Improving Clinical Outcomes and Quality of Life with Massage Therapy in Youth and Young Adults with Cystic Fibrosis: a Pilot Study

Division of Child Life & Integrative Care

Division of Pulmonary Medicine

Patient Services
Cincinnati Children's Hospital Medical Center
Research, CincinnatiOH

All About Health
CincinnatiOHUSA

Improving Clinical Outcomes and Quality of Life with Massage Therapy in Youth and Young Adults with Cystic Fibrosis: a Pilot Study
R E S E A R C Hcystic fibrosismassage therapymusculoskeletal painpulmonary functionquality of life
Background: Cystic Fibrosis (CF) is an autosomal recessive disorder of exocrine glands characterized by abnormal production of thick mucus, primarily in bronchi of the lungs. Individuals experience recurrent respiratory infections, increased work of breathing, cough and musculoskeletal changes with pain. Previous research found that massage therapy (MT) decreased pain, muscle tightness, and anxiety in individuals with CF, but did not use valid/reliable measurements of quality of life (QOL).Purpose: To evaluate the effects of MT on QOL and clinical outcomes in individuals 8 to 21 years old with CF.Setting: A 622-bed nonprofit pediatric hospital in Ohio in the United States.Participants: Convenience sample of 24 patients with CF; 12 randomly assigned to treatment and control groups, respectively.Research Design and Intervention: Prospective two-group controlled pre/post pilot study using deep tissue myofascial trigger point massage over 10 to 12 weeks.Measurements: Pediatric Quality of Life Inventory (Peds QL 4.0); Cystic Fibrosis Questionnaire-Revised (CFQ-R); numeric rating scales (NRS) for pain, muscle tightness, ease of breathing, relaxation; pulmonary function (PFT); single breath count; thoracic excursion (TE).Results: All participants were Caucasian; mean age 15.7 (SD = 3.5) years; 16 (66.6%) female. No significant differences were found in terms of age, gender, baseline pain between MT and control groups. At the final visit, compared to the control group, the children in MT group showed statistically significantly reduced muscle tightness (p = .048) with a large effect size (ω²=0.163) and marginally statistically significantly higher levels of relaxation (p = .052), less pain (p = .076), and improved upper TE (p = .078) and lower TE (p = .056) scores with large and moderate effect sizes (ω² = 0.156, ω² = 0.095, ω² = 0.083, and ω² = 0.073). No statistically significant differences in children's and caregivers' QOL scores between the two groups were found.Conclusions:Massage therapy was found to significantly reduce muscle tightness, marginally significantly help pain, relaxation, and thoracic excursion in participants with CF.

INTRODUCTION

Cystic Fibrosis (CF), a common life-shortening genetic disease, affects approximately 30,000 individuals in the United States. The incidence of CF varies by race and ethnicity, with 1:3200 whites, 1:15000 people of African descent, and 1:35000 people of Asian descent. (1,2) The disease results from mutations in the gene that codes for the cystic fibrosis transmembrane conductance regulator (CFTR) leading to abnormal movement of salt and water and retention of thick, sticky mucous in the lungs, pancreas, and other organs. (3) Consequently, most individuals with CF develop chronic bacterial lung infections and pancreatic insufficiency with malnutrition. Morbidity and mortality are primarily due to a progressive decline in lung function and eventual respiratory failure. Although there is still no cure for CF, medical discoveries are increasing life expectancy, with median predicted survival age now exceeding 40 years. (1,3) As CF progresses, individuals often experience an increase in pulmonary exacerbations and associated respiratory symptoms. Increased respiratory effort and inefficient muscle function and fatigue may result in musculoskeletal changes and associated pain, affecting posture, ease of breathing, comfort, and overall quality of life (QOL).

Anecdotally, over several years of practice at the study site, prior to and including time of the study, licensed massage therapists providing massage therapy (MT) to hospitalized youth and young adults with CF found recurrent patterns of muscle dysfunction and postural changes, suggesting overuse of respiratory muscles and inefficient recruitment of accessory Kathleen (Kate) Zink, MSN, RN, AHN-BC, LMT, 1* [retired], Barbara Chini, MD, 2 Joyce Cowens, AD, LMT, 4 Lois Kremer, BSN, RN, 1 [retired], Li Lin, MS, BS 3

METHODS

Participants

Participants were 8-to 21-year-old English speaking males and females with a CF diagnosis based upon documented positive sweat test (> 60 mEq/ ml by quantitative pilocarpine iontophoresis) and genotype with two identified mutations consistent with CF who received approval to participate from a pulmonary physician, gave informed consent if adult participant, or consent obtained from primary caregiver if participant younger than 18 years old, and agreed to refrain from receiving MT outside of study activities for the duration of study participation. Data collection occurred from September 2013 through March 2015. Recruitment activities included medical record review for eligibility of patients with CF followed by invitation to participate during clinic appointment (convenience sample).

Potential study participants were excluded if an illness was present at the time of enrollment for which MT was contraindicated, per pulmonary physician; if the person was unable to lay flat on the massage table; had a skin condition or injury contraindicated for MT; or had a history of lung and/or liver transplant.

Confidentiality was maintained by assigning a unique number to each participant. There were 12 participants in treatment and control groups, respectively; all were enrolled from the CF clinic database at a Midwestern-pediatric-hospital in the United States.

Participants in the treatment group received a series of three to five MT treatments over 10 to 12 weeks. Each treatment lasted 60-90 min. If diagnosed with a pulmonary exacerbation requiring hospitalization, treatment participants were permitted to continue in the study with pulmonary physician approval. Participants with a history of hepatomegaly or splenomegaly were eligible for the study with the provision that abdominal massage was not performed. If the participant had recently received MT, the first study visit was delayed for 30 days.

For all treatment participants, time between visits was incrementally increased, following a common outpatient model for massage therapy. Anecdotally, as a client's symptoms improve following repeated sessions, time between visits is often increased. For this study, time between visits increased incrementally from 1 week, to 2 weeks, to 3 weeks, to 4 weeks. This study compared findings over time, looking for patterns in timing of musculoskeletal changes following MT and how long the changes lasted.

Participants in the control group were seen twice in the outpatient clinic for data collection at study Weeks zero (time one) and 10 (final study visit). Follow-up phone calls correlated with treatment group visits at Weeks One, Three, and Six. The control group did not receive MT during active study participation. muscles. With overuse, muscle fatigue can occur, with the development of trigger points (TrP). Trigger points, highly sensitive tender nodules in tight, overused, or strained muscles, may restrict mobility as the muscle itself is restricted from lengthening upon demand. (4) Subsequently, muscle fatigue develops as muscles work beyond normal capacity. When muscle fatigue combines with tissue restriction, circulation through muscles is impaired, limiting the amount of oxygen and nutrients traveling to the muscles and waste products leaving the muscles. Toxicity within muscle tissue irritates nerve endings, and can contribute to muscle weakness and associated pain. (4,5) In summary, hospitalized patients with CF experiencing disease progression often presented with muscle dysfunction and pain-factors negatively influencing QOL.

Previous studies of individuals with CF found difficulty breathing, muscle tightness, and postural changes associated with pain. Even children with mild CF reported frequent mild pain, especially in chest, head/neck, and abdomen. (6) In youth, healthrelated QOL was found to significantly decrease as pain increased or persisted over time. (7) A database review from this pediatric study hospital in the state of Ohio in the United States found that MT and MT, combined with another modality such as energy therapy, significantly decreased pain in hospitalized youth with CF. (8) Studies of adults with CF found that MT decreased muscle tightness and musculosketeletal pain in postural muscles. (9.10) Studies of parents administering nighttime massage found lower anxiety and improved pulmonary function in children with asthma, (11) and decreased anxiety in children with CF and their parents, along with improved child mood and peak airflow. (12) Massage protocols in previous studies in CF varied in number of sessions, from single dose (9,10) to nightly for 30 consecutive days. (12) In summary, there were no studies on massage and CF which directly measured QOL. However, there was preliminary support for the use of MT to promote comfort and relaxation and improve ease of breathing in children and young adults with CF.

The purpose of this pilot study was to describe the effects of deep-tissue MT using myofascial TrP techniques on QOL in youth and young adults 8 to 21 years old with CF. The study proposed that a massage protocol focusing on releasing tight tissue and TrPs, improving tissue mobility and functioning, and decreasing musculoskeletal pain, may improve QOL in individuals with CF. (See Appendix A: Protocol). The primary aim of this study was to evaluate if MT in youth and young adults with CF resulted in improved QOL when compared to youth and young adults with CF who did not receive MT. Quality of life was measured with standardized QOL tools and subjective measures including ease of breathing, muscle tightness, and overall relaxation. Results of this study found preliminary support for the use of MT in improving QOL in youth and young adults with CF.

version is a 35-item tool with eight domains: physical, emotional state, social, body image, eating, treatment burden, respiratory, and digestion. Each scale yields a standardized score ranging from 0-100, with higher scores indicating better HRQOL. (18) The Adolescent/ adult version demonstrates internal consistency (α = 0.67-0.94) and test/retest reliability (rs = 0.45-0.90) among patients with CF ages 14 to 53 years old. (19) The child version demonstrates internal consistency and reliability (α = 0.7-0.92) among children with CF ages 6 to 13 years old. (20) Construct validity has been tested by means of correlation with FEV 1 % predicted (r = 0.01-0.18). The parent version demonstrates internal consistency (α = 0.59-0.91) and parent/child agreement = 0.27-0.57. (20) This study focused on the child and teen reports.

Subjective Measures of Quality of Life

In this study, the author created three numeric rating (0-10) scales capturing subjective descriptions of QOL in individuals with CF:

1. Muscle tightness. Participants were asked: "On a scale from 0 to 10, how would you describe how your muscles feel right now, with 0 being the least tight (you are able to move very easily), and 10 being the most tight, the greatest amount of tightness and greatest difficulty moving you have ever experienced?" 2. Ease of breathing. Participants were asked: "On a scale from 0 to 10, how would you describe your breathing right now, with 0 being the least difficulty breathing (you are able to breathe very easily), and 10 being the most difficulty breathing you have ever experienced?" 3. Relaxation. Participants were asked: "On a scale from 0 to 10, how would you describe your overall relaxation right now, with 0 being the least tense and stressed (you feel the most relaxed and calm you have ever felt), and 10 being the most tense and stressed you have ever felt?"

Pain

In this study, pain was measured using a previously established scale, the Numeric Rating Scale (NRS-11), which is a self-report measure of pain intensity for children 8 years and older, with endpoints corresponding to no pain (0) and the worst pain possible (10). The pain scores are categorized as mild (1-3), moderate (4)(5)(6), and severe (7)(8)(9)(10). Previously, validity was demonstrated with three samples of children: correlation with the Faces Pain Scale -Revised (r = 0.87); a visual analogue scale (VAS) (r = 0.89); and between-group comparisons of the distribution of pain intensity scores on the NRS-11 and VAS which showed very similar distributions (paired t = 1.88, df = 117, p = .06), except for scores at the very lowest Participation in the study was voluntary; participants could withdraw at any time. The study included financial compensation for study participants (maximum $60 control group; $90 treatment group). At the conclusion of the study, small bolsters used during MT were to be given to the treatment group participants. A courtesy massage was to be offered to the control group participants at completion of data collection.

Measures

Data were collected by trained study assistants during and between visits. Massage therapists were trained in, and assisted with, data collection outside of the treatment visit.

Statistical Methodology

Descriptive analyses were performed on sample demographics and outcome variables in the treatment and control groups. Two-sample t test and Fisher's exact test were applied for demographic comparison. Continuous variables were summarized using means, standard deviations, and ranges, while categorical variables were described using counts and percentages. Final outcome measures between the treatment and control groups were compared by ANCOVA controlling for age, gender, and baseline prescores. Effect size Omega-squared (ω²) and Cohen's d were calculated to estimate magnitude of the effect. According to Cohen, (13) 0.14, 0.06 and 0.01 are the cut points for ω² and 0.8, 0.5 and 0.2 for d in terms of large, moderate, and small effects. Data were analyzed employing SAS statistical software, version 9.3 (SAS Institute, Cary, NC). A two-sided significance level was set at 0.05.

Quality of Life Measurements

PedsQL

The PedsQL, originally developed to measure health related QOL in children ages 2 to 18 years old, (14) was modified to the PedsQL 4.0, a 23-item scale of general health-related quality of life (HRQOL) in children and adolescents and young adults. (15) The PedsQL 4.0 has demonstrated internal consistency reliability for the total scale score (child self-report α = 0.88, parent proxy report α = 0.90), psychosocial scale score (child self-report α = 0.83, parent proxy report α = 0.86), and physical health summary scale score (child self-report α = 0.80, parent proxy report α = 0.88). Construct validity was demonstrated using known groups method. (16) This study used the selfreport scales and parent proxy reports for children and teens, and self-reports for young adults.

CFQ-R

The CFQ-R is a disease-specific measure of QOL among children and adults with CF. (17) The child Massage techniques were provided by a licensed massage therapist (LMT) and focused on releasing TrPs by applying pressure to affected tissue for 60-90 sec, followed by stretching techniques, specifically PIMR (post-isometric muscle release), to retrain the affected muscle to stay lengthened to its natural resting state. The massage focused primarily on muscles involved in supporting respiration and posture, areas commonly compromised in individuals with CF. Each treatment group participant was assigned to a specific LMT. When the LMT was unavailable, another study trained LMT provided the massage.

The massage therapy protocol included application of massage strokes with the participant placed in three different positions on a massage table: supine, side-lying and sitting. The sequence of massage techniques were administered over 60-90 min and included:

1. In the supine position, gentle bilateral leg stretch and TrP release of quadratus plantae; sacro-sternal fascial releases; L5-S1 release; upper trunk and bilateral shoulder warm-up; chest warm-up; digital kneading bilateral temporalis muscles; posterior neck and suboccipital massage; trapezius warm-up and release; serratus anterior release; pectoralis major TrP release; rectus abdominis and psoas TrP release; tensor fascia lata stretch and PIMR; and ended with assistive inspiration. 2. In the side-lying position (left side down, then repeated all techniques with right side down), spine warm-up with fascial stretches; erector spinae rocking; intercostal stretch and TrP release; levator scapula TrP release and PIMR; rhomboid TrP release and PIMR; and ended with pectoralis minor TrP release and PIMR. 3. In the sitting position on side of table, thoracic PIMR for external intercostals; rotational trunk PIMR for intervertebral muscles.

The entire protocol ended with resting hands on shoulders followed by relaxation stroking down back.

Training

Three LMTs assisted the Principal Investigator (PI) in study related activities. Two of the LMTs had pediatric hospital experience in caring for hospitalized youth and young adults with CF. The third LMT had extensive experience in myofascial TrP therapy and assisted in development of the study MT protocol. The LMTs were trained in the MT protocol over three practice sessions by the PI and the LMT who assisted in protocol development. Additionally, the PI had extensive experience in providing massage therapy to hospitalized individuals with CF at the study hospital. All LMTs, including the PI, demonstrated the ability to consistently provide the massage protocol as outlined for the study with replicable skills. end of the scales (p = .03 at 0). (21) In this study, the NRS scale was administered at predetermined times to evaluate potential effects of MT on musculoskeletal pain.

Pulmonary Function

Spirometry

Measurements for this study included the Forced Vital Capacity (FVC) and Forced Expiratory Volume in 1 sec (FEV 1 ), performed using the American Thoracic Society standards. (22) Previous studies used pulmonary function measurements in individuals with CF who received MT. (9,10,12) Forced Vital Capacity is the total amount of air forcefully exhaled after a full inspiration. During spirometry, the subject must inhale as much air as possible and then exhale as much air as possible. The "F" in FVC is used because this is a forced maneuver. FEV 1 is the total amount of air forcefully exhaled in the first second following a full inspiration.

Assessment of the ease of breathing for this study was measured using the Single Breath Counting Score. (23) This score was determined by having the subject stand with arms relaxed at their sides, take a large breath and then count out loud, reading the numbers from a digital stop watch aloud, one number per second. The highest number the subject was able to verbalize before taking the next breath was the score. The Single Breath Counting Score was previously found to demonstrate test/retest reliability at rest (ICC = 0.93), and construct validity through correlations with FEV 1 after exercise (r = 0.68, p < .001), not at rest.

Thoracic excursion

The upper and lower thoracic excursion of each subject was measured by the cloth tape measure technique of the subject's chest. (24) Both upper and lower thoracic excursion (thoracic circumference) were determined by the following formula: forced inspiration minus forced expiration = thoracic excursion. Test/retest reliability was previously determined with upper thoracic excursion ICC = 0.91 and 0.86 (95% CI, 0.69-0.99) for two sessions of measurement, respectively. Lower thoracic excursion ICC of 0.84 and 0.81 (95% CI 0.69-0.99) was obtained at two measurement sessions respectively.

Procedures

Intervention

A specific MT protocol based on deep tissue myofascial TrP therapy (25) was developed by the lead author in collaboration with MT experts. The massage protocol blended Swedish strokes and myofascial TrP therapy, creating a full body sequence of massage strokes.  25. When compared to the control group, by the end of the study, the child psychosocial and total health subscales in the treatment group improved a little more with very small effect sizes (ω² = 0.006, and 0.005) (see Table 1). Additionally, the post parent/ caregiver physical health scores improved more in the treatment group than the control group (ω² = 0.010).

The treatment group reported a decrease in muscle  Table 2). However, results were not statistically significant. Of note, the male participants had significantly higher PedsQL scores on emotional, social, and school functioning, and general psychosocial health than the female participants at the conclusion of the study. Interestingly, when comparing a child one year younger in age (e.g., 10-year-old compared to 11-year-old), the younger participant had significantly higher social functioning scores at the end of the study (p = .0466).

Timeline

In an effort to determine the body's ability to maintain musculoskeletal changes following the massage protocol, time between treatments was gradually increased. The required three to five MT treatments were administered over 10 to 12 weeks. (See Appendix B: Timeline).

RESULTS

Demographics

This pilot study enrolled a convenience sample of 30 males and females, 8-to 21-year-olds; 24 participants completed the study and six were lost to attrition (four declined participation after initial enrollment; one was unable to be reached; and one was withdrawn due to missed visits (only completed two of the three required visits). All remaining participants completed the required number of visits/phone data collection. All participants in the study were Caucasian, ranging in age from 9.9 to 20.6 years old, with a mean age of 15.7 (SD = 3.5) years. Sixteen (66.6%) of the participants were female. There were no significant differences for age and gender (p > .66) between the treatment and control groups. The number of hospitalizations was compared between the treatment and control groups. Three participants in the treatment group were hospitalized four times collectively and six participants in the control group were hospitalized 16 times collectively, (ranging from 1 to 8 times). The number of hospitalizations in treatment group was lower (Mean (SD) = 0.33 (0.65) than control group (Mean (SD) = 1.35 (2.30), but did not achieve statistical significance (Wilcoxon rank-sum test, Z = 1.2741, p = .2026) with close to medium effect size (r = 0.24).

Quality of Life

Quality of life was measured with the PedsQL 4.0 and CFQ-R and with subjective measures of muscle tightness, ease of breathing, and relaxation created for this study. Previous studies described similar quality of life indicators for individuals with CF (e.g., subjective reports of improved breathing; (9,10,12) decreased pain, less restricted breathing, and increased relaxation (21) ); and reduced muscle tightness, easier breathing, increased muscle strength and chest expansion, improved sleep, increased relaxation, and an overall feeling of improved well-being. (10) No statistically significant differences in children's and caregivers' QOL scores in treatment group between pre-and post-MT intervention or compared to the control group was achieved when using the  LSmean: Least-Squares mean adjusted for the covariates age, gender, and pre-score to 9-year-old) (p = .0418) had significantly higher FVC percent predicted measure by 1.13 at the end of the study (see Table 3). The treatment group had higher single breath counting scores (d = 0.47) than the control group at the last study visit. No statistically significant changes in PFTs were found for either group over time.

DISCUSSION

Cystic Fibrosis is a common, life-shortening genetic disease which may negatively affect QOL. With disease progression, individuals may experience an increase in pulmonary exacerbations including increased work of breathing and related cough, and musculoskeletal changes with pain and tissue dysfunction. Children with mild CF have reported frequent mild pain in chest, head/neck, and abdomen. (6) Previously, youth with CF were found to experience significant decreases in QOL as pain increased or persisted over time. (7) Additional findings supported the use of massage therapy in individuals with CF to improve QOL-for example, MT significantly decreased pain in hospitalized youth, (8) decreased anxiety and improved mood and peak airflow in children, (12) and decreased muscle tightness and musculoskeletal pain in postural muscles in adults with CF. (9,10) Other subjective descriptions of improved QOL included improved breathing and pulmonary function, (8,9,10) decreased pain, less restricted breathing, and increased relaxation, (26) and

Musculoskeletal Pain

When comparing the participants' pain scores of mild, moderate, and severe, the treatment group reported lower Pain NRS score ((Mean (SD) = 0 (0) vs. Mean (SD) = 0.67 (1.23), d = 0.94)) at the last follow-up call. NRS pain scores had improved compared to the control group at post-visit 5, with marginal significance (p = .076) and a moderate effect size (ω² = 0.095) (see Tables 2 and 3).

ZINK: IMPROVING QOL WITH MASSAGE THERAPY IN INDIVIDUALS WITH CF

Pulmonary Function

Pulmonary function measures included upper and lower thoracic excursion and spirometry scores (  Table 2). The PFT in the treatment group showed a slightly higher trend than in the control group. The participant who was 1 year older in age (e.g., 10-year-old compared visits (e.g., every three months) than a longer, more frequent MT intervention. Preventative measures in CF care, including MT, may subsequently be found to improve musculoskeletal function and form, decrease related pain (e.g., triggered by cough and increased respiratory effort), and may ultimately contribute to a decrease in frequency of hospitalizations and an increase in quality of life in individuals with CF. reduced muscle tightness, easier breathing, increased muscle strength and chest expansion, improved sleep, increased relaxation, and an overall feeling of improved well-being. (10) As previously discussed in the Results section of this pilot study, statistically significant results were not achieved for some outcomes with large and moderate effect sizes between the treatment and control groups. These findings may be due to the low statistical power attributed to the small sample size.

ACKNOWLEDGMENTS

This study aimed to explore the trend and effect sizes in the measured outcomes to determine the feasibility and potential value of future large scale multi-site studies. In this sense, effect size and trend were more useful than statistical significance due to the small sample size (N = 24) which could not provide enough power for the statistical tests to detect statistical significance on some large and moderate effect sizes. Number of hospitalizations in treatment group was lower than control group with a close to medium size effect, but did not achieve statistical significance. There were inconsistent findings from the PedsQL and CFQ-R tools. The time-specific subjective measures of QOL, including pain, muscle tightness, ease of breathing, and overall relaxation, found positive effects of MT and may be more sensitive to treatment specific changes. There were no significant changes in PFTs. However, improved ease of breathing and thoracic excursion scores were found in participants who received MT. A study limitation was the applicability of using the single breath counting score for subjects at rest. Test/retest reliability had been previously found at rest, and construct validity found after exercise. Additionally, the data did not include reports of significant life events which could impact QOL.

CONCLUSION

The feasibility of conducting a study on MT in CF over 10 to 12 weeks was demonstrated in this pilot study. Trends in the data suggested that the use of a myofascial TrP massage in CF care may be beneficial. Overall, the results of this study contributed to the body of knowledge related to the effects of MT on individuals with CF. However, the protocol was based on MT outpatient practices and is limited in its application to outpatient CF care (no related studies found). Future recommendations include a shortened version (15 to 30 min) of the study protocol, using subjective measures of QOL and modifying the deep tissue myofascial TrP protocol to focus on areas where TrPs most frequently occur in this population. This study primarily found TrPs in the intercostal muscles, thoracic erectors, and sternal and lower ribcage attachments. A shortened MT protocol targeting musculoskeletal dysfunction and pain may be more feasible for routine outpatient CF clinic With fingertips bilateral to cervical muscles, apply gentle medial pressure alternating left to right from upper to lower cervicals (x3). 8 The techniques and sequence detailed below were performed at each study visit. Techniques included variability in strokes, amount of pressure and frequency, e.g., repeated 3-5 times, per therapist's professional judgment, to achieve muscle release. Flaxseed pillows and standard pillows or half round bolsters were used for proper positioning.

A. Supine position. Bolsters at occiput and under knees.

tightness ((Mean (SD) = 0.36 (1.81) vs. Mean (SD) = 1.80 (1.48), d = 1.06)); greater ease of breathing ((Mean (SD) = 0.73 (1.01) vs. Mean (SD) = 0.50 (0.97), d = 0.06)); and improved relaxation ((Mean (SD) = 0.91 (1.14) vs. Mean (SD) = 1.40 (1.35), d = 0.66)) at the last follow-up call. Compared to the control group, muscle tightness in the MT group was significantly reduced (p = .048) at post-visit 5, with a large effect size (ω² = 0.163). Relaxation scores in the MT group were improved (p = .052) compared to the control group at post-visit 5, with a large (ω² = 0.156) effect size (see

PedsQL 4.0 and the CFQ-R tools. However, PedsQL 4.0 scores clinically improved in the treatment group in psychosocial ((Mean (SD) = 84.72 (15.04) vs. ZINK: IMPROVING QOL WITH MASSAGE THERAPY IN INDIVIDUALS WITH CF

FEV 1 and FVC). The upper and lower Mean TE scores in the MT group were improved at the post-visit 5 ((Mean (SD) = 3.72 (1.23) vs. Mean (SD) = 3.06 (1.28), d = 0.53)) and ((Mean (SD) = 5.47 (1.75) vs. Mean (SD) = 5.14 (2.30), d = 0.26)). Compared to the control group, the upper and lower Mean TE scores were marginally statistically significantly higher (p = .078, and p = .056) in the last visit, with moderate effect sizes (ω² = 0.083 and ω² = 0.073) (see

This study was supported by a grant from the Carolyn Stoll Nursing Research Fund, Cincinnati Children's Hospital Medical Center. This funding source had no specific involvement in the conduct of this research or related presentations, publications or other reporting activities. Earle Timberlake, Registered Massage Therapist and clinical expert in myofascial trigger point massage consulted on this study related to massage protocol development. James Taddeo, BSN, RN, LMT and Margaret Bottenhorn, MA, LMT assisted with data collection and massage therapy when the primary therapist was unavailable. Barbara Giambra, PhD, RN, CPNP, Assistant Professor in the Center for Professional Excellence at CCHMC, assisted in the review of literature. Melissa Liddle, MA, CCLS, CTRS assisted in manuscript development. Kate Zink dedicates this study to the courageous young individuals with Cystic Fibrosis who have inspired her work and reminded her of the value of living our lives to the fullest. With heartfelt appreciation, she wish each of you joy and a rich and meaningful life.

Table 1 .
1Children and parent post-intervention Peds QL 4.0 scoreLSmean for Post Score

p-value Control Treatment

Table 3 .
3Postintervention Clinical MeasurementsLSmean for Post Score

p-value Control Treatment
Effect
Size, ω²

Pain NRS score
0.076 # 1.44
0.02
0.095
NRS score Muscle Tightness 0.048 * 1.48
0.36
0.163
Ease of Breathing
0.223
1.10
0.35
0.032
Ease of Relaxation
0.052 # 1.97
0.66
0.156
Pulmonary Measures Single
Breath Count
0.164 17.49
21.27
0.027

Pulmonary Measures Upper
Mean TE
0.078 # 2.94
3.81
0.083

Pulmonary Measures Lower
Mean TE
0.056 # 4.04
5.28
0.073

FVC measured
0.848
3.42
3.44
0.001
FVC percentage
0.864 92.94
93.58
0.009
FEV 1 measured
0.968
2.73
2.73
0.002
FEV 1 percentage
0.871 84.89
85.40
0.005

* p< 0.05; # 0.05≤ p <0.1; 0.14, 0.06 and 0.01 are the ω² cut points
for large, moderate and small effects;
LSmean: Least-Squares mean adjusted for the covariates age,
gender, and pre-score

Table 2
2Clinical outcome means and standard deviations, not
adjusted for covariates

Outcome

Treatment
Control

Pre_visit
1

Post_visit
5

Pre_visit
1

Post_visit
5

Pain NRS score
0.67
(1.23)
0 (0)
1.17
(1.80)

1.58
(2.39)
NRS score Muscle
Tightness

1.80
(1.48)

0.27
(0.65)

2.11
(1.96)

1.80
(1.81)

Ease of Breathing
0.50
(0.97)

0.36
(0.67)

0.56
(0.86)

1.00
(1.63)

Ease of Relaxation
1.40
(1.35)

0.36
(0.50)

2.28
(2.05)

2.40
(2.17)
Pulmonary Measures
Single Breath Count

17.00
(5.01)

20.42
(9.10)

17.45
(8.70)

16.73
(7.10)
Pulmonary Measures
Upper Mean TE

3.06
(1.28)

3.72
(1.23)

3.34
(1.22)

2.99
(1.15)
Pulmonary Measures
Lower Mean TE

5.14
(2.30)

5.47
(1.75)

3.90
(1.56)

3.94
(1.68)

FVC measured
3.11
(1.16)

3.12
(1.29)

3.73
(1.33)

3.74
(1.31)

FVC percentage
88.17
(17.07)

88.42
(17.06)

98.08
(15.62)

98.08
(19.13)

FEV 1 measured
2.48
(0.98)

2.44
(1.03)

3.13
(1.13)

3.06
(1.09)

FEV 1 percentage
81.92
(20.64)

79.25
(20.31)

95.08
(17.09)

92.83
(21.63)

. Trapezius warm up and release.Cradle oc-
ciput with left hand while applying pressure
with right thumb to mid sagittal suture on
top of head x 1-2 minutes. Sift trapezius
for areas of restriction and release 1-2
TrP's as available. Sift scalenes and release
Trp's as indicated. Lift and cradle head on
open palms, head in forward flexion, x 1-2
minutes. Follow with occipital base release
(head on table). Right hand on left shoulder
and left hand cradling head on left, gently
resist lateral head flexion left while gently
resisting left shoulder shrug up and perform
PIMR x 1. Left hand on right shoulder and
right hand cradling head on right, gently
resist lateral head flexion right while gen-
tly resisting right shoulder shrug up and
perform PIMR x 1. With therapist's arms
crossed and under subject's head, subject's
eyes open, move head up to barrier. Instruct
subject to push back into therapist's arms,
breathe in, and then relax head and allow
therapist to move head farther into flexion.
Invite subject to drop shoulders down to
enhance the stretch.
9. a. Serratus anterior. (Bolster under head).
Right side. Locate TrP at T6 on lateral
rib. Instruct subject to breathe in while
therapist holds TrP with finger tips, raising
subject's hand above head and lowering
flexed arm to side. Repeat sequence as
indicated. Finish with PIMR x 1.
b. Pectoralis major. Bolster under right
elbow, arm flexed 90 degrees with palm
on table. Sift lateral body of pectoralis
major, searching for 2-3 trigger points and
release if found. Perform pectoralis major
stretches with subject close to side/edge
of table. Stretch at 90 degrees abduction
(palm up), opposite hand fixed on the ster-
nal head (between breast tissue) followed
by PIMR x 3.
Repeat above sequence (serratus anterior and
pectoralis major) on left side.
10. Rectus abdominis and psoas (omit this section
for persons with hepatomegaly or spleno-
megaly). Starting on left side, flex knees, feet
flat on table. With finger tips, follow inferior
costal border medial to lateral, for 2 inches,
searching for TrP's; hold 60 seconds. Allow
left flexed knee to drop laterally, externally
rotating hip. Search anterior ileum for TrP's
and release, including ASIS joint. Right leg
on table, flex left leg 90 degrees off table.
Gently press fingertips into abdomen 1-2"
lateral to umbilicus while subject lifts flexed

APPENDICES

Appendix A: Massage therapy intervention: Myo-
fascial trigger point therapy.

Temporalis. (Remove bolster from under head). Gentle digital kneading bilateral temporalis muscles 15-30 seconds. 7. Posterior neck and sub occipitals. Cradle head with fingertips on posterior cervical muscles. leg and therapist locates psoas muscle. Apply light to moderate pressure, allowing psoas to soften (30-60 seconds). Release pressure. Perform PIMR flexed leg x 1. Repeat rectus abdominis and psoas releases on right side. 11. Tensor fascia lata (TFL). Therapist on right side. Left leg extended, right leg flexed, foot crossed left knee and foot flat on table. With left hand, gently push right knee to left while pulling left ankle with right hand across midline. Instruct subject to pull left leg lateral (to the left) and push right knee into therapist's hand (to the right) to perform PIMR x 3; end last PIMR with medial pull/ jerk. Repeat on left side, changing direction of PIMR stretches accordingly. Remove bolster from head. 12. Assistive inspiration. Small bolster under lower back. Therapist positioned at head of table with subject raising arms up with palms toward ceiling. Therapist grasps hands, palm to palm, interlocking thumbs and bringing arms superior, overhead with subject inhaling, to expand chest. Subject instructed to exhale while therapist brings arms down toward abdomen and therapist applies gentle downward pressure on inferior ribcage; perform X 3. B. Side lying position, left side down. Small bolster under waist to arch spine laterally; large bolster anterior to chest for arm support and between legs/ knees for leg support; pillow bolster under head. 1. Spine warm up. Standing posterior to subject, perform passive touch and gentle back stretch; one hand on sacrum, other hand on upper back, stretching fasciae, hands away from one another. 2. Erector spinae. Apply thumb presses with rocking motion along spine (deep paraspinals), from upper neck to sacrum, on the up side of vertebrae, X 3. 3. Intercostals. Apply gentle stretch, one palm down and other palm on top of hand. Gently press fascia inward and anterior, over ribs. Upper arm above head, subject's hand holding head of massage table. Using P-ball or fingertips, apply gentle intercostal presses from T4 (under axilla) to T12, posterior to anterior. Treat costal angle going anterior, and then treat anterior intercostals under breast. 4. Levator scapula. Perform digital kneading of levator scapulae with upper arm over head. With fingertips, locate TrP's at insertion of levator scapulae at superior border and medial angle scapula. Treat TrP with massage tool at angle of neck where muscle surfaces, at ZINK: IMPROVING QOL WITH MASSAGE THERAPY IN INDIVIDUALS WITH CF muscle twist at anterior border of trapezius and superior medial angle of scapula. 5. Rhomboids. Position upper arm anterior to subject, closed fist on massage table and elbow flexed and pointed toward ceiling. Search rhomboids inferior to superior (cross fiber) and treat myofascial trigger points along vertebral border of scapula. Move upper arm in extension above head and back to 90 degree flexion. Finish with PIMR rhomboids x 1 by extending arm over head (pushing anterior at shoulder). 6. Pectoralis Minor. With upper arm relaxed across body and lying on large bolster, palm down, perform myofascial TrP therapy. Work with fingertips/thumb deep to lateral body of pectoralis major from attachments on 5 th , 4 th , and 3 rd ribs toward coracoid process. Perform PIMR x 1. Assist subject in positioning to the right side; repeat above steps 2-6. C. Sitting position. Therapist assists subject to sitting position on side of the table. 1. Thoracic PIMR for external intercostals. Therapist in front of subject, subject takes breath in while therapist gently assists subject in performing a side-bending movement right, at which time subject releases the breath and therapist extends the stretch with gentle pressure on right shoulder. Perform PIMR X 1. Therapist returns subject to center position and repeats sequence left. 2. Rotational trunk PIMR for intervertebral muscles. Therapist behind subject, instructs subject to cross arms at chest, hands on opposite shoulders. First position -therapist rotates subject to left (grasping right elbow), while subject turns head right. Therapist instructs subject to take breath in x 5 seconds and release the breath out while therapist continues to gently rotate trunk left with head turning left. Therapist supports back with opposite hand. Second position -therapist rotates subject to right (grasping left elbow), while subject turns head left. Therapist instructs subject to take breath in x 5 seconds and release the breath out while therapist continues to gently rotate trunk right with head turning right. Therapist supports back with opposite hand. 3. Resting hands on shoulders. Therapist gently rests hands on subject's shoulders x 15-30 seconds. 4. Relaxation stroking. To finish treatment, therapist uses full open hands palms down to stroke subject from the top of the head, down the full back. Perform X 3. Procedures: Pre, during massage & Post f/u phone call * f/u phone call * f/u phone call * f/u phone call * f/u phone call * Numeric rating scale for muscle tightness (0-10 worst possible) Post f/u phone call * f/u phone call * f/u phone call * f/u phone call * f/u phone call * Numeric rating scale for ease of breathing (0-10 worst possible) Pre & Post Pre & Post Pre & Post Pre & Post Pre & Post f/u phone call * f/u phone call * f/u phone call * f/u phone call * f/u phone call * Numeric rating scale for relaxation (0-10 worst possible) Pre & Post Pre & Post Pre & Post Pre & Post Pre & Post f/u phone call * f/u phone call * f/u phone call * f/u phone call * f/u phone call * Pulmonary Function Test (Forced Vital Capacity and Forced Expiratory Volume in 1 minute) * Phone calls (included call, text or email) were made 1-2 days following each study visit. Summary of Treatment group schedule: Visit 1 was day 0.Visit 2 was scheduled 5-10 days following visit 1.Visit 3 was scheduled 12-17 days following visit 2.Visit 4 was scheduled 19-24 days following visit 3.Visit 5 was scheduled 26-31 days following visit 4.1. Gentle leg stretch followed by TrP (trigger
point) release of quadratus plantae at soles
of feet and Post Isometric Muscle Release
(PIMR) each leg.
2. Sacro-sternal fascial releases. Hold sacrum in
palm of hand and allow tissue to relax. Apply
gentle pressure with other hand on abdomen,
lower ribcage, and upper ribcage/sternum and
traction toward umbilicus.
3. L5-S1 release. Stand on right side, place open
palm right hand under sacrum and open fisted
left hand horizontal at L5, cupping spinous
processes. Gently distract hands away from
one another.
4. Upper trunk/shoulder warm up, right and left
sides. (Bolster under shoulder being worked)
Passive arm stretches repeated 5-10 times in
three arm positions:

i. Upper arm at 90 degrees, elbow flexed,
palm down. Hand raised toward head,
then down to side.
ii. Upper arm at 90 degrees, elbow flexed,
palm down. Elbow raised toward head
and back down to 90 degree flexion.
iii. Upper arm at 90 degrees, palm facing up.
Arm raised over head, fingers extended.
Return arm to 90 degrees flexion.
iv. Remove bolster, reposition under left
arm/shoulder and repeat sequence on left
side. Remove bolster.

5. Chest warm up. Digital kneading bilater-
ally, sterno-costal points of attachment, from
clavicle to xiphoid process (x3). Apply gentle
pressure to points of attachment bilaterally
and perform horizontal tissue glide (x3).
Perform costal raking upper chest bilaterally,
medial to lateral (5-10 times).
6. Massage Therapy
X
X
X
X
X
Measures:
Peds QL 4.0 (Pediatric Quality of Life
Inventory)
Parent & Child
Parent & Child

CFQ-R (Cystic Fibrosis Questionnaire -
Revised)
Parent & Child
Parent & Child

Ease of Breathing (Single breath counting
score)
Pre & Post
Pre & Post
Pre & Post
Pre & Post
Pre & Post

Thoracic Excursion (Cloth Tape Measure)
Pre, During
massage, Post

Pre, During
massage, Post

Pre, During
massage, Post

Pre, During
massage, Post

Pre, During
massage, Post
Numeric pain scale
(0 no pain;
10 worst possible pain)

Pre, during
massage & Post

Pre, during
massage & Post

Pre, during
massage & Post

Pre, during
massage & Post

Pre & Post
Pre & Post
Pre & Post
Pre & Post
Pre & Clinical Data
Collected
X

•

•

•

•

•

International Journal of Therapeutic Massage and Bodywork-Volume 12, Number 1, March 2019
CONFLICT OF INTEREST NOTIFICATIONThe authors declare there are no known conflicts of interest associated with this study.COPYRIGHTPublished under the CreativeCommons Attribution-NonCommercial-NoDerivs 3.0 License.
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* Phone calls (included call, text or email) were made 1-2 days following each study visit and at study week 1, 3, and 6. * Phone calls (included call, text or email) were made 1-2 days following each study visit and at study week 1, 3, and 6.

Additionally, a study phone call, text or email was made at the following times. Additionally, a study phone call, text or email was made at the following times:


Is it possible to use specific IgE to single latex allergens to discriminate between spina patients with natural rubber latex allergy and sensitization?
2010

Reinhold Cremer
Hans-Peter Rihs
Angela Gaspar
Graca Pires
Monika Raulf-Heimsoth
Is it possible to use specific IgE to single latex allergens to discriminate between spina patients with natural rubber latex allergy and sensitization?

Canada. BMC Bioinformatics
112010201010.1186/1743-8454-7-S1-S17O R A L P R E S E N T A T I O N
BackgroundEleven characterized allergens of Hevea brasiliensis are available as recombinant proteins for in vitro IgE diagnosis. Hev b 2 and Hev b 13 are only suitable as native proteins. By testing patient sera against this panel of recombinant and native allergens of Hevea brasiliensis individual sensitization profiles and the relevance of single allergens can be assessed.Materials and methodsSera of 30 spina bifida patients with specific IgE to NRL were tested for allergen-specific IgE antibodies (sIgE) to natural rubber latex (NRL) and 13 single Hev b allergens using the ImmunoCAP system. The results of the specific IgE values against single allergens were plotted (frequency of antibodies against the single allergen vs. the percentage of the total latex-specific IgE-response). Minor and major allergens for spina bifida patients sensitized or allergic against NRL could be identified.ResultsRegarding all 30 spina bifida patients with sIgE Hev b 1, 2, 3, 5, 6.01 and 13 were identified as major Hev b allergens. In the patients without latex-related symptoms Hev b 2 and Hev b 6.01 were found only in small percentages of the latex-specific IgE response and low frequencies (minor allergens) whereas in patients with latex-related symptoms these allergens were found in high concentrations and frequencies. Hev b 5 represents the allergen with the highest percentage of the latex specific IgE response in all groups of patients, Hev b 1 is the allergen with the highest frequency of sensitization (about 80%) in all groups.ConclusionsLatex extracts for skin prick testing or in vitro allergosorbents should contain the major allergens Hev b 1, 2, 3, 5, 6.01 and 13. In spina bifida patients Hev b 6.01 and Hev b 2 could be useful to distinguish sensitized from allergic patients.AcknowledgementsThis article has been published as part of

Is it possible to use specific IgE to single latex allergens to discriminate between spina patients with natural rubber latex allergy and sensitization?

Background Eleven characterized allergens of Hevea brasiliensis are available as recombinant proteins for in vitro IgE diagnosis. Hev b 2 and Hev b 13 are only suitable as native proteins. By testing patient sera against this panel of recombinant and native allergens of Hevea brasiliensis individual sensitization profiles and the relevance of single allergens can be assessed.

Materials and methods

Sera of 30 spina bifida patients with specific IgE to NRL were tested for allergen-specific IgE antibodies (sIgE) to natural rubber latex (NRL) and 13 single Hev b allergens using the ImmunoCAP system. The results of the specific IgE values against single allergens were plotted (frequency of antibodies against the single allergen vs. the percentage of the total latex-specific IgE-response). Minor and major allergens for spina bifida patients sensitized or allergic against NRL could be identified.

Results

Regarding all 30 spina bifida patients with sIgE Hev b 1, 2, 3, 5, 6.01 and 13 were identified as major Hev b allergens. In the patients without latex-related symptoms Hev b 2 and Hev b 6.01 were found only in small percentages of the latex-specific IgE response and low frequencies (minor allergens) whereas in patients with latex-related symptoms these allergens were found in high concentrations and frequencies. Hev b 5 represents the allergen with the highest percentage of the latex specific IgE response in all groups of patients, Hev b 1 is the allergen with the highest frequency of sensitization (about 80%) in all groups.

Conclusions

Latex extracts for skin prick testing or in vitro allergosorbents should contain the major allergens Hev b 1, 2, 3, 5, 6.01 and 13. In spina bifida patients Hev b 6.01 and Hev b 2 could be useful to distinguish sensitized from allergic patients.
 © 2010 Cremer et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
AcknowledgementsThis article has been published as part of BMC Bioinformatics Volume 11 Supplement 12, 2010: Proceedings of the 11th Annual Bioinformatics Open Source Conference (BOSC) 2010. The full contents of the supplement are available online at http://www.biomedcentral.com/1471-2105/11?issue=S12.):S17 http://www.cerebrospinalfluidresearch.com/content/7/S1/S17 CEREBROSPINAL FLUID RESEARCH


Ships, ports and particulate air pollution -an analysis of recent studies

Daniel Mueller
Stefanie Uibel
Masaya Takemura
Doris Klingelhoefer
David A Groneberg
Ships, ports and particulate air pollution -an analysis of recent studies
R E V I E W
The duration of use is usually significantly longer for marine vessels than for roadside vehicles. Therefore, these vessels are often powered by relatively old engines which may propagate air pollution. Also, the quality of fuel used for marine vessels is usually not comparable to the quality of fuels used in the automotive sector and therefore, port areas may exhibit a high degree of air pollution. In contrast to the multitude of studies that addressed outdoor air pollution due to road traffic, only little is known about ship-related air pollution. Therefore the present article aims to summarize recent studies that address air pollution, i.e. particulate matter exposure, due to marine vessels. It can be stated that the data in this area of research is still largely limited. Especially, knowledge on the different air pollutions in different sea areas is needed.

Introduction

Air quality issues are extremely important for both occupational and environmental health. In this respect, numerous airborne factors negatively influence human health [1][2][3][4][5][6]. In port cities and coastal areas many sources of air pollution can be found. These air pollution sources are ship traffic, industry, rail traffic, and usual sources such as residential emissions ( Figure 1). Whereas numerous studies on road traffic-related air pollution have been conducted in the past, only little is known about the magnitude and effects of air pollution due to marine vessels. According to the U.S. environmental protection agency (EPA) particulate matter (PM) is one of the six common air pollutants [7]. PM can be categorized to the main fractions such as PM10, PM2.5 and ultrafine particles (UFP). PM10 and PM2.5 are defined as particulate matter with a diameter of 10 micrometers (μm) respectively 2.5 μm collected with 50% efficiency by a sampling collection device [8]. UFP are particles with a diameter less than or equal to a nominal 0.1 μm. These small particles can depose deep in the respiratory tract, and there are multiple proven associations between these particles and acute or chronic health effects [9][10][11][12][13][14][15][16][17][18][19][20]. Therefore, this review focuses on air pollution by PM emission, especially PM10 and PM2.5 emissions, due to shipping and port activities.

Measurements of PM concentration in coastal regions

In a multi-year study conducted from 2003 to 2007 by Pandolfi et al., ambient PM10 and PM2.5 data were collected at four sampling locations around the Bay of Algeciras in southern Spain. To identify major PM sources -with particular attention paid to the quantification of total shipping emissions -positive matrix factorization models were used [21]. After that, the impact of the emissions from the harbor of Algeciras and vessel traffic at the Western entrance of Mediterranean Sea were quantified. For the estimation of shipping dependent PM emissions, ambient levels of vanadium (V), nickel (Ni), lanthanum (La) and cerium (Ce) were used as markers in this study [21]. According to the scientists, the shipping emissions were characterized by La/ Ce ratios between 0.6 and 0.8 and V/Ni ratios around 3 for both PM10 and PM2.5. It was estimated that the direct contribution from shipping in the Bay of Algeciras PM10 was 1.4 to 2.6 μg/m 3 (3-7%) and PM2.5 concentration was 1.2 to 2.3 μg/m 3 (5-10%). The study demonstrated further, that the total contribution from shipping reached 4.7 μg/m 3 (13%) for PM10 and 4.1 μg/ m 3 (17%) for PM2.5 [21].

In another study Agrawal et al. investigated the impact of primary fine particulate matter PM2.5 from ship emissions within the Southern California Air Basin. In this study also V and Ni were used as marker for the shipping emissions [22]. V and Ni were measured in stack emissions of in-use ocean-going vessels (OGVs) and then compared with ambient measurements made at 10 monitoring stations throughout Southern California. The researcher could demonstrate that the transition metals V and Ni are robust markers for the combustion of heavy fuel oil in OGVs [22]. In this respect, it was found that ambient measurements of fine particulate V and Ni within Southern California are shown to decrease inversely with increased distance from the ports of Los Angeles and Long Beach. To estimate the primary PM2.5 contributions from OGVs at the multiple monitoring locations the researcher used normalized emission rates. In relation to the total PM2.5 Agrawal et al. found that primary PM2.5 contributions from OGVs range from 8.8% at the monitoring location closest to the port to 1.4% monitored 80 km inland [22]. The scientists concluded that the results of their analysis will be useful in determining the impacts of primary particulate emissions from OGVs upon worldwide communities downwind of port operations.

In the same region of Southern California, Ault et al. studied the impact of emissions during regional shipping transport events [23]. Atmospheric aerosol measurements during time periods with regional transport showed an increase in 0.5-1 μm sized single particles with unique signatures including soot, metals (i.e., vanadium, iron, and nickel), sulfate, and nitrate in La Jolla, California [23]. Ault et al. assumed as well that these particles can be attributed to primary emissions from residual oil sources such as ship engine exhaust. However, the authors of this study state that these particles could also be attributed to emissions of refineries and traffic in the port region as well as to secondary processing during the transport. The results of these measurements showed 2-4 times higher PM2.5 concentrations than typical average concentrations from local sources [23]. Ault et al. therefore conclude that unless significant regulations are imposed these emission sources will become even more important to California air quality as cars and truck emissions. Elevation of PM2.5 concentration in coastal regions due to ship engine emissions was as well reported by a Canadian study carried out by Poplawski et al. They investigated the association between community level concentrations of PM2.5 with cruise ships traffic in Victoria, British Columbia [24]. They obtained data from 2005 to 2008 at a close air quality network site (3.5 km from the study area) and took continuous measurements in the James Bay community over a three-month period during the 2009 cruise ship season. Next to PM2.5 they also investigated concentrations of some gaseous air pollutants. The measurements downwind the port showed an elevation of PM2.5 concentration on weekends when cruise ship activity reached the weekly maximum [24].

In Turkey, Deniz et al. investigated in 2010 within two adjacent studies the shipping emissions in coastal regions with heavy shipping traffic. The first study was carried out in the Candarli Gulf and the second study at the Ambarli Port [25,26]. The objective of the studies was to estimate the amount of major atmospheric components emitted from heavy ship engines. Next to some gaseous air pollutants the studies focused mainly on PM with no distinction between different PM-fractions. The first study in the Candarli Gulf PM investigated the annual shipping emissions from 7520 ships during the year of 2007 and the researcher estimated 57.4 tons per year (t/y) for PM [26]. In the second study Deniz et al. calculated the exhaust emissions from ships at the Ambarli Port by utilizing data acquired in 2005. The total emission from ships at this port was estimated with 36 t/y for PM by the scientists [25].

Healy et al. characterized in a 2009 study single particles from in-port ship emissions in the Port of Cork in Ireland [27]. In this study, the size and composition of freshly emitted individual ship exhaust particles was investigated. For the measurement an aerosol time-offlight mass spectrometer was used (ATOFMS) colocated with a suite of real-time instrumentations at a site in the Port of Cork. Clustering the collected spectra by using the K-means algorithm, they could identify a unique ship exhaust class containing internally mixed elemental and organic carbon, sodium, calcium, iron, vanadium, nickel and sulfate [27]. During the three week measurement period in August 2008 the Healy et al. group could observe over twenty sharp emission events for this particle type. Coincident increases in mass concentrations of sulfate, elemental carbon and PM2.5 were also observed during these events in this study. Furthermore, simultaneous scanning mobility particle sizer (SMPS) measurements were used. The results of this SMPS monitoring showed that the vast majority of freshly emitted ship exhaust particles is present in the ultrafine mode (< 100 nm diameter) [27]. A second particle class constituted of internally mixed organic carbon, elemental carbon, ammonium and sulfate. The scientists tentatively attributed this second particle class to aged or regionally transported ship exhaust. On basis of these findings, Healy et al. suggested that ATOFMS single particle mass spectra may be useful in determining the contribution of local shipping traffic to air quality in port cities, when used in conjunction with other air quality monitoring instrumentation [27].

Effect of ship type and fuel type on the PM concentration in ship emissions

In a recent article Johnson et al. investigated sizeresolved emission factors for particle number (EF (PN)) and mass (EF (PM)) for 734 individual ship passages. This study was carried out in Sweden near the entrance to the port of Gothenburg [28]. In their experiments an extractive sampling method of the passing ship plumes was used and next to gaseous emissions (CO 2 ) the particle number/mass were measured with high time resolution (1 Hz). The place of measurement was situated in an emission control area (ECA) and near to populated areas. The investigation resulted in an average EF (PN) and EF (PM) of 2.55 +/-0.11 × 10 16 (kg fuel) -1 and 2050 +/-110 mg (kg fuel) -1 , respectively [28]. For ships with multiple passages, a great reproducibility for the determined EF was shown and the EF(PN) peaked at particle sizes similar to 35 nm [28]. Interestingly, compared to ships with diesel engines, ships equipped with gas turbine showed smaller particle sizes and less mass. On average 36 to 46% of the emitted particles by number were non-volatile [28].

In a 2011, a real-time study by Jayaram et al. assessed gaseous emissions and PM2.5 emissions of a ship engine powered with different fuel types [29]. The authors measured regulated and unregulated emissions from an inuse marine propulsion engine (EPA Tier 2) on a ferry in a real-time fashion. For comparison with the certification standards and across biodiesel blends the investigated engine was operated following the loads in ISO 8178-4 E3 cycle. Furthermore, real-time measurements were made during a typical cruise in the bay. As a result Jayaram et al. were able to demonstrate that in-use PM2.5 emission factors were within the not-to-exceed standard for Tier 2 marine engines. The comparison of the fuels showed for PM2.5 a reduction of 16% on ships fuelled with Biodiesel B20 and of 25% on ships fuelled with Biodiesel B50 [29]. Furthermore, reductions in the volume mean diameter and total number concentration in the accumulation mode with increasing biodiesel blends was observed. These findings were consistent with trends found in gravimetric PM2.5 mass emissions [29]. In other studies similar trends of particle size and number reduction in accumulation mode with biodiesel was reported [30,31]. Jayaram et al. were able to demonstrate the important effects of ocean/bay currents on emissions. Due to this effect, PM2.5 mass increased about 6-fold and ultrafine particles (UFP) disappeared [29]. Based on the findings, the authors conclude that for the development of emission inventories the effect of ocean currents should be considered. In this respect, inuse measurements may provide necessary data for accurate inventories [29].

In regard to an approaching fuel switch within the marine sector, a study was conducted by Winnes et al. with the aim to investigate the effects of different fuel types on ship exhaust gas composition and emission factors with a focus on particles [32]. The field emission measurements were carried out on the 4500-kW fourstroke main engine on-board a product tanker. In the study, heavy fuel oil and marine gas oil were tested on the same engine for comparable load settings [32]. In this study PM with no distinction of different fraction was measured. The authors reported for heavy fuel oil generally higher specific PM emissions than for marine gas oil but for the smallest size-fraction containing particles 0.30-0.40 μm in diameter, the opposite was observed [32]. The authors' conclusion of these findings is that further regulation is needed to reduce small-sized particles and hence negative health effects of particles from ships.

Characterization of the PM composition in ship emissions

Only few published studies focused on the characterization of the PM composition in ship emissions. One project was an international study carried out by Moldanova et al. (2009) that investigated PM in emissions from a large ship diesel engine [33]. The engine was fueled with heavy fuel oil (HFO). The investigation of the emitted PM included mass, size distribution, chemical composition and microphysical structure of the PM. The study assessed an emission factor for PM of 5.3 g (kg fuel) -1 . Further, the mass size distribution showed increased particles of the accumulation mode (mean diameter of 0.5 μm) and the coarse mode (around 7 μm) [33]. The investigation demonstrated a domination of organic carbon (OC), ash and sulfate in the PM composition whereas elemental carbon (EC) composed only a few percent. It is to point out that increase of PM in the exhaust upon cooling, was associated with increase of OC and sulfate. Interestingly, cooling of the exhaust as well showed an effect on the quantity of polycyclic aromatic hydrocarbons (PAHs) absorbed on the surface of particulates. Whereas the analysis of the adsorbed phase in the cooled exhaust presented a rich mixture of PAH species with molecular mass between 178 and 300 atomic mass units (amu) the hot exhaust showed only 4 amu of PAH [33]. In the performed microstructure and elemental analysis of ship combustion residuals three following distinct morphological structures with different chemical composition were found: soot aggregates, significantly metal polluted; char particles, clean or containing minerals; mineral and/or ash particles [33]. In addition, the researcher could observe organic carbon particles of unburned fuel or/and lubricating oil origin were. It should be pointed out that hazardous constituents from the combustion of heavy fuel oil (V, Ni, Ca, and Fe (iron)) were observed in the PM samples as well. These metals were also used in other studies as marker for ship emissions as described above.

In a 2009 study carried out by Murphy et al. the particulate exhaust from a modern container ship burning heavy fuel oil was characterized [34]. The ship emissions were measured shipboard and airborne with a focus on the chemical composition and water-uptake behavior of particulate matter in the exhaust. The following results were obtained: The mass ratio of particulate organic carbon to sulfate was 0.23 +/-0.03 at the base of the ship stack and 0.30 +/-0.01 in the airborne exhaust plume [34]. The additional organic mass in the airborne plume was concentrated largely in particles below 100 nm in diameter [34]. The organic to sulfate mass ratio in the exhaust aerosol remained constant during the first hour of plume dilution into the marine boundary layer [34]. The authors also reported that the mass spectrum of the organic fraction of the exhaust aerosol appeared to be predominantly hydrocarbon-like organic (HOA) material [34]. The background aerosol contained a lower organic mass fraction than the fresh plume with much more oxidized organic component [34]. With a conducted analysis of the water-uptake behavior of particulate in the exhaust the researcher showed that a volume-weighted mixing rule is able to accurately predict hygroscopic growth factors in the background aerosol. However, measured and calculated growth factors do not agree for aerosols in the ship exhaust plume. The researchers estimated the particle number emission factor at 1.3 × 10 16 (kg fuel) -1 , with less than 1/10 of the particles having diameters above 100 nm and 24% of particles (> 10 nm in diameter) activate into cloud droplets at 0.3% supersaturation [34].

A third study that aimed to characterize the PM composition in ship emissions focused on the urban area of Venice in Italy. Contini et al. estimated in this study the direct influence of ship traffic on atmospheric PM2.5 and PM10. Next to PM, the study also estimated fifteen PAHs. The sample collection was performed over the summer when ship traffic is expected to be at a maximum and on three sites in that area [35]. From the received results the researcher concluded that the PM daily concentrations are not sufficiently detailed for the evaluation. Therefore they developed a new methodology, based on high temporal resolution measurements coupled with wind direction information and the database of ship passages of the Harbor Authority of Venice [35]. PM10 and PM2.5 were monitored with optical detectors operating at a high temporal resolution [35]. With this new setup, the study showed that direct contribution of ships traffic to PM 2.5 and to PM 10 ranges from 1% up to 8% [35].

Conclusion

This review of the recent published literature shows that port and populated coastal areas with heavy ship traffic are affected by exhausts of particulates from marine vessels. From the different studies it can be concluded that further international regulations are necessary to assess vessel-related air pollution due to ship traffic emissions. In this respect, recent articles have shown that simple fuel change of marine vessel engines alone may not sufficiently reduce effects caused by ship emissions. The few publications that analyzed the composition of PM in ship emissions show the importance of this kind of approach. Knowledge about the nature of the compounds of ship emissions helps to discriminate these pollutant sources from others in the port areas and coastal regions (Figure 1). Promising markers for ship engine exhaust are specific metals like vanadium and nickel although there are is a large variety and quantity of other harmful substances present (Figure 2). Since there is still only little published data regarding the quality and quantity of particles emitted from ship engines, modern scientometric tools which are in use for the analysis of other research areas are not applicable in this area [36][37][38][39][40][41][42][43][44].

Figure 1
1Factors that can influence air quality in port cities and coastal areas.

Figure 2
2Characterized compounds of emissions from marine vessel engines as reported in the reviewed articles.
© 2011 Mueller et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Mueller et al. Journal of Occupational Medicine and Toxicology 2011, 6:31 http://www.occup-med.com/content/6/1/31
AcknowledgementsWe thank G. Volante for expert help. Publication of this review was partly supported by EUGT e. V.Authors' contributions DM, SU, MT, DK, DAG have made substantial contributions to the conception and design of the review, acquisition of the review data and have been involved in drafting and revising the manuscript. All authors have read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.
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Groneberg-Kloft B: Density-equalizing mapping and scientometric benchmarking in Industrial Health. C Scutaru, D Quarcoo, M Takemura, T Welte, T C Fischer, Ind Health. 48Scutaru C, Quarcoo D, Takemura M, Welte T, Fischer TC, Groneberg-Kloft B: Density-equalizing mapping and scientometric benchmarking in Industrial Health. Ind Health 2010, 48:197-203.

Quality and quantity indices in science: use of visualization tools. B Groneberg-Kloft, D Quarcoo, C Scutaru, EMBO Rep. 10Groneberg-Kloft B, Quarcoo D, Scutaru C: Quality and quantity indices in science: use of visualization tools. EMBO Rep 2009, 10:800-803.

Density-equalizing mapping and scientometric benchmarking of European allergy research. C Scutaru, D Quarcoo, M Sakr, A Shami, K Al-Mutawakel, K Vitzthum, T C Fischer, T Zuberbier, B Groneberg-Kloft, J Occup Med Toxicol. 52Scutaru C, Quarcoo D, Sakr M, Shami A, Al-Mutawakel K, Vitzthum K, Fischer TC, Zuberbier T, Groneberg-Kloft B: Density-equalizing mapping and scientometric benchmarking of European allergy research. J Occup Med Toxicol 2010, 5:2.

Inter-disease comparison of research quantity and quality: bronchial asthma and chronic obstructive pulmonary disease. B Groneberg-Kloft, C Scutaru, Q T Dinh, T Welte, K F Chung, A Fischer, D Quarcoo, J Asthma. 46Groneberg-Kloft B, Scutaru C, Dinh QT, Welte T, Chung KF, Fischer A, Quarcoo D: Inter-disease comparison of research quantity and quality: bronchial asthma and chronic obstructive pulmonary disease. J Asthma 2009, 46:147-152.

Tobacco control: visualisation of research activity using densityequalizing mapping and scientometric benchmarking procedures. B Kusma, C Scutaru, D Quarcoo, T Welte, T C Fischer, B Groneberg-Kloft, Int J Environ Res Public Health. 6Kusma B, Scutaru C, Quarcoo D, Welte T, Fischer TC, Groneberg-Kloft B: Tobacco control: visualisation of research activity using density- equalizing mapping and scientometric benchmarking procedures. Int J Environ Res Public Health 2009, 6:1856-1869.

Analysis of research output parameters: density equalizing mapping and citation trend analysis. B Groneberg-Kloft, C Scutaru, A Fischer, T Welte, C Kreiter, D Quarcoo, 10.1186/1745-6673-6-31BMC Health Serv Res. 916Groneberg-Kloft B, Scutaru C, Fischer A, Welte T, Kreiter C, Quarcoo D: Analysis of research output parameters: density equalizing mapping and citation trend analysis. BMC Health Serv Res 2009, 9:16. doi:10.1186/1745-6673-6-31

Ships, ports and particulate air pollution -an analysis of recent studies. Mueller, Journal of Occupational Medicine and Toxicology. 631Cite this article asCite this article as: Mueller et al.: Ships, ports and particulate air pollution -an analysis of recent studies. Journal of Occupational Medicine and Toxicology 2011 6:31.