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Porównanie Skuteczności Urządzeń Oxybaria S I Laserobaria S W Skojarzonym Leczeniu Fizykalnym Owrzodzeń Kończyn Dolnych

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Porównanie Skuteczności Urządzeń Oxybaria S I Laserobaria S W Skojarzonym Leczeniu Fizykalnym Owrzodzeń Kończyn Dolnych Lekarz Mikołaj Pietrzak Porównanie skuteczności urządzeń Oxybaria S i Laserobaria S w skojarzonym leczeniu fizykalnym owrzodzeń kończyn dolnych Rozprawa na stopień doktora nauk medycznych Promotor: prof. dr hab. n. med. Grzegorz Cieślar Katedra i Oddział Kliniczny Chorób Wewnętrznych, Angiologii i Medycyny Fizykalnej Kierownik Katedry: prof. dr hab. n. med. Grzegorz Cieślar Wydział Lekarski z Oddziałem Lekarsko-Dentystycznym w Zabrzu Śląski Uniwersytet Medyczny w Katowicach Zabrze 2019 Pobrano z Repozytorium Śląskiego Uniwersytetu Medycznego w Katowicach / Downloaded from Repository of Medical University of Silesia 2021-09-26 Mikołaj Pietrzak Oddział Kliniczny Chorób Wewnętrznych, Angiologii i Medycyny Fizykalnej Szpitala Specjalistycznego nr 2 w Bytomiu 41-902 Bytom, ul. Batorego 15 e-mail: [email protected] RECENZENCI: Prof. dr hab. n. med. Andrzej Szuba Katedra i Klinika Angiologii, Nadciśnienia Tętniczego i Diabetologii Wydział Lekarski Kształcenia Podyplomowego Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu Dr hab. n. o kult. fiz. Jan Szczegielniak Prof. nadzw. PO Katedra Fizjoterapii Klinicznej Instytut Fizjoterapii Wydział Wychowania Fizycznego i Fizjoterapii Politechnika Opolska w Opolu 1 Pobrano z Repozytorium Śląskiego Uniwersytetu Medycznego w Katowicach / Downloaded from Repository of Medical University of Silesia 2021-09-26 SPIS TREŚCI WYKAZ STOSOWANYCH SKRÓTÓW…………………………………………. 4 WYKAZ TABEL……………………………………………………………………. 6 WYKAZ RYCIN…………………………………………………………………….. 8 1. WSTĘP…………………………………………………………………………. 9 1.1. Rany przewlekłe………………………………………………………….... 9 1.1.1. Definicja, epidemiologia, powikłania……………………………….. 9 1.1.2. Etiopatogeneza owrzodzeń w obrębie kończyn dolnych ………… 10 1.1.3. Proces gojenia ran przewlekłych…………………………………… 13 1.1.4. Leczenie owrzodzeń w obrębie kończyn dolnych ………………… 15 1.1.5. Rokowanie w przypadku owrzodzeń w obrębie kończyn dolnych 16 1.2. Wybrane metody fizykalne stosowane w leczeniu owrzodzeń kończyn dolnych……………………………………………………………………… 17 1.3. Leczenie skojarzone z użyciem metod fizykalnych w leczeniu owrzodzeń kończyn dolnych……………………………………………… 27 2. ZAŁOŻENIA I CELE PRACY………………………………………………… 32 3. MATERIAŁ I METODYKA……………………………………………………. 33 3.1. Materiał kliniczny…………………………………………………………... 33 3.2. Metodyka zabiegów fizykalnych………………………………………..... 34 3.3. Metodyka badań instrumentalnych i laboratoryjnych.………………….. 36 3.3.1. Pomiar powierzchni owrzodzenia metodą planimetryczną z wykorzystaniem zdjęć cyfrowych…………………………………. 37 3.3.2. Pomiar temperatury tkanek w centralnej części owrzodzenia przy użyciu kamery termowizyjnej ……………………………………….. 38 3.3.3. Subiektywna ocena nasilenia dolegliwości bólowych przy użyciu skali wzrokowo-analogowej VAS…………………………………… 38 3.3.4. Wykonywanie posiewów wymazów z owrzodzenia………………. 38 3.3.5. Procedura wykonywania badań laboratoryjnych………………….. 39 3.4. Analiza statystyczna…………………………………………………….. 39 4. WYNIKI…………………………………………………………………………. 40 4.1. Wartości pomiaru powierzchni owrzodzenia metodą planimetryczną z wykorzystaniem zdjęć cyfrowych………………………………………. 40 4.2. Wartości pomiaru temperatury tkanek w centralnej części owrzodzenia przy użyciu kamery termowizyjnej……………………….. 44 2 Pobrano z Repozytorium Śląskiego Uniwersytetu Medycznego w Katowicach / Downloaded from Repository of Medical University of Silesia 2021-09-26 4.3. Wyniki subiektywnej oceny nasilenia dolegliwości bólowych przy użyciu skali wzrokowo-analogowej VAS………………………………… 45 4.4. Ocena jałowości owrzodzenia w oparciu o wyniki posiewu wymazu z oczyszczonego owrzodzenia………………………………………….... 47 4.5. Wartości oznaczeń badanych parametrów laboratoryjnych…………… 48 5. OMÓWIENIE WYNIKÓW I DYSKUSJA…………………………………….. 56 6. WNIOSKI……………………………………………………………………….. 74 7. PIŚMIENNICTWO …………………………………………………………….. 75 8. STRESZCZENIE ……………………………………………………………… 93 9. ABSTRACT ……………………………………………………………………. 97 3 Pobrano z Repozytorium Śląskiego Uniwersytetu Medycznego w Katowicach / Downloaded from Repository of Medical University of Silesia 2021-09-26 WYKAZ STOSOWANYCH SKRÓTÓW ABI wskaźnik kostkowo-ramienny (ang. ankle-brachial index) ATP adenozyno-5′-trifosforan (ang. adenosine-5'-triphosphate) bFGF podstawowy czynnik wzrostu fibroblastów (ang. basic fibroblast growth factor) c-AMP cykliczny adenozyno-3′,5′-monofosforan (ang. cyclic adenosine monophosphate) CLI krytyczne niedokrwienie kończyny (ang. critical limb ischaemia) COX-2 cyklooksygenaza-2 (ang. cyclooxygenase-2) CRP białko C-reaktywne (ang. C-reactive protein) DNA kwas deoksyrybonukleinowy (ang. deoxyribonucleic acid) ELF-MF zmienne pole magnetyczne niskiej częstotliwości (ang. extremely- low frequency magnetic field) HBO hiperbaria tlenowa (ang. hyperbaric oxygen) HIF-1a czynnik indukowany hipoksją 1α (ang. hypoxia-inducible factor 1α) IGF-1 insulinopodobny czynnik wzrostu 1 (ang. insulin-like growth factor 1) INR międzynarodowy współczynnik znormalizowany (ang. international normalized ratio) LED diody półprzewodnikowe (ang. light emitting diodes) LLLT laseroterapia niskoenergetyczna (ang. low-level laser therapy) MCH średnia masa hemoglobiny w krwince czerwonej (ang. mean corpuscular hemoglobin) MCHC średnie stężenie hemoglobiny w krwinkach czerwonych (ang. mean corpuscular hemoglobin concentration) MCV średnia objętość krwinki czerwonej (ang. mean corpuscular volume) MMP-2 metaloproteinaza macierzy-2 (ang. matrix metalloproteinase-2) MPV średnia objętość płytki krwi (ang. mean platelet volume) NF-κB jądrowy czynnik transkrypcyjny kappa B (ang. nuclear factor κB) NO tlenek azotu (ang. nitric oxide) NOS syntaza tlenku azotu (ang. nitric oxide synthase) 4 Pobrano z Repozytorium Śląskiego Uniwersytetu Medycznego w Katowicach / Downloaded from Repository of Medical University of Silesia 2021-09-26 PAD choroba tętnic obwodowych (ang. peripheral arteries disease) PDGF płytkopochodny czynnik wzrostu (ang. platelet-derived growth factor) PGE2 prostaglandyna E2 (ang. prostaglandin E2) RDW-CV współczynnik zmienności rozkładu objętości krwinek czerwonych (ang. red blood cell distribution width, coefficient of variation) RNA kwas rybonukleinowy (ang. ribonucleic acid) TGF-β transformujący czynnik wzrostu beta (ang. transforming growth factor β) TNF-α czynnik martwicy nowotworów α (ang. tumor necrosis factor α) VEGF czynnik wzrostu śródbłonka naczyniowego (ang. vascular endothelial growth factor) 5 Pobrano z Repozytorium Śląskiego Uniwersytetu Medycznego w Katowicach / Downloaded from Repository of Medical University of Silesia 2021-09-26 WYKAZ TABEL Tabela I Charakterystyka kliniczna pacjentów z obu grup badawczych…... 40 Tabela II Porównanie wartości pomiarów powierzchni owrzodzenia dokonanych przy użyciu metody planimetrycznej wyrażonych w pikselach [px] (średnia ± SD) u pacjentów z obu grup badawczych, przed rozpoczęciem cyklu terapeutycznego oraz po jego zakończeniu, wraz z oceną statystyczną…………………. 43 Tabela III Porównanie wartości pomiarów temperatury [°C] dokonanych metodą termograficzną w centralnej części owrzodzenia (średnia ± SD) u pacjentów z obu grup badawczych, przed rozpoczęciem cyklu terapeutycznego oraz po jego zakończeniu, wraz z oceną statystyczną ………………………………………………………….. 45 Tabela IV Porównanie intensywności bólu ocenianej w skali VAS [pkt] (średnia ± SD) u pacjentów z obu grup badawczych, przed rozpoczęciem cyklu terapeutycznego oraz po jego zakończeniu, wraz z oceną statystyczną.…………………………………………. 46 Tabela V Porównanie wartości wybranych parametrów morfologii krwi (średnia ± SD) u pacjentów w obu grupach badawczych przed rozpoczęciem cyklu terapeutycznego, wraz z oceną statystyczną 49 Tabela VI Porównanie wartości wybranych parametrów morfologii krwi (średnia ± SD) u pacjentów w obu grupach badawczych po zakończeniu cyklu terapeutycznego, wraz z oceną statystyczną.. 49 Tabela VII Porównanie wartości wybranych parametrów układu krzepnięcia (średnia ± SD) u pacjentów w obu grupach badawczych przed rozpoczęciem cyklu terapeutycznego, wraz z oceną statystyczną………………………………………………………….. 50 Tabela VIII Porównanie wartości wybranych parametrów układu krzepnięcia (średnia ± SD) u pacjentów w obu grupach badawczych po zakończeniu cyklu terapeutycznego, wraz z oceną statystyczną.. 50 Tabela IX Porównanie stężenia wybranych parametrów biochemicznych (średnia ± SD) w surowicy krwi pacjentów w obu grupach badawczych przed rozpoczęciem cyklu terapeutycznego, wraz z oceną statystyczną………………………………………………… 51 Tabela X Porównanie stężenia wybranych parametrów biochemicznych (średnia ± SD) w surowicy krwi pacjentów w obu grupach badawczych po zakończeniu cyklu terapeutycznego, wraz z oceną statystyczną………………………………………………… 52 6 Pobrano z Repozytorium Śląskiego Uniwersytetu Medycznego w Katowicach / Downloaded from Repository of Medical University of Silesia 2021-09-26 Tabela XI Wartości współczynnika korelacji r Pearsona i Spearmana pomiędzy wartościami oznaczeń poszczególnych parametrów biochemicznych, a wartościami powierzchni owrzodzenia w obu grupach badawczych – leczonych Oxybarią S i Laserobarią S – przed rozpoczęciem cyklu terapeutycznego oraz po jego zakończeniu………………………………………………………….. 53 Tabela XII Wartości współczynnika korelacji r Pearsona i Spearmana pomiędzy wartościami oznaczeń poszczególnych parametrów biochemicznych, a wartościami temperatury w centralnej części owrzodzenia w obu grupach badawczych – leczonych Oxybarią S i Laserobarią S – przed rozpoczęciem cyklu terapeutycznego oraz po jego zakończeniu…………………………………………… 54 Tabela XIII Wartości współczynnika korelacji r Pearsona i Spearmana pomiędzy wartościami temperatury
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