medical and biological sciencesmedical and biological sciences, 2009, 23/4 content p. reviews...

UNIWERSYTET MIKOŁAJA KOPERNIKA w TORUNIU

COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA

W BYDGOSZCZY

MEDICAL AND BIOLOGICAL

SCIENCES

(dawniej ANNALES ACADEMIAE MEDICAE BYDGOSTIENSIS)

TOM XXIII/4 październik – grudzień ROCZNIK 2009

R E D A K T O R N A C Z E L N Y E d i t o r - i n - C h i e f

Grażyna Odrowąż-Sypniewska

Z A S T Ę P C A R E D A K T O R A N A C Z E L N E G O C o - e d i t o r Jacek Manitius

S E K R E T A R Z R E D A K C J I S e c r e t a r y

Beata Augustyńska

R E D A K T O R Z Y D Z I A Ł Ó W A s s o c i a t e E d i t o r s

Mieczysława Czerwionka-Szaflarska, Stanisław Betlejewski, Roman Junik, Józef Kałużny, Jacek Kubica, Wiesław Szymański

K O M I T E T R E D A K C Y J N Y E d i t o r i a l B o a r d

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

K O M I T E T D O R A D C Z Y A d v i s o r y B o a r d

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

A d r e s r e d a k c j i A d d r e s s o f E d i t o r i a l O f f i c e Redakcja Medical and Biological Sciences

ul. Powstańców Wielkopolskich 44/22, 85-090 Bydgoszcz Polska – Poland

e-mail: [email protected], [email protected] tel. (052) 585-3326

www.medical.cm.umk.pl

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ISSN 1734-591X

UNIWERSYTET MIKOŁAJA KOPERNIKA W TORUNIU COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA

BYDGOSZCZ 2009

Medical and Biological Sciences, 2009, 23/4

CONTENT p.

REVIEWS

K a t a r z y n a S k o n i e c z n a , M a r c i n W o ź n i a k , U r s z u l a R o g a l l a , P a t r y c j a D a c a ,

M a r t a M i e l n i k , K a t a r z y n a L i n k o w s k a , M a r t a G o r z k i e w i c z , J a r o s ł a w B e d n a r e k , E d y t a R y c h l i c k a , A n n a C z a r n e c k a , T o m a s z G r z y b o w s k i – Genome sequencers – towards personalized genomics and medicine . . . . . . . . . . . . . . . . . . . . . . . . . . 5

M a c i e j Ś n i e g o c k i – Image analysis – medical and technical problem . . . . . . . . . . . . . . . . . . . . . . . . . . 11 ORIGINAL ARTICLES A n n a B e d n a r e k , B e a t a J ę d r u s z a k – Health threats in children in the selected rural environment 17 M a r t a C e b u l a k , A n n a K s y k i e w i c z - D o r o t a – Structure of utilization of nursing time in psy-

chiatric ward – preliminary studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 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 build of physical education students

at the Kazimierz Wielki University in Bydgoszcz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 M i r o s ł a w a F e l s m a n n , E l ż b i e t a K ę d z i e r s k a – Patients suffering from acute coronary

syndromes and the accompanying anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 M a r i u s z K l i m c z y k – Sport profiles of 13-year-old pole vault jumpers . . . . . . . . . . . . . . . . . . . . . . . . . . 45 M o n i k a W i ł k o ś ć , B e a t a A u g u s t y ń s k a , A l e k s a n d e r A r a s z k i e w i c z , K i n g a

S o b i e r a l s k a - M i c h a l a k , A n n a D u d z i c - K o c , P i o t r B i j a k o w s k i – Cognitive functions in alcohol dependent patients. A description of a new cognitive battery – QMT (Quick Mind Testing) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

CASE REPORT M a ł g o r z a t a Ł u k o w i c z , J a n P a w l i k o w s k i , P a w e ł Z a l e w s k i , M a g d a l e n a

W e b e r - Z i m m e r m a n n , K a t a r z y n a C i e c h a n o w s k a , A g n i e s z k a P a w l a k – Body weight supoort during treadmill therapy in patients after SCI – case study . . . . . . . . . . . . . . . . . 59


SPIS TREŚCI str.

PRAGE POGLĄDOWE

K a t a r z y n a S k o n i e c z n a , M a r c i n W o ź n i a k , U r s z u l a R o g a l l a , P a t r y c j a D a c a ,

M a r t a M i e l n i k , K a t a r z y n a L i n k o w s k a , M a r t a G o r z k i e w i c z , J a r o s ł a w B e d n a r e k , E d y t a R y c h l i c k a , A n n a C z a r n e c k a , T o m a s z G r z y b o w s k i – Sekwenatory genomowe – narzędzia spersonalizowanej genomiki i medycyny . . . . . . . . . . . . . . . . . . 5

M a c i e j Ś n i e g o c k i – Analiza obrazu – wspólny problem lekarza i inżyniera . . . . . . . . . . . . . . . . . . . . . 11 PRACE ORYGINALNE A n n a B e d n a r e k , B e a t a J ę d r u s z a k – Zagrożenia zdrowotne u dzieci w wybranym środowisku

wiejskim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 M a r t a C e b u l a k , A n n a K s y k i e w i c z - D o r o t a – Struktura wykorzystania czasu pracy pielęgnia-

rek na oddziałach psychiatrycznych – badania wstępne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 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 – Budowa morfologiczna studentów Uniwersytetu

Kazimierza Wielkiego w Bydgoszczy z kierunku wychowania fizycznego . . . . . . . . . . . . . . . . . . . . . . . . 31 M i r o s ł a w a F e l s m a n n , E l ż b i e t a K ę d z i e r s k a – Pacjenci z ostrymi stanami wieńcowymi

a towarzyszący im lęk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 M a r i u s z K l i m c z y k – Profile sportowe 13-letnich skoczków o tyczce . . . . . . . . . . . . . . . . . . . . . . . . . . 45 M o n i k a W i ł k o ś ć , B e a t a A u g u s t y ń s k a , A l e k s a n d e r A r a s z k i e w i c z , K i n g a

S o b i e r a l s k a - M i c h a l a k , A n n a D u d z i c - K o c , P i o t r B i j a k o w s k i – Funkcje poznawcze u pacjentów uzależnionych od alkoholu. Opis nowej baterii testów poznawczych – QMT (Quick Mind Testing) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

OPIS PRZYPADKU M a ł g o r z a t a Ł u k o w i c z , J a n P a w l i k o w s k i , P a w e ł Z a l e w s k i , M a g d a l e n a

W e b e r - Z i m m e r m a n n , K a t a r z y n a C i e c h a n o w s k a , A g n i e s z k a P a w l a k – System dynamicznego odciążenia w terapii chodu na bieżni u pacjenta po urazie rdzenia kręgowego – prezentacja przypadku . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Regulamin ogłaszania prac w Medical and Biological Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Medical and Biological Sciences, 2009, 23/4, 5-10

REVIEW / PRACA POGLĄDOWA

Katarzyna Skonieczna, Marcin Woźniak, Urszula Rogalla, Patrycja Daca, Marta Mielnik, Katarzyna Linkowska, Marta Gorzkiewicz, Jarosław Bednarek, Edyta Rychlicka, Anna Czarnecka, Tomasz Grzybowski

GENOME SEQUENCERS – TOWARDS PERSONALIZED GENOMICS

AND MEDICINE

SEKWENATORY GENOMOWE – NARZĘDZIA SPERSONALIZOWANEJ GENOMIKI I MEDYCYNY

Department of Molecular and Forensic Genetics, Chair of Forensic Medicine, Nicolaus Copernicus University Collegium Medicum in Bydgoszcz

Head: PhD Tomasz Grzybowski

S u m m a r y

In recent years, the development in the DNA sequencing technology has resulted in the invention of new platforms for DNA sequence analysis. The achievements in sequencing technology offer promising opportunities for a fast and cheap, full genome determination which spur research

development in biodiversity studies, agriculture or personalized medicine. This review provides information on both whole genome sequencers and sequencing technology applied in each instrument to determine the nucleotide sequence of complete genomes.

S t r e s z c z e n i e

W ostatnich latach rozwój technologii sekwencjonowania

DNA zaowocował powstaniem nowych urządzeń umożliwiających poznanie sekwencji DNA. Osiągnięcia dokonane w dziedzinie sekwencjonowania niosą obiecujące możliwości szybkiego i taniego poznania sekwencji pełnych genomów, a tym samym rozwoju badań nad zróżnicowaniem

organizmów, rozwojem rolnictwa czy też tzw. „medycyny spersonalizowanej”. Niniejsza praca dostarcza informacji o sekwenatorach genomowych oraz wykorzystywanych w nich metodach sekwencjonowania stosowanych do określania sekwencji nukleotydowej pełnych genomów.

Key words: Automated Capillary Array Analyzer, FLX Sequencer, Illumina/Solexa Analyzer, SOLiD Analyzer, Heliscope

Sequencer, SMRT Sequencer, Nanopore DNA Sequencer Słowa kluczowe: sekwenator kapilarny, sekwenator FLX, sekwenator Illumina/Solexa, sekwenator SOLiD, sekwenator

Heliscope, sekwenator SMRT, sekwenator Nanopore

INTRODUCTION Information about the whole genomic DNA

sequence of individuals could provide us with a better understanding of its influence on a phenotype of organisms. This would have a great impact on and application to many areas of our life, such as energy production (selection and/or modification of organisms like bacteria or fungi to produce energy), agriculture

(selection and/or modification of plants, which would boost crop yields) and especially to our health as information about the genome sequence and its variation could provide information on disease risk, diagnosis and proper treatment.

In 1977 two methods of sequencing, proposed by Sanger and Maxam and Gilbert respectively, were

Katarzyna Skonieczna et al.

6

announced and brought the opportunity to determine the DNA sequence [1, 2]. Since then, development in sequencing technology, which allows to improve the sequencing speed, has led to the introduction of new instruments for DNA sequence determination to the market. AUTOMATED CAPILLARY ARRAY ANALYZER

The chain termination sequencing method

developed by Frederick Sanger is based on the DNA chain termination by dideoxyribonucleotide triphosphates (ddNTP’s). The original Sanger method relied on oligonucleotide chain elongation with deoxyribonucleotide triphosphates (dNTP’s) by DNA polymerase, which was terminated by incorporation of 32P labeled ddNTP. Four separate reactions were performed for one DNA template, each containing unlabeled dNTP’s and one of four ddNTP terminators: ddATP, ddCTP, ddGTP, ddTTP. As the DNA polymerase was not able to distinguish between dNTP’s and ddNTP’s, and lack of 3’OH group of ddNTP stopped the elongation of DNA, a mixture of fragments of different size was obtained in a single experiment. The determination of the DNA sequence was then elucidated from denaturing acrylamide gel electrophoresis of the four sequencing reactions running simultaneously on the same gel [1]. The modification of the Sanger method based on the usage of four ddNTP’s labeled with fluorescent dyes of different colors in a single reaction is called dye terminator sequencing. The separation of the DNA fragments of varying lengths and DNA sequence determination could be further provided by slab gel or capillary electrophoresis; however, capillary electrophoresis is much less time-consuming [3]. The first automated 1-capillary array analyzer for capillary electrophoresis was developed by Applied Biosystems and commercialized in 1995. Three years later, in 1998, Applied Biosystems introduced the high-throughput automated 96-capillary sequencer to the market [4]. Since then, the dye terminator sequencing technology with the application of an automated capillary array sequencer has been applied for whole genome sequencing of many species from bacteria [5] to a human [6, 7]. The highest throughput of currently available capillary sequencers can be achieved on ABI 3730xl instrument, capable of sequencing 96 DNA fragments (each with reads longer than 900 bp) in a single run time of 3 hours [4]. Despite the above, the

method is still too time- and cost-consuming for large genome sequencing projects, given the growing need for sequence data from many fields of molecular biology. To put the matter of costs and time in a perspective one should realize that sequencing of the entire human genome with one high-throughput 96-capillary analyzer would take about 60 years and cost over 30 million US dollars [8]. Thus, invention of new sequencing technologies was necessary to speed up the generation of new large sets of sequence data from either genomes or transcriptomes of different organisms. Below we present a few of those new sequencing techniques, some of them currently available and some announced to arrive to the market in the near future.

FLX GENOME SEQUENCER

The method used to elucidate the DNA sequence with the FLX instrument relies on an emulsion polymerase chain reaction (emPCR), which allows the clonal amplification of a 400 bp long DNA fragment and a subsequent pyrosequencing reaction (sequencing by synthesis method) performed in a PicoTiterPlate (PTP) on an FLX instrument [9]. Emulsion PCR is a reaction of DNA amplification in a water-in-oil emulsion. During emPCR a single DNA fragment is linked to the specific adaptor and bound to a single streptavidin-coated bead. Thereafter DNA carrying beads are suspended in a water-in-oil emulsion, so that each bead with a single DNA fragment resides in an individual emulsion droplet, and DNA fragments are amplified in the polymerase chain reaction. As a result of emPCR each bead is coated with millions of copies of a single DNA fragment. Subsequently beads carrying amplified DNA are placed into fiber-optic wells on PTP where one bead resides in one well (which is determined by the size of a well), and a DNA sequence is determined through a pyrosequencing reaction on the FLX sequencer [10]. During pyrosequencing the universal sequencing primer anneals to the DNA fragment and afterward is elongated in repeated cycles of sequential dNTP incubations and washing with apyrase enzyme (which degrades nucleotides) between each dNTP flow. dNTP incorporation to the growing DNA strand (whenever it happens) causes the release of inorganic pyrophosphate, which is measured chemiluminescently by a charge-coupled device (CCD) camera and allows the DNA sequence to be determined [11]. The FLX analyzer was developed by 454 Life Science and

Genome Sequencers - towards personal genomics and medicine

7

Roche Diagnostics and commercialized in 2007. The highest throughput of the FLX instrument could be achieved with Titanium reagents, which allow to generate 1 million reads of up to 400 bp long in a single sequencing run that takes less than 10 hours [9]. The disadvantage of the FLX genome sequencer is low quality of reads of nucleotide homopolymers longer than eight bases [10]. During the last two years the FLX analyzer has made it possible to sequence and re-sequence whole genomes of bacteria, viruses, plants, and humans [12, 13]. High throughput and ability to perform reads from a single molecule, whose length covers the average length of DNA extracted from fossils, allowed the application of FLX instrument for sequence determination of degraded ancient DNA (aDNA). The analysis of aDNA, which could be extracted from hair shafts or bones would have a great impact on evolutionary studies. To date, the FLX analyzer has enabled aDNA sequence of Neanderthal [14], mammoth [15] or Tasmanian Tiger [16] to be determined. The FLX instrument was also applied in the investigation of the methylation status of CpG sites, transcriptome analysis, metagenomics studies or small RNA molecules characterization [9]. ILLUMINA/SOLEXA ANALYZER

Sequencing DNA with the Illumina/Solexa Analyzer is based on sequencing by synthesis method that employs reversible terminators with removable fluorescent dyes. To determine the sequence of DNA, the molecule is fragmented and ligated to adaptors. Subsequently DNA fragments are attached to the optically transparent surface, known as flow cell, via adaptors that bind to the adaptor complementary sequence that resides on a flow cell. During bridge PCR, DNA fragments that are bound by adaptors to the flow cell to create a “bridge” are amplified to obtain approximately 1000 clonal copies of an individual DNA molecule that forms a local cluster on a flow cell. Up to 100 million clusters of different DNA fragments could be obtained on a single flow cell. Sequencing of DNA molecules in the clusters is carried out on the Illumina/Solexa Analyzer with a universal sequencing primer. Throughout the DNA sequencing one of four reversible terminators labeled with different removable fluorescent dyes is incorporated to the growing DNA chain and the laser detection enables the determination of the DNA sequence. Next, the fluorescent dye is removed and the 3’OH group of the incorporated nucleotide is regenerated allowing DNA elongation

with the next reversible terminator [17, 18]. The Illumina/Solexa Genome Sequencer was designed by Illumina, Inc. and introduced to the market in 2006. The analyzer is able to generate at least 1 Gb of sequence composed of 35 bp long reads in a single run that takes approximately 3 days [17]. Application of the Illumina/Solexa Sequencer to whole genome re-sequencing enabled the determination of the DNA profiles of many species, for example, human [18], Caernohabditis elegans [19] or Bacillus subtilis [20]. The Illumina/Solexa sequencer was also applied for transcriptome analysis, metagenomics or characterizing the DNA methylation patterns [17]. SOLiD™ ANALYZER

The SOLiD (Sequencing by Oligonucleotide Ligation and Detection) system, which was designed and commercialized in 2007 by Applied Biosystems, takes advantage of sequencing by ligation technology to determine the sequence of DNA [4]. Preparation of DNA fragments for sequencing with the SOLiD analyzer begins with sequencing library construction through the emPCR process. Thereafter the 3’OH end of DNA fragments is chemically modified so that the molecules bind covalently to the glass surface. The sequencing step of the DNA template on the SOLiD analyzer begins with sequencing primer hybridization and subsequent repeated cycles of ligation of fluorescently labeled di-base probes and color detection [4, 21]. To date, the application of the SOLiD Analyzer to whole genome sequencing has been published only for Escherichia coli [22]; however, Applied Biosystems announced the re-sequencing of the whole human genome with this instrument early this year. The SOLiD instrument was also applied to whole transcriptome analysis of undifferentiated mouse embryonic stem cells, mouse blastomere, colon cancer cell line HT-29 or Bacillus anthracis. The highest throughput of the SOLiD sequencing platform could be achieved with the SOLiD 3 System, which enables the generation of up to 20 Gb data of more than 50 bp long reads in a single sequencing run that takes approximately 7 days [4]. HELISCOPE™ SINGLE MOLECULE SEQUENCER

Sequencing DNA templates with the Heliscope Sequencer relies on True Single Molecule Sequencing (tSMS) technology. The tSMS technology begins with DNA library preparation through DNA shearing and


8

addition of poli(A) tail to generated DNA fragments. Next, DNA fragments hybridized to the poli(T) oligonucleotides are attached to the flow cell and simultaneously sequenced in parallel reactions. The sequencing cycle consists of DNA extension with one out of four fluorescently labeled nucleotides, which is followed by nucleotide detection with the Heliscope sequencer. Subsequent chemical cleavage of fluorophores allows the next cycle of DNA elongation to begin with another fluorescently labeled nucleotide and so enables the determination of the DNA sequence [23]. The Heliscope sequencer was developed by Helicos Biosciences Corporation and is capable of sequencing up to 28 Gb in a single sequencing run that takes about 8 days. The Heliscope sequencer generates short reads with a maximal length of 55 bases [24]. So far the Heliscope sequencer has been applied for genome sequencing of the M13 virus [23]. SMRT™ SEQUENCER

DNA sequencing with the SMRT (Single Molecule Real Time) sequencer relies on single molecule real time sequencing by synthesis method provided on the sequencing chip containing thousands of zero-mode waveguides (ZMWs). The sequencing reaction of a DNA fragment is performed by a single DNA polymerase molecule, which is attached to the bottom of each ZMW, so that each DNA polymerase resides at the detection zone of ZMW. During the sequencing reaction the DNA fragment is elongated by DNA polymerase with dNTP’s that are fluorescently labeled at the terminal phosphate moiety (each nucleotide is labeled with a fluorophore of different color). DNA sequence is determined on the basis of fluorescence nucleotide detection with CCD array, which is performed before nucleotide incorporation, while the labeled dNTP forms a cognate association with the DNA template. The fluorescence pulse is stopped after phosphodiester bond formation, which causes the release of a fluorophore that diffuses out of ZMW. Subsequent labeled nucleotide incorporation and detection allows to determine the DNA sequence [25, 26, 27]. The SMRT sequencer was designed and is still being developed by the Pacific Bioscience company. Although the SMRT instrument is not available on the market, the company claims that the SMRT analyzer (capable of obtaining 100 Gb per hour with reads longer than 1000 in a single run) will be commercialized in 2010 [25].

NANOPORE DNA SEQUENCER

In contrast to all DNA sequencers mentioned above, sequencing a DNA molecule with the Nanopore DNA sequencer is free of nucleotide labeling and detection. DNA sequencing with the Nanopore instrument is based on converting the electrical signal of nucleotides passing through a nanopore into the DNA sequence. The nanopore is an α-hemolysin pore with a covalently attached cyclodextrin molecule – the binding site for nucleotides. During the sequencing process the ionic current that passes through the nanopore is blocked by the nucleotide (previously cleaved by exonuclease from a DNA strand) that interacts with cyclodextrin. The time period of current block is characteristic for each base and enables the DNA sequence to be determined [28, 29, 30]. The Nanopore sequencer is still under development by Oxford Nanopore Technologies [28]. CONCLUSIONS

A wide range of genome sequencers is currently available (3730xl sequencer, FLX sequencer, Illumina/Solexa sequencer, SOLiD sequencer, Heliscope sequencer) or will be soon available (SMRT sequencer) on the market (Tab. I).

Genome sequencers reviewed in this paper allow to generate high quality sequencing data from many thousands or even millions of single sequence reads varying from 35 to more than 1000 bp. All of the genome analyzers are capable of obtaining short reads, whereas long reads are obtainable only with the 3730xl capillary analyzer, FLX genome sequencer or SMRT sequencer. Although short reads are sufficient for whole genome re-sequencing, they might be inadequate for de novo sequencing, due to problems related to sequence assembly in segments of genomic DNA containing sequence repeats.

The current commercially available high-throughput genome sequencers such as the FLX, Illumina or SOLiD platforms allow the whole human genome to be re-sequenced for a fraction of costs required to perform the same task with Sanger technology. The goal is to determine the human genome sequence for no more than 1000 US dollars [30], which would enable individual genomes to be analyzed on a routine basis. To promote the development of human genome sequencing technology the X PRIZE Foundation established the Archont X

Genome Sequencers - towards personal genomics and medicine

9

PRIZE for Genomics in Ocotber 2006. The 10 million US dollar award will be given to the first team that will be able to sequence 100 human genomes in 10 days for no more than 10,000 dollars per genome [31]. None of the currently available sequencers presented above could reach the 1000 dollar genome or the Archont X PRIZE. REFERENCES 1. Sanger F., Nicklen S., Coulson A.R.: DNA sequencing

with chain-terminating inhibiotrs. Proc. Natl. Acad. Sci. USA (1997) 74:5463-5467.

2. Maxam A.M., Gilbert W.: A new method for sequencing DNA. Proc. Natl. Acad. Sci. USA (1997) 74:560-564.

3. Huang X.C., Quesada M.A., Mathies R.A.: DNA Sequencing Using Capillary Array Electrophoresis. Anal. Chem. (1992) 64:2149-2154.

4. http://www.appliedbiosystems.com/ 5. Oh J.D., Kling-Backhed H., Giannakis M. et al.: The

complete genome sequence of a chronic atrophic gastrisis Helicobacter pylori strain: Evolution during disease progression. Proc. Natl. Acad. Sci. USA (2006) 103:9999-10004.

6. Lander E.S., Linton L.M., Birren B. et al.: Initial sequencing and analysis of the human genome. Nature (2001) 409:860-921.

7. Venter J.C., Adams M.D., Myers E.W.: The sequence of the human Genome. Science (2001) 291:1304-1351.

8. Bennett S.T., Barnes C., Cox A. et al.: Toward the 1,000 dollars human genome. Pharmacogenomics (2005) 6:373-382.

9. http://www.454.com/ 10. Margulies M., Egholm M., Altman W.E. et al.: Genome

sequencing in microfabricated high-density picoliter reactors. Nature (2005) 437:376-380.

11. Ronaghi M., Karamohamed S., Pettersson B. et al.: Real-Time DNA Sequencing Using Detection of Pyrophosphate Release. Anal. Biochem. (1996) 242:84-89.

12. Ronaghi M., Shokralla S., Gharizadeh B.: Pyrosequencing for discovery and analysis of DNA sequence variations. Pharmacogenomics (2007) 8:1437-1441.

13. Rounsley S., Marri P.R., Yu Y., et al.: De Novo Next Generation Sequencing of Plant Genomes. Rice (2009) 2:35-43.

14. Green R.E., Malaspinas A.S., Krause J. et al.: A Complete Neandertal Mitochondrial Genome Sequence Determined by High-Throughput Sequencing. Cell (2008) 134:416-426.

Table I. Properties of sequencers Tabela I. Charakterystyka sekwenatorów

GENOME SEQUENCER TYPE

(RODZAJ SEKWENATORA GENOMOWEGO)

SEQUENCING TECHNOLOGY

(TECHNOLOGIA SEKWENCJONOWANIA)

MAXIMAL READ LENGTH

(MAKSYMALNA DŁUGOŚĆ ODCZYTU)

BASES/RUN (ILOŚĆ ZASAD\

EKSPERYMENT)

RUN TIME (CZAS

TRWANIA EKSPERY-MENTU)

COMMERCIALLY AVAILABLE

(DOSTĘPNOŚĆ NA RYNKU)

3730xl Capillary Analyzer

(sekwenator kapilarny 3730xl)

dye terminator sequencing (sekwencjonowanie z

wykorzystaniem znakowanych

„terminatorów”)

> 900 bp 96 Kb 3 hours (3 godziny)

YES (TAK)

FLX Sequencer (sekwenator FLX)

pyrosequencing (pirosekwencjonowanie)

400 bp 400 Mb 10 hours (10 godzin)

YES (TAK)

Illumina/Solexa Analyzer

(sekwenator Illumina/Solexa)

Sequencing-by-synthesis with reversible terminators

(sekwencjonowanie poprzez syntezę z wykorzystaniem

odwracalnych „terminatorów”)

35 bp 1 Gb 3 days (3 dni)

YES (TAK)

SOLiD 3 System (system SOLiD 3)

sequencing-by-ligation (sekwencjonowanie poprzez

ligację)


YES (TAK)

Heliscope Sequencer (sekwenator Heliscope)

single molecule sequencing-by-synthesis

(sekwencjonowanie pojedynczych cząsteczek

poprzez syntezę)


YES (TAK)

SMRT Sequencer (sekwenator SMRT)

single molecule real-time sequencing-by-synthesis

(sekwencjonowanie pojedynczych cząsteczek poprzez syntezę w czasie

rzeczywistym)

> 1000 bp 100 Gb 1 hour (1 godzina)

NO (NIE)

Nanopore Sequencer (sekwenator Nanopore)

Nanopore sequencing (nanosekwencjonowanie*)

No information (brak informacji)

No information (brak informacji)

No information

(brak informacji)

NO (NIE)

* - „nanosekwencjonowanie” to proponowana przez autorów niniejszego artykułu nazwa techniki polegającej na ustalaniu sekwencji DNA na podstawie sygnałów generowanych przez nukleotydy przechodzące przez otwór o średnicy kilku nanometrów


10

15. Gilbert M.T., Drautz D.I., Lesk A.M., et al.: Intraspecific phylogenetic analysis of Siberian woolly mammoths using complete mitochondrial genomes. Proc. Natl. Acad. Sci. USA (2008) 105:8327-8332.

16. Miller W., Drautz D.I., Janecka J.E. et al.: The mitochondrial genome sequence of the Tasmanian tiger (Thylacinus cynocephalus). Genome Res. (2009) 19:213-220.

17. http://www.illumina.com/ 18. Bentley D., Balasubramanian S., Swerdlow H.P., et al.:

Accurate whole human genome sequencing using reversible terminator chemistry. Nature (2008) 456:53-59.

19. Hillier L.W., Marth G.T., Quinlan A.R., et al.: Whole-genome sequencing and variant discovery in C. elegans. Nat. Methods (2008) 5:183-188.

20. Srivatsan A., Han Y., Peng J., Tehranchi A.K., et al.: High-Precision, Whole-Genome Sequencing of Laboratory Strains Facilitates Genetic Studies. PLoS Genet. (2008) 4:e1000139.

21. Ondov B.D., Varadarajan A., Passalacqua K.D., et al.: Efficient mapping of Applied Biosystems SOLiD sequence data to a reference genome for functional genomic application. Bioinformatics (2008) 24:2776-2777.

22. Durfee T., Nelson R., Baldwin S., et al.: The Complete Genome Sequence of Eschrichia coli DH10B: Insights into the Biology of a Laboratory Workhorse. J. Bacteriol. (2008) 190:2597-2606.

23. Harris T.D., Buzby P.R., Babcock H., et al.: Single-Molecule DNA Sequencing of a Viral Genome. Science (2008) 320:106-109.

24. http://www.helicosbio.com/ 25. http://www.pacificbiosciences.com/ 26. Levene M.J., Korlach J., Turner S.W., et al.: Zero-Mode

Waveguides for Single-Molecule Analysis at High Concentrations. Science (2003) 299:682-686.

27. Eid J., Fehr A., Gray J., et al.: Real-Time DNA Sequencing from Single Polymerase Molecules. Science (2009) 323:133-138.

28. http://www.nanoporetech.com/ 29. Astier Y., Braha O., Bayley H.: Toward Single Molecule

DNA Sequencing: Direct Identification of Ribonucleoside and Deoxyribonucleoside 5’-Monophosphates by Using an Engineered Protein Nanopore Equipped with a Molecular Adapter. J. Am. Chem. Soc. (2006) 128: 1705-1710.

30. Rusk N.: Cheap third-generation sequencing. Nat. Methods (2009) 6:244-245.

31. http://www.xprize.org/

Address for correspondence: PhD Marcin Woźniak ul. Skłodowskiej-Curie 9 85-094 Bydgoszcz tel. (052) 585-35-56 e-mail: [email protected] Received: 26.05.2009 Accepted for publication: 21.07.2009


REVIEW / PRACA POGLĄDOWA

Maciej Śniegocki

IMAGE ANALYSIS – MEDICAL AND TECHNICAL PROBLEM

ANALIZA OBRAZU – WSPÓLNY PROBLEM LEKARZA I INŻYNIERA

Department of Neurotraumatology, Nicolaus Copernicus University Collegium Medicum in Bydgoszcz

S u m m a r y

Not only is medicine full of humanism, but also it counts

on many technological modernizations in this field of science. Modern technologies are frequently used in therapy. However, the most important is to present illnesses and monitor therapy. Technical development gives access to many pieces of information, which can be called a media chaos. Technological development has changed the way in which radiologists analyze images. They used to analyze

only one available picture, whereas nowadays they are able to compare as many pictures as were taken. If research on digital analysis is stopped, therapy and diagnostics will not achieve the highest level of advance. The mainstream of researches on digital way of analyzing images is presented in this essay. The most important problem which is taken into consideration in this article is cooperation between doctors and engineers.


Współczesna medycyna, mimo przepajającego ją

humanizmu, opiera się na zdobyczach techniki. Nowoczesne technologie znajdują codzienne zastosowanie w terapii. Najważniejszą wydaje się obrazowanie procesów chorobowych i monitoring terapii. Postęp technologiczny umożliwia dostęp do wielkiej ilości informacji, które stanowią szum informacyjny. Radiolog, który dotychczas w zaciszu gabinetu analizował pojedynczą kliszę fotograficzną, jest obecnie zasypany setkami obrazów w jednym badaniu, ponadto, istnieje możliwość wykonania setek takich badań w ciągu doby.

Zatrzymanie prac nad cyfrową analizą obrazu nie jest możliwe, ponieważ spowoduje automatycznie ograniczenie diagnostyki i terapii chorych z wszystkimi tego następstwami. Praca przedstawia główne kierunki badań i opracowań inżynierów i lekarzy w zakresie cyfrowej analizy obrazu. Szczególnie podkreślona jest rola bliskiej współpracy pomiędzy nimi oraz konieczność wypracowania wspólnego języka zrozumiałego dla obu stron uczestniczą-cych w tym procesie.

Key words: image analysis, CT, MRI, USG, co-operation Słowa kluczowe: analiza obrazu, tomografia komputerowa, rezonans magnetyczny, ultrasonografia, współpraca

Although modern medicine is very humanistic, technical achievements have a great influence on its development. Biotechnical, metallurgical, optical, scientific, chemical and other inventions are often used in diagnostics and therapy. Imaging diseases and monitoring therapy seem to be the most important in medicine. Radiologists frequently use new techniques and technologies which help them to gather a great amount of information which is called information noise. Doctor, who used to analyse simple photo on his own, now is able to carry out analysis of many pictures at the same time. It is possible to make hundreds of such medical examinations during 24 hours. If research

on digital picture analysis stops, diagnostics and therapy will be bound to cease automatically.

Digital radiology has a very serious problem with collecting data because of having no more storage space for modern pictures and photos. A widely used method of changing classical picture into a digital one is the use of a digital camera or a laser scanner (1). Famous program Adobe Photoshop 6.0 makes editing radiological photos easier and more popular. What is more, it also makes them more legible. Editing radiological photos and data is possible with a simple computer with 256 Mb RAM at least. Modern digital cameras have resolution close to 2-3 mega pixels. For

Maciej Śniegocki

12

radiology it is important to use cameras with lens which allow to focus on things which are close to the camera. The transfer of photos from the camera to a computer is done by USB. It is not done automatically, but manually. The effect depends on person’s knowledge and skills.

Digital pictures are available in a few types which are called formats: bits maps (.bmp), a standard type of pictures in the Windows system, GIF (.gif) Graphical Interchange Format, with 256 colors only, JPEG (.jpg) Joint Photographic Experts Group Format mostly used in the Internet, TIFF (.tif) Tagged Image File Format – elastic bits maps, commonly used in printing and publishing.

A Photoshop user has many possibilities to edit picture in an appropriate way to achieve its highest quality. This program allows to rotate picture in any way that is needed, select and delete inappropriate parts of the picture – it is possible to change the shape, size, color, contrast and brightness of the photo. It is also possible to add some comments, footnotes and elements such as arrows or overlapping pictures. Digital camera and graphical programs let people convert traditional radiological photos into digital data with a small cost, which leads to achieving an acceptable standard of the pictures. It is important that any change in an original radiogram must be accepted by the owner of the photo. Converting and manipulating the data may create an opportunity and simultaneously a danger to change pictures or introduce fake data.

25 years ago one of the most important American medical organizations – ACR (American College of Radiology) signed an agreement with NEMA (National Electrical Manufacturers Assosiation). The aim of this agreement was to establish a standard of medical imaging. No one expected how important it would be for the development of digital radiology in the XXIst century (2). Looking back, there are some doubts if DICOM solved all problems connected with digital visualization of medical data. The medical imaging standard, which was created in 1985, guarantees now compatibility between all active departments of radiology, as well as in a whole hospital. The main advantage and the main aim of imaging standard is providing criteria according to which such process must be conducted. Nowadays, when technological changes are so often, the biggest problem is to rate if it is not a disadvantage for digital radiology. There is a race between producers of medical software (PACS/RIS/HIS), whose aim is to offer users as many functions as possible and use the biggest number of possibilities which are available by using medical hardware that is already in hospital (3.4). However, to

make it commonly available on the market, it has to satisfy the requirements given by e.g. DICOM’s standards. Assessment of the problem from a doctor’s and an economist’s point of view is definately positive – independent body takes care of compatibility between devices from different producers, which prevents monopolizing.

We have to face a lot of challenges – the importance of telemedicine and work at distance grows, the amount of medical digital data increases in geometric rate and technology of recording data on mobile media constantly develops . How is DICOM’s standard in such a situation? DICOM is updated every 2 months. However, it may seem not to be up-to-date as the parts 10 or 12 of the “Declaration of compliance with DICOM”, which were written more than 10 years ago, are barely changed, which may be perceived as obvious archaism even by a medic (5,6).

It is not a mystery that with progressive specialization of medical units their requirements are becoming less and less common. To avoid DICOM as an obstacle in their development, it should be incorporated into the Integration Profiles, which were developed by IHE (Intergrating the Healthcare Enterprise). The organization, which does not create any new standards, puts them appropriately in practice.

An example of such a conception is the product Agfa – a specific system of digital radiography dedicated to radiology. This system co-operates with X-ray cameras, which produce radiation with small or big energy and also may prepare digital simulation for small or big dose of radiation.

The new system of computed radiotherapy is a complete solution, which allows to make radiological pictures by digital radiography methods. In contrast to traditional technology, which was based on photographic film, digital photos may be edited, which allows to improve contrast and visibility of details.

The new system of radiotherapy can support a few irradiation stands. It is offered with the CR 25.0 system. The system is a supplement and can even replace electronic stands which are prepared for EPID pictures, because quality of the photos is better than the EPID system. Fields of exposure and resolution of pictures are also bigger. It is possible to co-operate with a common type of picture cassettes, which allows to manipulate photos easily.

Thanks to not using traditional plate and chemical processing in a darkroom any more, the new system of radiotherapy is really economical. Pictures taken by DICOM can be put into an information network, which allows to transmit and share them.

The main point is the fact, that this system was created in connection with specific requirements of

Image analysis - medical and technical problem

13

radiotherapist, which are different than medical requirements. Software system is easy to use and transmission of photos can be done by DICOM. Nearly 60-70% of examinations are based on radiology, which similarly to other sciences wants to use new digital techniques. Radiology changes the way in which pictures are saved from analog to digital. It also benefits from electronic transmission and data saving. Lack of highly qualified radiological staff and the need to increase the effectiveness of work cause using digital techniques. Another factor is the PACS system (Picture Archiving and Communication System). Digital techniques are to improve work in a small hospital departments. If use of digital radiology is encouraged, possible challenges should also be presented. In analog radiology it is hardly possible that all processors break down at the same time, whereas in digital radiology, for example in the DR technique, such a security no longer exists. Systems should be connected with different installations which allow to save and store data at least for 24 hours. In the case when the PACS system fails, functionality gradually decreases as it is in the CT/MR system. At the same time radiologists carry on their work with CT or MR photos on consoles.

Of course, discussion about computed systems which let analyze pictures is a part of academic research until their importance and practical purpose is realised. All medical techniques are to help take therapeutic decisions and decrease possibility of making a mistake. This goal can be achieved by imaging structures a doctor is interested in.

Fig. 1. Brain tumour

Fig. 2. Haemorrhagic zone presented in brain tumour

Fig. 3. The reason of bleeding presented in brain tumour

Figures 1, 2, 3 present brain tumour. Picture analysis is needed. In the Figure 1 the change in brain is not clear enough to assess its topography properly. Use of an appropriate technique allows to locate it exactly. In the Figure 3 the reason of bleending in brain tumour is presented. It is important for operation planning.

Maciej Śniegocki

14

Fig. 4. LS spine injury

Fig. 5. LS spine injury. Assessment of bone union after

operation

Fig. 6. LS spine injury. 3D picture

Figures 4, 5, 6 present spine just after injury and show the possibility to assess effects of treatment. It is achieved by an assessment of bone’s union and 3D visualization of spine’s deformation.

Final diagnosis and treatment not always can be based only on classical radiography. Figure 7 presents compression fracture of thoracic vertebra. It is not possible to say if it is better to operate or not. Figure 8 presents an analysis of radiogram by digital methods, which shows spinal cord compression and makes it easier to decide if it is necessary to operate or not.

Fig. 7. Thoracic vertebra fracture

Image analysis - medical and technical problem

15

Fig. 8. Spinal cord compression. The same as in the Figure 7

Classical radiograms are not able to solve every problem.

Is the bone cement in Figure 9 in the right place or not? The answer cannot be based only on this picture. A method of image analysis should also be used to decide if vertebroplasty was successful.

Fig. 9. Classical radiogram after vertebroplasty procedure

Fig. 10. Patient after vertebroplasty procedure. Example of

use of picture analysis methods

Picture analysis methods are very useful to assess the effect of an operation. They are used to assess if implants which stabilize spine are put correctly.

Fig. 11. Incorrect setting of TPF screw – operation is needed

Fig. 12. TPF screw is put improperly. Operation is needed

Maciej Śniegocki

16

The doctor who helps immediately after accident often has difficulties to assess radiograms quickly, because he/she does not have time to do some more radiological projections. Figure 13 presents cranio-vertebral junction damage not very clearly. Only the use of digital methods lets choose a proper kind of treatment.

Fig. 13. Damage of cranio-vertebral junction after accident

Fig. 14. Fracture of the first cervical vertebrae

All the problems reviewed are difficult for both the doctor who faces them during diagnosis and treatment, and the engineer who is interested in medical techniques. The article shows how important an analysis of pictures is. Nowadays, every medical examination is connected with many pictures, from which any may be the most important to save patient’s life. Only computed method, which allows to analyze many pictures, gives a solution to this problem and lets assess health status and choose appropriate data. If modern digital methods are not used, much of the potential of diagnostic equipment will be wasted, which can result in difficulties with curing and restoring patient’s efficiency.

The main aim of this essay is to encourage medical higher education institutions to co-operate with technical ones. Based on my experience I can tell that a co-operation between a doctor, an engineer and a scientist allows to use equipment efficiently. Doctor expects to find appropriate data to decide about treatment. The main problems with medical techniques which must be solved by scientists are: making sick cells more evident, making healthy tissue which is located improperly more evident, imaging changes in a body after accident, imaging location of implants, including these which cannot be seen in classical radiology.

I hope the co-operation between doctors and scientists is open to such new methods, because their aim is worthy – it is people’s health and life. LITERATURE 1. 1.Chalazonitis AN, Koumarianos D, Tzovara J,

Chronopulos P. Journal of Digital Imaging, 2003, 16, 216-229.

2. 2.http://www.nema.org. 3. PACS users wise to maintain DICOM object integrity,

Erik L., Ridley, 2006. 4. Exploring PACS Secrets -- How to fix DICOM, Michael

J., Cannavo, 2006. 5. The Dicom Standard, Dicom Analyser,,

http://www.dicomanalyser.co.uk/, 2006. 6. Digital Imaging and Communications in Medicine;

NEMA PS 3 2004 ed.; Global Engineering Documents, Englewood CO, 2004.

7. DICOM Basics, Oosterwijk, Herman and Paul T. Gihring; 3nd ed.; OTech, Inc., Aubrey, TX; 2002.

Address for correspondence: Katedra i Klinika Neurochirurgii i Neurotraumatologii UMK w Toruniu Collegium Medicum im. L. Rydygiera ul. M. Curie Skłodowskiej 9 85-090 Bydgoszcz tel.: (52) 585 45 10 fax: (52) 585 40 31 Received: 29.12.2009 Accepted for publication: 8.01.2010


ORIGINAL ARTICLE / PRACA ORYGINALNA Anna Bednarek1, Beata Jędruszak2

HEALTH THREATS IN CHILDREN IN THE SELECTED RURAL ENVIRONMENT

ZAGROŻENIA ZDROWOTNE U DZIECI W WYBRANYM ŚRODOWISKU WIEJSKIM

1Head of the Chair and Department of Paediatric Nursing, Faculty of Nursing, Medical University in Lublin 2 Nurse working in the educational environment in the Łęczna county

S u m m a r y

I n t r o d u c t i o n . The quality of health in the population of the developmental age is shaped from the babyhood under the influence of diverse factors, i.e. intracorporeal and environmental ones as well as the health culture of the family and school. Patterns of health behavior are developed. Biologically negative patterns bring about threats or loss of health of an organism. Health education and health promotion among children and young people are included in essential tasks of nurse in an educational environment.

T h e o b j e c t i v e . Identification of health threats in the selected school community in the rural area.

M a t e r i a l s a n d m e t h o d s . There were analyzed 823 cards of preventive examination of pupils of the primary school in the Łęczna town near Lublin, in the years 2007 and 2008, with regard to health threats . 85.0% of pupils attending the school come from the rural environment. The primary school in Łęczna belongs to the All-Poland Network of Schools Promoting Health.

R e s u l t s . Essential health threats observed in 38.9 % of cases result from different dysfunctions of the osseo-articular system . An often observed illness of the sight organ in the analyzed school community is first of all short-sightedness (35.7%). At the primary school in classes of the Ist-IIIrd grade allergoses are a quite common health threat (6.0%), including bronchial asthma, which constituted 3.4% of the allergy cases. In the IVth-VIth grade classes additional complications are: eating disorders (3.8%), excess weight (4.9 %), short height (8.8 %), chronic illness, i.e. epilepsy - 1.4%, diabetes - 2.3% and mental handicap – 1.0%.

C o n c l u s i o n s . 1. On the basis of an analysis of medical documentation of pupils of the primary school the number and character of health threats were stated. Among the health threats illnesses of the locomotor system , eyesight defects as well as allergoses prevailed. 2. The knowledge about the health situation of pupils allows to define the educational priorities and develop effective programs of prevention of the identified threats.


W s t ę p . Jakość zdrowia w populacji wieku rozwojowego kształtuje się od wczesnego dzieciństwa pod wpływem różnorodnych czynników, tj. wewnątrz-ustrojowych, środowiskowych oraz kultury zdrowotnej rodziny i szkoły. Bionegatywne wzorce zachowań zdrowotnych wywołują zagrożenia bądź utratę zdrowia organizmu. Edukacja zdrowotna oraz promocja zdrowia wśród dzieci i młodzieży należy do istotnych zadań pielęgniarki w środowisku nauczania i wychowania.

C e l p r a c y . Identyfikacja zagrożeń zdrowotnych wybranej społeczności szkolnej dzieci wiejskich.

M a t e r i a ł i m e t o d y . Przeanalizowano 823 karty profilaktycznego badania zdrowia uczniów szkoły podstawowej w miejscowości Łęczna k/Lublina, w roku 2007 i 2008, w zakresie występowania zagrożeń zdrowotnych. Do szkoły uczęszcza 85,0% uczniów ze środowiska wiejskiego. Szkoła Podstawowa w Łęcznej należy do Ogólnopolskiej Sieci Szkół Promujących Zdrowie.

W y n i k i . Istotne zagrożenia zdrowotne, zaobserwowane w 38,9% przypadków, wynikają z różnych dysfunkcji układu kostno-stawowego. Często obserwowane choroby narządu wzroku w analizowanej społeczności szkolnej to przede wszystkim krótkowzroczność (35,7%).

Anna Bednarek, Beata Jędruszak

18

W szkole podstawowej w klasach I-III dość powszechnym zagrożeniem zdrowotnym są choroby alergiczne (6,0%), w tym astma oskrzelowa, która stanowi 3,4% przypadków. W klasach IV-VI dodatkowymi problemami są zaburzenia odżywiania (3,8%), nadwaga (4,9%), niskorosłość (8,8%), choroby przewlekłe, tj. epilepsja – 1,4%, cukrzyca – 2,3% oraz upośledzenie umysłowe – 1,0%.

W n i o s k i . 1. Na podstawie analizy dokumentacji medycznej uczniów szkoły podstawowej zaobserwowano ilości i jakość zagrożeń zdrowotnych, wśród których przeważały problemy związane z chorobami narządu ruchu, wadami wzroku oraz chorobami alergicznymi. 2. Wiedza na temat sytuacji zdrowotnej uczniów umożliwia określenie priorytetów edukacyjnych oraz wypracowanie skutecznych programów w zakresie profilaktyki rozpoznanych zagrożeń.

Key words: health threats, children, rural environment Słowa kluczowe: zagrożenia zdrowotne, dzieci, środowisko wiejskie INTRODUCTION

Conditionings of the health in the population of children and young people are strictly influenced by diverse environmental modifiers. Among them the progressing degradation of the natural and social environment, of the status and socio-economic situation of the family as well as working and learning conditions do not support maintaining optimal attitudes towards the care of one’s own health [1].

Eliminating harmful factors from the environment for the sake of correct functioning and shaping the health culture belongs to significant tasks of the social policy implemented by different public sectors and in the indirect way monitored by educational and promotional actions of health service employees [2].

A lifestyle, i.e. a system of behaviours and health attitudes, is the most important factor conditioning the health of an individual. Biologically negative health behaviours trigger threats or loss of one's health. Effects of the deficiency of pro-health attitudes and occurrence of behaviours risky for the health usually appear after many years. Children and young people do not usually notice the direct connection between their behaviour and health and, in general, are not very susceptible to educational influences [3].

Review of the medical literature concerning the health status of the Polish society, including children and young people, isn't satisfactory. Studies reveal that over half of the Polish society displays wrong health behaviours, and about 90% of Poles do not notice the connection between worsening of their health and lack of care for it [4]. The evaluation of pro-health behaviours and resulting from them health threats is an important component of preventive and emergency actions carried out in the population at the developmental age, which is supposed to encourage children and young people to make deliberate, prudent and healthy choices [5, 6].

The aim of the study was to identify health threats in

the selected school community of countryside children. MATERIAL AND METHOD

There were analyzed 823 cards of preventive

examination of pupils of the primary school in the town Łęczna near Lublin, in 2007 and 2008, with regard to health threats. The health card of a pupil consists of four parts. First of them includes information obtained from parents about the health and social functioning of the child in the family and surroundings. Second part includes data obtained from the class tutor concerning identified school problems of the pupil. The third and fourth part concern the information obtained from the school nurse, being the result of conducted screening tests, and the information obtained from a primary health care doctor, being a general evaluation of health and results of physical examination. The statistical software SPSS 14.0PL with the use of numbers, percentage calculations, chi square test of compliance and chi square test of independence, were used. RESULTS

823 pupils attend the school in the Łęczna town, icluding Ist-IIIrd grade classes - 411 pupils (207 boys and 204 girls) and the IVth – VIth grade classes - 421 pupils (212 boys and 209 girls). The school is located in the centre of the town. The school operates in a two-shift system of work and the school nurse’s room and the dentist's surgery are in the school building. The school is attended by 85.0% of pupils from the rural environment. The primary school in Łęczna belongs to the All-Poland Network of Schools Promoting Health.

Health threats observed in pupils of the Ist-IIIrd grade classes of the primary school (Figure 1) result from different dysfunctions of the osseo-articular

Health threats at children in the chosen country environment

19

system and they predominate in boys (33.4%). Among the dysfunctions pravail flat and lopsided feet - 10.9% of pupils of the Ist-IIIrd grade classes of primary education and abnormal spinal curvatures - 3.9% of pupils, also of the upper grade classes of the primary school. About 2.0% of pupils have flat foot, and 1.5% asymmetry of shoulder blades. Slouch, coming off shoulder blades and round back are found in 1.0% of pupils. Hyperkyphosis do not appear among the examined population of school children.

Fig. 1. Structure of health threats amongst pupils of the lower grade (I-III) classes of primary school

Ryc. 1. Struktura zagrożeń zdrowotnych wśród uczniów klas młodszych (I-III) szkoły podstawowej

Another problem is short height in 12.1% of pupils

and eyesight defects in 11.2% of boys and 9.8% of girls. Often observed illnesses of the sight organ in the analyzed school community are mainly short-sightedness, and in 1.4% long-sightedness. Squint occures in 1.7% of children, but disorders connected with seeing colours and astigmatism in 1.0% of the pupils.

At the primary school in classes of Ist-IIIrd grade allergoses are a common health threat 6.0%), including the bronchial asthma, which constitutes 3.4% of cases in the analyzed group. Over 4.4 % of pupils of the primary education are obese, and 1.5 % are overweight. The next health threat is connected with speech disorders (4.2%), while in 1.2% of pupils hearing defects appear. To sum up, health threats in pupils of the lower grade classes of the primary school are connected first of all with different dysfunctions of the locomotor system, with sight and speech defects, metabolic disorders and physical development, as well as allergoses of the respiratory tract.

In the IVth-VIth grade classes (Figure 2) the structure of health threats looks similar, and additional problems are: eating disorders (3.8 %), excess weight (4.9 %), short height (8.8 %), chronic illnesses, mainly epilepsy - 1.4 % and diabetes - 2.3 % and low-grade mental deficiency – 1.0 %

Fig. 2. Health threats in pupils of upper grade (IV-V) classes Ryc. 2. Zagrożenia zdrowotne uczniów klas starszych (IV-V)

In the group of priority health threats in pupils of the

primary school (Figure 3) there prevail: short-sightedness - 18.4%, short height - 5.6%, obesity - 4.9%, scoliosis - 4.6 %, bronchial asthma - 2.8% and diabetes - 2.3%. Both amongst younger pupils, as well as the upper grade primary school pupils (Figure 4) health threats appeared more often in boys than in girls.

Fig. 3. Priority health threats of pupils of the primary school Ryc. 3. Priorytetowe zagrożenia zdrowotne uczniów szkoły

podstawowej

p < 0.001

Problemy zdrowotne

Heath problems *p<0,05

Skolioza Scoliosis 4,6%*

Krótko- Wzroczność

Short-sightedness

18,4%*

Astma oskrzelowa Bronchial

asthma 2,8%*

Niski wzrost Short height

5,6%*

Otyłość Obesity 4,9%*

Cukrzyca Diabetes 2,3%*

0%

5%

10%

15%

20%

25%

30%

35%

chłopcy boys dziewczę ta girls

Wady narządu ruchu - Deffects in the motor organ Wady narządu wzroku - Defect in the sight organ Choroby alergiczne - AllergosesNiskorosłość - Short height Nadwaga - Excess weightOtyłość - ObesityWady serca - Heart defectsWady mowy - Speech defectsWady słuchu - Hearing defectsEpilepsja - Epilepsy

p < 0,001

0%

10%

20%

30%

40%

50%

60%

chłopcy dziewczętaWady narządu ruchu - Defects in the motor organWady narządu wzroku - Defects in the sight organ Choroby alergiczne - AllergosesNiskorosłość - Short heightNiedobór m. ciała - Deficiency of the body weight Nadwaga - Exscess weightOtyłość - ObesityWady serca - Heart defectsWady mowy - Flows in the speechWady słuchu - Hearing defectsEpilepsja - EpilepsyCukrzyca - DiabetesUpośledzenie umysłowe w stopniu lekkim - Mental Handicap in the slight grade

p < 0,001

Anna Bednarek, Beata Jędruszak

20

Fig. 4. Distribution of health threats depending on the sex of

the study subjects Ryc. 4. Podział zagrożeń zdrowotnych ze względu na płeć

badanych DISCUSSION

School age is a period of rapid development of children, when they develop or deepen health irregularities and when health behaviours and abilities of the children children are shaped [7].

Over years substantial and organizational assumptions as to the health care for pupils at school underwent many changes. At first health of a pupil was associated exclusively with providing appropriate sanitary-hygienic conditions at school. The pupil himself/herself and his/her health problems were treated as secondary issue. In recent years a single pupil has become the priority interest of the school Health Service, along with his health status and development and the quality of his/her family environment. Therefore, monitoring parameters of the biological, psychological and social development, conducted by a nurse in the educational environment, constitutes the essential element of the identification of children’s disorders and undertaking preventive actions, and of health promotion in the population of school children [8].

Since 1999 a new system of health care for pupils at school has caused that the nurse in the educational environment has been working independently in the partner cooperation with a primary health care doctor. Simultaneously the duty of promoting health amongst pupils is also assigned to the teaching staff of the school and children’s parents [9.10].

The present organization of the school system gives the possibility of providing children and young people with comprehensive preventive health care, particularly screening tests, preventive medical check-ups, health

education and psychological and pedagogical care. Participation of educational environment nurses in the preventive care of pupils is becoming more and more significant. This tendency reveals the need to accept by nurses specific professional tasks related to health promotion and health education [1.2].

Data obtained during the analysis of medical documentation of the study pupils allows to define their health status as unsatisfactory. Numerous health threats result from different disorders and dysfunction mainly of the locomotor system and eyesight. Growing adverse ecological influences decide about the growing prevalence of allergoses. Also of the growing number of metabolic disorders manifesting itself in excess weight and obesity is alarming.

Health threats observed at the primary school in Łęczna are consistent with the health problems characteristic for the entire population of school children.

Studies by Wojnarowska [11] and Felińczak et al. [12] also show that about 39.7% of children have different irregularities concerning health, above all dysfunctions of the locomotor system, eyesight defects, metabolic disorders and allergoses. Own studies clearly show that a high percentage of children (82.5%) are categorized to many sorts of “unhealthy” groups due to their various health problems.

Similar data is presented in analyses of other authors. Examinations conducted amongst 15.951 children from educational institutions in Bielsko – Biała show that health problems already occur in nursery schools in 23.3% of children, and at primary schools and lower secondary schools the most common irregularities concern the locomotor system - 41.1%, eyesight defects - 14.7%, somatic development - 7.8% and allergoses of the respiratory system - 5.8% [13]. Unhealthy lifestyle of modern societies is bringing about more and more negative effects on health, of which consequences are particularly harmful to the youth.

An analysis of the health situation at the primary school in Łęczna gives guidelines concerning the scope of duties of the nurse working in an educational environment, which should include both the identification of health problems in individual pupils and help in solving them, as well as the health education and setting oneself an example to follow [14, 15].

0

10

20

30

40

50

60

I-III IV-VI

chłopcy boys

dziewczynkigirls

p < 0,001

Health threats at children in the chosen country environment

21

CONCLUSIONS 1. In the group of children from the primary school in

Łęczna different health threats were found, first of all disorders of the locomotor system, eyesight defects and allergoses, which are consistent with the health problems characteristic for the entire population of children in Poland.

2. Sex of the examined pupils has a diversifying character as health threats occur more often in boys than in girls.

3. The analysis of health threats in pupils of the primary school allows to define the priorities in the education and prevention in the population of school children.

REFERENCES 1. Pawlaczyk B.: Zarys pediatrii. PZWL, Warszawa, 2005 2. Żołnierczuk-Kieliszek D.: Zachowania zdrowotne i ich

związek ze zdrowiem, (w): Zdrowie Publiczne (red.) Kulik T., Latalski M., Czelej, Lublin 2002, 75-93.

3. Ostręga W.: Opieka pielęgniarska nad uczniami w środowisku szkolnym. Magazyn Pielęgniarki i Położnej, 2002, 4, 10-14.

4. Cisińska A., Jałmużna T.: Pielęgniarka i Położna wobec edukacji zdrowotnej, (w): Zdrowie Publiczne, 2003, 3/4, 113-115.

5. Sygit K., Sygit M. i współ.: Znaczenie znajomości zachowań zdrowotnych młodzieży wiejskiej dla poprawy stanu zdrowia, (w): Zdrowie Publiczne, 2003, 1/2, 113-117.

6. Jodkowska M., Ostręga W., Oblacińska A.: Zasady i metodyka nadzoru w profilaktycznej opiece zdrowotnej nad uczniami. IMiDZ, Warszawa, 2003.

7. Oblacińska A. (red.): Standardy i metodyka pracy pielęgniarki i higienistki szkolnej. Warszawa, 2003

8. Siemiński M.: Środowiskowe zagrożenia zdrowia. PWN, Warszawa, 2008.

9. Woynarowska B.: Problemy zdrowotne – epidemiologia, (w): Woynarowska B. (red): Zdrowie i Szkoła, PZWL, Warszawa, 2000.

10. Górniak K.: O potrzebie działań profilaktyczno-korekcyjnych i rehabilitacyjnych w środowisku szkolnym. Ann. UMCS, 2003, 58 (supl. 13): 51-56.

11. Wojnarowska B., Mazur J.: Zachowania zdrowotne młodzieży szkolnej w Polsce: wyniki badań HBSC, 2002. Zdrowie Publiczne, 2004;114 (2): 159-167.

12. Felińczak A., Ziarkiewicz G. i współ.: Analiza porównawcza oceny zachowań zdrowotnych młodzieży w wieku 16-18 lat na podstawie badań własnych oraz przeglądu literatury. Pol. Med. Rodz. 2004; 6 (1): 337-340.

13. Ślusarski J.: Samoświadomość dorastającej młodzieży w zakresie zdrowego stylu życia i sposobu odżywiania się. Zdrowie Publiczne, 2002;112 (supl.1): 188-191.

14. Lipska R.: Zachowania zdrowotne uczniów. Edukacja i dialog, 1994; 3 (56): 13-18.

15. Kołłajtis-Dołowy A., Pietruszka B.: Stosowanie diet alternatywnych w wybranej grupie młodzieży. Ann. UMCS 2003;58 (supl. 13): 51-56.

Address for correspondence: Chair and Department of Paediatric Nursing, Faculty of Nursing Medical University in Lublin tel.: 817185375, 607607115 e-mail: [email protected] Received: 24.11.2009 Accepted for publication: 8.01.2010


ORIGINAL ARTICLE / PRACA ORYGINALNA Marta Cebulak1, Anna Ksykiewicz-Dorota2

STRUCTURE OF UTILIZATION OF NURSING TIME IN PSYCHIATRIC WARDS

– PRELIMINARY STUDIES

STRUKTURA WYKORZYSTANIA CZASU PRACY PIELĘGNIAREK NA ODDZIAŁACH PSYCHIATRYCZNYCH – BADANIA WSTĘPNE

¹ Zakład Pielęgniarstwa Klinicznego i Teorii Pielęgniarstwa, Instytut Ochrony Zdrowia,

Państwowa Wyższa Szkoła Zawodowa w Jarosławiu

² Katedra i Zakład Zarządzania w Pielęgniarstwie, Wydział Pielęgniarstwa i Nauk o Zdrowiu,

Uniwersytet Medyczny w Lublinie

kierownik: dr hab. n. med. prof. nadzw. UM Anna Ksykiewicz-Dorota

S u m m a r y

I n t r o d u c t i o n . The effectiveness of the functioning of a health care unit depends on highly specialist diagnosis and treatment, and on proper staff management. Hence, the selection of adequate methods of staff scheduling is so important, so that their number would be in accordance with the demands of patients for a specified type of service, and simultaneously guarantee the effective use of these methods.

The introduction of changes in the organization of nursing care requires, among other things, an analysis of the utilisation of working time and the structure of activities performed at nurses’ workplaces.

T h e o b j e c t i v e of the study was to determine the utilisation of working time, and the structure of activities performed by charge nurses in general psychiatric wards.

M a t e r i a l s a n d m e t h o d s . The study was conducted in general psychiatric wards at one of the psychiatric hospitals in the Rzeszów region. The research methods were: a continuous observation (day-long observation) and snapshot observation (Tippett’s method). Day-long observation was an introduction for snapshot observation. The presented studies are of preliminary character and will be continued in other psychiatric hospitals of various reference level.

R e s u l t s . For the needs of analysis of the research material obtained, the activities performed by nurses were divided into four basic working time fractions: direct nursing, indirect nursing, coordination and current organization of work in the ward, breaks at work and personal activities.

The study showed that the degree of utilization of working time by nurses in general psychiatric wards is unsatisfactory. Analysis of the research material showed that only 36.70% of the working time was devoted to direct nursing, while the remaining 63.30% were non-nursing activities, including: preparation for performing primary tasks (direct nursing), keeping records, communication within the team, provisioning the ward, breaks and personal activities.

C o n c l u s i o n s . The results obtained allow us to presume that in the general psychiatric wards examined the degree of utilization of nurses’ working time is unsatisfactory, and the structure of activities evokes reservations. While introducing changes into the organization of nursing care attention should be paid to the structure of activities performed by nurses and the performance of all occupational functions, according to the specificity of the ward and patients’ demand for care.

Marta Cebulak, Anna Ksykiewicz-Dorota

24


W s t ę p . Efektywność funkcjonowania zakładu opieki zdrowotnej zależy zarówno od wysoko specjalistycznego diagnozowania i leczenia, jak i od odpowiedniego zarządzania kadrami. Stąd tak istotny jest wybór odpowiednich metod planowania kadr, tak aby ich liczba była zgodna z zapotrzebowaniem chorych na określony typ świadczeń, a jednocześnie gwarantowała efektywne ich wykorzystanie.

Wprowadzenie zmian w organizacji opieki pielęgniarskiej wymaga m.in. analizy wykorzystania czasu pracy oraz struktury czynności wykonywanych na pielęgniarskich stanowiskach pracy.

C e l e m p r a c y było ustalenie wykorzystania czasu pracy oraz struktury czynności wykonywanych przez pielęgniarki odcinkowe oddziałów psychiatrii ogólnej.

M a t e r i a ł i m e t o d y . Badania przeprowadzono na oddziałach psychiatrii ogólnej jednego ze szpitali psychiatrycznych w województwie podkarpackim. Metodami badawczymi były: obserwacja ciągła (fotografia dnia pracy) i obserwacja migawkowa (metoda Tippetta). Obserwacja ciągła była wstępem do obserwacji migawkowej. Badania te mają charakter wstępny i będą kontynuowane w innych szpitalach psychiatrycznych o różnym poziomie referencyjności.

W y n i k i . Dla potrzeb analizy uzyskanego materiału badawczego, czynności wykonywane przez

pielęgniarki pogrupowano w cztery podstawowe frakcje czasu pracy: pielęgnację bezpośrednią, pielęgnację pośrednią, koordynowanie i bieżące organizowanie pracy na oddziale oraz przerwy w pracy i czynności osobiste.

Z przeprowadzonych badań wynika, że stopień wykorzystania czasu pracy pielęgniarek oddziałów psychiatrii ogólnej jest niezadowalający. Analiza materiału badawczego wykazała, że tylko 36, 70% czasu pracy stanowiła pielęgnacja bezpośrednia, pozostałe 63, 30% to czynności pozapielęgnacyjne, w skład których wchodzą: przygotowanie się do wykonania zadań głównych (pielęgnacji bezpośredniej), dokumentowanie, komunikowanie się w zespole, zaopatrzenie oddziału oraz przerwy i czynności osobiste.

W n i o s k i . Uzyskane wyniki pozwalają stwierdzić, że w badanych oddziałach psychiatrii ogólnej stopień wykorzystania czasu pracy pielęgniarek jest niezadowalający, a struktura czynności budzi zastrzeżenia. Przy wprowadzaniu zmian w organizacji opieki pielęgniarskiej należy zwrócić uwagę na strukturę czynności wykonywanych przez pielęgniarki oraz realizację wszystkich funkcji zawodowych, zgodnie ze specyfiką oddziału i zapotrzebowaniem pacjentów na opiekę.

Key words: structure of working time, psychiatric ward, nursing care Słowa kluczowe: struktura czasu pracy, oddział psychiatryczny, opieka pielęgniarska INTRODUCTION

For every organization, including a health care unit, the employees are the most valuable resource, who, by their collective effort, contribute to the realisation of the goals assumed by the organization. Due to workers’ knowledge, skills, motivation and engagement, the organization may offer good quality services. However, salaries constitute the greatest load, i.e. approximately 60-80% of the total costs in each health facility. Therefore, in many countries, studies concerning the evaluation of the effectiveness of care provided by physicians, nurses and midwives are still being undertaken to more effectively utilise employees’ potential in the future, and to improve the quality of services provided [1, 2, 3, 4, 5].

The study of working time is the source of information concerning the existing state of the organization, its efficiency and productivity. This study determines the structure of working time, including wasted work time, its amount, character and causes. It also creates a basis for finding methods for elimination of the wasted time [5].

Without the knowledge of the structure of working

time it is difficult to undertake actions in order to improve its effectiveness and better utilization of the working time of the staff employed.

The study of working time of nurses constitutes a starting point for the introduction of changes in the organization of nursing care, nursing staff scheduling, services cost calculation and economisation of activities of this occupational group.

The objective of the studies was to determine the structure of utilization of the working time of charge nurses in general psychiatric wards. MATERIAL AND METHODS

The studies were conducted within 10 days, in two

general psychiatric wards at one of the psychiatric hospitals in the Rzeszów region, and covered 8-hour morning and afternoon duties. A total number of 1, 040 observations were registered. The studies are of

Structure of utilization of nursing time in psychiatric wards - preliminary studies

25

preliminary character and will be continued in other psychiatric wards of various reference levels.

The structure of working time at workplaces of charge nurses was determined on the basis of two methods: day-long observation and snapshot observation (Tippett’s method). The research tools were standardised charters: individual day-long observation and snapshot observation. Day-long observation, consisting of the detailed registration of all activities performed by an employee in the ward, was an introduction for snapshot observation.

Snapshot observation is the method of sample studies, its assumptions being based on principles of the representative method, probability theory and mathematical statistics, providing a high level of confidence (up to 99.7%). The number of snapshot observations was determined according to the following formula: P(100 – P)

N = 4 ------------------ L ²

where: N – number of observations required; P – value of the smallest fraction determined on the basis of day-long observation; L – mean squared error (absolute error), the value of which in the presented research is ±2 [6, 7, 8]. RESULTS

For the needs of analysis of the research material

obtained, the activities performed by the nurses were divided into four basic fractions, according to the proposal for division of working time presented by Lenartowicz:

Fraction 1: direct nursing, which covers nurses’ activities focused on patients and their families, performed in the presence of patients or their family members, or other significant activities, i.e. activities associated with the maintenance of a patient’s personal hygiene and the hygiene of the nearest surroundings, activities associated with nutrition and excretion, patient’s mobility and body position, diagnosis making and treatment, communication with patients and/or their families;

Fraction II: indirect nursing: i.e. activities performed away from a patient, which are preparatory or closely associated with direct nursing, i.e. keeping records, communication with the staff directly concerning patients, preparation of all activities within the scope of direct nursing;

Fraction III: coordination and current organization of work in the ward. This fraction covers activities connected with the functioning of the ward, providing adequate conditions for hospitalization of patients in the ward, their treatment and nursing, i.e. information within the team (among other things: reports in the ward, handing over the ward between shifts, giving and receiving orders, cleaning and tidying, office work activities not requiring nursing qualifications;

Fraction IV: breaks at work and personal activities, including breaks designed for leisure and physiological needs, and personal activities (non-duty), associated with neither patient care nor organization of work in the ward [9, 10].

The investigations showed that the nurses in general psychiatric wards devoted 36.70% of their time to direct nursing. Non-nursing activities (auxiliary) performed away from patients occupied 63.30% of the nurses’ working time, including: activities connected with indirect nursing, coordination and current organization of work in the ward, breaks and personal activities. Table I presents the percentage of individual fractions within the structure of working time of nurses.

Table I. Percentage of individual fractions in the structure of

nurses’ working time during 8-hour duty (% and minutes)

Tabela I. Udział poszczególnych frakcji w strukturze czasu pracy pielęgniarek podczas ośmiogodzinnego dyżuru (dane w % i w minutach)

Lp. No.

Frakcja czasu pracy Working time fraction

Czas w % Percentage

of time

Czas w minutach Minutes

1. Pielęgnacja bezpośrednia Direct nursing 36.70 176.16

2. Pielęgnacja pośrednia Indirect nursing 28.00 134.40

3.

Koordynowanie i bieżące organizowanie pracy na oddziale Coordination and current organisation of work in the ward

10.65 51.12

4.

Przerwy w pracy i czynności osobiste Breaks and personal activities

24.65 118.32

5. Ogółem Total 100 480

Within direct nursing, the nurses utilised the greatest

amount of time for therapeutic activities – 9.7%, followed by diagnostic activities – 8.6%, communication with patients and their families – 8.4%, activities connected with the maintenance of personal hygiene and hygiene of the surroundings - 5.0%;


26

activities associated with nutrition and excretion – 3.5%, while activities pertaining to patients’ body position and mobility constituted 1.5% of the total working time. The results of the studies indicate that charge nurses on 8-hour duty devoted 176.16 min. on average to direct nursing. Table II presents the detailed percentage contribution of individual sub-fractions within direct nursing in the structure of nurses’ working time (% and minutes). Table II. Percentage of time of individual direct activities in

working time structure during an eight – hour duty (data in % and minutes)

Tabela II. Udział czasu poszczególnych rodzajów czynności z zakresu pielęgnacji bezpośredniej w strukturze czasu pracy pielęgniarek podczas ośmiogodzinnego dyżuru (dane w % i w minutach)

Lp. No.

Grupy czynności z zakresu pielęgnacji bezpośredniej Groups of activities within direct care

Czas w % Percentage

of time

Czas w minutach Minutes

1.

Higiena osobista chorego i najbliższego otoczenia Personal hygiene and hygiene of the nearest surroundings

5.00 24.00

2. Żywienie i wydalanie Nutrition and excretion 3.50 16.80

3. Ruch i pozycja pacjenta Patient’s position and mobility 1.50 7.20

4. Diagnozowanie Making a diagnosis 8.60 41.28

5. Leczenie Treatment 9.70 46.56

6.

Komunikowanie się z pacjentem i (lub) jego rodziną Communication with patients and (or) their families

8.40 40.32

7. Ogółem Total 36.70 176.16

The second basic fraction of working time was the

time of indirect nursing, i.e. activities performed away from a patient, which are of a preparatory character and closely associated with patient care. In the wards examined, the mean value for this fraction was 28.00% of working time. Indirect nursing consisted of three sub-fractions:

a) preparation for activities and procedures within the scope of direct nursing or those ordered by physicians, e.g. preparation of drugs, intravenous drips, dressings, tool kit building, etc., taking 11.7% (56.20 min.) of the working time;

b) keeping records of doctors’ orders, procedures performed, dates of appointments for specialist tests and consultations, writing reports, supplementation of individual nursing records, etc., taking 10.30% (49.40 min.) of the working time;

c) conversation with staff members, directly or on the phone, directly concerning patients, which constituted 6.00% (28.80 min.) of the working time.

The third fraction of working time in the wards examined constituted breaks and personal activities, which occupied 24.65% (118.32 min.) of nurses’ working time.

The time devoted by nurses to coordination and current organization of work in the ward was 10.65% (51.12 min.) of the working time, including the provision of information within the team – 7.08% (33.98 min.), cleaning and tidying – 1.50% (7.2 min.), provisioning the ward – 1.15% (5.52 min.), office activities not requiring nursing qualifications – 0.92% (4.42 min.).

DISCUSSION

The Pareto principle is of great importance in

undertaking actions on behalf of the quality of care. This principle shows both the scope of effectiveness of to-date methods of work, and the directions for improvement of the present state of things. According to the Pareto principle, in ineffective systems 20% of activities performed by employees (key tasks) decide about 80% of the effects, and the opposite, the remainder – 80% of activities (secondary activities) focuses on 20% of the effects [11, 12].

If the relationship between the costs of work and effects is in accordance with the Pareto principle, in order to obtain a better quality of care, efforts should be undertaken to change this ratio [11, 12].

At nursing workplaces the most important activities are those within the scope of direct nursing, and these activities should be the basis in the structure of working time of charge nurses. According to Ksykiewicz-Dorota after Daugherty, the auxiliary time (non-nursing) should constitute from 10-25% of the total time [4].

In the national health system there is a lack of research concerning the ultilisation of working time by nurses in psychiatry. A review of the Polish literature shows that the studies pertaining to the structure of working time of nurses and midwives in national hospitals (apart from psychiatry) were conducted by, among other researchers, Lenartowicz, Ksykiewicz-Dorota et al., and Kowalska. The researchers indicated that the structure of nurses’ and midwives’ working time was not optimal , because the nursing activities resulting from doctor’s orders constituted from 25 to 50% of the working time [10, 13, 14, 15, 16, 17, 18].


27

Studies concerning the utilisation of working time by nurses in psychiatric wards were also carried out in Northern Ireland. The studies confirmed that the nurses devoted less than a half of their working time - 42.7% - to direct nursing, whereas the remaining time – 57.3% - to auxiliary activities (non-nursing). Within the direct activities the nurses devoted 9.39% of their time to the administration of drugs, 7.56% - to individual therapy, including 6.75% to psychotherapeutic interactions with a patient, 5.81% - surveillance of meals, 4.98% - social conversations, 3.62% - group therapy, 3.21% - electric shock therapy, 2.43% - escorting to other wards or other hospitals, 1.36% - activities in treatment rooms (e.g. blood taking, making dressings), 1.97% - non-interactive close observation, 1.84% - activities within the scope of physical care (washing, feeding, toilet), 0.53% - interactive close observation. The nurses in the study devoted a small amount of time (6.75%) to psychotherapeutic interactions. As emphasized by the authors, conversation with a patient occupies a considerable part of psychiatric care, and the amount of time devoted to a patient is an important indicator of quality. For psychiatric nurses in particular , concentration on interaction with patients should be of primary importance. Some nurses involved in the study perceived themselves as not fully competent to undertake psychotherapeutic interactions. The authors highlight that the studies were conducted on a small sample in one environment, and should be repeated on a larger study group. Despite these limitations, they are of an opinion that the research provides guidelines concerning changes in the organization of nursing care, education of nurses and further investigations in this area [19]. The technique of measuring working time used in the studies was day-long observation. This technique is rarely applied to determine the structure of a workday due to low objectivity of the results and a change in the behaviour of the employee who is aware of the presence of the observer (which was indicated by the authors); the technique is also time consuming [7].

Results similar to the above-mentioned were obtained by Furaker who examined the utilisation of the working time of psychiatric nurses in a psychiatric ward at a hospital in Sweden. The results of these studies also show that a relatively small percentage of working time – 41% - is utilised by psychiatric nurses for direct care [20]. The author applied day-long self-observation as the method to evaluate the structure of nurses’ working time. The application of day-long self-observation for the evaluation of working time is methodologically

incorrect, and leads to decreased reliability of the results obtained due to high subjectivity. Day-long self-observation is a good basis for improvement of qualifications and better utilisation of own time at work; however, apart from that, it has no value as a method for the evaluation of the structure of working time, i.e. its standardisation. In order to determine the structure of the utilisation of working time, the following methods of its measurement should be applied: a continuous observation (day-long observation) and snapshot observation (Tippett’s method) [7].

Results of research conducted in the United Kingdom indicated that psychiatric nurses devoted only 21.8% of their working time to direct activities. The author stressed that in many countries psychiatric nurses devote a small amount of time to the activities for which they have been trained [21].

Similar conclusions were formulated by some Australian researchers who investigated nurses’ working time in a psychiatric hospital in Adelaide. The objective of that study was to determine whether there occur differences in time devoted by nurses to direct activities depending on the number of staff, with the same number of patients. Analysis of the research material confirmed that when the number of nurses on duty increased, the amount of time devoted to direct nursing remained relatively constant, whereas the amount of time which the nurses spent on staff-staff interactions increased with the number of staff [22].

In the own studies, the time devoted to direct nursing was 36.7% of the total amount of time. The greatest amount of time within direct activities was devoted by nurses to diagnostic and treatment activities, which constituted approx. 50% of all direct activities. A high percentage of diagnostic activities within nurses’ working time in general psychiatric wards was due to the fact that according to the adopted division of work, apart from diagnostic activities within this sub-fraction, such activities as observation of a patient or participation in doctor’s visit were also classified as diagnostic. In the wards studied, the nurses did not fully perform care and educational tasks, which are the basic nature of professional nursing and are decisive for the essential quality of the work [23]. Sometimes the nurses omitted some activities, or executed them in a superficial way not in accordance with the principles and technique of their performance. This, for instance, concerned therapeutic conversations, psychological support, providing information and education,


28

observation of a patient, toilet of the whole body or oral cavity.

The presented own studies and international reports show that the structure of working time in psychiatric wards is unsatisfactory, and there is a need for improvement.

Analysis of the own research material indicates that efforts should be undertaken to shorten non-nursing time to an indispensable minimum, while prolonging the time devoted to direct nursing, and within direct nursing, for the realisation of all occupational functions, according to the hospital specificity and patient demand for care. It is also worth mentioning that the structure of working time depends not only on nurses or their direct supervisors, but also on the organizational and technical conditions in the ward, provisioning it and method of management by higher level managerial staff.

CONCLUSIONS 1. Based on snapshot observation, it was noted that

direct nursing occupied 36.70% of time, on average, in the structure of nurses’ working time in general psychiatric wards. The remaining working time concerned indirect nursing – 28.00%, breaks and personal activities – 24.65%, and coordination and current organization of work – 10.65%.

2. The nurses in the wards studied devoted the greatest amount of direct nursing time to diagnostic and treatment services, while they did not fully perform care and educational tasks.

3. While introducing organizational changes, attention should be paid to the structure of activities performed by nurses and the realisation of all occupational functions, according to the specificity of the hospital and patient’s demand for care.

REFERENCES 1. Kulczycka K., Ksykiewicz-Dorota A., Saracen A.,

Karauda M., Gradowska S.: Specificity of staff management in the system of health care. Ann. UMCS Sect. D 2005; 60(16): 172-175.

2. Amstrong M.: Managing human resources. Strategy and action. Second Edition. Professional Business School Publishers, Kraków 1998.

3. Dyk D., Wołowicka L.: Scientific studies in nursing from international perspective. Polish Nursing 1999, 8:5-11.

4. Ksykiewicz-Dorota A. Nursing staff scheduling in inpatient treatment. Czelej Publishers, Lublin 2001.

5. Sapuła R., Wdowiak L., Sitko S.J.: Measurement of working time of medical rehabilitation physicians in

Rehabilitation Ward. Ann. UMCS Sect. D 2004;59 supl.14[cz.]6:91-96.

6. Mikołajczyk Z.: Organizational techniques in solving management problems. State Scientific Publishers, Warszawa 1994.

7. Ksykiewicz-Dorota A. (red.): Management in nursing. Czelej Publishers, Lublin 2005.

8. Kulczycka K., Ksykiewicz-Dorota A., Karauda M., Saracen A., Gradowska S.: Metodological problems of evaluation of staff resources in obstetric midwifery. Ann. UMCS Sect. D 2005; 60(16): 167-171.

9. Lenartowicz H.: Measurement of working time in inpatient treatment. Nurse and Midwife. 1985; 0(6):6-8.

10. Lenartowicz H.: Nursing staff in inpatient treatment. (From studies on utilisation of working time and professional qualifications). Medical University, Lublin 1987.

11. Obłój K.: Micro-school of management. State Economic Publishers, Warszawa 1994.

12. Ksykiewicz-Dorota A., Rusecki P. (ed.): Improvement of organization of nursing care in inpatient. Editorial Office ABRYS, Kraków – Lublin 1996.

13. Rogala-Pawelczyk G, Piątek A, Ksykiewicz-Dorota A: Utilisation of working time by nurses. In: Systemic changes in organization of nursing care in military hospitals and military spa hospitals in Cracow Military District [Materials from III Sesssion, II Congress of Polish Nurses]. Ed. A. Ksykiewicz-Dorota. Busko-Zdrój, 24-25.V.1994:48-51.

14. Rogala-Pawelczyk G.: Structure of activities and utilisation of working time by nurses at workplaces. Problems of Nursing 1995;1-2(5):94-99.

15. Ksykiewicz-Dorota A., Wysokiński M., Kurek M.: Standards for nursing staff scheduling in intensive care units and artificail kidney centres. Public Health. 2002;112(1):55-59.

16. Ksykiewicz-Dorota A, Karauda M: Working time schedule of midwives in obstetric-neonatal unit versus the level of mother satisfaction with care. Ann. UMCS Sect. D 2004; 59 (2):371-374.

17. Ksykiewicz-Dorota A, Saracen A.: Structure of working time of midwives in maternity ward organized in rooming-in system. Pol. J. Environ. Stud. 2007;16 (5A): 253-256.

18. Kowalska A.: Utilisation of working itme by environmental nurses in Łódź and the Łódź Region. Theory and practice of organization of health protection. Vol. 1: Primary health care in Poland. Łódź 1990:131-138.

19. Whittington D., McLaughlin C.: Finding time for patients: an exploration of nurses' time allocation in an acute psychiatric setting. J Psychiatr Ment Health Nurs. 2000 Jun;7(3):259-268.

20. Furåker C.: Nurses' everyday activities in hospital care. J Nurs Manag. 2009 Apr 1;17:269-277.

21. Martin T: Psychiatric nurses' use of working time. Nurs Stand. 1992 Jun 3-9;6(37):34-6.

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23. Ciechaniewicz W.: Pielęgniarka. W: Ciechaniewicz In (ed.): Nursing practical training. Vol. 1. Ed. State Medical Publishers, Warszawa 2006:136-183.

Address for correspondence: Marta Cebulak Państwowa Wyższa Szkoła Zawodowa Instytut Ochrony Zdrowia Czarnieckiego 16 37-500 Jarosław Tel./fax 0-16 624-46-03 e-mail: [email protected]

Received: 15.12.2009 Accepted for publication: 8.01.2010


ORIGINAL ARTICLE / PRACA ORYGINALNA Jerzy Eksterowicz, Marek Napierała

MORPHOLOGICAL BUILD OF PHYSICAL EDUCATION STUDENTS

AT THE KAZIMIERZ WIELKI UNIVERSITY IN BYDGOSZCZ

BUDOWA MORFOLOGICZNA STUDENTÓW UNIWERSYTETU KAZIMIERZA WIELKIEGO W BYDGOSZCZY Z KIERUNKU WYCHOWANIA FIZYCZNEGO

Department of Physical Education, Kazimierz Wielki University in Bydgoszcz Head: dr Mariusz Zasada

S u m m a r y

The size of human body undergoes continuous changes. The changes are caused by genetic and environmental conditions. It is observed that variability in development of the population depends on economical situation, place of living (town, countryside), family headcount, education. Acceleration and secular trends in individual and environmental development are perceived. Depending on general conditions of the environment, both positive secular trends and negative trends (i.e. decrease of the size of a human body over successive decades), are noticed. Morphological changes of numerous populations, including those of students from various academic centres are being evaluated.

The aim of this work, based on the examination of the 1st year physical education full-time students (32 males and 18 females) of the Kazimierz Wielki University in Bydgoszcz, was to: • determine specific body proportions (lengths, widths,

circumferences and composition of body mass), • indicate the condition of nutrition (by means of the AMC

index),

• compare this year’s results with the previous year students of the same specialization.

The examination of the specific morphological features was carried out in December 2008, and the presentation of the results was tabular and graphical.

The most numerous group shared the athletic build (women – over 55%, men 50%), less numerous were leptosomatic (ca. 40% of women and 44% of men), whereas pyknics were in the least numerous group. Body mass index (BMI) shows that the majority of the study group is characterized by proper body mass and arm muscle circumference (AMC) proves that students are exceptionally well-nourished.

In spite of considerable scientific output in the field of physical development there is still need for further research of the phenomenon since the matter analyzed in the present work has not been fully examined.


Wielkość ciała ludzkiego na przestrzeni dziejów ulega ciągłym zmianom. Powodem tych zmian są uwarunkowania genetyczne i środowiskowe. Obserwuje się zmiany w rozwoju populacji w zależności od sytuacji ekonomicznej, miejsca zamieszkania (miasto, wieś), liczebności rodziny, wykształcenia itp. Dostrzega się akcelerację i trendy sekularne w rozwoju osobniczym i środowiskowym. W zależności od ogólnych warunków otoczenia, odnotowuje się zarówno pozytywne trendy sekularne, jak i negatywne, które oznaczają zmniejszenie rozmiarów ciała ludzkiego pomiędzy kolejnymi

dekadami. Ocenie zmian morfologicznych podlegają liczne populacje, w tym również studenci z wielu ośrodków akademickich.

Celem niniejszej pracy było określenie wybranych rozmiarów ciała (długościowych, szerokościowych, obwodów, oraz składu i masy ciała) studentów I roku (32 mężczyzn i 18 kobiet) z kierunku wychowania fizycznego studiów stacjonarnych Uniwersytetu Kazimierza Wielkiego w Bydgoszczy. Badania wybranych cech morfologicznych przeprowadzono w grudniu 2008 roku, a wyniki

Jerzy Eksterowicz, Marek Napierała

32

przedstawiono tabelarycznie i graficznie. Rezultaty tegorocznych badań bydgoskich studentów z kierunku wychowania fizycznego przedstawione w niniejszym opracowaniu porównano z wynikami z roku poprzedniego tego samego kierunku.

Najliczniejszą grupę stanowią osobnicy o budowie atletycznej (kobiety ponad 55%, mężczyźni 50%, mniej licznie występują leptosomatycy (ok. 40% kobiet i 44% mężczyzn, a najmniejszą grupę stanowią piknicy (ponad 5%

kobiet i ok. 6% mężczyzn). Wskaźnik BMI pokazuje, że większość badanych charakteryzuje się prawidłową masą ciała, a wskaźnik AMC określa, że studenci wyróżniają się dobrym stanem odżywienia.

Pomimo znacznego dorobku naukowego w dziedzinie poznawania zjawisk dotyczących rozwoju fizycznego, istnieje potrzeba dalszego ich prowadzenia, gdyż omawiana tematyka jest nadal ważna i nie do końca zbadana.

Key words: morphological features, physical education students Słowa kluczowe: budowa morfologiczna, studenci INTRODUCTION

The size of human body undergoes continuous changes. The process of phylogenetic creation of a man has led to today’s form of Homo Sapiens. On the other hand, the ontogenetic changes lead to shaping of individuals adjusted to living in certain conditions, which may influence the species’ procreation ability. The human ontogenesis is a cohesive process which takes into account the genetic and environmental conditions [1]. Undoubtedly changes in the population’s evolution depending on economic situation, place of living (city, countryside), the family headcount, education, etc. are observed for this reason. Acceleration and secular trends in ontogenesis and environmental evolution are noticed [2]. Depending on general surrounding conditions, positive as well as negative secular trends are noted, which signify the decrease of the human body size over successive decades. Knowledge of these processes allows to select such educational and pedagogical methods for the young generation, which are conducive for optimal psycho-physical development of young people.

The aim of this work is to describe the size of human body, including the composition and body mass, of 1st year physical education full-time students (both males and females) of the Kazimierz Wielki University in Bydgoszcz. The results may serve to describe the health condition of the young generation, to make the medical development forecasts, as well as the needs of the science of ergonomics in a broad sense. RESEARCH MATERIAL AND METHODOLOGY

The research was carried out in December 2008. It

covered 50 1st year full-time physical education students (32 men and 18 women) of the Kazimierz Wielki University in Bydgoszcz.

The following anthropometric measurements were taken: body height (cm), body mass (kg), thickness of three dermal-aliphatic folds (mm) held in different body spots, i.e. in the back, below the bottom shoulder blade angle (subscapular skinfold - SCSF) – the horizontal fold; over the triceps muscle of arm (triceps skinfold -TSF) – vertical fold; and over crista iliaca (suprailiac skinfold - SISF) – oblique fold. Furthermore, using the placement of certain anthropometric points, the length measurements of the following body parts were conducted: arm measurement (a-r), forearm (r-sty), upper limb (a-da III), lower limb (tro-B) and foot (pte-ap).

Analogically, the widths of the following body parts were measured: shoulders (a-a), hips (ic-ic), pelvis (is-is), hand (mm-mu), palm (mr-mu) and foot (mtt-mtf).

Selected circumference measurements were taken : chest - while full breathing in and full breathing out, waist, hips, arm - tensed and loosened, as well as thigh and calf. The anthropometric measurements were taken by means of mobile medical scales – model: TANITA BF 662M and the anthropometric tool-kit (anthropometer, compasses, anthropometric tape, slide-compasses, foldometer) produced by a Swiss firm Siber Hegner & Co. Ltd. in accordance with the guidelines presented by Z. Drozdowski [3].

According to the mentioned measurements, values of some somatic indexes were calculated: BMI (Body Mass Index, kg/m2), WHR (Wist to Hip Ratio), AMC (Arm Muscle Circumference, cm), FM (Fat Mass, kg) by means of the Durnin – Womersley algorithm, proportional Fat Mass (%FM), FFM (Fat Free Mass, kg) and proportional Fat Free Mass (%FFM).

Particular BMI values were presupposed for men and women: under 19.0 – body mass deficit, 19.0 – 25.0 - proper body mass, 25.1 – 29.9 - overweight, 30.0+ - obesity [4]. The border value of WHR index, which enables to note obesity is over 0.95 for men and

Morphological build of physical education students at the Kazimierz Wielki University in Bydgoszcz

33

over 0.85 for women, and AMC value of under 22.7 for men and under 20.8 for women indicates malnutrition.

The arm circumference (cm) was taken into consideration, then the arm muscles circumference was calculated in order to describe the AMC aluminous nutrition according to the formula: arm circumference – (3.14 x thickness of the dermal-aliphatic fold over the triceps). In order to explain the results, the following AMC evaluation criteria were taken into consideration: proper nutrition: men – over 22.8 (slight malnutrition 22.7-20.2; moderate malnutrition 20.1-17.7; and heavy malnutrition – below 17.7) and women – over 20.9 (20.8-18.6; 18.5-16.2; and below 16.2 respectively) [3].

The somatic build of students was characterized according to Kretschmer’s typology based on the guidelines applied by Curtis with the use of the Rohrer index. Sex was taken into account in all measurements and calculations. Average values ( X ) and standard deviations (s) were calculated. The results obtained in the present year were compared to those from the previous year, the differences were determined by the t-student test, and the magnitude of the differences was determined by the Mollison index [3].

THE RESEARCH RESULTS

Table I presents numerical characteristics of the

examined morphological features of the students who started studies in the academic year 2008/2009. The results may be used to monitor the differences of particular morphological features between physical education students from successive academic years and may constitute material which will document the values of mentioned parameters.

Using the slenderness characteristics according to Kretschmer’s typology and Curtis’s key, it may be noticed that the most numerous group of students consists of individuals of athletic build (women – over 55%, men 50%). Leptosomatics are less numerous (ca. 40% of women and 44% of men). The pyknics are the least numerous (5% and 6% respectively). The graphical image of slenderness profiles is shown in the Figure 1.

Based on the measurements of body height and mass, BMI was calculated. It may be stated that average body mass values in the examined group are: 23.41 for men, 22.30 for women. Figure 2 shows BMI for all examined students. Around 19% of men and 6% of women are overweight.

Table I. Numerical characteristics of some somatic features of men and women

Men

(N-32) Women (N- 18)

Tested feature x 1

1σ x 22σ

body height (cm) (B – V) 181,0 8,01 170,01 7,02 body mass (kg) 76,7 9,7 64,3 6,36 FM (kg) fat mass ( kg) FM (%) fat mass (%)

12,23 15,73

3,62 3,14

18,3428,38

3,25 2,80

FFM (kg) fat free mass ( kg) FFM (%) fat free mass (%)

64,48 84,27

7,17 3,14

45,9371,62

3,66 2,80

- sum of skin – fat folds (mm) - under lower shoulder blade angle (mm) - over the triceps muscle (mm) - over the iliac bone (mm)

30,3 10,8 9,0 10,5

6,70 2,6 2,0 3,3

34,2 11,1 12,9 10,2

8,0 2,88 3,72 2,70

length measurements (cm): - arm (a-r) - forearm (r-sty) - upper limb (a – da III) - lower limb (tro-B) - foot (pte-ap)

32,51 27,43 79,45 91,88 27,15

2,51 1,86 3,95 3,89 1,51

29,0425,6572,4886,8525,19

1,65 1,78 3,64 6,23 1,30

width measurements (cm): - shoulders (cm) (a-a) - hips (cm) (ic – ic) - pelvis (cm) (is –is) - hand (cm) (mm-mu) - palm (cm) (mr-mu) - foot (cm) (mtt-mtf) t

43,07 30,59 24,23 10,93 8,78 10,14

1,89 2,19 2,29 0,64 0,64 0,67

39,6132,6223,979,59 7,79 9,35

1,56 3,32 2,36 0,35 0,28 0,52

circumference measurements (cm): - chest (aspiration) (cm) - chest (expiration) (cm) - waist (cm) - hips (cm) - arm (tensed) (cm) - arm (relaxed) (cm) - thigh (cm) - calf (cm)

97,31 91,82 78,02 95,53 32,88 29,93 52,93 36,78

91,825,53 5,32 6,15 2,28 2,67 3,77 2,82

91,8187,6671,5797,1128,3526,7654,7036,68

5,22 4,61 3,45 5,43 1,71 1,69 3,04 1,72

BMI body mass index 23,4 1,70 22,3 1,7 AMC Arm Muscle Circumference 27,11 2,42 22,81 1,30 WHR Wist to Hip Ratio 0,82 0,04 0,74 0,03

Fig. 1. Body slenderness of the tested women and men AMC index was used to evaluate nutrition of the

examined group. Average values prove that both women (AMC = 22.81) and men (AMC = 27.11) are remarkably well-noutrished .

The border value of the WHR index (0.95 for men and 0.85 for women) – under which obesity is identified – was not exceeded (by any of the examined individuals), which indicates no obesity (Figure 3).

38,9

55,6

5,5

43,7

50

6,3

0

10

20

30

40

50

60

leptosomatics athletes pyknics

w omen

men


34

Fig. 2. BMI of the tested women and men

Fig. 3. WHR of the tested women and men

DISCUSSION Changing life conditions caused by social and

economic transformations urge investigators to frequently monitor and evaluate the state of physical evolution of the society. In order to observe the changes which occur in the morphological build of students, it is necessary to conduct systematic research, which numerous academic centres perform [5, 6, 7, 8, 9].

The research work done by L. Cymek and partners [5] among students from Słupsk indicated differences in somatic build of female students examined in 1994 and 2000. The year 1994 students were, on average, 1.02 kg heavier, had deeper chests and larger humerus and thighbone epiphysis than the year 2000 students. The examined year 2000 students were, on average, 2.44 cm higher and had higher values of the length features.

The problem of greatness of changes in morphological features occurring during a sports camp was examined by J. Eksterowicz and partners as well as J. Eksterowicz, M. Napierała [10, 11]. They observed significant changes concerning differences in circumference of hips, chest during full breath in and full breath out (1%) as well as in thigh measurements (5%). In the group of examined women, the average body mass, BMI and adipose (not statistically examined) decrease was noticed. Some slight differences in systolic and diastolic pressure

measurements appeared. The differences in pulse rate measurements proved statistically significant – 1%.

Anthropometric parameters of students and physical activity were the issues of the research of J. Szymelfejnik and partners [12]. The results, among other things, proved that moderate physical activity is favourable to keeping a proper body mass.

This year’s results of Bydgoszcz physical education students described in the present study were compared to the last year’s results from the same university specialization. The results constitute a document showing morphological build changes. Despite a considerable academic output in the field of research concerning the physical development, there is a need for continuation of the research, as the presented issue is still important and not entirely investigated .

The results of morphological measurements of men and women made in 2008 were presented in the Table II and Table III and they were compared to the analogical measurements from 2007. The results for both men and women in particular years differ. It shows that in the case of male groups the dermal-aliphatic fold over the triceps was thicker, but the waist size and the WHR index were smaller (statistically relevant differences). In the group of examined women, they had higher average results of FM (kg), FM (%), arm circumference and the AMC index (statistically relevant difference). Average values of the total sum of dermal-aliphatic folds, the thickness of the fold below the inferior angle of the shoulder blade over the crista iliaca, waist circumference as well the WHR index rate decreased (statistically relevant).

The largest differences defined by the Mollison index were stated among male individuals with the FM% of 0.65, waist circumference of 0.60 and the WHR of 0.50, and among female individuals with arm circumference of 1.37, WHR of 1.33 and the thickness over the crista iliaca of 1.30. The graphical image of the differences is shown in the Figure 4.

18,0

19,020,0

21,0

22,0

23,024,0

25,0

26,0

27,028,0

29,0

30,0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55

w omen

men

0,65

0,70

0,75

0,80

0,85

0,90

0,95

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

w omen

men

Morphological build of physical education students at the Kazimierz Wielki University in Bydgoszcz

35

Table II. Comparison of values of morphological measurements in men (years 2007 and 2008)

Men 2007 N=87

Men 2008 N=32

MWTested feature

X S X S

d

u

body height (cm) 180,5 7,79 181,0 8,01 0,5 0,31 0,06 body mass (kg) 76,3 8,43 76,7 9,7 0,4 0,21 0,04FM (kg) fat mass ( kg) FM (%) fat mass (%)

10,6 13,7

2,872,72

12,23 15,73

3,623,14

1,732,03

2,44 3,23

0,480,65

FFM (kg) fat free mass ( kg) 65,7 6,70 64,48 7,17 1,22 0,84 -0,17

sum of skin – fat folds (mm) 27,83 5,34 30,3 6,70 2,47 1,88 0,37

below the inferior angle of the shoulder blade (mm) 10,38

1,91 10,8 2,6 0,42 0,83 0,16

over the triceps (mm) 8,08 2,77 9,0 2,01 0,92 1,98* 0,46over the iliac bone (mm) 9,37 4,08 10,5 3,3 1,13 1,55 0,34arm length measurement (cm) 30,1 3,13 29,93 2,67 0,17 0,29 -0,06 waist measurement (cm) 81,2 5,76 78,02 5,32 3,18 3,88** -0,60hip measurement (cm) 96,0 5,68 95,53 6,15 0,47 0,81 -0,08BMI body mass index 23,41 2,11 23,40 1,70 0,01 0,03 -0,01AMC Arm Muscle Circumference 27,5 3,21 27,11 2,42 0,39 0,71 -0,16WHR Waist to Hip Ratio 0,84 0,04 0,82 0,04 0,02 2,42* -0,50

N – numbers , X – average value, S - standard variation, u - statistical importance of differences * p<0,05;** p<0,01;t α = 0,05 = 1,98; t α = 0,01 = 2,56,

d – difference of statistical averages, MW - Mollison indicator

Table III. Comparison of values of morphological

measurements in women (years 2007 and 2008)

Women 2007/8 N=45

Women 2009 N=18 Tested feature

X S X S

d u MW

body height (cm) 170,0 4,97 170,01 7,02 0,01 0,01 0,001body mass (kg) 63,7 6,66 64,3 6,36 0,6 0,33 0,09 FM (kg) fat mass ( kg) FM (%) fat mass (%)

16,3 25,4

3,443,50

18,34 28,38

3,25 2,80

2,042,98

2,21*3,54**

0,63 1,06

FFM (kg) fat free mass ( kg) 47,4 4,28 45,93 3,66 1,47 1,37 -0,40sum of skin – fat folds (mm) 40,83 5,33 34,2 6,55 6,63 3,82** -1,01below the inferior angle of the shoulder blade (mm)

12,78 3,37 11,1 2,88 1,68 2,54* -0,58

over the triceps (mm) 14,34 4,28 12,9 3,72 1,44 1,33 -0,38over the iliac bone (mm) 13,71 4,49 10,2 2,70 3,51 3,80** -1,3 arm measurement length (cm) 26,0 2,27 28,35 1,71 2,35 4,46** 1,37 waist measurremont (cm) 75,2 6,64 71,57 3,45 3,63 2,83** -1,05hip measurement (cm) 96,3 5,04 97,11 5,43 0,81 0,51 0,15 BMI body mass index 22,0 1,92 22,3 1,7 0,3 0,61 0,18 AMC Arm Muscle Circumferen 21,5 2,04 22,81 1,30 1,31 3,03** 1,00 WHR Wist to Hip Ratio 0,78 0,05 0,74 0,03 0,04 4,31** -1,33

N – numbers , X – average value, S - standard variation , u - statistical importance of differences * p<0,05;** p<0,01;t α = 0,05 = 2,00; t α = 0,01 = 2,66 ,

d – difference of statistical averages MW - Mollison indicator

CONCLUSIONS 1. The most numerous group of students shared the

athletic build, less numerous were leptosomatics, whereas pyknics were in the least numerous group.

2. The average BMI result confirms proper body mass (23.41 for men and 22.3 for women).

3. The AMC index proves that both examined women and examined men are characterized by, on average, good nutrition (average result for men – 27.11, for women – 22.81).

4. No obesity was stated in the examined group according to BMI, which was additionally confirmed by the WHR index (men – 0.82, women – 0.74).

BIBLIOGRAPHY 1. Wolański N., (2006), Rozwój biologiczny człowieka,

Wydawnictwo Naukowe PWN, Warszawa. 2. Łaska – Mierzejewska T., (1999), Antropologia w

sporcie i wychowaniu fizycznym, Wydawnictwo COS, Warszawa.

3. Drozdowski Z., (1998), Antropometria w wychowaniu fizycznym, Wydawnictwo AWF, Poznań.

4. Woynarowska B., (2008), Edukacja zdrowotna, PWN, Warszawa.

5. Cymek L., Rożnowski F., Zaworski B., (2002), Środowiskowe uwarunkowania rozwoju fizycznego studentek Pomorskiej Akademii Pedagogicznej w Słupsku, [w:] Ontogeneza i promocja zdrowia w aspekcie medycyny, antropologii i wychowania fizycznego, (red.) Malinowski A., Tatarczuk J., Asienkiewicz R., Oficyna Wydawnicza Uniwersytetu Zielonogórskiego.

6. Paś A., (2005) Charakterystyka cech somatycznych studentek i studentów kierunków wychowania fizycznego w świetle wybranych wskaźników, [w:] Promocja zdrowia w hierarchii wartości, (red.) Lewicka W., Jasik J., „Annales”, Sectio D, vol. LX, Suppl. XVI,

nr 4, Uniwersytet Marii Curie – Skłodowskiej, Lublin, s 45 – 52.

7. Napierała M. , Cieślicka M., Dmitruk K., (2007), Budowa morfologiczna a zdolności motoryczne studentów I roku wychowania fizycznego Uniwersytetu Kazimierza Wielkiego w Bydgoszczy, „Annales”, (red.) W. Śladkowski, Universitatis Mariae Curie–Skłodowska, Sectio D, Medicina, Lublin, vol. LXII, Suppl. XVIII, nr. 5, s. 226-229.

8. Lewandowski A., (1999), Środowisko a czynniki budowy i sprawność studentów medycyny, [w:] Zdrowie i sprawność

Fig. 4. Differences in the tested values measured by Mollison’s rate


36

motoryczna w kulturze fizycznej dzieci i młodzieży, (red.) M. Zasada, WSP, Bydgoszcz.

9. Asienkiewicz R., (2002), Charakterystyka porównawcza budowy somatycznej studentów i studentek kierunków pedagogicznch na przykładzie rzeszowskiej i zielonogórskiej WSP, [w]: Ontogeneza i promocja zdrowia w aspekcie medycyny, antropologii i wychowania fizycznego, (red.) Malinowski A., Tatarczuk J., Asienkiewicz R., Oficyna Wydawnicza Uniwersytetu Zielonogórskiego, Zielona Góra.

10. Eksterowicz J., Napierała M., Dmitruk K., (2007), Zmiany morfologiczne studentów z kierunku wychowania fizycznego w trakcie letniego obozu sportowego, „Medical and Biological Science”, nr 21/3, s. 49 - 52.

11. Eksterowicz J., Napierała M., (2008), Wpływ obozu letniego na zmiany morfologiczne u studentek Uniwersytetu Kazimierza Wielkiego w Bydgoszczy z kierunku wychowania fizycznego, [w]: Exercitatio corpolis – motus – salus, (red.) M. Bence, Univerzita Mateja Bela, Banska Bystrica, s. 49 – 57.

12. Szymelfejnik J., Jarząbek J., Eksterowicz J., Cichoń R., (2007), Parametry antropometryczne studentów a aktywność fizyczna, Międzynarodowa Konferencja Naukowa pt. Interdyscyplinarny wymiar nauki o zdrowiu, UMK, CM Bydgoszcz, s. 424-431.

Address for correspondence: Jerzy Eksterowicz Uniwersytet Kazimierza Wielkiego w Bydgoszczy Katedra Kultury Fizycznej ul. Sportowa 2 85-091 Bydgoszcz tel.: 601 63 91 81 e-mail: [email protected]



ORIGINAL ARTICLE / PRACA ORYGINALNA Mirosława Felsmann, Elżbieta Kędzierska

PATIENTS SUFFERING FROM ACUTE CORONARY SYNDROMES

AND THE ACCOMPANYING ANXIETY

PACJENCI Z OSTRYMI STANAMI WIEŃCOWYMI A TOWARZYSZĄCY IM LĘK

Department of Pedagogy and Nursing Didactics, Nicolaus Copernicus University Collegium Medicum in Bydgoszcz

Head: Mirosława Felsmann MD, PhD

S u m m a r y

Acute coronary syndromes have taken on the form of a „modern epidemic”. It is believed that by the year 2020 the number of deaths caused by heart disease will have increased by almost 100%. In Poland acute myocardial infarction morbidity reaches 100 thousand people annually. Taking into account the fact that the majority of these individuals are in their productive age, humanity attacked by these diseases bears enormous losses. This situation has prompted scientists to carry out research to determine the cause of the diseases and compile effective ways of prevention and treatment. Many researches have shown that psychological factors have an influence on the emergence, course and treatment of the disease. Attention has also been focused on anxiety as a symptom accompanying myocardial infarction.

The main objective of the presented study and research was to gain information on the occurrence and cause of the increase of anxiety in patients hospitalized due to acute

coronary syndrome. 100 patients treated for acute coronary syndrome in the Cardiology Ward of the Provincial Hospital in Włocławek took part in the research. The research was conducted based on a self-constructed survey and the Polish version of the STAI questionnaire.

Conducting an exact analysis of the obtained results allowed for the conclusion that socio-demographical and health factors significantly influence the level of anxiety experienced by individuals. Results show that the highest level of anxiety occurs in patients with primary education residing in urban areas and in those hospitalized for the first time who have no information about the disease and about the principles of a healthy lifestyle. It is therefore essential to pay particular attention to the proper health wise education, of hospitalized patients suffering from acute coronary syndrome.


Ostre zespoły wieńcowe przybrały w niektórych krajach formę „nowoczesnej epidemii”. Przyjmuje się, że do 2020 roku należy się spodziewać prawie 100% przyrostu zgonów spowodowanych chorobami serca. W Polsce zachorowalność na ostry zawał serca sięga 100 tysięcy osób rocznie. Biorąc pod uwagę fakt, że są to głównie osoby w wieku produkcyjnym, ludzkość nękana tym schorzeniem ponosi ogromne straty. Sytuacja ta skłoniła naukowców do prowadzenia badań w celu ustalenia przyczyny choroby oraz opracowania skutecznego zapobiegania jej i leczenia. Wiele badań wykazało, że wpływ na powstawanie, przebieg i leczenie tej choroby mają czynniki psychologiczne.

Zwrócono również uwagę na lęk jako objaw współwystępuj-jący przy ataku serca.

Głównym celem prezentowanej pracy i przeprowa-dzonych badań było uzyskanie informacji na temat występowania oraz przyczyn nasilenia lęku u chorych hospitalizowanych z powodu ostrych zespołów wieńcowych. Badaniem objęto 100 pacjentów leczonych z powodu ostrego zespołu wieńcowego w Oddziale Kardiologii Szpitala Wojewódzkiego we Włocławku. Badania przeprowadzono opierając się na ankiecie własnej konstrukcji oraz kwestionariuszu STAI.

Mirosława Felsmann, Elżbieta Kędzierska

38

Dokonanie wnikliwej analizy uzyskanych wyników pozwoliło na ustalenie, że czynniki socjo-demograficzne i zdrowotne w istotny sposób wpływają na poziom lęku. Wyniki wskazują, że najwyższy poziom lęku występuje u chorych zamieszkujących na wsi i mających wykształcenie podstawowe oraz u osób hospitalizowanych po raz pierwszy,

nieposiadających informacji na temat choroby i nieznających zasad zdrowego stylu życia. W opiece nad chorymi hospitalizowanymi z powodu ostrych zespołów wieńcowych należy zatem zwrócić szczególną uwagę na prawidłową edukację zdrowotną.

Key words: anxiety, acute coronary syndromes Słowa kluczowe: lęk, ostre stany wieńcowe INTRODUCTION

Throughout the 60’s-80’s of the XXth century a series of clinical tests were conducted in which special attention was paid to the group of socio-demographical factors which provoke circulatory disturbances. Emotions leading to the development of these diseases were the main interest, it was also pointed out that such emotional states as anger, depression and anxiety along with the experience of stress are connected with an unfavourable cardiologic prognosis.

Many cardiologists pay attention to the anxiety accompanying a heart attack and treat this emotional state as one of the elements compiling the acute coronary syndrome and note that it can lead to a series of adverse consequences.

Because disease always constitutes a greater or smaller life threat, occurrence of anxiety is hence an understandable event . Under normal circumstances an individual is able to look at his/her concerns from a perspective and determine actions which will help him/her deal with the causes and the concerns themselves. An ill individual experiences a state of concern which is pervasive and intense, disturbing normal functioning. Thus, the problem of anxiety occurrence in patients with severe heart disease cannot be ignored by any team of doctors taking care of such a patient. The extent of emotional difficulties connected with myocardial infarction is best characterized by Dudley White, who wrote: “It is necessary to recognize that the heart may return to health more quickly than the state of mental depression, which is a frequent complication” [ 1].

Surely there exist a number of factors influencing the occurrence and level of intensification of anxiety in patients hospitalized due to acute coronary syndrome. An analysis of these factors and their influence on the level of anxiety experienced by cardiology patients is also a fundamental objective of the presented study.

MATERIAL AND METHOD The research material used in this study was

gathered among patients being treated for acute coronary syndromes in the Cardiology Ward and Stimulator Implant Centre of the Provincial Hospital in Włocławek. The research was carried out from February to June 2008. The respondents who took part in the study were informed about its point and aim and then confirmed their participation by signature. The approval of the Bioethical Commission was also obtained prior to commencing the research.

The research was conducted on a group of 100 hospitalized respondents suffering from acute coronary syndrome, whose cardiologic and general states allowed for participation.

The group of respondents comprised of individuals aged between 41 and 79. The largest group consisted of 43 individuals aged between 55-69, then 36 individuals aged between 41-54 and 21 individuals aged between 10-79. Male respondents were undoubtedly the leaders- 61individuals whereas only 39 female respondents agreed to take part in the research. Amongst the respondents, 40 individuals stated to have secondary education, 25 vocational education, 21 primary education and 14 higher education. 75 individuals from the group resided in urban areas and 25 in rural areas. The majority of the group (64) were not occupationally active, only 36 were employed. 80 of them had already been hospitalized a number of times, only 20 of them were in a hospital for the first time.

A self-constructed survey and the STAI (X1) (State-Trait Anxiety Inventory) were used to gather material for analysis. The collected research material was subjected to quantitative and qualitative analysis in accordance with the objectives and purpose of the study. The statistical software package STATISTICA 7.1 for Windows StatSoft ® company was used for the statistic analysis.

The State-Trait Anxiety Inventory STAI compiled by C.D. Spielerger, R.L. Gorsuch and R.E Lushene, an

Patients suffering from acute coronary syndromes and the accompanying anxiety

39

adaptation of the American State-Trait Anxiety Inventory (STAI). The adaptations to Polish standards were prepared by C.D. Spielberger, J. Strelau, M. Tysarczyk, K. Wrześniewski.

The construction of the STAI is based on the differentiation between transitional and conditional anxiety known as individual anxiety state and anxiety as a relatively stable personality trait. The raw results of the STAI scale may vary between 20 points- low level of anxiety, to 80 points- high level of anxiety. After obtaining the raw results they were transformed into sten scores for an overall sample of adults, standardized in 2000.

The interpretation of the sten scores is as follows: 0-4 points - low level anxiety, 5-6 points - increased anxiety, 7-10 points - high level anxiety [2]. RESULTS

Testing normal distribution showed that the analyzed parameters are characterised by a distribution differing from normal. Due to that fact nonparametric tests were carried out in order to grade differences between groups: Kruskal-Wallis and Mann-Whitney. The value of p≤0.05 was adopted as statistically significant and was marked as „*”. Variability of the examined parameters was illustrated in the form of descriptive statistics: arithmetic mean (M) and standard deviation (SD).

To verify the hypothesis concerning the impact of socio-demographic factors on the occurrence and level of anxiety in patients hospitalized due to acute coronary syndromes, an analysis of the relationship between demographic variables and the level of anxiety was carried out. Results show that age is not a variable which has an influence on the level of anxiety. A significant variable turned out to be the gender of the examined patients. It appears that women are characterized by a higher level of anxiety than men, therefore further analysis was carried out after a gender subdivision was introduced. Table No. I and its results indicate that education has an influence on the level of anxiety in those patients who took part in the study. The highest level of anxiety was experienced by the individuals with primary education, and the lowest by those with higher education. In both cases the level of significance was 0.01, therefore the studied relationships were statistically significant. In the case of women no significant relationship between education and the level of anxiety was noted. On the

other hand, in the case of men such a relationship proved to exist: the higher the education the lower the level of anxiety, with the level of significance being 0.0024.

Table I. The level of anxiety depending on the level of

education of the respondents

Education N M SD p Primary 1 21 8,71 1,79 Vocational 2 25 8,44 1,87 Secondary 3 40 7,55 2,16 Higher 4 14 6,71 1,86

0,03712-4

0,01081-4

According to the results in the Table II patients

residing in the country react with a higher level of anxiety than those residing in cities. No attention was paid to the differences between men and women living in the same area (rural or urban). The level of significance of the gained results which prove the existence of a higher level of anxiety in individuals living in the countryside is close to p=0.05 showing that the obtained results are statistically significant.

Table II. The level of anxiety in relation to the place of

residence of respondents divided according to gender

Place of residence

city country N M SD N M SD

p

Men 45 7,38 2,14 16 8,13 2,47 0,1357 Women 30 8,20 1,79 9 9,11 0,93 0,2713 Total 75 7,71 2,03 25 8,48 2,08 0,0521

Patients hospitalized for the first time experience a

higher level of anxiety than those hospitalized more frequently. However, the statistically significant difference applies only to women (Table III).

Table III. The level of anxiety in the hospital depending on

the frequency of hospitalization of the respondents divided according to gender

Number of hospitalizations Once More times

N M SD N M SD p

Men 13 7,46 2,26 48 7,60 2,25 0,7984 Women 7 9,71 0,49 32 8,13 1,70 0,0122* Total 20 8,25 2,12 80 7,81 2,05 0,2833

It was hypothetically assumed that the level of

anxiety would be lower in the cases of patients who


40

have some knowledge about their condition. Data from Table IV clearly indicates a statistically significant difference between the level of anxiety in individuals with adequate knowledge about their condition, and those individuals who received no knowledge or for whom the obtained knowledge was not enough.

Table IV. The level of anxiety depending on the respondents

knowledge about the disease, divided according to gender

Knowledge about the disease Yes No

N M SD N M SD

p

Men 50 7,24 2,26 11 9,09 1,30 0,0084*

Women 29 8,17 1,79 10 9,10 0,99 0,2156 Total 79 7,58 2,14 21 9,10 1,14 0,0026*

According to the statistic analysis a lack of

knowledge about the condition increases the level of anxiety in men more than in women. The level of statistical significance was 0.0084 meaning that the obtained results were of importance for the research conducted.

Knowledge of the principles of a healthy lifestyle and proper health behaviour after leaving the hospital influences the level of anxiety experienced by patients with acute heart disease in a significant way. (Table V) Respondents with the choice of four answers: „yes”, „rather yes”, „rather no” and „no” mainly (46 individuals) answered „yes” and they were those patients who had the lowest level of anxiety (M=7.13). Whereas the smallest number of individuals (8) answered “rather no” and it was in those cases that the level of anxiety was the highest (M=9.38). In the remaining sub-groups the level of anxiety was similar and varied between M=8,40 to M=8.42. The obtained results are statistically significant (p=0.029).

The following stage of verification of the hypothesis concerning the correlation between knowledge about a healthy lifestyle and the level of anxiety calculated the results according to all of the respondents and according to gender. Owing to small group size in this analysis, two types were singled out linking the answers „ yes” and „rather yes” as „yes” and „rather no” and „no” as „no”. The interdependence between knowledge about a healthy lifestyle and the level of anxiety in the group of respondents is shown in the Table VI.

Table V. The level of anxiety depending on the respondents’ knowledge of the principles of healthy lifestyle

Lifestyle N M SD p

Yes 1 46 7,13 2,26 Rather yes 2 20 8,40 1,67 Rather no 3 8 9,38 0,74 No 4 26 8,42 1,77

0,02871-3

Table VI. The level of anxiety depending on the respondents’

knowledge of the principles of healthy lifestyle divided according to gender

Lifestyle

Yes No N M SD N M SD

p

Men 45 7,16 2,29 16 8,75 1,61 0,0103*

Women 21 8,29 1,68 18 8,56 1,69 0,6320

Total 66 7,52 2,16 34 8,65 1,63 0,0108*

The analysis of the above calculations shows that

statistically significant results were obtained throughout the whole group of respondents which, in turn, shows that individuals who know about the principles of a healthy lifestyle display a significantly lower level of anxiety (M=7.25) in comparison with those who answered that they did not know the principles of a healthy lifestyle (M=8.65). An analysis carried out in a group of male respondents and in a group of female respondents shows that, in the case of men, a significant relationship between knowledge about a healthy lifestyle after leaving hospital and the level of anxiety exsisted, whereas no such statistically significant differences were found in women.

DISCUSSION

Many contemporary cardiologists treat anxiety as

one of the factors accompanying the symptoms of a heart attack, which bring about an array of negative consequences. Williams and others have carried out a research questionnaire among 36 cardiologists belonging to different American clinics. They were asked about the most common problem which they encounter during the treatment of patients suffering from cardiovascular disease. Anxiety was cited as the fundamental difficulty in working with these patients. Similar results were obtained by Fisher, who sent out surveys to many cardiology centres in different countries. One of the questions asked was aimed at the main psychological problem which doctors have with their cardiology patients. Out of 56 obtained replies


41

from 30 countries anxiety or fear were the most frequently mentioned. Out of 50 heart attack patients examined by Hackett, 40 displayed symptoms of anxiety during their stay in the Cardiac Intensive Care Ward. Similar values were obtained by the same authors in later studies. Out of 24 patients 21 admitted to suffer from anxiety [3].

Within the last thirty years many articles paying attention to the problem of anxiety accompanying cardiology patients have been published in cardiology magazines. Studies on 845 cardiology patients from the Cardiac Intensive Care Ward in the Thorax Centre of the University Hospital in Rotterdam, showed that 80% of them (680 individuals) displayed strong anxiety.

About 1500 residents of London between the age of 40 and 64, along with 2280 residents of Boston and over 51000 American citizens took part in a research program in which a distinct relationship between the high level of anxiety and cardiac deaths was stated [1].

The above results clearly show that it is vital to take into consideration the anxiety experienced by cardiac patients as it plays a destructive role during the period of hospitalization and thereafter.

61 male respondents and 39 female respondents took part in the research program. This does not mean that men are more prone to acute coronary syndromes than women. On the contrary, the latest epidemiological data shows that the number of female cardiac patients is higher. The fact that more men took part in the research may be due to the fact that women more frequently refused to cooperate. It may be important to mention that the choice of respondents was made based on the disease entity, good general health and cardiovascular status and voluntary consent to participate in the study. This places certain restrictions on the interpretation of the results in relation to other people (not covered by the survey), so these results should be cautiously generalized. The short period of hospitalization also caused a complication in the choice of patients. Modern treatment techniques, mainly invasive treatment, reduced the period of hospitalization to 3-4 days.

In the group of respondents the most numerous were patients with secondary education and the least numerous with higher education. When discussing the aspect of the obtained results it is worth mentioning that very different results were obtained in studies conducted in Asia and Europe, which showed that individuals with higher and secondary education suffer from coronary disease more frequently than those with

primary or no education. In contrast, studies conducted in the United States by Rosenman show that individuals with higher education are less likely to suffer from heart attacks. Another American researcher, Shekelle, stated that myocardial infarction is much more common in individuals with primary and secondary education. It is believed that the incidence of ischemic heart disease may be particularly high in individuals with primary education as they are assigned tasks for which they are not prepared. These controversial results highlight the complexity of the research issue and do not allow to draw specific conclusions [4].

Research results show that hospitalization due to acute coronary syndrome is generally accompanied with a higher level of anxiety (M=7.90), with a standard deviation (2.06). While dealing with the same relationship between genders, the results showed that women display a greater increase of anxiety as a currently experienced emotional state than men. This result may be connected with that fact that, in our culture, states of anxiety are less approved in men than in women, and for this reason it may be assumed that the surveyed male respondents did not admit to be experiencing anxiety.

It appeared that age has no impact on the level of anxiety experienced by the group of respondents. However, there is a strong likelihood that the small number of respondents in particular groups of examined patients had an impact on the obtained results. When comparing individuals residing in rural areas and those residing in the urban areas it turned out that rural dwellers react with a higher anxiety level than those residing in the city. Perhaps this is associated with lower awareness of health issues of the rural population which is connected with worse access to programs of health promotion and prevention of cardiovascular disease. It is possible to assume that education also has an influence in this matter because, as an earlier analysis of these results has shown, individuals with lower education react with a higher level of anxiety than those with higher education and it is commonly known that most of the rural residents have primary or vocational education. Following this logic, it is possible to refer to studies by Antonina Ostrowska concerning the influence of the mechanisms of social determinants on health behavior, which show that individuals living in larger cities pay more attention to their health and life style [5].


42

A Comparison of the level of anxiety in patients hospitalized repeatedly and patients who are in the hospital for the first time shows that patients hospitalized for the first time, especially women, experience higher levels of anxiety than patients repeatedly hospitalized. When considering this issue based on the theoretical grounds of the matter it can be assumed that, for patients who experience their first contact with hospital, it is a new situation which requires an additional adaptation effort. Individuals who are in hospital for the first time frequently suffer from insomnia, increased tension and anxiety and are often surprised and terrified. Anxiety and depression are natural reactions of patients who have experienced an attack, especially when it is their first experience of a life-threatening situation that requires assistance from others. This situation is especially difficult for individuals who valued their independence and relied on themselves [6].

It seems therefore important to take into account, both the theoretical aspects and the results obtained when dealing with patients who have been hospitalized for the first time.

Special attention should be paid to the results which indicate that individuals who suffer from acute coronary disease and possess information about their illness have a statistically significant lower level of anxiety. Research results indicating that lack of information increases the level of anxiety more in male patients than in female patients, were also of significance for this study. Many authors dealing with psychological problems of post heart attack patients draw attention to how big an impact on the process of recovery well-provided information about the disease has. According to Braunwald emphasis should be placed on the patients’ awareness of their illness while still in hospital. According to the author, the patient should be informed about the nature of ischemic heart disease and how to behave after leaving hospital [7].

The results obtained during the study show that awareness of life style and proper health behavior in a statistically significant way lowers the level of anxiety, especially in male patients. Educating patients in order to motivate them to introduce changes to their current system of values and life style not only leads to the reduction of fear and anxiety, but also facilitates the patients’ self-treatment after leaving hospital [8].

Both the presented study and the studies of many other authors were carried out not only for theoretical reasons but also for practical ones. Acute coronary

syndromes are in fact one of the most common causes of hospital admissions in the industrialized countries, but also in Poland constitute a serious health problem. Despite the long tradition of research into the psychological factors which are significant in ischemic heart disease, still thousands of patients are deprived of professional help in dealing with life after having a heart attack. Multi-dimensional actions, which would increase the effectiveness of treatment and help in the process of recovery and the broadly understood psychosocial rehabilitation of acute coronary syndrome patients, are of vital importance. CONCLUSIONS

Summarizing the results of the study and the considerations on the treatment of anxiety as an emotional state that occurs among patients with acute coronary conditions, the following conclusions can be formulated:

1. Anxiety is one of the basic emotional responses leading to a number of adverse consequences that occur in patients with acute coronary syndrome.

2. Patients hospitalized because of acute cardiac conditions experience raised levels of anxiety. The results show that women experience a greater increase of fear than men.

3. Results concerning the relationship between socio-demographic factors and the level of anxiety showed that education and place of residence have a significant impact on the level of anxiety, but there was no such relationship with regard to age and occupational activity.

4. Statistically significant data regarding the impact of health on the level of anxiety was obtained. Results showed that patients who were hospitalized for the first time, did not receive information about the disease and did not know the rules of a healthy lifestyle are characterized by the highest level of anxiety. From the perspective of research it is important that the correlation between health factors and increased anxiety is at a much greater statistically significant level among men than among women.

5. In the care of patients treated due to acute heart disease particular attention should be


43

paid to proper health education, which should contain information about the disease and the principles of a healthy lifestyle. These factors significantly affect the level of anxiety as an emotional state.

REFERENCES 1. Opolski G., Filipiak K.J., Poloński L. (red.): Acute

Coronary Syndromes. Urban & Partner, Wrocław 2003. 2. Wrześniewski K., Santorski J.: State-Trait Anxiety

Inventory. Polish adaptation of STAI, Polish Psychological Society, Warsaw 1987.

3. Wrześniewski K.: The psychological problems of patients with myocardial infarction. PZWL, Warsaw 1986.

4. Dzikowski W.: How to take care of your heart. Polish Cultural Foundation, London 1991.

5. Majchrowska A.: Selected elements of sociology. Manual for students, Publisher - Czelej, Lublin 2003.

6. Maties P.: Heart Attack Patient’s Guide,Doctor’s Publisher PZWL, Warsaw, 2005.

7. Braunwald E., Goldman L.: Cardiology, Medical Publisher Urban & Partner, Wrocław 2003.

8. Widomska-Czekajska T. (red.): Outpatient Cardiologic Care. PZWL, Warsaw 1994.

Praca finansowana z grantu UMK 31/2008

Address for correspondence: Department of Pedagogy and Nursing Didactics Nicolaus Copernicus University Collegium Medicum in Bydgoszcz Mirosława Felsmann 85- 801 Bydgoszcz ul Techników 3 [email protected]



ORIGINAL ARTICLE / PRACA ORYGINALNA Mariusz Klimczyk

SPORT PROFILES OF 13-YEAR-OLD POLE VAULT JUMPERS

PROFILE SPORTOWE 13 LETNICH SKOCZKÓW O TYCZCE

Faculty of Physical Education, Kazimierz Wielki University in Bydgoszcz Head: dr Mariusz Zasada

S u m m a r y

I n t r o d u c t i o n . Based upon longtime observations backed by studies and research, it can be concluded that achieving the best results in top-level sport competitions is feasible when accompanied by a high level of motor capabilities of sportsmen and a skill to utilize them appropriately in competitions.

An ongoing improvement in a longstanding training process of, among others, pole vault jumpers, is related to the use of a wide array of training means and methods assignable to the proper development of individual motor capabilities.

A well-defined profile of motor preparation of individual sportsmen provides a basis for planning, control and processing of training schedules.

In order to develop an optimal training plan, the realization of which will contribute to intended progress in a sport result, it is essential to establish a specific sport profile for individual sportsmen who may vary in terms of their level.

M a t e r i a l s a n d m e t h o d s . The study was conducted from the year 2002 to 2008 on the group of 27 boys aged 13, who underwent a basic training in a pole vault jump in the “Zawisza” Bydgoszcz and “Gwardia” Piła sports clubs. They trained 3 times a week in their clubs. A training unit equals 60-90 minutes. At school, the boys attended 3 hours of physical education classes weekly, and the main objective of the PE classes was shaping general physical fitness. For the purposes of the present study, the following research methods and tools were utilized: testing physical fitness, recording sport results, methods of statistical analysis.

R e s u l t s . In the first part of the study, an analysis of physical development of 13-year-old pole vault jumpers was conducted. It was observed that the coefficient of variation fluctuated significantly, i.e. from 3.6 (lower limb length,

where the mean value was 85.17 cm, the minimum 79.1 cm, and the maximum 93 cm at standard deviation of 3.06) up to 19.47 (chest expansion at mean, minimum, maximum values and standard deviation of 6.83 cm, 4.50 cm, 11.00 cm and 1.33 cm respectively).

The analysis of the body weight to body height ratio showed that the value of this parameter for the competitor with the best result in a pole vault jump (295cm /P.K./) was 1.05, whereas for the athlete whose score was the worst of all (190 cm /M.P./), it was 0,93. The mean value of this parameter for the jumpers under the study was 1.04.

The analysis of physical fitness of 13-year-old pole vault jumpers proved a significant variability of variation coefficient in individual control tests, ranging from 386 in the second stage of a running test (between 5 and 10 metres of the stage; a 15-metre run with a pole with the plant; a 20-metre run-up) where the mean value was 0.8s, the minimum 0.75s, the maximum 0.88s, standard deviation was 0.03 up to 66.63 s in pull-ups to a fixed bar (quantity), with the mean value of 6.07, the minimal value of 1 pull-up, whereas the maximum was 16 pull-ups, the standard deviation being 4.05.

In the present study there was developed an example profile of sport preparation of those competitors who achieved the best and the worst result in a pole vault jump (P.K. and M.P. respectively) with respect to the group mean value (in this case these were 27 thirteen-year-old jumpers) in individual control tests.

When comparing the results of the best athlete (P.K.) with the mean value, it becomes emergent that this particular sportsman outperformed the group in the majority of tests. It should be noted that this competitor achieved his best result in a number of pull-ups to a fixed bar (16 times), and came third in a 15-metre running test with a pole. In turn, the results of M.P. were in all cases below the mean group value,

Mariusz Klimczyk

46

and his worst result was in a 15-metre running test with a pole and in feet lifting to a fixed bar (2.48 s and 2 times respectively). These results were the worst in the study group.

S u m m a r y . The analysis of physical development demonstrated considerable fluctuation in the coefficient of variation. The differences between competitors were ranging from 3.6 (lower limb length) up to 19.47 (chest expansion). The analysis of physical fitness confirmed even greater differences between the athletes in a 15-metre running test with a pole with the plant and a 20-metre run-up, where the results ranged from 3.86 (the second stage, i.e. the distance between the fifth and tenth metre), up to 66.63 in pull-ups to a fixed bar (quantity).

Developing an individual sport profile for each competitor will make it possible to demonstrate their current sport capabilities. It also gives an opportunity to make corrections in training plans with particular attention paid to the “weakest points” of athletes’ sport preparation. What is remarkable in the present study, is the reason why a sportsman achieving the best result in a pole vault jump in four control tests obtained lower scores than the mean value of the group was.

Thus, an individual sport profile will make it possible, assuring systematic control and appropriate corrections in training plans, to manage sport development of competitors properly and to bring their pole vault jump results to the highest sport result attainable to them.


W s t ę p . Na podstawie prowadzonych przez wiele lat obserwacji, popartych badaniami i doświadczeniami szkoleniowymi, stwierdzić można, że osiąganie najlepszych wyników sportowych na zawodach najwyższej rangi jest możliwe przy wysokim poziomie rozwoju zdolności motorycznych sportowców i umiejętności ich wykorzystania w okoliczności zawodów sportowych.

Nieustanne doskonalenie wieloletniego procesu treningowego, między innymi skoczków o tyczce, jest związane z wykorzystaniem szeregu środków i metod treningowych przynależnych również właściwemu rozwojowi poszczególnych zdolności motorycznych.

Podstawą planowania, kontroli oraz przetworzenia planów szkolenia jest określony profil przygotowania motorycznego poszczególnych sportowców.

W celu stworzenia optymalnego planu treningowego, by jego realizacja przyczyniła się do zamierzonej progresji wyniku sportowego, należy dla poszczególnych ćwiczących reprezentujących określony poziom sportowy wytyczyć konkretny profil sportowy.

M a t e r i a ł i m e t o d y . Badania prowadzono w latach 2002-2008. Objęto nimi 27 chłopców w wieku 13 lat uprawiających skok o tyczce w klubie sportowym „Zawisza” Bydgoszcz i „Gwardia” Piła, na etapie szkolenia podstawowego. Ćwiczący 3 razy w tygodniu uczęszczali na zajęcia treningowe w klubie. Jednostka treningowa wynosi 60-90 min. W szkole realizowali program wychowania fizycznego w wymiarze 3 lub godzin lekcyjnych tygodniowo, z akcentem na kształtowanie ogólnej sprawności fizycznej. W pracy posłużono się następującymi metodami i narzę-dziami badań: ocena rozwoju fizycznego: testowanie sprawności fizycznej, rejestracja wyników sportowych, metody statystycznego opracowania.

W y n i k i b a d a ń . W pierwszej części badań przeprowadzona została analiza rozwoju fizycznego 13-letnich tyczkarzy, gdzie zauważyć można znaczne wahania współczynnika zmienności od 3,6, (długość kończyny dolnej, gdzie wartość średnia wyniosła 85,17 cm, minimalna 79,1 cm, a maksymalna 93 cm przy odchyleniu standardowym 3,06) do 19,47 (rozmach klatki piersiowej przy wartości średniej, minimalnej, maksymalnej i odchyleniu

standardowym wynoszącym odpowiednio 6,83 cm, 4,50 cm, 11,00 cm i 1,33).

Przeprowadzona analiza stosunku masy ciała do jego wysokości wykazała, że wartość tego wskaźnika u zawodnika posiadającego najlepszy wynik w skoku o tyczce (295 cm /P.K./) wyniosła 1,05, a u sportowca z najsłabszym rezultatem (190cm /M.P./) 0,93. Średnia wartość tego wskaźnika u badanych sportowców to 1,04

Analiza poziomu sprawności fizycznej, której zostali poddani 13 letni zawodnicy uprawiający skok o tyczce dowiodła bardzo duże zróżnicowanie współczynnika zmienności w poszczególnych próbach kontrolnych od 3,86 w próbie na drugim odcinku pomiędzy 5-10 m (biegu na 15 m z tyczką z założeniem z 20 m nabiegu), gdzie wartość średnia wyniosła 0,8 s, minimalna 0,75 s, maksymalna 0,88s, a odchylenie standardowe 0,03 do 66,63 w podciąganiu na drążku (ilość), przy średniej wynoszącej 6,07, wartości minimalnej wynoszącej 1 podciągnięcie na drążku, natomiast maksymalnie jeden z zawodników podciągnął się na drążku 16 razy, odchylenie standardowe w tej próbie wyniosło 4,05.

W pracy opracowano przykładowy profil sportowego przygotowania zawodników, którzy uzyskali najlepszy i najsłabszy wynik w skoku o tyczce (odpowiednio P.K.; M.P.) do średniej grupy (w tym przypadku 27 trzynastoletnich tyczkarzy) w poszczególnych próbach kontrolnych.

Analiza wyników badań, jeśli porównamy efekty zawodnika, który uzyskał najlepszy rezultat w skoku o tyczce (P.K.), ze średnią wykazała, że sportowiec ten w zdecy-dowanej większości prób przewyższał osiągniętymi przez siebie wynikami średnią grupy. Przy czym, indywidualnie najlepszy wynik uzyskał w próbie polegającej na jak największej liczbie podciągnięć na drążku (16 razy), trzeci w próbie biegowej na 15 m z tyczką. Z kolei wyniki wszystkich prób M.P. plasują się poniżej średniej, gdzie wyraźnie najsłabszy wynik sportowiec ten uzyskał w biegu na 15 m z tyczką i w próbie unoszenia stóp do drążka (odpowiednio: 2,48 s i 2 razy) (są to najgorsze rezultaty w badanej grupie).

P o d s u m o w a n i e . Analiza rozwoju fizycznego wykazała znaczne wahanie współczynnika zmienności.

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Różnice międzyosobnicze mieszczą się w granicy pomiędzy 3,6 (długości kończyny dolnej) do 19,47 (rozmach klatki piersiowej). Natomiast analiza poziomu sprawności fizycznej dowiodła istnienia jeszcze większych różnic międzyosob-niczych od 3,86 w próbie na drugim odcinku pomiędzy 5 m-10 m (biegu na 15 m z tyczką, z założeniem z 20 m nabiegu), do 66,63 w podciąganiu na drążku (liczba).

Opracowanie indywidualnego profilu sportowego dla poszczególnych ćwiczących umożliwia wykazanie ich aktualnych możliwości sportowego przygotowania, daje sposobność naniesienia korekt w planach treningowych, ze zwróceniem szczególnej uwagi na „słabsze strony”

przygotowania sportowego zawodników. W przypadku omawianym w pracy ciekawe jest to, dlaczego sportowiec osiągający najlepszy wynik sportowy w skoku o tyczce uzyskuje w czterech próbach kontrolnych wyniki słabsze od średniej grupy.

Takie opracowanie indywidualnego profilu sportowego umożliwi, przy systematycznej kontroli i odpowiednich korektach w planach treningowych, właściwie kierowanie rozwojem sportowym zawodników i doprowadzenie ich wyniku w skoku o tyczce do najwyższego możliwego do uzyskania przez nich sportowego poziomu.

Key words: somatic build, pole vault, training Słowa kluczowe: rozwój fizyczny, sprawność fizyczna, indywidualny profil sportowy INTRODUCTION

Based upon longtime observations backed with studies and research, it can be concluded that achieving the best results in top-level sport competitions is feasible when accompanied by a high level of motor capabilities of sportsmen and a skill to utilize them appropriately in competitions (1, 2 and others).

Extremely high records established in pole vault have motivated coaches to seek reserves in a training process. Moreover, the process of training planning should be dependent on the most advanced technologies, exercise machines and simulators available that foster the optimization of training tasks and their effects from early stages of a training (2, 3,4).

An ongoing improvement in a longstanding training process of, among others, pole vault jumpers, is related with the use of a wide array of training means and methods assignable to a proper development of individual motor capabilities (5, 6, 7, 8, 9 and 10).

The basis for the planning, control and processing of training plans is a well-defined profile of motor preparation of individual sportsmen (2).

In order to establish an optimal training plan, the realization of which will contribute to the progress in a sport result, it is essential to draw up a specific sport profile for individual sportsmen who may vary in terms of their level (2, 8, and 11).

The objective of the study was to develop

individual profiles of sport preparation of 13-year-old pole vault jumpers.

RESEARCH MATERIAL

The study was conducted from the year 2002 to 2008 in the group of 27 boys aged 13, who underwent a basic training in a pole vault jump in the “Zawisza” Bydgoszcz and “Gwardia” Piła sports clubs. They trained 3 times a week in their clubs. A training unit equals 60-90 minutes. At school, the boys attended 3 hours of Physical Education classes, where the main objective was shaping general physical fitness. RESEARCH METHODS

In the present study the following research methods and tools were utilized:

• assessing physical development, • testing physical fitness, • recording sport results, • methods of statistical analysis.

THE ASSESSMENT OF PHYSICAL DEVELOPMENT

In order to assess physical development, the measurements of such somatic traits as length, width, circumference and weight were taken.

1) body height (basis-vertex), 2) body weight, 3) torso length (suprasternale-symphysiom), 4) lower limb length (basis-symphysion), 5) upper limb length (acromion-daktylion III), 6) shoulder width (acromion-acromion), 7) pelvis width (iliocristale-iriocristale), 8) thigh circumference, 9) lower limb circumference,

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10) shoulder circumference, 11) chest circumference at inhalation, 12) chest circumference at exhalation, 13) chest expansion (volume difference in chest at

inhalation and exhalation) The Rohrer’s index of somatic build was calculated

based on the ratio of body weight to body height. body weight (g) x 100 ------------------------------- body height (cm) 3

The measurements were taken using a large sliding caliper, medical scales and metric tape. CONTROL OF PHYSICAL FITNESS

In order to develop fitness tests that would comprehensively evaluate jumpers’ physical fitness at the training stage under the study, a comparison with other disciplines was utilized. Namely, a jumper can be compared to a sprinter (at a run-up stage), a long jump athlete or a triple jumper (the ”step” phase), an athlete doing a forward roll to a handstand (in one of the phases of a jump), and finally to an acrobat (performing complex evolutions while jumping over a bar) (12, 13). The International Fitness Test developed by the International Committee on the Standardization of Physical Fitness Tests was also used.

The following parameters were recorded: 1. A 15-metre run with a 20-metre run-up 2. A 15-metre run with a 20-metre run-up with a

pole 3. A 15-metre run with a pole

with a 20-metre run-up the last 15 metres split into three 5-metre stages (with light sensors located at each stage); the time was recorded for each stage separately and for all of them

4. A standing long jump: the jumper stands at a line and then takes off and lands using both feet.

5. A long jump with a 35-metre run-up: 20 meters of approach run, the last 15 meters of maintaining rhythm and entering the jump.

6. An approach run to a long jump.

7. Feet lifting to a fixed bar with arms straight. 8. Rope climbing (3-meter long rope). 9. Pull-ups using a fixed bar. 10. Pole vault (cm).

The athletes were given precise instructions prior to the above tests. A 15-minute warm-up preceding the test was conducted by a coach. METHODS OF STATISTICAL ANALYSIS

The study results were processed statistically by

calculating arithmetic averages, standard deviation, minimum and maximum value of a set, and the differentiation within the group was evaluated on the basis of the coefficient of variation (V). STUDY RESULTS AND DISCUSSION

The first stage of the present research was devoted

to the analysis of physical development of 13-year-old pole vault jumpers, where significant fluctuations in the coefficient of variation were noted, i.e. from 3.6 (lower limb length, where the mean value was 85.17 cm, minimum 79.1 cm, and maximum 93 cm at standard deviation of 3.06) up to 19.47 (mean, minimum, maximum value of chest expansion and standard deviation were 6.83cm, 4.50 cm, 11.00 cm and 1.33 respectively) (See Table I). The remaining parameters under the study are shown in the Table I.

Table I. Results of physical development tests of 13-year-old pole vault jumpers (n-27)

Parameters Statistic values

It. under the studyM min max SD V

1 body height (cm) 159.87 149 178 6.22 3.89

2 body weight (kg) 42.32 32.1 71 7.16 16.91

3 shoulder girdlewidth (cm) 35.59 29.4 40.3 2.56 7.2

4 pelvic girdlewidth (cm) 23.97 21.5 28.5 1.53 6.4

5 lower limblength (cm) 85.17 79.1 93 3.06 3.6

6 upper limblength (cm) 70.34 65.3 79.1 3.37 4.79

7 thighcircumference (cm) 43.64 36.5 52.5 2.96 6.77

8 lower legcircumference (cm) 31.42 25 41.2 3.14 9.99

9 shoulder circumference (cm) 22.1 17.5 28.5 1.87 8.46

10 chest circumferenceat inhalation (cm) 79.54 70.5 94 4.56 5.74

11 chest circumferenceat exhalation (cm) 72.7 65 88 4.18 5.75

12 chest expansion (cm) 6.83 4.5 11 1.33 19.47

13 torsolength (cm) 44.71 40 47.6 2.11 4.71

Sport profiles of 13-year-old pole vault jumpers

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The analysis of the body weight to the body height ratio revealed that the value of this parameter for the athlete who achieved the best results in a pole vault jump (295cm /P.K./) was 1.05, whereas for the weakest athlete (190cm /M.P./) it was 0.93. The mean value of this parameter in the subjects was 1.04 (Table II).

Table II. Index of body build per Rohrer of 13-year-old pole

vault jumpers (n-27) and of the best and the worst pole vault jump result (P.K., M.P)

The analysis of physical development level, to

which 13-year-old pole vault jumpers were subjected, indicated considerable fluctuation in the coefficient of variation in individual control tests from 3.86 in the test of a second stage between the fifth and tenth metre (a 15-metre run with a pole with the plant and a 20-metre run-up), where the mean value was 0.8 s, minimum 0.75 s, maximum 0.88s, and standard deviation was 0.03, up to 66.63 in pull-ups to a fixed bar (quantity), with the mean value of 6.07, the minimum value being 1 pull up, whereas the maximum value for one competitor was 16 pull-ups, and the standard deviation in this test was 4.05 (Table III).

The main objective of the study was to develop an individual profile of sport preparation of 13-year-old pole vault jumpers. In order to accomplish that, the results of control tests conducted for individual athletes were contrasted with the mean result of the group. An example profile of sport preparation for the best and worst sportsman (P.K.; M.P. respectively) was developed in the present paper and contrasted with the group mean value (including 27 thirteen-year-old jumpers) in respective control tests.

Fig. 1. The profile of an individual sport preparation of 13-year-old jumpers who scored the best and the worst result in a pole vault jump: P.K. – 295cm and M.P. – 190cm

When comparing the results of

a competitor with the best result in a jump (P.K.) with the mean value, it is apparent that this particular sportsman outperformed the group mean value. It should be noted that this competitor achieved his best result in pull-ups to a fixed bar (16 times), and came third in a 15-metre running test with a pole. It is curious that this athlete’s result was the fourth below the group mean result (See Figure 1). Whereas , the results of M.P. were in all cases below the mean value, and the worst result was obtained in a 15-metre running test with a pole and in feet lifting to a fixed bar (2.48 s and 2 times respectively). These results were the worst in the study group.

Subject Rohrer pole vaultindex jump result (cm)

P.K 1.05 295M.P. 0.93 190

M (mean) (n-27) 1.04 233.89

Table III. Level of physical fitness of 13-year-old jumpers (n-27)

Parameters statistic valuesIt. under

analysis M min max SD V1 15-metre run

with a 20-metre run-up (s) 2.13 1.94 2.3 0.1 4.522 15-metre run with a pole

with a 20-metre run-up (s) 2.28 1.98 2.48 0.12 5.333 15-metre run with a pole

with the plant and 20m run-up(s) 2.43 2.25 2.67 0.1 4.194 0 - 5m(s)

0.79 0.72 0.85 0.03 3.995 5m - 10m (s)

0.8 0.75 0.88 0.03 3.866 10m - 15m(s)

0.84 0.76 0.94 0.04 5.357 standing long jump

(cm) 216.74 195 265 15.8 7.298 long jump

(cm) 447.07 394 555 31.34 7.019 run-up to a long jump (s)

2.21 1.98 2.42 0.1 4.6710 feet lifting to a bar

(qty) 6 2 12 2.39 39.7611 rope climbing (s)

3-metre rope 12.34 6.51 17.2 2.88 23.3212 pull-ups to a fixed bar

(qty) 6.07 1 16 4.05 66.6313 pole vault jump result (cm)

233.89 190 295 24.86 10.63

x

1 2 3 4 5 6 7 8 9 10 11 12 13

1. 15-metre run with a 20-metre run-up(s), 2. 15-metre run with a pole with a 20-metre run-up (s), 3. 15-metre run with a pole and the plant and 20-metre run-up (s),4. 0 - 5m (s),5. 5m - 10m (s),6. 10m - 15m (s),7. standing long jump (cm),8. long jump (cm),9. run-up to a long jump (s),

10. feet lifting to a fixed bar (qty),11. 3-metre rope climbing (s),12. pull-ups to a fixed bar (qty)13. pole vault jump result (cm).

P.K.: 295cm; ( ): M.P.; 190cm ( )

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SUMMARY The analysis of physical development revealed

considerable fluctuation of the coefficient of variation. The differences between the subjects were all between 3.6 (lower limb length) up to 19.47 (chest expansion). Moreover, the analysis of the level of physical development proved even greater differences ranging from 3.86 in the second stage between the fifth and tenth metre (a 15-metre run with the plant and 20-metre run-up), up to 66.63 in pull-ups to a fixed bar (quantity).

Establishing an individual sport profile for each competitor will make it possible to demonstrate their current sport capabilities. It also gives an opportunity to introduce corrections into training plans with particular attention paid to the “weakest points” of competitors’ sport preparation. What is remarkable in the study in question, is the reason why the athlete achieving the best result in a pole vault jump in four control tests obtained lower scores than the mean value for the group. The coach’s role in this case is to direct the preparation process so that this athlete improves the result significantly (especially in a run with a pole with the plant, where it is crucial to hold the pole at the right angle to the ground, to master the running technique and dropping the pole tip into the box /the latter phase poses serious difficulties especially to beginner jumpers/).

The development of an individual sport profile will make it possible, providing systematic control and corrections in training plans are maintained, to direct the sport development of athletes properly and to bring their pole vault result to the highest level attainable to them. REFERENCES 1. Kochanowicz K.: Kompleksowa kontrola w gimnastyce

sportowej. AWF, Gdańsk 1998. 2. Kochanowicz K.: Podstawy kierowania procesem

szkolenia sportowego w gimnastyce. AWFiS, Gdańsk 2006.

3. Napierała M., Cieślicka M., Muszkieta R., Szark M., Klimczyk M., Żukow W., Swimming endurance of 10 – 13-year old children determined by the Cooper test in water, [w]: Current challenges of tourism and recreation to the health. Physiotherapeutic aspects in the prevention and treatment of diseases in marine tourism, (red.) Kwaśnik Z., Żukow W., Muszkieta R., Napierała M., Radom College in Radom, Radom 2009, s. 58 - 69.

4. Sozanski H. (red.): Podstawy teorii Treningu sportowego. AWF, Warszawa 1999.

5. Prusik K.: Podstawy indywidualizacji treningu sportowego biegaczy na orientację. AWFiS, Gdańsk 2003.

6. Harre D. (1985): Trainingslehre. Sportverlag. Berlin 1985, s. 279.

7. Naglak Z.: Metodyka trenowania sportowca. AWF Wrocław 1991.

8. Płatonow W. N.: Obszczaja tieorija podgotowki sportsmienow w olimpijskom sportie. Olimpijskaja Literatura, Kijew 1997.

9. Shephard R.J., Astrond P.O.: Endurance in sport. Blackwell Scientific Publikations 1992.

10. Zasada M.: Przygotowanie fizyczne specjalne gimnastyków w procesie treningu sportowego. Wydawnictwo Uniwersytetu Kazimierza Wielkiego, Bydgoszcz 2008.

11. Kruczalak E.: Biegi krótkie. W: Lekkoatletyka, biegi pod red. Z. Mroczyńskiego. AWF, Gdańsk 1997, s. 52-54.

12. Klimczyk M.: Kierowanie i kontrola szkolenia sporto-wego tyczkarzy na etapach wstępnym i podstawowym. Wydawnictwo Uniwersytetu Kazimierza Wielkiego, Bydgoszcz 2008.

13. Zaglaniczny J.: Technika i metodyka nauczania skoku o tyczce. W: Lekkoatletyka, skoki, rzuty, wieloboje pod red. Z. Mroczyńskiego. AWF, Gdańsk 1995, s. 667-691.

Address for correspondence: Faculty of Physical Education Kazimierz Wielki University in Bydgoszcz kierownik: dr Mariusz Zasada ul. Sportowa 2 85-091 Bydgoszcz tel,/fax. 663089733 (052} 37 67 910 e-mail: [email protected]



ORIGINAL ARTICLE / PRACA ORYGINALNA Monika Wiłkość1,2, Beata Augustyńska1, Aleksander Araszkiewicz1, Kinga Sobieralska-Michalak3,

Anna Dudzic-Koc1, Piotr Bijakowski1

COGNITIVE FUNCTIONS IN ALCOHOL DEPENDENT PATIENTS.

A DESCRIPTION OF A NEW COGNITIVE BATTERY – QMT (Quick Mind Testing)

FUNKCJE POZNAWCZE U PACJENTÓW UZALEŻNIONYCH OD ALKOHOLU. OPIS NOWEJ BATERII TESTÓW POZNAWCZYCH – QMT (Quick Mind Testing)

1Psychiatry Department, Nicolaus Copernicus University Collegium Medicum in Bydgoszcz

2Department of Individual Differences Psychology, Institute of Psychology, Kazimierz Wielki University in Bydgoszcz

3Department of Clinical Psychology, University of Nicolaus Copernicus in Toruń Collegium Medicum in Bydgoszcz

S u m m a r y

Numerous studies have investigated the effects of alcohol consumption on cognitive processes. It was suggested that

continued substance involvement in adolescence leads to greater neurocognitive difficulties, nevertheless cognitive deficits may also be a risk factor for the development of drug and alcohol dependence. Chronic use of alcohol has been consistently associated with cognitive impairments including attention mechanisms, information processing, visual - spatial perception, working memory, problem solving and decision making. In order to address cognitive domains which are reported to be vulnerable to the alcohol abuse we constructed the computerized cognitive battery QMT – Quick Mind Testing. The battery consists of six tests. The study included 16 male patients hospitalized at the Psychiatric

Clinic of the University Hospital No 1 in Bydgoszcz with an alcohol dependency diagnosis and 16 healthy males. Conclusions: 1. The alcohol dependent patients performed worse in the following parameters of QMT: mean reaction time for incorrect reactions (Test 2), mean reaction time for correct target reactions (Test 4), reaction time in subliminal priming task (Test 5) and number of correct responses in part 2 and 3 of Test 3. 2. It may be concluded that reaction time is the most vulnerable cognitive parameter in alcohol dependent patients. 3. The QMT is a quick, precise and effective computerized method to measure reaction time, attention and subliminal processing. 4. Our study was preliminary. The results obtained should be confirmed in a larger cohort.


Liczne badania wykazały wpływ nadużywania alkoholu na funkcje poznawcze. Wskazuje się, iż długotrwałe spożywanie alkoholu w okresie adolescencji prowadzi do deficytów kognitywnych, jednocześnie deficyty poznawcze mogą być czynnikiem ryzyka wystąpienia uzależnień od substancji psychaktywnych. Chroniczne nadużywanie alkoholu związane jest z wystąpieniem zaburzeń funkcji poznawczych, tj.: funkcji uwagi, przetwarzania informacji, percepcji wzrokowo-przestrzennej, pamięci operacyjnej, rozwiązywania problemów oraz podejmowania decyzji. Komputerowa bateria testów poznawczych QMT – Quick

Mind Testing jest propozycją narzędzia, które umożliwia diagnozę tych obszarów poznawczych, które wskazano jako szczególnie podatne na wystąpienie zaburzeń u osób uzależnionych od alkoholu. Bateria składa się z sześciu testów. Badanie przeprowadzone zostało u 16 mężczyzn hospitalizowanych w Katedrze i Klinice Psychiatrii UMK, w Szpitalu Uniwersyteckim nr 1 w Bydgoszczy z rozpoznaniem uzależnienia od alkoholu oraz u 16 zdrowych mężczyzn z grupy kontrolnej. Osoby uzależnione od alkoholu uzyskały gorsze wyniki w zakresie: średniego czasu reakcji dla odpowiedzi niepoprawnych (Test2), średniego czasu reakcji

Monika Wiłkość et al.

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dla poprawnych reakcji targetowych (Test 4), czasu reakcji w prymowaniu podprogowym (Test 5) oraz liczby odpowiedzi poprawnych w części 2 i 3 Testu 3 w porównaniu z grupą kontrolną. Uzyskane wyniki sugerują, iż czas reakcji jest najbardziej podatnym na zaburzenia parametrem kognitywnym u pacjentów uzależnionych od

alkoholu. Bateria QMT wydaje się szybkim, precyzyjnym i efektywnym narzędziem do komputerowego pomiaru czasu reakcji, uwagi i podprogowego przetwarzania informacji. Badanie to miało charakter wstępny, a wyniki powinny zostać potwierdzone na wiekszej grupie badawczej.

Key words: cognitive functions, alcohol dependence Słowa kluczowe: funkcje poznawcze, uzależnienie od alkoholu

Numerous studies have investigated the effects of alcohol consumption on cognitive processes. A

longitudinal study by Tapert and Brown (1) suggested that continued substance involvement in adolescence leads to greater neurocognitive difficulties, nevertheless cognitive deficits may also be a risk factor for the development of drug and alcohol dependence. Chronic use of alcohol has been consistently associated

with cognitive impairments including attention mechanisms, information processing, visual - spatial perception, working memory, problem solving and decision making (2, 3, 4).

It was demonstrated that simple reaction time (RT) and complex RT are also impaired in alcohol dependent patients, leading to slowing of one's response to simple stimuli (5, 6). Researches on the effect of alcohol on simple RT have concluded that even a low dose of alcohol can impair performance (7, 8, 9). In the study on attention mechanism Maylor et al. (10), using a visual-tracking task, found that speed of detection was impaired by alcohol. A measurement of total information processing by reaction time, vigilance and attention tasks showed greater impairment in dual-task conditions compared to single-task conditions. Generally, results suggest that, when demands are higher, such as in dual - task conditions, the deficits in performance due to alcohol become more significant. Such results have been described as the deleterious effects of alcohol on central processing capacity over time (10, 11). Bartl et al. (12) found three times more errors in a concentration task, two times more errors in RT tasks and two times more in a visual structuring task due to alcohol, compared to performance in a placebo (no alcohol) condition. Similarly, Maylor et al. (10) found that errors increased with task complexity in RT tasks. The results of Zinn et al. (13) have showed the greatest impairment in timed motor tasks with visual perception elements and memory demands. On the other hand it was suggested that information processing could be impaired at the same time when motor functions are facilitated, hence, false alarms and errors occur as premature reactions (6). Individuals

with alcohol dependency are characterized by both attention bias and prepotent response inhibition deficit. Noel et al. (3) assumed that presenting alcohol-related information to be suppressed in a go/no-go task to the participants addicted to alcohol, would exhibit greater cognitive disinhibition. In order to verify the hypothesis, author examined a group of forty recently detoxified individuals and healthy controls. The task required a motor response to the targets and no response to distractors. The results showed that the group of alcohol dependents made significantly more commission errors (reaction go when a distractor displayed) and more omission errors (inhibited reaction no go when a target displayed) compared to controls.

The results of many researches confirm that information does not have to be consciously perceived to initiate motor reaction according to the intention of the participant. The results also indicate that motor reaction can be initiated before the stimulus, which to be responded, becomes part of the conscious perception (14, 15, 16).

Subliminal priming is a technique that allows testing of the influence of subliminal information on our behavior. This technique is based on presenting the prime before the stimulus to be responded (target). Prime can be a word, picture or sound and is presented for a very short period of time (few miliseconds). Prime can influence the reaction to the target by facilitating it or inhibiting.

Neumann and Klotz (16) were the first to show that subliminal information can not only influence perception but also affect motor reaction. Usually, when prime points to the same direction as target (compatible trails), responses to the target are faster and reaction times shorter and more accurate. However when prime and target point to different directions (incompatible trials) reaction times are longer (17, 18, 19, 20, 21, 22, 23). In this case a positive (straight) priming effect can be observed.

Eimer and Schalghecken obtained an interesting result (24, 25, 26, 27, 28, 29, 30). They found that in case of compatible trials reaction times to target can be

Cognitive functions in alcohol dependent patients. A description of a new cognitive battery - QMT (Quick Mind Testing)

53

longer comparing to incompatible trials. This effect is called negative or reversed.

Subliminal priming is a sensitive method which allows to detect even small differences in processing visual information and can be a useful tool for testing cognitive processes. An interesting question should be asked: are there any differences in strength and direction of priming effect between healthy people and alcohol dependent patients? If alcohol dependent patients suffer from cognitive deficits, which, as a result, may lead to problems in recognizing the structure of the stimulus, positive priming effect should be observed. Healthy controls should have a negative priming effect independently of time intervals between prime and target.

In order to check if different priming effects are linked with difficulties in recognizing the structure of stimulus, the additional experiment of stimulus degradation was performed. It should be assumed that alcohol dependent patients need more time to complete the test comparing to healthy controls, however, the accuracy of responses should be high. METHODS

In order to address cognitive domains which are reported to be vulnerable to the alcohol abuse we constructed the computerized cognitive battery QMT – Quick Mind Testing. The battery consists of six tests.

Test 1. This test assesses simple reaction time. The stimuli are visual (green star). A total of 25 stimuli are presented to the participant who is asked to respond as quickly as possible by pressing a spacebar after each stimulus. The reaction time and number of correct responses are measured.

Test 2. This test is based on go/no-go paradigm. It assesses sustained attention and response control. The participant is asked to respond by pressing a spacebar while given certain stimuli (“go„ response) and inhibit that response under a different set of stimuli (‘no-go” response). The frequency of “go” stimuli relative to “no-go” stimuli is 80%, which maintains a bias and tendency to respond on every trial. The total number of stimuli is 100 of which 75 are main targets and 25 distractors. All the stimuli are visual (4 stimuli for “go” responses and 2 for “no-go” responses). The presentation of a stimulus lasts 350 ms, or until participant responds. Practice trials are given and the participant is trained in the correct performance of the test before formal testing is initiated. The measures

include the number of correct and incorrect responses, as well as reaction times for all “go” and “no-go” responses.

Test 3. This test measures the selective attention and process of visual perception. The participants are required to cross out target stimuli embedded among distractors. The participant touches the target stimuli directly on the touch screen, when the touch is available. Otherwise the participants use the left mouse button to select the target stimuli. Altogether 300 stimuli are randomly displayed on the screen - 75 of them are targets and 225 are distractors. Test consists of 3 parts. In each part different stimuli are presented: numbers, letters and blue arrows, respectively. Each part has a total time of 1 minute to complete the task. After finishing one part, test advances to the next part until all the parts are completed. The number of correct and incorrect responses is measured.

Test 4. This test measures sustained attention, cognitive inhibition and discrimination abilities. It is based on continuous performance paradigm. Eighty stimuli are presented to a participant. Twenty percent of the stimuli are targets. Stimuli are presented for 200 ms each. The participant is instructed to respond with a right key press whenever the target stimulus is proceeded by a particular distractor stimulus. The left key is pressed for all other stimuli, including the particular distractor stimulus, the target stimulus that was not preceded by the particular distractor stimulus, or any other stimulus. Practice trials are given and the participant is trained in the correct performance of the test before formal testing is initiated. The number of correct and incorrect responses and reaction times are measured.

Test 5. This test measures the process of subliminal priming. Double arrows pointing to the left or to the right were used both as primes and targets. Mask consisted of 20 randomly generated lines. A new random mask was constructed in each trial. Prime and mask are presented on the left and on the right from the fixation point. A target is presented in the center of the screen. Three SOA – Signal Onset Asynchrony (time intervals between prime and target) are used: 80, 160, and 240 ms. The participant is required to respond according to the direction of the target by pressing the right key on the keyboard. Reaction time and percentage of correct responses are measured.

Test 6. The test measures the recognition and processing of the structure of the visual stimulus. The arrow-shaped dot pattern in a rectangular dotted frame


54

(64 dots) is displayed on the screen. Each arrow consists of 15 dots pointing to the left or to the right. Stimuli are degraded by placing 10 (medium level of degradation) to 14 (high level of degradation) dots from the surrounding frame of the intact stimuli to random positions within the frame on places not occupied by dots of the arrow. The participant is required to respond according to the direction of the stimulus by pressing the right key on the keyboard. Reaction time and percentage of correct and incorrect responses are measured.

All the tests of QMT were programmed in Java JDK 6. SUBJECTS

The study included 16 male patients aged 41.6 ± 12 years old hospitalized at the Psychiatric Clinic of the University Hospital No 1 in Bydgoszcz with a diagnosis of alcohol dependency and 16 healthy male volunteers aged 43 ± 9 years with no history of any psychiatric disorder, substance abuse or serious somatic illnesses. There was no statistical difference between mean age and years of education in both groups. The Bioethics Committee of the Nicolaus Copernicus University Collegium Medicum in Bydgoszcz approved the study. Informed consent was received from all participants after the aim and procedure of the study had been fully explained to them. RESULTS

Table 1 below demonstrates significant differences between patient and control groups obtained in tests 1-4 of QMT. These results show longer mean reaction time for incorrect reactions in Test 2 and longer reaction time for correct target reactions in Test 4 in patients’ group compared to healthy controls. Table 1. Significant differences between patients and healthy

controls for tests 1-4 of QMT

Parameter Patients’ group

X ± SD

Control group X ± SD

p

Test 2 – mean RT for incorrect reactions (ms)

423.8 ± 110.9 336.2 ± 115.5 0.036

Test 3 – number of correct responses in part 2

32.1 ± 8.9 40.2 ± 7.4 0.014

Test 3 – number of correct responses in part 3

17.4 ± 4.1 22.1 ± 4.7 0.008

Test 4 – mean RT for correct target reactions (ms)

12.6 ± 2.3 7.1 ± 5 0.001

Also, they indicate lower number of correct responses in part 2 and 3 of Test 3 in patients’ group compared to control group. For statistical analysis t-Student test was performed, using SPSS 14.0. statistical software (p<0.05).

In Test 5 of QMT reaction times and percentage of correct responses were measured relative to the target stimulus. The statistical analysis of the reaction time and percentage of correct responses for patients’ and control group was performed in ANOVAs using within-subject factors such as Compatibility (compatible vs incompatible) and SOA (60, 120,240). The mean reaction times for compatible and incompatible trials are presented separately for each group in Figure 1 and 2.

RTs were shorter in the control group compared to the patients’ one (412 ms vs 503), p = 0.02. RTs also depended on SOA, the shortest reactions were for SOA 240 (445 ms) then for SOA 120 (449ms), the longest for SOA 60 (478 ms), p < 0.001. A significant interaction was noted between Group and SOA, p = 0.03. RTs were shorter with SOA for each group, but only the difference between SOA 60 and SOA 120 was significant (post hoc p=0.05). RTs were equally long for compatible and incompatible trials, p = 0.25.

Fig. 1. RTs in compatible and incompatible trials for each

SOA in control group

Fig. 2. RTs in compatible and incompatible trial for each SOA in patients’ group


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Percentage of correct responses was similar in control and patients’ group, p = 0.64. Percentage of correct responses in each group depended on SOA, p=0.002. All participants obtained 70%, 72%, 75% for SOA 240, SOA 120, SOA 60 respectively. Three - way interaction between the factors: Group, SOA, Compatibility was significant, p = 0,05, control group differed from patients’ group regarding compatibility and SOA. Post hoc comparison indicated that PC in incompatible trials for SOA 240 was higher in the control than patients’ group, and also PC in incompatible and compatible trials for SOA 60 and 120 was higher in the control group than in the experimental group for SOA 240 in incompatible trials, (p=0.05). Mean percentage of correct responses for compatible and incompatible trials is displayed separately for each group

Fig. 3. PC in compatible and incompatible trial for each SOA

in control group

Fig. 4. PC in compatible and incompatible trial for each SOA

in patients’ group

The statistical analysis has not demonstrated any differences in performance of patients and healthy controls in Test 1 and Test 6 of QMT.

DISCUSSION The results obtained demonstrated longer mean

reaction time for incorrect reactions in Test 2 in patients’ group compared to the control group. This effect of slower reaction in patients is also demonstrated in Test 4. These data confirmed the previous finding that reaction time is one of the cognitive areas impaired by alcohol (5, 6). However, in Test 1, which measures simple reaction time no differences between the groups were found. It may indicate that the effect on reaction time is greater in a task with higher cognitive demand.

Moreover, lower number of correct responses in part 2 and 3 of Test 3 was found in the patients’ group compared to the control group. These results may demonstrate deficits of visual processing, especially in scanning the visual field.

Subliminal priming is a technique that allows to test the influence of subliminal information (the one below the conscious level) on our behavior. Positive or negative effect of priming can be observed. Mask has an active impact on direction of priming effect. We expected positive compatibility effect in alcohol dependent patients independently of SOA or negative compatibility effect if time between prime and target was long enough, due to cognitive deficits, which, consequently, may lead to problems in recognizing the structure of the stimulus, mask. In controls, negative compatibility effect independent of SOA was expected. However, we did not note differences in strength and direction of priming effect between healthy people and alcohol dependent patients measured by Test 5 of QMT. The compatibility effect and interaction between Group and Compatibility were not significant. Discrepancies in results among particular participants were observed. Some of them had the strong negative and some had the strong positive compatibility effect, so in consequence the compatibility effect was suppressed. Probably, in order to observe these effects, larger groups are needed. Alcohol dependent patients needed more time to respond to the imperative stimulus than the healthy controls. This indicates that alcohol dependent patients might have more difficulties with identification of an arrow direction, which is why they needed more time to give an answer. It confirmed the results of Maylor et al. (1990) who found that speed of detection can be impaired by alcohol.


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CONCLUSIONS

1. The alcohol dependent patients performed worse in

the following parameters of QMT: mean reaction time for incorrect reactions (Test 2), mean reaction time for correct target reactions (Test 4), reaction time in subliminal priming task (Test 5) and number of correct responses in part 2 and 3 of Test 3.

2. It may be concluded that reaction time is the most vulnerable cognitive area in alcohol dependent patients.

3. The QMT is a quick, precise and effective computerized method to measure reaction time, different functions of attention and subliminal processing.

4. Our study was preliminary. The results obtained should be confirmed in a larger cohort.

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16. Neumann, O., Klotz, W. (1994). Motor responses to nonreportable, masked stimuli: Where is the limit of direct parameter specification? In Umilta, C. and Moscovitch, M. (Eds.), Conscious and Unconscious Information Processing (pp. 123-150). Cambridge, MA, MIT Press.

17. Ansorge, U., Klotz, W. & Neumann, O. (1999). Manual and verbal responses to completely masked (unreportable) stimuli: Exploring some conditions for the metacontrast dissociation. Perception 27, 1177-1189.

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19. Jaśkowski, P., Skalska, B. i Verleger, R. (2003). How the self controls its "automatic pilot" when processing subliminal information. Journal of Cognitive Neuroscience, 15, 911-920.

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negative and positive priming effects induced by masked arrows. Journal of Experimental Psychology: General, 133, 494-515.

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Address for correspondence: Katedra Psychiatrii UMK w Toruniu Collegium Medicum im. L. Rydygiera 85-096 Bydgoszcz ul. Kurpińskiego 19 tel.: (52) 585 40 39 fax: (52) 585 37 66 e-mail: [email protected]



CASE REPORT / OPIS PRZYPADKU Małgorzata Łukowicz, Jan Pawlikowski, Paweł Zalewski, Magdalena Weber-Zimmermann, Katarzyna

Ciechanowska, Agnieszka Pawlak

BODY WEIGHT SUPPORT DURING TREADMILL THERAPY IN PATIENTS

AFTER SCI – CASE STUDY

SYSTEM DYNAMICZNEGO ODCIĄŻENIA W TERAPII CHODU NA BIEŻNI U PACJENTA PO URAZIE RDZENIA KRĘGOWEGO – PREZENTACJA PRZYPADKU

Chair and Department of Laser Therapy, Nicolaus Copernicus University Collegium Medicum in Bydgoszcz

Head: dr n. med. Małgorzata Łukowicz

S u m m a r y

I n t r o d u c t i o n . Body weight support therapy is a concept of rehabilitation that uses an external device to support a percentage of a patient’s body weight allowing them to perform a variety of therapeutic activities in an upright position and safe environment. Typically in aeurological pathologies, the patient’s body weight is supported in between 20-40% to assist in developing proper gait patterns and improvements in cardiovascular and muscular endurance with less physical demand. The ability to initiate exercise early in the rehabilitation process can be of benefit to the patient by allowing neural pathways to develop through muscular patterning.

T h e p u r p o s e of our study was to present a case study of a young male patient after spinal cord injury at the

level T12 who had gait therapy on a treadmill in dynamic unweighting. He was admitted to Rehabilitation Department 5 months after the injury and he had one month training.

M a t e r i a l a n d m e t h o d s . We supported his weight on the level of 20%, the time of therapy was dependent on patient’s capacity, we started from 5 minutes and stopped at 30 minutes. We used special scales for evaluation of patient’s mobility and disability: ASIA scale, WISCI II, TWT, spirometry, HR and others.

C o n c l u s i o n s . The main benefits of this kind of therapy are: the increase of muscle strength of hip adductors and quadriceps bilaterally, the increase of time without fatigue, we did not observe any complaints from the cardiovascular system.


W s t ę p . Dynamiczne odciążenie, czyli system odciążenia pacjenta podczas reedukacji chodu na bieżni lub na otwartej przestrzeni (korytarz) jest systemem rehabilitacji, w którym wykorzystuje się urządzenia do podtrzymania masy ciała pacjenta, aby umożliwić pacjentowi wykonywanie ćwiczeń w pozycji wyprostowanej, z dużym poczuciem bezpieczeństwa. Ten system terapii zwiększa możliwości funkcjonalne pacjenta z niekompletnym urazem rdzenia kręgowego, niektórymi chorobami neurologicznymi, po urazie czaszkowo-mózgowym. W schorzeniach typowo neurologicznych stosuje się odciążenie w zakresie 20-40% masy ciała, aby umożliwić wykonanie prawidłowego wzorca

chodu, poprawić wytrzymałość mięśniową oraz zmniejszyć obciążenia krążeniowo-oddechowe. Wczesne rozpoczęcie reedukacji chodu u pacjentów ze schorzeniami neurologicznymi może przynieść korzyści w postaci stymulacji szlaków nerwowych i rozwoju prawidłowych wzorców ruchowych.

C e l e m p r a c y była wstępna ocena miesięcznej terapii chodu na bieżni w systemie dynamicznego odciążenia u pacjenta po urazie rdzenia kręgowego.

M a t e r i a ł i m e t o d a . Przedstawiono przypadek pacjenta, lat 32, po urazowym uszkodzeniu rdzenia kręgowego na poziomie Th12. Terapię rozpoczęto 5 miesięcy

Małgorzata Łukowicz et al.

60

po urazie. Stosowano odciążenie 20% i czas terapii uzależniony od możliwości pacjenta, początkowo pacjent tolerował sesje po 5 minut, ostatecznie, po 4 tygodniach terapii, pacjent chodził na bieżni 30 minut dziennie. Ocena pacjenta obejmowała badanie wg skali ASIA, WISCI, ocenę

parametrów chodu, spirometrię, badanie ciśnienia tętniczego krwi, AS, ankietę.

W y n i k i . Pacjent wydłużył dystans chodu, wzrosła siła mięśni przywodzicieli uda z 1 na 2 w skali Lovetta, oraz mięśni czworogłowych uda z 1-2 do 3 w skali Lovetta.

Key words: SCI, BIODEX, body weight support, treadmill, gait Słowa kluczowe: uraz rdzenia kręgowego, BIODEX, system dynamicznego odciążenia, trening chodu na bieżni, chód INTRODUCTION

The annual value of spinal cord injuries oscillates within the range from 7000 to 10000 and usually concerns the age group of 16 to 30 year old. The amount of accidents increases along with the development of means of transport as well as technology. Most patients after spinal cord injury (SCI) still want to walk, hence the question ‘What is my chance to walk again?’ directed to physicians, physiotherapists, nurses appears.

Body weight support (BWS) treadmill training presents one of the method for gait therapy. The method is based on neurobiological principle that part of recovery process depends on neuroplasticity as well as specific and unspecific activity of uninjured nervous system. The training, electrostimulation and pharmacology contribute to the improvement of treatment results in patients suffering from acute spine cord injury.

Body weight support therapy applied in patients with adynamia (muscular weakness) improves the gait motor activity within free environment. Studies concerning the therapy will allow to disseminate the method as well as evolve the standards of therapeutic management.

Most patients suffering from SCI aim to accomplish vertical position and a gait, thus new methods of therapy are searched for to achieve the goal – walking. So far, there has been no effective method of treatment that would result in spinal cord regeneration. However, a number of the functional therapy methods allow to take efforts to create the same methods of compensation and influence the plasticity of the central nervous system. The early tilting the patient to erect position and walk therapy influence the activation of spinal cord generator, prevent from muscular athropy and circulatory as well as vascular complications and also increase the general fitness.

Many researches concerning the body weight support therapy were conducted within last few years

among patients suffering from spinal cord and central nervous system injuries, Parkinson’s disease and patients after strokes, to evaluate the therapy’s superiority in various models application. There are questions concerning the therapy and individual session duration, the moment of its beginning, the velocity of a gait as well as extent of body weight support. The functional tests, neurophysiological examinations including EMG, PW as well as physical efficiency test predominate in methodology. They show the effectiveness of the method and encourage further examinations.

Dynamic body weight support during reeducation of walking on treadmill or open in the environment (corridor) presents a concept of rehabilitation that uses an external device to support patient’s body weight, which allows to perform a variety of therapeutic activities in an upright position and safe environment. The body weight support increases the functional abilities of patients suffering from incomplete spinal cord injury. Typically used in neurological pathologies, the patient’s body weight is supported to the extent of 20-40% to assist developing of proper gait patterns and improving cardiovascular and muscular endurance with less physical demand at the same time.

The physiological benefits are the following: Symmetric body weight support of both limbs

assures the equal length of steps as well as duration of the limb support phase, which influences the proper biomechanics of gait and regeneration of the proper gait patterns.

Decrease of parasympathetic activity – reduction of muscular tone (decrease of spastic reflexes) as well as increase of the range of movement within joints.

Decreased load of both the circulatory and respiratory system, which is of great importance in case of patients with decreased efficiency, after long-lasting lying and injuries. 40% body weight

Body weight support during treadmill therapy in patients after SCI - case study

61

support lessens the oxygen absorption, which makes the long-lasting exercises possible.

The body weight support enables the therapy at a very early stage after serious injuries, surgical procedures within joints, spinal fracture. The therapy allows to adjust the body weight support to medical recommendation.

Axial traction enables the management of a patient suffering from spinal ailments.

Medical cover in a system of body weight support enables rehabilitation of patients suffering from dysequlibrium and dyssynergia decreasing the possibility of fall. Somatosensory stimulation secures the proprioceptive feedback in body location over the base of gait, which also releases the correct gait patterns.

Sense of security.

The aim of this research project was to evaluate benefits resulting from the regular gait rehabilitation supported by treadmill ambulation training in the BIODEX system of dynamic unweighting for patients suffering from spinal cord injury located at the level of Th12.

MATERIAL AND METHOD The case of a 32-year old patient after incomplete

spinal cord injury located at the level of Th12 was introduced. The therapy procedures were applied within 5 months after the injury.

Criteria of application: spinal cord injury, sitting without support, lack of contraindications for tilting the patient to erect position, cooperation, motivation, lack of joint contracture and periarticular ossifications. MEP as well as ENG examination were carried out. In MEP examination: lack of tibial muscles response – bilateral, lack of quadriceps muscle of thigh response at right side, response from quadriceps muscle of thigh at the left side. Motor NCS: correct amplitudes of motor potential as well as adequate velocity of conductivity within tibial nerves – bilateral, minimal amplitude of motor potential from peroneal nerve at the right side, lack at the left side.

The patient was subjected to rehabilitation supported by GAIT TRAINER 2 treadmill ambulation for 5 days a week, during 4 weeks, starting from 5 minutes (for the sake of intolerance symptom) up to 30 minutes per day (without intolerance symptoms). The intensity of BIODEX body weight support was

adjusted optimally to affect the patient in a small extent (20% of the body mass) and to enable the economical gait at the same time

The evaluation included examinations in accordance with ASIA and WISCI scale, encompassed estimation of the gait parameters, spirometry, examination of arterial blood pressure, AS, therapy evaluation questionnaire.

RESULTS

The initial time of therapy was 5 minutes. After this, patient felt tired and the training was interrupted. At first, active commitment of two therapists was needed. The therapists were moving lower extremities of the patient according to the rhythm of a treadmill. The patient was equipped with orthopedic orthoses preventing from foot drop (photo 1). After few sessions, the patient wearing ortheses was able to move his limbs at a rate possible for him . After 30 minutes, there were no symptoms of physical fatigue (photo 2).

Photo 1. Beginning of the therapy assisted by 2 therapists

Photo 2. At the end of the therapy – independent gait with

orthopedic ortheses


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Evaluation of the patient, according to ASIA scale, before and after the therapy is shown in the table Ia and Ib. Table Ia. Evaluation according to ASIA scale, before therapy

Level Motion R Motion L Tactile sensation

R/L

Algaesthesia R/L

C3

C4

C5 5 5 2/2 2/2

C6 5 5 2/2 2/2

C7 5 5 2/2 2/2

C8 5 5 2/2 2/2

Th1 5 5 2/2 2/2

Th2 2/2 2/2

Th3 2/2 2/2

Th4 2/2 2/2

Th5 2/2 2/2

Th6 2/2 2/2

Th7 2/2 2/2

Th8 2/2 2/2

Th9 2/2 2/2

Th10 2/2 2/2

Th11 2/2 2/2

Th12 2/2 2/2

L1 2/2 1/1

L2 4 4 2/2 1/1

L3 1 1 1/1 1/1

L4 0 0 1/1 0/0

L5 0 0 1/1 0/0

S1 0 0 1/1 0/0

S2 1/1 0/0

S3 0/0 0/0

S4-5 0/0 0/0

In accordance with Lovett scale (before therapy):

adductor muscles of hip joint: 1/5, quadriceps muscle of thigh R and L: 1/5. The strength of adductor muscles of hip joint increased: 2/5 as well as the strength of quadriceps muscle of thigh (2/5) at the left side and (3/5) at the right side. The patient reported burning sensation at the external side of his left calf. The patient had no sensations around this area before.

In accordance with WISCI scale, before therapy, 9 points were given (>10 metres, walker, ortheses, without assistant), 12 after therapy (>10 metres, 2 crutches, ortheses, without assistant). The gait time has decreased at the examined distance.

In accordance with gait parameters evaluation: acceptable time period: 5 minutes, average gait velocity: 0.46 m/s, average step length: R 1.01 m, L

0.93 m, support time: R-60%, L-40%.. After therapy acceptable time: 30 minutes and more, average gait velocity: 0.55 m/s, average step length: R 0.66m, L 0.8 m, support time: R-60%, L-40%.

Table Ib. Evaluation according to ASIA scale, after therapy

Level Motion R Motion L Tactile sensation

R/L

Algaesthesia R/L

C3

C4

C5 5 5 2/2 2/2

C6 5 5 2/2 2/2

C7 5 5 2/2 2/2

C8 5 5 2/2 2/2

Th1 5 5 2/2 2/2

Th2 2/2 2/2

Th3 2/2 2/2

Th4 2/2 2/2

Th5 2/2 2/2

Th6 2/2 2/2

Th7 2/2 2/2

Th8 2/2 2/2

Th9 2/2 2/2

Th10 2/2 2/2

Th11 2/2 2/2

Th12 2/2 2/2

L1 2/2 1/1

L2 4 4 2/2 1/1

L3 3 2 1/1 1/1

L4 0 0 1/1 1/1

L5 0 0 1/1 0/0

S1 0 0 1/1 0/0

S2 1/1 0/0

S3 0/0 0/0

S4-5 0/0 0/0

The evaluation of circulatory and respiratory

efficiency is shown in the table IIa and IIb. Table IIa. AS, arterial blood pressure and number of breaths

before therapy

Parameter Beginning End Heart rhythm 66 78 Arterial blood pressure (mmHg) 130/90 160/100

Number of breaths 12 24 Table IIb. AS, arterial blood pressure and number of breaths

after therapy

Parameter Beginning End

Heart rhythm 60 66

Arterial blood pressure (mmHg) 130/90 130/90

Number of breaths 12 20

Body weight support during treadmill therapy in patients after SCI - case study

63

The inspiration volume of patient increased; flow-volume parameters did not reveal any significant changes; number of breaths decreased after each session (Table IIa).

The patient assessed the sense of security as very good and so he assessed the results of therapy. The patient suggested performing the therapy twice a day and revealed willingness to cooperate.

DISCUSSION

Shepherd & Carr (1999) show three advantages of the method (20):

1. It enables rehabilitation of the whole gait cycle.

2. It improves the pace as well as the step length.

3. It presents the optimal form of aerobic exercises for patients with spinal cord injury.

Nymark et al. (1998) confirmed that a patient suffering from incomplete spinal cord injury reveals effective results of this form of therapy. Gardner et al. (1998), Wernig (1999) proved the improvement of independent gait of a patient even after a few years after injury. Behrman & Harkema (2000) described the range of sensory signals needed for correct gait reciprocal patterns of patients after SCI during rehabilitation supported by treadmill ambulation training:

The correct response of walking induced by a speed of treadmill.

The maximal body weight support applied during the standing phase.

Full extension of trunk and head. Nearly standard kinematics of gait cycle

for hip, knee and tarsal joint. Time synchronization of extension and

load of the extremity which adopts the body weight with simultaneous body weight support of the other one.

Motion of upper extremities during the gait (thanks to the body weight support).

The present study concern the BWS system as a profitable method of therapy in patients after spinal cord injury [3, 7, 8] as well as after cerebral stroke [4, 5]. The best results are achieved within the first 12 months after the injury, when neuroplasticity is the biggest.

Wirz, Zemmon, Rupp et al. described the pulse as well as arterial blood pressure during the gait. The decrease of arterial blood pressure as well as increase of pulse occurred [19]. The improvement of gait parameters and general fitness were noticed [10, 14, 15]. The authors underlined the importance of therapists in the process of correct positioning of the lower extremities as well as walking (one therapist at each side of the body and third one to stabilize the pelvis, if necessary). The motion evoked by therapists is not symmetric, hence new robots for gait automation are being constructed [1, 4, 5]. The unsymmetric motion also limits the application of Biodex, however if advanced devices are not available and therapists assist carefully, it could be used as a sufficient method of gait treatment in patients suffering from neurological dysfunctions.

Rehabilitation of gait supported by treadmill ambulation training contributes to the improvement of general fitness, gait, increase of muscle force and enables the independent shifting of lower extremities supported by orthoses preventing from foot drop.

CONCLUSIONS

BWS therapy contributed to the extension of gait distance as well as enabled crutches supported gait (WISCI scale: 9-12). The strength of adductor muscles of thigh increased from 1 to 2 according to Lovett scale, quadriceps muscles of thigh from 1-2 to 3 according to Lovett scale. The physical efficiency improved. The patient was satisfied with the therapy as well as the high sense of security. Body weight support and rehabilitation of gait simulated on treadmill bring measurable profits to patients after spinal cord injury.

LITERATURE 1. Behrman Andrea L., Harkema Susan J.: Locomotor

Training After Human Spinal Cord Injury: A Series of Case Studies. Phys. Ther, Vol. 80, No. 7, July 2000, p. 688-700.

2. Barbeau H., Pepin A., Norman K.E., Ladouceur M., Leroux A.: Walkig After Spinal Cord Injury: Control and Recovery. Neuroscientist, 4:14-24, 1998.

3. Hall KM, Cohen ME, Wright J, Call M, Werner P.: Characteristics of the Functional Independence Measure in traumatic spinal cord injury. Arch Phys Med Rehabil. 1999 Nov;80(11):1471-6.


64

4. Herterich B, Steube D, Buhner M.: Treadmill therapy in patients after ischaemic stroke. Rehabilitation (Stuttg). 2004,Jun;43(3):137-41.

5. Inácio Teixeira da Cunha Filho, PT, PhD; Peter A.C. Lim, MD; Huma Qureshy, PT, MS; Helene Henson, MD; Trilok Monga, MD; Elizabeth J. Protas, PT, PhD: A comparison of regular rehabilitation and regular rehabilitation with supported treadmill ambulation training for acute stroke patients. Journal of Rehabilitation Research and Development.Vol. 38 No. 2, March/April 2001.

6. Macko RF, DeSouza CA, Tretter LD, Silver KH, Smith GV, Anderson PA, Tomoyasu N, Gorman P, Dengel DR.: Treadmill aerobic exercise training reduces the energy expenditure and cardiovascular demands of hemiparetic gait in chronic stroke patients. A preliminary report. Stroke. 1997 Feb;28(2):326-30.

7. Marino RJ., Goin JE, Development of a short-form Quadriplegia Index od Function Scale. Spinal Cord, 1999, 37: 289-296.

8. Melis EH, Torres-Moreno R, Barbeau H, Lemaire ED, Analysis of assisted –gait characteristics in persons with incomplete spinal cord injury. Spinal Cord, 1999, 37: 430-439.

9. Middleton JW, Harvey LA, Batty J, Cameron I, Quirk R, Winstanley J., Five additional mobility and locomotor items to improve responsiveness of the FIM in wheelchair-dependent individuals with spinal cord injury. Spinal Cord. 2006, Aug;44(8):495-504. Epub 2005 Dec 6.

10. Middleton JW, Truman G, Geraghty TJ., Neurological level effect on the discharge functional status of spinal cord injured persons after rehabilitation. Arch Phys Med Rehabil. 1998 Nov;79(11):1428-32.

11. Morganti B , Scivoletto G , Ditunno P , Ditunno J F and Molinari M , Walking index for spinal cord injury (WISCI): criterion validation. Spinal Cord (2005) 43, 27–33.

12. Ota T, Akaboshi K, Nagata M, Sonoda S, Domen K, Seki M, Chino N., Functional assessment of patients with spinal cord injury: measured by the motor score and the Functional Independence Measure. Spinal Cord. 1996 Sep;34(9):531-5.

13. Pinter MM, Dimitrijevic MR, Gait after spinal cord injury and the central pattern generator for locomotion. Spinal Cosd, 1999, 37, 531-537.

14. Sawicki Gregory S., Domingo Antoinette, Ferris Daniel P., The effects of powered ankle-foot orthoses on joint kinematics and muscle activation during walking in individuals with incomplete spinal cord injury. J Neuroengineering Rehabil. 2006; 3: 3.

15. Stinear James W., Hornby T George, Stimulation-induced changes in lower limb corticomotor excitability during treadmill walking in humans. J Physiol. 2005 September 1; 567(Pt 2): 701–711.

16. Subbaru Jay V., Walking After Spinal Cord Injury Goal or Wish? West.J.Med 1991, May, 154: 612-614.

17. Visintin M., Barbeau H., Korner-Bitensky N., Mayo N.E., A New Approch to Retain Gait in Stroke Patients

Through Body Weight Support and Treadmill Stimulation. Stroke, 1998, 9:1122-1128.

18. Werner C, Von Frankenberg S, Treig T, Konrad M, Hesse S. Treadmill training with partial body weight support and an electromechanical gait trainer for restoration of gait in subacute stroke patients: a randomized crossover study. Stroke. 2002 Dec; 33(12):2895-901.

19. Wirz M., Zemon D.H., Rupp Ruediger, Scheel A., Colombo G., Dietz V., Hornby G, Effectiveness of Automated Locomotor Training in Patients With Chronic Incomplete Spinal Cord Injury: A Multicentral Trial. Archiv of Phys.Med.and Rehab, 2005, 86: 672-80.

20. Haas BM, Jones F. Physical activity and exercise in neurological rehabilitation. Stokes M. Physical Management in Neurological Rehabilitation. Elservier Mosby. Edinburgh, London, New York, Oxford, Phyladelp

Address for correspondence: Uniwersytet Mikołaja Kopernika w Toruniu Collegium Medicum im. Ludwika Rydygiera w Bydgoszczy Katedra i Zakład Laseroterapii i Fizjoterapii ul. Marii Skłodowskiej-Curie 9 85-094 Bydgoszcz tel.:. +48 52 5853485 e-mail: [email protected]



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