 2(4%)
Wykształcenie/ Podstawowy/Primary
0(0%)
Education
Zawodowy/Vocational
4(8%)
Średnie/Secondary
4(8%)
Wyższe/ Higher
10(20%)
When analysing the opinion regarding the trends
in physiotherapeutic care in Poland for the next 10
years in relation to age subgroup; 9 (18%) patients
from subgroup I, 9 (18%) patients from subgroup II
and 4 (8%) patients from subgroup III think that the
situation will improve. 2 patients from subgroup II
(4%) and 3 from subgroup III (6%) predict changes for
worse. No changes are predicted by 12 (24%)
respondents from subgroup I, 1 (2%) from subgroup II,
1 (2%) from subgroup III and 1 (2%) from subgroup
IV. 5 (10%) patients from subgroup I and 3 (6%) from
subgroup II gave no opinion [Fig 4, Table II ].
Fig 4. Changes in the Polish physiotherapeutic care
proposed by the elderly for the next 10 years - in
relation to age
Ryc. 4. Proponowane zmiany w polskiej opiece
fizjoterapeutycznej na przestrzeni najbliższej dekady
zgodnie z wiekiem
Analysing the opinion regarding the trends in
physiotherapeutic care in Poland for the next decade in
relation to the place of residence showed that
according to 7 (14%) patients from cities with more
than 100 000 residents, 11 (22%) from cities below
50 000 and 3 (6%) from rural areas believe that this
care will develop. to 1 (2) patient from a city with
more than 100 000 residents and 2 (5%) from cities
below 50 000 believe that it will degrade.
Respectively, 4 (8%) and 10 (20%) think it will not
change. No opinion was voiced by 5 (10%) patients
from cities with less than 50 000 residents and 2 (4)
from rural areas [Table II].
An analysis of the trends in physiotherapeutic care
in Poland for the next decade in relation to marital
status showed that 12 (24%) married, 5 (10%)
widowed, 2 (4%) single and 2 (4%) divorced patients
believe that the changes will be for the better. Changes
for the worse are predicted by 2 (4%) married, 2 (4%)
widowed and 1 (2%) single patients. 7 (14%) married,
3 (6%) widowed and 2 (4%) single patients did not
state any opinion on this matter [Table II].
Opinions regarding changes in geriatric care for
the next decade were compared in relation to
education. Changes for the better are predicted by 4
(8%) patients with vocational education, 4 (8%) with
secondary education and 10 (20%) with higher
education. Changes for the worst are expected by 2
(4%) patients with primary education, 2 (4%) with
secondary education and 3 (6%) with higher education.
According to 3 (6%) patients with primary education,
5 (10%) with vocational, 5 (10%) with secondary and 2
(4%) with higher education no changes will happen.
No opinion regarding this topic was stated by 3 (25%)
patients with vocational education, 5 (31%) with
secondary education and 2 (4%) with higher education
[ Table II].
Methods for improving the aforementioned care
could be: advertising the need for physiotherapeutic
health care (25 patients, 50%), education in one’s own
social group (city, region) (11 patients, 22%) and more
funds (1 patient, 2%). 13 (26%) patients expressed no
faith in any positive changes. Opinions on the methods
for improving physiotherapeutic care in relation to sex,
age, place of residence, marital status and education
are shown in table III.
The respondents were asked about what changes
they would like to see in the next 10 years. The
answers
were:
shorter
waiting
time
for
physiotherapeutic treatment (42%, n=21), more
physiotherapeutic centres for the elderly (50%, n=25)
and an improvement in the qualification of the
physiotherapeutic staff (8%, n=4).
When analyzing the results based on the
respondents’ sex, 16 (32%) women and 9 (18%) men
voted for an increase in the number of
physiotherapeutic centres for the elderly. Shorter
waiting time was pointed out by 16 (32%) women and
8 (16%) men. 2 women (4%) and 2 men (4%) wanted
better qualified staff [Table IV]
39
physiotherapy centres for the elderly. For 5 (10%)
patients from cities above 100 000 residents and 9
(18%) from cities below 50 000 residents the most
important issue is the shortening of waiting times.
Physiotherapeutic staff with higher qualification is a
priority for 1 (2%) person from a city above 100 000
residents and 9 patients (18%) from cities below 50000
residents [Table IV].
Table III. Methods for improving physiotherapeutic care given by the elderly in relation to the given characteristic
Tabela III. Sposoby poprawienia opieki fizjoterapeutycznej wśród osób starszych w zależności od danej cechy
Płeć/Sex
Kobiety/Women
Mężczyźni/Men
Wiek/
PodgrupaI/
Age
Subgroup I
PodgrupaII/ Subgroup
II
PodgrupaIII/Subgroup
III
PodgrupaIV/
Subgroup IV
Miejsce
Pow.100 tys.> 100k
zamieszkania/
Do 50tys. < 50k
Place
of Wieś/ Rural area
residence
Stan
Zamężny/Married
cywilny/Marital Wdowiec/Widowed
status
Wolny/ Single
Rozwiedziony/
Divorced
Nagłośnienie
Edukacja
Większe
konieczności społeczeństwa/ fundusze/
opieki
Educating the
More
zdrowotnej
society
funds
wśród
pacjentów w
starszym
wieku/
Promoting
the need for
healthcare for
the elderly
14 (28%)
7 (14%)
11 (22%)
3 (6%)
1 (2%)
20 (40%)
5 (10%)
1(2%)
Brak wiary w
jakiekolwiek
zmiany/
Lack of faith
in any changes
Razem/Total
10 (20%)
4 (8%)
31 (62%)
19 (38%)
26(52%)
8 (16%)
4 (8%)
3 (6%)
15 (30%)
5 (10%)
2 (4%)
1 (2%)
8 (16%)
1 (2%)
1 (2%)
8 (16%)
18 (36%)
3 (6%)
5 (10%)
2 (4%)
2 (4%)
20 (40%)
7 (14%)
5 (10%)
2 (4%)
2 (4%)
1 (2%)
2 (4%)
Analysing the opinion regarding the expected
changes in physiotherapeutic care in Poland for the
next decade in relation to age subgroups showed that
14 patients (28%) from subgroup I, 8 (16%) from
subgroup II and 4 (8%) from subgroup III wanted the
number of physiotherapeutic centres to increase. A
shorter waiting time was chosen by 1 (2%) person from
subgroup I , 5 (10%) from subgroup II , and 4 (8%)
from subgroup III. 1 patient (2%) from subgroup I, 2
(4%) from subgroup II, none from subgroup III and
1(2%) from subgroup IV wanted the staff to be better
qualified [Table IV].
When analysing the expectations regarding
physiotherapeutic care for the next decade in relation
to the place of residence it has been observed that 11
(22%) respondents from cities above 100 000
residents, 10 (20%) from cities below 50 000 residents
and 5 (10%) from rural areas wanted more
1(2%)
1(2%)
4 (8%)
7 (14%)
17(34%)
28(56%)
5(10%)
11 (22%)
1 (2%)
36(76%)
10(20%)
1 (2%)
5(10%)
2 (4%)
An analysis of the patients' expectations for
physiotherapeutic care in the next decade in
comparison to marital status showed the following
results. 18 (35%) married, 5 (10%) widowed, 3 (6%)
divorced and 1 (2%) single patient wanted more
physiotherapeutic care centres for the elderly. Shorter
waiting times were expected by 15 (30%) married and
5 (10%) widowed patients). 3 (6%) married patients
wanted the physiotherapeutic staff to become more
qualified [Table IV].
When analysing the expectations regarding
physiotherapeutic care for the next decade in relation
to education it has been observed that 2 (4%) patients
with primary education, 6 (12%) with vocational
education, 8 (16%) with secondary education and 9
(18%) with higher education wanted more
physiotherapeutic centres for the elderly.
40
caused
by
worries
regarding their own health
and the fact that they will
have to start using
physiotherapeutic services
Więcej
Krótszy czas
Bardziej
Razem/Total
due to disability growing
ośrodków
oczekiwania na wykwalifikowany
fizjoterapeutycznych/ zabiegi/Shorter personel/Better
with
age.
This
is
More physiotherapeutic waiting times
qualified staff
centres
corroborated
by
Płeć/Sex
Kobiety/Women
16(32%)
13(26%)
2(4%)
31(62%)
Bogowolska
at
al.
study
Mężczyźni/Men
9(18%)
8(16%)
2(4%)
19(38%)
Wiek/ Age
Podgrupa I/Subgroup I
14(28%)
11(22%)
1(2%)
26(52%)
entitled ‘Life conditions of
PodgrupaII/Subgroup II
8(16%)
5(10%)
2(4%)
15(30%)
PodgrupaIII/Subgroup III
4(8%)
4(8%)
0(0%)
8(16%)
the elderly from Lower
PodgrupaIV/Subgroup IV
0(0%)
0(0%)
1(2%)
1(2%)
Silesia’ which shows that
Miejsce
Pow.100tys./> 100k
11(22%)
5(10%)
1(2%)
17(34%)
zamieszkania/
Do 50tys./< 50k
10(20%)
9(18%)
9(18%)
28(56%)
21.3% of patients aged
Place
Wieś/Rural area
5(10%)
0(0%)
0(0%)
5(10%)
of residence
from
60-64
use
Stan cywilny/
Zamężny/Married
18(36%)
15(30%)
3(6%)
36(72%)
rehabilitation
services
Marital status
Wdowiec/Widowed
5(10%)
5(10%)
0(0%)
10(20%)
Wolny/Single
3(6%)
0(0%)
0(0%)
3(6%)
this percentage grows to
Rozwiedziony/Divorced
1(2%)
0(0%)
0(0%)
1(2%)
Wykształcenie/ Podstawowe/Primary
2(4%)
1(2%)
2(4%)
5(10%)
24.26 in the 65-69 age
Education
Zawodowe/Vocational
6(12%)
6(12%)
0(0%)
12(24%)
group. It drastically drops
Średnie/Secondary
8(16%)
9(18%)
0(0%)
17(34%)
Wyższe/Higher
9(18%)
5(10%)
2(4%)
16(32%)
for even older patients but
not due to a lack for this
treatment
but
because
of
the
impossibility to make use
Shorter waiting times are a priority for 1 (2%) of
of it. This study shows the need for physiotherapeutic
the respondents with primary education, 6 (12%) with
care and its current maladjustment to the elderly [10].
vocation education, 9 (18%) with secondary education
The need is greatest amongst people living in
and 5 (10%) with higher education. 2 (4%) patients
cities
with a population below 50 000. This may be
with primary education and 2 (4%) with higher
connected with a small number of physiotherapeutic
education would wish for more qualified staff [Table
facilities – this causes longer waiting times. What is
IV].
more, more than one fifth of the elderly from Lower
Silesia complain about a lack of a health care centre in
DISCUSSION
their place of residence and this means no chance for
any physiotherapeutic care [10, 11]. Bień confirms
According to Kostka, the elderly are the largest
there results. According to her, health state as well as
social group benefiting from rehabilitation services.
the access to healthcare is much worse on rural areas
This is caused by a higher frequency of chronic
when compared to cities. This applies to using medical,
diseases, a decrease of functional fitness and growing
dentist and rehabilitation facilities [12]. Moscovice et
dependency on others [5]. Despite these data the Polish
al. share this view – according to them healthcare in
national health fund was planning to spend only one
the rural areas of the USA is different from the one in
billion PLN more on healthcare in 2011 than the year
the cities. People face many challenges when it comes
before. Only 4% of this amount will be spent on health
to accessing healthcare services [13]. These services
resort care (a part of physiotherapeutic care) for the
can be improved by developing cost-effective and
elderly. These amounts are about 3 times smaller than
practical standards for the healthcare centres. This is a
in case of German and French healthcare.
task for the monitoring agencies, service providers and
According to Kornatowska et al. physiotherapeutic
people buying medical insurance [13].
care for the elderly was neglected in the 20th century.
Majority of married people voted for a need for an
This was connected with constant degradation of the
improvement
of physiotherapeutic care. It must be said
vital energy of a person [9]. Patients from the
that this was the most numerous group. This need is
Department and Clinic of Geriatrics of the University
probably connected with the fact that a patient cares for
Hospital No. 1 in Bydgoszcz voice a need for
his/her health as well as the spouse’s health.
improvements in the field of Polish physiotherapeutic
Kalpakjian et al. say that marriage leads to improved
care. They were mostly from the first age subgroup
welfare and the dissolution of marriage to
(between 60 and 70 years of age). This was probably
Table IV. Changes in the Polish physiotherapeutic care proposed by the elderly for the next
10 years in relation to the given characteristic
Tabela IV. Proponowane zmiany na najbliższą dekadę w opiece fizjoterapeutycznej w opinii
osób starszych w zależności od cechy
impoverishment. What is more, patients who suffer
from spinal cord injuries and who are at the same time
marred, have a better frame of mind and are less prone
to depression than divorced, single or widowed
patients. This study is also interesting as it shows that
women after divorce are more satisfied with life and
judge their health better than divorced men [14]. This
is corroborated by DeVivo et al. According to them,
people after such injuries rather stay married and
divorce more rarely. Increased divorce risk is true only
for the young, Afro-American and without children
[15].
Most people with secondary education wanted
physiotherapeutic care to improve. This was the most
populous group. Oztürk believes this to be otherwise.
According to his study, there is no statistically
significant difference between education, sex, marital
status and the appearance of chronic diseases and their
type amongst the elderly [16].
According to most women, people from the first
and second age subgroup, residents of cities below
50 000, married people and people with higher
education Polish physiotherapeutic care will improve
in the coming decade. This may be connected with the
fact that these groups are the most numerous and the
youngest – and consequently the most optimistic and
having a stabilised personal life. The issues which
should be addressed first in the coming years are long
waiting times for physiotherapy, not enough
physiotherapy centres and an improvement of the
qualification of the physiotherapy staff.
According to the 2009 report, the Mazovian
Centre of Social Policies spent over 7 million PLN on
physiotherapeutic care. The money was spent on
rehabilitation facilities, as well as and modernising the
existing social help centres [17].
We have a similar situation in the Greater Poland
voivodeship where the Family, Social Issues and
Public Healthcare Commission of the Poznan City
Council spent 600 000 PLN for rehabilitation services
for Poznan citizens older than 60. The aim of this
initiative was to ensure the elderly access to
rehabilitation (underfinanced by the National Health
Fund) and, in consequence, to improve their health and
stop further disabilities. However, this is only a small
part of the physiotherapeutic need of the elderly in
Poland [18].
41
CONCLUSIONS
Elderly
patients
in
Poland
expect
physiotherapeutic care to improve. This is irrespective
of age, sex, marital status, place of residence and
education.
REFERENCES
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2.
3.
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Zembaty A. Kinezyterapia tom1 . Kraków 2002.
Wydawnictwo Kasper S.p. z.o. o str. 9-14.
Kędziora-Kornatowska K, Muszalik M. Kompendium
pielęgnowania pacjentów w
starszym wieku.
Wydawnictwo Czelej Lublin 2007 str 79-88
Prognoza ludności na lata 2008-2035, GUS Warszawa
2009 tab. A6 str 204
Wieczorowska-Tobis K, Kostka T, Borowicz A.M.
Fizjoterapia w geriatrii, Wydawnictwo Lekarskie
PZWL. Warszawa 2011.
Kostka T, Koziarska- Rościszewska M. Choroby wieku
podeszłego.
Wydawnictwo
Lekarskie
PZWL.
Warszawa 2009: 164
Rosławski A. Wybrane zagadnienia z geriatrii. AWF
Wrocław 2008: 9-11
Wieczorowska-Tobis K., Talarska D. Geriatria i
pielęgniarstwo geriatryczne. PZWL Warszawa 2008:
335-341
Uprawnienia kombatantów do korzystania ze
świadczeń zdrowotnych bez kolejki [Narodowy
Fundusz Zdrowia]
Adres:
http://
www.nfzwarszawa.pl/index/pacjent/kom_11082010
Kondycja życiowa dolnośląskich seniorów Raport z
badań. Część II. Analiza wyników
badań.
http://www.dops.wroc.pl/publikacje.php
Kondycja życiowa dolnośląskich seniorów. Raport z
badań. Część I http://www.dops.wroc.pl/publikacje.php
Bień B. Health care services for the elderly living in the
rural area of Poland
Przegl Lek. 2002, 59(4-5): 211-215
mgr Alicja Rzepka
Departament and Clinic of Geriatrics
of the Nicolaus Copernicus University in Toruń
85-094 Bydgoszcz, M. Curie-Skłodowskiej 9 Street
tel/fax (052) 585-49-00
CASE REPORT / PRACA KAZUISTYCZNA
Małgorzata Łukowicz1, Magdalena Mackiewicz-Milewska2, Sabina Lach-Inszczak2, Iwona Szymkuć2,
Wojciech Hagner2
TRANSPEDICULAR STABILIZATION COMPLICATIONS IN THORACIC REGION
OF THE SPINE AFTER SCI - THREE CASES REPORT AND LITERATURE REVIEW
POWIKŁANIA PO STABILIZACJI TRANSPEDIKULARNEJ ODCINKA PIERSIOWEGO
KRĘGOSŁUPA U PACJENTÓW PO URAZIE RDZENIA KRĘGOWEGO
– OPIS TRZECH PRZYPADKÓW I PRZEGLĄD LITERATURY
1
The Lasetherapy and Physical Therapy Department, Nicolaus Copernicus University in Toruń
Head: dr n. med. Małgorzata Łukowicz
2
The Department of Rehabilitation, University Hospital in Bydgoszcz
Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz
Head: prof. dr hab. Wojciech Hagner
Summary
A case report of three cases of complications after
transpedicular stabilization in thoracic part of the spine.
O b j e c t i v e s . The aim of the study was to report the
complications after surgical stabilization in thoracic level of
the spine that could be very dangerous and cause many
symptoms. All patients were treated in The Department of
Rehabilitation, University Hospital in Bydgoszcz, Collegium
Medicum of Nicolaus Copernicus University in Bydgoszcz,
Poland
C a s e r e p o r t 1 . The case of 24 year old patient
after spinal fracture within T9 as well as T12 level was
introduced. The patient was subjected to transpedicular
stabilization within the levels of T8-T10 and T11-L2. In
ASIA classification A, the lack of any sensation in sacral
segments, no anal sphincter motor activity was noticed.
Complications manifested by dislocation of screws as well as
postoperative wound infection occurred, what caused the
necessity for the stabilizer removal. These complications
exerted harmful effect on early rehabilitation process. The
patient underwent three surgical procedures resulted from
dislocation of screws.
C a s e r e p o r t 2 . 31 year old male patient after SCI
in T6 region of the spine. He was treated with transpedicular
stabilization within the levels of T5-T6. The complication
was screw translocation in vertebral body T5 and connecting
aortic aneurysm. He was successfully operated by thoracic
surgeons.
C a s e r e p o r t 3 . 26 year old male patient after
fracture of T5 and T6 vertebra column. He was operated with
transpedicular stabilization. He had fever and respiratory
tract infection symptoms; after radiological examination the
diagnosis of pleuritis was stated and a dislocation of screw in
T3 and T4 vertebral body. He was treated conventionally
without operation.
Conclusions
Complications prolong as well as disturb rehabilitation
treatment. The control radiographic examinations need to be
performed directly after operative treatment to evaluate the
stabilization system during walking and assuming the erect
position. Increased pain ailments within spinal cord segment
that was subjected to surgical procedure may signify the
possible dislocation of screws. Such dislocation, noticed
within thoracic region, can be life-threatening, because of the
nearness of the significant anatomical structures.
44
Małgorzata Łukowicz et. al.
Streszczenie
Opisano trzy przypadki pacjentów, u których wystąpiły
powikłania po stabilizacji transpedikularnej odcinka
piersiowego kręgosłupa.
C e l e m p r a c y było opisanie powikłań po stabilizacji
odcinka piersiowego kręgosłupa, które mogą być
niebezpieczne dla zdrowia i życia chorych oraz są przyczyną
wystąpienia wielu dolegliwości.
1 o p i s p r z y p a d k u . 24-letnia chora po złamaniu
kręgosłupa z uszkodzeniem rdzenia kręgowego na poziomie
T9 i T12. Została zakwalifikowana do wykonania stabilizacji
transpedikularnej na wysokości od T8 do T10 oraz od T11 do
T12. W klasyfikacji ASIA A, bez czucia oddawania moczu i
stolca oraz czynności zwieraczy odbytu i cewki moczowej.
Powikłaniem
po
stabilizacji
było
nieprawidłowe
umieszczenie śruby transpedikularnej oraz zakażenie rany
pooperacyjnej. Wskutek tych powikłań konieczne było
usunięcie całej stabilizacji transpedikularnej. Zdarzenia te
znacznie spowolniły i ograniczyły cały proces rehabilitacji.
Pacjentka łącznie została poddana trzem operacjom
neurochirurgicznym wskutek nieprawidłowego umieszczenia
śrub transpedikularnych.
2 o p i s p r z y p a d k u . 31-letni mężczyzna po urazie
rdzenia kręgowego na wysokości T6. Wykonano stabilizacje
transpedikularną na poziomach od T5-T6. Powikłaniem było
nieprawidłowe umieszczenie w trzonie kręgu T5 śruby
transpedikularnej, co spowodowało powstanie tętniaka aorty.
Ostatecznie chory ponownie był operowany przez zespół
neurochirurgów i chirurgów naczyniowych z dobrym
rezultatem.
3 o p i s p r z y p a d k u . 26-letni mężczyzna po
złamaniu kręgosłupa i uszkodzeniu rdzenia kręgowego na
wysokości T5 i T6. Po wykonaniu stabilizacji
transpedikularnej wzrosły parametry stanu zapalnego tj.
gorączka oraz cechy zapalenia dróg oddechowych.
Wykonano zdjęcie radiologiczne płuc, które wykazało
zapalenie opłucnej oraz nieprawidłowe położenie śrub
transpedikularnych w trzonach T3 i T4. Chorego leczono
zachowawczo.
W n i o s k i . Powikłania opóźniają oraz zaburzają cały
proces rehabilitacji pacjenta. Kontrola radiologiczna po
wykonaniu stabilizacji transpedikularnej powinna być
wykonywana również po zabiegu operacyjnym, aby
zapewnić choremu bezpieczną pionizację oraz naukę chodu.
Wystąpienie dolegliwości bólowych wzdłuż dermatomów
odpowiadających
poziomom
wykonanej
stabilizacji
transpedikularnej może wskazywać na nieprawidłowe
położenie śrub transpedikularnych. W odcinku piersiowym
takie powikłanie może być groźne dla życia chorych, z
powodu
bliskiego
położenia
ważnych
struktur
anatomicznych.
Key words: spinal cord injury, thoracic injury, paraplegia, transpedicular stabilization
Słowa kluczowe: uraz rdzenia kręgowego, urazy odcinka piersiowego kręgosłupa, stabilizacja transpedikularna
INTRODUCTION
It was estimated during the International Spinal
Cord Society Conference in 2001 that approximately
17.2 people per million of the population in Europe
suffer from traumatic SCI (spinal cord injury) every
year. [1] Young people with average age of 40 years
old suffer from these injuries. More often these are
men than women; it is approximately 5-6 times more.
The cause of the spinal cord injuries are usually
communication accidents.
Looking at the incidence of levels of the injury it is
estimated that approximately 52% of cases are in
cervical region, 46% in thoracic, lumbar and sacral
region, remaining percentage is unrecorded.
In complete paraplegia there was the evidence of
recovery from flaccid muscle to antigravity grade in
86% of the muscles, but if there was no activity, only
26% of muscles can improve their activity to
antigravity grade. The presence of sensation in the
sacral region or voluntary anal sphincter motor activity
is a good prognostic factor for neurological recovery
and whole rehabilitation process. [2]
There are a lot of therapeutic indications to
neurosurgery interventions after spinal cord injury.
Without any doubts the most serious and obvious is
instability of the spine or/and neurovascular structures
compression.
Immediate
those
structures
decompression decreased the risk of neurological
deficits progression. The treatment of choice presents
transpedicular stabilization performed within the first
twenty-four hours following injury and then – intensive
rehabilitation. This procedure gives patients a chance
to improve their quality of life and achieve maximum
progress in rehabilitation process and treatment.
The postoperative complications are very seldom.
However, the most common are both general
postoperative wound infections, especially the
postoperative wound infection, as well as
extravertebral localization of transpedicular screws.
Dislocation of the screws are the cause of vascular
or/and neurological structures damage. However, for
example thoracic aorta aneurysm is a rare complication
after transpedicular stabilization because of spinal cord
injury.
Transpedicular stabilization complications in thoracic region of the spine after SCI - three cases report and literature review
CASE 1
system was removed since the improvement had not
been noticed.
History data. Patient (female) sustained the fraction
of T9 and L1 vertebral bodies along with spinal cord
injury within this level. Moreover, there were
haemothorax as well as bilateral rib fracture noticed.
The transpedicular stabilization was applied at the day
of accident, at the level of T8 – L1. Twenty days after
surgical procedure, the patient was subjected to another
– the correction of localization (decompression of
spinal cord, removal of osteal fragments from dural
sac, replacement of stabilization, introduction of titan
plates).
Examination. During the admission to a hospital,
the patient notified intense pain ailments – root pain
type. The examination revealed decreased muscle tone
of lower limbs, decreased tendon and periosteal
reflexes, lack of active movements within lower limbs
and trace movement in hip joint. Fecal and urinary
incontinence were observed.
Evaluation:
‐ ASIA (A)
‐
45
WISCI II 7- The patient adapted to active
wheelchair
Course of treatment. Girdle pain ailments within
the thorax intensified while tilting the patient to erect
position and limited significantly the breathing
exercises. That is why the imaging examination, which
revealed incorrect localization of stabilization system
of T8-T10 – direct neighborhood of screw with aorta at
the left side, within T8 level (Fig. 1), as well as
infringement of vertebral body, was carried out.
Another surgical procedure was carried out –
repositioning of T11 screw, at the left side and T8, at
the same surface, due to excessive mobility and also
limited location. The control CT examination revealed
position of T11 screw; T8 screw localized in a direct
contact with vertebral canal but not clashing with
vertebral column structures. There were antibiotics
introduced into the therapy.
Persistent pain ailments, notified by the patient
within the thorax, receded immediately after the
procedure. At the beginning the healing process of
postoperative wound proceeded successfully, but then,
the wound started dripping. The inoculation was
performed. Unfortunately, the infection (MethicillinSensitive Staphylococcus Aureus) covered the whole
stabilization region. The attempt of a treatment with
guided antibiotic was taken. The whole stabilizing
Fig. 1. NMR examination of the spinal column – the screw
modulates the abdominal aorta
CASE 2
History data. 31 year old patient (male) was
admitted to the University Hospital in Bydgoszcz with
deep tetraparesis.
Six weeks before admission, the patient sustained
multiorgan injury (ski accident), including cranial
trauma (brain and brain stem contusion, secondary
subarachnoid bleeding) as well as the thoracic spinal
cord injury. NMR examination revealed: compression
fracture of T6 vertebral body along with angular
position of spinal column, intervertebral stenosis
between T5-T6 and T6-T7, some part of chondroosseous structures translocated into the central canal,
exerting pressure on spinal cord at the distance of
about 15 mm.
The neurosurgical procedure for thoracic spinal
cord stabilization was delayed up to the fifth day, due
to the serious general condition (3 GCS).
Transpedicular screws were introduced within the level
of T5-T7, using X-ray monitor. There was
decompression laminectomy applied at the T6 level.
The existing compression syndrome evoked by
fragments of fractured bone from vertebral body was
noticed within the dural sac. The posterior spinal
arthrodesis was carried out by means of OMEGA
instrumentarium what made decompression within the
level of fracture possible.
Examination. Patient admitted to the rehabilitation
department within 6 weeks after the injury. Patient was
conscious, without verbal contact; serious paresis of
lower limbs was observed, without arbitrary movement
46
of lower limbs, upper limbs paresis, more significant at
the right side, paresis in regression, without
dysesthesia.
Evaluation:
GCS 13
ASIA B
WISCI II 0 (at admission) and 7 (after therapy)
Course of treatment. The arbitrary movement of
lower limbs, flexion within hip, knee joints as well as
feet movement appeared in a course of hospitalization.
Upper limbs paresis subsided completely. Because of
pain ailments within thoracic cord intensification, there
was guided X-ray imaging of T5-T7 carried out which
disclosed extravertebral location of T5 screw (Fig. 2).
Guided CT examination of T3-T8 thoracic cord level
was performed and revealed posttraumatic-state of T6
vertebral body fracture and postoperative state of
stabilization within T5-T7 level. The screws
incorporated at the level of T5 and T7, at the left side laterally situated from the vertebral pedicles and
bodies, and their extremities were localized within
direct neighbourhood of descending aorta.
Fig. 3. The aorta aneurysm in angio-CT examination
A group of physicians consisting of neurosurgeon,
vascular surgeon as well as cardiosurgeon decided to
remove dislocated screw.
The procedure was accompanied by vascular
surgeons because of the serious risk of surgical
intervention. Postoperative course was uncomplicated.
As a result of stabilization removal from T5 region
and non-union of fragments of T6 vertebra, patient was
equipped with orthesis stabilizing thoracic cord,
anticipated for the period of three months. CT control
examination of aorta that was carried out directly after
the procedure, 6 and 12 months after it, revealed
aneurysmal bulge of descending aorta at the distance of
7mm and diameter of 5 mm. The patient stays under
regular supervision of vascular surgeon.
Nowadays, the patient reveals satisfactory
neurological state (ASIA C), walks independently,
with crutches at long distances (WISCI), went back to
work.
CASE 3
Fig. 2. CT scan of T5 screw extravertebral location
Another, CT angiography examination revealed
aneurysmal bulge of thoracic aorta within a distance of
about 5 mm and T5 screw extremity adhered to it. The
screw applied to T7 vertebra at the left side modulated
thoracic aorta from medial side (Fig 3.).
History data. 26 year old patient admitted to the
rehabilitation department with serious paraparesis, two
weeks after surgical operation of spinal fracture. He
sustained the fracture of T5 and T6 vertebral bodies
along with the spinal cord injury, located at the same
level, as a result of traffic accident. The transpedicular
stabilization within the level of T3-T8 was carried out.
There were screws applied to T3, T4, T6, T7 as well as
T8 vertebral bodies.
Examination. Patient suffering from paraparesis,
none muscle tone, deep reflexes, superficial sensibility,
deep pain and temperature sensitivity below T6 level.
Fecal and urinary incontinence was observed.
Evaluation:
ASIA A
WISCI II 0 (at admission), 1 (after therapy)
Course of treatment. Patient demonstrated
subfebrile states, gradual increase of temperature as
well as inflammatory state indexes (CRP 163 mg/l,
WBC 14 x 103/ul), at the beginning the pleural rub
over lung fields, then vesicular murmur lowered. There
were X-ray examination of lungs and CT scan of spinal
column carried out within the region of stabilization to
find the source of inflammation. Dislocation of screw
within T3 and T4 vertebral column was disclosed – it
protruded about 9mm in front of T3 and 6mm in front
of T4 vertebral body (Fig.4).
Fig. 4. CT scan of T3 and T4 screw extravertebral location
Inflammatory atelectasis connected with pleural
exudates. The pleurisy was diagnosed. After
consultation with neurosurgeon and thoracosurgeon, it
was decided to abandon the operative treatment and
apply conservative therapy. Patient discharged from
hospital with improvement, tilted up.
DISCUSSION
The application of spinal column stabilization
increased in frequency during the last few decades. It is
connected with development of knowledge concerning
spinal column injuries, operative techniques as well as
application of more and more advanced instruments
[7].
47
The precursor of currently applied transpedicular
stabilization technique was King which introduced the
method in 1948. Roy-Camille improved it and spread
within the 70’s.
Unfortunately, along with increased amount of the
transpedicular stabilization procedures, the problems
connected with damages like: fractures or dislocations
of screws appear more often. In accordance with
Vanichkachorm, the value amounts to 3-19% and 4-8%
- according to McAfee [7, 8].
The diameter of spinal canal is of great significance
in thoracic spine fractures. The canal diameter of the
thoracic spine is narrower than that of the cervical and
lumbar spine. At the T6 level, the long axis of the
spinal canal is approximately 16 mm in diameter,
whereas in the middle of cervical and lumbar spine, the
long axis is 23 mm and 26 mm, respectively. The
smaller diameter may make fixation techniques such as
sublaminar wire fixation more difficult.
Dislocation of screws may damage partially or
completely the spinal cord, roots, liquorrhoea as well
as may cause the injury of main vessels [10, 11, 12].
There was compression on spinal roots noticed,
correlated with pain ailments of thorax, escalated
during the motion. In case of the third patient,
dislocated screw at the level of T3 and T4 vertebral
bodies, modulated the pleura, what caused
inflammatory reaction. In the second case, incorrect
location of transpedicular screw caused aneurysmal
bulge of thoracic aorta at a distance of about 5 mm,
where Th5 screw extremity adhered to it. The
anatomical nearness of thoracic cord and the aorta
presents increased danger of injury during the
procedure [13].
Most of described injures of aorta, resulting from
complication after transpedicular stabilization, were
caused by the damage of wall due to interaction of
vascular wall and metal instruments. Metal causes
erosion of vascular walls and finally the aortoclasia,
which may be deadly [12, 13, 14].
Another reason for damage of aorta is dislocation
of transpedicular screws, what causes direct tremor of
vascular wall. This dislocation caused formation of
thoracic aorta false aneurysm in the first case report.
Minor described similar case [14]; dislocation of screw
within T5 segment caused aortic wall injury and it was
discovered within the routine CT examination.
Dislocation of transpedicular screws, described in
our cases as well as by Minor, had place despite the
48
fact that the procedures were enhanced by X-ray
imaging. Such control presents a standard [8].
Nearness of thoracic spinal cord as well as aorta
run the risk of vascular injury resulted from the
procedure of screws removal [14, 16]. In the second
case, the procedure of screw removal was carried out
by posterior-access surgical procedure, in a presence of
vascular surgeon and the operating room was prepared
for the possible thoracotomy. Minor assumed the
similar pattern of procedure [14]. Vanichkachorn
describes difficulties of broken screw removal within
T12 segment, which translocated during the procedure
and had direct contact with aorta [7]. The possibility of
aorta injury resulting from application of
transpedicular stabilization in thoracic region of the
spine is caused by nearness of these structures.
Especially, the anterior-access procedures bring a risk
of complications [12, 13, 16].
Iatrogenic false aneurysm of thoracic segments
occurs during the invasive cardiologic procedures or
after some time, as a postoperative complication (e.g.
intraaortic counterpulsation) [13] or as a result of
cardiosurgical procedures (after coarctation of the
aorta, direct vascular wall injury, aortic valve
replacement and others) [16, 17, 18]. Transpedicular
stabilization presents rarely described etiology of such
aneurysms.
It seems, the correctly performed supervision of
patients after transpedicular stabilization located within
thoracic region, allows early detection of the possible
complications. In accordance with many authors, the
control should take place after 2, 8, 12, 26 and 52
weeks [8, 11, 14, 19, 21]. There is no standard
regarding the imaging method (X-ray or CT scan).
Computer tomography examination seems to be
indicated at least in case of the first supervision.
The back pain can not be disregarded in case of
patients subjected to procedures of spinal cord injuries,
which may stay irrelevant; however, it can result from
dislocation of stabilization instruments, the presence of
aortic aneurysm or irritation of other structures that are
located within direct neighbourhood [22, 23, 24, 25,
26, 27, 28, 29].
CONCLUSIONS
Complications prolong as well as disturb
rehabilitation treatment.
The control radiographic examinations need to be
performed directly after operative treatment to evaluate
the stabilization system during walking and assuming of
erect position. Increased pain ailments within spinal
cord segment that was subjected to surgical procedure
may signify the possible dislocation of screws. Such
dislocation, noticed within thoracic region, can be lifethreatening, because of the nearness of the significant
anatomical structures.
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[email protected]
Received: 8.03.2011
49
CASE REPORT / PRACA KAZUISTYCZNA
Edyta Sutkowska1, Anna Kołtowska2, Krzysztof Mastej3, Rajmund Adamiec3
TUBEROUS SCLEROSIS, LATE DIAGNOSIS: A CASE ANALYSIS
STWARDNIENIE GUZOWATE, PÓŹNE ROZPOZNANIE: OPIS PRZYPADKU
1
Department and Clinic of Orthopaedic and Traumatologic Surgery- Division of Rehabilitation
Head of the Department: Prof Szymon Dragan
Head of the Division of Rehabilitation: Prof Zdzisława Wrzosek
2
General Radiology, Interventional Radiology and Neuroradiology Clinic of Wroclaw Medical
University3Department of Angiology, Hypertension and Diabetology of Wroclaw Medical University
Summary
Tuberous sclerosis (TS) is an uncommon, congenital
disease, usually diagnosed during childhood. It is rare to find
undiagnosed adult patient. The fundamental feature of TS is
the presence of multifocal malignant tumors. In this study we
present a case of a 50-year-old woman with multiple tumors.
The characteristic features e.g. on the brain and abdomen CT
helped us diagnose this rare disease despite patient’s age. We
aimed at stressing the importance of careful medical
examination because of oligosymptomatic patients with TS.
Streszczenie
Stwardnienie guzowate jest rzadką chorobą wrodzoną,
zazwyczaj diagnozowaną już w dzieciństwie. Wyjątkiem są
osoby dorosłe, u których diagnoza zapada w życiu dojrzałym.
Typowo w tym schorzeniu występują liczne guzy, o bardzo
różnej lokalizacji. W poniższym opracowaniu prezentujemy
przypadek 50-letniej kobiety z późno zdiagnozowanymi,
licznymi zmianami guzowatymi w narządach. Ze względu, jak
wspomniano, na nietypowy dla rozpoznania stwardnienia
guzowatego, wiek pacjentki dopiero charakterystyczne zmiany
w tomografii komputerowej głowy i jamy brzusznej pozwoliły
na postawienie diagnozy. Opisany przykład podkreśla wagę
dokładnych badań, także dodatkowych, u chorych z
niejasnymi zmianami i konieczność uwzględnienia także
nietypowych dla wieku, rzadko występujących chorób
wrodzonych.
Key words: tuberous sclerosis, mutation, hamartoma, congenital disease
Słowa kluczowe: stwardnienie guzowate, mutacja, hamartoma, choroba wrodzona
INTRODUCTION
Tuberous sclerosis complex (TSC) is an
uncommon, autosomal dominant disorder characterized
by multifocal tumors. The prevalence of TSC is 1:8
000 to 1: 30 000 [1].
Disease is caused by mutations in the TSC1 and
TSC2 tumor suppressor genes on chromosomes 9q34
and 16p13.3, respectively [2]. These mutations result
in uncontrolled cell growth and tumourigenesis.
The main changes in TSC include hamartomas,
hamartias, hamartoblastomas, or choriostomas [3].
In TSC a number of organs are affected, including
the skin (prevalence depends on the type of
disturbances), eyes (approximately 40%) [4], heart
(rare in adults) and liver (40%-50%) [5], lungs (26%39%) [6,7], while the kidneys (75T-85%) [8] and brain
52
Edyta Sutkowska et. al.
(80%-95%) [9] are the two most frequently involved
organs [10].
Tuberous sclerosis (TS) is a disorder with a
variable clinical presentation usually diagnosed during
childhood. Mental retardation and seizures are the
most frequent clinical problems that are manifested
during infancy or childhood. The diagnosis is based on
clinical criteria - a combination of signs classified as
major or minor [11], is required to establish a clinical
diagnosis.
very small fatty tissue component); however,
malignancy was not excluded. TSC was suggested.
CASE REPORT
The study was approved by Commission of
Bioethics of Wroclaw Medical University. A
50year-old lady with left calf pain, originally diagnosed
as a symptom of deep venous thrombosis (DVT), was
admitted to the hospital.
The laboratory test results, including D-dimer, were
within norms except for a slight increase in
triglycerides and a slight decrease in the magnesium
level. She denied any chronic diseases.
She had 3 healthy, adult children and a 52-year-old
healthy sister. Her mother died at 77 years of age from
colon cancer and her father died at 57 years of age
from a stroke.
The physical examination showed a large, supple
tumour in the left popliteal space-there was no swelling
of the leg. An enlarged, heterogenic thyroid gland and
multiple, yellow-red papules on her nose and cheeks
were noted. She confirmed that she had been diagnosed
and treated for acne since the age of 5. . The remainder
of the physical examination was normal.
The history included several years of recurrent
abdominal pain. The pain was independent of the
menstrual cycle, bowel movements, or meals.
An ultrasound study did not show venous
thrombosis, but revealed a large (5x10 cm) Baker’s
cyst in the left popliteal space. A number of
irregularities were detected on abdominal echography,
so a CT scan was ordered. The abdominal tomography
showed a few cysts within both lobes of the liver up to
3 cm in diameter, multiple nodular lesions within both
kidneys
with
heterogeneous
densities
and
heterogeneous contrast enhancement with small
calcifications ( Fig.1, Fig.2). There was an enlarged
lymph node, measuring 1.5 cm in the short axis, within
the retroperitoneal space. The diagnosis suggested
multiple benign tumours within the kidneys, most
likely atypical angiomyolipomas (with or without a
Fig. 1. Right renal tumour-abdomen CT no 1
Ryc. 1. Guz prawej nerki-tomografia komputerowa jamy
brzusznej nr 1
Fig. 2. Right renal tumour-abdomen CT no 2
Ryc. 2. Guz prawej nerki- tomografia komputerowa jamy
brzusznej nr 2
There were inhomogenous and normoechogenic
nodules in the ultrasound study of the thyroid. There
were no changes on the chest x-ray and ECG.
A CT scan of the head (Fig.3, Fig.4) showed
several tiny calcified nodules bilaterally along the
cauodothalamic grooves in the caudate nuclei areas and
one adjoining to the body of the right ventricle. There
were several further cortical and subcortical white
matter calcified tubers in both the frontal and temporal
lobes. The appearance was classified as compatible
with TS.
A dermatologic consultation described the skin
changes as a high probability of angiofibromas.
Tuberous sclerosis, late diagnosis: a case analysis
Fig. 3. Brain CT no 1
Ryc. 3. Zmiany w tomografii komputerowej głowy- zdjęcie nr 1
53
tumours. Epithelioid angiomyolipomas can also be
found [14].
For the brain, the most characteristic findings are
subependymal and cortical and subcortical tubers. The
prevalence of subependymal giant cell ependymomas
(SEGAs) in patients with TSC is 6%-14% [15].
In such cases we found few important features
characteristic of TSC, including facial angiofibromas,
cortical tubers, subependymal nodules, 11 renal
angiomyolipomas, and liver cysts.
Our patient did not agree to further examination, or
for psychological testing. It was a very awkward
situation because of the possibility of renal cancer.
Two things could influence the patient decision.
Firstly, the patient’s mental status seemed to be slightly
deficient and limited the comprehension of the problem
and risk. Secondly, the course of the disease was nearly
asymptomatic. We offered patient diagnostic tests and
treatment wherever she decided for such care and
informed her about obligatory control.
As we presented, even for adult patients, we should
consider the presence of rare congenital diseases. It is
important especially if the patient’s clinical picture is
not consistent with our findings (e.g. ultrasound). The
brain characteristic image can be helpful for TSC
detection even if there are no clear signs from nervous
system. We aimed at stressing the importance of
careful medical examination because of such kind
oligosymptomatic patients.
REFERENCES
Fig. 4. Brain CT no 2
Ryc. 4. Zmiany w tomografii komputerowej głowy- zdjęcie nr 2
The patient was referred to an urologist who
recommended surgery for probable renal carcinoma.
The patient did not consent to surgery or any other
diagnostic tests (e.g., thyroid biopsy, skin biopsy,
colonoscopy, or genetic tests). She was informed of
the risk and was discharged from the hospital with an
information card.
CONCLUSIONS
Renal lesions associated with TS are serious, as
they are the second common cause of death after
lesions of the nervous system [12]. The most common
findings are polycystic kidney disease, renal lipomata,
or renal cancer [13], as a result of many benign
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tel.: 48 71 734 32 20; 48/503077016
fax:48 71 734 32 09;
Selected articles presented during
the 2nd International Conference
„Europejski Wymiar Nauk o Zdrowiu”
organized on the occasion of the XVth Anniversary
of Faculty of Health Sciences
at Collegium Medicum, Nicolaus Copernicus University
BYDGOSZCZ, March 19-20, 2012
GUEST EDITOR: PROFESSOR ZBIGNIEW BARTUZI
CONTENT
p.
Ewa Barczykowska, Anna Burczyk, Iwona Sadowska-Krawczenko,
M a r t a G r a b i n s k a , A n d r z e j K u r y l a k – Quality of life in children, adolescents
and young adults suffering from cystic fibrosis and in their parents . . . . . . . . . . . . . . . . . . . . . . . . .
61
G r a ż y n a B ą c z e k , E w a D m o c h - G a j z l e r s k a – Independent midwifery practice
in Poland – legal considerations versus reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
Bernadeta Cegła, Małgorzata Filanowicz, Aneta Dowbór-Dzwonka,
E w a S z y n k i e w i c z – Does the character of hypertension and mode of therapy determine
changes in the quality of life? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
77
Kamila Faleńczyk, Agnieszka Pluta, Wiesława Kujawa, Halina Basińska,
M a r i a B u d n i k - S z y m o n i u k , A l i c j a M a r z e c – Analysis of problems and their
determinants among family caregivers taking care of chronically ill people . . . . . . . . . . . . . . . . . . .
85
M i r o s ł a w a F e l s m a n n , A g a t a K o s o b u c k a – The influence of external, internal and artificial
environment upon the occurrence of breast cancer and coping with this disease. The verification
of the systemic theory of Betty Neumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
93
Mirosława Felsmann, Barbara Futyma, Mariusz Zbigniew Felsmann,
M a r z e n a A n n a H u m a ń s k a , B e a t a H a o r – Quality of life in children with epilepsy,
evaluated by the parents on the basis of QOLCE questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . .
99
Grażyna Franek, Marta Ćmiel-Giergielewicz, Zofia Nowak-Kapusta,
M a r z e n a Z m y s ł o - R o g o z i k – Awareness of risk factors assessment among individuals
with ischemic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
107
Małgorzata Graczyk, Michał Przybyszewski, Jacek Tlappa, Jacek Mućka,
Andrzej Kuźmiński, Magdalena Żbikowska-Gotz, Ewa Szynkiewicz,
Katarzyna Napiórkowska, Joanna Kołodziejczyk, Robert Zacniewski,
A n n a R ó ż a l s k a , Z b i g n i e w B a r t u z i – Determination of ECP concentration in patients
with allergic type of food hypersensitivity and in subjects with dyspeptic symptoms not associated
with food allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
113
Anna Grzanka-Tykwińska, Alicja Rzepka, Katarzyna Porzych, Krzysztof
K u s z a , K o r n e l i a K ę d z i o r a - K o r n a t o w s k a – The quality of life of patients
over 60 including demographic and environmental factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119
Beata Haor, Kamila Korniluk , Mirosława Felsmann, Marzena Humańska
– Tasks of a nurse in seniors’ preparation for self-care in the course of type 2 diabetes . . . . . . . . . .
125
Judyta Kutowska, Małgorzata Gierszewska, Estera Mieczkowska,
G r a ż y n a G e b u z a , M a r z e n a K a ź m i e r c z a k – Quality of life among women
with gestational diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
133
M a g d a l e n a M i ń k o , D o r o t a S i w c z y ń s k a – Breast cancer prevention as a part
of health policy activities in Lublin province . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
139
Agnieszka Pluta, Magdalena Skrzeszewska, Halina Basińska,
M a r i a B u d n i k - S z y m o n i u k , K a m i l a F a l e ń c z y k – The functional
efficiency in elderly patients treated with hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
143
Iwona Sadowska-Krawczenko, Agata Staśkiewicz, Andrzej Kurylak,
B a r c z y k o w s k a E w a , A l d o n a K a t a r z y n a J a n k o w s k a – The knowledge
of nurses working in pediatric wards of assessment and treatment of pain in children . . . . . . . . . . .
149
P a w e ł S z c z u d ł o , M a r t a H r e ń c z u k – Variability of drugs with narrow therapeutic window
in transplantology – potential costs and clinical consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
155
Monika Zawadka, Paweł Zalewski, Jacek J. Klawe, Małgorzata
Tafil-Klawe, Joanna Pawlak, Krzysztof Kunikowski, Anna Bitner
– Cardiovascular autonomic regulation in response to orthostatic stress with Parkinson’s
disease – case report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
161
A n e t a Z r e d a - P i k i e s , A n d r z e j K u r y l a k – Evaluation of the quality of life of children
who have completed acute lymphoblastic leukemia treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
169
SPIS TREŚCI
str.
Ewa Barczykowska, Anna Burczyk, Iwona Sadowska-Krawczenko,
M a r t a G r a b i n s k a , A n d r z e j K u r y l a k – Jakość życia dzieci, młodzieży
i młodych dorosłych chorych na mukowiscydozę oraz ich rodziców . . . . . . . . . . . . . . . . . . . . . . . . .
61
G r a ż y n a B ą c z e k , E w a D m o c h - G a j z l e r s k a – Samodzielna praktyka położnej
w Polsce – uwarunkowania prawne a rzeczywistość . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
Bernadeta Cegła, Małgorzata Filanowicz, Aneta Dowbór-Dzwonka,
E w a S z y n k i e w i c z – Czy specyfika choroby nadciśnieniowej i sposób przyjmowania leków
w zastosowanej terapii są determinantami zmian w jakości życia chorych? . . . . . . . . . . . . . . . . . . .
77
Kamila Faleńczyk, Agnieszka Pluta, Wiesława Kujawa, Halina Basińska,
M a r i a B u d n i k - S z y m o n i u k , A l i c j a M a r z e c – Analiza problemów opiekunów
rodzinnych osób przewlekle chorych oraz czynników wpływających na ich występowanie . . . . . .
85
M i r o s ł a w a F e l s m a n n , A g a t a K o s o b u c k a – Wpływ środowiska zewnętrznego,
wewnętrznego i wykreowanego na występowanie raka piersi i radzenie sobie z chorobą.
Weryfikacja teorii systemowej Betty Neumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
93
Mirosława Felsmann, Barbara Futyma, Mariusz Zbigniew Felsmann,
M a r z e n a A n n a H u m a ń s k a , B e a t a H a o r – Jakość życia dzieci z padaczką
w ocenie rodziców na podstawie kwestionariusza QOLCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
99
Grażyna Franek, Marta Ćmiel-Giergielewicz, Zofia Nowak-Kapusta,
M a r z e n a Z m y s ł o - R o g o z i k – Ocena stanu wiedzy na temat czynników ryzyka
wśród chorych z niedokrwienną chorobą serca . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
107
Małgorzata Graczyk, Michał Przybyszewski, Jacek Tlappa, Jacek Mućka,
Andrzej Kuźmiński, Magdalena Żbikowska-Gotz, Ewa Szynkiewicz,
Katarzyna Napiórkowska, Joanna Kołodziejczyk, Robert Zacniewski,
A n n a R ó ż a l s k a , Z b i g n i e w B a r t u z i – Ocena stężenia ECP u pacjentów z nadwrażliwością pokarmową typu alergicznego i u pacjentów z objawami dyspeptycznymi bez alergii
pokarmowej . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
113
Anna Grzanka-Tykwińska, Alicja Rzepka, Katarzyna Porzych, Krzysztof
K u s z a , K o r n e l i a K ę d z i o r a - K o r n a t o w s k a – Jakość życia pacjentów powyżej
60 roku życia z uwzględnieniem czynników demograficzno-środowiskowych . . . . . . . . . . . . . . . . .
119
Beata Haor, Kamila Korniluk , Mirosława Felsmann, Marzena Humańska
– Zadania pielęgniarki w przygotowaniu do samoopieki seniorów w przebiegu cukrzycy typu 2 . .
125
Judyta Kutowska, Małgorzata Gierszewska, Estera Mieczkowska,
G r a ż y n a G e b u z a , M a r z e n a K a ź m i e r c z a k – Jakość życia kobiet z cukrzycą
ciążową . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
133
M a g d a l e n a M i ń k o , D o r o t a S i w c z y ń s k a – Profilaktyka raka piersi jako element
działań z zakresu polityki zdrowotnej w województwie lubelskim . . . . . . . . . . . . . . . . . . . . . . . . . .
139
Agnieszka Pluta, Magdalena Skrzeszewska, Halina Basińska,
M a r i a B u d n i k - S z y m o n i u k , K a m i l a F a l e ń c z y k – Sprawność funkcjonalna
u pacjentów w wieku podeszłym leczonych hemodializą . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
143
Iwona Sadowska-Krawczenko, Agata Staśkiewicz, Andrzej Kurylak,
B a r c z y k o w s k a E w a , A l d o n a K a t a r z y n a J a n k o w s k a – Wiedza pielęgniarek
pracujących w oddziałach pediatrycznych w zakresie oceny i leczenia doznań bólowych u dzieci . .
149
P a w e ł S z c z u d ł o , M a r t a H r e ń c z u k – Zmienność leków o wąskim oknie terapeutycznym
w transplantologii – potencjalne koszty I konsekwencje kliniczne . . . . . . . . . . . . . . . . . . . . . . . . . .
155
Monika Zawadka, Paweł Zalewski, Jacek J. Klawe, Małgorzata
Tafil-Klawe, Joanna Pawlak, Krzysztof Kunikowski, Anna Bitner
– Autonomiczna regulacja sercowo-naczyniowa w odpowiedzi na pionizację u pacjentów z chorobą
Parkinsona – studium przypadku . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
161
A n e t a Z r e d a - P i k i e s , A n d r z e j K u r y l a k – Ocena jakości życia dzieci po zakończonym
leczeniu ostrej białaczki limfoblastycznej . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
169
Ewa Barczykowska1, Anna Burczyk2, Iwona Sadowska-Krawczenko1, Marta Grabinska3, Andrzej Kurylak1
QUALITY OF LIFE OF CHILDREN, ADOLESCENTS AND YOUNG ADULTS
SUFFERING FROM CYSTIC FIBROSIS AND OF THEIR PARENTS
JAKOŚĆ ŻYCIA DZIECI, MŁODZIEŻY I MŁODYCH DOROSŁYCH
CHORYCH NA MUKOWISCYDOZĘ ORAZ ICH RODZICÓW
1
Paediatric Nursing Research Institute Nicolaus Copernicus University in Toruń
2
Graduate from nursing, second level degree studies at , Nicolaus Copernicus University in Toruń Collegium
Medicum in Bydgoszcz, operating theatre ward at A. Jurasz University Hospital no. 1. in Bydgoszcz.
3
Students' Paediatric Nursing Research Society, student of nursing research, first level degree full-time studies at
Nicolaus Copernicus University in Toruń Collegium Medicum in Bydgoszcz
Summary
A i m . Assessment of quality of life of children,
adolescents and adults suffering from cystic fibrosis and of
their parents.
Met h o d s . Examination involved 23 persons (16
patients and 7 parents). Questionnaires CDQ-12-13, CFQ-14
and CFQ-6-13 were used as research tools.
R e s u l t s . Children between 12 and 13 years old, as
well as young adults and adolescents ranked their physical
aptitude and their food-related behaviours as highest, and the
appearance of their bodies as lowest. Parents, on the other
hand, assessed eating as a difficult effort for their children. A
decisive majority of the parents claimed, that everyday
therapy was time-consuming, yet fulfilling the therapy
recommendations was not intensely difficult for the child.
Also for adolescents and young adults, only minimally do the
limitations resulting from a prolonged systematic therapy
obstruct everyday life.
C o n c l u s i o n . The assessment of quality of life of
children suffering from cystic fibrosis is varied. The highest
patients' quality of life assessment is found in schoolchildren
aged 12 to 13. Patients assess their body image as very poor.
Streszczenie
C e l . Ocena jakości życia wśród dzieci, młodzieży i
dorosłych chorych na mukowiscydozę oraz ich rodziców.
M e t o d y . Badaniu poddano 23 osoby (16 chorych i 7
rodziców). Jako narzędzia badawcze wykorzystano
kwestionariusze CFQ-12-13, CFQ-14 + oraz CFQ- 6-13.
W y n i k i . Dzieci w wieku 12-13 lat oraz młodzi
dorośli i młodzież powyżej 14 lat najwyżej ocenili
funkcjonowanie fizyczne oraz zachowania związane z
jedzeniem a najniżej wygląd własnego ciała. Natomiast
rodzice najwyżej ocenili stan emocjonalny, a najniżej zakres
dotyczący masy ciała chorego dziecka. Wśród chorych na
mukowiscydozę problemy związane z jedzeniem występują
sporadycznie. Natomiast większość rodziców chorych dzieci
ocenia, że jedzenie jest dla dzieci trudne. Zdecydowana
większość rodziców stwierdza, że codzienna terapia jest
czasochłonna, jednak stosowanie się do zaleceń
terapeutycznych nie sprawia dziecku dużych trudności.
Także dla młodzieży i młodych dorosłych ograniczenia
związane z przewlekłym i systematycznym leczeniem w
niewielkim stopniu utrudniają życie codzienne.
Wnioski.
Ocena jakości życia dzieci z
mukowiscydozą jest zróżnicowana. Najwyższa ogólna ocena
62
Ewa Barczykowska et. al.
jakości życia wśród chorych występuje w grupie dzieci
szkolnych w wieku 12-13 lat. Chorzy bardzo nisko oceniają
wygląd własnego ciała.
Key words: quality of life, children, cystic fibrosis
Słowa kluczowe: jakość życia, dzieci, mukowiscydoza
INTRODUCTION
Cystic fibrosis (CF) is a genetically conditioned,
multi-organ systemic disease [1, 2, 3]. The disease is
caused by mutation of a gene coding protein synthesis,
CFTR (Cystic Fibrosis Transmembrane Regulator),
which regulates transportation of ions within the cell
membrane. Due to disturbances in the transportation of
chloride ions, re-absorption of sodium ions and water
is increased, while mucus rises in density and
viscosity. As a result, an irreversible and gradual
depletion of respiratory system occurs [1, 2, 4].Chronic
infections of respiratory tracts, as well as bronchitis,
lead to a gradual respiratory failure [5]. In 85-90% of
cases exocrine pancreatic insufficiency and gastrointestinal problems occur. The clinical picture is
conditioned by the patient's age [1].
Standard therapy in cystic fibrosis is multidirectional and includes antibiotic therapy, chest
physiotherapy,
bronchi-expanding
and
antiinflammatory medicines, oxygen therapy and treatment
of late after-effects of the disease and its complications
[6, 7, 8]. All patients receive pancreas enzyme
preparations before each meal, pharmaceuticals
decreasing hydrochloric acid secretion, preparations of
vitamin A, D, E and K. An intensive consumption of
calories (130% of norm) is necessary [2, 9].
An early beginning of treatment leads to
progression of changes and is a key to increasing
quality of life in CF patients [10]. Progress in medicine
over the years led to extension of cystic fibrosis
patients' lifespan [2, 6, 7]. Average lifespan of these
patients increased from 31 to 37 years over the last
decade (30 years in 1999) [11, 12]. Average lifespan
for children born in the 21st century is estimated as 50
years [13]. A well managed therapy effects in a
satisfactory quality of life for most adult patients [7].
The disease and its treatment have a considerable
impact on patient's everyday life [2, 9, 14]. Therefore,
examining the influence of the disease on patient's
quality of life has become very popular in recent years.
Such examination aims, among other goals, at
determining the impact of treatment on patient's
functioning, assessing benefits and losses ensuing from
introduction of new forms of therapy, facilitating
clinical decision making [15, 16, 17].
First results of cystic fibrosis patients' quality of
life examination were published in 1989. The research
concentrated on assessing the physical mobility and
social limitations in the context of respiratory system's
functioning and exercise-stress capacity [18, 19]. Later
research involved measuring the effect of different
therapies, including lungs transplantation [20, 21].
Valuable research compared cystic fibrosis patients'
quality of life to the quality of life of patients suffering
from other chronic diseases of the respiratory system
[22, 23].
AIM OF THE RESEARCH
The research aimed at assessing the quality of life
in cystic fibrosis patients, including physical activity,
roles played by the patient, vitality, social and
emotional activity, perception of patient's own
condition, body image, digestion disturbances,
Treatment Constrains, symptoms within the respiratory
and digestive systems.
Research problems were formed into the following
questions:
1. Which of the areas covered by the
examination were ranked highest and lowest by
adolescents and adults, by schoolchildren and parents
of children aged 6 to 13?
2. What is the general quality of life rating in
cystic fibrosis patients in a group of adolescents and
adults, schoolchildren and parents of children aged 6 to
13?
3. How do cystic fibrosis patients perceive their
own bodies?
4. What was the rating of digestive behaviours in
adolescents and adults, schoolchildren and parents of
children aged 6 to 13?
5. How do patients perceive constrains related to
their treatment?
PATIENTS AND METHODS
Research involved examining 23 persons: parents
of children aged 6-13, adolescents and young adults
suffering from cystic fibrosis, who were patients of
Quality of life of children, adolescents and young adults suffering from cystic fibrosis and of their parents
Paediatrics, Pneumologic and Alergologic Ward with
Infant Subward and of cystic fibrosis out-patient clinic
at Children's Regional Hospital in Bydgoszcz.
In the research conducted among parents, a decisive
majority of their children were aged between 12 and 13
(42.9% and 28.6%). There were also two younger
children, aged 8 and 10 (14.3%). Questionnaires were
filled by mothers only (100%). The mothers were aged
between 33-35 (42.9%) and 36-47 (57.1%). A decisive
majority of children came from married parents; one
child had parents living in concubinage. 42.9% of the
women were graduates of high schools and the same
percentage graduated from vocational schools.
Questioned about current occupation, 57% of the
mothers answered: „housekeeping”, while 28.6%
worked full-time or part-time. Most children (71.4%)
studied in schools.
In case of questionnaire CFQ-14+, 61.5%
respondents were persons between 14 and 17 years,
while 38.5% are persons between 20 and 28 years. A
decisive majority of the respondents, 10 persons, were
women (76.9%), while 3 were men (23.1%).
Questioned about school and work, 53.8% of the
respondents answered, they kept going to school as
usual. 4 persons (30.8%) answered, they restrained
from going to school or work because of health
problems. Among 13 respondents, only 1 was married,
and 92.3% were single. Questioned about education,
61.5% respondents confessed they graduated from a
high school. Only 1 person had achieved a high school
finals diploma (7.7%), the same number completed a
junior college, 23.1% graduated from a vocational
school. Answering the question about educational or
occupational situation, 38.5% responded they attended
classes at school, while 30.8% learned at home. 1
person (7.7%) worked full- or part-time, the same
number was searching for a job. Only 1 person
admitted they did not go to school or work because of
their health condition.
Questionnaire CFQ-12-13 was filled by 3 persons
only. 66.7% were children aged 12, and 33.3% were
children aged 13. Majority of the group consisted of
girls (66.7%), boys forming 33.3%. 2 children (66.7%)
attended classes at school as usual, the same number
were 5th grade primary school pupils. Only 1 person
had an individual mode of education.
Research was done using a polish version of
Quality of Life Questionnaire adapted for children and
adults with cystic fibrosis, as well as for their parents
63
(CFQ-R). The Questionnaire consisted of three
versions:
- adolescents and parents (age 14 and older) - CFQ14+,
- older schoolchildren (age 12-13) - CFQ-12-13,
- parents of children aged 6 to 13 - CFQ-6-13.
The original version of the questionnaire was
assembled in France and became adapted in Germany,
Netherlands, Brazil and United States. The Polish
version of the questionnaire originated from an
international research and is adapted from the
American test. The questionnaires were adjusted to
Polish conditions by D. Sands, Ph.D., and U.
Borawska-Kowalczyk, MA at Mother and Child
Institute in Warsaw [24].
The aim of the statistic analysis was to determine
quality of life in groups of patients for each domain,
and to compare general quality of life levels in these
groups. Parametric and non-parametric significance
tests were used to verify hypotheses proposed.
Respondents filled the questionnaires answering
questions they contained. Questions demanded
answering with grades according to Likert's scale, from
1 to 4. In several cases, grades in the questionnaire
demanded an inversion, following the formula: grade=
5-X, where X was a grade to be inverted.
Standardized quality of life ratings (QoLR) of each
patient in a given domain were calculated according to
the formula:
sum of points − minimum possible sum of points
QoLR=
─────────────────────────────
x 100
maximum possible sum of points - minimum possible
sum of points
All QoLR values are situated within the range of 0
to 100, a higher rating signifies a better quality of life.
RESULTS
In the analysis and discussion of the results, a
system resulting from specific research problems of
this paper was used.
1. Areas ranked highest and lowest by
adolescents and young adults, schoolchildren and
parents of children aged 6 to 13.
7
81.5 93.3 80.0 50.0 55.6 77.8 77.8 66.7 77.8 88.9 88.9
M
70.9 74.3 64.8 61.9 52.4 57.1 58.7 33.3 63.5 71.4 66.7
SD
17.3 15.1 12.0 35.6 17.8 32.3 24.6 27.2 28.5 24.1 29.4
Digestive behaviours
Treatment Constrains
Respiratory system
functioning
33.3
M
79.6 73.6 77.8 48.1
55.6
74.1
75.0
66.7
29.4
17.0
16.7
33.3
7.3
28.0
Group 2. Children aged 12 and 13. The examined
group included 3 children at this age. Highest results
were achieved in scales measuring physical
functioning (M=79.6) and social limitations (M=77.8).
Lowest were the ratings related to body image
(M=48.1) and digestive behaviours (M=55.6). Group 3.
Adolescents and adults (patients aged over 14). (table
3).
Table III. Means and standard deviations for respective
areas of the CFQ-14+ test
Areas
1 100 83.3 86.7 100 100 100 77.8 88.9 100 100 100
100
2 37.5 33.3 6.7 66.7 44.4 33.3 50.0 33.3 25.0 66.7 55.6 88.9
3 50.0 83.3 66.777.8 66.7 88.9 83.3 66.7 75.0 100 94.4 100.0
4 33.3 33.3 53.333.3 33.3 44.4 50.0 55.6 58.3 33.3 0.0
22.2
5 79.2 33.3 6.7 77.8 88.9 55.6 55.6 0.0 66.7 33.3 83.3 66.7
6
Highest results were achieved in the areas related to
the emotional state (M=74.3) and functioning of the
respiratory system (M=71.4), while the lowest result
was achieved in the area of body mass (M=33.3).
(table 2).
Emotional condition
SD 21.0 13.4
Digestive sytem
functioning
Body image
58.3
Social limiations
88.9
Physical functioning
33.3
Respiratory system
functioning
Digestive sytem
functioning
70.4 86.7 60.0 100.0 77.8 100.0 44.4 66.7 66.7 77.8 88.9
94.4 83.3 85.7 77.8
Body mass
6
3
Role limitations
88.9 73.3 60.0 50.0 44.4 55.6 77.8 33.3 77.8 55.6 44.4
66.7
Body image
40.7 66.7 66.7 83.3 22.2 33.3 33.3 33.3 11.1 66.7 77.8
5
100
91.7
Social limiations
4
75.0
55.6
Health perception
74.1 73.3 80.0 50.0 66.7 66.7 77.8 33.3 66.7 83.3 100
77.8
44.4
85.2 46.7 46.7 00.0 55.6 00.0 22.2 00.0 44.4 100.0 22.2
3
88.9
88.9 58.3 71.4 22.2
55.6 80.0 60.0 100.0 44.4 66.7 77.8 00.0 100 27.8 44.4
2
55.6 79.2 76.2 44.4
2
Emotional condition
1
1
Vitality
Respiratory system functioning
Body mass
School performance
Body image
Social limiations
Health perception
Emotional condition
Vitality
Respondents
Areas
Areas
Table I. Means and standard deviations for respective areas
of the CFQ-6-13 test
Table II. Means and standard deviations for respective areas
of the CFQ-12-13 test
Respondents
2. General CF patients' quality of life rating in
the group of adolescents and young adults,
schoolchildren and parents of children aged 6 to 13.
3. Body appearance rating.
4. Digestive behaviours in adolescents and
young adults, schoolchildren and parents of children
aged 6 to 13.
5. Treatment Constrains.
1. Areas ranked highest and lowest by
adolescents and young adults, schoolchildren and
parents of children aged 6 to 13.
Group 1. Parents/ legal guardians of children aged 6 to
13.
The following table contains quality of life ratings for
each of the 7 respondents in respective domains,
calculated according to the foregoing formula, as well
as mean values (M) and standard deviations (SD) in
each domain. (table1)
Respondents
64
4.2 50.0 46.766.7 33.3 22.2 44.4 33.3 50.0 0.0 61.1 77.8
7 66.7 25.0 100 100 55.6 77.8 66.7 100 58.3 100 27.8 66.7
8 70.8 66.7 86.7 100 44.4 77.8 77.8 55.6 66.7 66.7 44.4 88.9
9 91.7 66.7 100 100 88.9 77.8 88.9 100 83.3 100 88.9 88.9
10 70.8 33.3 46.788.9 66.7 44.4 61.1 0.0 50.0 33.3 72.2 44.4
11 62.5 58.3 66.7 100 33.3 66.7 55.6 66.7 50.0 0.0 22.2 66.7
12 66.7 83.3 100 100 66.7 88.9 66.7 11.1 100 0.0 72.2 88.9
13 79.2 75.0 86.7 100 66.7 44.4 88.9 33.3 83.3 66.7 50.0 88.9
M 62.5 55.8 65.685.5 60.7 63.2 66.7 49.6 66.7 53.8 59.4 76.1
SD 25.9 22.1 32.520.5 22.5 24.2 15.4 34.7 21.5 39.8 30.1 22.6
The test for persona over 14 revealed highest
results in the scale for digestive behaviours (M=85.5)
and functioning of the digestive system (M=76.1), and
the lowest results in the area related to body image (M49.6) and body mass (M=53.8).
2. quality of life rating among cystic fibrosis
patients, in the group of adolescents and adults,
schoolchildren and parents of children aged 6-13.
The following table presents mean values and
standard deviations for quality of life ratings in the
three compared groups, as well as the result of testing
distribution normality in group 2 numbering less than
50. ( table 4)
Table IV. Mean values and standard deviations for quality of
life ratings
W
Group 1
77
61.4
25.8
-
Group 2
24
68.8
21.5
0.940
Group 3
156
63.8
27.5
-
Wkr
-
0.914
-
normality
n/a
yes
n/a
n*
Mean
SD
ShapiroWilk's test
for
normality
Among the three groups the highest quality of life
was found in children aged 12 and 13.
Shapiro-Wilk's test for normality did not reject a
hypothesis that the distribution of quality of life ratings
in group 2 did not significantly differ from a normal
distribution.
To compare mean values, a z-test was used, based
on a normal distribution and Student's t test. Z-test is
used to compare mean values in two large (>50)
groups, in this case groups 1 and 3.
It was proved, that the distribution of quality of life
ratings in group 2 did not significantly differ from the
normal. Snedecor's F test also did not detect significant
differences between variances in groups 1-2 and 2-3
(values of calculated F-statistics are lower than critical
values). This allowed using the Student's parametric t
test to compare mean values in these groups. To
compare groups 1-3 the z-test was used.
No significant difference between mean quality of
life ratings in the compared groups was detected. All
values received through statistic calculations are lower
than critical values collected from respective tables at
significance level p=0.05.
3. Perception of body image.
Body image received the lowest grade among all
domains ranked by the respondents. In one of the
65
groups it received a mean value M of 48.1, while in the
other, 49.6.
Questions about body mass appeared in two
versions of the test only, and also this domain was not
ranked high among CF patients and their parents. The
parents graded this domain very poor (M=33.3).
4.
Digestion-related
behaviours
among
adolescents and adults, schoolchildren and parents of
children aged 6-13.
Rating digestion-related behaviours, patients with
cystic fibrosis and their parents ranked high compared
to other domains. Adolescents and adults suffering
from cystic fibrosis received a high result in this
domain (M=85.5).
Questioned about difficulties related to eating, most
parents agreed, that eating was difficult for their
children.
Over a half of adolescent and adult respondents
(69.2%) claimed they always ate with pleasure.
Ranking an answer about forcing themselves to eat,
84.6% claimed it was untrue. Difficulties with eating
appeared occasionally or never in 92.3% of
respondents.
5. Limitations related to treatment.
Answering questions about treatment-related
limitations, 85.7% of parents of children aged 6 to 13
answered, that to follow therapy instructions daily
causes child little difficulty. Moreover, a large number
of parents (71.4%) claimed, that treatment did not
obstruct child's everyday activities. A majority of
parents though, namely 85.8%, confirmed that medical
procedures take a considerable amount of time every
day.
84.6% of adolescents and adults answering
questions about treatment-related limitations claimed
that treatment caused little or some difficulties for their
everyday life. Questioned about perception of everyday
treatment, 61.6% claimed, that treatment had caused
them little or no difficulty.
DISCUSSION
As research reveals, the age of the examined patient
is one of the factors determining perception of quality
of life [19, 25]. Results of research undertaken by
Sands and Borawska-Kowalczyk on 128 persons (91
cystic fibrosis patients and 37 parents) show, that
children aged 12-13 achieved the most points in scales
measuring emotional state (M=72.91) and functioning
of the respiratory system (M=72.12), while the least
66
points were achieved in the areas related to body image
(M=65.38) and limitations associated with digestion
(M=65.81) [24]. In our independent research, the
highest results for the same age group were achieved in
the scales measuring physical functioning and social
limitations, while the lowest were achieved in areas
related to body image and digestive limitations. In
instances, body image as well as digestive limitations
was ranked poorest. In the test by Sands and
Borawska-Kowalczyk for persons aged over 14,
digestion-related behaviours ranked highest (M=84.23)
and body mass perception ranked lowest (M=55.91)
[24]. These results agree with the results of our
research.
Subject literature suggests differences between
quality of life perception by child patients [25] and
their parents. In the parents' questionnaire Sands and
Borawska-Kowalczyk received the highest ranks in the
area related to functioning of the digestive system
(M=81.68), while the lowest ranks appeared in the area
related to body mass (M=48.65) [24]. Our research
does not confirm this as for the highest ranks. Parent
respondents indicated the area related to emotional
stress and functioning of the respiratory system.
However, we recorded agreement of the results in the
lowest range, which is the child patient's body mass.
Cystic fibrosis patients perceive their digestive
problems as intermittent. Nevertheless, Polish research
on CF child patients' nutrition conducted by Brudziński
and focusing on biological indicators, revealed
deficient body mass in relation to height in 35% of
children. L. Majek's research showed underweight in
64% of respondents [26]. Analysis of our independent
research's results indicates that a decisive majority of
cystic fibrosis patients are aware of the fact, that they
experience problems with body mass and body image
as compared to their healthy peers. A majority of child
patients' parents define eating as difficult for children.
A decisive majority of the parents claim, that
everyday therapy takes time, nevertheless following
therapy recommendations does not cause significant
difficulties for the child. Hegarty notes, that “treatment
burden” is perceived as less significant by child
patients aged 6 to 13, than by their parents [25].
Global quality of life factor achieved by
respondents varies between (M=61.4) and (M=68.8).
In the research conducted by Sands and BorawskaKowalczyk quality of life factor is higher than in our
research, and amounted to (M=70.21) in children aged
12-13, (M=65.2) in parents, and (M=70.4) in patients
aged over 14 [24].
Belgian research reveals that beginning education
or work by CF patients is closely connected with health
condition. Decision to stop attending classes at school
or quit work, is difficult and has impact on personal,
social and financial quality of life [27]. In Majek's
research, the number of CF patients engaging in
marriages or employment is low. 36% had never
worked professionally, and 16% lived in formal or
informal relationships. One can notice a high
percentage of persons with high school education
(about 88% of respondents graduated from a primary
school) [26].
Every chronic disease evokes strong negative
emotions. Many authors emphasise not only somatic
symptoms on patient's functioning, but also mental
burden as well [28, 29]. In Staab's research special
attention was focused on the demand to mentally
support the patient with their adaptation and everyday
functioning with a chronic disease like cystic fibrosis,
and not only delivering medical service [30].
CONCLUSION
1. Quality of life assessment for children with cystic
fibrosis is varied.
2. Highest general ranking of quality of life among
patients appears in a group of schoolchildren aged 1213.
3. Patients rank their body image very poor.
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Ewa Barczykowska
UMK w Toruniu
Collegium Medicum im. L. Rydygiera
ul. Techników 3
85-801 Bydgoszcz
tel: 52 585 21 93
Grażyna Bączek, Ewa Dmoch-Gajzlerska
INDEPENDENT MIDWIFERY PRACTICE IN POLAND
– LEGAL CONSIDERATIONS VERSUS REALITY
SAMODZIELNA PRAKTYKA POŁOŻNEJ W POLSCE
– UWARUNKOWANIA PRAWNE A RZECZYWISTOŚĆ
Department of Gynecologic and Obstetrical Didactics, Warsaw Medical University, 00-424 Warsaw, Poland
Zakład Dydaktyki Ginekologiczno-Położniczej
Kierownik: prof. dr hab. Ewa Dmoch-Gajzlerska, Wydział Nauki o Zdrowiu, Warszawski Uniwersytet Medyczny
Summary
O b j e c t i v e . To assess the readiness of midwives in
regards to carrying out complex independent care for
expecting families during physiological pregnancy, delivery
and puerperium; to evaluate the role of midwifery practice
during individual preparation of a woman (and her spouse)
for childbirth; to define the elements of health education
included in preparation for childbirth.
M a t e r i a l a n d m e t h o d . Design - questionnaire
survey. Setting - eight types of hospitals located in and
outside of Warsaw. Participants - 291 practicing midwives
with current or past practice in the delivery room.
F i n d i n g s . The majority of midwives (232; 80%)
declared their readiness to provide complex care to expecting
families and offered individual preparation of women (and
their spouses) for delivery. Most state obstacle is the lack of
practice, the need to improve skills and prevent system. The
majority of midwives practice individual preparation of
women for childbirth (172; 59%).
Midwives complementary education for masters, much
less frequently (72; 47%) operate this type of care than the
other (76; 71%) - p = 0.001. This form of practice is
implemented by the midwives hot properties (25; 83%) - p =
0.017. The most frequent components of prenatal health
education included: biological aspects of pregnancy, delivery
and puerperium, followed by psychological aspects, hygiene,
diet, physical activity and prenatal communication with the
child.
Conclusions
and
implications
for
p r a c t i c e . Independent midwifery practice is not limited
by Polish law. The obstacles faced by independent midwives
are associated rather with the healthcare system and the
mentality of its workers. The profession of midwifery should
be strengthened by extensive media campaigns promoting the
competency of this professional group, along with the
completion of graduate and postgraduate education curricula
in aspects useful for running independent practice.
Streszczenie
C e l e m p r a c y jest próba odpowiedzi na pytanie czy
położne mają możliwość podejmowania, gwarantowanej
przez ustawodawstwo, indywidualnej i samodzielnej praktyki
w opiece nad zdrową kobietą oczekującą dziecka.
M a t e r i a ł i m e t o d a . Badania przeprowadzono
metodą sondażu diagnostycznego. Narzędziem badawczym
był samodzielnie skonstruowany dla celów pracy
kwestionariusz ankiety. Zbadano grupę 291 położnych
praktykujących obecnie lub w przeszłości w sali porodowej,
zatrudnionych w ośmiu szpitalach warszawskich i poza
Warszawą.
W y n i k i . Większość badanych (232, 80%) uznała, że
położne są przygotowane do objęcia całościową i
samodzielną opieką rodziny oczekującej dziecka. Najczęściej
wymienianą przeszkodą jest brak praktyki, konieczność
podnoszenia kwalifikacji oraz przeszkody systemowe.
Większość
położnych
praktykuje
indywidualne
przygotowanie kobiety do porodu (172, 59%). Położne
uzupełniające wykształcenie na studiach magisterskich
znacznie rzadziej (72, 47%) świadczą ten rodzaj opieki niż
pozostałe (76, 71%) – istotność statystyczna p = 0,001.
Znamiennie częściej ta forma praktyki realizowana jest przez
70
położne specjalistki (25, 83%) - istotność statystyczna
wynosi p = 0,017. Najczęściej realizowane elementy edukacji
zdrowotnej w przygotowaniu do porodu dotyczyły:
biologicznych aspektów ciąży, porodu, połogu, higieny,
psychologicznych aspektów ciąży, porodu, połogu i diety,
ruchu oraz komunikacji z dzieckiem.
W n i o s k i . Prawodawstwo nie ogranicza samodzielnej
praktyki położnej w Polsce. Badane położne w większości
uznały, że są gotowe do objęcia całościową opieką zdrowej
rodziny oczekującej dziecka. Większość badanych
praktykuje indywidualne przygotowanie kobiety do porodu
edukując swe podopieczne najczęściej w zakresie
biologicznych i psychologicznych aspektów ciąży, porodu,
połogu. Konieczne jest wzmocnienie zawodu położnej oraz
uzupełnienie treści kształcenia przeddyplomowego i
podyplomowego w elementy samodzielnej praktyki.
Key words: midwife, independent practice, legal aspects
Słowa kluczowe: położna, samodzielna praktyka, uwarunkowania prawne
INTRODUCTION
The internationally accepted definition of
midwifery states: „A midwife is a person who, having
been regularly admitted to a midwifery educational
programme, duly recognized in the country in which it
is located, has successfully completed the prescribed
course of studies in midwifery and has acquired the
requisite qualifications to be registered and/or legally
licensed to practice midwifery. The midwife is
recognized as a responsible and accountable
professional who works in partnership with women to
give the necessary support, care and advice during
pregnancy, labour and the postpartum period, to
conduct births on the midwife’s own responsibility and
to provide care for the newborn and the infant. This
care includes preventative measures, the promotion of
normal birth, the detection of complications in mother
and child, the accessing of medical care or other
appropriate assistance and the carrying out of
emergency measures. The midwife has an important
task in health counseling and education, not only for
the woman, but also within the family and the
community.
This work should involve antenatal education and
preparation for parenthood and may extend to women’s
health, sexual or reproductive health and child care. A
midwife may practice in any setting including the
home, community, hospitals, clinics or health units.”
[1]
The majority of Polish midwives belong to the
Polish Midwives Association, a member organization
of the International Confederation of Midwives. As
such, the aforementioned definition also encompasses
the role of midwifery practice in Poland. Poland, as a
member state of the European Union, is obliged to
follow EU directives regulating various aspects of life.
Midwifery practice is regulated by Directive
80/155/EWG, particularly by article 4. According to
this article: „Member States shall ensure that midwives
are at least entitled to take up and pursue the following
activities: 1) to provide sound family planning
information and advice; 2) to diagnose pregnancies and
monitor normal pregnancies; to carry out the
examinations necessary for the monitoring of the
development of normal pregnancies; 3) to prescribe or
advise on the examinations necessary for the earliest
possible diagnosis of pregnancies at risk; 4) to provide
a program of parenthood preparation and a complete
preparation for childbirth including advice on hygiene
and nutrition; 5) to care for and assist the mother
during labor and to monitor the condition of the fetus
in utero by the appropriate clinical and technical
means; 6) to conduct spontaneous deliveries including
where required an episiotomy and in urgent cases a
breech delivery; 7) to recognize the warning signs of
abnormality in the mother or infant which necessitate
referral to a doctor and to assist the latter where
appropriate; to take the necessary emergency measures
in the doctor's absence, in particular the manual
removal of the placenta, possibly followed by manual
examination of the uterus; 8) to examine and care for
the new-born infant; to take all initiatives which are
necessary in case of need and to carry out where
necessary immediate resuscitation; 9) to care for and
monitor the progress of the mother in the post-natal
period and to give all necessary advice to the mother
on infant care to enable her to ensure the optimum
progress of the new-born infant; 10) to carry out the
treatment prescribed by a doctor; 11) to maintain all
necessary records.” [2]
“The law on nurse and midwife profession” is a
legally binding act in Poland. Specific considerations
regarding the practice of midwifery are included in
article 5 of this act: „1) The profession of midwifery is
practiced by a person with the required qualifications,
being confirmed by proper documents, and includes
providing healthcare services, particularly nursing,
preventive, diagnostic, therapeutic and rehabilitative
services as well as health promotion to women,
including pregnant women, delivering women and
women in puerperium as well as the neonates. 2) These
Independent midwifery practice in Poland - legal considerations versus reality
aforementioned services are mostly provided by means
of: a) education in terms of preparation for parenthood,
methods of family planning and protection of maternity
and paternity, b) pregnancy detection, providing care to
pregnant women during physiologic pregnancy and
performing tests necessary in normal pregnancy
monitoring, c) referral to examinations necessary for
the earliest possible detection of high-risk pregnancies,
d) conducting spontaneous deliveries and monitoring
of fetal welfare with the aid of medical devices, e)
conducting spontaneous deliveries including perineal
incisions and suturing, f) undertaking necessary actions
in emergency situations in the physician’s absence,
conducting breech deliveries and manual removal of
the placenta, g) care for future mothers and monitoring
of them during the prenatal period, h) examination and
care of neonates, i) execution of physician’s orders
during diagnostics, treatment and rehabilitation, j)
independent, preventive, diagnostic, therapeutic and
rehabilitative services to a limited extent, and k)
prevention of gynecologic diseases and obstetrical
pathologies.” [3]
These aforementioned documents, along with
ongoing discussions within the Polish midwifery
community, prompt detailed competence analysis of
particular members of the therapeutic team responsible
for taking care of women during normal pregnancies,
during physiological deliveries, and in puerperium.
The hereby presented results constitute part of this
analysis and in our opinion, will provide the basis for
future discussion.
The aim of this study was to verify if midwives
have real possibilities for providing individual and
independent care to healthy expecting women, as is
guaranteed to this profession by the aforementioned
laws. The detailed objectives of this study were: 1) to
assess the readiness of midwives in regards to complex
and independent care giving for expecting families
during physiological pregnancy, delivery and
puerperium, 2) to evaluate the role of midwifery
practice during individual preparation of woman (and
her spouse) for childbirth, and 3) to define the elements
of health education included in preparations for
childbirth.
MATERIAL AND METHOD
The diagnostic survey was completed by 291
practicing midwives. The inclusion criterion for this
study was current or past practice in the delivery room.
71
The study included midwives employed at eight types
of hospitals located in and outside of Warsaw.
Moreover, the study group included students of
weekend and complementary courses in midwifery at
Warsaw Medical University.
All participants were asked to complete the
questionnaire prepared by the authors for the purpose
of this study. Grouping variables for further analysis
included: participant’s age, place of residence,
education level, current educational status, place of
work, and work experience. The distributions of
answers (in percentages) in the groups distinguished
based on these variables were compared using the chisquare test. Calculations were performed using
Statistica 7 (StatSoft®, Poland) software, with
statistical significance defined as p≤0.05.
FINDINGS
The first problem that was analyzed in this study
was the readiness of midwives to provide complex
independent care for expecting families during
physiologic pregnancy, delivery and puerperium
(Table I). Most of the study participants (n=232; 80%)
declared their readiness for this type of caregiving.
Twenty-seven out of 59 participants who answered this
question with a “no” gave their reasons for this answer.
The most frequently declared reasons were: lack of
sufficient experience (n=14; 46%), need to improve
qualifications (n=7; 23%), and systemic obstacles
(n=5; 17%). Positive answers were observed most
frequently (n=14; 88%) amongst midwives older than
50 years of age. A relationship was observed between
the age of participants and the distribution of their
answers – the younger the age of respondents, the
lower the fraction of declared readiness for complex
independent caregiving to healthy women during
pregnancy, delivery and puerperium. This finding is
undoubtedly related to the lack of sufficient experience
in younger midwives. Another association was
observed between answer distributions and the place of
residence. Nearly all respondents living in mediumsized towns (n=34; 92%) declared that they were ready
to provide complex independent care – contrary to
participants living in Warsaw (n=129; 75%) or in the
countryside (n=69; 83%). This finding is probably
related to the fact that midwives working in mediumsized town hospitals have more freedom and are more
independent than their colleagues employed at clinical
hospitals in Warsaw. An interesting association was
72
observed between answer distributions and the
education levels of participants.
Table I. Readiness of midwives in regards to complex and
independent care giving for expecting families
during physiological pregnancy, delivery and
puerperium
Tabela I. Gotowość położnych do świadczenia kompleksowej
i samodzielnej opieki w zakresie fizjologicznej
ciąży, porodu i połogu
Grouping variable/
Yes/ Tak
No/ Nie
Grupa zmiennych
Total (n=291)
232 (80%)
59 (20%)
Age/ Wiek
≤30 years / lat
39 (76%)
12 (24%)
(n=51)
31-50 years/ lat
179 (80%)
45 (20%)
(n=224)
>50 years/ lat (n=16)
14 (88%)
2 (12%)
Place of residence/ Miejsce zamieszkania
Big city/ Duże
129 (75%)
42 (25%)
miasto (n=171)
Medium-sized
34 (92%)
3 (8%)
towns/ Średnie
miasto (n=37)
Countryside / Wieś
69 (83%)
14 (17%)
(n=83)
Education/ Wykształcenie
Secondary/
186 (81%)
44 (19%)
Zawodowe (n=230)
Higher/ Wyższe
46 (75%)
15 (25%)
(n=61)
Studies/ Osoby aktualnie studiujące
Yes/ Tak (n=153)
115 (75%)
38 (25%)
No/ Nie (n=107)
92 (86%)
15 (14%)
Specialization/ Specializacja
Yes/ Tak (n=30)
28 (93%)
2 (7%)
No/ Nie (n=261)
204 (78%)
57 (22%)
Place of work/ Miejsce pracy
Clinical hospital/
32 (74%)
11 (26%)
Szpital kliniczny
(n=43)
Institute/ Instytut
28 (88%)
4 (12%)
(n=32)
City hospital/
69 (81%)
16 (19%)
Szpital miejski
(n=85)
Obstetric30 (64%)
17 (36%)
gynecologic
hospital/ Szpital
położniczo ginekologiczny
(n=47)
Outpatient clinic/
14 (78%)
4 (22%)
Ambulatorium
(n=18)
Specialist hospital/
17 (81%)
4 (19%)
Szpital
specjalistyczny
(n=21)
Voivodeship
21 (88%)
3 (12%)
hospital/ Szpital
wojewódzki (n=24)
Professional experience/ Staż pracy
<10 years/ lat (n=85)
65 (76%)
20 (24%)
11-20 years / lat
114 (79%)
31 (21%)
(n=145)
53 (87%)
8 (13%)
*chi-square test
p value*
0.626
0.052
0.893
0.033
0.08
0.08
0.272
Midwives with secondary education gave positive
answers more frequently (n=186, 81%) than their
colleagues with higher education (n=46, 75%).
Presumably, the opinions of midwives with higher
education are more consciously and carefully
formulated. The aforementioned relationship was
confirmed when answer distributions were compared
in relation to the current educational status of
participants: midwives who were completing their
education at the time of this survey gave positive
answers less frequently (n=115; 75%) than their
colleagues (n=92; 86%; p=0.033). An opposite
relationship, however, was observed in the group of
specialized midwives. Therefore, it may be assumed
that specialization provides more useful skills than
university education. No significant association was
observed between the type of hospital the study
participants were employed at and their answer
distributions.
Autonomy was most frequently declared by nurses
who worked at voivodeship hospitals or institutes
(n=21; 88% and n=28; 88%, respectively). Negative
answers were in turn most frequently observed
amongst workers of specialist obstetric-gynecologic
hospitals (n=17; 36%). Midwives from voivodeship
hospitals declared organizational obstacles as their
most frequent limitation in providing independent care.
Midwives working for 20 years or longer (n=53; 87%)
declared the highest readiness for complex and
independent care when the duration of professional
experience was included in the analysis.
Another analyzed question pertained to the
readiness of midwives for the individual preparation of
women (and their spouses) for delivery (Table II).
More than half of the study participants (n=173; 59%)
declared that they execute this task in their everyday
practice. Again, positive answers were most frequent
amongst midwives older than 50 years of age (n=11;
69%). Another association was observed in relation to
the participants’ place of residence. Most respondents
from medium-sized towns (n=29; 78%) declared their
readiness for this type of care – contrary to midwives
practicing in Warsaw (n=101; 59%) or in the
countryside (n=42; 51%). Again, a higher degree of
freedom and independence amongst midwives from
medium-sized town hospitals may be the potential
reason for this finding. Surprisingly, midwives who
were continuing their education at the time of this
survey declared providing this type of care less
frequently (n=72; 47%) than their colleagues (n=76;
71%, p=0.001).
Table II. Readiness of midwives in regards to individual
preparation of woman (and her spouse) for
childbirth
Tabela II. Gotowość położnych do świadczenia indywidualnego przygotowania kobiety (i jej małżonka) do
porodu
Grouping variable/
Yes/ Tak
No/ Nie
Grupa zmiennych
Total (n=291)
173 (59%)
118 (41%)
Age/ Wiek
≤30 years/ lat (n=51)
28 (55%)
23 (45%)
31-50 years/ lat
134 (60%)
90 (40%)
(n=224)
11 (69%)
5 (31%)
Place of residence/ Miejsce zamieszkania
Big city/ Duże
101 (59%)
69 (41%)
miasto (n=170)
Medium sized
29 (78%)
8 (22%)
towns/ Średnie
miasto (n=37)
Countryside/ Wieś
42 (51%)
41 (49%)
(n=83)
Studies/ Osoby aktualnie studiujące
Yes/ Tak (n=152)
72 (47%)
80 (53%)
No/ Nie (n=107)
76 (71%)
31 (29%)
Specialization/ Specjalizacja
Yes/ Tak (n=30)
25 (83%)
5 (17%)
No/ Nie (n=260)
147 (57%)
113 (43%)
Place of work/ Miejsce pracy
Clinical hospital/
19 (44%)
24 (56%)
Szpital kliniczny
(n=43)
Institute/ Instytut
25 (78%)
7 (22%)
(n=32)
City hospital/
47 (55%)
38 (45%)
Szpital miejski
(n=85)
Obstetric30 (65%)
16 (35%)
gynecologic
hospital/ Szpital
położniczo ginekologiczny
(n=46)
Outpatient clinic/
8 (44%)
10 (56%)
Ambulatorium
(n=18)
Specialist hospital/
15 (71%)
6 (29%)
Szpital
specjalistyczny
(n=21)
Voivodeship
16 (67%)
8 (33%)
hospital/ Szpital
wojewódzki (n=24)
Professional experience/ Staż pracy
<10 years/ lat (n=85)
45 (53%)
40 (47%)
11-20 years/ lat (n=
88 (61%)
57 (39%)
145)
39 (65%)
21 (35%)
*chi-square test
p value*
0.859
0.063
0.001
0.017
0.23
73
type of care more frequently than the other respondents
(n=25, 83%; p=0.017). Considering the participants’
place of work, individual preparation for delivery was
most frequently provided by the midwives who worked
at institutes (n=25; 78%) or specialist hospitals (n=15,
71%).
This form of care was declared least frequently
amongst employees of academic hospitals (n=19,;
44%) and outpatient clinics (n=8; 44%). Readiness for
individual preparation for delivery increased
proportionally along with the participants’ professional
experience. This form of care was most frequently
declared by nurses whose professional experience was
greater than 20 years (n=39; 65%).
Describing the aspects of health education provided
for the preparation of expecting parents was the third
objective of this study. The most frequently declared
aspects were: biological aspects of pregnancy, delivery
and puerperium (n=150; 19%), followed by hygiene
(n=145; 18%), psychological aspects of pregnancy,
delivery and puerperium, and proper nutrition (each
n=131; 16%), physical activity (n=127; 16%), and
prenatal communication with the child (n=106; 13%).
Some respondents (n=14) proposed their own elements
in regards to the health education provided to parents
during prenatal education. The most frequent answers
in this category were: breastfeeding (n=8; 44%),
preparation for the parental role, and childcare (each
n=4; 22%).
DISCUSSION
0.19
One reason for this discrepancy might be that
respondents currently studying had less time, due to
studying, to provide this type of care. An opposite
relationship, however, was observed in the subgroup of
specialized midwives who declared readiness for this
The question of providing complex and
independent midwifery care to healthy expecting
women and women at the time of delivery or during
puerperium is strongly associated with the continuity
of healthcare. The selection of a midwife who will
accompany women on their way to maternity is of
crucial importance. Analysis by Green et al. (2000)
confirmed that women who experienced continuous
care during their pregnancies and deliveries were more
satisfied than those who did not experience this type of
care. Consequently, these authors suggest organizing
centers of perinatal care in such a way as to ensure that
continuous care would be standard. Such an attitude
would follow patients’ expectations and strengthen the
role of midwives amongst healthcare professionals. [4]
Polish law in regards to the profession of
midwifery does not prohibit practicing outpatient
74
midwifery. Still, there is no room for such independent
practice in the Polish healthcare system.
However, there is a group of independent midwives
who provide care for pregnant women during
physiologic pregnancies, conduct deliveries at homes,
and take care of mothers and their neonates. Their
services, however, are not refunded by the public
healthcare system.
A study by Pollard (2010) [5] gives an interesting
insight into midwifery practice in Great Britain. The
aim of the study was to analyze if, and in what way,
midwifery practices influenced maternity care and
issues regarding the medicalization of childbirth. The
author was also interested in inter-relationships present
between the medical authority, gender, and the degree
of midwife professionalism. Qualitative methods were
used, including interviews and observations taken in
neutral environments. The study revealed that
midwives are often inconsistent and that systemic
obstacles force them to perform activities different
from what they declare. Consequently, midwife
professionalism and a degree of delivery
“medicalization” are mostly considered traditionally.
These findings confirm the complexity of the situation
faced by midwives and the challenges faced by this
professional group.
Our analysis revealed a wider context to this
problem, identifying the reasons which inhibit
midwives from providing complex care to pregnant
women, women during delivery, or in puerperium.
One-fifth of our respondents declared that they were
not ready to provide this type of care due to the lack of
experience and qualifications. Another declared reason
was systemic obstacles faced during independent
midwifery practice.
These aforementioned obstacles suggest the need
for the integration of therapeutic team members and a
mutual appreciation of competence. This hypothesis
was confirmed by Schmied et al. (2010) [6] who
analyzed the role of integrated perinatal care. The
authors highlighted the importance of cooperation
between midwives, nurses and primary care
physicians. They also emphasized the role of an
integrated healthcare model for pregnant women,
neonates and their families. The efficiency of this
integrated care depends mostly on the quality of
communication within therapeutic teams along with
mutual appreciation of competence.
The appreciation of competence is still problematic
in Poland. Even though laws pertaining to the
profession of midwifery state that these professionals
are competent to independently conduct spontaneous
deliveries, in most cases, such deliveries are still
conducted by physicians.
An interesting example of midwifery care was
presented by Johnson et al. (2003). [7] Their model of
care was geared towards women in low-risk
pregnancies. Among numerous factors studied, the
authors analyzed practical considerations, elements of
continuity and patient satisfaction. The study included
patients subjected to standard hospital care and women
who received primary health care from midwives. The
quality and continuity of care experienced by women
subjected to midwifery care was better, resulting in
better satisfaction when compared to hospitalized
patients.
Our study revealed that more than half of the
respondents (59%) provide future parents with
individual preparations for delivery. It should be noted,
however, that this form of practice is only a parasystemic (not refunded by the social insurance)
element of perinatal care. Nonetheless, it is a substitute
of aforementioned primary health midwifery care.
Therefore, although not respected by the Polish
healthcare system, this type of activity constitutes
proper direction of Polish midwifery development.
According to Polish professional law, midwives are
allowed to administer some drugs and may carry out
individual practice. Unfortunately, there are no
regulations in regards to the purchasing of prescription
drugs necessary for the practice of midwifery (e.g.
during childbirth at home or in a labor house).
Therefore, Polish law paradoxically allows and
simultaneously disables carrying out individual
practice.
In the curriculum of birthing schools in Poland,
particular attention is paid to the promotion of
breastfeeding. Questions pertaining to this aspect of
perinatal education were not included in our
questionnaire on purpose, since breastfeeding is a
compulsory subject in Polish birthing school curricula.
Interesting research on the importance of
breastfeeding promotion and public health was carried
out by Agampodi and Agampodi (2008) [8]. They
analyzed breastfeeding in a group of 336 mothers and
observed that the efficiency of breastfeeding increased
from 19% to 70% in women who participated in health
promotion programs, Moreover, this study confirmed
the positive impact of educational intervention on the
duration of breastfeeding (up to six months of life).
In our study, none of the participants declared the
use of aromatherapy during preparations for delivery or
during delivery itself. However, we know from
unpublished information that this type of assistance is
used by some midwives in Poland. Aromatherapy is a
medical practice based on the use of plant oils. It has
been used for ages in female healthcare. The proper
composition of different plant-derived oils attenuates
the woman’s feelings during delivery and puerperium.
[9] Therefore, further research is needed on the use of
aromatherapy by Polish midwives.
Birthing schools have for years been established
areas for independent midwifery practice. Our study
confirmed that this type of education is complex and
includes both physical, mental, and social aspects of
health. A separate problem pertains to the question of
female education in terms of decision making and
participation in the delivery process. A Dutch study
analyzed the opinions of midwives in regards to
decision making by pregnant and delivering women.
[10] Interestingly, decision making was more frequent
amongst younger patients (below 29 years of age). In
the author’s opinion, the increased “medicalization” of
deliveries results from a conflict between the attitudes
of midwives to delivery care and the freedom of choice
of pregnant women.
Problems in the implementation of independent
midwifery practices in Poland suggest the necessity for
detailed analysis of the forms and extent of services
provided by midwives. Standardized tools, enabling
comparison between our own results and results from
other centers, allow for detailed evaluation of
midwifery practices.
An example of such studies was published by
Murphy and Fullerton (2001). [11] According to these
authors, studies on the effectiveness of midwifery care
are complicated due to the lack of proper investigative
tools. Therefore, they described their observations with
the use of an existing tool (Optimality Index-US)
during the evaluation of midwifery practices in the
United States. The results of preliminary studies
suggest that this tool could be used in the assessment
of perinatal care.
Other results of midwifery practice assessments (in
terms of optimal care) were published by Cragin and
Kennedy (2006). [12] They analyzed a group of 375
patients along with 179 physicians and 196 midwives
to compare the quality of care provided by the two
latter medical professions. After adjustment for actual
risk, the optimal model of care (low intervention and
75
“medicalization” rates) was more frequently offered to
patients who were subjected to midwifery care.
The results of our study constitute a kind of
diagnosis pertaining to the readiness of Polish
midwives for independent professional care of childexpecting women. These findings provide the basis for
the implementation of further proper procedures and
tools.
CONCLUSIONS
Independent midwifery practice is not limited by
Polish law. The obstacles faced by independent
midwives are associated rather with the healthcare
system and the mentality of its workers, who often do
not appreciate the competence of midwives. The
majority of midwives (80%) declare their readiness in
providing complex care for expecting families.
Additionally, most of the participants (59%) offer the
individual preparation of women (and their spouses)
for delivery, even though this service is not refunded
by social insurance. The biological aspects of
pregnancy, delivery and puerperium are the most
frequent components of prenatal health education,
followed by psychological aspects, hygiene, diet,
physical activity and prenatal communication with the
child.
The role of the midwife should be strengthened by
extensive media campaigns promoting the competence
of this professional group, along with the completion
of graduate and postgraduate education curricula in
aspects useful for running independent practice.
Perinatal care models and the methods of their
evaluation in different centers inspire Polish midwives
to search for ways to establish their professional
autonomy.
REFERENCES
1. Confederation of Midwives Council Meeting. 19 July
2005,
Brisbane,
Australia.
http://www.
internationalmidwives.org. Accessed: 6.07.2006.
2. Council Directive of 21 January 1980 concerning the
coordination of provisions laid down by law, regulation
or administrative action relating to the taking up and
pursuit of the activities of midwives (80/155/EEC)
3. The law on nurse and midwife profession, 1996 (Dz. U.
Nr 91, poz. 410)
http://www.portalmed.pl/xml/prawo/medycyna/medycyn
a/r2005/051461u,18.04.2009
76
4. Green J.M., Renfrew M.J., Curtis P.A.,. Continuity of
career: what matters to women? A review of the
evidence. Midwifery 2000,16, 186-196.
5. Pollard K.C., How midwives' discursive practices
contribute to the maintenance of the status quo in English
maternity care. Midwifery 2010, 6 [Epub ahead of print]
6. Schmied V., Mills A., Kruske S., at all.,. The nature and
impact of collaboration and integrated service delivery
for pregnant women, children and families. Journal of
Clinical Nursing 2010, 19, 3516-3526.
7. Johnson M., Stewart H., Langdon R. at all. Womencentred care and caseload models of midwifery.
Collegian 2003, 10, 30-34.
8. Agampodi, S.B., Agampodi T.C., Effect of low cost
public health staff training on exclusive breastfeeding.
Indian Journal of Pediatrics 2008, 75, 1115-1119.
9. Tillett J., Ames D., The uses of aromatherapy in women's
health. Journal of Perinatal & Neonatal Nursing 2010, 24,
238-245.
10. van der Hulst L.A., van Teijlingen E.R., Bonsel G.J. at
all. Dutch women's decision-making in pregnancy and
labour as seen through the eyes of their midwives.
Midwifery 2007, 23, 279-286.
11. Murphy P.A., Fullerton J.T., Measuring outcomes of
midwifery care: development of an instrument to assess
optimality. Journal of Midwifery & Women’s Health
2001, 46, 274-284.
12. Cragin L., Kennedy H.P., Linking obstetric and
midwifery practice with optimal outcomes. Journal of
Obstetric, Gynecologic, and Neonatal Nursing 2006,
35,779-785.
Grażyna Bączek PhD
Department of Gynecologic and Obstetrical Didactics
Warsaw Medical University
ul. Solec 57
00-424 Warsaw, Poland.
Tel./fax +48 22 621 14 15;
tel. 603 500 337
Bernadeta Cegła, Małgorzata Filanowicz, Aneta Dowbór-Dzwonka, Ewa Szynkiewicz
DOES THE CHARACTER OF HYPERTENSION AND MODE OF THERAPY
DETERMINE CHANGES IN THE QUALITY OF LIFE?
CZY SPECYFIKA CHOROBY NADCIŚNIENIOWEJ I SPOSÓB PRZYJMOWANIA LEKÓW
W ZASTOSOWANEJ TERAPII SĄ DETERMINANTAMI ZMIAN W JAKOŚCI ŻYCIA CHORYCH?
Department of Health Sciences Division of Nursing in Internal Diseases
The Nicolaus Copernicus University in Toruń Collegium Medicum named after Ludwik Rydygier in Bydgoszcz
Summary
I n t r o d u c t i o n . The study of factors which
determine changes of life quality in patients with arterial
hypertension is crucial to relevancy and effectiveness of
secondary activities which are implemented for patients’
care. Does the character of hypertension and mode of therapy
determine changes in the quality of life? For many years, the
improvement in quality of life has been taken into account.
Apart from activities eliminating the symptoms of disease
and prolonging the duration of patient’s life, it is essential to
improve the quality of life. Conducting research aiming at
determining factors allows taking proper preventive and
reparative steps.
T h e a i m o f t h e s t u d y is to determine:
- what the level of quality of life in patients with arterial
hypertension is,
- if duration of illness influences changes in the quality of
life,
- if differences in quality of life reflect severity of
hypertension,
- if the type of leading symptom and its intensity change
the quality of life.
M a t e r i a l s a n d m e t h o d s . The studied group
comprised of 185 patients with arterial hypertension. The
mean age of patients was 55.6±14.2 years. Diagnostics
survey was applied as the analysis method. The selfdeveloped ‘Quality of Life Questionnaire’ and ‘Interview
Questionnaire’ were exploited. The study was performed in
the area of city of Bydgoszcz.
T h e r e s u l t s showed that mean Quality of Life
[QoL] in patients was 0.58, where 0 represented the lowest
and 1.0 the highest level of QoL. The lowest level of QoL
(0.54) was demonstrated by patients with long history of
hypertension. In patients with short duration of disease the
Quality of Life was 0.69. The level of hypertension had the
most important influence on the Quality of Life. The
dependence between the leading symptom and the quality of
life was not demonstrated. The level of intensity of the
leading symptom of the disease revealed to be the most
strongly influencing factor.
C o n c l u s i o n s . 1. The quality of life in patients with
arterial hypertension is significantly low. 2. The duration of
the disease influences the patients’ quality of life. 3. The
mode of therapy is not a relevant factor causing changes of
life quality. 4. The intensity of the leading symptom
determines the quality of life in patients.
Streszczenie
W s t ę p . Badanie czynników determinujących zmiany
jakości życia chorych na nadciśnienie tętnicze jest istotne z
punktu widzenia trafności i skuteczności wtórnych działań
wdrażanych do opieki nad pacjentem. Od wielu lat w
leczeniu uwzględnia się poprawę jakości życia. Oprócz
działań likwidujących objawy choroby i przedłużania życia
chorego istotna jest poprawa jego jakości. Prowadzenie
badań
mających
na
celu
poznanie
czynników
determinujących pogarszanie jakości życia pozwala
podejmować celowe działania prewencyjne i naprawcze.
Cel badań
- jaki jest poziom jakości życia chorych z nadciśnieniem
tętniczym,
- czy długość chorowania wpływa na zmiany w jakości
życia,
78
Bernadeta Cegła et. al.
- czy różnice w poziomie jakości życia związane są z
ciężkością nadciśnienia,
- czy rodzaj wiodącego objawu i jego nasilenie
powodują zmiany jakości życia.
Materiał i metody. Grupę badaną stanowiło 185 osób
chorych na nadciśnienie tętnicze. Średni wiek pacjentów
wynosił 55,6±14,2 lat. Do gromadzenia danych
wykorzystano metodę sondażu diagnostycznego. Posłużono
się Kwestionariuszem Jakości Życia i Kwestionariuszem
Wywiadu konstrukcji własnej. Badania przeprowadzono na
terenie miasta Bydgoszczy.
W y n i k i b a d a ń wykazały, że średnia JŻ (jakość
życia) chorych wynosi 0.58, przy czym 0 stanowi najniższą a
1.0 najwyższą JŻ. Najniższą JŻ, 0.54 wykazywali pacjenci,
chorujący długo na nadciśnienie. U pacjentów chorujących
krótko JŻ była na poziomie 0.69. Czynnikiem najsilniej
wpływającym na JŻ był stopień ciężkości nadciśnienia. Nie
stwierdzono wpływu rodzaju, wiodącego w nadciśnieniu
objawu, na JŻ pacjentów. Zdecydowanie najsilniej
wpływającym na zmiany jakości życia czynnikiem okazał się
stopień nasilenia głównego objawu choroby.
Wnioski.
1. Jakość życia pacjentów z
nadciśnieniem tętniczym jest znacznie obniżona. 2. Czas
trwania choroby wpływa na jakość życia chorych. 3. Sposób
przyjmowania leków nie jest istotnym czynnikiem
powodującym zmiany jakości życia. 4.Stopień nasilenia
wiodącego objawu choroby determinuje jakość życia
chorych.
Key words: hypertension, therapy, quality of life
Słowa kluczowe: nadciśnienie tętnicze, terapia, jakość życia
INTRODUCTION
Nine million Poles have been suffering from
arterial hypertension while the number of Americans
with the disease reached 50 millions [1]. Among all of
them, about 15% in Poland and 50% in the U.S. have
been effectively treated meaning not only the dose or
type of the prescribed medication but also granting
priority to such factors as proper life style, adequate
self-control, regularity and scrupulosity of drug
administration. Arterial hypertension belongs to the
diseases which symptoms significantly burden
everyday functions and decrease patients’ comfort [2,
3]. Pain, vertigo and blurred vision worsen
concentration. The necessity of regular and continuous
drug administration, diet adjustment and quitting bad
habits imply limitations which often result in
frustration, discouragement and returning to negative
and hazardous behavior. On the other hand, the disease
can be easily (in majority of cases) managed and
controlled providing comfort and function on a
satisfactory level. The above mentioned change of life
style, adequate self-control and diet are elements
determining improved Quality of Life and decreasing
hypertension level. For example, a reduction in body
weight of 5.1kg on average is related to a mean
decrease of systolic pressure by 4.4 mm Hg and
diastolic pressure by 3.6 mm Hg [4]. It is obvious that
beside elimination of disease symptoms and life
prolongation of patients, an improvement in Quality of
Life plays an essential role and has been included in
the management of patients with hypertension for
many years now. Without diagnosing specific reasons
for worsening life quality, areas of better quality and
determinants of changes, undertaken measures cannot
lead to desired goals. The importance of exploration
and confirmation of existing relations is essential as a
basis and reference for recommended changes.
This type of study is required when considering
pertinence and effectiveness of prospective activities
which will be implemented in patients care to help
reaching good preventive and reparative targets.
The aim
The aim of this study was determining:
- what a quality of life in patients with arterial
hypertension is,
- if duration of diseases influence changes life quality,
- if differences in quality of life reflect severity of
hypertension,
- if type of the leading symptom and its intensity
change the quality of life.
The studied group comprised 185 patients with
arterial hypertension. Among them 104 were women
and 81 - men aged from 21 to 84 years. The mean age
of patients was 55.6±14.2 years. Patients diagnosed
with arterial hypertension, patients hospitalized due to
various reasons in whom hypertension was a
concomitant disease and patients treated for
hypertension under control of out-patient clinic were
enrolled into the study. The consent for participation in
the study was given by signing a consent form after
getting information about the study. The detailed
characteristic of the studied group is presented in
Table I.
Does the character of hypertension and mode of therapy determine changes in the quality of life?
Table I. The characteristics of the studied group
Tabela I. Charakterystyka grupy badanej
Marital status
Stan cywilny
Education
Wykształcenie
Single
Married
Elementary Professional College
Wolny Żonaty/Zamężna Podstawowe Zawodowe Średnie
n
48
137
30
% 26%
74%
16.2%
Mean height średni wzrost
Mean weight średnia waga
BMI
43
23.2%
Residence
Zamieszkanie
University
Rural Urban
Wyższe
Wieś Miasto
80
32
36
149
43.2%
17.3% 19.5% 80.5%
168.2 ±9.2 cm
81.5 ±17.8 kg
28.7 ±5.4 kg/m2
The study was performed in university
departments, wards and out-patient clinics in the area
of Bydgoszcz. In order to conduct the study, authors
obtained the approval of the Bioethics Board of the
Nicolaus Copernicus University Collegium Medicum
in Bydgoszcz, (No. KB/44/2008). For the analysis the
method of diagnostic survey was used. The selfdeveloped Quality of Life questionnaire for Patients
with Arterial Hypertension and Interview and Activity
Assessment questionnaire were exploited.
For gathering personal, physical activity and life
style data the Interview and Activity Assessment
questionnaire was applied. In statistical analysis, as
relevant p=0.05 level of significance was assumed,
for which critical values are given in the tables.
RESULTS
Hereby presented results are a part of a more
comprehensive study which analyzed influence of
various life areas and modes of patient functioning on
the quality of life and the change determinants in
observed quality of life. The presented results comprise
selected topics and concentrate on factors which are
specific to disease and patient’s self-control.
The gathered data were subject to a quantitative and
statistical analysis. Firstly, data concerning patients
with arterial hypertension were analyzed. The analysis
of data revealed the level of Quality of Life in
particular patients. For normalization of values in 0-1
scale the linear conversion was applied; in result each
patient received Quality of Life result in normalized 01 scale, where the worst possible Quality of Life was
represented by 0, while the best one by 1. The mean
value of Quality of Life in the studied group was
calculated as 0.58 which is slightly higher than mean
value of 0.5. The result allows concluding that Quality
of Life in patients with arterial hypertension is
significantly decreased by the disease and its
consequences. The discussed results are presented in
Table II.
79
Table II. The quality of life in patients with arterial
hypertension
Tabela II. Poziom jakości życia chorych z nadciśnieniem
tętniczym
Parameters
Parametry
Min
Max
Median
Mean
SD
Quality of life level
Poziom jakości życia
0.04
0.99
0.60
0.58
0.21
Subsequently, the relation between Quality of Life
and duration of illness was assessed. The levels of
observed Quality of Life were compared in a subgroup
between patients with a recently diagnosed
hypertension (six months ago) and those with a longer
history of hypertension (diagnosed ten years ago). Both
subgroups had been treated since the diagnosis was
made. The analysis revealed decreasing Quality of Life
along with the duration of the disease. Patients with
the longest history of disease had the lowest Quality of
Life. An interesting result appeared in Quality of Life
among patients who have been treated for a year in
comparison to a group of patients with a recently
diagnosed hypertension (six months ago). It could be
concluded that significantly worsened Quality of Life
does not improve instantly with introducing treatment,
whereas the longer the disease duration is, the more the
Quality of Life decreases. The differences between
marginal values of Quality of Life are statistically
significant. It could be stated for certain that duration
of disease determines Quality of Life in patients. The
results suggest that this state is caused by patients’
condition worsening along with disease duration or
healthy life style becoming neglected.
The detailed data on the subject are presented in
Table III.
Table III. The duration of disease and quality of life in
patients with arterial hypertension
Tabela III. Długość trwania choroby a poziom jakości życia
chorych z nadciśnieniem tętniczym
Quality of
life
Jakość
Życia
ANOVA
test
(Fkr=2.42)
Parame
ters
Parametry
n
mean
SD
F
p
Duration of disease (in years)
Długość trwania choroby (w latach)
0.5
1
15
0.58
0.20
15
0.69
0.15
3
36
0.64
0.23
2.83
<0.03
5
10
35
0.56
0.22
81
0.54
0.20
80
Another
specific
factor
of
hypertension
characteristics is its severity. According to ESH
classification, patients were grouped into mild,
moderate and severe hypertension groups. 8 patients
were not able to determine the level of hypertension
diagnosed by physician and blood pressure measures
were normal during treatment. In data analysis, the
levels of Quality of Life among three subgroups were
compared. Distinctly, the worst Quality of Life was
demonstrated by patients with severe hypertension.
The difference in Quality of Life in studied subgroups
reached the level of p=0.0006. The analyzed data are
presented in Table IV.
Although significant influence of a type of leading
symptoms on the Quality of Life was not stated, its
intensity determined the level of Quality of Life.
Patients with the highest intensity of their main
symptom in the VAS scale demonstrated the lowest
Quality of Life. Based on the results, negative
correlation between Quality of Life and intensity of
perceptible symptom was stated.
Table IV. The level of hypertension and level of quality of life
Tabela IV. Stopień nadciśnienia a poziom, jakości życia
Quality of
life
Jakość
Życia
ANOVA
test
(Fkr=2.65)
Parameters
Parametry
n
mean
SD
F
p
Level of hypertension
Stopień nadciśnienia
Normal*
Mild
Moderate
Severe
Prawidłowe* Łagodne Umiarkowane Ciężkie
8
0.57
0.19
66
0.65
0.18
66
0.57
0.22
35
0.47
0.23
6.02
Pic. 1. Dependence between the quality of life and the
intensity of the leading symptom experienced by
hypertension patients
Ryc. 1. Zależność poziomu jakości życia od nasilenia
wiodącego objawu odczuwanego przez chorych z
nadciśnieniem
0.0006
*patients with hypertension undergoing therapy with normal
results of blood pressure
*pacjenci z nadciśnieniem, którzy biorą leki, a wyniki
pomiarów ciśnienia są prawidłowe
Hypertension is manifested by a number of specific
symptoms. The comparison of values and levels of
Quality of Life in patients with common leading
symptom of hypertension allows stating that a type of
symptom is not a significant determinant of Quality of
Life. Although absolute values showed that the lowest
values of Quality of Life were demonstrated by
patients with hypertension and most aggravating
vertigo (0.52), and the highest value (0.62) in patients
with headache, the differences were not statistically
significant. The results are presented in Table V.
Table V. The type of leading symptom and a level of quality
of life in patients with hypertension
Tabela V. Rodzaj wiodącego objawu a poziom, jakości życia
Type of leading symptom
Rodzaj wiodącego objawu
ParameBlurred
ters
Vertigo
Tinnitus
Headache
vision
Zawroty
Szum w
Quality of life Parametry
Ból głowy
Niewyraźne
głowy
uszach
Jakość Życia
widzenie
n
66
40
31
29
mean
0.62
0.52
0.55
0.56
SD
0.20
0.18
0.21
0.24
F
1.54
ANOVA test
(Fkr=2.42)
p
0.19 (ns)
Other
Inny
12
0.62
0.25
Subsequently, data on therapy compliance and
mode of drug administration in particular were
analyzed. With no regard to taking medication
regularly or only in case of discomfort, the levels of
Quality of Life were similar. It could be concluded
that mode of drug administration does not influence
Quality of Life. It is worth to note that more than 80%
of patients declared regular medicines taking. The
discussed results are presented in Table VI.
Table VI. The mode of therapy and level of quality of life in
patients with arterial hypertension
Tabela VI. Sposób przyjmowania leków a poziom jakości
życia chorych z nadciśnieniem tętniczym
Mode of therapy
Sposób przyjmowania leków
Parameters
In case of
Quality of Parametry
Regular discomfort Sometimes No
life
Regularnie Gdy źle
Niekiedy Nie
Jakość
czuję
Życia
n
152
10
9
12
mean
0.57
0.61
0.50
0.67
SD
0.21
0.20
0.16
0.25
ANOVA
F
1.35
test
p
0.26 (ns)
(Fkr=2.66)
According to subsequent data within RR
measuring, regular self-control does not determine the
level of Quality of Life. Although average Quality of
Life levels are the higher when the measurements are
less frequent, it is obvious that rarity or lack of
measurements cannot increase the Quality of Life. The
differences in Quality of Life levels in particular
subgroups of patients can confirm good condition and
self-esteem or health status of patient. Lack of
symptoms, quiet and comfort decrease alertness and
stop the need for regular health status control. Unifactorial ANOVA test of variance analysis revealed
differences at least in marginal values. It could be
stated that mean level of Quality of life in patients who
do not measure their blood pressure is significantly
higher than in patients who take their blood pressure
measurements on regular basis. The discussed results
are presented in Table VII.
Table VII. Self-control and level of quality of life in patients
with arterial hypertension
Tabela VII. Samokontrola a poziom jakości życia chorych z
nadciśnieniem tętniczym
Quality of
life
Jakość
Życia
ANOVA
test
(Fkr=2.65)
Blood pressure measurements
Pomiar ciśnienia tętniczego
Parameters
In case of
Parametry
Regular discomfort Sometimes No
Parametry Gdy źle
Niekiedy
Nie
czuję
n
91
53
30
11
mean
0.53
0.59
0.64
0.68
SD
0.20
0.22
0.20
0.20
F
3.46
p
<0.02
DISCUSSION
Arterial hypertension is considered a disease which
can be effectively prevented, treated and with proper
therapy decrease the risk of concomitant organ
pathology and clinical complications. It is estimated
that the number of deaths which could have been
avoided by applying efficient anti-hypertension therapy
may reach even tens of thousands per year [6]. The
correctness of the applied therapy is not exclusively
limited to proper pharmacotherapy. According to
WHO/ISH
recommendations
on
hypertension
management, the role of non-pharmacologic is
underlined with particular focus on the change of
patients’ life style [7]. Activities improving the quality
of life, increasing satisfaction and comfort are of great
importance for patients. Medical studies tend to
evaluate efficiency and usefulness of a particular
treatment method using ‘quantitative values’, for
example the improvement of measurable parameters or
the duration of life. However, more and more attention
81
is paid to ‘qualitative values’ measuring therapeutic
success [8], such as improvements in various areas of
patients’ lives and satisfaction from everyday
functioning. The basic area and baseline for activities
aiming at improving the quality of life is to understand
the factors which decrease the quality of life and the
level to which various areas of functioning worsen.
Studying the ‘qualitative’ factors is of such great
importance because it is a chronic disease which, apart
from high risk of death, decreases the quality of life
and considerably worsens patient’s functioning in
various areas of life [2,3,4]. Own research has
confirmed the occurrence of decreased quality of life
caused by hypertension. Patients who participated in
the study showed results not much higher than half of
the maximum level on the quality of life scale which
proves deep negative influence this disease has on
human functioning. Among factors which are related to
the quality of life and determine its level, extent of
blood pressure control and the number and type of
taken medicine are most frequently mentioned [9].
Specifics of the course of hypertension are of similar
importance. Essential factors which determine the
quality of life are the disease duration, level of its
severity and intensity of the symptoms. Some
investigators claim that some patients with newly
diagnosed hypertension may show a decrease in the
quality of life even before applying the treatment as a
reaction to the diagnosis. This is related to the so called
‘disease labeling’ [8]. The existence of such influence
was clearly confirmed by the hereby study. Data
indicate that in the initial phase of the disease, the
quality of life is significantly lower whereas its level
among patients who had been diagnosed and treated
for a year was significantly higher. The level was
decreasing with the following years. Patients who have
been suffering from the disease for over ten years
displayed the lowest level of quality of life. One might
relate patient’s worsening condition to disease
advancement or neglecting the treatment. A similar
problem is mentioned by Szczęch et al. whose study
indicates that around 60% of patients treated for
hypertension stop therapy within 6 months after the
start of the treatment [10]. It is an important indicator
with regards to the areas and time of taking proper
therapeutic interventions and implementing education
activities. Another fundamental factor determining the
quality of life in patients suffering from hypertension is
the severity of the disease. While studying quality of
life in patients with hypertension both with and without
82
complications, Woźnicka et al. stated that in both men
and women, the levels of quality of life is lowest in
patients with hypertension with complications [11]. In
own research, the quality of life in patients with severe
hypertension was observed at the lowest level in
comparison to all other analyzed groups. Variety and
intensity of the symptoms which constitute the
characteristics of the disease are also the determinants
of quality of life in patients suffering from
hypertension.
When studying the relation between symptoms and
the quality of life, Erickson et al. stated that symptoms
have more influence on the quality of life than blood
pressure, taken medicine and other patients’
characteristics [12]. Own study demonstrated that the
lowest level of quality of life occurred in patients with
vertigo as the most common and most severe symptom
and reached the level below the mean value for the
whole studied group. In groups where headache or
blurred vision was the leading symptom, the levels of
quality of life were comparable and differences were
not statistically significant. However, the intensity of
each leading symptom already substantially influenced
the quality of life in patients. The basic element of
pharmacotherapy in hypertension management is a
proper medicine administration. Taking medicine on
regular basis and systematically should level
hypertension symptoms and assure life comfort in this
scope. Unfortunately, own studies did not demonstrate
such regularity. Patients, who took anti-hypertension
medicines regularly, displayed low level of quality of
life, similarly to patients who took medicine from time
to time. A significantly higher quality of life was
observed in patients who take medicine only
sometimes or when they feel well. Differences in levels
of quality of life were not statistically significant.
Although obtained results show that the mode of
medicine administration is not a relevant factor for
changes in quality of life, it cannot be suggested that
regular administration of drugs lowers the quality of
life. However it may be stated that it is the group of
patients with the most severe hypertension who are
most determined to take medicine systematically and
the factor decreasing quality of life in this case is
severity of the disease or burden of this type of
treatment. Lack of regularity in adhering to treatment
guidelines, including not taking medicine, is
considered an important reason for unsuccessful
treatment of hypertension. It concerns both
pharmacological as well as life style related course of
action [13].
Regular self-control is another element of
successful hypertension therapy and related quality of
life improvement. Above quoted studies showed that
reminding and mobilizing fair compliance with
therapeutic (pharmacologic and related with life style)
recommendation reduce systolic and diastolic pressure
in a significant way. The studies were of observational
type and were connected to an educational program
[13]. Own studies demonstrated that patients who
regularly measure their blood pressure have distinctly
lower quality of life than those who do not measure it
at all or measure it only sometimes. This data confirms
an analogy to the previously discussed results
concerning regularity of medicine administration. In
this case, the differences in levels of quality of life
were statistically significant and it could be implied
that the quality of life is related to self-control and
regularity of blood pressure measurements. However,
it cannot be concluded that regular measures contribute
to lowering of quality of life exclusively. Results
regarding precision of medicine administration and
blood pressure control provide interesting information
namely that patients with severe hypertension, which
substantially decreases quality of life, adhere to
therapy recommendations more systematically and
faithfully. On the other hand, the fact that performance
of these activities, their burden and imposed
functioning mode may be the causes of quality of life
decreasing is of great importance. It can be concluded
from the studies that characteristics of the disease and
self-control determine the quality of life in patients
with arterial hypertension. There are also other crucial
determinants such as psychological factors, e.g. anxiety
and fear of stroke. Therefore, it should be studied to
what extent they contribute to changes in the quality of
life. Only then will implemented therapy and education
be of purpose, performed in proper areas and, most
importantly, effective. It is not anxiety and fear of
complications that should force proper behavior but a
belief in their rightness and efficiency. The slogan of
Sir George Pickering, an outstanding expert in
hypertension, becomes even more true: ‘whatever we
do, most importantly let us not scare the patient’.
CONCLUSIONS
1. The quality if life in patients with arterial
hypertension is significantly decreased by the
disease and its consequences.
2. Duration of the disease considerably influences the
quality of life in patients.
3. The mode of therapy is not a relevant factor
resulting in changes in the quality of life.
4. Intensity of the leading symptom determines the
quality of life in patients.
2006; 10(5): 350-361.
11. Woźnicka L., Posadzy-Małaczyńska A., Leśkiewicz G.,
Głuszek J. Ocena jakości życia pacjentów chorujących na
nadciśnienie tętnicze według ankiety SF-36. Nadciśn.
Tętn., 2008; 12(2): 109-117.
12. Erickson S.R., Williams B.C., Gruppen L.D.
Relationship between symptoms and health-related
quality of life in patients treated for hypertension.
Pharmacotherapy 2004; 24(3): 344-350.
13. Wizner B., Gaciong Z., Narkiewicz K., Grodzicki T.
Zwiększenie skuteczności terapii hipotensyjnej u
pacjentów z nadciśnieniem tętniczym dzięki edukacji
przez SMS. Nadciśn. Tętn., 2009; 13(3): 147-157.
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7. Widecka K., Grodzicki T., Narkiewicz K., Tykarski A.,
Dziwura J. (zespół redakcyjny). Zasady postępowania w
nadciśnieniu tętniczym - 2011 rok Wytyczne Polskiego
Towarzystwa Nadciśnienia Tętniczego. Nadciśn. Tętn.,
2011; 15(2): 55-82.
8. Kawecka-Jaszcz K., Klocek M., Jakość życia chorych na
nadciśnienie tętnicze [w]: Andrzej Więcek (red.),
Franciszek Kokot (red): Postępy w nefrologii i
nadciśnieniu tętniczym. Med. Prakt. 2007; 6: 154-156.
9. Klocek M., Brzozowska-Kiszka M., Rajzer M.,
Kawecka-Jaszcz K. Zmiany w jakości życia chorych na
nadciśnienie tętnicze w czasie telemonitorowania
domowych pomiarów ciśnienia. Nadciśn. Tętn., 2010;
14(2): 120-127.
10. Szczęch R., Szyndler A., Wierucki Ł. i wsp. Jak
poprawić skuteczność terapii nadciśnienia tętniczego?
Doświadczenia z programu edukacji pacjentów w ramach
Polskiego Projektu 400 Miast. Arterial Hypertension
83
B. Cegła
Division of Nursing in Internal Diseases
CM UMK
85-801 Bydgoszcz
ul. Techników 3
tel. 600 482 836
Kamila Faleńczyk, Agnieszka Pluta, Wiesława Kujawa, Halina Basińska, Maria Budnik-Szymoniuk, Alicja Marzec
ANALYSIS OF PROBLEMS AND THEIR DETERMINANTS AMONG FAMILY CAREGIVERS
TAKING CARE OF CHRONICALLY ILL PEOPLE
ANALIZA PROBLEMÓW OPIEKUNÓW RODZINNYCH OSÓB PRZEWLEKLE CHORYCH
ORAZ CZYNNIKÓW WPŁYWAJĄCYCH NA ICH WYSTĘPOWANIE
The Department and Institute of Public Nursing
Nicolaus Copernicus University of Toruń Collegium Medicum in Bydgoszcz
acting as the director: Ph. D. Kamila Faleńczyk
Summary
I n t r o d u c t i o n . All over the world, family caregivers
constitute the main pillar of the state care system.
Nevertheless, they usually do not receive the sufficient
institutional support. Therefore, an attempt has been made in
order to identify the most frequently appearing problems
among the caregivers and to define factors which influence
their behaviour.
M a t e r i a l s a n d m e t h o d s . The research was
conducted among 300 caregivers who take care of the
chronically ill family members in domestic conditions. The
research was conducted with the use of the diagnostic poll. In
order to collect data, four following diagnostic tools were
used: the modified Bartel's Scale, the Caregiver's Strain
Index, Beck's Depression Scale and the author's
questionnaire.
R e s u l t s . Despite of the high self-evaluation in
preparation of the caregivers, most of them pointed out
numerous problems concerning the daily care of the
chronically ill people. The respondents most frequently
pointed out the following: the difficulties with moving the ill
person (55.7%), lack of time (50.0%), difficulties with
hygienic activities (49.3%) and difficulties with obtaining
financial support (38.7%). Majority of the caregivers (69.3%)
suffered from a great level of strain, while 43.7% diagnosed
themselves with a gentle stage of depression. Occurrence of
strain and depression and their intensity was strictly
connected with the deficit level of ward's self-service,
intensity of care and the level of caregiver's preparation.
Functioning of the institutions responsible for supporting the
chronically ill people and their families was assessed
negatively by most of the caregivers (76%).
C o n c l u s i o n s . Family caregivers of the chronically
ill people pointed out a number of problems connected with
daily care. They have also revealed a significant level of
strain. The difficult situation of caregivers is affected by
numerous factors, one of which is lack of the
interdisciplinary support in fulfilling the caring function. For
this reason, there is an urgent necessity of change in the
current state care system, which would enable effective caretaking in domestic conditions.
Streszczenie
W s t ę p . Na całym świecie opiekunowie rodzinni
stanowią główny filar systemu opiekuńczego państwa, mimo
to zazwyczaj nie otrzymują oni dostatecznego wsparcia
instytucjonalnego w realizacji opieki wobec swoich bliskich.
Stąd też
podjęto próbę identyfikacji najczęściej
występujących problemów u opiekunów oraz określenia
czynników mających wpływ na ich występowanie.
Materiał
i
metody.
Badania zostały
przeprowadzone wśród 300 opiekunów sprawujących opiekę
nad przewlekle chorymi członkami rodziny przebywającymi
w środowisku domowym. Badanie przeprowadzono metodą
sondażu diagnostycznego, natomiast do zebrania materiału
badawczego zostały wykorzystane 4 narzędzia badawcze:
86
Kamila Faleńczyk et. al.
zmodyfikowana Skala Bartel, Skala obciążenia opiekuna,
Skala Depresji Becka oraz autorski kwestionariusz ankiety.
W y n i k i . Mimo wysokiej samooceny badanych w
zakresie przygotowania do sprawowania opieki większość z
nich zgłaszało liczne problemy związane z codzienną opieką
nad przewlekle chorym. Badani najczęściej wskazywali na:
trudności w przemieszczaniu chorego (55,7%), brak czasu
(50,0%), trudności w wykonywaniu czynności higienicznych
(49,3%), a także problemy z pozyskaniem wsparcia
finansowego (38,7%). Większość opiekunów (69,3%)
wykazywało duży stopień poczucia obciążenia, a 43,7%
badanych rozpoznało u siebie łagodną postać depresji.
Występowanie poczucia obciążenia i depresji oraz ich
nasilenie pozostawało w istotnym związku ze stopniem
deficytu
w
zakresie
samoobsługi
podopiecznego,
intensywnością opieki oraz stopniem przygotowania do
pełnienia roli opiekuna. Większość opiekunów (76%)
negatywnie oceniło funkcjonowanie instytucji powołanych
do wspierania osób przewlekle chorych i ich rodzin.
W n i o s k i . Opiekunowie rodzinni osób przewlekle
chorych wskazywali na liczne problemy związane z
codzienną opieką oraz wykazywali duży stopień obciążenia.
Na trudną sytuację opiekunów wpływa wiele czynników,
jednym z nich jest brak interdyscyplinarnego wsparcia w
realizacji funkcji opiekuńczej, stąd też istnieje pilna potrzeba
zmiany dotychczasowego systemu opieki państwa, które
umożliwiałyby skuteczne sprawowanie opieki w warunkach
domowych.
Key words: family caregivers, problems of the caregivers, caregivers' strain, caregiver's depression, long-term care
Słowa kluczowe: opiekunowie rodzinni, problemy opiekunów, obciążenie opiekunów, depresja opiekuna, opieka
długoterminowa
INTRODUCTION
In most of the countries, including Poland, a
fundamental part of caring responsibilities towards the
chronically ill patients rests on family. Yet, the current
socio-demographical determinants make the situation
of family caregivers extremely difficult. First of all,
the percentage of elderly, chronically ill and disabled
people, who demand long-term care and support of the
relatives, is systematically growing. This tendency is a
result of in lengthening of human life and ageing of the
population. In the developed countries, the highest
population growth pace concerns people older than 75
years old [1]. Another factor involving family in care
giving is the growth of chronic illnesses incidence rate.
Among Polish population, most frequently appearing
diseases are: cardiovascular diseases, cancer, spine
diseases, inflammatory and degenerative diseases of
joints, neurological diseases [2]. Most of the diseases
are of progressive character and lead towards gradual
deterioration of general condition and growth of the
self-service deficit. Another unfavorable occurrence is
a quick growth pace of the number of the disabled in
Poland. In 1998, the disabled constituted 6.5% of the
whole of society, while in 2004; the percentage grew
up to 16.3% of the whole population [3].
The growing number of people demanding longterm care is followed by the family caregivers
proportion decrease. Among other things, the
occurrence is connected with a change in the family
structure, which transforms from a multigenerational
into a nuclear one. In consequence there is a continually
growing number of the elderly living on their own,
this might hinder taking daily care by the family. Polish
families evolve also when it comes to the number of
brought up children. Nowadays, families with one or
two children are a dominant pattern, which considerably
lowers the family care potential. The forecast clearly
points out a growth of demographical strain. By 2020,
the child strain of the society will have decreased from
44 to 33 on every 100 people in productive age. What is
more, the elderly strain will have risen from 24 up to 35
on every 100 people in productive age [1].
Apart from that, a difficult situation of family
caregivers is also influenced by an inefficient system
of institutional care, which is supposed to provide
support. Unfortunately, in most cases, family
caregivers’ need resulting from care responsibilities are
underestimated, not discerned nor realized by the state.
On account of the presented tendencies, taking daily
care of an ill family member, substantially strains the
family caregivers on various levels of life. For this
reason an attempt at identifying problems most
frequently appearing among the caregivers together with
a diagnose of factors influencing their behavior has been
made.
METHOD AND MATERIAL
The research has been conducted among 300
caregivers taking care of the chronically ill members of
family, who stay in domestic environment. The
analysis embraced a group of the main caregivers, who
supported their relatives for at least 6 months. Women
dominated the group constituting 89.3% of the
Analysis of problems and their determinants among family caregivers taking care of chronically ill people
respondents. The average age in the group equaled
50.2 years old (x ±SD 13.6 years). In most of the cases,
the ward was taken care by their child (40.3%) and
spouse (22%), rarely the responsibility belonged to a
parent or a distant relative. Most of the caregivers
(75%) were permanently living with the ill person,
15.7% took care of the ill person living separately,
while 9.7% declared to temporarily move in with the
ward, ex. in times of health deterioration. A significant
part of the respondents have been taking care of their
ward for more than 5 years – 39.3%, and from 6
months to 2 years – 35.0%. Almost half of the
respondents (49.0%) provided care 24 hours a day,
while every fifth respondent devoted half of a day or
several hours a day (18.7%) for care taking.
The research was conducted with the use of a
diagnostic poll, while the diagnostic material was
collected with the use of the 4 following diagnostic
tools: Bartel's Scale, Caregiver Strain Index, Beck's
Depression Scale and the Author's Questionnaire. The
modified Bartel's Scale allowed evaluating of the selfsufficiency abilities in case of people remaining under
direct care of the respondents. The Caregiver Strain
Index included 13 questions and enabled to define the
strains of the caregiver which are connected with
physical effort, finances and social life. Beck's
Depression Scale was used for self-evaluation of
presence and intensification of depression symptoms
among the tested people. The Author's Questionnaire
included
questions
concerning
the
sociodemographical data, problems resulting from caretaking and expectations in the field of social support.
T-Student's test, r-Spearman's test of the rank corelation and r-Pearson's test of linear co-relation was
used in the statistical analysis. While verifying the
hypothesis, the border level of relevance was agreed on
p ≤ 0.05.
RESULTS
Analysis of the research material collected on the
basis of The Caregiver Strain Index revealed a
substantial strain of the responding caregivers. An
average strain equalled 8.43 points, while the diversity
in the tested group equalled Sd=2.6. A bearable level
of strain (up to 7 points inclusive) was pointed out by
30.7% of the questioned people; however, the majority
of the caregivers were diagnosed with a great degree of
strain. Most of the respondents obtained from 8 to 10
points on a 13 points scale.
87
The sense of strain usually results from specific
problems which accompany care taking of a
chronically ill family member. The following research
proved that the activities which cause the greatest
difficulties to the caregivers were: moving the ill
person (55.7%), hygienic activities (49.3%) and
conducting exercises (35.7%). Feeding the ill person
(13.3%) and servicing the equipment (6.0%) were the
least problematic activities. Among the organizational
problems, respondents most frequently pointed out lack
of time (50%), difficulties with acquiring financial
support (38.7%) and lack of information concerning
the rights and help opportunities for the ill (34%).
Long-term care taking also causes a significant
emotional strain, the consequence of which might be
depression. Conducted research allowed measuring the
occurrence of depression among the tested group of
caregivers. 33.0% of the questioned caregivers did not
show any symptoms of depression. Symptoms of
gentle depression were stated in 43.7% of cases, while
moderate depression was diagnosed by 22.0% of the
caregivers. Four of the questioned caregivers (1.4%)
diagnosed themselves with heavy depression. The
average level of depressiveness in the diagnosed group
amounted to 18.34 points, which indicates a gentle
stage of depression. Diversity in the questioned group
was rather high (Sd=12.21).
Another significant problem pointed by the
caregivers is lack of social support. A prevalent
majority of the questioned people – 76%, claimed that
the institutions qualified to support the chronically ill
people and their families, do not fully implement their
tasks, therefore, relatives of the caregivers are their
main source of support. When fulfilling activities
connected with direct care-taking, the main caregivers
may count on help of the closest family (84.7%), a
nurse (34%), neighbours and friends (15.3%). The
respondents received emotional support considerably
less often. In most of cases, it was granted by nurses
(25.7%), neighbours, friends (21.7%) and family
(20.7%). Only 4.3% could count on a psychologist
support and 6.7% of the respondents did not receive
any emotional support.
The research looked into the factors which might
influence the occurrence of caregivers’ problems. The
data analysis proved that one of the most important
factors determining strain of the caregivers is their
wards’ functional efficiency. The modified Bartel’s
Scale was used in order to assess the respondents’
ward’s efficiency. Considering self-sufficiency of the
88
wards, it was proven that only 11.7% of ill people
staying in the custody of the questioned caregivers
demands slight help with the basic everyday activities
(over 80 points on the Barthel Scale). Almost half of
the wards (48.0%) were found in the range of 40-80
points, which gives evidence to their significant
inefficiency in self-service. 40.3% of the ill were
classified under 40 points on Bartel's Scale, which
indicates full dependence on the caregivers. The
average degree of shortage in the examined group
equalled 44.7 points. The detailed analysis pointed out
a relation between ward’s efficiency level and the
frequency of appearing problems - the greater the
ward’s inefficiency, the more difficulties concerning
care taking and organizational matters appear.
The analysis disclosed a significant relation
between the level of self-care deficiency and the strain
level of the caregiver. The more efficient the patient is,
the lesser the strain of the caregiver (p=0.0001)
(Table I).
Tab. I. Dependence between the deficiency level and the
strain index
Tab. I. Zależność między stopniem deficytu a wskaźnikiem
obciążenia
stopień deficytu
podopiecznych a wskaźnik
obciążenia badanych
level of the wards' deficiency
in relation to the strain index
of the caregivers
r(X,Y)
r2
t
p
-0.22
0.05
-3.95
0.0001
r(X,Y) - współczynniki korelacji
r2 – współczynnik determinacji
t- wynik test t-Studenta badającego istotność siły związku
p- poziom istotności statystycznej
r(X,Y) – co-relation factor
r2 – determination factor
t - result of the t-Student test on the strength of the
relationship
p - level of the statistic relevance
It has been also proven that there is a relationship
between the level of deficiency and the level of
caregiver's depressive inclinations. The more selfsufficient the patient is, the less depressive the
caregiver is (Table II).
The deficiency level of the ward's self-service is
related to the intensity of care performed by the
questioned caregivers. In this aspect, analysis pointed
at a statistically significant relation between the
intensity of care, the level of depressive inclinations
(p<0.001) and the caregiver's strain index (p = 0.009).
The more intensive the care was, the higher the level of
depressive inclinations and strain index was (Tab. III).
Tab. II. Dependence between the deficiency level and the
depression index
Tab. II. Zależność między stopniem deficytu a wskaźnikiem
depresji
poziom deficytu
podopiecznych a stopień
depresyjności badanych
level of the wards' deficiency in
relation to the depressive
inclinations of the caregivers
r(X,Y)
r2
t
p
-0.29
0.08
-5.21
<0.001
Tab. III. Relation between the intensity of care, the
depression index and strain index
Tab. III. Zależność między intensywnością opieki a
wskaźnikiem depresji oraz stopniem obciążenia
r
intensywność opieki a poziom
depresyjności
intensity of care in relation to the
depression index
intensywność opieki a stopień obciążenia
intensity of care in relation to the strain
index
-0.359
t(N2)
-6.63
p
<0.001
-0.151
-2.64
0.009
No statistically significant relation was stated
between the duration of care-taking, the level of
depressiveness and the caregiver's strain level. (Tab.
IV)
Tab. IV. Dependence between the duration of care-taking,
depression index and strain index
Tab. IV. Zależność między czasem trwania opieki a
wskaźnikiem depresji oraz stopniem obciążenia
czas trwania opieki a poziom
depresyjności
duration of care-taking and
depression index
czas trwania opieki a stopień
obciążenia
care-taking preparation level in
relation to the strain level
r
t(N-2)
p
0.039
0.674
0.501
-0.023
-0.399
0.690
Another significant element influencing the strain
and depressiveness level of the respondents turned out
to be the degree of preparation to care giving. The
majority of the questioned people assessed their
preparation to care giving as good (68.7%) or very
good (23.7%). Despite that fact, a significant part of
the caregivers pointed out numerous problems related
to everyday care of a chronically ill person. The
detailed analysis revealed that there is a small but
statistically significant relation between these factors.
The less prepared to fulfil the role of a caregiver the
respondents were, the greater their strain was
(p=0.001) and depressive inclinations (p=0.021) were
(Tab. V). The low index of correlation is connected
with a huge variation of the strain index and
depressiveness index results among the groups of
various preparation levels.
Tab. V. Dependence between the care-taking preparation
level, the depression level and the strain level
Tab. V. Zależność między stopniem przygotowania do
sprawowania opieki a wskaźnikiem depresji oraz
stopniem obciążenia
stopień przygotowania a poziom
depresyjności
care-taking preparation level in relation
to depression level
stopień przygotowania a poziom
obciążenia
care-taking preparation level in relation
to the strain level
r
t(N-2)
p
0.133
2.312
0.021
0.187
3.278
0.001
The research also looked into the influence of
family caregivers’ social support system on dealing
with problems resulting from care-taking. The detailed
analysis proved that there are no significant differences
on the level of strain and depressiveness between the
caregivers who received support in fulfilling care
responsibilities (regardless of the source) and
caregivers who did not receive such support. There
were no significant differences found on the level of
depressiveness and strain among the caregivers who
received emotional support (regardless of the source)
and those who did not receive such support.
DISCUSSION
Conducted research confirmed that long-term care
of an ill family member significantly influences
caregiver’s strain. One of the factors which determine
the strain level is the deficit level of ward’s selfefficiency. Most of the reports confirm that caregiver’s
strain significantly grows together with the decrease of
patient’s efficiency. The research conducted as a part
of EUROFAMCARE project, in which 6 European
countries took part (Poland, Greece, Germany,
Sweden, Great Britain and Italy), proved that
caregiver’s strain connected with caregiving
substantially grows together with the decrease in an ill
person’s state of health and efficiency [4]. Van Exel et
al., with the use of various tools to assess the strain
89
level of caregivers, also proved that independently on
the diagnostic tool, the strain level was significantly
higher in the group taking care of the ill with a serious
efficiency deficit [5,6]. It was estimated that the ward’s
inefficiency is one of the most important factors
determining caregivers’ strain.
Analysis of this report’s results also pointed out a
relation between the ward’s efficiency level and the
number of appearing problems. The higher the
efficiency deficit of a patient was, the more difficulties
in care activities and organizational difficulties
appeared. Among the most frequently reported
problems there were: difficulties with relocating of the
ill person, lack of time, difficulties with hygienic
activities, conducting exercises and problems
connected with obtaining financial support. According
to other reports focusing on examining the caregivers,
the catalogue of problems and difficulties was quite
similar. In the research conducted by Jaracz, family
caregivers who took care of people after a stroke, also
pointed out problems with moving an ill person (39%)
and with fulfilling the sanitary activities (34%) [7].
Kachaniuk et al. proved that the greatest difficulty was
caused by moving the ill person from the bed (38.2%)
and changing patient's body position (33.1%), despite
the fact that most of the caregivers declared knowledge
of the proper relocation of an ill person [8].
Authors of this research analysed also the
emotional problems of caregivers, the consequence of
which may frequently lead towards depression. The
research revealed that only 33% of the respondents
remained untouched by the depression symptoms. The
average level of depressiveness in the group amounted
to 18.34, which indicates the gentle stage of
depression. Academic literature is dominated by the
reports on fear and depression intensity among the
caregivers of patients with dementia. According to
Witusik research, the depression intensity – on Beck's
Scale – was greater in case of people taking care of a
person with dementia, than within the test group
(18.00±7.90 regarding 13.12±10.49, p<0.05) [9]. Other
researches based on self-assessment provide a
conclusion that depression appears among 34-55% of
caregivers, which is 2-3 times more often than within
the rest of population [10,11]. Taking care of an ill
family member is one of the most stressful life
situations and may cause an emotional burn-out, which
might enhance the incidence of mental and somatic
illnesses.
90
The detailed analysis of the results of this research
proved that appearance of depression symptoms were
influenced by: the deficiency level in wards’ selfservice, care intensity and the preparation of caregivers
to conduct caring functions. The dependence between
the depression level and ward’s functional deficiency
level is also pointed out by other authors. Wade et al.
confirmed that the lower the efficiency of a patient
gets, the more possible it is for the caregiver to become
depressed [12]. Some researches [13,14] prove that the
risk of depression appearance grows together with the
lengthening of care-taking time. While, in the research
conducted by the authors of this report, the dependence
has not been stated.
Another significant factor influencing the condition
of caregivers is the support from the environment. In
this report, it has been proved that the respondents may
count on help in daily care from the closest family,
nurses, neighbours and friends. Caregivers received
emotional support considerably less often. Results of a
great number of research point out that caregivers
above all receive help from the family [15,16,17,18].
Unfortunately, caregivers assessed the institutional
help rather negatively, which was proved in this
research and other reports. For example, only few
could count on psychologist's support [15,18]. In the
report on Alzheimer disease from 2009, lack of
economical, psychological and social support for the
informal caregivers was pointed out [19]. This very
report has not stated any relation between the received
support and the appearing problems; however, a
number of other reports point out the dependence. For
example, support of the daily care centers is bringing
positive effects on the caregivers. Through her
research, Wojcierowska proved that a significant
evolution of certain behaviours, feelings and emotions
of the caregivers take place after placing the ward with
Alzheimer disease in a daily care centre. The tension,
helplessness, irritation and loss of emotional control in
relation with the ill person, as well as weepiness, have
significantly weakened among the respondents [20].
Despite the fact that the most favourable form of care
is a family care model, the research proved that family
caregivers are not able to fulfil care duties efficiently
and effectively, since they are not receiving proper
support, neither from the welfare, nor from the social
service.
CONCLUSIONS
1.
2.
3.
4.
5.
A great level of strain is diagnosed among
majority of caregivers. It strictly relates to the
deficiency level in ward's self-service, care
intensity and preparation level of the caregiver.
Despite high self-evaluation in preparation for
care taking, the majority of respondents point out
numerous problems connected with daily care
taken of a chronically ill person. The most
frequently raised problems concern: difficulties
with moving the ill person, lack of time,
difficulties with hygienic activities and
conducting exercises as well as difficulties with
obtaining financial support.
More than a half of the respondents reveal
depression symptoms, which are mostly of gentle
nature. Depression symptoms are influenced by:
the level of ward's deficiency in self-service, care
intensity and the preparation level of the
caregiver.
During everyday care-taking, the respondents
may count on help from the closest relatives,
nurses, neighbors and friends. The caregivers
receive emotional support significantly less often.
Most of the caregivers negatively assess the
functioning of institutions qualified to support the
chronically ill people and their families.
However, the research did not reveal any
substantial relation between the caregivers’
support system and appearance of the problems
connected with looking after a chronically ill
family member.
The difficult situation of family caregivers points
out a necessity of change in current institutional
support system.
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opiekunów nad chorymi po przebytym udarze mózgu –
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Kachaniuk H. i wsp.: Zakres działań podejmowanych
przez opiekunów na rzecz osób starszych. Probl.
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91
dr n. med. Iwona Sadowska-Krawczenko
Zakład Pielęgniarstwa Pediatrycznego
Wydział Nauk o Zdrowiu Collegium Medicum UMK
ul. Techników 3
85-801 Bydgoszcz
tel. (52) 3655262
Mirosława Felsmann, Agata Kosobucka
THE INFLUENCE OF EXTERNAL, INTERNAL AND ARTIFICIAL ENVIRONMENT
UPON THE OCCURRENCE OF BREAST CANCER AND COPING WITH THE DISEASE.
THE VERIFICATION OF THE SYSTEMIC THEORY OF BETTY NEUMANN
WPŁYW ŚRODOWISKA ZEWNĘTRZNEGO, WEWNĘTRZNEGO I WYKREOWANEGO
NA WYSTĘPOWANIE RAKA PIERSI I RADZENIE SOBIE Z CHOROBĄ.
WERYFIKACJA TEORII SYSTEMOWEJ BETTY NEUMANN
Departament of Pedagogy and Nursing Didactics, Nicolas Copernicus University
Head: Mirosława Felsmann MD, PhD
Summary
Betty Neumann makes an assumption that a human being
may exert influence upon the environment, or be subjected to
the influence exerted upon him or her by the environment, in
both negative and positive manner. She enumerates three
varieties of environments, which act through so-called
‘stressors’ and permeate each other. Apart from the external
and internal environment, she singles out an artificial
environment as well.
The qualitative analysis of the literature and also that of
collected research material aimed at performing the
classification of environmental stressors, which may exert
influence upon the occurrence of breast cancer. A
particularly important task was that of conducting the
assessment of the artificial environment, which is created by
female patients in order to cope with the disease and its
consequences. In the research, women suffering from breast
cancer and without assessed genetic mutation, and women
with a diagnosed mutation of the BRCA gene participated.
It turns out that the development of the artificial
environment, which means one’s own defense mechanisms,
does not always have an appropriate course. Nurses ought to
be aware of the existence of such an environment and support
its positive development.
Streszczenie
Betty Neumann zakłada, że człowiek może oddziaływać
lub być poddawany oddziaływaniu środowiska zarówno w
pozytywny, jak i negatywny sposób. Wymienia trzy rodzaje
środowisk, które działają przez tzw. stresory i przenikają się
wzajemnie.
Oprócz
środowiska
zewnętrznego
i
wewnętrznego wyróżnia również środowisko wykreowane.
Analiza jakościowa literatury oraz zebranego materiału
badawczego miała na celu dokonanie klasyfikacji stresorów
środowiskowych mogących mieć wpływ na wystąpienie raka
piersi. Szczególnie istotnym zadaniem była ocena
Key words: the systemic theory of Betty Neumann, breast cancer
Słowa kluczowe: teoria systemowa Betty Neumann, rak piersi
środowiska wykreowanego, które tworzą pacjentki by radzić
sobie z chorobą i jej konsekwencjami. W badaniach wzięły
udział kobiety z rakiem piersi bez ocenionej mutacji genowej
i kobiety z diagnozą mutacji genu BRCA.
Okazuje się, że rozwój środowiska wykreowanego, czyli
własnych mechanizmów obronnych nie zawsze przebiega w
sposób prawidłowy. Pielęgniarki powinny mieć świadomość
istnienia takiego środowiska i wspierać jego pozytywny
rozwój.
94
INTRODUCTION
Betty Neumann is the authoress of the systemic
theory, the principal assumptions of which were
formulated upon the basis of the theory of stress of
Selye and the theory of systems of von Bertalanffy.
The authoress indicated, first and foremost, the
necessity of understanding a human being as a
creature, in constant interaction with the environment.
She singled out the three kinds of environments, which
exert influence upon an organism. Among the
environments singled out by the authoress particular
attention, apart from the external and internal
environments, is deserved by the artificial
environment. The latter one of the three constitutes a
certain defense mechanism of a human being. In the
opinion of the authoress of this theory, it is activated in
an unconscious manner at the times of danger, and it
mobilizes all the areas of functioning of a human
being: physical, mental, social-cultural, developmental
and spiritual. The environments, enumerated by
Neumann, exert influence upon the functioning of a
human being with the use of stressors, and their impact
may be positive or negative. It is dependent upon the
force of the stressors and the number of stressors
exerting impact upon a human being at a given time,
and upon the condition of the organism, alike.
Characterizing a human organism, Neumann draws
attention to the so-called defense lines of it, which are
formed in the course of a human being’s life. The
particularly important ones are the immunological
lines, which the immunological system, which protects
us directly, and its imperfection may bring about a
danger to our life [1]. Since the 1970s, we have
witnessed a number of studies which confirm the
mutuality of the impact exerted by three systems
(nervous, hormonal and immunological) upon each
other. In that period, a branch of science called
psychoneuroimmunology started developing in a more
intensive manner; the purpose of that is determining
the influence which is exerted upon the immunological
system by the psycho-social factors, which means the
personality and the milieu of a human being. The
representatives of this branch of science point out the
necessity of appreciating the force of our psyche.
Breast cancer is the neoplasm most frequently
occurring among women, and the cause of death in
case of approximately 50% of female patients. The
dynamics of the increase in its incidence and deaths is
an outcome not only of the improper health-related
behaviours, but it also results from many limitations,
present in the organization of screening examinations,
the insufficient knowledge of women in the field of
prophylaxis and the fact of adaptation disorders in case
of affected women frequently being neglected as well.
The research proves that some of the women suffering
from breast cancer cope well with both the disease and
its results. As the time passes, they become
accustomed to the new situation. However, a large
group of these women cannot come to terms with the
disease and become adjusted to it. Such women require
support in the numerous spheres of life, early and
appropriate assessment of the problems and
appropriate therapy [2].
The research was carried out in the premises of the
Center of Oncology in Bydgoszcz, on a group of five
patients diagnosed with breast cancer, without a
genetic handicap being discovered, and five women
with the positive outcome of family interview and the
genetic mutation of BRCA, remaining under care of
the above-mentioned establishment and the
Prophylaxis and Promotion of Health Department of
Genetic Clinic. The patients had received information
about the course of the research and maintaining
anonymous character of the results, after which they
signed a document of acceptance of voluntary
participation in the research. What was also obtained
was the approval of the Commission of Bioethics of
Collegium Medicum of Nicolas Copernicus University
in Bydgoszcz.
A typical feature of qualitative research is obtaining
the records of an interview. In the course of collecting
the material, a technique of individual structuralized
interviews was utilized, with the use of Nurse
Diagnosis Data Collection Sheet [3]. This sheet makes
it possible to conduct the detailed assessment of all the
areas of the functioning of a human being which were
enumerated by B. Neumann, and that means: physical,
psychic and social-cultural, developmental and
spiritual spheres. What were also utilized were
standardized psychological tools, and that was done in
order to investigate the issue of the assessment of
prophylactic activities and the styles of coping with a
disease or with a danger in a reliable manner. Among
those tools, there were: Health-Related Behaviours
The influence of external, internal and artificial environment upon the occurrence of breast cancer and coping with the disease
Inventory, the Mini MAC scale, indicating the
strategies used in the field of coping with a disease,
and DS.-14, identifying the characteristics of stress
personality.
RESULTS
The analysis of individual cases was carried out in
accordance with the assumptions of B. Neumann. First
of all, the environment and areas being the source of
stress were determined.
Within the group of women in case of whom the
BRCA gene had not been previously discovered,
among the external stressors possibly capable of
exerting influence upon the disease, there were: the
toxic environment of work, smoking tobacco and using
hormone replacement therapy. The internal factors
included: age, menopause, arterial hypertension,
general decrease in the functioning of the
immunological system, being overweight or obese.
In case of women with the positive outcome of
BRCA, what was discovered, was the occurrence of
principally internal stressors, such as: the fact of the
occurrence of genetic mutation, mastopathic changes,
age, and also positive family interview, which means
the incidences of breast cancer and other neoplasms in
the closest family – those stressors may be treated as
the external ones as well. It is worth emphasizing that
some of the elements of the internal and external
environment cannot exert influence upon by patients;
nor is it possible for them to change or eliminate the
risk factor, and they can only exert impact upon it in
such a manner so as to minimize its influence. The
analysis of the outcomes gives rise to the conclusion
that a group of patients with a handicap and the
mutation of the BRCA gene more frequently undergoes
prophylactic examinations and remains under the
constant care of specialists, still prior to the occurrence
of changes in their breast. Patients without genetic
mutation generally did not tend to undergo a breast
examination and did not take advantage of screening
examinations systematically. Prior to the discovery of a
neoplasm, self-examination had been performed by
only as few as one patient within this group. Healthrelated behaviours, and, thus, life-style, is formed in
the process of mutual interaction of the internal
environment and the individual patterns of behaviour,
determined in particular by social-cultural factors and
the individual characteristic of a human being. The
results of individual health-related behaviours indicate
95
that the health-related behaviours of the women with a
genetic handicap are at a higher level, which means
better overall outcome of the ‘health-related
behaviours’. Health-related behaviours amount to 91.2
in the stenic scale received 7 points, whereas in case of
women without a genetic handicap the overall outcome
in terms of health-related behaviours amounts to 74.6,
which means 4 points in the stenic scale. Similar
differences favouring women with the BRCA gene
occur in all categories of behaviours. The lowest
outcome in the group of women without the mutation
was discovered in the category of ‘health-related
practices’ (HRP). According to the assessment of the
artificial environment in the psychic sphere, the Mini
MAC scale was utilized; it makes it possible to become
acquainted with the strategies of coping with the
disease used by women. Female patients with genetic
handicap most frequently utilize the ‘fighting spirit’
strategy, and least frequently the strategy, called
‘hopelessness and helplessness’. A group of women
without discovered genetic mutation takes advantage
of the ‘fighting spirit’ strategy most frequently as that
of a ‘positive revaluation’; these are strategies having
constructive qualities. The assessment of the socialcultural sphere indicates that women with a genetic
handicap take advantage of such actions fulfilling their
passions, pursuing hobbies and doing various forms of
sports. In case of women without a genetic handicap, it
refers to home related activates and working in the
garden or meetings at the Associations of Amazons.
Among the mechanisms facilitating coping with the
disease, there is also a spiritual sphere; that is most
frequently connected with hope and faith. All patients
with genetic handicaps are religious and church-going
individuals. Among the women without genetic
handicaps two women defined themselves as atheists.
The analysis of the D-14 scale showed that the
group of women included in the research does not
possess the typical indicators of stress personality.
Slightly elevated outcomes in the scale of ‘negative
emotionality’ were received by the patients with
genetic handicaps.
The majority of the interviewed declared receiving
social support in the form of family and friends’
support. In one case, in the course of the disease, a
partner left the woman, as he was unable to cope – in
the opinion of the patient – with the entire situation.
The majority of the patients subjected to the analysis
indicate a large number of infections and allergies, and
96
also taking quite a lot of antibiotics
characterizing their immunological system.
when
DISCUSSION
The normal functioning of the organism is possible
thanks to the fact that approximately thirty billion of
the cells of which it is composed live and proliferate in
a controlled manner. Thanks to that, every tissue
maintains an appropriate structure and fulfills its
functions in dependence upon the needs of a given
organ and the entire organism. Nevertheless, what also
happens is that certain factors of both external and
internal origin contribute to an error occurring in the
course of this process and the cells start proliferating in
an uncontrolled manner. As one of the factors predisposing for the incidence of various diseases,
including neoplasms as well, stress, understood in a
very broad manner, is regarded. H. Saley and R.
Lazarus are the most frequently quoted authorities as
far as connection of stress and its influence upon the
organism and the state of health. Saley, researching
principally the issues connected with biological stress,
proved that prolonged stress may bring about physical
damage. He compared the functioning of the organism
to that of the alarm clock, which keeps ringing until the
battery is flat. He proved that the reaction of the
system, regardless of a causative factor, is similar [4].
In turn, Lazarus arrived at the conclusion that we
witness stress when an individual assesses a situation
in which he/she has found himself/herself as exceeding
his/her resources. The core characteristic of a stress
situation is the occurrence of external or internal
requirements making an individual reach the limit or
exceed his/her capacity; most frequently, it is
accompanied by emotional strain, and the feelings of
fear and anger. An attempt to take action the outcome
of which is restoring an organism to the state of peace
and balance, which means overcoming a stressor, is a
phenomenon natural in this situation. Currently, there
is a dominating tendency of devoting more attention in
the studies on stress to the ways of coping with
stressful situations rather than with the factors causing
this phenomenon themselves. A human organism has
its own manner of coping with stress because it is
believed that the outcomes of a confrontation are
determined, to a greater degree, by an activity taken up
rather than by the objective impact of the stressor [5].
Similar conclusions drawn by Betty Neumann, too,
presuming that the beginning of the disease is
connected not only with the activating of individual
risk factors, but principally with the impacts of coexisting stressors of various origins and degrees of
intensification, in connection with the individual
characteristics of personality of a given human being
subjected to the exposition of them. Enumerating in her
theory the third kind of the environment, the so-called
artificial environment, she ascertained that every
human being creates it for his/her own protection in an
unconscious manner. Such a creation is connected with
all the spheres of life: physical, mental social-cultural,
developmental and spiritual.
Taking under consideration the outcomes of the
research, one may be of the opinion that the women
who were aware of their handicaps were modifying, as
far as it was possible, the factors in their external
environment and created certain manners of coping
with this stressor, thus, protecting their organism. The
principal strategy of coping which was used by them
was ‘fighting spirit’. This strategy is connected with
mobilization for the struggle against the disease.
Existing common conviction says that strategies
concentrated upon a problem, when an individual takes
up active struggle with the problem and tries to
eliminate or reduce the impact of stress, are superior to
strategies directed on emotions, consisting in
withdrawing oneself, denial and negation [6]. Women
with the BRCA gene were also caring more about their
physical and mental health, as it is indicated by the
outcomes of individual health-related behaviours. It
was particularly revealed by correct heating habits,
prophylactic behaviours and a positive mental attitude.
The fundamental motivation for such behaviours was
fighting against what may not be possible to avoid, but
the outcomes of what may be minimized; it was
working for strengthening one’s health. Betty
Neumann calls such activities primary intervention,
consisting in strengthening all the lines of defense. At
this point, one ought to agree with the opinion of the
majority of researchers stating that genetic clinics
providing both medical and psychological care
constitute an important positive external environment
for women with the diagnosed BRCA gene. Upon the
confirmation of the mutation, a patient receives
recommendations relevant to the modification not only
of her life style for a more pro-health one, but she is
also included into a detailed and comprehensive
prophylactic programme. Thanks to such action, it is
possible to reduce the risk of the development of
advanced neoplasm within this group of patients from
The influence of external, internal and artificial environment upon the occurrence of breast cancer and coping with the disease
the high 80% to only as few as 20%. One of very
important targets of such work is strengthening the
feeling of one’s own effectiveness of patients [7].
According to Betty Neumann, the fundamental
system which protects our organism against dangerous
stressor is the immunological system. For years, it has
been known that in case of individuals with the
handicapped immunological system there is an
elevated tendency for the development of neoplasms. It
is assumed that in accordance with the theory of
immunological supervision, which was explicated by
Thomas and Burnet for the first time ever, even healthy
individuals (in the clinical meaning of this term) have
had cancer many a time. However, it does not mean
that a neoplasm possible to be diagnosed developed in
their organisms. Appearing neoplastic cells were
rapidly discovered and destroyed by the immune
system. Another thesis, which was put forward,
claimed that the increase of likelihood of the incidence
of cancer may be a result of tolerating stressors
prolonged in time. Those stressors exert influence upon
the change of hormonal reactions, and, as a result,
suppress the activity of macrophages, T lymphocytes
and the NK cells, which together participate in the
destruction of neoplastic cells.
It was also proved that there is a connection
between the changes in tolerance occurring under the
influence exerted by stressors to the defense system of
the organism, and the passive style of coping with
difficulties and depression. There are more and more
outcomes of research, principally in the field of
psychology, which give rise to the conclusion that
neoplasm is mostly developed by individuals who
torment themselves all the time, who forgive others,
but not themselves and who devote time to others; this
type of behaviours is termed by psychologists as the
pattern of behavior C [8]. Female patients participating
in the research and without a discovered genetic
mutation presented the attitude characteristic of
positive revaluation. This is a strategy which is
expressed in the reorganization of the problem of one’s
disease in order to find hope and satisfaction with the
years already passed. This is the so-called ‘constructive
strategy of coping’, confirmed in the course of research
as the one thanks to which patients have better
prospects of recovery, live longer, and thanks to which
there are fewer recurrences and the quality of patients’
life is better [9].
As it turns out, in case of approximately 20-40% of
women with breast cancer the incidence of various
97
disorders of psycho-social character is discovered, the
principal cause of which is – in the opinion of
researchers – stress accompanying them. The most
frequently quoted stressors include: fear of the
recurrence of the disease, unwanted influence of the
medication, limited ability, lack of self-acceptance,
fear of the lack of acceptance of the milieu, in
particular, of spouses or common law spouses. The
level of fears being experienced is dependent upon the
stages of the disease. The first stage is obtaining
information about the diagnosis, which is accompanied
by shock, regardless of the fact, whether a woman
knew about her genetic handicaps, or whether the
diagnosis was unexpected. The following stressgenerating stage is that of treatment, administered
medications and their side-effects, an operational
procedure and ailments connected with it. After the
conclusion of the treatment, the feeling of the fear of
recurrence remains for several years [10]. In case of
patients with breast cancer, anxiety, insomnia, the
feeling of tiredness, and the fear of the following visit
at the doctor’s are observed. It is disturbing that very
frequently such reactions are treated as normal
behaviours, not requiring therapy. In case of some of
the women, such a state passes, whereas in case of
some of the other it does not; those latter women
undergo a mental break-down, which results in
decrease in their activity, and also the occurrence of
family and social problems.
A group of female patients participating in the
research and not having a confirmed genetic handicap
did not take advantage of prophylactic examinations.
As it turns out, in spite of the accessibility of
examinations, many women do not take advantage of
them. One of the most important causes of this fact, in
the opinion of the researchers, is the fear of
examination. Among the demographic factors, age,
education and dissatisfaction with the information are
quoted. So-called situational stress is one of the factors
limiting the number of women taking advantage of
prophylactic examinations as well. Situational stress
occurs as a result of being unaware of the importance
and necessity of undergoing the examinations,
inappropriate preparation to the examination, and the
inaccurate reading of the information about the danger
[11]. Many controversies are connected with the
performance of genetic tests within the groups of
women with a so-called ‘positive family interview’.
Some of the women, out of fear of their emotions
connected with the result, wonder, whether they ought
98
to undergo the test at all. According to some of the
authors, these women have a high level of stress [12].
Within the group of women included in the research,
no stress personality was discovered, and that is
certainly where positive prophylactic behaviours
originate from. Deciding to undergo genetic testing is
dependent upon the decision of a patient, but, because
they are of significant importance for prospects, one
ought to take action in order to minimize the stress
connected with them.
To conclude, in accordance with the theory of
Neumann, the fundamental activity of professional
individuals looking after women suffering from breast
cancer, or threatened by this disease, is identifying the
kind and source of stressors, and, afterwards,
assistance in activating the best defense mechanisms. If
we fail to take appropriate and timely actions together
with the patient and her milieu, then, in accordance
with the principles of psychoneuroimmunology, these
stressors may contribute to the incidence of the disease,
or to its reoccurrence. Let us not forget that the state of
mind changes the state of body.
6. Wotson M., i inni: The Mini MAC: further development
of the Mental Adjustment to Cancer Scale. Jurnal of
Psychosocial Oncology, 1994, 12,3, 38-46
7. Michałowska- Wieczorek.: Medical and psychological
care of patients in cancer genetic counseling clinic. Via
Medica 2006, 10,1
8. Umed Sing, Nidhi Verma: Psychopatology among
Female Breast cancer Patients. Jornal of the Indian
Academy of Applied Psychology. 2007, Vol 33, 1:61-64
9. Salmon P.: Psychology in medicine, Psychological
Publisher in Gdańsk. Gdańsk 2002.
10. National Cancer Policy Bard. Meeting psychosocjal
needs of women with breast cancer. Hewitt M., Herdman
R., Holland J.(red) Nat. Acad. Press. Washington,D.C.
2004;1012, 21-62.
11. Wronkowski Z. inni.: Psychological aspects of breast
cancer screening Sł. Zdr. 2000; 24-26.
12. Lerman C., Hughes c., Lemon S,J i wsp. What You don´t
know can hurt you: adverse psychological effects in
members of BRCA1 and BRCA2 – linked families who
decline testing. J. Clin. Oncol. 1998, 16, 5: 1650-1654
tel. 601-299-824
CONCLUSIONS
1. A human being is a system functioning in the
great system of nature. Between these
systems/environments, constant interactions
and transactions are in progress. Healthy and
proper functioning consists of appropriate
adaptation mechanisms and skillfully taking
advantage of all the resources of the external,
internal and artificial environments.
2. Nurses ought to be aware of the existence of
the artificial environment of the patient and
support the positive development of it.
REFERENCES
1. Górajek-Józwik J: Philosophy and theories of nursing,
Czelej Publisher, Lublin 2004: 324-334
2. Ślubowska M., Ślubowski T.: Psychosocial problems in
breast cancer. Psychooncology 2008, 12; 1:14-26
3. Felsmann M.: Data Collection Sheet for Nursing
Diagnoses developed by CM UMK, teaching material.
4. Wrona- Polańska H.: Health, stress, illness,
psychological dimension", Impuls Publisher, Cracow
2008: 21-33
5. Dolińska- Zygmunt D.: Base of health psychology,
Publisher of Wrocław's University, Wrocław 2001: 71-99
Mirosława Felsmann1, Barbara Futyma1, Mariusz Zbigniew Felsmann2, Marzena Anna Humańska1, Beata Haor1
QUALITY OF LIFE IN CHILDREN WITH EPILEPSY, EVALUATED BY THE PARENTS
ON THE BASIS OF QOLCE QUESTIONNAIRE
JAKOŚĆ ŻYCIA DZIECI Z PADACZKĄ W OCENIE RODZICÓW
NA PODSTAWIE KWESTIONARIUSZA QOLCE
1
Department of Pedagogy and Nursing Didactics, Nicolaus Copernicus University
Head: Mirosława Felsmann MD, PhD
Summary
Epilepsy is a neurological chronic disease, which may
negatively influence physical, psychological and social
functioning. This problem mainly refers to children with
epilepsy in whom, as the research proves, a number of
common problems appears, not only those related to epileptic
seizures, but also problems connected with cognitive sphere
and difficulties at school, as well as social stigma among
peers.
In the last years, the researches evaluating the quality of
life in children with epilepsy have been focused on its
complex evaluation. Therefore, adequate measuring tools
have been looked for in order to make this evaluation
possible.
In the research, evaluation of the quality of life was
made in a group of 43 children with epilepsy, with the use of
QOLCE questionnaire, adapted to Polish conditions by a
team directed by K. Mathiak.
Most of 16 subscales showed a high and very high
reliability according to Cronbach’s α from 0.734 to 0.942.
These results point to existence of significant dependence
between individual spheres of children’s functioning. In the
authors’ opinion, it is worth to compare parents’ evaluation
with opinions of children, especially elder ones.
Streszczenie
Padaczka
jest
neurologicznym
przewlekłym
schorzeniem, które może negatywnie wpływać na fizyczne,
psychologiczne i społeczne funkcjonowanie. Problem ten
dotyczy szczególnie dzieci z padaczką, u których, jak
donoszą badania, często występuje szereg problemów nie
tylko dotyczących napadów, ale związanych ze sferą
poznawczą i trudnościami szkolnymi a także piętnem
społecznym wśród rówieśników.
Badania oceniające jakość życia dzieci z padaczką
nakierowane są w ostatnich latach na kompleksową jego
ocenę. W związku z tym poszukuje się narzędzi pomiaru,
które by tę ocenę umożliwiły.
Key words: epilepsy in children, quality of life.
Słowa kluczowe: padaczka u dzieci, jakość życia
W badaniach dokonano oceny jakości życia w grupie 43
dzieci z padaczką wykorzystując kwestionariusz QOLCE
adaptowany na warunki polskie przez zespół pod kierunkiem
K. Mathiak.
Większość z 16 podskal wykazywała wysoką i bardzo
wysoką rzetelność według α Cronbacha od 0.734 – 0,941.
Wyniki wskazują na istotnie statystyczną zależność
pomiędzy poszczególnym sferami funkcjonowania dzieci.
Potwierdziły się również wyniki innych badaczy o wpływie
wieku i czasu choroby na funkcjonowanie poznawcze i
społeczne dzieci. Zdaniem autorów warto porównywać
oceny rodziców z opiniami dzieci, szczególnie tych
starszych.
100
Mirosława Felsmann et. al.
INTRODUCTION
Epilepsy in children is one of the most common
neurological diseases. It is chronic in character and it
has a multi-level influence on functioning of a child
and its family. The researcher’s reports show that it
may often lead to inhibition of psycho-social
development [1]. Epilepsy is not a uniform disease
entity; it is rather a number of variegated symptoms,
starting with performance of automatic, repetitive
movements by the patient, through the individual fits,
to strong epileptic seizures with the loss of
consciousness. One should not omit or ignore also
other disorders, which are behavioural, educational or
cultural in character [2]. Epilepsy, due to the lack of
social knowledge on its reasons and appearance, is
burdened with myths and stereotypes and thus, it
directly influences the patient and his/her functioning
in the society.
In the end of the 20th century, intensification of the
research on the quality of life in patients was observed,
also those with epilepsy. The tools were searched for,
which would allow for evaluation of that quality in the
most reliable way. In medical literature, most often we
can find reports on the research evaluating the quality
of life in patients with epilepsy; they mainly aim at
verification of the efficiency of the newest therapies in
the aspect of minimisation or elimination of epileptic
seizures or appearance of undesirable symptoms.
Influence of various
pharmacological therapies,
chirurgical operations at patients with drug-resistance
or stimulation of a vagus nerve, as well as some
complementary therapies e.g. diet-therapy has been
evaluated [3,4]. Unfortunately, each of therapies, apart
from advantages, also adds to appearance of new
problems, which the patient is not prepared for and
he/she is not able to deal with. Still, we observe the
lack of concentration of the chronic patient, i.e. the
child with epilepsy. There is a continuous insufficiency
of a complex evaluation of the quality of life and tools
measuring all life’s aspects with regard to taking care
of man as a whole, together with his/her closest
relatives and surrounding society. One of tools tested
in the last years, also in Poland is the Health-Related
Quality of Life in Childhood Epilepsy Questionnaire
QOLCE. This questionnaire is directed to parents of
epileptic children in order to let them evaluate
functioning of their children in various spheres.
Adaptation of the tool for Polish conditions was
performed by the team of researchers directed by K.
Mathiak at Warsaw University. High reliability and
theoretical accuracy qualifies this questionnaire as a
reliable tool in scientific research and in individual
diagnostics.
The research aimed at testing this questionnaire, as
well as determining and finding out those spheres of
life of an epileptic child, which may decrease its
quality and thus, they result in disfunctioning of a child
and his/her family.
The research was made on 43 parents of children
with epilepsy. The questionnaire was filled in by
16.28% of fathers, 79.07% of mothers and one
committee. The average age of a person filling in the
questionnaire was 42. The youngest one was 30 and
the oldest – 64. Among the interviewees, there were
16.28% of persons with primary education, the same
number of persons after studies, 41.86% with
professional education, and 25.58% with secondary
education.
The average age of children that underwent
evaluation was 11.8 ± 3.4. The time of lasting of the
child’s disease ranged within less, than one year to 14
years.
The research excluded children with co-existing
chronic diseases different from epilepsy and mentally
handicapped children.
Parents of children that were qualified for the
research received information on the aim and the
course of the research, as well as the consent of the
Commission of Bioethics at the Collegium Medicum of
Nicolaus Copernicus University in Bydgoszcz for
performing the research.
The research consisted of gathering information
from parents on the basis of socio-demographic and
QOLCE questionnaires, while the latter was used upon
the consent of its authors.
QOLCE questionnaire consists of 76 questions
grouped in 5 scales and 16 subscales. Five basic scales
make the functional category of a child in the
following fields: physical, cognitive, emotional, social,
as well as manners of a child. In addition, the scale
evaluates health and the quality of life in general
meaning. The individual subscales refer to such
aspects,
as:
physical
limitations,
tiredness,
attention/concentration, memory, language, other
Quality of life in children with epilepsy, evaluated by the parents on the basis of QOLCE questionnaire
cognitive, depression, anxiety, control/helplessness,
self-evaluation, social interactions, social activity,
stigmatization, behaviour, general health, the quality of
life.
Parents provided their replies by marking one of the
given options: very often, often, from time to time,
seldom, never, does not apply. All replies were
calculated in such a way, that the high score reflects
good functioning of a child in a given domain. The
total score of the individual subscales, as well as total
quality of life is received by calculating of the
arithmetic average of all questions presented in a given
subscale. If parents decide, that some question does not
refer to their child, the score is calculated only on the
basis of all remaining questions.
All statistical calculations were made with the use
of the statistical program package STATISTICA 9.0.
Most of 16 subscales showed high and very high
reliability according to Cronbach’s α from 0.734 to
0.941. Only the scale of depression shows too low
reliability and it is 0.407. In case of three subscales:
stigmatisation, general health and the quality of life,
the reliability cannot be calculated, because they
consist of only one question. In the field of the general
quality of life, the co-efficient was 0.973.
RESULTS
The average value received in the scale of the
general quality of life was 63.72. According to 44.19%
of parents, in spite of the disease, their children
function quite well, and 32.56% think, that even
perfectly. 23.26% of parents point to some difficulties
related to functioning in everyday life.
In the functional scale in the field of physical
limitations, the average value is 56.48% points. Great
variegation of evaluations can be observed here. 42%
of parents think that they children are not limited
physically, and 33% point to great limitations, which
influence physical functioning of their child. Usually,
physical activity of a child depends on amount of
energy and tiredness felt by a child. In that field, the
average value is 55.23. More than 32% of parents point
to frequent and very frequent appearance of the lack of
energy and tiredness at their children. At remaining
children, according to their parents’ opinions, lack of
energy and tiredness appear seldom or even never.
Evaluation of cognitive functioning consists of 22
questions, which are grouped into 4 subscales:
attention/concentration, memory, language, and other
101
cognitive. The questions refer to various cognitive
disorders which may result from structural
malfunctions of the brain, epilepsy seizures or psychosocial problems. In the field of concentration, the value
obtained in evaluated children was 64.07. Majority of
parents (44%) think that their children do not have any
problems with concentration and focusing of their
attention on tasks imposed on them. 13% of parents
state that difficulties of that type appear quite often in
case of their children, and 6% of parents claim, that
those problems are frequent. Memory makes the next
ratio of the cognitive sphere. In that subscale, the score
is 58.53. 27% of parents state, that their children do not
have any problems with memory, problems appear
periodically at 34%. 27% of parents notice some
disorders in the process of memorising at their
children. 44.18% of parents stated, that their children
do not have any problems with understanding of texts,
tracing the course of a conversation or understanding
of instructions and orders given to them. 9% of parents
observe these limitations in a very large part at their
children. In evaluation of the so-called other cognitive
functions, the abilities of planning, solving problems
and time of reaction were taken into consideration. The
average numerical value of that subscale is 59.11
points. More, than 39% of parents think, that their
children do not have problems with functions of that
type. Only in case of about 17% of children, parents
notice some problems regarding analysed cognitive
functions.
Emotional functioning was evaluated on the basis
of 19 questions making a subscale: depression, anxiety,
control/helplessness, self-evaluation. Questions in that
subscale refer to a general wellness of a child, with
regard to some stated dysfunctions. Results of these
scales are 71.07points for depression and 65.27 points
for anxiety. Thus, they prove that at majority of
evaluated children, there is no presence of blues or
depression; they do not feel frustrated or worried.
51.17% of parents think that way. The next large group
of parents (46.51%) does not observe such symptoms
and attitudes nearly at all. In most of children
(41.86%), anxiety states never appear, as well.
However, 20.93% of parents state, that their children
often feel tense and anxious. Evaluations related to
control and helplessness seem to be a little worse, here
the average value is 61 points. According to 41.86% of
parents, this feeling does not appear at all and 30.23%
think that it appears form time to time. However more,
than 20% of parents believe, that their child has a
102
problem with controlling his/her own life and some
events surpass them. 6.98% of parents think that
generally, their children do not cope with controlling
their own life.
In the subscale self-evaluation, the average value
obtained is 64.97 points. Parents think that their
children have the high self-respect, they are happy,
self-confident and they feel that they can cope with the
disease and adversities. 51.16% of parents state so.
Three subscales are made of a list of questions
evaluating functioning of a child in the society. Factors
evaluated are: social interactions, social activity and
stigmatisation. The research questions focus on social
problems at school, relations with peers and relatives,
as well as limitations regarding free time and social
activity. The average value obtained in evaluation of
social interactions is 76.49 points. According to
62.79% of parents, their children never had to limit
their social interactions due to their disease, and in
their opinion, the disease did not influence those
interactions. However, 16.28% of parents think, that
the disease had the inconvenient influence on relations
of their child with other persons in some situations,
whereas 11.63% state, that epilepsy considerably
limited social interactions of the child and isolated
him/her from the society.
During analysis of the results evaluating social
activity, the similar high scores were obtained. The
average value is 76.74 points. Evaluating the problem
of stigmatisation in children with epilepsy in the
society, majority of parents think that their children do
not feel stigmatised or marked in any way due to their
disease. The average value of points in that subscale is
83.82.
Behaviour is the next dimension that underwent
evaluation. It includes typical functional disorders
described in many children with epilepsy. As opposed
to previously-stated categories, the main assumption of
this evaluation is to measure the manners of the child
observed directly. The average value of points obtained
in evaluation of children’s manners is 65.28.
According to 37.21% of parents, the above-stated
disorders never appeared. 44.19% of parents
sometimes observe such behaviour, in 11.63% they
appear often, and in case of 6.98% of children, they are
very frequent. Attitudes that make functioning really
difficult are: aggression, anger or disobedience.
The questionnaire also includes some questions
referring to the general health condition and quality of
life. The average score evaluating general health
condition in children is 41.86 points, whereas the
average score referring to evaluation of the quality of
life – 59.88. In spite of the fact, that a large part of
parents evaluates the general health condition of their
child as not very good one, as much as 48.84% of
parents believe, that the quality of life of their children
is perfect, 41.86% think, that it is very good, and
9.30% consider it to be average.
In the comparative analysis, results and conclusions
gathered during adaptation of the tool for Polish
conditions were considered. The fact of particular
importance is that none of the subscales showed a great
and statistically significant correlation with clinical
indexes, which advocates a good theoretical accuracy
of the questionnaire. It also means, that clinical indexes
explain only a part of results.
In the authors’ research, evaluation of the strength
of correlation between individual subscales and general
quality of life was discussed. The results show, that all
correlations ire statistically significant. In the
evaluation, r-Person correlation coefficient and tStudent test were used (Table I).
Table I. Relations between criteria of functioning and the
general result of the quality of life
Tabela I. Związki kryteriów funkcjonowania z ogólnym
wynikiem jakości życia
Physical limitations*
Ograniczenia fizyczne
Energy/tiredness*
Energia/zmęczenie
Attention/concentration*
Uwaga/koncentracja
Memory*
pamięć
Language*
język
other cognitive*
Inne poznawcze
Depression*
depresja
Anxiety*
lęk
Control/helplessness*
Kontrola/ bezradność
Self-evaluation*
samoocena
Social interactions*
Interakcje społeczne
Social activity*
Aktywność społeczna
Stigmatisation*
stygmatyzacja
Manners*
zachowanie
General health*
Zdrowie ogólne
Quality of life*
Jakość życia
*statistically significant
r
r²
t
p
0.687
0.472
5.981
<0.001
0.652
0.425
5.441
<0.001
0.895
0.800
12.662 <0.001
0.764
0.584
7.493
0.882
0.778
11.855 <0.001
0.835
0.697
9.585
<0.001
0.600
0.360
4.741
<0.001
0.804
0.646
8.543
<0.001
0.742
0.550
6.993
<0.001
0.581
0.337
4.511
<0.001
0.692
0.479
6.069
<0.001
0.716
0.512
6.483
<0.001
0.573
0.329
3.958
<0.001
0.792
0.627
8.200
<0.001
0.666
0.443
5.643
<0.001
0.482
0.232
3.478
0.001
<0.001
Moreover, evaluation of the influence of age and
time which passed from the beginning of the disease
on the individual subscales was performed. It turns out,
that the older the child is, the better functioning of that
child is observed in the spheres described by subscales:
attention/concentration, memory language, social
activity, and behaviour (Table II). Also the time of the
disease has the influence on such subscales, as:
control/resourcefulness and general health. The longer
the disease lasts, the lower quality of life in that
spheres is observed (Table III).
Table II. Relation between age of a child and the criteria of
functioning
Tabela II. Związek wieku dziecka z kryteriami
funkcjonowania
AGE OF A CHILD
Wiek dziecka
Physical limitations
Energy/tiredness
Energia/zmęczenie
Attention/concentration*
Uwaga/koncentracja
Memory*
pamięć
Language*
język
other cognitive
Kontrola/bezradność
Depression
depresja
Anxiety
lęk
Control/helplessness
Self-evaluation
samoocena
Social interactions
Social activity*
Stigmatisation
stygmatyzacja
Manners*
zachowania
General health
Zdrowie ogólne
Quality of life
Jakość życia
General QOLCE
Ogólna QOLCE
r(X,Y)
r2
t
p
0.228
0.052
1.48
0.147
-0.012
0
-0.07
0.941
0.339
0.115
2.28
0.028
0.356
0.127
2.41
0.021
0.401
0.161
2.77
0.008
0.264
0.07
1.73
0.092
-0.293
0.086
-1.94
0.06
0.123
0.015
0.78
0.439
0.058
0.003
0.36
0.717
0.058
0.003
0.37
0.715
0.242
0.059
1.58
0.122
0.401
0.161
2.77
0.008
0.110
0.012
0.624
0.537
0.316
0.1
2.11
0.041
-0.066
0.004
-0.42
0.678
0.015
0
0.1
0.924
0.249
0.062
1.62
0.112
103
Table III. Relation between the time of lasting of the disease
and the criteria of functioning
Tabela III. Związek czasu chorowania dziecka z kryteriami
funkcjonowania
TIME OF LASTING OF
THE DISEASE
Czas chorowania dziecka
physical limitations
Energy/tiredness
Energia/zmęczenie
Attention/concentration
Uwaga/koncentracja
Memory
pamięć
Language
język
other cognitive
Inne poznawcze
Depression
depresja
Anxiety
lęk
Control/helplessness*
Self-evaluation
samoocena
Social interactions
Social activity
Stigmatisation
stygmatyzacja
Mannerszachowania
r(X,Y)
r2
t
p
-0.299
0.09
-1.98
0.054
-0.089
0.008
-0.56
0.577
-0.168
0.028
-1.08
0.288
-0.091
0.008
-0.58
0.567
-0.184
0.034
-1.18
0.244
-0.215
0.046
-1.39
0.172
-0.224
0.05
-1.45
0.154
-0.224
0.05
-1.45
0.154
-0.317
0.101
-2.12
0.041
-0.195
0.038
-1.26
0.215
-0.215
0.046
-1.39
0.171
-0.177
0.031
-1.14
0.261
-0.158
0.025
-0.905
0.372
-0.129
0.017
-0.83
0.414
General health*
Zdrowie ogólne
Quality of life
Jakość życia
General QOLCE
Ogóne QOLCE
-0.325
0.106
-2.17
0.036
0.048
0.002
0.3
0.763
-0.259
0.067
-1.7
0.097
DISCUSSION
Epilepsy belongs to the group of chronic diseases,
which may negatively influence physical, psychical
and social functioning. Epileptic seizures make only
one of the aspects of life of the child patient. In
scientific literature we can find some research-based
information, that e.g. in psycho-social aspect, epilepsy
influences appearance of anxiety, depression, it lowers
the quality of life, it results in low self-evaluation, it is
stigmatised. It also impairs such domains of activity, as
education, professional work, family life, everyday
activities, social contacts and friendship relations. It is
a chronic disease that considerably influences the
quality of life of both the sick child and his /her whole
family [6, 7].
The authors’ research proves that each of the
evaluated subscales with their constituents is
significant for the overall quality of life. In the
104
evaluated group of children, the strongest relation, i.e.
the influence on the general quality of life is observed
in case of such subscales, as attention/concentration,
language and other cognitive, whereas this relation is
weaker in case of such subscales, as self-evaluation
and stigmatisation. Most of results of the research on
the quality of life in epileptic children show, that the
factors, which considerably worsen the quality of life
are disorders of cognitive functions [8].
In opinion of parents taking part in the research, the
biggest problem in case of epileptic children is their
general health condition, physical limitations and
similar to what other researchers say, deficiencies of
cognitive functions, whereas the least number of
problems is observed in the fields of social functioning,
social interactions, social activity and stigmatisation.
Similar results, pointing to simply good functioning in
social sphere of both the children and their relatives
were obtained by P. Hoere, and P. and M. Russel [9].
By his/her parents, an epileptic child will always be
treated as seriously ill or even handicapped. Health
condition was also low-estimated by the parents under
research. The research performed by Ch.B. Baca et al.
prove, that cognitions of a child with epilepsy by
his/her parents can be distorted by conviction, that their
child is yet ‘ill’. The author is afraid, that such feelings
of parents can lead to under-estimation of the child and
his/her quality of life. Such a negative evaluation of
parents often makes them lower their expectations
towards the child, as they claim, that the child must be
protected. Over-protectiveness, as well as taking over
total control on the child can add to appearance of a
number of behavioural problems. The child becomes
dependent, hypochondriac, and immature and he/she
has the low self-esteem. In this research, children with
epilepsy evaluated their quality of life as equal to that
of their healthy siblings, whereas, the parents thought
of it as much worse. The authors named this
phenomenon ‘a paradox of disability’ [10].
Cognitive deficiencies refer both to intelligence and
other selected deficiencies. The deficiency is
influenced by existing brain defects, as well as those,
which appeared in result of repeating seizures and
pharmacotherapy. Environmental factors also influence
the scope and level of cognitive deficiencies. In the
research done by Baker, Loring, and Talarska it is
stated, that in comparison to their peers, the level of
intelligence in school children with epilepsy is within
normal limits or it is only slightly handicapped in 80%
of cases [11,12]. At 30% of children, partial
deficiencies of cognitive functions and disorders in the
field of sight and hearing abilities are observed. Age of
the child in which the first symptoms of epilepsy
appeared has a decisive influence on development of
cognitive functions. In those children, in which
epileptic seizures appeared very early, deficiencies in
the field of sight and movement correlation, memory
and attention were observed, also longer time of
attention and better dynamics of cognitive processes
are seen. In the research performed by Mojs in the
years 2001 and 2007, the statistically significant
correlation between the time of appearance of the first
seizure and the level of operational memory, learning
ability and the level of sight and movement integration
was proved, as well. The authors’ research confirms
reports of the researchers on the significant influence
of the child’s age on attention and concentration,
memory, as well as social activity and behaviour. The
period of disease considerably influences self-control
and resourcefulness. Unfortunately, the longer the
period of disease is, the lower the quality of life in that
sphere is.
Most of all, epilepsy is characterised by seizures of
various frequency and strength. The most frequent
symptoms of the seizure are: loss of consciousness,
body distortions during the fits, salivation, and urinary
incontinence. The seizures are unpredictable and they
often cause injuries. It terrifies both the patient and
above all, the unaware observer. So, many people feel
anxious while witnessing the seizure and dealing with
a person, that suffers from epilepsy. Many research and
reports in media points to the fact, that epilepsy is
socially stigmatised and that sooner or later, the
epileptic child will experience it. The results prove that
the quality of life in children under research is
evaluated on the average level of 59.88. 62.79% of
children got the highest scores in the scale of social
interactions, social activity and stigmatisation.
Therefore, it can be assumed that our society does not
perceive epilepsy as something ignominious, that
children did not lose their self-esteem that they are
open to social interactions and the states of depression
do not appear in their case. Certainly, these results
come from their parents’ opinion. Maybe the children
would prove these aspects to be worse and maybe,
better. We must remember that children may go by
their own values. The authors of the presented research
think that the next research on the quality of life in
epileptic children should connect the parents’ and
children’s opinions.
CONCLUSIONS
1. The tested tool shall be regarded as accurate
and significant from the point of view of a
complex care of a child and his/her family.
2. The research on the quality of life in children
with epilepsy shall compare evaluations of
children and their parents.
3. The quality of life in epileptic children is
seriously influenced by physical, cognitive,
and emotional functioning, behaviour and
general health condition, so therapeutic
programs shall be complex in character.
4. Age of the child significantly influences
his/her cognitive functions, such as
concentration, attention, memory, but also
social activity. Worsening of cognitive
functions considerably influences functioning
in everyday life. A precise diagnosis on
cognitive
deficiencies
becomes
very
important in order to start activities
preventing from further worsening of these
functions with the flow of time.
5. The period of disease has a significant
influence on the quality of life in children
with epilepsy. The more time passed since the
first seizure, the worse the general health
condition is and it refers also to functioning in
emotional sphere and such indexes, as control
and resourcefulness.
Adaptation to life with epilepsy requires hard
work on the part of a child and his/her
parents. It is crucial, that from the very
beginning, the child takes over control on
his/her life and health as early as possible. In
a normal development, each child tends to get
independence and esteem for himself/herself
and we shall enable him/her to achieve that. In
the name of increased care, parents cannot
isolate their ill children from activities, which
are performed by other healthy children.
Extortionate mindfulness and limitation of
freedom of a child often leads to development
of a syndrome of learned helplessness. Then,
the child fully accepts one basic role of ‘a
patient’
and
thus,
he/she
excludes
himself/herself from social life.
105
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Tettenbaum B, Kramer G.: Total patient care in
epilepsy. Epilepsy 1992,33(suppl1):S 28-32
Austin J.K., Shafer P.D., Dering J.B.: Epilepsy
familiarity, knowledge, and perceptions of stigma:
Report from survey of adolescents in the general
population. Epilepsy Behavior 2002,3:368-375
Mojs E., Głowacka M.D. Samborski Wł.: Appearance
of Cognitive Disorders and Emotions in Epilepsy and
Their Implications in Therapy. Annales Academiae
Medicae Stetinensis. 2007, 53,3, 82-87.
Hoare P, Russell M.: The quality of life of children
with chronic epilepsy and their families: Preliminary
Findings with a new assessment measure. Dev med
Child Neurol 1995,37:689-696.
Baker G.A. et al.: Quality of life of people with
epilepsy: A European Study. Epilepsia, 1997,38 (3),
353-362.
Loring D.W. Kimford J.M.: Cognitive side effects of
antiepileptic drugs in children. Neurology, 2004, 62,
872-877.
Talarska D.: The Quality of Life in Children with
Epilepsy on the Basis of QOLCE questionnaire. Polish
Family Practice Medicine, 2004, 6.Suppl.1, 42-44.
Mojs E. Evaluation of cognitive functions at children
and adolescents with epilepsy, treated with lamotrygine
or vigabatrin in a system of mono- or poly-therapy.
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tel. 601-299-824
Grażyna Franek, Marta Ćmiel-Giergielewicz, Zofia Nowak-Kapusta, Marzena Zmysło-Rogozik
AWARENESS OF RISK FACTORS ASSESSMENT AMONG INDIVIDUALS
WITH ISCHEMIC HEART DISEASE
OCENA STANU WIEDZY NA TEMAT CZYNNIKÓW RYZYKA WŚRÓD CHORYCH
Z NIEDOKRWIENNĄ CHOROBĄ SERCA
The Department of Health Care and Nursing of Silesian Medical University In Katowice
Senior M.D. Tomasz Irzyniec
Summary
A i m . Awareness of risk factors assessment concerning
preventive measures to an ischemic heart disease depending
on socio-demographical factors such as: age, sex, education,
place of residence and financial situation among hospitalised
individuals.
I n t r o d u c t i o n . The ischemic heart disease is the
most frequent cause of death, hospitalisation and disability.
The increasing number of the individuals suffering from the
disease underlines the importance of taking preventive
measures among the whole population. Proper health
education and addressing the risk factors are one of the more
crucial parts of preventing the ischemic heart disease.
M a t e r i a l a n d m e t h o d . A method of a
diagnostic questionnaire along with the survey technique was
used in the work; an anonymous research was done among
101 individuals with ischemic heart disease. The individuals
were hospitalised in the Preventive Diagnostics and
Telemedicine of Heart and Lungs Conditions of the John
Paul II Hospital in Krakow. The questionnaire contained 47
questions concerning the awareness of preventive measures
to ischemic heart disease and its use in everyday life.
R e s u l t s . The obtained results pointed to the lack of
awareness among patients and their awareness of risk factors.
The researched individuals were not aware of all the factors,
did not know how to modify the risks in order not to develop
the ischemic heart disease. The obtained results revealed that
the higher the education, the improved the knowledge of the
risk factors of ischemic heart disease (58.1% of correct
answers). The results also showed that sex was the
differentiating factor in the knowledge about the condition.
Only 33% of the individuals were educated on the ways of
modifying the risk factors of the heart disease.
C o n c l u s i o n s . The data from the research point to
the lack of education among patients with ischemic heart
condition as well as the necessity to address the preventive
measures according to the education, sex and the age of
patients.
Streszczenie
C e l . Ocena wiedzy pacjentów hospitalizowanych na
temat czynników ryzyka w zakresie profilaktyki choroby
niedokrwiennej serca, w zależności od czynników
socjodemogaficznych, takich jak: wiek, płeć, wykształcenie,
miejsce zamieszkania, sytuacja materialna.
W s t ę p . Choroba niedokrwienna serca od wielu lat
jest najczęstszą przyczyną zgonów, hospitalizacji oraz
niepełnosprawności. Wzrastająca wciąż liczba wykrywanych
zachorowań wskazuje na potrzebę profilaktyki całej
populacji. Właściwie prowadzona edukacja zdrowotna oparta
na przedstawianiu czynników ryzyka zachorowania, jest
jednym z istotnych elementów profilaktyki choroby
niedokrwiennej serca.
M a t e r i a ł i m e t o d a . W pracy wykorzystano
metodę sondażu diagnostycznego z użyciem techniki ankiety.
Przeprowadzono anonimowe badanie wśród 101 osób z
niedokrwienną chorobą serca hospitalizowanych w
Pododdziale
Szybkiej
Diagnostyki
Prewencji
i
Telemedycyny Chorób Serca i Płuc Specjalistycznego
Szpitala im. Jana Pawła II w Krakowie. Kwestionariusz
zawierał 47 pytań dotyczących wiedzy o profilaktyce
choroby niedokrwiennej serca i wykorzystania jej w życiu
codziennym.
108
Grażyna Franek et. al.
W y n i k i . Uzyskane wyniki dowodzą, że stan wiedzy
pacjentów na temat czynników ryzyka jest niewystarczający.
Pacjenci nie znają wszystkich czynników ryzyka, nie wiedzą,
w jaki sposób można je modyfikować, aby nie doszło do
rozwoju choroby niedokrwiennej serca. Wyniki badań
potwierdziły, że im wyższe wykształcenie, tym wyższy
poziom wiedzy o czynnikach ryzyka choroby niedokrwiennej
serca (58,1% poprawnych odpowiedzi). Z badań wynika, iż
płeć była czynnikiem, który różnicował badanych pod
względem ich wiedzy. Zaledwie 33% pacjentów do 39 roku
życia była edukowana na temat modyfikacji czynników
ryzyka choroby wieńcowej.
W n i o s k i . Dane uzyskane w badaniu wskazują na
deficyt w edukacji pacjentów z chorobom niedokrwienną
serca oraz na celowość ukierunkowania działań
profilaktycznych z uwzględnieniem wykształcenia, płci oraz
wieku pacjentów.
Key words: awareness of risk factors assessment among individuals with ischemic heart disease
Słowa kluczowe: choroba niedokrwienna serca, czynniki ryzyka, profilaktyka
INTRODUCTION
The circulatory system ailments, and the ischemic
heart disease as one of them, are one of the most fatal
for an individual and their health in today’s life. These
diseases constitute the most often cause of morbidity,
high number of deaths as well as disability in Poland
and all over the world. The coronary atheromatosis has
been mostly responsible for such state of matters. [1]
In 2002 the World Health Organization revealed
that due to the circulatory system ailments 16.7 million
of individuals were deceased, 4 million of them in
Europe. The most frequent causes of death involve the
coronary disease (50%) and stroke (about 30%). [1]
Comparing the number of deaths caused by cancer and
heart diseases, we find out that the latter is responsible
for a death of every second Pole. [2]
The aetiology of circulatory and vascular diseases
is very complex, thus pointing to a single cause of the
disease is virtually impossible. One can merely address
the risk factors, which contribute to the incidence of
the ailment. [2] In the aftermath of the conceptive
introduction of risk factors, which association with the
disease is well documented, the factors were divided
into: alterable ones – closely linked with one’s
lifestyle, biochemical and physiological features, and
unalterable ones – individual features. [2] The third
group consists of risk factors defined as “new” - they
include inflammatory response indicators, homeostatic
factors and markers of endothelial dysfunction. [3]
In Poland the promotion of health and its actions
address the issues of diseases of modern civilization
and are executed on the basis of the National Health
Service Program from 2007 to 2015, as well as the
National Health Plan. The National Health Program
2007-2015 points to actions which threaten man’s
health and life and is addressed to all nongovernmental organisations as well as the local
governments. [4] The National Health Plan features
branches of preventive medicine and recovery
surgeries. The first goal of the National Health Plan is
to decrease the number of deaths linked to the
circulatory system diseases, while the National Health
Program concentrates on introducing early diagnosis
and active care of individuals with the risk of
developing an ischemic heart disease. [3, 4] The
established aims of the National Health Program and
the National Health Plan are executed through
numerous actions aiming at preventing an ischemic
heart disease. The following strategies are involved:
1. Population strategy – involving changing
one’s lifestyle and environmental factors of
the whole population, also the social and
economical conditions, which lead to the high
prevalence of the heart disease;
2. High risk strategy – separates the individuals
with high risk of heart conditions and
executes actions, which help modifying any
existing risks in these individuals;
3. Secondary preventive strategy – aims at
preventing heart disease prevalence, after the
initial one had occurred, as well as
diminishing the progress of the disease in
individuals with an identified ischemic heart
disease. [3]
The researchers strongly appeal for and prioritise
the control of the heart conditions through mastering
our knowledge of the risk factors linked with the
disease and the factors’ modification in individual’s
everyday life. Despite taking the actions on heart
disease prevention, this is not enough for some
individuals. [5] The aim of the research was to assess
the awareness among hospitalised individuals on risk
factors and prevention of ischemic heart disease,
depending on socio-demographic factors such as: age,
sex, education, place of residence and economic
situation. Due to the current state of medicine, today’s
man needs to mature to be aware of their own health,
Awareness of risk factors assessment among individuals with ischemic heart disease
realise the threats and make proper decisions, which
would consequently prevent the threats. [5]
The research included the author’s questionnaire
survey, which featured 47 closed, open-closed and
open questions. The survey involved questions
assessing the individuals and their awareness of risk
factors of ischemic heart disease, information questions
and a metrics. The research was completed by 101
individuals hospitalised in the Preventive Diagnostics
and Telemedicine of Heart and Lungs Conditions of
the John Paul II Hospital in Krakow from the 14th
February 2011 to 27th April 2011. The patients
volunteered to and were anonymous in the research.
The obtained data was then analysed both statistically
and descriptively, and was examined by the chi-2 test.
The STATISTICA v, 9 computer software was used in
the calculation.
55.5% of the researched individuals were females,
while 44.5% - males; the age ranged from 22 to 80.
The most popular group consisted of city residents
(75%); the other (25%) came from the countryside.
The majority of individuals completed a secondary
education degree (44%), then higher education (30%),
vocational (21%) and basic (5%). 45% of the
individuals were still working, 33% were either
pensioners or retired, while 22% remained
unemployed. As many as 54% marked their economic
situation as good, 41% as satisfactory, 4% as
insufficient and 1% as very good.
RESULTS
The results were analysed statistically and
examined in relation to the sequence of answers on
socio-demographic data: sex, age and education.
From the analysis we gather that 69% claimed to
knew the risk factors of an ischemic heart disease,
while 29% lacked such knowledge by choosing the
answer: not aware of and not able to describe the
knowledge. Only 7% admitted not to know the risk
factors. The respondents chose: smoking (92.1%),
improper diet (85.1%), alcohol abuse (82.2%), high
level of cholesterol (81.2%), stress (80.2%), low
physical activity (79.2%) and an increased blood
pressure (70.3%) as the most responsible factors for
heart disease. The less common factors given were: age
(25.7%), diabetes (39.6%) and genetic issues (47.5%).
109
The difference between the answers given by both
sexes was statistically insignificant. As for the diet, we
can reveal that more correct answers were given by
female (94.6%) than male individuals (64.1%). Some
men participants were not aware of the importance of a
diet in heart disease (38.6%), with much fewer female
who were not aware of it (5.4%). The BMI term was
familiar for 39.2% of female and 22.7% of male
participants. Nevertheless, men could calculate their
BMI twice as often (11.4%) as women. The query
about the alcohol consumption provided us with the
following data: 70% of men and 47% of women
admitted to have been drinking occasionally. As for the
physical activity, we can say that female individuals
were less active (52.2%) than male ones (66%). The
results also differed in preferences for physical
activities. Male participants often chose walks (63.3%
to 48.2% of female). Women participated more in
swimming (10.7% to 9.1% of men). The subsequent
part of the research checked whether the individuals
had followed their doctor’s advice on medicine use.
From the analysis we can read that women were more
disciplined (96.2%) than men (63%). Another query
concerned the behaviour in conflict situations where
the individuals could choose between: turning to
alcohol, housework, conversation, walk or consuming
confectionaries. The differences between given replies
were not statistically significant. However, two details
became noticeable: women turned to alcohol more
often than men (20% to 14%), while men chose walks
and housework more often than women (51% to
34.5% and 48.8% to 40%, respectively).
Another part concerned the answers related to age
of respondents. Thus, they were divided into three
groups: - Group I included individuals not older than
39, Group 2 – 40-59, Group III – 59 and above. The
first analysed question concerned the influence of age
on providing the correct answers on an ischemic heart
disease. The most knowledgeable was the second
group (aged 40-59). The two other groups had quite
limited knowledge of the subject. The subsequent
question concerned blood pressure checks. Individuals
aged 39 or younger did it rarely (55.6%), while some
did not do it at all (44.4%). As for the second group
(aged 40-59), 33% did it every day, 47.2% - rarely,
while 19.4% - not at all. Group III (aged 59 and above)
included individuals who did it every day (56%), while
those not controlling it at all were in minority (6%). In
the aftermath of such analysis, we could observe an
increasing regularity in blood pressure control, which
came with age. The following research featured
relation between age and modifying actions on risk
110
Grażyna Franek et. al.
factors of the heart disease. There, we can observe that
younger patients were twice less informed on the
modification of risk factors than their above 60’s
counterparts (33.3% to 79.6%). Out of every analysed
socio-demographic parameters, the level of education
was the most important factor in providing answers by
individuals. The most correct answers were given by
patients with higher education (46.2%), secondary
education (37.6%), vocational (37.4%) and basic
education (27.7%). From the analysis of education and
its influence on health awareness in heart conditions,
the following may be assumed: individuals with higher
and secondary education (58.1% and 50%,
respectively) possessed such awareness. However, only
20% with basic education and 28.6% with vocational
education claimed to have been aware. Interestingly,
66.7% with vocational education declared to have been
aware of only some of the health conducts, with only
34.1% with secondary education admitting so. 15.9%
with secondary education informed of their complete
lack of knowledge of the subject, with 4.8% with
vocational education and none from basic education
doing so. All things considered, we might state that
patients with secondary education were less aware of
the issues concerning the subject than the other
individuals. The subsequent research analysed the
correlation between the education and nutrition advice
relating to heart conditions. From the analysis we can
gather that the diet awareness was quite limited. Only
29% with higher education, 13.6% with secondary
education and 9.5% with vocational education chose a
completely correct answer. None with basic education
replied properly on the accurate diet in heart
conditions. Another question related to the knowledge
of approved values of cholesterol. The most correct
replies were given by the individuals with higher
education (25.8%), then basic education (20%) and
vocational education (19%), whilst only 15.9% with
secondary education responded accurately. One of the
last issues to be analysed concerned the responsibility
of individuals for their own health. The researched
patients could choose more than once between: me,
patient, nurse, environment, family, and a doctor. As
many as 92.8% felt their own responsibility for their
health. A doctor was responsible according to 43.3%,
while 19.59% thought that it was the environment’s
responsibility, 12.37% - family’s and 2.1% - nurse’s.
The respondents replied that the major source of their
knowledge about the disease came from: a doctor
(75%), friends and relatives (24%), television (24%), a
nurse (15%), while 10% did not use any source of
knowledge.
DISCUSSION
The issue of heart conditions is crucial for the
health care system and its work as well as in the social
aspect. This is, especially the case for politics, which is
why numerous actions are taken to educate and thus
diminish the problem. [6] For the cooperation between
a patient and a doctor to be effective, it is the patient
who needs to have minimal knowledge of the health
issues hence, helping in understanding the action
which needs some effort or sacrifices (e.g. quitting
smoking, losing weight, regular physical activity or
modifying one’s diet). [7] Unfortunately, modifying
the risk factors, which concentrates on healthy lifestyle
is, on the one hand the most available method, but on
the other the most challenging one of preventing heart
conditions. [8]
Following the research made by A. Kubica on the
awareness of the risk factors of the heart disease, we
can conclude that the knowledge about the risk factors
or the heart disease was higher among individuals aged
65 or below (54.4%) than in the ones aged 65 or above
(49%). [9] The similar results were obtained in this
work – the most knowledgeable ones were aged 40-59,
individuals aged 39 or below and 59 or above had a
limited knowledge. According to the research made by
Kubica, sex was not a factor, which differentiated the
individuals between their awareness on the subject. In
the subsequent part, A. Kubica focused on relations
between education and awareness. She noted that
individuals with basic education and vocational
education had a very limited knowledge of the heart
disease (45% and 52.3%, respectively), while those
with secondary and higher education differed
positively (61.2%). [9] The most correct answers on
the subject of an ischemic heart disease were given by
the individuals with higher education (46.2%), then
secondary education (37.6%), vocational education
(37.4%) and basic education (27.7%). Nevertheless,
the results were not satisfactory since more than a half
of individuals were not able to name half of the factors
causing the disease. The similar results were obtained
by G. Nowicki who analysed the risk factors of heart
disease among employed individuals. In his analysis,
50% of the individuals had an average knowledge of
the risk factors, while 30% - limited. The researched
group was well-educated on the diet used in heart
conditions [6]; similar results were obtained in this
work. Satisfyingly, a high proportion of respondents
was familiar with the diet in heart conditions and
valued its role in prevention and treatment of the
disease. Interestingly, 94.6% of women and 61.4% of
men thought that diet had a high influence on the heart
disease. On the basis of the research done by E.
Awareness of risk factors assessment among individuals with ischemic heart disease
Kawalec, it became evident that books or press are the
preferred source of knowledge about health (81.5%).
More than a half (52.2%) thought a doctor or a nurse
was a reliable source. [10] The results are only partly
confirmed here, with 75% of the individuals thinking
of a doctor as a main source, 41% choosing the
Internet, 35% - medical press, 24% - friends and
relatives, 24% - television and 15% - a nurse. The fact
that only 15% chose a nurse as their main source is
puzzling. Is this due to the fact that nurse do not
engage in health education? The confirmation of this
hypothesis came in the subsequent reply where
individuals claimed that a nurse plays alittlerole in
being responsible for their health (2.06%), with the
doctor on the contrary (43.3%). The subsequent part of
the research by E. Kawalec featured the analysis of the
female replies to difficult situations. There we can read
that 30.6% found conversation with their female friend
as helpful and 44.8% - housework [10]. The similar
answers were given in this work – 50.9% choosing
conversation, 40% - housework. From the research we
can read that regularity of blood pressure checks
increases with age. The obtained results here can be
compared with J. Kossak’s conclusions from the
research on environmental risk factors and their roles
in secondary prevention of heart conditions. There it
was claimed that the frequency of blood pressure
checks depends on age and education. [11]
The analysis points to the fact that education is
closely linked to awareness and healthy demeanour of
individuals and that despite numerous campaigns of
healthy lifestyle, the knowledge about the subject is
still limited. The research also showed a very crucial
and, at the same time. Unenthusiastic information
about the nurse care in that, the patients did not
associate nurses with educational functions whether in
hospital or at individual’s place of living. Thus, actions
need to be taken for the nurses to be involved in such
education.
CONCLUSIONS
1. Female individuals and their awareness of the
risk factors and health conduct were much
superior to that of their male counterparts.
2. Individuals aged 39 or below had very limited
knowledge of the risks of an ischemic heart
disease.
3. Individuals with higher education were more
aware of the risk factors of heart conditions
and health conduct.
111
4. Doctors were considered the most reliable
source of knowledge about the disease.
REFERENCES
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B.,
Pielęgniarstwo
Kardiologiczne,
Wydawnictwo Lekarskie PZWL, Warszawa 2010
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3. Andruszkiewicz A. Banaszkiewicz M., Promocja
zdrowia, Wydawnictwo Lekarskie PZWL, Warszawa
2010
4. Narodowy Program Zdrowia na lata 2007-2015.
Załącznik do uchwały nr 90/2007 Rady Ministrów z dnia
15 maja 2007 r.
5. Murynowicz-Hetka,
Pedagogika
społeczna,
Wydawnictwo PWN, Warszawa 2007
6. Nowicki G., Ślusarska B., Brzezicka A., Analiza stanu
wiedzy o czynnikach ryzyka chorób układu sercowonaczyniowego wśród osób pracujących, Probl. Piel.,
2009, 17 (4), 321-327
7. Kubica A., Koziński M., Sukiennik A., Skuteczna
edukacja zdrowotna- utopia czy niewykorzystane
możliwości kardiologii, Cardiovascular Forum, 2007, 12,
13-17
8. Ziółkowski M., Kubica A., Sienkiewicz W., Maciejewski
J., Zmniejszenie umieralności na chorobę niedokrwienną
serca w Polsce- sukces terapii czy prozdrowotny styl
życia?, Folia Cardiologica Ex Cerpta, 2009, tom 4, 5,
265-272
9. Kubica A., Pufal J., Moczulska B., Koziński M., Ocena
wiedzy dotyczącej profilaktyki i objawów choroby
niedokrwiennej serca u osób hospitalizowanych w klinice
kardiologii, Psychiatria w Praktyce Ogólnolekarskiej,
2004, 4 (3), 135-141
10. Kawalec E., Gabryś T., Brzostek T., Reczek A., Czynniki
ryzyka choroby niedokrwiennej serca u kobiet
pracujących umysłowo, Probl. Piel., 2008, 16 (4), 325330
11. Kossak J., Jędrzejczak M., Kossak D., Rola czynników
środowiskowych w prewencji wtórnej chorób układu
krążenia, Med. Rodz., 2004, 2, 78-85
The Department of Health Care and Nursing
of Silesian Medical University In Katowice
Medyków 12
40-752Katowice
tel.: 32 208 86 35
fax 32 208 86 35
Małgorzata Graczyk, Michał Przybyszewski, Jacek Tlappa, Jacek Mućka, Andrzej Kuźmiński, Magdalena
Żbikowska-Gotz, Ewa Szynkiewicz, Katarzyna Napiórkowska, Joanna Kołodziejczyk, Robert Zacniewski,
Anna Różalska, Zbigniew Bartuzi
DETERMINATION OF ECP CONCENTRATION IN PATIENTS WITH ALLERGIC TYPE
OF FOOD HYPERSENSITIVITY AND IN PATIENTS WITH DYSPEPTIC SYMPTOMS
NOT ASSOCIATED WITH FOOD ALLERGY
OCENA STĘŻENIA ECP U PACJENTÓW Z NADWRAŻLIWOŚCIĄ POKARMOWĄ TYPU ALERGICZNEGO
I U PACJENTÓW Z OBJAWAMI DYSPEPTYCZNYMI BEZ ALERGII POKARMOWEJ
Department and Clinic of Allergology, Clinical Immunology and Internal Diseases Collegium Medicum in
Bydgoszcz, UMK in Toruń
Head of Clinic of Allergology, Clinical Immunology and Internal Diseases:
prof. dr hab. n. med. Zbigniew Bartuzi
Summary
I n t r o d u c t i o n . The results of many studies suggest
that the tendency towards the prevalence of food allergies is
increasing [1, 2, 3]. It is estimated that approximately 20% of
population modifies their diet due to adverse reactions
observed after ingestion of certain foods [2]. Still, the exact
prevalence rate of food allergies in pediatric and adult
populations cannot be satisfactorily estimated [4].
T h e a i m o f t h i s s t u d y was to determine
serum concentrations of eosinophil cationic protein (ECP) in
patients with allergic type of food sensitivity and to compare
them to data obtained from patients with dyspeptic disorders
without a concomitant allergic condition.
M a t e r i a l a n d m e t h o d s . This study included a
group of 80 patients; among them 50 individuals with
diagnosed food sensitivity based on existing standards, and
30 subjects with dyspeptic symptoms without an associated
allergic condition. Venous blood was collected from each
participant and ECP concentration was determined by means
of fluoro-immunoenzyme assay (FIA) with UniCAP ECP test
(Pharmacia Diagnostics).
R e s u l t s . The arithmetic mean serum ECP
concentration in patients with food allergy was found to be
24.604 ± 40.36 µg/l. In all individuals, serum ECP
concentrations were within the detection limit of the applied
method. The average concentration of ECP in a group of
subjects without food allergy was determined to be 29.9±
64.76 µg/l and did not exceed the lower or the upper
detection limit of the applied method.
C o n c l u s i o n s . Patients with food allergy did not
differ significantly from those with dyspeptic symptoms
without a concomitant allergy in terms of ECP concentration
(Mann-Whitney U test, p=0.754218).
Streszczenie
W s t ę p . Jak wskazują wyniki wielu badań - częstość
występowania alergii pokarmowej wykazuje tendencję
wzrostową [1, 2, 3]. Szacuje się, że około 20% populacji
modyfikuje swoją dietę ze względu na spostrzegane
niepożądane reakcje po określonych pokarmach [2]. Jednak
dokładne określenie częstości występowania alergii na
pokarmy wśród populacji dzieci i dorosłych pozostaje nadal
niedostateczne [4].
C e l e m n i n i e j s z e g o b a d a n i a była ocena
stężenia ECP w surowicy u pacjentów z nadwrażliwością
pokarmową typu alergicznego i porównanie wartości z grupą
chorych
z
dolegliwościami
dyspeptycznymi
bez
współistniejących schorzeń alergicznych.
M a t e r i a ł i m e t o d y . Badaniem objęto grupę 80
chorych, wśród których wyodrębniono 50 pacjentów z
nadwrażliwością na pokarmy, rozpoznaną w oparciu o
114
Małgorzata Graczyk et. al.
obowiązujące standardy oraz 30 pacjentów z objawami
dyspeptycznymi bez towarzyszących chorób alergicznych.
Każdemu zakwalifikowanemu do badania pacjentowi
pobierano krew żylną w celu oznaczenia stężenia ECP, które
przeprowadzono metodą fluoroimmunoenzymatyczną (FIA),
testem UniCAP ECP, wyprodukowanym przez firmę
Pharmacia Diagnostics.
W y n i k i . Średnie arytmetyczne stężenie ECP w
grupie pacjentów z alergią pokarmową wynosiło 24,604 ±
40,36 ug/l. U wszystkich badanych oznaczane stężenia ECP
w surowicy mieściły się w granicach czułości stosowanej
metody. W grupie badanych pacjentów bez alergii
pokarmowej średnie stężenie ECP wynosiło 29,9± 64,76 ug/l
i nie przekraczało dolnego i górnego zakresu czułości
zastosowanej metody.
W n i o s k i . Nie wykazano istotnej statystycznie
różnicy między stężeniami ECP u pacjentów z alergią
pokarmową i u pacjentów z objawami dyspeptycznymi bez
alergii pokarmowej (Test U Manna-Whitneya, p=0,754218).
Key words: food allergy, ECP, eosinophil
Słowa kluczowe: alergia pokarmowa, ECP, eozynofil
INTRODUCTION
The results of many studies suggest that the
tendency towards the prevalence of food allergies is
increasing worldwide [1,2,3]. An increase in the
occurrence of allergic disorders has been particularly
evident during the recent half-century, when an
indisputable predominance of conditions with atopic
background has been observed [5]. Currently, allergies,
as one of the most common chronic disorders, are
frequently referred to as the epidemic of the 21st
century and constitute a serious medical and social
problem [6,7]. They are so widespread throughout the
contemporary world that some authors suggest that
more than 30% of human population may be affected
by various disorders that can be classified as atopic or
allergic. Allergic diseases are the 4th or 5th most
frequent condition amongst United States citizens, after
neoplasms, cardiovascular and respiratory conditions,
and AIDS [8]. Moreover, food allergies affect
approximately 3.7% of United States population and
6% to 8% of small children. Food allergies have been
revealed to affect the quality of life of patients and
their families [2,9,10]. It is estimated that
approximately 20% of population modifies their diet
due to adverse reactions observed after ingestion of
certain foods [2]. Still, the exact prevalence rate of
food allergies in pediatric and adult populations cannot
be satisfactorily estimated. The data that is available
derived from the studies of small populations, and the
variation in the results is considerable. The reasons for
this variation in the results include varied nutritional
conditions (dietary habits, cultural and ethnic
background), the lack of standardized diagnostic
methods, and differences in nomenclature related to
this condition [4].
It has been revealed that eosinophils are the central
effector cells involved in chronic allergic
inflammation. According to the current knowledge,
they are the principal source of mediators released
during the chronic phase of allergic reaction and are
responsible for many symptoms associated with atopic
reaction. Eosinophils express FcεRII surface receptors;
still, the presence of FcεRI surface receptors for IgE is
controversial, and it has not been confirmed if these
receptors are involved in the process of eosinophil
degranulation occurring during allergic conditions [11,
12]. Activated eosinophils release cytotoxic proteins,
such as major basic protein (MBP), eosinophil cationic
protein (ECP), and eosinophil protein X (EPX) [13].
The aim of this study was to determine serum
concentrations of ECP in patients with allergic type of
food sensitivity and to compare them to the data
obtained from patients with dyspeptic disorders
without a concomitant allergic condition.
This study included a total number of 80 patients
who were hospitalized at the Clinic of Allergology,
Clinical Immunology and Internal Diseases of
Nicolaus Copernicus University (NCU) Ludwik
Rydygier Collegium Medicum in Bydgoszcz, due to
dyspeptic disorders. This group was comprised of 56
women and 24 men aged between 18 and 65 years
(mean age of 37.575 years). A group of 50 subjects
diagnosed with allergic type of food sensitivity was
selected from these patients. The principal inclusion
criterion for the study was the presence of dyspeptic
disorders in patients aged between 18 and 65 years.
The exclusion criteria included severe chronic organic
Determination of ECP concentration in patients with allergic type of food hypersensitivity and in patients with dyspeptic...
Table I. Concentration of ECP in patients with food allergy
Tabela I. Stężenie ECP u pacjentów z alergią pokarmową
ECP (µg/l)
Sample size
Arithmetic mean
Standard deviation
Geometric mean
Median
Minimum
Lower quartile
Upper quartile
Maximum
Subjects with food allergy
50
24.604
40.36
13.6931
12.35
2.3
7.1
19.3
246.00
The average concentration of ECP in the group of
subjects without food allergy was determined to be
29.9± 64.76 µg/l, and did not exceed the lower or the
upper detection limit of the applied method.
Table II. Concentration of ECP in patients without food
allergy
Tabela II. Stężęnie ECP u pacjentów bez alergii pokarmowej
ECP(µg/l)
Sample size
Arithmetic mean
Standard deviation
Geometric mean
Median
Minimum
Lower quartile
Upper quartile
Maximum
Subjects without food allergy
30
29.9
64.76
12.3968
13.00
1.18
8.5
22.3
315.00
Patients with food allergy did not differed
significantly from those with dyspeptic symptoms
without a concomitant allergy in terms of ECP
concentration (Mann-Whitney U test, p=0.754218).
350
p = 0.7542
300
250
ECP [µg/ml]
conditions, such as status after stomach or intestine
resection, necrotic colitis, Crohn’s disease, intestinal
fistulas, coeliac disease, bacterial and fungal enteritis,
parasitic infections, disaccharide intolerance, colorectal
tumours, hyperthyroidism, acute or chronic leukaemia,
lymphoma or other malignancies, ongoing oncological
therapy, urinary tract infections, and tuberculosis.
Based on the established diagnosis, the patients were
divided into two groups.
1. A group of 50 patients between 18 and 65
years of age (mean of 38.36 years) with
allergic type of food sensitivity diagnosed
based on existing standards, i.e. results of
physical examination, skin prick tests with
food allergens, immunological tests as well as
provocation and elimination challenges;
2. Control group comprised of 30 patients
between 18 and 54 years of age (mean of
36.267 years) with dyspeptic symptoms
without the signs of atopy (negative personal
and familial history, negative result of skin
prick tests with food allergens, low
concentration of total IgE and specific IgE
class antibodies).
Concentrations of eosinophilic cationic proteins
were determined by means of fluoro-immunoenzyme
assay (FIA) with UniCAP ECP test (Pharmacia
Diagnostics). This method employed β-galactosidase
conjugated with anti-ECP mouse monoclonal
antibodies (β-Galactosidase-anti-ECP) as a marker and
4-metylumbelliferone-labeled β-D-galactose as the
fluorescent substance. In this assay, anti-ECP
antibodies interact with ECP present in patient’s serum
sample. The sensitivity of the method was less than 0.5
µg/l. According to the manufacturer, tests’ reference
values were as follows:
- 5.5 µg/l – for the geometric mean, or
- 11.1 µg/l – for the 90th-95th percentile value, or
- 13.3 µg/l – for the value between 90th and 95th
percentile, determined in a group of 95 healthy
individuals (44 men and 51 women between 18 and 76
years of age).
115
200
150
100
50
RESULTS
Arithmetic mean of serum ECP concentration in
patients with food allergy was found to be 24.604 ±
40.36 µg/l. In all individuals, serum ECP
concentrations were within the detection limit of the
applied method.
0
Group without food allergy
Group with food allergy
Median
25%-75%
Range
Ryc. 1. Concentration of ECP in egzaminated patients
Ryc. 1. Stężenie ECP u badanych pacjentów
116
DISCUSSION
The tissue eosinophils count is known to be 100- to
200-fold higher than in the peripheral blood. Thus,
eosinophils constitute the principal tissue cells,
showing particular predilection for skin, respiratory
system, and alimentary tract [14]. Eosinophil
infiltration can be present in every part of the
alimentary tract: eosinophilic inflammation has been
found in the esophagus, stomach, and the small
intestine of individuals with food allergy, and in the
large intestine of allergic and allergy-free subjects [15].
The opinion on the role played by eosinophils in the
pathomechanism of allergic disorders has been
changed substantially during the recent several years.
Previously, eosinophils were seen as the modulators of
inflammation. Presently, they are considered to be the
effector cells during inflammatory processes,
possessing a regulatory function and a potential toxic
influence on other cells present in their
microenvironment [16,17]. Allergic disorders are
associated with an enhanced migration of these cells
(with the involvement of adhesion molecules) to target
tissues, which is manifested by their elevated
peripheral blood count [16]. As a consequence,
eosinophils were postulated to be the inflammatory
cells involved in the pathogenesis of allergic conditions
[18,19].
It is widely believed that eosinophilic cationic
protein is a marker of inflammation in the course of
allergic conditions. ECP was isolated from
lymphoblastic leukaemia cells in 1971. In 1975, Olson
et al. identified eosinophils as the main source of this
protein [15]. It is the principal, potentially cytotoxic,
protein released as a result of eosinophil activation that
can modulate systemic immune response [18,19]. This
cationic toxin with 18-25 kDa molecular mass is stored
in eosinophil granules [20]. ECP levels in biological
fluids are currently used as specific markers in
monitoring and diagnosis of inflammatory conditions.
Cytotoxic properties of ECP can also cause injury to
host’s epithelial cells, and eosinophils are considered
the first leukocytes that respond to tissue injury during
inflammatory disorders [18]. The exact mechanism of
ECP-mediated injury is still unclear. In 1986 Young et
al. revealed that ECP can cause injury to artificial lipid
membranes in in vitro studies. ECP is known to
possess RNAase (ribonuclease) activity [20]. Two
forms of ECP have been identified during
immunochemical studies: ECP1 and ECP2. The first
can be found in the granules of non-activated
eosinophils, while the second one is associated with
activated cells. The gene that encodes human ECP
(RNS) was mapped to q24-q31 region of chromosome
14, in a close neighbourhood of genes encoding other
proteins
of
endonuclease
family:
RNAse-4
(pancreatic), and EPX/EDN. ECP is synthesized as a
precursor protein which is subsequently modified
inside eosinophil granules [15]. GM-CSF, a factor
required for eosinophil formation and maturation, does
not influence the degranulation of mature eosinophils;
it is IL-5 that stimulates these cells to release ECP.
According to Venge, measurement of ECP level can
constitute a useful tool in the assessment of eosinophil
activation status and activity of inflammatory process
in bronchial asthma patients [21]. Elevated levels of
ECP were observed to be associated with more severe
injury to bronchial tissue in patients with inadequate
anti-inflammatory treatment of bronchial asthma. In
these cases, bronchial injury corresponded with an
increased density of basal membrane, injury to
epithelial and glandular cells of the bronchi, and the
hypertrophy of bronchial smooth muscles with
resulting bronchial hyper responsiveness. Zapalka et al.
revealed that serum ECP correlates with the results of
functional pulmonary tests (FEV1, FEF50).
Furthermore, an increase is serum ECP was observed
during pollen season, and its concentrations were
higher in a group of patients with atopy [22]. Chung et
al. observed an association between the concentration
of ECP in the mucosa and the degree of injury to small
intestinal mucosa. Furthermore, Hill et al. showed that
eosinophils are involved in the intermediate phase of
antigen response (due to reaction time), while mast
cells and lymphocytes play roles in the immediate and
late phase, respectively.
Niggeman et al. studied the concentration of ECP
prior to and after allergen challenge in children with
atopic dermatitis. They observed that the positive result
of the challenge was associated with the decrease in the
number of circulating eosinophils, and interpreted this
finding as a consequence of their involvement at the
reaction site. The serum concentration of ECP initially
did not change (during the first eight hours), and then
increased thereafter.
Furthermore, involvement of ECP was reported in
the mechanism of mucosal membrane injury during
eosinophilic esophagitis [15].
Czaja-Bulsa et al. verified if the accumulation and
activation of eosinophils during positive provocation
Determination of ECP concentration in patients with allergic type of food hypersensitivity and in patients with dyspeptic...
challenge in children with IgE-dependent allergy to
cereal protein can be monitored based on eosinophil
count and serum ECP concentration. Significant
changes in both parameters were detected during
immediate adverse reaction observed as a result of
provocation challenge. However, the increase in serum
concentrations did not occur simultaneously. Typically,
a 2- to 3-fold, and sporadically even more pronounced
(9-fold), decrease in eosinophil count was observed
two hours after the provocation. This was followed by
an increase to the levels higher than baseline values
(most commonly 1.5- to 3-fold higher) one or two days
after the challenge. Two- to three-fold increase in ECP
concentration was usually noted 2 hours after the
provocation in the same group of children, and
persisted, or even continued to grow up to 24 hours
after the challenge [23].
Osterlund et al. proved that the determination of
ECP in the milk of lactating women can be used as a
novel approach in the early detection of allergic
disorders. Based on the measurements of breast milk
ECP concentration and breast milk and peripheral
blood leukocytes counts of 94 lactating women, of
which 58 had atopy and 36 did not, they observed that
the presence of ECP in human milk is associated with
the development of allergy to β-lactoglobulin in cow’s
milk and atopic dermatitis in breastfed children.
However, no association was observed between the
breast milk ECP concentration and maternal atopy.
In contrast, Maciorkowska and Kaczmarski
revealed that ECP concentration is not a reliable
indicator of the degree of injury to the alimentary tract
mucosa in the course of food allergy in children [24].
Additionally, the role of eosinophils in gastritis
associated with Helicobacter pylori infection is not
fully established. Aydemir et al. observed the
migration of eosinophils to the infected regions and a
subsequent release of ECP leading to considerable
injury of the gastric mucosa as a result of cytotoxic
effects of this protein [25].
CONCLUSIONS
with food allergy. The potential effects of H. pylori
infection on eosinophil activation and resulting
enhanced release of ECP in patients without food
allergy should be also considered.
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Małgorzata Graczyk
Klinika Alergologii
Szpital Uniwersytecki nr 2 im. J. Biziela
ul. Ujejskiego 75
85-168 Bydgoszcz
tel. 052 3655416; fax 052 3655416
Anna Grzanka-Tykwińska1, Alicja Rzepka1,2, Katarzyna Porzych1, Krzysztof Kusza2,3,
Kornelia Kędziora-Kornatowska1
THE QUALITY OF LIFE OF PATIENTS OVER 60 INCLUDING DEMOGRAPHIC
AND ENVIRONMENTAL FACTORS
JAKOŚĆ ŻYCIA PACJENTÓW POWYŻEJ 60 ROKU ŻYCIA
Z UWZGLĘDNIENIEM CZYNNIKÓW DEMOGRAFICZNO-ŚRODOWISKOWYCH
1
Department and Clinic of Geriatrics of the Nicolaus Copernicus University in Toruń
Head: Prof. Kornelia Kędziora-Kornatowska, PhD.,MD.
2
Department and Clinic of Anesthesiology and Intensive Care of the Nicolaus Copernicus University
in Toruń, Collegium Medicum in Bydgoszcz
Head: Prof. of UMK Krzysztof Kusza, PhD., M.D.
3
Department and Clinic of Anesthesiology, Intensive Care and Treatment of Pain Medical University in Poznań
Head: Prof. Leon Drobnik, PhD., M.D.
Summary
I n t r o d u c t i o n . The population of older people is a
diversified community. It can be differentiated by sex,
marital status or education. These factors may be also
connected with the assessment of older people’s lifestyle.
Not only life extension but also taking care about its quality
provides a challenge to contemporary medicine.
P u r p o s e . The quality of life assessment in patients
over 60 including demographic and environmental factors.
M a t e r i a l a n d m e t h o d s . The study was
conducted by means of WHOQOL-BREF Questionnaire. 119
patients of the Geriatric Outpatient Clinic at dr A. Jurasz
University Hospital No. 1 in Bydgoszcz and patients of
district outpatient clinics in Bydgoszcz were involved in it.
R e s u l t s . Those involved in the study gave the worst
assessment to their quality of life in the physical area (13.99
± 2.13 points), whereas the psychological area was assessed
most favourably (15.32 ± 1.93 points). Statistically
significant differences were determined between women and
men (p=0.0421) as well as between the married and the
widowed (p=0.0185) in the area of social relations, and
between people with vocational education and those with
university education (p=0.0015) in the area of environment.
C o n c l u s i o n s . As far as social relations are
concerned, quality of life was assessed less favourably by
women than by men and by the widowed than by the
married. Sex and marital status had an influence on quality of
life assessment in the field of social relations. As regards
quality of life assessment, the level of education was
influential. People with vocational education gave assessed
quality of their life less favourably than those with university
education.
Streszczenie
W s t ę p . Populacja osób starszych jest zbiorowością
zróżnicowaną. Indywidualizuje ją płeć, stan cywilny, czy
wykształcenie. Czynniki te mogą również wiązać się z oceną
jakości życia osób starszych. Wyzwaniem współczesnej
medycyny jest nie tylko przedłużanie życia, ale również
dbałość o jego jakość.
C e l . Ocena jakości życia pacjentów powyżej 60 roku
życia z uwzględnieniem czynników demograficznośrodowiskowych.
M a t e r i a ł i m e t o d y . Badania przeprowadzono
za pomocą Kwestionariusza WHOQOL-BREF. Wzięło w
nich udział 119 pacjentów Poradni Geriatrycznej Szpitala
120
Anna Grzanka-Tykwińska et. al.
Uniwersyteckiego nr 1 im. dr A. Jurasza w Bydgoszczy i
pacjentów bydgoskich poradni rejonowych.
W y n i k i . Uczestnicy badania najniżej oceniali swoją
jakość życia w dziedzinie fizycznej (13,99 ± 2,13 punkty), a
najwyżej w dziedzinie psychologicznej (15,32 ± 1,93
punkty). Istotne statystycznie różnice stwierdzono pomiędzy
kobietami a mężczyznami (p=0,0421) oraz pomiędzy
osobami pozostającymi w związku a osobami owdowiałymi
(p=0,0185) w dziedzinie relacji społecznych, a także
pomiędzy osobami z wykształceniem zawodowym a osobami
z wykształceniem wyższym (p=0,0015) w dziedzinie
środowisko.
W n i o s k i . W dziedzinie relacji społecznych niżej
oceniały swoją jakość życia kobiety od mężczyzn oraz osoby
owdowiałe od osób pozostających w związku. Płeć i stan
cywilny miały wpływ na ocenę jakości życia w dziedzinie
relacji społecznych. W dziedzinie środowisko, na ocenę
jakości życia wpływ miało wykształcenie. Osoby z
wykształceniem zawodowym gorzej oceniały swoją jakość
życia od osób z wykształceniem wyższym.
Key words: quality of life, old age
Słowa kluczowe: jakość życia, wiek podeszły
INTRODUCTION
A growing share of the older population in the
community is a success of contemporary medicine and
proves development of new technologies and
improvement in life conditions. At the same time this
provides a challenge from the point of view of
economy and state social policy. Older people face old
age problems. A bigger number of older people means
a growing demand for medical, nursing and caring
services [1]. The issues related to growing old and old
age arouse interest of a range of scientific disciplines,
therefore this period of life is perceived from different
perspectives. More and more often there are mentioned
the issues of independent functioning of older people
in the contemporary environment, providing them with
the possibility of further development and
accomplishment of subsequent developmental tasks
and an adaptation for new conditions [2]. Although
older patients are provided with constant medical
assistance, their quality of life is an incredibly import
ant and often considered problem. Not only life
extension but also taking care about its quality
provides a challenge to contemporary medicine.
Numerous definitions of this term can be found in
literature. With reference to growing old and old age
issues, Rowe and Kahn’s definition is most frequently
quoted. It involves three basic elements. The first one
is a low risk of disease and disability occurrence, the
second one is a good physical and mental condition of
an individual whereas the last one is active
involvement in life problems [3].
119 patients of the Geriatric Outpatient Clinic at dr
A. Jurasz University Hospital No. 1 in Bydgoszcz and
patients of district outpatient clinics in Bydgoszcz were
involved in the study. For the study there were
qualified people aged between 60 – 80 living in
Kujawsko-Pomorskie Province, capable of independent
functioning in everyday life in accordance with the
Lawton Instrumental Activities of Daily Living Scale,
without mental dexterity disorders coexisting with
stupor, according to Minimental State Examination
[4,5]. Quality of life study was conducted by means of
WHOQOL-BREF Questionnaire in the Polish language
version, developed under the supervision of Laura
Wałowicka and KrystynaJaracz [6]. WHOQOL-BREF
Questionnaire consists of 26 questions which provide
quality of life assessment in the following four fields of
life: physical health, psychological health, social
relations and environment. A higher number of points
obtained when using WHOQOL-BREF Questionnaire
proves a better quality of life of those involved in the
study.
PURPOSE OF THE DISSERTATION
The purpose of this dissertation was quality of life
assessment in patients of district outpatient clinics in
Bydgoszcz including demographic and environmental
factors.
RESULTS
The study involved 119 people, including 81
(68.1%) women and 38 (31.9%) men. The average age
of those involved in the study was 67.7 ± 5.6. Most of
them came from the city (95%). 12.6% of the persons
involved in the study had primary education, 27.7%
had vocational education, 39.5% had secondary
education whereas 20.2% had university education. As
far as marital status is concerned, 61.3% of those
involved in the study were married, 31.9% were
widowed, and there were also 3.4% of the divorced and
similarly 3.4% of singles. Among those involved in the
study, 73.1% live with their family while 26.9% lived
alone. For the purpose of cognitive functions
The quality of life of patients over 60 including demographic and environmental factors
assessment there was applied a brief screening tool
Mini-Mental State Examination. The average number
of points obtained by the people involved in the study
was 28.09 ± 1.41. Cognitive disorders without stupor
were recognised in 16 people (13.4%). The rest of
them (86.6%) achieved a correct result. The Lawton
Instrumental Activities of Daily Living Scale was
applied to make an assessment of possibilities of
independent functioning in daily living. All the people
involved in the study were independent in terms of
being able to perform complex everyday activities. The
average number of obtained points was 26.57 ± 0.95.
The quality of life of those involved in the study was
estimated
by
means
of
WHOQOL-BREF
Questionnaire. The estimation was made within the
following four areas: physical health, psychological
area, social relations and environment. The best quality
of life among the individuals involved in the study was
observed in the psychological area (15.32 ± 1.93
points) whereas the worst quality of life was in the
physical area (13.99 ± 2.13 points). Average scores
obtained by those involved in the study in the physical
and psychological area, relations and environment can
be found in table 1. When assessing the influence of
demographic and environmental factors on the
outcome of WHOQOL-BREF Questionnaire the
following were considered: sex, marital status,
education, residence (alone, with family). Detailed
results can be found in tables 2, 3, 4 and 5. Sex, marital
status, education and residence do not affect the quality
of life of the individuals involved in the study as
regards the physical and psychological area.
Statistically significant differences were noticed in the
field of social relations between women and men
(p=0.0421) as well as between married people and
those widowed (p=0.0185). As far as the area of
environment is concerned, statistically significant
differences were observed between those with
vocational education and those with university
education (p=0.0015).
121
Table I. Average score in selected groups obtained according
to the WHOQOL-BREF Questionnaire
Tabela I. Średnia liczba punktów w poszczególnych
dziedzinach
uzyskana
w
kwestionariuszu
WHOQOL-BREF
Fields of life
Dziedzina
Średnia ± SD
Average ±SD
Study group
Grupa badana
Min.
Maks.
Minimum
Maximum
Physical
13,99 ± 2,13
Fizyczna
Psychological
15,32 ± 1,93
Psychologiczna
Social relations
Relacje
14,41 ± 2,11
społeczne
Environment
14,16 ± 2,15
Środowisko
SD – standard deviation
8,00
19,43
10,67
19,33
9,33
18,67
8,50
18,00
Table II. Average score in selected groups according to
WHOQOL-BREF Questionnaire depending on sex
Tabela II. Średnia liczba punktów w poszczególnych
dziedzinach kwestionariusza WHOQOL-BREF
w zależności od płci
N
Women
Kobiety
Psychological
Physicaldiscipline
discipline
Dziedzina
Dziedzina
fizyczna
psychologiczna
Social relations
discipline
Environmentdiscipline
Dziedzina relacji Dziedzina środowisko
społecznych
Średnia ± SD
Average±SD
Średnia ± SD
Average±SD
Średnia ± SD
Average±SD
Średnia ± SD
Average±SD
81
13,90 ± 2,04
15,13 ± 1,98
14,141 ± 2,19
14,11 ± 2,18
Men
38
Mężczyźni
14,18 ± 2,32
15,72 ± 1,76
14,982 ± 1,85
14,25 ± 2,12
1-2 statistically significant difference p=0.0421
1-2 różnica istotna statystycznie p=0,0421
Table III. Average score in selected groups according to
WHOQOL-BREF Questionnaire depending on
marital status
Tabela III. Średnia liczba punktów w poszczególnych
w zależności od stanu cywilnego
Physical
discipline
Dziedzina
fizyczna
Średnia ± SD
N
Average±SD
Social relations
discipline
Psychologicaldiscipline
Dziedzina psychologiczna Dziedzina relacji
społecznych
Średnia ± SD
Średnia ± SD
Average±SD
Average±SD
In
connection
W związku
73
13,90 ± 2,07
15,47 ± 1,77
14,83 ± 2,02
Widowers
Wdowcy
38
14,26 ± 2,25
15,30 ± 2,16
Divorced
4
Rozwiedzeni
13,57 ± 2,40
13,43 ± 2,40
Unmarried
Stanu
wolnego
4
Environmentdiscipline
Dziedzina środowisko
Średnia ± SD
Average±SD
1
13,98 ± 2,02
13,86 ± 2,05
2
14,65 ± 2,19
14,17 ± 1,91
12,67 ± 3,17
12,38 ± 3,42
13,83 ± 2,06
13,67 ± 1,68
14,50 ± 2,16
1-2 różnica istotna statystycznie p=0,0185
Anna Grzanka-Tykwińska et. al.
122
Table IV. Average score in selected groups according to
WHOQOL-BREF depending on education
Tabela IV. Średnia liczba punktów w poszczególnych
w zależności od wykształcenia
Education
Wykształcenie
N
Psychological
Physicaldiscipline
discipline
Dziedzina
Dziedzina
fizyczna
psychologiczna
Social
relationsdiscipline
Dziedzina relacji
społecznych
Environment
discipline
Dziedzina
środowisko
Średnia ± SD
Average±SD
Średnia ± SD
Average±SD
Średnia ± SD
Average±SD
Średnia ± SD
Average±SD
Basic
Podstawowe
15
13,52 ± 2,24
15,42 ± 2,56
14,22 ± 2,18
14,83 ± 1,85
Vocational
Zawodowe
33
13,94 ± 2,12
15,29 ± 1,78
14,87 ± 2,11
13,231 ± 2,06
Medium
Średnie
47
13,76 ± 2,00
15,09 ± 1,83
14,33 ± 2,20
13,94 ± 2,09
Higher
Wyższe
24
14,81 ± 2,22
15,72 ± 1,94
14,06 ± 1,93
15,442 ± 1,91
1-2 różnicaistotnastatystycznie p=0,0015
Table V. Average score in selected groups according to
WHOQOL-BREF depending on residence
Tabela V. Średnia liczba punktów w poszczególnych
w zależności od miejsca zamieszkania
N
Psychological
Physicaldiscipline
discipline
Dziedzina
Dziedzina
fizyczna
psychologiczna
Social
relationsdiscipline
Dziedzina relacji
społecznych
Environment
discipline
Dziedzina
środowisko
Średnia ±
SDAverage±SD
Średnia ± SD
Average±SD
Średnia ±
SDAverage±SD
Średnia ±
SDAverage±SD
Wih
family
Z rodziną
87
13,95 ± 2,09
15,30 ± 1,86
14,56 ± 2,10
14,05 ± 2,05
Alone
Samotnie
32
14,11 ± 2,25
15,38 ± 2,13
14,00 ± 2,14
14,44 ± 2,41
DISCOURSE
The population of older people does not comprise a
homogenous group. Pędich et al. divided the
community of older people according to their health
condition and level of independence into four groups:
independent and able-bodied individuals, individuals
with minor diseases, chronically ill and bed-ridden [7].
This study involved people able to function in their
domestic environment on their own according to IADL
Lawton scale. However, the group of older people can
be distinguished not only by their health condition and
independence level but also marital status, sex or
education. These factors may have influence on the
quality of life assessment. Under this study the quality
of life was estimated in the physical and psychological
areas, social relations and environment. Statistically
significant differences including demographic and
environmental factors were determined only in the area
of social relations and environment. As regards social
relations, statistically significant differences were
observed between women and men (p=0.0421) and
between those married and those widowed (p=0.0185).
As far as environment is concerned, statistically
significant differences were recognized between
individuals with vocational education and with
university education (p=0.0015). The area of
environment consists of financial resources, recreation
and relaxation, as well as access to information and the
chance of gaining new skills. Thus, education may
affect the general social position which is connected
with a better economic situation, prestige or the
possibility of self-realizing. The study analysis in terms
of demographic and environmental factors revealed
that widowed people achieved lower scores as regards
the quality of life in the field of social relations than
those married. According to other authors, the quality
of life and frame of mind in older people are affected
by marital status and close relations with family and
friends [8, 9, 10, and 11]. Meaningful as it appears to
be was sex in the quality of life as regards the area of
social relations. As opposed to men, women gave
worse assessment to quality of their life in the area of
social relations. Perhaps this results from social roles
performed by women as well as their bigger
contribution to close relations with others. As it results
from the observation of other authors, older women are
more eager to participate in forms of activities
connected with frequent social contacts such as
attending courses organized by the University of the
Third Age [12, 13].
CONCLUSIONS
1. The highest assessment of the quality of life
was observed in patients in the psychological
area whereas the lowest one was in the
physical area.
2. Women assess the quality of life worse than
men as regards social relations. This might
result from their bigger need for interpersonal
contacts and membership in a group.
3. As regards social relations, widowed
individuals assess their quality of life worse
than married individuals. Marital status may
have an influence on quality of life
assessment in the area of social relations.
4. As far as environment is concerned, people
with university education give a more
favourable assessment of their quality of life
than those with vocational education.
The quality of life of patients over 60 including demographic and environmental factors
BIBLIOGRAPHY:
1. Zarzeczna-Baran M., Słodkowska D.: Sytuacja społeczna
seniorów a dostępność usług medycznych. ZdrPubl 2004;
114: 502-507.
2. Zielińska-Więczkowska H., Kędziora-Kornatowska K.:
Starość jako wyzwanie. Gerontol Pol 2008; 16: 131-136.
3. Depp C.A., Jeste D.V.: Definitions and predictors of
successful aging: a comprehensive review of larger
quantitative studies. Am J Geriatr Psychiatry 2006; 14: 620.
4. Lawton M.P., Brody E.M.: Assessment of older people:
Self-maintaining and instrumental activities of daily
living. Gerontologist 1969; 9:179-186.
5. Matczak A. (red.): Krótka Skala Oceny Stanu
Umysłowego. Przewodnik Kliniczny. Pracownia Testów
Psychologicznych. Warszawa 2009: 7-16.
6. Jaracz K., Wołowicka L.: Polska wersja WHOQOL-100 i
WHOQOL BFER (red.): Jaracz K., Wołowicka L.:
Jakość życia w naukach medycznych. Wydawnictwo
Akademii Medycznej w Poznaniu, Poznań 2001: 235281.
7. Błachnio A.: Pytanie o jakość życia w kontekście
rozważań nad naturą starości. W: Obuchowski K. (red.):
Starość i osobowość. Wyd. Akademii Bydgoskiej,
Bydgoszcz 2002: 13-49.
8. Antonucci T.C., Lansford J.E., Akiyama H.: Impact of
positive and vegative aspects of marital relationships and
friendships on well-being of older adults. Applied
Developmental Science 2001; 5: 68-75.
9. Makara-Studzińska M., Zaborska A.: Samotność wśród
osób starszych. Porównanie międzykulturowe. ZdrPubl
2006; 116: 619-622.
10. Nocon A., Pearson M.: The roles of friends and
neighbours in providing support for older people. Ageing
& Society 2000; 20: 341-367.
11. Peters A., Liefbroer A. C.: Beyond Marital Status:
Partner History and Well-Being in Old Age. Journal of
Marriage and Family 1997; 59: 687-699.
12. Lubryczyńska K.: Warszawskie uniwersytety trzeciego
wieku. E-mentor 2005; 9: 89-92.
13. Ziębińska B. Uniwersytety Trzeciego Wieku jako
instytucje przeciwdziałające marginalizacji osób
starszych.
http:////www.sbc.org.pl/Content/7028/doktorat2757.pdf.
Projekt jest współfinansowany przez Unię
Europejską z Europejskiego Funduszu Społecznego
oraz Budżetu Państwa w ramach Zintegrowanego
Programu Operacyjnego Rozwoju Regionalnego
mgr AlicjaRzepka
Department of and Clinic of Geriatrics
of the Nicolaus Copernicus University in Toruń
85-094 Bydgoszcz
M. Curie-Skłodowskiej 9 Street
Tel/fax (052)-585-49-00
e-mail:[email protected]
123
Beata Haor, Kamila Korniluk, Mirosława Felsmann, Marzena Humańska
TASKS OF A NURSE IN SENIORS’ PREPARATION FOR SELF-CARE
IN THE COURSE OF TYPE 2 DIABETES
ZADANIA PIELĘGNIARKI W PRZYGOTOWANIU DO SAMOOPIEKI SENIORÓW
W PRZEBIEGU CUKRZYCY TYPU 2
Department of Pedagogy and Nursing Didactics, Nicolaus Copernicus University in Toruń
Head: Mirosława Felsmann, MD PhD
Summary
I n t r o d u c t i o n . The key for a successful therapy of
the diabetes is patients’education, aiming at optimisation of
the patient’s quality of life and preparation for self-care. A
nurse actively participates in that process.
T h e t h e s i s aims at analysing tasks performed by
nurses in preparation of seniors suffering from diabetes for
self-care in the context of behaviour, they present in the
course of the disease.
M a t e r i a l s a n d m e t h o d s . The research was
conducted in 2011 on a group of 60 persons at the age ≥65.
The method of diagnostic sound with the use of a
questionnaire was applied. The statistical analysis was used
to check, if there were any differences or correlations
between behaviour of seniors with diabetes in the field of
self-care and their gender, age, place of residence, and
education. The statistically significant results of the
performed tests were those results, in which co-efficient p <
0.05.
R e s u l t s . Age and education of the surveyed had a
considerable influence on the scope of preparation of elder
persons for care in the course of the disease. Majority of
respondents pointed to the nurse and the doctor as the
professionals who run activities in the field of diabetes
education.
C o n c l u s i o n s . The nurse, who prepares a senior
for self-care in the course of diabetes, shall include a number
of factors, which will optimise the quality of the patient’s life
in the course of the disease, in her program of therapeutic
education.
Streszczenie
W s t ę p . Kluczem do osiągnięcia sukcesu w terapii
cukrzycy jest edukacja, której celem jest optymalizacja
jakości życia chorego i przygotowanie do samoopieki.
W procesie tym aktywnie uczestniczy pielęgniarka.
Celem
opracowania
jest analiza zadań
pielęgniarek w przygotowaniu seniorów z cukrzycą do
samoopieki w kontekście aktualnych zachowań, które
preferują w przebiegu choroby.
M a t e r i a ł i m e t o d y . Badania przeprowadzono w
2011 roku wśród 60 osób w wieku ≥ 65 lat. Zastosowano
metodę sondażu diagnostycznego z wykorzystaniem
kwestionariusza ankiety. W analizie statystycznej sprawdzono, czy istnieją różnice, bądź korelacje pomiędzy
zachowaniami seniorów z cukrzycą w zakresie samoopieki a
ich płcią, wiekiem, miejscem zamieszkania i wykształć-
ceniem. Za istotne statystycznie różnice w przeprowadzonych testach uznano wyniki, gdzie współczynnik p<0,05.
W y n i k i . Wiek i wykształcenie badanych istotnie
wpływały na zakres przygotowania osób starszych do opieki
w przebiegu choroby. Respondenci zdecydowanie najczęściej
wskazywali pielęgniarkę i lekarza jako profesjonalistów
prowadzących działania z zakresu edukacji diabetologicznej.
W n i o s k i . Pielęgniarka, która przygotowuje seniora do
samoopieki w przebiegu cukrzycy powinna uwzględnić w
programie edukacji terapeutycznej szereg czynników, które
będą służyć optymalizacji jakości jego życia w przebiegu
choroby.
Key words: nurse, knowledge, pain management, nonpharmacological, pharmacological, child, newborn
Słowa kluczowe: starość, cukrzyca, samoopieka
126
Beata Haor et. al.
INTRODUCTION
Diabetes is a metabolic disorder known as early as
in the ancient times [1]. At present, it is among both
social and civilisation diseases. It refers to people of all
races, on all continents and it can appear at any age. In
the last decades of the 20th century and in the
beginning of 21century, a systematic increase in
number of new cases was registered. It has been
assumed that there are about 150 million people
suffering from diabetes in the world now. According to
information from WHO, till 2025 the number of
patients will have increased even to 380 millions. It is
closely related to the fact that the society is growing
older, obese, used to sedentary lifestyle and incorrect
dietary habits [2,10]. Age makes an important factor of
the risk of diabetes. Development peak of type 2
diabetes is observed about the age of 60. In the
researchers’ opinion, per cent of patients in a
population of people older than 65 oscillates between
20% and 40% [3].
In Poland, there are about 2 million people
suffering from diabetes, which makes about 5% of the
population [4]. In addition, about 10% of the
population, i.e. nearly 4 million people suffer from
impaired glucose tolerance, whereas in older people,
type 2 of the disease appears in every fifth or sixth
person. In Europe, diabetes appears in about 10-30% of
the population in old age. Treatment of the disease and
its complications makes one of the main problems of
health care in medical, as well as social and economic
respect [4,5].
In spite of huge progress in therapy, at the time being,
diabetes is still an incurable disease. The key for
success in therapy of this disease is diabetes education.
Educating patients in the field of self-care and
engagement in the process of curing makes the most
important part of the therapy [5]. According to
recommendations of the Polish Diabetes Association,
therapeutic education in regard to adult persons with
diabetes shall be realised during each visit [6]. Effects
of that therapy depend mainly on the complete
engagement of the patient and his attitude toward the
disease. Within the course of the disease, the care is
rendered by inter-disciplinary team of professionals.
Specific tasks refer to the nurse, who, due to the fact of
frequent contacts with the patient, plays a crucial role
in preparation of the patient for self-control and selfcare. Educating patients who suffer from diabetes
imposes on her a duty of having substantial knowledge
of the subject. For that reason, she should take care of
her own professional development in order to gain or
improve her abilities in the field of preparing patients
with diabetes for care in the course of the disease. It is
important to recognise the scope of deficiency of selfcare in a person under her care and prepare that person
for self-control and self-care by motivating them to
acting for the benefit of one’s own health. Education is
mainly aiming at e.g. preparation of the patient for
implementation of an appropriate diet and physical
activity, evaluation of one’s own health through
observation,
measurements,
registering
and
interpretation of results [5,7]. Contents and a form of
health education shall be adjusted to both gender, age,
and education of the patient [2]. Important information
shall be conveyed many times and verified during each
meeting [7]. Also the family or curators of the patient
shall be involved in educational program, especially in
case of elder persons, which are not fully able to
control themselves at all times, [2,7].
The survey aims at analysing tasks of nurses in
preparation of seniors with diabetes for self-care in the
context of present manners which they present in the
course of the disease.
The research was conducted in 2011 on a group of
60 persons at the age ≥65, hospitalised in the
Department of Internal Diseases of the Self-Dependent
Public Heath Care Institution in Człuchów on a basis
of a previous consent of the respondents and Director
of the above-mentioned institution, as well as the
Committee of Bioethics, of the Collegium Medicum in
Bydgoszcz. In the statistical analysis it was checked if
there are any differences or correlations between
seniors’ manners in the field of self-care in the course
of diabetes, and such socio-demographic variables, as
gender, age, place of residence and education of
patients under research. Comparing two independent
tests (with regard to gender and place of residence of
the respondents), Mann-Whitney U test was applied.
When analysing results of the test in reference to the
age and education of seniors, Spearman’s rank
correlation test was used. The statistically significant
results of the performed tests were those of co-efficient
p <0.05. In the research, the method of diagnostic
sound was applied with the use of the authors’ own
questionnaire. It consisted of particulars which made it
possible to get information of socio-demographic
Tasks of a nurse in seniors' preparation for self-care in the course of type 2 diabetes
character. The basic part of the questionnaire consisted
of 27 questions and it referred to manners in the field
of self-care presented by seniors in the course of type 2
diabetes.
RESULTS
Among 60 respondents, women made 71.7%, and
men 28.3%. The biggest group consisted of seniors
aged between 71 and 80 (50% of persons under
research). Persons at the age of 65-70 constituted 20%,
and patients above 81 – 30% of the respondents. More,
than a half of the researched persons (55%) lived in
cities, and 45% came from the countryside. Majority of
the respondents (53.3%) had the professional education
and 18.3% - secondary education. 28.3% claimed to
have primary education. Among the researched
persons, there were no university graduates. A large
group of women (46.4%) and men (58.8%) claimed
that they had been suffering from diabetes for 6-10
years whereas within the last 5 years, the disease was
recognised at 39.5% of women, and 23.5% of men.
Diabetes recognised within the last 11-20 years
referred to 17.6% of men and 11.6% of women. Only 1
woman stated that the disease had been recognised in
her case more than 21 years ago.
Both gender and the place of residence did not have
much influence on the self-evaluation of seniors in the
field of the preparation for self-care in the course of
diabetes. More than a half of seniors (women- 53.5%,
men -52.9%) determined their self-dependence in the
field of care rendered in relation to the disease at
satisfactory level. Men (70.6%) more often than
women (48.8%) stated that their family was also
involved in the process of preparation for self-care.
Seniors significantly more often pointed to the
employees of the hospital – the nurse and the doctor as persons preparing them for self-dependent care in
relation to diagnosing diabetes, which is shown in table
I. Nevertheless, women more often stressed
participation of the nurse in such activities (62.8%),
whereas men – of the doctor (41.2%).
Inhabitants of cities (57.6%) significantly more
often (p=0.019) declared systematic visits of a
specialist in a diabetes outpatient clinic than
inhabitants of the countryside, who in a large part
(77.8%) did not make use of such visits. Seniors from
cities also more often proved to have the knowledge of
the usage of an injection pen and appropriate storage of
127
insulin (p=0.047), as well as knowledge of reasons for
hypo- and hyperglycaemia (p=0.023).
Table I. Professionals preparing seniors for self-care in
relation to diagnosing diabetes
Tab. I. Profesjonaliści przygotowujący seniorów do
samoopieki w związku z rozpoznaniem cukrzycy
Professionals
preparing seniors for
self-care in relation
to diagnosing the
disease
Profesjonaliści
przygotowujący
seniorów do
samoopieki w
związku
z rozpoznaniem
choroby
Family doctor
Lekarz rodzinny
Doctor in a hospital
Lekarz w szpitalu
Nurse in a hospital
Pielęgniarka w
szpitalu
Family nurse
Pielęgniarka
rodzinna
Total
Razem
Women
Kobiety
n
%
Men
Mężczyźni
n
%
4
9.3
5
29.4
11
25.6
7
41.2
27
62.8
5
29.4
1
2.3
0
0.0
43
100.0
17
100.0
p
0.016
Age significantly influenced the scope of selfdependence of seniors in the field of care in the course
of diabetes. Majority of the respondents between age of
65 and 70 (83.3%) evaluated their preparation for selfcare as good one, whereas the satisfactory evaluation
of these abilities was stated most often (p=0.000) by
older persons between the age of 71 and 80 (60%) and
more than 81 (77.8%). In the age groups of 65-70
(75%) and of 71-80 (50%), respondents more often
(p=0.028) made use of preparation for self-care in
result of educational activities performed by
professionals with the use of information brochures, as
well as presentations and exercises. Persons older than
81 (66.7%) preferred individual conversations with a
doctor/nurse, connected with analysis of information
materials. Respondents at the age of 65-70,
significantly more often confirmed making use of
regular visits in the diabetes outpatient clinic
(p=0.049). They also had more detailed knowledge on
reasons and the substance of the disease (p=0.002),
correct values of the contents of glucose in blood
(p=0.017), reasons for hypo- and hyperglycaemia
(p=0.024). They also more often declared to have the
ability to make the measurements of glucose with the
use of glucometer by themselves (p=0.001), the
knowledge of rules for controlling and taking care of
Beata Haor et. al.
128
the condition of feet in the course of the disease
(p=0.025), obeying to the dietary rules in diabetes
(p=0.004), the knowledge of activity of oral
antidiabetic medicines (p=0.008).
Education significantly influenced the scope of
preparation of seniors for self-care in the course of
diabetes. In their preparation for self-care, older
persons having secondary professional education ,
apart from self-dependent analysis of educational
materials on diabetes, significantly more often than
those with primary education (p=0.011) pointed to
consulting of problems with a nurse/doctor.
Independent on a type of school they graduated from,
respondents more often (p=0.007) pointed to
employees of the hospital – a nurse and a doctor as
persons who prepared them for self-dependent care as
a result of diagnosing diabetes, which is presented in
table II. Nevertheless, the researched graduates of
professional schools and secondary schools more often
stressed the participation of a nurse in such activities,
while seniors with primary education – of a doctor.
Table II. Participation of professionals in preparation of
seniors for self-care in the course of diabetes
Tab. II. Udział profesjonalistów w przygotowaniu seniorów
do samoopieki w przebiegu cukrzycy
Professionals
preparing of
seniors for selfcare in relation to
diagnosing of the
disease
Profesjonaliści
przygotowujący
seniorów do
samoopieki
w związku
z rozpoznaniem
choroby
Family doctor
Lekarz rodzinny
Doctor in a
hospital
Lekarz w szpitalu
Nurse in a
hospital
Pielęgniarka w
szpitalu
Family nurse
Pielęgniarka
rodzinna
Total
Razem
Primary
Podstawowe
n
%
Education
Wykształcenie
Professional
Zawodowe
n
%
Secondary
Średnie
n
%
5
29.4
4
12.5
0
0.0
6
35.3
11
34.4
1
9.1
5
29.4
17
53.1
10
90.9
1
5.9
0
0.0
0
0.0
17
100.0
32
100.0
11
100.0
p
0.007
Seniors with secondary education significantly
more often, than persons who graduated from
professional and primary schools, declared: running
self-control diary (p=0,030), knowledge of reasons and
the substance of the disease (p=0.003), ability to
measure the level of glucose in blood with the use of
glucometer (p=0.016) without assistance of any other
person. Moreover, they more often presented the
knowledge of the diet recommendations in diabetes
(p=0.002), the mechanism of activity of oral
antidiabetic medicines (p=0.001) and insulin
(p=0.005), the rules for correct dosing and storage of
insulin (p=0.003), as well as techniques of making
injection with a pen (p=0.002). Graduates of secondary
schools (81.8%) determined their level of abilities in
the field of self-care in the course of the disease as
good in comparison with satisfactory evaluation which
was made by seniors with primary (76.5%) and
professional education (56.3%). Respondents with
secondary (81.8%) and professional (56.3%) education
preferred individual educational activities offered by
professionals with the use of information brochures, as
well as presentations and exercises. Persons who
graduated from a primary school (82.4%) stated that
they only made use of individual conversations with a
nurse/a doctor, connected with analysis of information
materials in their preparation for self-care. All
graduates of secondary schools (100%) declared
systematic use of consultations in diabetological
outpatient clinic, as opposed to those with professional
education (40.6%) and primary education (5.9%).
In a large part, seniors did not participate in group
trainings on self-care in the course of diabetes. Only
one woman with secondary education in the age
category of 71-80, living in a city declared
participating in such educational activities. When
talking about preparation for self-care in relation to the
disease, older persons declared self-analysis of
brochures, leaflets as used more often than looking for
explanation of problems by a nurse/doctor. Selfeducation was declared by most of the respondents,
independent on gender (women – 60.5%, men –
52.9%), age category (65-70 years old – 50.0%, 71-80
years old – 60.0%, more, than 81 – 61.1%) and the
inhabitants of the countryside (74.1%). Only those
persons, who lived in cities (54.5%) more often sought
for explanation of problems by a nurse/doctor, as a part
of educational activities.
Preparation of seniors for self-care in the course of
diabetes was also realised by members of their
families. Participation of the relatives in activities in
the field of diabetological education was more often
confirmed by men (70.6%) than women (48.8%), and
persons in very old age (71-80 years old – 63.3%,
more, than 81 years old – 55.6%) in comparison to
seniors in the age between 65 and 70. Participation of
the members of the family in preparation for self-care
was also more often stressed by inhabitants of cities
(63.3%) than the countryside (44.4%) and patients with
professional (65.6%) and secondary education (45.5%)
rather than primary education (41.2%).
DISCUSSION
Therapy in the course of type 2 diabetes shall be
complex and multi-sided. While selecting forms of
therapy and diabetological education, the primary aim
is to provide the patient with the best possible quality
of life. It mainly refers to elderly persons, who make a
very variegated group regarding the time of lasting of
the disease, complications as well as the degree of
intellectual and physical ability [8, 9, 10].
Diabetological education aiming at preparation of
the patient for self-care should be implemented by
professionals, both in the hospital environment,
outpatient clinic, and the place of residence of the
patient. In the present research, seniors stressed the
participation of a nurse and a doctor in education,
especially in the process of hospitalization. The basic
role of a nurse in educational activities in the course of
diabetes is also confirmed by results of the research of
B. Kosicka, realised among patients of the outpatient
clinic and hospital in Lublin [11]. Significance of the
participation of a nurse and a doctor in preparation for
self-care is also proved by the results of the research of
A. Bocian et al., made among the patients with
diabetes in Łódź [12].
Chronic character of the disease predisposes for
appearance of therapeutic and care neglects which may
result from the fact of e.g. lack of strong will at the
patient, dejection, impoverishment, and insufficient
physical and mental proficiency. The above-mentioned
factors cannot be always controlled by a nurse in
relation to preparation of the patient for self-care.
Then, support from the relatives and co-operation with
the family members in the process of health education
is just necessary [13]. In the current research, seniors
pointed to participation of their relatives in educational
activities. Respondents evaluated their abilities of
living with the disease as satisfactory or good ones.
Stronger engagement of the family in therapeutic
education of older persons with diabetes could make
the basis for optimisation of their life in the course of
the disease and encourage them to make higher selfevaluation of the preparation for self-care. Similar
observations referring to participation of the relatives
in educational activities were cited by A. Bocian et al.
129
in their research [12]. A number of the researches in
the field of family medicine and intensive development
of family nursing provide arguments, which stress the
necessity of taking up educational activities in the
course of a chronic disease in co-operation with the
family [14]. However, in the current research seniors
pointed to a slight participation of a family nurse in
therapeutic education. Similar results were presented in
the research of A. Bocian et al. [12]. The research of A.
Kołtuniuk et al. realised among environmental/family
nurses in the area of Dolnośląskie Province show that
they had insufficient preparation for rendering care to
the patient with diabetes. They also expected more
engagement from the patient and his/her family in
activities related to self-care in the course of the
disease [15]. Consequently, it can make a significant
premise for appropriate preparation of nurses for
realisation of tasks in the field of diabetological
education for the benefit of the patient with chronic
disease in the environment of his/her place of
residence, which would add to optimisation of his/her
quality of life.
In the research, depending on advancement in age,
seniors presented worse and worse self-evaluation of
preparation for self-care and controlling of the course
of the disease. It may result from the advancement of
the process of growing old which substantially
influences functional ability in older people. It leads,
among others, to intellectual deficiencies, the ability to
perform activities in the field of self-care, which
additionally interfere with late complications of
diabetes and other co-existing diseases [16]. In the
research, older persons, depending on advancement in
age, more often pointed to self-dependent usage of
information materials referring to the disease and they
were prompt to make use of individual conversations
with a nurse on the subject of preparation for self-care.
Proceeding deficiency of recent memory at a senior
shall make the nurse to formulate simple,
understandable recommendations in a written form
during
educational
activities,
and
those
recommendations
shall
undergo
systematic
verification. It is also necessary to motivate a patient
and his/her family to actively participate in preparation
for self-care.
The current research proves that higher educational
level is related to the higher level of knowledge and
abilities in seniors in the field of self-care and selfcontrol in the course of diabetes. The influence of
education on the degree of preparation for self-care in
130
Beata Haor et. al.
the course of a chronic disease was also confirmed by
the research of M. Kadłubowska et al. [17].
patient and his/her family to actively
participate in preparation for self-care.
CONCLUSIONS
REFERENCES
Analysis of references and results of the research
allowed drawing the following conclusions:
1. A nurse who prepares the senior for self-care
in the course of diabetes shall include in her
program of therapeutic education a number of
factors, e.g. age advancement, education of a
patient, support from the patient’s family,
presence of co-existing diseases, and
complications related to diabetes, functional
ability, availability of specialist services in the
field of diabetological care, motivation, and
financial abilities of the patient.
2. Education of seniors clearly influences
preparation for self-care in the course of type
2 diabetes; the higher the education is, the
higher level of knowledge and abilities in the
field of self-control and self-care in the
disease are.
3. Preparation for self-care in seniors in the
course of diabetes is also considerably
influenced by age of the patients. Old age
persons show difficulties in acquiring
knowledge and abilities regarding self-care.
4. Both gender and place of residence of seniors
do not have much influence on the degree of
preparation for self-care in the course of the
disease.
5. Due to frequent contacts, a nurse plays an
important
role
in
preparation
of
a patient for self-control and self-care in the
course of diabetes.
6. In order to optimise the quality of life in the
course of a chronic disease, (diabetes), in their
environment, seniors require systematic and
planned activities in the field of diabetological
education, realised by a family/environmental
nurse, who is prepared on the merits of the
case.
7. In her activities in the field of education
regarding preparation of an old person with
diabetes for self-care, a nurse should pay
attention
to
formulating
simple,
understandable recommendations in a written
form, which shall be systematically verified. It
is also necessary to motivate
a
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2. Kalota M., Kurpas D.: A role of a nurse in education of
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taking care of the patients. Selected issues. Edited by
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old age. Medical Publishing House NMPH, Warsaw
2009: 110.
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in the field of diabetology. Problems in Nursing 2008, 16
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practice 2011, 12, supl. A: 7.
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education as a method of treatment of diabetes. Clinical
and Experimental Diabetology 2005, 5,4: 253-259.
8. Koziarska-Rościszewska M.: Diabetes in older persons.
Diagnosis, treatment, prevention from complications.
Publishing House Aktis, Łódź 2005.
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proceedings in case of patients with diabetes in 2010.
Diabetology in Practice 2010, 11, suppl. A.
10. Szelachowska M.: Diabetes. W:Daniluk J., Jurkowska G.
(edit.): Outline of internal diseases for students of
nursing. Publishing House Czelej, Lublin 2005:514-528.
11. Kosicka B., Wrońska I.: A role of a nurse in education of
patients with diabetes. Problems of Nursing 2007, 15,2,
3.
12. Bocian A., Borowiak E., Matuszewska M. : Importance
of education of a patient with diabetes for promotion of
salutogenic behaviour. W: Krajewska – Kułak E. et al.
(edit): Therapeutic and nursing problems: from the
conception to the old age. Volume II. Medical Academy
in Białystok, Białystok 2007: 391-399.
13. Dubiel E., Sobczyńska P., Kłys J.: Medical care on the
patient with type 2 diabetes. W: Rosińczuk-Tonderys J.,
Uchmanowicz I.: The patient with chronic disease –
nursing, rehabilitation and therapeutic aspects.
MeadPharm Poland, Wrocław, 2011:281-289.
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social problem. Medical Academy in Wrocław, Wrocław
2002.
15. Kołtuniuk A., Płatosz J., Abramczyk A.: Preparation and
expectations of environmental/family nurses in the field
of care over the patient with diabetes. W: The patient
with chronic disease – nursing, rehabilitation and
therapeutic aspects. MeadPharm Poland, Wrocław 2011:
349-356.
16. Grodzicki T., Kocemba J., Skalska A. (edit.):
Gerontology with elements of general gerontology. Via
Medica, Gdańsk 2007.
17. Bąk E., Kadłubowska M., Fraś M.: Influence of selfcontrol in diabetes on the time of appearance of diabetic
nephropathy. Problems in Nursing 2009, 17 (2): 105–
109.
Beata Haor
Department of Pedagogy and Nursing Didactics
Nicolaus Copernicus University in Toruń
L. Rydygier Collegium Medicum in Bydgoszcz
85-801 Bydgoszcz
3 Techników street
tel. 52 585 21 93
131
Judyta Kutowska1, Małgorzata Gierszewska2, Estera Mieczkowska2, Grażyna Gebuza2, Marzena Kaźmierczak2
QUALITY OF LIFE AMONG WOMEN WITH GESTATIONAL DIABETES MELLITUS
JAKOŚĆ ŻYCIA KOBIET Z CUKRZYCĄ CIĄŻOWĄ
1
2
student of Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz
Department of Obstetric Care Basics, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz
Summary
T h e a i m of this study was to evaluate the life quality
level among women who had diabetes diagnosed during their
pregnancy, and to define any changes related to a medical
treatment of the disease. Another purpose was to indicate a
number of factors which have a considerable impact on the
quality of life in the study group.
M a t e r i a l s a n d m e t h o d o l o g y . The research
was performed among 100 patients of the Pregnancy
Pathology Department of the Obstetrics and Gynecology
Clinic in the University Hospital No. 2 in Bydgoszcz. There
was a subjective assessment of patient’s life quality used in
the study, with a 10-points scale, where 1 means very bad’
and 10 - a ‘very good’ life quality.
R e s u l t s . Subjective assessment of pregnant patient’s
life quality was good. The average score was 6.9 points in the
1 – 10 scale. Majority (69%) of women with gestational
diabetes require application of a diet and insulin therapy
simultaneously. Adapting to a new diet seems to be the most
difficult for the patients. The less the patients know about the
disease, the lower level of life quality they indicate. 174% of
pregnant women, who applied insulin a few times a day,
were not aware of insulin's function in their body.
Conclusions:
1. Quality of life among pregnant women
significantly decreased after they fell ill with
diabetes.
2. High quality of life was more frequently indicated
by women with a high sense of influence on the
course of disease.
3. Women suffering from gestational diabetes need
mental support and thorough information due to
their emotional condition.
Streszczenie
C e l p r a c y . Zamysłem pracy była ocena poziomu
jakości życia kobiet, u których w czasie ciąży rozpoznano
cukrzycę oraz określenie jak się ona zmienia po rozpoczęciu
leczenia choroby, a także wyodrębnienie grupy czynników
warunkujących jakość życia kobiet chorujących na cukrzycę
ciążową.
Materiał
i
metodyka.
Badanie
przeprowadzono wśród 100 pacjentek Oddziału Patologii
Ciąży Katedry i Kliniki Położnictwa, Chorób Kobiecych i
Ginekologii Onkologicznej Szpitala Uniwerysteckiego nr 2
im. J. Bizela w Bydgoszczy. W badaniu wykorzystano
subiektywną ocenę jakości życia ciężarnych na
dziesięciopunktowej skali, na której 1 oznaczało złą, a 10
bardzo dobrą jakość życia.
W y n i k i . Subiektywna ocena jakości życia kobiet
chorujących na cukrzycę ciążową jest dobra, średni poziom
jakości życia wyniósł 6,9 pkt. w skali od 1 do 10. Większość
Key words life quality, gestational diabetes
Słowa kluczowe: jakość życia, cukrzyca ciążowa
badanych kobiet (69%) chorujących na cukrzycę ciążową
wymagało jednoczesnego zastosowania dietoi
insulinoterapii. Najwięcej trudności sprawia pacjentkom
dostosowanie się do nowych zaleceń dietetycznych. Kobiety
nisko oceniające swój poziom wiedzy na temat cukrzycy
wskazywały też na niższe oceny jakości życia.17,4% kobiet
ciężarnych stosujących kilka razy w ciągu dnia insulinę nie
zna jej roli w organizmie.
Wnioski:
1. Jakość życia kobiet w ciąży istotnie obniżyła się po
zachorowaniu na cukrzycę.
2. Wysokie oceny jakości życia częściej występowały
u kobiet z wysokim poczuciem wpływu na
przebieg choroby.
3. Kobiety
z cukrzycą
ciążową
potrzebują
psychicznego wsparcia oraz rzetelnej informacji z
uwagi na przeżywany stan emocjonalny.
134
Judyta Kutowska et. al.
INTRODUCTION
In recent years there has been an increase in the
number of pregnant women with diabetes, both in
Poland and worldwide. This is related to increasing
number of people with diabetes and prolonged period
of procreation. Despite the fact that pregnancy is a
short period in women’s life, it may be complicated by
any of the types of diabetes. In this heterogeneous
group, women with diagnosed disorders of
carbohydrate
metabolism
during
pregnancy
(gestational diabetes mellitus, GDM) constitute vast
majority In Poland, on average 4 out of 100 pregnant
women suffer from gestational diabetes [1]. Although
the biochemical abnormalities are often small, it is a
real threat to the mother and fetus. The presence
of diabetes during pregnancy predisposes women and
their children to reveal a disorder of carbohydrate
metabolism in the future.
Actually More and more attention is paid to the
psychological situation of patients with diabetes,
especially their attitude towards the disease and how
the disease has changed their lives. Psychological
situation of women suffering from gestational diabetes
is an extremely complex issue. Pregnant woman,
expecting the birth of a child, who has been diagnosed
with diabetes, is accompanied by contradictory
feelings: happiness and expectations on one hand,
uncertainty and fear on the other. In women diagnosed
with diabetes, a feeling of fulfillment is interfered by
the fear of pregnancy and child health. The knowledge
about diabetes that pregnant women have to get from
the basics and providing satisfactory glycemic control
require strong commitment and many sacrifices.
Suddenly, the woman who has diagnosed with diabetes
is forced to follow the treatment in the form of:
systematic and frequent measurements of blood sugar,
following the recommendations regarding diet and
exercise, and often - the insulin.
The term, which is related to the assessment of this
situation, is the ‘quality of life’ (QoL). It determines
physical and mental well-being, life satisfaction,
realization of expectations and desires in relation to
one’s own life. For the purposes of this article the most
useful definition is that quality of life is an
’individually perceived satisfaction due to meet the
needs of a given period’ [2]. The assessment of quality
of life includes: physical, mental and social well-being.
Pregnant women have many difficulties in evaluation
of the first two components of quality of life, due to the
presence of typical gestation period changes in these
areas. Physical and mental condition in pregnancy is
largely determined by the period of pregnancy, in
which currently a woman is. The dominant feature of
the well-being during pregnancy, and therefore often
perceived mental and physical [3], is very large
variability throughout the entire pregnancy.
In the literature there are a number of general
considerations about the quality of life among patients
with diabetes, but there is still insufficient empirical
evidence reported in this area. There are no studies that
show level of the quality of life of women with
gestational diabetes mellitus. This is followed by the
fact that the problems of women suffering from GDM
are little known and rarely discussed; attention is
focused on the pregnancy and baby. According to
some, disease affects only the period of pregnancy; the
problems associated with it end at the time of birth or
shortly afterwards, and the risk of complications
occurring later. In addition, symptoms of diabetes
diagnosed in pregnancy are smaller and intertwined
with other ailments common in pregnant women.
The intention of this study was to assess the quality
of life among women with diabetes diagnosed during
pregnancy, and to determine how it changes after
initiation of treatment, as well as the indications of
factors determining quality of life of women suffering
from gestational diabetes.
The study was conducted among 100 women with
gestational diabetes residing in the Pathology of
Pregnancy Department of J. Bizel Hospital in
Bydgoszcz. Patients were included to the study after
completing education on diet, physical activity,
measurement of blood glucose, insulin administration
(if necessary), not earlier than one week after
the diagnosis of gestational diabetes, on average, in the
tenth week of treatment of GDM. To determine the
level of quality of life we used subjective assessment
of quality of life for pregnant women, the 10-point
scale where 1 meant a poor, and 10 – a very good
quality of life. For the analysis of factors determining
quality of life of women suffering from gestational
diabetes we used Short Method of Assessment the
Quality of life among women with gestational diabetes mellitus
Sense of Impact on Diseases Course, and a survey
course of own design which takes into account the
situations of pregnancy that may correlate with the
level of quality of life.
RESULTS
Assuming 5 points as the boundary level of bad and
good quality of life it can be concluded that the level of
QoL among women with gestational diabetes is good,
because 71% of pregnant women rated the QoL with
more than 5 points on the 1-10 points scale. Every
fourth woman found that the quality of life is high by
indicating 9 and 10 points on that scale. Table I
contains basic data about the studied population.
135
treatment to the level of 6.9 points. 62 women reported
that their quality of life decreased after diagnosis of
diabetes and initiation of treatment, it was a large
decrease in most cases (an average of 2.55 points.).
The number of high ratings of quality of life (9 and 10
points) lowers drastically. Before the disease more
than a half of pregnant women (59%) assessed their
quality of life as high, while after the diagnosis this
percentage dropped to 25%. Therefore, the number of
low scores (≤ 5 pts.) rose from 9% to 29%. Summary
of QoL ratings before and after diagnosis of GDM is
shown in the figure 1.
Table I. Characteristics of the study group
Tabela I. Charakterystyka badanej grupy
Podstawowe dane populacji badanej (n=100)
Basic data concerning the studied population (No.=100)
30,9 lat /years
Wiek /age
(min. 18, max.
47)
wyższe /higher
38 %
Wykształcenie
średnie /secondary
40 %
Education
zawodowe /vocational
18 %
podstawowe /primary
4%
miasto >100 tys. /city >100
35 %
Miejsce
thousand inhabitants
zamieszkania
miasto
<100
tys.
/town
<100
Place of
31 %
thousand inhabitants
residence
wieś /village
34 %
36,7 Hbd
Tydzień ciąży w momencie badania
(min.23,
Week of pregnancy at the beginning of the study
max.41)
26,9 Hbd
Tydzień ciąży w momencie rozpoznania GDM
(min.7,
Week of pregnancy at the moment of diagnosis of
GDM
max.37)
9,8 Hbd
Czas trwania choroby/ Illness duration
(min.1,
max.33)
Dieta /diet (G1)
31 %
Sposób
leczenia
Dieta + Insulina (G2)
Method of
69%
diet + insulin
treatment
Dane z
wywiadu
Medical
history
Pierwiastki /Pregnancy first
Wieloródki /Pregnancy subsequent
Poronienia w wywiadzie
/Miscarriages in medical history
GDM w poprzedniej ciąży / GDM
in previous pregnancy
40 %
60 %
27 %
14%
Information about the disease affects the
assessment of pregnant women’s quality of life. After
diagnosis and initiation of the treatment of diabetes,
quality of life decreased (p <0.05). In a retrospective
evaluation the quality of life index was about 8.4
points before the disease, and decreased during
Fig. 1. Subjective assessment of quality of life for women
before and after diagnosis of gestational diabetes (n
= 100)
Ryc. 1. Subiektywna ocena jakości życia kobiet przed i po
zachorowaniu na cukrzycę ciążową (n=100)
All the surveyed women were asked to identify the
dominant mood during the treatment of diabetes.
Information about the variability of pregnant women
well-being presented in the introduction finds
reflection in the respondents’ opinion diversity.
According to half of the women mood during the
treatment is worse than before disease. The other half
of the respondents noticed that it was on the same
(17%) or better (20%) level. Between them there were
three women which found it definitely better.
During the study patients were asked about their
opinion about a sense of security - if it changed after
falling ill with diabetes. Nearly half of the respondents
declined it after the diagnosis of GDM (49%).
To find out how difficult for pregnant women
diagnosed with GDM, nuisances associated with the
disease are, patients were asked to give the rank on the
six-point scale, where 0 - means no difficulty, and 5 very difficult, to the following potential difficulties:
a systematic measurement of blood sugar levels, diet,
multiple medical checks, the administration of insulin.
136
The difficulty level was calculated as the sum of the
five variables and then was subjected to normalization
- brought to the scale of "0-1", where 0 indicates
complete lack of difficulty (corresponding to a zerosum), and 1 - the highest level of difficulty (which
correspondent to sum of 25) (Fig. 2). From the analysis
of variables in diabetes-related nuisance, the highest
average numbers were given to the diet and meal
planning. It is the most troublesome element of the
therapy for either diet therapy alone and the combined
diet and insulin therapy. Self-monitoring of blood
glucose using a glucometer received the lowest
average, showing the smallest nuisance. It should be
noted that the assessment of the difficulty of measuring
blood sugar levels, depending on the applied method of
treatment, varied significantly. For women treated with
insulin it was a bit more problematic task than for
those treated only with a diet. Probably the difference
observed in the evaluation results from a number of
glucose measurements for patients treated with insulin;
they also perform measurements during night.
women suffering from gestational diabetes with a low
sense of influence on the course of the disease. This is
a statistically significant relationship (p <0.05). Figure
3 shows the percentage distribution of the sense of the
impact on the course of the disease among women with
gestational diabetes mellitus.
Fig. 3. Percentage distribution of raw results of the influence
on the course of the disease sense (n = 100)
Ryc. 3. Rozkład procentowy wyników surowych poczucia
wpływu na przebieg choroby (n=100)
DISCUSSION
Fig. 2. Nuisance resulting from the disease (n = 100)
Ryc. 2. Uciążliwości wynikające z choroby (n=100)
A sense of control over the disease is an important
factor affecting the patient's well-being and
functioning. If someone feels that she may affect the
symptoms of the disease, it is the natural attitude to try
resolving problems connected with the disease. On the
contrary, persons declaring to be powerless against the
disease, experiencing unbearable emotions, feeling
frustrated, do not provide a solution to problems
arising from illness, and the strategies to help them
regaining well-being. Women with diabetes diagnosed
during pregnancy, had high sense of influence on the
course of the disease (76%). The level of sense of the
impact on the course of the disease significantly affects
the assessment of quality of life. Thus, the higher sense
of control of the disease process was, the higher Qi
and, conversely, the lower rating of Qi occurs in
Due to the lack of publications regarding to the
quality of life of women with gestational diabetes,
obtained results can be compared only with studies of
quality of life of people with diabetes type 1 and 2.
Results of the research conducted by B. GrabowskaFudala show a similar assessment of the quality of life.
In the group of 30 children with insulin-dependent
diabetes mellitus (DM 1) aged 12-18 years, quality of
life is shown as optimistic; children almost do not feel
the impact of diabetes on their lives [4].
The results of the study showed that the treatment
with insulin was associated with a slight increase in the
negative assessment of the quality of life. The need to
include insulin for treating diabetes is considered as
one of the three crises, difficult moments
in the treatment of diabetes, in addition to recognition
of complications and diagnosis of disease. Patients
within a few days need to learn theoretical and
practical knowledge about the technique and sites of
injection, maintenance of equipment for injection, dose
modification based on blood glucose and insulin
storage. Women often have to overcome a fear of
needles, and self-injection performance. Insulin
treatment is associated with making more frequent
blood glucose measurements, also at night. BandurskaStankiewicz observed a very important regularity pregnant women with GDM treated with insulin,
Quality of life among women with gestational diabetes mellitus
convinced of the need for only periodic injections
because of the welfare of the child, have fewer
problems with the achievement of good control [5].
Sense of security in nearly half the women (49%)
declined after the diagnosis of GDM. Safety is a
fundamental human need, hollowness it makes
impossible the implementation of other needs, and also
hinders the development. In Maslow's hierarchy of
needs, safety is the second most important human
need, after the physiological needs like hunger and
thirst. Security, in terms of a dictionary definition, is
‘condition of no-threat, serenity, confidence’ [6].
Pregnancy complicated by diabetes means three times
greater risk of pregnancy complications than a
physiological process. Additionally, in the case of
abnormal metabolic control, risk of complications
increases tenfold [5]. Awareness of potential
complications threatening to women and their children
entails anxiety and tension. According to Beisert and
Sęk, each hospitalization is stress. Particular care of
women with gestational diabetes may be understood as
confirmation of the risk. Assumption of failure can
potentiate anxiety, and this makes it difficult to treat.
A sense of control over the disease is an important
factor influencing the mood of patients and their
functioning. In the study of Langer et al. showed that
good adaptation to the disease promotes wellcontrolled diabetes [7]. However, Persily noted that
the adaptation to the disease affects the way it is
perceived by the patient. Women suffering from
gestational diabetes, as the disease affecting their lives,
have problems to come to introduce the changes
needed to treat, and it is a simple way to complications
[7].
Adjustments to the new dietary recommendations
constitute most difficulties to the patients. Statistically
significantly they, more often than other nuisance
(measurement of blood glucose, frequent medical
checks, treatment with insulin), indicated diet as the
most troublesome. Similar results obtained Fałkowska
et al., conducted in 2004 among a group of 42 women
with gestational diabetes. These studies indicate that a
small number of women with gestational diabetes,
despite the existence of the disease, apply a diabetic
diet (7.14%) [8]. According to research conducted by
Bandurksą-Stankiewicz et al. in 2005 in a group of 81
pregnant women with diabetes (both before pregnancy
and gestational), difficulties in accepting the new
dietary recommendations had especially those patients,
which previous dietary habits differed considerably
137
from those recommended in diabetes, and more
pregnant with abnormal body weight [5].
To conclude, it must be emphasized that good
health does not guarantee a high level of quality of life.
Quality of life among patients suffering from GDM
should always be closely related to pregnancy, its
course and the past experience of women with previous
pregnancies.
CONCLUSIONS
1.
2.
3.
4.
5.
6.
Subjective assessment of quality of life of
women suffering from gestational diabetes is
good.
A small percentage (6%) of low opinion of
QoL in pregnant women with diabetes
diagnosed during pregnancy was observed.
Quality of life of pregnant women
significantly reduced after falling ill with
diabetes.
An adjustment to the new dietary
recommendations is most difficult for the
patients.
The high quality of life occurs more common
in women with a high sense of influence on
the course of the disease.
Women with gestational diabetes need
psychological
support
and
reliable
information because of their emotional state.
REFERENCES
1.
2.
3.
4.
5.
6.
Cypryk K.: Ocena klinicznej wartości dotychczas
stosowanych metod i propozycja własnego modelu
diagnostyki cukrzycy ciążowej. Diabetol. Pol. 2002, 1:
3-64
Fałkowska J., Fórmaniak J., Gierszewska M. i wsp.:
Jakość życia kobiet operowanych z powodu raka szyjki
macicy. w: Grabiec M. (red.) Intedyscyplinarny
wymiar promocji zdrowia rodziny. Wyd. Scrypt,
Bydgoszcz 2008, 287-300
Sobol E. (red.) Mały słownik języka polskiego. Wyd.
PWN, Warszawa 1996, 1197
Grabowska-Fudala B.: Samokontrola a jakość życia
dzieci z cukrzycą typu I. Pielęgniarstwo Polskie
2004,1-2: 83-91
Bandura- Stankiewicz E., Wańczyk A.: Edukacja
terapeutyczna kobiet z cukrzycą przedciążową i
ciężarnych leczona insuliną. Medycyna Metaboliczna,
2006, 4: 40- 44
Szymczak M. (red.) Słownik języka polskiego T. I,
Wyd. PWN, Warszawa 1978, s. 147
138
7.
Bielawska- Batorowicz E., Cypryk K., Pawełczyk A:
Cukrzyca ciążowa i jej wpływ na psychiczne
funkcjonowanie kobiety. Diabetologia Polska. 1999, 3:
227- 231
Judyta Kutowska
ul. Młyńska 17A
86-122 Bukowiec,
tel. 888 490 558
Magdalena Mińko1, Dorota Siwczyńska2
BREAST CANCER PREVENTION AS A PART OF HEALTH POLICY ACTIVITIES
IN LUBLIN PROVINCE
PROFILAKTYKA RAKA PIERSI JAKO ELEMENT DZIAŁAŃ Z ZAKRESU POLITYKI
ZDROWOTNEJ W WOJEWÓDZTWIE LUBELSKIM
1. Medical University of Warsaw
2. Students Research Group of Public Health Department, Medical University of Lublin
Prof. dr hab. n. med. Teresa B. Kulik
Summary
I n t r o d u c t i o n . Breast cancer is the most common
malignancy tumour and it constitutes more than 20% of all
cases of cancer among Polish women. Despite the prevalence
of many risk factors for breast cancer and negative statistics
on morbidity and mortality of women in Poland, in the recent
years a number of actions, which have a positive influence on
this situation, have been observed. One of them is the
prevention programs, which often save health and lives of
women.
T h e a i m o f t h i s s t u d y was to evaluate the
effectiveness of prevention programs for breast cancer in the
Lublin Macroregion.
M a t e r i a l a n d m e t h o d . Analysis of the
prevention programs reports for breast cancer in 2007, 2008
and 2010 provided by the Regional Centre of Occupational
Medicine in Lublin was the research method. Screening tests
carried out during the above years covered a total of 3479
women.
R e s u l t s . The mostly studied group of women was
ladies between 40-49 years old, who gave birth before the
age of 30 years at least once. On average, 53% of the studied
women regularly performed breast self-examination. During
mammography 64% of women were described as ‘in norm’,
0.8% of women were diagnosed with suspected cancer, while
in the remaining participants of the study there were mild
changes found. They have been referred for further diagnosis.
C o n c l u s i o n . There is still a request for continued
prevention programs, especially among women aged 40-49
years. A request for education in the health prevention field
(in theoretical and practical meaning) has also been observed.
The percentage of morbidity and mortality from breast cancer
in the Lublin Macroregion has decreased in the recent years.
Streszczenie
W s t ę p . Rak piersi jest najczęściej występującym
nowotworem złośliwym u kobiet i stanowi aż 20%
wszystkich zachorowań na nowotwory złośliwe wśród Polek.
Pomimo występowania wielu czynników ryzyka raka piersi i
niekorzystnych
statystyk
dotyczących
zapadalności
i umieralności kobiet w Polsce, w ostatnich latach obserwuje
się wiele działań wpływających pozytywnie na tę sytuację.
Jednym z nich są programy profilaktyczne, które
niejednokrotnie ratują zdrowie i życie kobiet.
C e l e m p r a c y było dokonanie oceny skuteczności
realizowanych programów profilaktycznych dotyczących
raka piersi w makroregionie lubelskim.
M a t e r i a ł i m e t o d a . Metodą badawczą była
analiza sprawozdań z programów profilaktycznych
dotyczących raka piersi w 2007, 2008 i 2010 r.
udostępnionych przez Wojewódzki Ośrodek Medycyny
Pracy w Lublinie. Badaniami przesiewowymi na przestrzeni
trzech badanych lat łącznie objęto 3479 kobiet.
W y n i k i . Najczęściej badaną grupą kobiet były panie
pomiędzy 40-49 r.ż., które rodziły przynajmniej jeden raz
przed ukończeniem 30 lat. Średnio 53% badanych kobiet
regularnie wykonywało samobadanie piersi. Normę w
badaniu mammograficznym uzyskało 64% kobiet, u 0,8%
pań zdiagnozowano podejrzenie nowotworu, natomiast u
140
Magdalena Mińko, Dorota Siwczyńska
pozostałych uczestniczek badania wykryto łagodne zmiany i
zostały one skierowane do dalszej diagnostyki.
W n i o s k i . Wciąż istnieje duże zapotrzebowanie na
kontynuowanie programów profilaktycznych, szczególnie
wśród kobiet w wieku 40-49 lat. Obserwuje się również duże
zapotrzebowanie na edukację prozdrowotną w zakresie
teoretycznym i praktycznym. W ostatnich latach
w makroregionie lubelskim odsetek zachorowań i
umieralności z powodu raka piersi maleje.
Key words: breast cancer, prevention, mammography, prevention program
Słowa kluczowe: rak piersi, profilaktyka, mammografia, program profilaktyczny
INTRODUCTION
MATHERIAL AND METHOD
Oncological diseases are a main cause of the
mortality in the societies of developed countries. In the
last decade, their development has been particularly
intensified, causing the tumors to become a serious
social problem [1]. In the population of women one of
the major health problems is breast cancer. The
morbidity of this type of cancer is increasing on
average by 3% per each year [2]. In the opinion the
World Health Organization, Poland is on the 30th place
among 46 countries according to the level of breast
cancer. Nevertheless, the most worrying is the fact of
low survival rate (only 5-year survival in 40% of
women) after being diagnosed cancer, despite a
statistically low level of morbidity [3].
According to reports prepared on the basis of the
Oncology Centre in Warsaw, the number of reported
cases of breast cancer in the Lublin macro-region
increased dramatically in 1999-2003. Only since 2007,
a slight decrease in morbidity and mortality in the level
of this type of cancer has been noted [4,5].
Persistently high rate of incidence and the relatively
late diagnosis of cancer, cause that every year there is a
large number of women requiring hospital care and
burdensome treatment [6]. Therefore, a reduction the
mortality of women worldwide, including Poland is
highly influenced by knowledge about breast cancer,
its causes, risk factors, methods of prevention and early
detection of disease. Understanding the causes and
consequences greatly increases the chance to both to
avoiding the disease and in case of occurrence,
successful treatment. [7].
Prevention programs, which often save the health
and lives of women, play an important role in illnesses
risk reduction and early detection of disease.
According to the data provided by the Regional
Centre of Occupational Medicine - Center for
Prevention and Healing in Lublin, 1385 women
participated in the breast cancer prevention programs
in 2007(in Lublin - 1085, Zamość - 300), 1100 women
- in 2008 (Lublin - 800, Zamość - 300), and 994
women - in 2010 - (Lublin - 646, Zamość - 300). All
studied women were 40 to 69 years old. However,
annually the largest percentage of women who
participated in the program, affected ladies between the
ages of 40 to 49.
The analysis of reports prepared by the Regional
Centre of Occupational Medicine in Lublin was the he
research method. The analyzed documents concern
Health Program for early detection of breast cancer for
working women (from 2007), Merits reports on the
implementation of the prevention programs for
workers in 2008 (from 2008) and Merits reports of the
programs prevention for workers in 2010 (from 2010).
AIM OF THE STUDY
The aim of this study was to evaluate the
effectiveness of prevention programs for breast cancer
in the Lublin Macroregion.
RESULTS
The etiopathology of breast cancer is influenced by
many factors. This group includes, e.g. childlessness or
the late age of first birth. In the majority of respondents
there were women, who gave birth at least once before
turning 30 years old. In 2007 it was 78% of women, in
2008 - 83%, and in 2010 – 81%.
Another factor which increases the possibility of
breast cancer morbidity is the occurrence of mild
changes in women’s breasts. The appearance of
symptoms such as chest pain, nipple discharge, nipple
retraction, lump, thickening, or skin changes should
mobilize women to have a mammography [8,9].
Among women participating in the research in 2007,
complaints described above were felt by 36% of
women, in the following year nearly 34%, and in 2010
only among 31% of the studied population.
Breast cancer prevention as a part of health policy activities in Lublin province
70%
60%
69%
64% 66%
50%
34%
40%
31%
26%
30%
20%
10%
0%
Without complaints - bez
dolegliwosci
2007
2008
2010
With complaints dolegliwosci
Graph 1. Existence of worrying complaints
Ryc. 1. Występowanie niepokojących objawów
Besides the breast cancer risk factors, there are
preventive actions, which help to reduce the
probability of illness. These activities are a part of
healthy lifestyle, which includes e.g. regular breast
self-examination by women. This easy and painless
self-examination can help to detect cancer at the
earliest possible stage, which considerably increases
the chance for cure [7]. According to the data provided
by WOMP, the systematic performance of breast selfexamination in 2007 was declared by more than 52%
of women, in 2008 – by about 61% of women, while in
2010 by only 45% of respondents.
Graph 2. Breast self-examination
Ryc. 2. Samobadanie piersi
An important point of reference for the research,
was the answer to the question about the last performed
breast mammography. Among women participating in
the study, the largest group in all the researched years
constituted the ladies, who had never had a
mammography performed. In 2007 it was about 52%
of the studied population, in 2008 - 44%, and in 2010 43% of women.
The results of mammography of all analyzed years
are quite diverse. In 2007 the norm was found in 56%
of women, in 2008 at nearly 70%, in the last research
year – (2010) the norm has reached by 66% of the
studied population. Suspected cancer detected from
year to year was smaller and equaled 1.5% (2007),
141
0.63% (2008) and only 0.3% (2010). The decreasing
trend of suspected breast cancer, partially agree with
the declining number of mild changes, which were
diagnosed in 42% of women in 2007, 30% in 2008 and
almost in 34% of women in 2010. The results of
mammography resulted in referral for additional tests
such as ultrasonography, targeted therapy, the repeat of
research the following year or referral to the Breast
Pathology Clinic in 32% of women in 2007, 34% - in
2008 and 34.5% in 2010 of researched women.
DISCUSSION
Breast cancer is the most common malignancy
tumor and it constitutes more than 20% of all cases of
cancer among Polish women [10]. Undoubtedly, it is
also the social problem, concerning in particular the
developed countries, including Poland.
Genetics and age of women are still the main
determinants of the existence of disease, but in the
recent years, special attention has been also drawn to
the risk factors associated with lifestyle. These include:
nutrition, decreased physical activity, adverse
reproductive factors, and use of hormones [10].
Appropriate prophylaxis has a significant impact on the
early detection of mild changes. Its scope includes
women's education, self-examination and screening
test. The focus on prevention is justified by the results
of subsequent treatment, which depend on the
detection of cancer at the earliest possible stage.
Despite the prevalence of many risk factors for
breast cancer and negative statistics on morbidity and
mortality of women in Poland, in the recent years the
improvement on this situation has been observed. The
preventive program for early detection of breast cancer
among working women, which is systematically
organized and carried by WOMP, plays an important
role. It complements the National Program of Cancer
Control, an element of which is also fighting the breast
cancer. The Ministry of Health program is aimed at
women aged 50-69 years old. The breast cancer
prevention programs, which are organized by WOMP,
make possible to do a free mammography also for
younger women. Alike the WOMP reports, the largest
group among the study population were women aged
40-49 years.
Nowadays, Lublin province is in the forefront in
terms of statistics on the number of women covered by
the breast cancer prevention programs in all Poland,
with a score of 40.7%. The percentage of women living
142
Magdalena Mińko, Dorota Siwczyńska
in Lublin region, which took part in prevention
programs against breast cancer, slightly increases year
by year [11]. Prevalence of prevention programs has a
positive effect. Consequently, the mortality of the
breast cancer by women in Lublin macro-region
decreases. In this respect once again Lublin province
has the satisfactory results in comparison to other
provinces [12].
The introduction of breast cancer prevention
programs resulted in positive changes not only in
health-related behaviors among women, but also
allowed for early detection of change in tumor. These
programs also helped to create a uniform and
continuous monitoring of the prevention programs
against the breast cancer morbidity. Currently, it is
possible to have a regular supervision over the
epidemiological indicators relating to the declaration,
detection and breast cancer mortality. It allows for
efficient use of the potential of prevention programs.
CONCLUSIONS
The analyzed reports of the breast cancer prevention in
Lublin macro-region allow formulating the following
conclusions:
- there is huge need to perform mammography among
women aged 40-49 years; - demand for education in
breast self-examination and to emphasis of the role of
systematic testing is observed;
- referral of patients, in whose pathology was detected,
for further diagnosis often contributed to saving their
health and even life;
- prevention program could have had a direct impact on
a slight decrease in breast cancer morbidity and
mortality in Lublin province reported by the Oncology
Centre in Warsaw;
- there is a need to continue the prevention programs
because of the large number of interested women.
LITERATURE
1. Grodzki L., Łangowska-Grodzka B., Ziółkowski M.,
Ocena profilaktyki wtórnej raka piersi wśród mieszkanek
Torunia, Zdrowie Publiczne 2004; 114(4):483-486.
2. Waliłko E., Profilaktyka raka sutka, Pielęg i Położ 1995;
6:7-11.
3. Wabiszewska E., Ocena programu profilaktycznego
wczesnego wykrywania raka piersi zrealizowanego w
województwie lubuskim w 2001 roku, Zdrowie
Publiczne 2005 115(2);161-163.
4. Liczba zachorowań w podziale na województwa i grupy
wiekowe, Raporty na podstawie Centrum Onkologii,
(epid.coi.waw.pl, dostęp 10.04.2011 r.).
5. Liczba zgonów w podziale na województwa i grupy
wiekowe, Raporty na podstawie Centrum Onkologii,
(epid.coi.waw.pl, dostęp 10.04.2011 r.).
6. Karwat I.D., Kołłątaj W., Kołłątaj B., PiecewiczSzczęsna H., Ocena realizacji potrzeb informacyjnych i
edukacyjnych kobiet w trakcie szpitalnego leczenia raka
gruczołu piersiowego, Zdrowie Publiczne 2010
120(4);351-355.
7. Kochaniec I., Program zdrowotny w zakresie wczesnego
wykrywania raka piersi dla kobiet pracujących, WOMP,
Lublin 2007.
8. Salomon B., Kochaniec I., Sprawozdanie merytoryczne z
realizacji programów profilaktycznych dla pracujących w
roku 2008, WOMP, Lublin 2008.
9. Kochaniec I., Sprawozdanie merytoryczne z realizacji
programów profilaktycznych dla pracujących w roku
2010, WOMP, Lublin 2010.
10. Program profilaktyki raka piersi – część administracyjnologistyczna (2005-2010), Ministerstwo Zdrowia,
Departament Polityki Zdrowotnej, Warszawa 2005
(www.mz.gov.pl, dostęp 15.04.2011 r.).
11. Raport „Objęcie populacji programem profilaktyki raka
piersi”, Wojewódzki ośrodek koordynujący populacyjny
program
wczesnego
wykrywania
raka
piersi
(www.onkologia.lublin.pl, dostęp 16.04.2011 r.).
12. Sytuacja zdrowotna ludności Polski pod. red. Wojtyniak
B., Goryński P., Narodowy Instytut Zdrowia Publicznego
– Państwowy Zakład Higieny, Warszawa 2008, s.
59-60.
Magdalena Mińko
ul. Sarmacka 22A/51
02-972 Warszawa
+48 694 274 567
[email protected]
Agnieszka Pluta1, Magdalena Skrzeszewska2, Halina Basińska1, Maria Budnik -Szymoniuk1 Kamila Faleńczyk1
THE FUNCTIONAL EFFICIENCY IN ELDERLY PATIENTS TREATED
WITH HEMODIALYSIS
SPRAWNOŚĆ FUNKCJONALNA U PACJENTÓW W WIEKU PODESZŁYM
LECZONYCH HEMODIALIZĄ
1
Katedra i Zakład Pielęgniarstwa Społecznego Collegium Medicum w Bydgoszczy Uniwersytetu Mikołaja
Kopernika w Toruniu
Kierownik: dr n. med. Kamila Faleńczyk
2
Katedra Nefrologii, Nadciśnienia Tętniczego i Chorób Wewnętrznych ze Stacją Dializ Szpitala Uniwersyteckiego
CM w Bydgoszczy
Kierownik: prof. dr hab. n. med. Jacek Manitius
Summary
B a c k g r o u n d . During the last few years in the world
as well as in Poland the number of patients with chronic renal
disease is observed to grow. Thanks to the great development
that was made in the field of dialysis therapy all the patients
despite of their age are provided with a renal substitution
therapy. Most of the dialyzed patients are constituted by elder
people, not meeting the renal transplantation criteria. They
have to be treated with special care because of the coexistence
of many chronic diseases. Often the coexistence of many
somatic illnesses and the dialysis therapy influence the
functional efficiency that remains restricted, especially with
elder patients.
O b j e c t i v e s . The aim of these studies was to evaluate
the functional efficiency in elderly patients treated with
hemodialysis.
M a t e r i a l a n d m e t h o d s . The study involved a
group of 48 respondents aged between 66 and 90 years.
Standardized ADL and IADL scales were used and also the
final part of the questionnaire containing the demographic
information.
C o n c l u s i o n s . From the undertaken research such
conclusions were made: 1. For the patients the biggest number
of problems among everyday tasks made taking a bath, the
smallest number of problems was made with nutrition. In
performing complex everyday tasks the biggest problem for
the patients was connected with performing small home
repairs. 2. Together with the increase of the education
increased the level of independence in the evaluation of the
basic everyday tasks. The biggest independence showed the
patients with higher education. Also in the evaluation of the
complex everyday tasks the patients with higher education
showed bigger independence. 3. The period of the dialysis did
not influence the functional efficiency of the respondents in
the range of evaluation of the basic as well as complex
everyday tasks.
Streszczenie
W p r o w a d z e n i e . W ciągu ostatnich lat zarówno na
świecie jak i w Polsce obserwuje się wzrost liczby pacjentów
z przewlekłą chorobą nerek. Dzięki ogromnemu postępowi
jaki osiągnięto w dializoterapii wszyscy pacjenci niezależnie
od wieku mają zapewnione leczenie nerkozastępcze.
Większość dializowanych stanowią osoby w podeszłym
wieku, niespełniający kryteriów do przeszczepienia nerki.
Muszą oni zostać objęci szczególną opieką z powodu
współwystępowania wielu chorób przewlekłych. Często
współistnienie wielu schorzeń somatycznych oraz
dializoterapia wpływa na sprawność funkcjonalną, która
zostaje znacznie ograniczona, szczególnie u pacjentów w
podeszłym wieku.
Celem
niniejszych
b a d a ń była ocena
sprawności funkcjonalnej osób w podeszłym wieku
leczonych hemodializą.
M a t e r i a ł i m e t o d y . Badaniem objęto 48
respondentów w wieku od 66 do 90 lat. Wykorzystano
144
Agnieszka Pluta et. al.
standaryzowane skale ADL i IADL oraz metryczkę
zawierającą dane demograficzne.
W n i o s k i . Z przeprowadzonych badań uzyskano
następujące
wnioski:
1.Najwięcej
problemów
w
podstawowych czynnościach dnia codziennego stwarzała
badanym kąpiel, najmniej problemów przejawiali przy
odżywianiu się. W wykonywaniu złożonych czynności dnia
codziennego najwięcej problemów stwarzało badanym
pacjentom samodzielne wykonywanie drobnych napraw
domowych. 2. Wraz ze wzrostem wykształcenia wzrastał
stopień niezależności w ocenie podstawowych czynności w
życiu codziennym. Największą niezależność przejawiali
badani z wykształceniem wyższym. Również w ocenie
złożonych czynności codziennych badani z wykształceniem
wyższym przejawiali najwyższą niezależność. 3. Okres
dializowania nie wpłynął na sprawność funkcjonalną
respondentów w zakresie oceny podstawowych jak i
złożonych
czynności
dnia
codziennego.
Key words: elder, functional efficiency, hemodialysis, ADL scale, IADL scale
Słowa kluczowe: wiek podeszły, sprawność funkcjonalna, hemodializa, skala ADL, skala IADL
INTRODUCTION
According to WHO data in the second half of the
XX century the average length of life will be extended
by 20 years, and in the year 2030 about 30% of the
population in the developed countries will live longer
than 65 years. Actual demographic data, as well as
prognosis for the future show the increasing problem
of elder patients with chronic renal disease. 10 years
ago the availability of dialysis for elder patients with
end-stage renal disease was limited in Poland. The age
of over 65 years was one of the factors disqualifying a
patient from a renal replacement therapy. Currently, it
is the largest group of patients starting dialysis.
According to the data from the Report of the state of
the renal replacement therapy, patients aged over 65
constituted 55.5% [1]. The analysis of the mentioned
above report shows that the diabetic nephropathy is
one of the main reasons of the end-stage renal
insufficiency. Old age, because of the natural course of
events, and evolutionary changes predispose to
changes in both anatomy and renal function [2].
Dialysis as a form of renal replacement therapy puts
people in a difficult situation, with which they have to
struggle. Because of the renal insufficiency the
position of the sick is special due to general lack of
permanent treatment outcomes. Chronic renal disease
is considered an incurable disease. The dialysis therapy
is connected with a necessity of adjustment to new life
conditions. The dissimilarity of this situation results
among all from frequent and long term hospitalization,
and also the necessity of undergoing many diagnostic
procedures. As a result it leads to a change in a sick
person's functioning in the family, work and social
environment and limits the functional efficiency.
Functional efficiency is the ability to be independent
from other people in the field of basic life activities,
such as: moving, eating, controlling physiological
functions of the body and maintaining the body's
hygiene.
Many health (system and organ diseases) and
socio-demographical (age, sex, education, place of
residence) factors have influence on functional
efficiency [3].
OBJECTIVES
Evaluation of the functional efficiency of elder
people treated with hemodialysis. In this work we
analyzed the ability of elder people to self-function
depending on their age, sex, education level and
duration of the renal replacement therapy.
The research was carried out between September
2010 and November 2010 in the Department and
Clinic of Nephrology, Hypertension and Internal
Medicine with Dialysis Station of NCU Collegium
Medicum in Bydgoszcz. In order to undertake the
research a grant was given by the Bioethical
Commission at NCU Collegium Medicum in
Bydgoszcz. All the patients that took part in the
research signed a consent form.
The research involved 48 respondents aged
between 66 and 90 years.
The following research tools were used:
-A survey questionnaire designed for the purpose of
this study,
-The ADL scale of everyday functioning;
determining the ability to perform basic everyday
activities, such as using the toilet, ability to move (at
home and outside), eating, bathing, foot care and nail
care, dressing and undressing, control of urine and
stool excretion, which may be perform alone, an ability
The functional efficiency in elderly patients treated with hemodialysis
to function without others’ help. The basic activities
were evaluated on three levels: able to perform a
certain activity alone – 3 points, ability to perform a
certain activity under supervision or with small help –
2 points, and lack of ability to perform activities alone
– 1 point [4];
-the IADL scale of complex everyday activities
evaluating complex activities of daily living such as
using telephone, getting to places beyond walking
distance, going out shopping, preparing meals,
performing housework, home repairs, doing the
laundry, preparation and intake of drugs, and
management of funds.
In the statistical analysis we used Statistica 6.0.
software. In the study we used the Spearman's
nonparametric test, Mann-Whitney test. The
significance of differences between the assessed
groups was evaluated with the use of analysis of
variance and Student's t-test for dependent and
independent trials. Statistically significant level was
considered when p<0.5. Similarly, factors of Pearson's
correlation were considered as statistically significant
with the level of significance of p ≤ 0.05.
OUTCOME
The age of the researched was between 66 and 90
years (average 75.2). The respondents were divided
into three age groups: to 70 years, 71-80 years and
above 80 years. The biggest group consisted of patients
aged between 71-80 years – 27 people (56.3%), the
smallest group included the patients aged over 80 years
– 10 people (20.8%). Men, although on average a bit
older, presented a similar age as women. Men's
average age was 76 years, women's – almost 75 years.
Men were the majority among the researched patients.
The number of men was 28 patients (58.3%). The
women presented barely 71% of that number.
People with secondary education constituted the
largest group – 18 patients (37.5%), also a lot of people
declared having vocational education and 13 people primary education. Only 7 patients (14.6%) had higher
education.
People dialyzed for 2 to 5 years constituted the
largest group – 25 people (52.1%) and about 1 year –
13 people (27.1%). Only 3 people were dialyzed over
10 years (6.3%) and they constituted the smallest
group.
A definite majority of the respondents lived with
family – 40 people (83.3%), the rest lived alone.
145
Among the questioned, 58.3% were married, and 39%
of the patients declared to be widowed. One in every
10 people declared the need of total help in
maintaining personal hygiene (10.4%). Performing
activities such as individual usage of the toilet,
washing hands and doing the laundry was declared by
only 14 patients.
One of the basic elements of efficient functioning is
the ability to move alone. Among the questioned every
tenth person did not get up from bed or chair alone.
Efficient functioning is also the dependence in
physiological activities. Most of the researched
(70.8%) self-controlled the excretion of urine and
stool. Concerning this issue, every tenth person needed
the control of a third person or the usage of a catheter.
Another element of an efficient functioning is the
ability to eat alone. Lack of help while eating meals
was declared by 64.6% of the researched; every tenth
person needed help or a complete feeding. The analysis
of the basic everyday activities with Katz scale (ADL)
shows that taking a bath was most difficult for the
researched. The obtained average 2.04 stated that in
general the researched needed help with washing one
part of the body. The least problems were caused by
nutrition – average 1.46, physiological activities –
average 1.40 and movement – average 1.33. In the
researched group three out of four patients were
independent – 36 people (75.0%), while the rest
included patients that needed assistance or partial help
or patients needing help, in an equal number.
The analysis of the complex everyday activities
with the usage of Lawton's scale (IADL) showed that
the greatest difficulty for the patients was caused by:
self-repairs at home – average 1.42; self-making
laundry – average 1.58 and self-making of housework
– average 1.65. The patients had least problems with
self-preparing and intake of drugs – average 2.31, and
especially using of the phone – average 2.46.
In the researched group three out of four people
were independent patients – 36 people (75.0%). While
the rest was in an equal number patients that needed
assistance or partial help or patients needing help,
dependent.
Among the researched, 19 patients (39.6%) were
people completely independent in the IADL manner,
and was stated of the ability to function and perform
complex everyday activities. Hardly every eighth
patient was a completely dependent person in the
IADL manner – 6 people (12.5%). These patients were
in a large degree deprived of the basic functional
efficiency. The rest, constituting the largest group, are
people partially dependent in the IADL manner.
This work showed that along with the increase of
the education level, the level of independence in the
evaluation of basic daily activities increased. The
biggest independence was noted among people with
higher education – average 8.0; the smallest
independence among the researched with primary
education – average 12.7. Patients with secondary
education and vocational education had a similar
outcome to the patients with higher education.
punkty
146
28
26
24
22
20
18
16
14
12
10
8
6
podstawowe
Średnia
±Błąd std
±Odch.std
średnie
zawodowe
wyższe
wykształcenie
Tabela 1. Korelacje skali oceny zagadnień ADL ze względu
na wykształcenie
Table 1. Correlation of the ADL scale of task evaluation due
to education
Zmienna
Variable
N
R
t(N-2)
poziom p
P level
Kąpiel
48 -0,509583 -4,01682 0,000216
Bath
Ubieranie się
48 -0,466335 -3,57541 0,000835
Dressing up
Higiena osobista
48 -0,435484 -3,28106 0,001977
Personal hygiene
Przemieszczanie się
48 -0,372503 -2,72236 0,009125
Mobility
Czynności fizjologiczne
48 -0,249066 -1,74422 0,087801
Physiological activities
Odżywianie się
48 -0,496381 -3,87812 0,000333
Nutrition
N – number
R - Spearman correlation coefficient
t(N-2) – distribution of t-Student of N-2 Levels of freedom
Level p – level of relevance
Evaluation of ADL scale in some particular issues
was found to be in a crucial correlation with the
education (p<0.05), with the exception of physiological
activities.
In this work it was shown that along with the increase
of the education level, the degree of independence in
the evaluation of the complex daily activities
increased. The biggest independence was noted among
patients with higher education – average 21.4; the
smallest - among patients with primary education –
average 12.2.
Fig. 1. IADL scale of evaluation with the consideration of
education
Ryc. 1. Skala oceny IADL z uwzględnieniem wykształcenia
Table 2 presents the correlation of IADL scale of
task evaluation with the consideration of the
respondents’ age. The evaluation of the IADL scale in
the particular issues remains in a crucial correlation
with the education (p<0.05), with the exception of selfmaking laundry.
Table 2. Correlation of the IADL scale of task evaluation
with the consideration of education
Tabela 2. Korelacje skali oceny zagadnień IADL z
uwzględnieniem wykształcenia
Zmienna
Variable
Korzystanie z telefonu
Using the telephone
Docieranie do miejsc poza
odległością spaceru
Going to places away from the
walking distance
N
R
t(N-2)
Poziom
p
P level
48 0,626244 5,44798 0,000002
48 0,505418 3,97266 0,000248
Chodzenie na zakupy po
artykuły spożywcze
Going shopping for groceries
48 0,353095 2,55969 0,013828
Samodzielne przygotowanie
posiłków Self-making of
meals
48 0,424133 3,17647 0,002662
posiłków Self-doing
housework
48 0,477299 3,68391 0,000603
Wykonywanie drobnych
napraw domowych
Self-doing of small repairs
48 0,337085 2,42834 0,019137
Samodzielne wypranie swoich
rzeczy Self-doing laundry
i przyjmowanie leków
Self-preparing and intake of
drugs
Samodzielne gospodarowanie
pieniędzmi
Self-management of funds
48 0,230974 1,61008 0,114222
48 0,571303 4,72107 0,000022
48 0,518983 4,11790 0,000157
The functional efficiency in elderly patients treated with hemodialysis
In this work the dependence of functional
efficiency was evaluated with the ADL scale and the
duration of the dialysis did not reach a statistical
significance (p = 0.48).
DISCUSSION
Old age brings a lot of limitations, the body's
functional capacity gets worse and functional
efficiency decreases gradually together with age.
From the research it results that taking a bath
constitutes the biggest problem for dialyzed elder
patients, while nutrition – the smallest problem. These
researches correspond with Mazurkiwicz's research
undertaken among dialyzed patients at the University
Hospital No.1 in Bydgoszcz [5]. In the research of
Muszalik et al. questioned people reported the largest
problem with performing housework; our research did
not confirm mentioned above outcomes, since small
home repairs were the biggest difficulty for the
researched. This may be connected with the fact that
83.3% of the researched lived with family and ran a
common household. Due to that fact that elder people
were dismissed from performing repair tasks or doing
the shopping, what limited their independence [6]. In
the Mazurkiewicz’s research performance of small
house repairs as well as self-performance of housework
caused the most difficulty to the patients [5].
From the researched made by Kachaniuk et al. [7] it
results that 31% is not able to self-do the shopping,
14% needs help, 55% does the shopping
independently. Our own results not correspond with
the outcomes of Kachaniuk et al., because 56.3% is
entirely not able to do any shopping, 14.6% - with a
little help 29.2%. - without help. This may be
connected with the specificity of the disease (creation
of arteriovenous fistula usually in the upper limb,
saving this limb).
In the research performed by Borowiak et al. [8] it
is shown that the patients independent in the field of
everyday activities also showed a high level of
functional efficiency in the range of instrumental
activities. These researches correlate with our research,
also in the field concerning independence in the IADL
evaluation scale.
The research performed by Muszalik et al. [9] show
lack of influence of education on functional efficiency
of geriatric patients, while the results obtained by
Borowiak et al. [8] and Fortuniak [10] show an
influence of education on functional efficiency as well
147
as on quality of life. This may be related with the fact
that people with lower education level more often
exposed to harmful factors in their workplaces and had
bigger work load in the past were. The level of
education is often connected with patients' health
consciousness and sets a lifestyle and pro-health
behaviour. This may be the reason of lower functional
efficiency and some of the health problems present
among people with lover education level.
Our research corresponds with researches of
Borowiak et al. and Fortuniak M., because together
with the increase of education, the level of
independence of elder patients treated with
hemodialysis increases [8, 10, 9].
From the research it results that the period of
dialysis does not have influence on functional
efficiency of the respondents in the range of evaluation
of the basic as well as complex daily activities. Above
researches correspond with the research performed by
Mazurkiewicz [5]. This may result from the chronic
disease, long-term dialysis. Patients dialyzed for years
accepted their health state and do not show problems in
everyday life, despite the old age.
Regular physical activity is the element of a
functional efficiency in everyday life of the dialyzed
patients as well as of the entire society is a [11].
Physical rehabilitation leads to improvement of
physical condition, increases the ability to perform
everyday tasks with the end-stage renal disease and
improves quality of life rate. The problem of increasing
physical activity by patients chronically dialyzed was
shown in the orders of the U.S. National Kidney
Disease Foundation – Performance Improvement
Initiative for Dialysis (NKF-K/ DOQI).
The results of research performed [12] on the group
of 82 hemodialysis patients by Vischini et al. highlight
the importance of targeted rehabilitation, as well as of
preventing and treatment of disability in the positive
influence on one of the sides of quality of life of
hemodialysed patients, while the other side on the
workload of the caregiver.
CONCLUSIONS
1. As it results from the undertaken research the most
problems in the basic daily activities were made by
taking a bath, the least problems were made by
nutrition. In the performance of complex daily
activities the most problems were made by selfperforming small home repairs.
148
2. Along with the increase of education increased the
level of independence in the evaluation of the basic
everyday tasks. The biggest independence showed
the patients with higher education. Also in the
evaluation of complex everyday tasks the patients
with higher education showed bigger independence.
3. The duration of the dialysis did not have influence
on the functional efficiency of the respondents in
the range of evaluation of basic as well as complex
everyday activities.
LITERATURE
Rutkowski B., Lichodziejewska-Niemierko M., Grenda R.,
Czekalski S., Durlik M., Bautembach S.: Raport o
stanie leczenia nerkozastępczego w Polsce 2007.
Drukonsul. Gdańsk. 2008: 7 - 34.
Kokoszka- Paszkot J., Paszkot M.: Cukrzycowa choroba
nerek. Geriatria 2009; 3: 214 – 218.
Biercewicz
M.,
Szewczyk
M.T.,
Ślusarz
R.
:Pielęgniarstwo geriatryczne. BORGIS Wydawnictwo
Medyczne, Warszawa 2006: 7-11.
Sosnowski M., Chmara –Pawlińska R.: Czynnościowa
ocena pacjentów skalą ADL w różnych typach
otępienia . Medycyna Rodzinna. 2002, 5: 176-178.
Mazurkiewicz S.: Zachowania zdrowotne a stany
depresyjne u chorych dializowanych w podeszłym
wieku. Collegium Medicum im. Ludwika
Rydygiera w Bydgoszczy Uniwersytet Mikołaja
Kopernika w Toruniu 2005. Praca magisterska.
Muszalik M., Bartuzi Z., Kędziora-Kornatowska K.,
Marzec A.: Jakość życia chorych przewlekle w
badaniu profili zdrowia. Ann. Universit. Mariae CurieSkłodowska. Lublin 2004, vol.59. suppl XIV, 4: 158163.
Kachaniuk H., Droździe D., Fidecki i wsp.: Samodzielność
osób starszych jako element jakości życia. Piel. XXI
w., 2006; 4: 75-76.
Borowiak E., Barylska A.: Problemy seniorów
przebywających w Domu Dziennego Pobytu
wyzwaniem dla pielęgniarki. Problemy Pielęgniarstwa
2007, tom 15, nr 1:13-15.
Muszalik M., Ćwikła A., Kędziora-Kornatowska K.,
Kornatowski T.: Ocena wpływu czynników socjodemograficznych i medycznych na poziom sprawności
funkcjonalnej
pacjentów
geriatrycznych.
Pielęgniarstwo XXI wieku 2010; 1: 2 - 9.
Fortuniak M.: Problemy zdrowotne osób chorych w wieku
podeszłym.Pielęgniarstwo Polskie 2003, 1( 15 ), 54-56.
Gołębiowski T., Wende W., Kusztal M. i wsp.: Ćwiczenia
fizyczne w rehabilitacji chorych dializowanych.
Postępy Hig. Med. Dośw. 2009; 63: 13 -22.
Vischini G., Tendas A., Ferrannini M. et all.: Motor
disability in end-stage renal failure: An
epidemiological study on Italian dialyzed patients.
J. Kidney Dis Arabii transpl. 211; 22: 1236 – 7.
Agnieszka Pluta
e-mail [email protected]
tel.6937169890
Iwona Sadowska-Krawczenko1, Agata Staśkiewicz2, Andrzej Kurylak1, Barczykowska Ewa1,
Aldona Katarzyna Jankowska3
THE KNOWLEDGE OF NURSES WORKING IN PEDIATRIC WARDS OF ASSESSMENT
AND TREATMENT OF PAIN IN CHILDREN
WIEDZA PIELĘGNIAREK PRACUJĄCYCH W ODDZIAŁACH PEDIATRYCZNYCH W ZAKRESIE
OCENY I LECZENIA DOZNAŃ BÓLOWYCH U DZIECI
1
Department of Pediatric Nursing, Nicolaus Copernicus University in Toruń Collegium Medicum in Bydgoszcz
Head: dr hab. n. med. Andrzej Kurylak, profesor UMK
2
Graduate from nursing, second level degree studies at Nicolaus Copernicus University in Toruń
3
Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University in Toruń
Head: Prof. Mariusz Wysocki, MD
Summary
I n t r o d u c t i o n . Children's pain is often undiagnosed
and wrongly treated. The skill of diagnostics and
counteraction of long-lasting pains is an extremely important
element in the work of nursing staff. The knowledge of rules
of estimation and treatment of the pain in children is a basis
of individualized care-giving for patient.
T h e p u r p o s e of the research is to estimate the
knowledge of the nurses working in pediatric wards in the
fields of diagnostics, estimation and treatments of pain in
children.
M a t e r i a l a n d m e t h o d s . Evaluation based on
questionnaires filled out by 68 nurses working in neonatal,
pediatric and pediatric surgery wards was conducted.
R e s u l t s . Research shows that 79% of respondents nurses, working in pediatric wards know the estimation
scales of pain in children, and 59% of persons use the
evaluation tools of pain experiences in their professional job.
The results show that nurses possess a good knowledge about
non pharmacological treatment of pain, which was on a better
level than their knowledge about pharmacological treatment.
82% of respondents consider non pharmacological methods
of treatment to be effective. 74% of respondents confirm the
use of pharmacological and non pharmacological methods of
pain alleviation in their professional job. 42% of nurses
estimate their knowledge about treatment of pain as good.
Conclusions:
•
Knowledge of nurses working in pediatric wards
concerning estimation of pain experiences in
children is not sufficient.
•
The level of nurses’ knowledge concerning non
pharmacological pain alleviation methods is
average, but at the same time higher than
knowledge concerning pharmacological pain
alleviation methods.
•
Main factors determining pediatric nurses’
knowledge about pain treatments in children are:
their education, their practice in-service and their
participation in additional trainings for pain
alleviation.
150
Iwona Sadowska-Krawczenko et. al.
Streszczenie
W s t ę p . Ból u noworodka i małego dziecka jest często
nie rozpoznawany i źle leczony. Umiejętność rozpoznawania,
przeciwdziałania i leczenia bólu jest niezmiernie ważnym
elementem pracy personelu pielęgniarskiego. Znajomość
zasad oceny i leczenia bólu u dzieci jest podstawą w
zindywidualizowanej opiece świadczonej na rzecz pacjenta.
C e l e m p r a c y była ocena wiedzy pielęgniarek
pracujących w oddziałach pediatrycznych w zakresie
rozpoznawania, oceny i leczenia doznań bólowych u dzieci.
Materiał
i
m e t o d y . Badanie ankietowe
przeprowadzono w grupie 68 pielęgniarek pracujących w
oddziałach pediatrycznych, neonatologicznych i chirurgii
dziecięcej
W y n i k i : . 79%
respondentów- pielęgniarek,
pracujących w oddziałach pediatrycznych zna skale oceny
bólu u dzieci, a 59% osób wykorzystuje narzędzia oceny
doznań bólowych w pracy zawodowej. Ponadto wykazano,
że wiedza ogólna badanych w zakresie metod
farmakologicznego leczenia bólu jest istotnie mniejsza niż
wiedza w zakresie niefarmakologicznych metod uśmierzania
bólu. 82% badanych uważa niefarmakologiczne metody
leczenia za skuteczne. 74% badanych potwierdza, że w pracy
zawodowej stosuje farmakologiczne i niefarmakologiczne
metody leczenia bólu. 42% badanych ocenia swoją wiedzę na
temat leczenia bólu jako dobrą.
Wnioski:
•
Wiedza pielęgniarek pracujących w oddziałach
pediatrycznych w zakresie oceny doznań bólowych u
dzieci jest niewystarczająca.
•
Stan
wiedzy
pielęgniarek
w
zakresie
niefarmakologicznych metod leczenia jest średni i
jednocześnie lepszy od stanu wiedzy pielęgniarek w
zakresie farmakologicznych metod leczenia bólu u
dzieci.
•
Głównymi czynnikami determinującymi stan wiedzy
pielęgniarek pediatrycznych w zakresie leczenia bólu u
dzieci są wykształcenie, staż pracy oraz uczestnictwo w
szkoleniach na temat bólu.
Key words: nurse, knowledge, pain management, nonpharmacological, pharmacological, child, newborn
Słowa kluczowe: pielęgniarka, wiedza, leczenie przeciwbólowe, niefarmakologiczne, farmakologiczne, dziecko, noworodek
INTRODUCTION
Pain is ‘an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage’ [1, 2].
It is a subjective sensation, not always proportional to
the tissue damage level. Pain can be classified
according to an assumed criterion, for example: the
time, the place or the mechanisms of its incidence.
Untreated pain leads to adverse somatic body
reactions, like: increased heart and breath rate, high
blood pressure or an increased demand for oxygen.
Unrelieved pain can also alter immune function [3].
The purpose of the pain is to warn and protect against
danger, expansion of the damaged area and illness. In
the initial stage of sensing the pain, the reaction of the
nervous system allows the body to adapt itself to
stimulation for pain. Although pain stimuli have a
beneficial influence on the body in the first stages, its
continuation triggers a number of undesirable systemic
reactions [4]. A loss of the ability to sense pain can be
a distant after-effect of chronic pain stimulation. There
are assumptions that late consequences of continuous
pain can be: emotional and behavioral disorders and
learning disability [5].
Estimation of pain in small children, especially
infants, is very hard due to a non-existent or limited
verbal communication. Small children cannot express
what they feel and usually cannot estimate the level of
pain. In consequence, children's pain is often
undiagnosed and wrongly treated. Nurses play a
significant role in the process of estimating pain
experiences in small children. Therefore, it is important
that they have a proper level of knowledge about
recognizing and treating pain in children. A method of
estimating pain in children should be easy to conduct,
estimate not only the child’s feelings but also
efficiency of pain alleviation methods used at that time.
The method should be adapted to: the child’s
development period, the rate of severity and chronicity
of the disease, type of conducted surgery and medical
treatment and the hospital environment [6]. A lack of
pain management knowledge leads to inadequate
management and treatment of pain.
THE OBJECTIVE OF THE STUDY
The objective of this study is estimating knowledge
of the nurses working in pediatric wards in the fields of
diagnostics, estimation and treatments of pain in
children.
Following issues have been researched:
1. What is the level of nurses’ knowledge about
estimation of pain experiences in children?
The knowledge of nurses working in pediatric wards of assessment and treatment of pain in children
non pharmacological methods of treating pain
in children?
pharmacological methods of treating pain in
children?
4. What factors determine the level of nurses’
knowledge about estimation and treatment of
pain in children?
The research was conducted in the group of 153
pediatric and neonatal nurses from wards: Department
of Neonatology and Department of Pediatric Surgery,
Dr J. Biziel University Hospital No. 2 in Bydgoszcz,
Department of Pediatric Surgery, Department of
Pediatrics, Allergy and Gastroenterology, Dr A. Jurasz
University Hospital No. 1 in Bydgoszcz. The research
was conducted between the 10th and the 30th of July
2010. Consent KB 336 /2010 from Bioethical
Commission of L. Rydygier Collegium Medicum in
Bydgoszcz was obtained.
The research was conducted with the use of an
opinion poll. Data was collected through a
questionnaire created on the basis of a research
conducted in the article: Nurses’ Knowledge About
Pharmacological and Nonpharmacological Pain
Management in Children, published in the Journal of
Pain and Symptom Management [7]. The questionnaire
contained 4 sociodemographic questions and 45
questions concerning the topic of the research,
including 3 open-ended questions and 2 multiplechoice questions. The questionnaires were anonymous
and members of the researched group provided a
written consent of participation.
Statistical analysis of the questionnaire was done.
Questions from 18 to 49 were Likert-type questions,
containing answers: agree, agree to some extent, don’t
know, disagree to some extent and disagree. Numerical
value was attributed to these answers, 2 for correct
answers and -2 for incorrect answer, and calculations
were conducted. The differences between knowledge
types were counted through t tests for dependent
groups. Differences between sexes were counted
through t tests for independent groups. Differences
resulting from service in-practice, estimation of own
knowledge and level of education were estimated
through ANOVA test (variation test). All calculations
were done in the SPSS program for Windows 17.0.
151
RESULTS AND DISCUSSION
Out of 153 nurses employed in wards listed above,
68 persons declared agreement of participation in the
research and answered the questions provided in the
questionnaire. Out of the researched group of 68, there
are 62 women. Average age of respondents is 38.2
(median 39), the youngest person was 23 years old and
the oldest was 55 years old. The majority of
respondents acquired high-school diploma – 49
(72.1%) of respondents, 7 people (10.3%) had higher
professional education, whereas 12 (17.6%) had a
master’s degree. 57 (83.8%) of respondents had
worked in-service for over 10 years.
54 persons confirmed their acquaintance with pain
scales, out of which 32 respondents uses the scales in
their professional work. 84.4% of the group (27
persons) uses the scales for pain estimation several
times during their shifts. The respondents list 15
different pain estimation methods. The most often used
scales are Visual Analog Scale VAS and Numerical
Rating Scale NRS. All respondents using the pain scale
considered it to be a good method of pain estimation.
21 people say that they use the scales in their
professional job because it is regulated by adequate
rules and procedures used on the ward. 40 respondents
(74.1%) say that at their workplace both
pharmacological and non pharmacological pain
alleviation methods are used, while 10 persons (18.5%)
say that on their ward only pharmacological pain
alleviation methods are used. 56 people (82.4%)
consider non pharmacological methods of treatment to
be effective. 29 of respondents (42.6%) think that they
have a good knowledge about treating pain in children,
7 (10.3%) think that their knowledge is bad, and 32
(47.1%) cannot assess their knowledge about treating
pain. 20 nurses (29.4%) say that on their wards
trainings concerning pain estimation and alleviation
methods are conducted. 29 persons (42.6%) say that
they had underwent training in pain alleviation during
last two years.
In order to estimate the nurses’ knowledge, the
results were divided into categories as following: non
pharmalogical methods of pain treatment, general
knowledge of pharmalogical pain treatment, rules of
non-steroid anti-inflammatory drugs and paracetamol
administration, opioids administration and knowledge
about regional anesthesia. Dependencies such as
education, work experience and the examinees’
152
Iwona Sadowska-Krawczenko et. al.
opinion of their knowledge were used for obtaining
proportions.
The level of knowledge of the studied nurses was
varied. Respondents scored on average 0.927 points
(the maximum to acquire was 2 points – an average of
points for all answers), with deviation ±0.674. The
worst score was -0.255 points, and the best was 2. It
was also the most frequently achieved score. The
researched group of nurses was giving mainly correct
answers to the questions in the questionnaire.
There is no significant statistic difference between
the nurses’ general level of knowledge about treating
pain in children and their education. There is, however,
correlation between education and the level of
knowledge in the area of pain pharmacotherapy. It
shows that nurses with only a high school diploma
have the smallest knowledge in this particular area.
Nurses with a master’s degree scored average, and the
highest score was that of nurses with bachelor’s
degree. In the correlation between education and the
area of non pharmacological methods of pain
alleviation, rules for administering non-steroid antiinflammatory drugs and paracetamol, rules of
administering opioids and the knowledge about
regional anesthesia there are no statistically significant
differences.
In the correlation between the nurses’ general
knowledge and their seniority, the ones with seniority
in nursing of 10 to 15 years obtained the best results.
There are no statistical differences in the correlation
between the general knowledge of pharmalogical and
non-pharmalogical methods of pain treatment and
nurses’ seniority. The knowledge of administering nonsteroid anti-inflammatory drugs and paracetamol is the
highest among nurses with 1 to 5 years of practice. The
knowledge about administering opiods and regional
anesthesia is the highest among nurses with 5 to 10
years of work experience.
The examinees’ general knowledge about
pharmalogical pain treatment methods is indeed lower
than their knowledge about non pharmalogical pain
treatment methods. The general knowledge level about
pharmalogical pain treatment is lower in the area of
administering non-steroid anti-inflammatory drugs,
paracetamol and opioids, with the knowledge level
being the highest for the last of these methods. There
are no statistically significant differences between the
nurses’ general knowledge about pharmalogical
methods and local treatment – both are relatively low.
The knowledge about non-steroid anti-inflammatory
drugs and paracetamol is significantly higher than the
knowledge about regional anesthesia. There are no
significant differences between the knowledge about
non-steroid anti-inflammatory drugs and paracetamol
and the knowledge about opioids – both are relatively
high.
DISCUSSION
The above study was conducted among nurses from
four wards in two university hospitals. Out of 153
nurses working at these wards only 68 expressed the
willingness to take part in the study. The questionnaire
used in the study had never been used in these centers.
Own study showed that nurses working on the
pediatric wards know the pain estimation scales and
use them in their work. The research by Tymecka et al.
conducted in 2000 showed that nurses mainly use the
observation of the child’s behavior as a pain estimation
method [8].
The analysis of own research showed that the
nurses’ knowledge about non pharmalogical and
pharmalogical pain treatment in children is insufficient.
The results are in accordance with the results of other
researchers [7,9]. It was proven that the pediatric
nurses’ knowledge about non pharmalogical pain
treatment is higher than their knowledge about
pharmalogical methods of pain treatment. Similar
results were obtained by Salanterä and Luri in 1999,
and Twycross in 2004 [7,9].
The nurses are aware of their knowledge
deficiencies in certain areas. It is confirmed by the
estimation of their knowledge. Similar results were
shown in the study of the Finnish nurses [7].
In own study the comparison between the
knowledge of the nurses working at different centers
was omitted, due to too small number of respondents
from each particular centre and the examinees’
objection. The study of Finnish nurses showed
statistically significant differences in correlation
between the level of knowledge and the branches of
pediatrics in which the nurses worked [7].
In own study the correlation between the nurses’
education level and their knowledge level was shown.
Nevertheless, it must be noted that a part of the
respondents held a diploma in a different field than
nursing. The questionnaire asked for the level of
education without specifying the field in which it was
obtained. It was proven by the research done by
Salanterä that the level of education has a significant
The knowledge of nurses working in pediatric wards of assessment and treatment of pain in children
influence on the nurses’ knowledge [7]. In a study
estimating the knowledge and attitude towards pain in
children conducted in 2000, Manworren proved that
nurses with a higher education diploma obtained
significantly better results [22].
In 2004 Twycross suggested that nurses’ seniority
has no influence on their knowledge about pain
estimation and treatment [9]. The analysis of our own
research has shown that the best results in the
estimation of pain treatment methods were obtained by
nurses who worked professionally from 10 to 15 years.
In the research conducted in 2007, Rieman et al.
showed that nurses who were active in nursing
organizations obtained better results in the tests of their
knowledge about pain treatment in children [10]. The
analysis of the nurses’ knowledge should be conducted
in accordance with factors that have a direct influence.
Own study did not take into consideration the
following factors: the nurses’ workstation, membership
in nursing organizations, the school’s curriculum,
participation in scientific research.
Our study indicated that more education is needed
in the area of pain management. Further research is
needed to find the most effective way of educating
nurses in pain estimation and management field.
CONCLUSIONS
On the basis of the conducted research the
following conclusions were drawn:
• Knowledge of nurses working in pediatric
wards concerning estimation of pain
experiences in children is not sufficient.
• The level of nurses’ knowledge concerning
non pharmacological pain alleviation methods
is average, but at the same time higher than
knowledge concerning pharmacological pain
alleviation methods.
• Main factors determining pediatric nurses’
knowledge about pain treatments in children
are: their education, their practice in-service
and their participation in additional trainings
for pain alleviation.
REFERENCES
1.
International Association for the Study of Pain
Subcommittee on Taxonomy. Classification of chronic
pain syndromes and definitions of pain terms. Pain,
1986, 3 (Suppl. 3), S1-S226.
153
2.
Wordliczek J., Dobrogowski J.: Leczenie bólu
pooperacyjnego. Zestaw szkoleniowy dla pielęgniarek.
PERF 02/ 02/ 2009.
3. Lynch, M.: Pain as the fifth vital sign. J Intraven Nurs,
2001, 24, 85-93.
4. Sokół- Kobielska E.: Leczenie bólu. Część I.
Wprowadzenie: patofizjologia, klasyfikacja i ocena
bólu. Pediatria i Medycyna Rodzinna, 2007, 3, 2, 95100.
5. Wytyczne Komisji ds. Płodu i Noworodka oraz Sekcja
Chirurgii American Academy of Pediatrics, Komisji ds.
Płodu i Noworodka Canadian Paediatric Society.:
Zapobieganie i leczenie bólu u noworodków:
Uaktualnienie. Pediatria po Dyplomie, 2007, 11 , 3, 1326.
6. Morton N. S.: Zapobieganie i leczenie bólu u dzieci- Cz.
I. Med Prakt Pediatr, 2000, 4, 56- 61.
7. Salanterä S., Lauri S., Salami T. T. Helenius H.: Nurses’
Knowledge
About
Pharmacological
and
Nonpharmacological Pain Management in Children. J
Pain Symptom Manage, 18, 4 October 1999, 289- 299.
8. Tymecka I., Flis E.: Rozpoznawanie bólu u dzieci
badania pilotażowe.
Anndes Universitis Mariae Curie- Skłodowska, 2000,
LV, VII, 64.
9. Twycross A., Dowden J. S.: Satatus of pediatric nurses’
knowlegle about pain.
Pediatric Pain Letter, 11, 3, December 2009.
10. Rieman MT., Gordon M.: Pain management
competency evidenced by a survey of pediatric nurse’
Knowledge and attitudes. Pediatr Nurs 2007, 33, 307312.
dr n. med. Iwona Sadowska-Krawczenko
Zakład Pielęgniarstwa Pediatrycznego
Wydział Nauk o Zdrowiu Collegium Medicum UMK
ul. Techników 3
85-801 Bydgoszcz
Tel. (52) 3655262
Paweł Szczudło1, Marta Hreńczuk2
VARIABILITY OF DRUGS WITH NARROW THERAPEUTIC WINDOW
IN TRANSPLANTOLOGY – POTENTIAL COSTS AND CLINICAL CONSEQUENCES
ZAMIENNOŚĆ LEKÓW O WĄSKIM OKNIE TERAPEUTYCZNYM W TRANSPLANTOLOGII
– POTENCJALNE KOSZTY I KONSEKWENCJE KLINICZNE
1
Astellas Pharma Sp. z o.o.
Department of Surgical and Transplantation Nursing Medical University of Warsaw
Head: prof. dr hab. n. med. Piotr Małkowski
2
Summary
Demand for organ transplants is growing fast due to the
senescence of population and increased incidence of such
diseases as diabetes mellitus and viral hepatitis. Resources of
health care providers are limited and steadily increasing.
Transplant recipients require chronic medical management
and life-time immunosuppressant therapy. Patients must take
multiple drugs, such as immunosuppressants, anti-infective
agents as well as drugs to treat comorbidities. A patient after
organ transplantation may take an average of 11 different
drugs daily. The aim of treatment of such patients is to avoid
loss of a transplant through ensuring high safety level due to
monitoring of concentrations of drugs with narrow
therapeutic index (tacrolimus, cyclosporine). Potential costs
of loss of a transplant include return to dialysis therapy, and
in case of a liver or heart – retransplantation or death.
Availability of generic immunosuppressants results in
increased availability of these drugs, improved quality of
care and sometimes increased patient compliance. Generic
formulations of cyclosporine, mycofenolate mofetil (MMF)
and tacrolimus received marketing authorization in EU.
Conclusions:
Due to the fact that generic formulations of calcineurin
inhibitors are becoming available, both health care providers
and health care payers must realize that their bioavailability
is highly variable and depends on multiple factors that have
not yet been taken into account in studies of clinical
bioequivalence. Changes in systemic exposure may result in
loss of transplant function or toxic effects of an administered
drug. Therefore, it is important for the transplant recipient
and payer to evaluate evidence for safety and efficacy of any
approved alternative formulation that contains a drug with a
narrow therapeutic window used in transplantology.
Streszczenie
Zapotrzebowanie na przeszczepy narządów szybko
rośnie, z powodu starzenia się populacji i wzrostu częstości
występowania takich chorób jak cukrzyca i wirusowe
zapalenie wątroby. Środki świadczeniodawców są
ograniczone i stale rosną. Biorcy wymagają przewlekłego
postępowania medycznego, leczenia immunosupresyjnego
stosowanego przez całe życie. Pacjenci muszą zażywać wiele
leków jak immunosupresanty, leki przeciwzakażeniowe oraz
zwalczające
choroby
współistniejące.
Pacjent
po
przeszczepie może zażywać średnio 11 różnych leków
dziennie. Celem leczenia u takich pacjentów jest uniknięcie
utraty przeszczepu poprzez zapewnienie wysokiego poziomu
bezpieczeństwa dzięki monitorowaniu stężenia leków o
niskim indeksie terapeutycznym, (takrolimus, cyklosporyna).
Potencjalne koszty utraty organu oznaczają powrót na dializy
a w przypadku wątroby lub serca retransplantację lub śmierć.
Dostępność generycznych leków immunosupresyjnych
oznacza zwiększenie ich dostępności, poprawienie jakości
opieki, czasami zwiększenie stopnia stosowania się
pacjentów do zaleceń dotyczących przyjmowania. Preparaty
generyczne cyklosporyny, mykofenolanu mofetylu (MMF) i
takrolimusu, uzyskały pozwolenie na dopuszczenie do obrotu
w UE.
Wnioski:
Ze względu na to, że generyczne preparaty inhibitorów
kalcyneuryny stają się dostępne, świadczeniodawcy i
płatnicy usług zdrowotnych muszą być świadomi tego, że ich
biodostępność, jest wysoce zmienna i uzależniona od wielu
czynników, które nie zostały jeszcze uwzględnione w
badaniach nad biorównoważnością kliniczną. Zmiany w
ekspozycji ogólnoustrojowej mogą prowadzić do utraty
funkcji przeszczepu lub efektów toksyczności podawanego
156
Paweł Szczudło, Marta Hreńczuk
leku. W interesie biorcy organu i płatnika ważne jest zatem
dokonanie oceny dowodów świadczących o bezpieczeństwie
i skuteczności każdego zatwierdzonego preparatu
alternatywnego zawierającego lek o wąskim
terapeutycznym stosowanym w transplantologii.
oknie
Key words: transplantation; tacrolimus; cyclosporine
Słowa kluczowe: transplantacja; takrolimus; cyklosporyna
INTRODUCTION
Demand for organ transplants in Europe is
growing fast, largely due to the senescence of
population and increased incidence of such diseases as
diabetes mellitus and viral hepatitis. Resources of
health care providers required for transplantation are
substantial and are increasing steadily, although they
account only for a small fraction of total health care
costs. To meet this growing demand for organs, criteria
for organ donation for transplantation and their use are
being expanded. For example, in many European
countries organs from elderly subjects, live donors and
non heart beating donors are increasingly used.
Unfortunately, despite of these initiatives and efficacy
of transplantology organisations that are responsible
for organ procurement and distribution, we still
experience imbalance between available organ pool
versus patients who require transplantation. Therefore,
organs are considered as valuable materials that should
be used appropriately.
Transplant recipients require chronic medical
management, including lifetime immunosuppressive
therapy, required to sustain function of a transplanted
organ, preventing return to dialysis therapy, another
transplantation or death of the transplant recipient.
Patients with a transplanted organ must take multiple
drugs to control their chronic disease, including
immunosuppressants, drugs that prevent infections and
drugs to treat comorbidities. A patient with a
transplanted organ may take an average of 11 different
drugs daily. Therefore, the aim of medical management
of the patients treated with immunosuppressants is to
avoid loss of a transplanted organ through ensuring
high safety level due to monitoring of clinical
condition of the patient as well as monitoring of
concentrations of drugs with narrow therapeutic index
represented by tacrolimus and cyclosporine).
Availability of alternative generic drugs, when a
patent for an original drug expires, is usually
welcomed by payers and healthcare providers because
they can provide better access to drugs and redistribute
saved, limited health care resources. The need to stop
rapidly increasing costs of health care is generally
accepted and the development of generic drugs is
supported. Government agencies and payer groups
increasingly use legal regulations and incentives to
support the use of generic drugs by pharmacists,
doctors and patients. Generic alternatives for multiple
drugs used by transplant recipients are also available in
the field of transplantology.
The process of decision making with regard to
safe launching of tacrolimus based generic
formulations must be based on detailed tacrolimus
studies and experience with other tacrolimus generic
formulations approved outside of the European Union
(EU). Authorities must take into consideration
available evidence and expert opinions regarded as
particularly important for the interested parties
(surgeons, doctors, pharmacists and payers) in
providing and funding transplantological care.
Due to the fact that generic tacrolimus
formulations are becoming available, health care
providers and health care payers must realize that
bioavailability of tacrolimus class member of
calcineurin inhibitor, is highly variable and depends on
multiple factors that have not yet been included in
bioequivalence studies and are currently required to
approve generic formulations. Bioavailability of
calcineurin inhibitors is of particular importance
because these drugs have narrow therapeutic index
(NTI), and changes of drug exposure may depend on
the type of the formulation. Other factors affecting
systemic exposure includes clinical condition of the
patient, drug to drug interactions, patient genetic
material and concomitant food intake. Changes in
systemic exposure may result in transplant loss or drug
toxicity. Therefore, in the best interest of both organ
recipient and payer is to evaluate evidence supporting
the safety and effectiveness of any alternative
tacrolimus formulation that has been approved.
Previous experience with generic cyclosporine
formulations, another calcineurin inhibitor, raised
concerns over therapeutic equivalence of these generic
alternative drugs, which were related to the evidence
indicating worse clinical outcomes obtained in certain
cases. Therefore, caution must be exercised in
prescribing or dispensing these drugs when alternative
formulations are available.
Variability of drugs with narrow therapeutic window in transplantology - potential costs and clinical consequences
Practical aspects of switching tacrolimus
formulations also have the highest priority with regard
to ensuring full patient safety. Prograf (original
tacrolimus) should not be converted to other tacrolimus
formulations and other tacrolimus formulations should
not be converted between them without monitoring of
blood levels of these drugs to ensure that systemic
exposure for this drug (area under curve, AUC)
remains unchanged. Furthermore, immunosuppressants
should be converted only by transplantologists.
Substitution of tacrolimus formulations requires careful
cooperation between subjects responsible for continued
care – one has to be sure that errors related to use of a
drug, e.g. wrong drug substitution, will not be
detrimental for the treatment effectiveness. Various
parties involved in organ transplantation – starting
from decision makers, registration authorities and
payers to doctors, patients and manufacturers – share
the responsibility and have a common interest in
maintaining transplant function after the procedure of
transplantation. Costs related to the treatment failure
are enormous, both for patients and for the health care
system. Evaluation of total costs of transplantation
obviously demonstrates that effective treatment with
immunosuppressants to preserve normal function of a
transplanted organ should remain priority. Relatively
small reduction of costs of purchase that could result
from use of different tacrolimus formulations could
prove cost ineffective if clinical effectiveness and drug
safety are concomitantly reduced.
Therefore a decision to use a generic formulation of
e.g. tacrolimus in a patient with a transplanted organ is
of great importance. Health care providers and health
care payers should carefully consider available
evidence and potential clinical and practical
consequences of their decisions before they allow
treatment with alternative tacrolimus formulations or
their uncontrolled substitution in pharmacies.
Suggestions for safe combination of various
tacrolimus formulations in clinical practice
• Changes in immunosuppressive therapy should be
made only by doctor experienced in this method of
treatment and in management of patients with
transplanted organs. Such changes should be
accompanied by proper monitoring of drug
concentration in patient’s blood.
• Health care professionals who are responsible for
care of patients with transplanted organs should be
aware of differences between tacrolimus
formulations.
•
•
157
Doctors who want to be sure that their patients
continue to receive the same tacrolimus
formulation can:
- decide to maintain control by prescribing the
same brand of the drug;
- include specific instructions in protocols of
common patient care and in referrals.
- prepare guidelines ensuring that the patient is
treated with the same tacrolimus formulation
unless clinical circumstances require drug
switching;
- discuss relevant clinical evidence and
guidelines with:
• collaborators from the transplantation
center,
• hospital and regional pharmacists,
• Drug and Therapy Committee,
• primary care physicians.
Doctors should ensure that patients receive
complete information explaining the use of the
drug with critical doses, so patients should be
informed and aware:
- which formulation was prescribed by their
doctor;
- learn and recognize brand of the formulation;
- understand the importance of consistent
immunosuppressive therapy;
- those changes of immunosuppressive therapy
should be made only under strict supervision of
a transplantologist.
LAUNCHING GENERIC DRUGS IN EU INCREASED ROLE OF GENERIC DRUGS
Clearly, society benefits from generic drugs are
mainly related to the reduced costs of
pharmacotherapy. European Generic Medicines
Association (EGA) estimates that use of generic drugs
in EU results in annual 20 billion euro savings by
patients and health care systems [1]. Generic drugs are
very important for patients who cannot afford high fees
related to co-payments for drugs in certain EU member
states, in particular in new EU member states with
developing health care markets[2].
Proper substitution of original innovative drugs
with generic drugs in the EU may result in reduction of
increasing health care costs. Such policy may
potentially lead to substantial cost reduction.
Importance of generic drugs for optimal use of limited
health care budgets is appreciated in all therapeutic
158
fields. In 2007 generic drugs accounted for 17.8% of
all drugs costs in the EU[3].
Availability
of
cheaper
generic
immunosuppressants may lead to increased drug
availability and therefore to improvement of health
care quality, may also result in increased patient
compliance where health care resources are limited[4,5].
Generic formulations of prednisone, azathioprine,
cyclosporine and recently also mycofenolate mofetil
(MMF) received marketing authorization. Since its
approval, generic azathioprine became a commonly
used drug in the USA[6] and in Europe (for example,
generic azathioprine accounted for 79% of sales of
azathioprine in the United Kingdom[7]). Adoption of
generic cyclosporine, that, unlike azathioprine, has a
narrow therapeutic index, was much more cautious.
In 2007 immunosuppressants accounted for only
1.4% of total drugs expenditures in the EU; this
number includes drugs used in the treatment of
rheumatoid arthritis and other indications unrelated to
organ transplantation[3].
Generic drugs expenditures accounted for 3.2% of
total cost of immunosuppressive therapies. Fig. 1
presents immunosuppressant expenditures in various
European countries, as a function of total drug costs in
2008 (from January to September)[3]
IMS MIDAS-MAT, September 2008.
* Only retail sales
IMS MIDAS-MAT, wrzesień 2008r
* sprzedaż apteczna
Fig. 1. Immunosuppressant expenditures in various European
countries as a function of total drug expenditures in
2008 (from January to September) [3]
Ryc. 1. Wydatki na leki immunosupresyjne w różnych krajach
europejskich w funkcji łącznych wydatków na leki w
roku 2008 (od stycznia do września)[3]
APPROVAL OF GENERIC DRUGS IN THE EU
To receive approval (marketing authorization) for a
generic drug, such drug must be proven bioequivalent
to an innovative (reference) drug.
To demonstrate bioequivalence, the manufacturer
must prove that:
• qualitative and quantitative composition of active
ingredients of a generic drug are comparable to that
of an innovative drug with regard to pharmaceutical
characteristics and
• relative bioavailabilities of these two drugs exhibit
acceptable similarity.
This is the base to assume that there is a therapeutic
equivalence of a generic and innovative drug.
There are three procedures to approve drugs in the
EU. According to the first, “central” procedure, a
marketing authorization application is submitted to
EMA (to undergo scientific evaluation by its advisory
committee, CHMP) and if it is approved, marketing
authorization granted by European Committee is valid
in all EU member states. “National” and “mutual
recognition” procedures allow the manufacturer to
gradually receive national approvals for the EU
territory basing on preliminary scientific evaluation
performed by a main office for registration of
medicinal products in a member state (“reference
member state”). This evaluation will be the base for
other EU member states (“interested member states”)
to grant national marketing authorization.
After approval, a generic drug may obtain identical
summary product characteristics as the innovative drug
and therefore may be used in the same indications and
with the same safety precautions, while the
manufactured is not obliged to demonstrate clinical
efficacy and safety in the target patient population.
Clinical efficacy and safety profile of a generic drug
and innovative drug are assumed to be the same and
the same drug interactions are expected. Unless proved
otherwise, bioavailability is also the basis to support
assumption of interchangeability of a generic drug and
innovative drug in stable patients. There is no
requirement to demonstrate efficacy and safety of a
generic drug in patients; however in EU any office for
registration of medicinal products may require
submission of additional data to further explain issues
related to efficacy and safety of a generic drug if it is
justified by the patient safety and requirements of
public health.
Variability of drugs with narrow therapeutic window in transplantology - potential costs and clinical consequences
DEVELOPMENT OF GENERIC DRUGS IN THE EU
Due to lower costs of development, generic drugs
are usually cheaper than innovative drugs and usually
have larger market share due to sales volume, but not
sales value. Their market share largely differs in
different EU member states[2].
Principles for establishing drug costs
Basing on national principles for establishing drug
costs, usually price of an innovative drug is reduced
after expiration of patent protection. However, these
principles depend on whether an innovative drug is
reimbursed in a national health care system.
Regulations and principles of cost limitation also affect
the use of a generic drug, although they may be
affected by historical and economic circumstances in
particular countries. For each member state,
reimbursement level may be defined by an initially
determined level or depend on market prices,
established by free competition between its suppliers.
Initiatives have been adopted, both with regard to
supply and demand, to increase the market share of
generic drugs, in particular in more advanced generic
markets (e.g. Germany and United Kingdom)[8].
In countries with “free price establishment” (e.g.
Germany, United Kingdom, Poland, the Netherlands
and Denmark), generic drugs usually have larger
market share, than in countries with tighter control of
drug prices (e.g. Austria, Belgium, France, Italy,
Portugal and Spain) [9]. In the latter group, differences
between prices of innovative and generic drugs are
smaller.
Traditional rules of drug dispensing, legal
regulations and incentives
To reduce health care expenditures for
pharmaceutical agents, several EU member states use
principles of mandatory substitution of innovative
drugs with generic drugs, unless a doctor clearly
indicates otherwise. In other countries generic
substitution by a pharmacist is allowed, but not
mandatory, while some countries do not allow generic
substitution. However, generic substitution of certain
drug classes, including immunosuppressive drugs with
narrow therapeutic index, is limited in certain member
states, such as Denmark[10] and Spain[11].
According to an internal analysis prepared by
European Generic Medicines Association (EGA) in
2006, despite the fact that prescription of generic drugs
159
is mandatory only in 7% of EU member states,
incentives for their prescribing are present in 50% of
member states[12]. Physicians must consider both
patient therapeutic needs as well as financial
consequences related to any prescription issued by
them, because not all drugs are reimbursed and in
certain countries there may be some financial
incentives to prescribe generic drugs (or penalties
when planned expenditures are exceeded when
physicians have their budgets). In many countries
physicians have tools and databases for electronic drug
prescribing, guideline protocols and formularies.
In many countries (e.g. in the United Kingdom)
there are incentives to encourage physicians to enter
international non-proprietary names (INN) on their
prescriptions. However, regulations differ with regard
whether such practice is obligatory and if this practice
is not preferred by a pharmacist’s remuneration
system, it not universally results in dispensing generic
drugs[12]. In certain countries (e.g. in France),
physicians are required to prescribe certain fraction of
generic drugs, while in another countries (such as
Lithuania) physicians must use international nonproprietary names on their prescriptions for drugs to be
reimbursed[12]. Only in Portugal physicians are
required to use international non-proprietary names on
their prescriptions if generic alternative is available[12].
Payer groups
Payer groups (e.g. insurance companies that offer
health insurances and foundations) usually decide
which drugs are prescribed and dispensed and they can
implement rules promoting the use of generic drugs, in
particular if the price difference between generic drugs
and brand innovative drugs is substantial.
Patient co-payment
There are patient co-payment systems in majority
of countries where a patient contributes to the costs of
his/her treatment[12]. When there is a difference
between a price of a brand of innovative drug and a
generic drug, patient may be obliged to cover the price
difference to be able to continue treatment with
innovative (original) drug. Therefore, patient ability or
willingness to contribute to the treatment costs may
partially affect the use of generic and innovative drugs.
However, when there is a lump-sum (or constant) copayment or when insurance companies fully reimburse
costs of co-payment for drugs, patients have smaller
motivation to prefer therapies based on generic drugs.
160
Different principles of establishment of drug prices and
drug reimbursement in the EU result in totally different
use of generic drugs in various countries. Physicians
remain responsible for ensuring safe and cost-effective
treatment of patients. However, options available for
physicians regarding the limitation of substitution of
innovative drugs with generic alternative drugs also
differ in different countries.
FUTURE TRENDS
Demographic changes and increasing costs of
health care in EU countries clearly indicate that a
tendency to expand the use of generic drugs will
continue. It is also probable that actions will be taken
to ensure more homogeneity in drug policy in the EU.
The requirement for the reduction of health care costs
will be increasing, but patient needs and safety should
remain the priority.
Traditional policy of launching and reimbursement
of generic drugs may generally contribute to the
introduction of safe and effective drugs with
concurrent limitation of health care expenditures.
Patients with transplanted organ require lifetime
immunosuppressive therapy to prevent rejection of the
transplanted organ. Immunosuppressive treatment is
individualized only by transplantologists. Therefore it
is important for decision makers and other persons who
are involved into decisions making related to drug
prescription, to be aware that the presence of even very
small differences between generic and innovative
formulations of immunosuppressants may establish
risks or benefits related to the conversion between
alternative formulations in individual patients.
REFERENCES
1.
2.
3.
4.
5.
European Generic Medicines Association. EGA fact
sheet
on
generic
medicines.
Available
at
www.egagenerics.com/doc/ega_factsheet-01.pdf. Last
accessed on: 6 October 2008.
European Generic Medicines Association. Available at
www.egagenerics.com/gen-geneurope.htm.
Last
accessed on: 6 October 2008.
IMS MIDAS-MAT, September 2008.
Alloway RR, Isaacs R, Lake K, et al. Report of the
American Society of Transplantation conference on
immunosuppressive drugs and the use of generic
immunosuppressants. Am J Transplant 2003; 3: 1211–5.
Sabatini S, Ferguson RM, Helderman JH, et al. Drug
substitution in transplantation: a National Kidney
Foundation White Paper. Am J Kidney Dis 1999; 33:
389-97.
6.
Haroldson JA, Somerville KT, Carlson S, et al. A
retrospective assessment of safety, efficacy and
pharmacoeconomics of generic azathioprine in hearttransplant recipients. J Heart Lung Transplant 2001; 20:
372-4.
7. IMS Health, BPI/HPAI/MAT 12/2008.
8. Simoens S, De Coster S. Sustaining generic medicines
markets
in
Europe;
2006.
Available
at
www.egagenerics.com/doc/simoens-report_200604.pdf. Last accessed on: 6 October 2008.
9. Burgermeister J. Generic medicines could rescue EU
governments’ spending. BMJ 2006; 332: 992.
10. Danish Drug Agency. Bioequivalence and labelling of
medicinal products with regard to generic substitution.
Available
at
www.dkma.dk/1024/visUKLSArtikel.asp?artikelID=64
37. Last accessed on: 15 October 2008..
11. Agencia Española de Medicamentos y Productos
Sanitarios. Ministerstry of Health and Consumer Issues,
18994, regulation datek 12 November 2008.
12. Perry G. The European generic pharmaceutical market
in review: 2006 and beyond. Journal of Generic
Medicine 2006; 4: 4-14.
M.D. Paweł Szczudło
Astellas Pharma Sp. z o.o. Poleczki 21
02-822 Warsaw Poland
mobile+48 608 336 159
Monika Zawadka1, Paweł Zalewski1, Jacek J. Klawe1, Małgorzata Tafil-Klawe2, Joanna Pawlak1,
Krzysztof Kunikowski3, Anna Bitner1
CARDIOVASCULAR AUTONOMIC REGULATION IN RESPONSE
TO ORTHOSTATIC STRESS WITH PARKINSON’S DISEASE – CASE REPORT
AUTONOMICZNA REGULACJA SERCOWO-NACZYNIOWA W ODPOWIEDZI
NA PIONIZACJĘ U PACJENTÓW Z CHOROBĄ PARKINSONA – STUDIUM PRZYPADKU
1
Chair and Department of Hygiene and Epidemiology Nicolaus Copernicus University in Toruń
Head: prof. dr hab. Jacek J. Klawe
2
Chair of Physiology, Department of Human Physiology Nicolaus Copernicus University in Toruń
Head: prof. dr hab. n. med. Małgorzata Tafil-Klawe
3
ALAB Laboratory, Military Hospital, No 10, Bydgoszcz
Summary
Background
and
p u r p o s e . The most
commonly reported disturbances of ANS function in PD are
cardiovascular symptoms. The aim of the study was to
evaluate hemodynamic parameters and heart rate variability
in response to orthostatic stress in patient with Parkinson’s
disease.
M a t e r i a l a n d m e t h o d s . In our study we used
Task Force Monitor System designed for non-invasive
measurement of cardiovascular system and assessment of
functional autonomic nervous system. The device measures
and calculates hemodynamic parameters such as: cardiac
output (CO), cardiac index (CI) stroke volume (SV), heart
rate (HR), RR-Interval (RRI), Total Peripheral Resistance
(TPR) and systolic (sBP), diastolic (dBP), mean (mBP)
blood pressures [25;26]. Estimated parameters of heart rate
variability (HRV) spectral analysis: LFnu-RRI, HFnu-RRI,
LF-RRI, HF-RRI, PSD-RRI, LF/HF.
Results
and
c o n c l u s i o n s . Parkinson’s
disease
causes autonomic dysfunctions leading to
abnormalities in cardiovascular regulation. Dysautonomia in
Parkinson’s disease patient is demonstrated by decreased
heart rate variability (HRV). The head up tilt test revealed a
decreased LF/HF ratio and sympathovagal balance disorders
Streszczenie
W s t ę p i c e l p r a c y . W chorobie Parkinsona
najczęściej
zgłaszanymi
objawami
uszkodzenia
autonomicznego układu nerwowego są zaburzenia sercowonaczyniowe. Celem badania była ocena parametrów
hemodynamicznych krwi i zmienności rytmu serca w
odpowiedzi na pionizację.
M a t e r i a ł i m e t o d y . W badaniu wykorzystano
system Task Force Monitor służący do nieinwazyjnego
badania układu sercowo-naczyniowego czynnościowej oceny
autonomicznego układu nerwowego W sposób nieinwazyjny
określano: pojemność minutową (CO), wskaźnik sercowy
(CI), objętość wyrzutową (SV), częstość pracy serca (HR),
interwał RR (RRI) całkowity naczyniowy opór obwodowy
(TPR) oraz skorygowane ciśnienie skurczowe(sBP),
rozkurczowe (dBP), ciśnienie średnie (mBP) mierzone
metodą ciągłą. Oceniano następujące parametry zmienności
rytmu serca (HRV): LFnu-RRI, HFnu-RRI, LF-RRI, HFRRI, PSD-RRI, LF/HF.
Wyniki
i
w n i o s k i . Choroba Parkinsona
prowadzi do zaburzeń w układzie sercowo-naczyniowym.
162
Monika Zawadka et. al.
Dysautonomia w chorobie Parkinsona manifestowana jest
poprzez zmniejszoną zmienność rytmu serca (HRV). Test
pochyleniowy wykazał zmniejszenie współczynnika LF/HF
oraz zaburzoną równowagę współczulno-przywspółczulną.
Key words: Parkinson’s disease, heart rate variability (HRV), cardiovascular regulations
Słowa kluczowe: choroba Parkinsona, zmienność rytmu serca (HRV), regulacja sercowo-naczyniowa
INTRODUCTION
Parkinson’s disease (PD) is a neurodegenerative
disorder associated not only with motor symptoms but
also with autonomic nervous system (ANS)
dysfunction. The overall prevalence of autonomic
symptoms varies from 76% to 93% and may antedate
main motor symptoms by years [1;2;3;4,]. In idiopathic
cases of PD these autonomic dysfunctions can be
explained by damage to neurological structures [7].
Although mechanisms of their formation have not been
thoroughly known, they are probably related to
accumulation of Lewy bodies in the central and
peripheral nervous system [9]. Lewy bodies can be also
seen in autonomic regulatory region, including
hypothalamus, sympathetic (intermediolateral nucleus
of the thoracic cord and sympathetic ganglia), and
parasympathetic system (dorsal, vagal, and sacral
parasympathetic nuclei) [10;11].
Since PD involves postganglionic sympathetic
noradrenergic lesions, the disease seems to be not only
a movement disorder with dopamine loss in the
nigrostriatal system of the brain, but also a
dysautonomia with norepinephrine loss in the
sympathetic nervous system of the heart [7]. The most
commonly reported disturbances of ANS functioning
in PD are cardiovascular symptoms, i.e. orthostatic
hypotension, decreased heart rate variability, reversal
of circardian rhythm [8,9].
Cardiovascular
dysautonomia is an integral part of the disease and at
least 20% of PD patient suffer from orthostatic
hypotension (OH). Symptoms may be non specific
with generalized weakness and lethargy, dizziness may
also occur [10].
Most patients with Parkinson’s disease have
increased heart rate and experience inversion of normal
trend 24-h blood pressure pattern, with highest
pressures at night and lowest in the morning [4].
Considering assessment methods (invasive/noninvasive measure) and patient groups (different stage
of disease) with Parkinson’s disease, 24-h blood
pressure measurement revealed decreased, normal or
increased values [11]. Significance of cardiovascular
regulation disorders among PD patients is not yet fully
known. It is possible that the dysbalance of the
sympathetic and the parasympathetic activity is
connected with arrhythmias and may cause ischaemic
heart muscles [1].
Presence of dysautonomia depended mainly on
method of assessment. Analysis of heart rate variation
(HRV) has become a popular noninvasive tool for
assessing activities of the autonomic nervous system
(ANS), which reflects the balance between the
sympathetic and parasympathetic nervous system [12].
Heart rate variability involves a complex interaction
between several mechanisms working to maintain heart
rate and blood pressure within normal limits [13].
Many factors influence heart rate and display
enormous variability of measured parameters such as
age, drugs, breathing frequency, physical exercise and
orthostatic stress [12]. It is also presumed that there is a
connection between the autonomic dysbalance and
high mortality among Parkinson’s disease patients [1].
Additionally, aging is associated with decreased HRV,
particularly HF component, reflecting a reduced
cardiovascular autonomic control [14]. It is still
unclear whether the disease itself or its treatment is the
cause of ANS failure. For the evaluation of
cardiovascular autonomic control, the current bedside
golden standard is the study of cardiovascular reflexes
and it has been suggested that these reflexes can even
reveal ANS dysfunction in untreated patients with
early Parkinson disease [7]. The aim of the study was
to evaluate hemodynamic parameters and heart rate
variability in response to orthostatic stress in
Parkinson’s disease patient.
MATERIAL AND METHOD
We report a case of an 84-year-old man with an 8year history of Parkinson’s disease (BMI=26.6).
Patient was in IV stage of Hoehn-Yahr (H-Y) scale
50% in Schwab-England scale.
Cardiovascular autonomic regulation in response to orthostatis stres with Parkinson's disease - case report
Table I. Characteristic of patient with Parkinson’s disease
Tabela I : Charakterystyka pacjenta z chorobą Parkinsona
Duration of
Activities of
Age
Weight Height
illness
daily living Medications
Wiek
BMI
H&Y
Waga
Wzrost
Czas
trwania
Aktywność [mg]
[years]
[kg/m2]
[kg]
[cm]
choroby [years]
dnia
Leki
[lata]
[lata ]
codziennego
84
75
168
26.6
8
IV
50%
Madopar 750
Madopar HBs
1000
H&Y scale is commonly used to assess disease’s
severity and symptom progress of PD, ranging between
stages 1 to 5. [15,16]. The Schwab and England Test
was used to evaluate the daily living activities. [16]. In
our study we used Task Force Monitor System
designed
for
non-invasive
measurement
of
cardiovascular system and assessment of functional
autonomic nervous system. Task Force Monitor® was
used for non-invasive beat-to-beat measurement of the
patient’s hemodynamic parameters and heart rate
variability (HRV). Tilt testing was chosen as the most
appropriate way of evaluating the patient’s symptoms
after normal findings on non-invasive assessment [13].
System Task Force Monitor is composed of:
impedance cardiography (ICG), electrocardiography
(ECG), oscillometric BP (osc BP), continuous BP
(cont BP) [11,17]. Six electrodes were placed on the
thorax of the patient, one on the neck and one on the
leg. Furthermore, one cuff for the oscillometric blood
pressure measurement was placed on upper arm of the
patient and the other cuff for the continuous blood
pressure was placed on the fingers. Task Force Monitor
System measures and calculates hemodynamic
parameters such as: cardiac output (CO), cardiac index
(CI) stroke volume (SV), heart rate (HR), RR-Interval
(RRI), Total Peripheral Resistance (TPR) and systolic
(sBP), diastolic (dBP), mean (mBP) blood pressures
[17, 11].
Before the test, patient was informed about the
procedure of the study. Fasting was required for 2-3
hour before the test. Study procedures were performed
in a silent room with ambient temperature of 23 to 26
C and stable humidity. The subject was studied in the
morning and instructed to remain in resting position for
at least 40 minutes. The study consisted of 3 phases:
01- supine position before pionization, duration about:
6 min; 02- upright position, duration: 5 min; 03resting, supine position, duration: 5 min. Patient in
phase 02 was tilted upright to angle 60° on an electrical
tilt table with feet support and chest and knee straps.
During the entire procedure blood pressure and heart
163
rate
were
monitored
continuously
by
electrocardiography
(ECG)
and
finger
plethysmography.
Heart rate variability spectral analysis
Heart
rate
variability
(HRV)
represents
cardiovascular control mediated by the autonomic
nervous system and other mechanisms. In the
established task, force HRV monitoring different
cardiovascular control mechanisms can approximately
be identified at typical frequencies of heart rate
oscillations by power spectral analysis [13, 14].
Table II. Parameters of heart rate variability spectral
analysis
Tabela II. Parametry analizy widmowej zmienności rytmu
serca
Parameters of heart rate variability spectral analysis
Parametry analizy widmowej zmienności rytmu serca
Parameter
Description (opis)
Unit
(parameter)
(jednostka)
Normalized unit In low frequency domain HRV
(Znormalizowana składowa w zakresie niskich
[%]
LFnu-RRI
częstotliwości HRV)
HFnuRRI
LF-RRI
HF-RRI
PSD-RRI
LF/HF
Normalized unit In high frequency domain HRV
(Znormalizowana składowa w zakresie wysokich
częstotliwości HRV)
Heart rate variabilty LF
(Składowa widmowa wysokiej częstotliwości
widma HRV)
Heart rate variability HF
(Składowa widmowa wysokiej częstotliwości
widma HRV)
Power spectra density
(Widmowa gęstość mocy HRV)
Sympatho-vagal balance (LF_RRI/HF_RRI)
(Współczynnik balansu współczulnoprzywspółczulnego
[%]
[ms2]
[ms2]
[ms2]
[1]
Very low frequency (VLF) (below 0.03 Hz)
describes activity of chemoreceptors, dependent on
vasomotor,
and thermoregulatory reflexes the
participation of renin-angiotensin-aldosterone system.
Low frequency (LF) ranged (0.04-0.15 Hz) is a result
of oscillatory alterations,
R-R-intervals, and
concomitant pressure changes due to stimulation of
baroreceptors. It corresponds with sympathetic activity
of ANS. High frequency power (HF) (0.15 to 0.4 Hz);
absolute values in milliseconds squared. The HF
determines direct component related to activity of
nervus vagus and respiratory rhythm, and displays
activity of parasympathetic parts of ANS. The LF/HF
ratio is considered, by a lot of investigators to mirror
sympatho-vagal balance or to reflect the sympathetic
modulations
in
numerous
physiologic
and
pathophysiologic conditions. High values for the ratio
suggest a higher sympathetic nervous variability. The
164
results of LF, HF components are presented in absolute
units [ms2] of spectrum power as well as in normalized
units, in this case percentage of [%] total spectrum
power without VLF component. According to available
literature, components: LFnu-RRI, LF-RRI are
collerated with sympathetic activity of ANS, whereas:
HFnu-RRI, HF-RRI connected with parasympathetic.
Task Force Monitor System uses autoregressive
parameters uses adaptive algorithm [12, 13, 18].
Description of heart rate variability spectral analysis is
presented in table II.
values of total peripheral resistance (TPR) on tilting
and decreased after supine position. Upright position
(02) resulted with the increase in sBP, dBP and mBP
values. Our findings showed no significant increase of
heart rate in response to orthostatic stress. Value of
RR-Interval (RRI)
in supine position (01) was
794.868, in upright position (02) it decreased to
782.013. Analysis of hemodynamic parameters is
presented in table IV, V. Normal (resting) results are
placed in brackets according to quoted literature- table
IV [17].
RESULTS
Table III. Mean values of heart rate parameter.
Tabela III. Średnie wartości parametrów zmienności rytmu
serca (HRV)
Analysis of heart rate variability during tilt test
showed significant differences in all phases of the
study. Obtained results are presented in mean values in
table 2. Values of normalized units (LFnu-RRI, HFnuRRI) in supine position (01) were following: LFnuRRI01=80.635; HFnu-RRI01=19.365. Our study
revealed decreased values of LFnu-RRI02 (72.974) and
increased HFnu-RRI (27.026) in upright position.
These results indicate an increase of parasympathetic
tone in response to head up tilt test. Power spectrum in
the low frequency domain (LF-RRI) in supine position
(01) was 27.918, while in upright position (02) it
increased to 35.53. Power spectrum in high frequency
domain also underwent essential changes at particular
phases of the study. In phase (01) HF-RRI was 5.193,
in the upright position (02) the value increased to 9.29
(HF-RRI). Time analysis of particular normalized units
of HRV confirms stimulating effect of sympathetic
nervous system. Values of spectral power density
(PSD-RRI) were following: (01) PSD-RRI= 56.623,
(02) PSD-RRI = 99.501, (03) PSD-RRI= 76.699. Our
study revealed increased values of PSD-RRI in upright
position (02). The LF/HF power ratio decreased by
50.6% compared with the supine value, (from 4.448 to
2.248). Analysis of parameters of heart rate variability
is presented in table III.
We also measured hemodynamic response to
tilting. The analysis of hemodynamic parameters (SV,
CO, TPR) in tilt test revealed no significant differences
than those expected for patient’s age.
At rest, from supine to upright position (02) value
of stroke volume (SV) and cardiac output (CO)
typically decreased.
Furthermore, return to supine position (03) showed
increased values of SV and CO but they were lower
than in phase 01. Our study also revealed increased
Mean
values
(Średnie
wartości)
Parameter
Unit
Supine
(Parametr) (Jednostka) position
(Leżenie
na
plecach)
01
LFnu-RRI
[%]
80.635
HFnu[%]
19.365
RRI
2
LF-RRI
[ms ]
27.918
HF-RRI
PSD-RRI
Mean
values
(Średnie
wartości)
Mean values
(Średnie
wartości)
Upright
Resting
position
position
(Pozycja
(Pozycja
pionowa) spoczynkowa)
02
03
72.974
78.12
27.026
21.88
35.53
42.495
2
5.193
9.29
6.014
2
[ms ]
56.623
99.501
72.699
[1]
4.448
2.248
2.564
[ms ]
LF/HF
Table IV. Basic statistics cardiovascular parameter and total
peripheral resistance
Tabela IV. Statystyka podstawowych parametrów sercowonaczyniowych
oraz
całkowitego
oporu
obwodowego
Mean
(Średnia)
Supine
Unit
position
(jednostka)
(Leżenie na
plecach)
01
Mean
(Średnia)
Upright
position
(Pozycja
pionowa)
02
Mean
(Średnia)
Resting
position
(pozycja
spoczynkowa)
03
SV
[ml]
76.396
66.763
73.834
CO
[l/min]
Parameter
(Parametr)
CI
TPR
5.769
5.125
5.55
2
[l/(min*m )] 3.071
2.728
2.954
5
1364.962
1054.481
[dyn*s/cm ] 1141.124
SV- stroke volume (objętość wyrzutowa) (60-120 ml)
CO- cardiac output (pojemność minutowa) (4-8 L/min)
CI- cardiac index (wskaźnik sercowy) (2.5-4.5 L/min/m2)
HR- heart rate (częstość akcji serca) (60-90 bpm)
sBP- systolic blood pressure (skurczowe ciśnienie tętnicze) (90-129 mmHg)
dBP- diastolic blood pressure (rozkurczowe ciśnienie tętnicze) (50-84 mmHg)
mBP- mean blood pressure (średnie ciśnienie tętnicze) (<100 mmHg)
TPR- total peripheral resistance (całkowity opór obwodowy)
(900-1200 dyn*s/cm3)
RRI-RR-Interval (intervał R-R) (660-1000 ms)
Table IV. Basic statistics of heart variability parameters such as:
systolic, diastolic and corrected mean blond pressure
measured constantly
Tabela IV. Statystyka podstawowa parametrów zmienności rytmu
serca, systolicznego, diastolicznego oraz skorygowanego
ciśnienia średniego krwi, mierzonego metodą ciągłą
Mean
(Średnia)
Supine
Parameter
Unit
position
(parameter) (jednostka) (Leżenie
na
plecach
01
794.868
RRI
[ms]
Mean
(Średnia)
Mean
(Średnia)
782.013
800.282
HR
[1/min]
75.545
76.755
75.154
sBP
[mmHg]
116.001
120.058
104.46
dBP
[mmHg]
68.0017
73.946
59.355
MBP
[mmHg]
85.214
90.282
75.508
Upright
Resting
position
position
(Pozycja
(Pozycja
pionowa) spoczynkowa)
02
03
DISCUSSION
Spectral analysis of heart rate variability has been
used to explore dynamic mechanisms in the
cardiovascular system and sympathovagal interactions.
In normal subjects, the autonomic response to head up
tilt test has been well documented. Increased LF power
and decreased HF power, as well as an increased
sympathovagal balance, reflect the normal response to
upright tilt [13].
Our study indicates that patients with Parkinson’s
disease have a different autonomic response to
orthostatic stress. Head up tilt test revealed a decline
LF/HF power ratio after they assumed the upright
position. These results show an increase in
parasympathetic tone and decrease in sympathetic.
These findings agree with those of Mastrocola et al.
who also reported increased low frequency power
domain [19]. Our results confirm the sympathovagal
balance disturbances found in previous HRV studies.
Furthermore, the heart rate variability abnormalities
might therefore present a cardiovascular mortality risk
[12]. Additionally, decreased sympathetic tone is also
characteristic for healthy elderly. The results show that
the heart rate variability decreases with aging.
In our study we also measured hemodynamic
response to tilting. On standing, the rapid migration of
blood from thorax to the lower parts of body results in
a decrease in venous return and fall in cardiac output.
These changes promptly activate compensatory
mechanisms, with a consequent increase in heart rate
and total peripheral resistance. The most important
165
compensatory mechanism is an increase in sympathetic
activity, which results with a 25% acceleration of HR
and increase in myocardial contractility [20, 13].
Normal cardiac response to orthostatic stress is
acceleration of HR by 5-20 bpm [21]. In our patient
mean value of heart rate slightly increases. In phase 01
HR was 75.55 bpm, HR in phase 02 was 76.75 bpm.
Several studies on heart rate variability measures also
confirm our findings. In the study by Niehaus et al.,
head up tilt test provoked smaller HR increases in
Parkinson’s patient than in healthy subjects [4].
Parkinson's disease is known to affect the reflex of
cardiovascular control systems, resulting in a
suppressed heart rate variability, which is a
pathological phenomenon indicating disorders in
activity of autonomic system (decreased activity of
parasympathetic system) [20]. Our results demonstrate
that values of resting blood pressure (sBP, dBP, mBP)
in our 84- old patient are lower than in his age group,
probably as a consequence of diminished ability to
secrete rennin [22]. These findings agree with those of
Barbeau et al., Aminoff and Wilcox who also reported
resting blood pressure lower than expected for age and
sex. Those disorders are due to baroreceptor reflex
damage, one of the main RR regulations [4]. While
blood pressure responses during orthostatic stress
depend on the sympathetic activity and changes in
peripheral vascular resistance, heart rate alterations
during orthostatic stress are mainly vagally mediated
and contribute to a lesser extent to blood pressure. The
contribution of heart rate to maintaining blood pressure
becomes more important in the elderly, especially
since the sympathetic tone decreases with age [23].
Additionally, these symptoms may be intensified
by drugs used in PD treatment. It is still unclear
whether the disease itself or its treatment is the cause
of ANS failure. In study of Goetz et al. and several
reports usage of levodopa did not show to affect
cardiovascular reflexes, whereas Mesec et al.
suggested that BP levels at rest are lower during
levodopa treatment. Levodopa did not suppress the
autonomic cardiovascular responses and the
sympathetic BP response to tilting [4,24]. Van Dijk et
al. have reported that age explained most of the HR
variability (HRV), whereas various PD medications
contributed to only 7% of HR fluctuation [4]. The
results of this study displayed that PD interferes not
only with the cardiovascular HR and BP reflexes, but
also with the tonic autonomic regulation of HRV.
Assessment of heart rate variability (HRV) and
166
hemodynamics parameters in response to tilt test
provide important information about sympathovagal
balance and autonomic regulation in patients with
Parkinson’s disease. It could be also a first step in the
assessment of a possible cardiovascular risk marker
[12]. Furthermore, our results demonstrate practical
use of Task Force Monitor System as a device of
hemodynamic blood parameters measurement and
cardiovascular autonomic regulation.
CONCLUSIONS
1. Parkinson’s disease causes autonomic
dysfunctions leading to abnormalities in
cardiovascular regulation.
2. Dysautonomia in a Parkinson’s disease patient
is demonstrated by decreased heart rate
variability (HRV).
3. The head up tilt test revealed a decreased
LF/HF ratio and sympathovagal balance
disorders.
9.
10.
11.
12.
13.
14.
15.
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Monika Zawadka
Department of Hygiene and Epidemiology,
M. Skłodowskiej-Curie 9 Street
85-094 Bydgoszcz
tel: 504099619
167
Aneta Zreda-Pikies, Andrzej Kurylak
EVALUATION OF THE QUALITY OF LIFE OF CHILDREN WHO HAVE COMPLETED
ACUTE LYMPHOBLASTIC LEUKAEMIA TREATMENT
OCENA JAKOŚCI ŻYCIA DZIECI PO ZAKOŃCZONYM LECZENIU
OSTREJ BIAŁACZKI LIMFOBLASTYCZNEJ
Department of Paediatric Nursing, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń
Head: Aneta Zreda-Pikies, Andrzej Kurylak
Summary
I n t r o d u c t i o n . The progress in treating lifethreatening diseases, which led to an increased number of
cured persons, forces us to look closely at the functioning of
patients after completed treatment. The results of ALL
treatment which apply to children have been improving
systematically for the past years. At present over 80 percent
of children are considered to be cured; therefore, it is
justified to evaluate the quality of their life. Learning a
subjective evaluation of the quality of life may be a source of
information which often differs from the evaluation made by
medical staff or sick children’s parents. The information
might indicate existence of non-perceived needs of patients
who require specialist care and help outside the hospital
environment. As far as the following paper is concerned, an
attempt was made to determine the connection between
chosen factors (sex, age at the time of diagnosis, age at the
time of examination, time that passed from treatment
completion, family’s economic situation, parents’ education,
place of residence, risk group, treatment program,
implementation of CNS radiotherapy) and a subjective
evaluation of the quality of life of children who have
undergone ALL treatment.
M a t e r i a l a n d m e t h o d s . The research was
conducted among patients treated in the Chair and Clinic of
Paediatrics, Haematology and Oncology of Copernicus
University Collegium Medicum in Bydgoszcz, who
completed acute lymphoblastic leukaemia treatment. It
comprised children whose ALL treatment finished at least 6
months prior to the research. The final group of patients who
participated in the research consisted of 64 persons. The
number of boys and girls was comparable and amounted to
33 and 31, respectively. In order to evaluate the quality of
life of children who completed ALL treatment and of healthy
children James W. Varni’s standardized research instrument
was used.
R e s u l t s . The evaluation of general quality of life of
children who have completed ALL treatment does not
depend on: patient’s age at the time of diagnosis, age at the
time of examination, sex, place of residence, family’s
economic situation or being in the risk group. The quality of
life conditioned by the state of health depends on:
implementation of radiotherapy, the time that passed from
completing treatment and parents’ education. The general
evaluation of the quality of life is significantly lower in the
group of patients who have completed ALL treatment. The
most visible difference pertains to their functioning at school.
As the time that passed from treatment completion goes by,
the subjective evaluation of physical functioning decreases.
Children’s fathers who have higher education evaluate the
general quality of life lower than fathers who have education
of a lower degree.
Streszczenie
W s t ę p . Postęp w leczeniu chorób zagrażających
życiu, który spowodował wzrost liczby osób wyleczonych
wymusza spojrzenie na funkcjonowanie pacjenta po
zakończonym leczeniu. W przypadku dzieci w ostatnich
latach systematycznie poprawiają się wyniki leczenia ALL,
obecnie ponad 80% dzieci uznaje się za wyleczone, zasadną
więc jest ocena jakości ich życia. Poznanie subiektywnej
oceny jakości życia może być źródłem informacji, które są
niejednokrotnie odmienne od oceny dokonywanej przez
personel medyczny, a także rodziców chorych dzieci. Mogą
one wskazywać na istnienie niedostrzeganych potrzeb
pacjentów, wymagających zapewnienia fachowej opieki i
170
pomocy poza środowiskiem szpitalnym. W pracy podjęto
próbę określenia zależności pomiędzy wybranymi
czynnikami (płeć, wiek w chwili rozpoznania, wiek w chwili
badania, czas od zakończenia leczenia, sytuacja ekonomiczna
rodziny, wykształcenie rodziców, miejsce zamieszkania,
grupa ryzyka, program leczenia, stosowanie radioterapii
OUN), a subiektywną oceną jakości życia dzieci po
zakończonym leczeniu ALL.
M a t e r i a ł i m e t o d y . Badania przeprowadzono
wśród pacjentów leczonych w Katedrze i Klinice Pediatrii,
Hematologii i Onkologii Collegium Medicum Uniwersytetu
Mikołaja Kopernika w Bydgoszczy, którzy zakończyli
leczenie ostrej białaczki limfoblastycznej. Badaniami objęto
dzieci, które zakończyły leczenie ALL przynajmniej 6
miesięcy przed badaniem. Ostateczna liczba osób, biorących
udział w badaniu wynosiła 64. Liczba chłopców i
dziewczynek była porównywalna i wynosiła odpowiednio 33
i 31 osób. Do oceny jakości życia dzieci po zakończonym
leczeniu ALL oraz dzieci zdrowych użyto standaryzowanego
narzędzia badawczego autorstwa Jamesa W. Varni.
W y n i k i . Ocena ogólnej jakości życia dzieci po
zakończonym leczeniu ALL nie zależy od: wieku w chwili
rozpoznania choroby, wieku pacjenta w chwili badania, płci,
miejsca zamieszkania, sytuacji ekonomicznej rodziny oraz
przynależności do grupy ryzyka. Jakość życia uwarunkowana
stanem zdrowia jest uzależniona od: stosowania radioterapii,
czasu od zakończenia leczenia oraz wykształcenia rodziców.
Ogólna ocena jakości życia jest znamiennie niższa w grupie
pacjentów u których stosowano radioterapię OUN,
najbardziej widoczna różnica dotyczy funkcjonowania w
szkole. Wraz z upływem czasu, który minął od zakończenia
leczenia obniża się subiektywna ocena funkcjonowania
fizycznego. Ojcowie dzieci, którzy posiadają wyższe
wykształcenie oceniają ogólną jakość życia gorzej niż
ojcowie o niższym wykształceniu.
Key words: acute lymphoblastic leukemia, quality of life
Słowa kluczowe: ostra białaczka limfoblastyczna, jakość życia
INTRODUCTION
The progress in treating life-threatening diseases,
which led to an increased number of cured persons,
forces us to look closely at the functioning of patients
after completed treatment. The results of ALL
treatment which apply to children have been improving
systematically for the past years. At present over 80
percent of children are considered to be cured;
therefore, it is justified to evaluate the quality of their
life. Learning a subjective evaluation of the quality of
life may be a source of information which often differs
from the evaluation made by medical staff or sick
children’s parents. The information might indicate
existence of non-perceived needs of patients who
require specialist care and help outside the hospital
environment.
The purpose of this paper is to determine the
connection between chosen factors (sex, age at the time
of diagnosis, age at the time of examination, time that
passed from treatment completion, family’s economic
situation, parents’ education, place of residence, risk
group, treatment program, implementation of CNS
radiotherapy) and a subjective evaluation of the quality
of life of children who completed ALL treatment.
Collegium Medicum in Bydgoszcz, who have
completed acute lymphoblastic leukaemia treatment. It
comprised children whose ALL treatment finished at
least 6 months prior to the research. The final group of
patients who participated in the research consisted of
64 persons. The number of boys and girls was
comparable and amounted to 33 and 31, respectively.
The average age of children at the moment of the
research was 11.3 (4-18 years old, median - 11) and at
the moment of diagnosis - 6 (1-17 years old, median 5). The average age at the moment of falling ill in the
analysed group of 64 children was 6 (median – 5). The
children’s age varied from 1 to 17. The majority of
patients (53.12 percent) were qualified to the standard
risk (SR) group, whereas the intermediate risk (IR)
group consisted of 21 patients, i.e. 32.8 percent of all
patients, the high risk group comprised 9 patients
(14.05 percent). In order to evaluate the quality of life
of children who have completed ALL treatment and of
healthy children, James W. Varni’s standardized
research instrument was used [1, 2, 3, 4, 5, 6].
Permission to use the questionnaire was granted by the
Mapi Research Trust Institute in Lyon.
RESULTS
The research was conducted among patients treated
in the Chair and Clinic of Paediatrics, Haematology
and Oncology of Nicolaus Copernicus University
An analysis of the collected materials indicates that
the quality of children’s lives is not affected by their
age at the moment of diagnosis or at the moment of
research.
Evaluation of the quality of life of children who have completed acute lymphoblastic leukaemia treatment
However, there is a connection between the time
that passed from treatment completion and direct
evaluation of functioning in the physical sphere. The
more time passes from treatment completion, the better
the results of an evaluation of the quality of life in the
said sphere. Regardless of the time that passed from
the treatment completion, the indirect quality of life
evaluation was similar.
Having observed the above correlation, an attempt
was made to evaluate, in detail, the quality of life in all
spheres of functioning depending on the time that
passed from treatment completion.
171
lower than other patients (79.44 vs. 88.41). The
smallest discrepancy between the groups was found
within the sphere of emotional functioning (66.11 vs.
73.05).
Fig. 2. Correlation between an evaluation of the general
quality of life and the time that passed from treatment
completion
Ryc. 2. Zależność pomiędzy oceną ogólnej jakości życia a
czasem od zakończenia leczenia
Fig. 1. Evaluation of specific spheres of functioning
depending on the time that passed from treatment
completion
Ryc. 1. Ocena poszczególnych sfer funkcjonowania w
zależności od czasu, który upłynął od zakończenia
leczenia
The worst quality of life in all the spheres of
functioning was observed with respect to children who
completed treatment 4-6 years before the research. The
quality of life of children/teens improved 6 years after
treatment completion.
When performing an analysis of the group of
children who completed acute lymphoblastic
leukaemia treatment which took into consideration
using/not using CNS radiotherapy, significant statistic
correlations between variables were found.
The general evaluation of the quality of life
performed by children is lower in the group where
CNS irradiation was applied as compared with children
who did not undergo radiotherapy (71.08 vs. 79.96;
p=0.023). The above evaluation was influenced by
children’s functioning in all the analysed spheres;
however, the biggest and, at the same time, statistically
significant difference was found in connection with
functioning at school (60.00 vs. 73.88; p=0.01). A
major, yet unimportant as far as statistics is concerned,
difference pertained to social functioning. Children
who had undergone radiotherapy graded it 8.97 points
When analysing the indirect evaluation, no
statistically significant differences between the two
groups were found. However, from the perspective of
parents whose children underwent CNS irradiation, the
evaluation of children’s functioning is lower. The most
significant differences pertained to functioning at
school (59.72 vs. 69.78) and physical functioning
(77.73 vs. 83.87). The smallest difference was
discovered in relation to evaluation of emotional
functioning (62.78 vs. 69.24).
Fig. 3. Correlation between radiotherapy used during
treatment and an evaluation of the quality of life
Ryc. 3. Zależność pomiędzy stosowaniem w trakcie leczenia
radioterapii a oceną, jakości życia
While analyzing the gathered materials, it was
noticed that there is a correlation between the applied
treatment program and evaluation of the quality of life.
According to the evaluation, the best quality of life can
be observed among children who underwent BFM 90
172
treatment (79.10 pts. – direct evaluation; 79.34 pts. –
indirect evaluation). The worst quality of life, on the
other hand, is experienced by patients who were treated
as per the New York protocol (66.24 pts. – direct
evaluation; 67.09 pts. – indirect evaluation).
A comparison of groups in relation to the applied
program of treatment, revealed a statistically essential
difference between the indirect evaluation of
functioning at school, depending on the use of specific
treatment programs. However, children treated with the
use of the New York program (50 pts. – direct
evaluation; 48.75 pts. – indirect evaluation) have the
most difficulty with functioning at school; the least
difficulty is encountered by children treated according
to the BFM 90 program (73 pts. – direct evaluation;
75.5 pts. – indirect evaluation).
Fig. 4. Correlation between programs applied during
treatment and an evaluation of the quality of life
Ryc. 4. Zależność pomiędzy stosowanym programem leczenia
a oceną, jakości życia
DISCUSSION
Own research has shown that an evaluation of the
quality of life does not depend on patient’s age at the
time of diagnosis. This result is consistent with results
obtained by Pemberg, S. et al. from Australia [7].
The results of own research concerning the
prevalence of the disease among boys and girls
indicate that the incidence of the disease is slightly
higher with respect to boys (51.7 percent) (girls – 48.3
percent). The above information is in agreement with
the general characteristics of the population of children
diagnosed with acute lymphoblastic leukaemia. The
research carried out among 170 patients by Meeske, K.
et al. reveals that boys are the dominant group of
patients (59 percent) among children/teens who suffer
from acute lymphoblastic leukaemia [8].
According to own research, the number of children
and teens living in cities (64.1 percent) was visibly
higher than the number of children living in the
country (35.8 percent). Based on the research carried
out in Lublin on a group of 44 children who completed
ALL treatment, one concludes that the environment, in
which a child has been brought up, is differential with
respect to its intellectual functioning after the
completion of treatment. Children living in cities had a
significantly higher intelligence quotient than children
living in the country [9].
As far as the results of own research are concerned,
children living in the country evaluated their
functioning in all the spheres covered by the research
slightly lower; however, the differences were not
noteworthy from the statistical point of view. The
evaluation performed by children’s parents was the
same as direct evaluation only with respect to
functioning in the physical sphere. Their evaluation of
functioning in all other spheres was lower than
children’s evaluation.
Own research has shown that the evaluation of the
quality of life of children who completed ALL
treatment does not depend on: patient’s age at the time
of examination, age at the time of diagnosis, sex, place
of residence, family’s economic situation or mother’s
education.
While analyzing the gathered materials, it was
noticed that there are essential statistical correlations
between the evaluation of the quality of life and the
time that passed from completing treatment, using
CNS radiotherapy, treatment program and father’s
education.
Due to small sizes of groups comprising patients,
the carried out analysis of evaluating the quality of life
depending on the treatment programs used does not let
one draw binding conclusions. Nevertheless, it was
observed that the lowest evaluation of functioning in
the emotional, social and school sphere pertained to the
group of children who were treated with the use of the
New York program. The results of the said evaluation
might stem from a preventive CNS irradiation dose
which is higher than with respect to other patients (18
Gy vs. 12 Gy).
According to the opinion of Constine, L.,
deviations in the neuropsychological state connected
with CNS irradiation start to show up not earlier than
3-5 years after its completion [10].
In connection with reports stating that CNS
irradiation has a negative effect on the functioning of
children after treatment completion, an analysis of the
quality of life in all spheres of functioning conditioned
by using/not using CNS radiotherapy was carried out.
A general evaluation of the quality of life performed by
children is lower in the group where CNS irradiation
was applied as compared with children who did not
undergo radiotherapy (71.08 vs. 79.96; p=0.023). The
above evaluation was influenced by children’s
functioning in all the analysed spheres; however, the
biggest and, at the same time, statistically significant
difference was found in connection with functioning at
school (60.00 vs. 73.88; p=0.01). A major, yet
insignificant as far as statistics is concerned, difference
pertained to social functioning (79.44 vs. 88.41). The
smallest discrepancy between the groups was found
within the sphere of emotional functioning (66.11 vs.
73.05). When analysing the indirect evaluation, no
statistically significant differences between the two
groups were found. However, from the perspective of
parents whose children have undergone CNS
irradiation, the evaluation of children’s functioning is
lower in all spheres.
The research carried out by Samardakiewicz, M.,
Dudzińska, M. and Zdebska, S. did not reveal any
significant differences between intelligence quotients
achieved by children with respect to whom various
irradiation doses were used [9, 11, 12]. Yet, Von der
Weid, N. revealed that patients who had undergone
CNS irradiation had worse results in arithmetic, shortterm memory, concentration and data processing speed
[13].
When examining the correlation between parents’
education and evaluation of the quality of life, it was
noticed that the evaluation of functioning at school was
lower among children whose parents had higher
education. The lowest evaluation in the above
mentioned sphere was demonstrated in the group of
children whose mothers had higher education.
Additionally, a statistically important difference in
evaluation was presented with respect to the education
of the father. Children whose fathers had higher
education evaluated their functioning at school
noticeably lower than children of fathers with high
school, vocational school and primary school
education. When looking at the indirect evaluation, one
notices that functioning in the physical sphere and
functioning at school received the lowest evaluation
from children whose fathers had higher education.
Such evaluation probably stems from higher
expectations of parents with higher education towards
their own children.
Parents of children who have completed treatment
often face a parenting dilemma. Do they have the right
173
to demand the same they would have demanded from
their child if the child had not fallen ill? Should they
‘go easy’ on a child in connection with the past
disease?
In one of her articles Zdebska, S. stated that the
degree to which a child is privileged in a family as well
as the scope of requirements it is faced with as per its
age and abilities is a measure of parents’ hopes for
permanent recovery. In families where permanent
recovery is an option, the requirements are similar to
usual ones [14].
A long-lasting disease of a child modifies parents’
attitude. As the formation of an attitude is distorted,
negative attitudes such as rejection, avoidance,
excessive protection or excessive requirements may
arise. As a consequence, a child’s needs may not be
satisfied and its development might be disturbed [15,
16, 17, 18].
According to the research carried out by professor
Mess, E. et al., a demanding attitude is one of the least
formed attitudes towards a child suffering from ALL.
A loving and protecting attitude dominates clearly;
however, these attitudes bear the risk of limiting a
child’s independence [19]. An evaluation of parents’
attitudes did not take into account their education so
one cannot exclude that they are also formed with
respect to parents who have higher education.
The own research did not attempt to evaluate the
attitude of parents towards children. Therefore, it is
impossible to determine the reason for a lower
evaluation of life quality of children of parents with
higher education in an explicit way.
Having carried out research on intellectual
functioning of children who have completed leukaemia
treatment, Samardkiewicz, M. and Kowalczyk, J. R.
demonstrate that parents’ higher level of education has
a positive effect on children’s intellectual functioning,
which might be connected with greater development
stimulation in such families [9].
As far as own research is concerned, it was
demonstrated that there is a connection between the
time that passed from treatment completion and direct
evaluation of functioning in the physical sphere. The
more time passes from oncological treatment
completion, the lower the results of an evaluation of
physical functioning. The above situation might be
influenced by occurrence of late complications of
oncological treatment, which might limit former
patients’ physical fitness. The own research was not
aimed at evaluating complications occurring after the
174
treatment. Consequently, it is impossible to draw
binding conclusions in this matter. However, the
obtained results indicate a necessity for further
research that would answer the following question:
why does functioning in the physical sphere decrease
as the time from treatment completion goes by?
During a research carried out in Los Angeles and
San Diego, parents of children who completed ALL
treatment evaluated their children’s physical
functioning lower than in the own research (71.65 vs.
82.14). The said evaluation differed for children who
have completed treatment <12 months and > 12
months before the research (65.4 vs. 77.9) [8].
CONCLUSIONS
1.
Evaluation of the general quality of life of
children who have completed ALL treatment
does not depend on: age at the time of
diagnosis, age at the time of examination, sex,
place of residence, family’s economic
situation or being in the risk group.
2. The quality of life conditioned by the state of
health depends on: implementation of
radiotherapy, the time that passed from
finishing treatment and parents’ education.
2.1 The general evaluation of the quality of
life is significantly lower in the group of
patients who have undergone CNS therapy
and is the most visible as far as
functioning at school is concerned.
2.2 As the time which has passed from
treatment completion goes by, the
subjective
evaluation
of
physical
functioning decreases.
2.3 Children’s fathers who have higher
education evaluate the general quality of
life lower than fathers with education of a
lower degree.
REFERENCES
1. Meeske K., Katz E., Palmer S., Burwinkle T., Varni J.
Parent Proxy-Reported Health- Related Quality of Life
and Fatigue in Pediatric Patients Diagnosed with Brain
Tumors and Acute Lymphoblastic Leukemia, Cancer
2004, 101: 2116-2125
2. Varni J.W., Burwinkle T.M., Seid M. The PedsQL TM
4.0 as a school population health measure: Feasibility,
reliability and validity. Quality of Life Research 2006,
15: 203-215
3. Varni J.W., Limbers Ch.A., Burwinkle T.M. Impaired
health- related quality of life in children and adolescents
with chronic conditions: a comparative analysis of 10
disease cluster and 33 disease categories/ severities
utilizing the PedsQL TM 4.0 Generic Core Scales. Health
and Quality of Life Outcomes 2007, 5: 43-58
4. Varni JW, Burwinkle TM, Seid M, Skarr D. The PedsQL
4.0 as a pediatric population health measure: Feasibility,
reliability and validity. Ambul Pediatr 2003; 3: 329-341
5. Varni JW, Burwinkle TM, Seid M. The PedsQL 4.0 as
school population health measure: Feasibility, reliability
and validity. Quality of Life Research 2006; 15: 203-215
6. Varni, JW, Burwinkle TM, Katz ER et al. The
PedsQL in pediatric cancer: Reliability and validity of
the Pediatric Quality of Life Inventory Generic Core
Scales, Multidimensional Fatigue Scale, and Cancer
Module. Cancer 1994: 2090-2106.
7. Pemberger S., Jagsch R., Frey E., Felder-Puig R., Gadner
H., Kryspin-Exner J., Topf R. Quality of Life in longterm childhood cancer survivors and the relation of late
effects and subjective well-being. Support Care Cancer
2005, 13: 49-56
8. Meeske K., Katz E., Palmer S., Burwinkle T., Varni J.
Parent Proxy-Reported Health- Related Quality of Life
and Fatigue in Pediatric Patients Diagnosed with Brain
Tumors and Acute Lymphoblastic Leukemia, Cancer
2004, 101: 2116-2125
9. Samardakiewicz M., Kowalczyk J., R. Retrospektywna
ocena intelektualnego funkcjonowania dzieci po
zakończonym leczeniu białaczki, Przegląd Pediatryczny
2005, vol 35, nr 4: 205-210
10. Constine L. Late effectc of radiation therapy. Pediatrician
1991, 18: 37-48
11. Dudzińska M., Sońta-Jakimczyk D., Izydorczyk B.
Ocena stanu neuropsychicznego dzieci żyjących w
remisji ostrej białaczki limfoblastycznej, Pediatria Polska
1994, LXIX, 9: 753-758
12. Zdebska S., Armata J., Balwierz W. Wyniki kontrolnych
badań psychologicznych testem Wechslera leczonych z
powodu nowotworowych chorób krwi, Ped. Pol., 1987,
62, 7: 490-498
13. Von der Weid N. Late effects in long-term survivors of
ALL in childhood: experiences from the SPOG late
effects study. Swiss Med. Wkly 2001, 131 (13-14): 180187
14. Zdebska S., Armata J. Udział rodziców w leczeniu ich
dziecka z chorobą nowotworową, Ped. Pol., 1978, 53:
621-627
15. Budziszewska B.K., Piusińska-Macoch R., Sułek K.,
Stępień A. Psychologiczne problemy rodziny pacjentów
z chorobami nowotworowymi krwi w koncepcji
systemowej. Acta Haematologica Polonica 2005; 36, 3:
317-325
16. Łatka J. Postawy rodzicielskie – uwarunkowania,
Magazyn Pielęgniarki i Położnej 2005, nr 6: 22-23
17. Yeh Ch-H., Lee T-T., Chen M-L. Adaptational process of
parents of pediatric oncology patients. Pediatric
Hematology and Oncology 2000, 17: 119-131
18. Zdebska S., Armata J. Psychologiczne problemy w
nowotworowych chorobach krwi u dzieci [w:] Ochocka
M. Hematologia kliniczna wieku dziecięcego. Warszawa
1982. PZWL: 369-381
19. Mess E., Wójcik D., Niedzielska E., wsp. Adaptacja
społeczna dzieci leczonych na ostrą białaczkę
limfoblastyczną, Onkol. Pol. 2005, 8, 3: 166- 169
List of abbreviations
RFS functioning at school, as evaluated by a child’s
parents
funkcjonowanie w szkole w ocenie dokonanej przez
rodziców dziecka
RSE functioning in the emotional sphere, as evaluated by
a child’s parents
funkcjonowanie w sferze emocjonalnej w ocenie
dokonanej przez rodziców dziecka
RSF functioning in the physical sphere, as evaluated by a
child’s parents
funkcjonowanie w sferze fizycznej w ocenie
RSS functioning in the social sphere, as evaluated by a
child’s parents
funkcjonowanie w sferze społecznej w ocenie
SE
functioning in the emotional sphere – direct
evaluation
funkcjonowanie w sferze emocjonalnej – ocena
bezpośrednia
SF
functioning in the physical sphere – direct evaluation
funkcjonowanie w sferze fizycznej – ocena
bezpośrednia
SS
functioning in the social sphere – direct evaluation
funkcjonowanie w sferze społecznej – ocena
bezpośrednia
Aneta Zreda-Pikies
ul. Osiedlowa 6/12
85-794 Bydgoszcz
175
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Medical and Biological Sciences
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BYDGOSZCZ 2012
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medical and biological sciences

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