White Plains: March
of Dimes Research Foundation,
1987.
Stress and "Type A" Behavior as Precipitants of Post-Polio
Sequelae:
The Felician/Columbia Survey
Richard
L. Bruno, PhD, and Nancy M. Frick, MDiv, LhD
LS Halstead and DO Wiechers (Eds.):
A behavioral profile has begun to emerge from studies of persons who survived acute poliomyelitis and are now experiencing post-polio sequelae. Persons who had polio have been shown to be employed full time at four times the rate of the general disabled population ( 1, 21. Persons who had polio have more years of formal education on average than the general population [31, and marry at approximately the same rate as those who are not disabled (4]. These data, combined with our own experience with thousands of persons who had polio, indicated that "polio survivors" are competent, hard-driving and time-conscious overachievers who demand perfection in all aspects of their personal, professional, and social lives. It appeared that those who survived polio exhibit "Type A" behavior and would therefore experience chronic emotional stress. The notion that individuals who had polio exhibit "Type A" behavior and experience chronic stress was thought to be extremely important for an understanding of the pathophysiology and treatment of post-polio sequelae (PPS). Animal studies have demonstrated that stress accelerates the onset of muscle fatigue [51, augments age-related decreases in the terminal axon branch number (6], and accelerates age-related losses of neurons (7). Therefore, this study was designed to test 2 hypotheses: 1) persons who had poliomyelitis exhibit "Type A" behavior and symptoms pathognomonic of chronic stress, and 2) "Type A" behavior and stress precipitate or exacerbate PPS.
METHODS
The Felician/Columbia Survey
In order to test the above-stated
hypotheses,
a self-administered survey was designed to record demographic data,
quantify
"Type A" behavior, Research funded by the Joel Leff Foundation.
Document
psychophysiologic symptoms that are recognized as concomitants of
chronic
stress (including disturbed sleep), and identify the conditions that
precipitated
or exacerbated PPS.
Quantification of "Type A" behavior.
To quantify "Type A"
behavior, the Young
and Barboriak brief "Type A" questionnaire [8] was included as part of
the survey. This instrument consists of 10 questions that
elicit
responses characteristic of "Type A" behaviors and attitudes (Table
1).
It was tested by its authors on a sample of nondisabled males (mostly
professional
or paraprofessional hospital employees) who were employed full time and
who were without cardiovascular disease. They obtained a mean
score
of 35,6 (+/- 14.0) for this control sample, and 80% agreement was found
between their brief "Type A" score and that obtained using the
65-question
Jenkins Activity Survey.
All "Type A" questionnaires,
including the
Young and Barboriak instrument [81, are designed to quantify the
behavior
of men who are employed full time outside of the home. Since
the
post-polio population includes men and women, some of whom are employed
part time, in the home, unemployed, or receiving social security
disability,
it was recognized that some of the post-polio respondents would not be
able to complete all 10 questions. Therefore, the scoring of the Young
and Barboriak questionnaire [8) was modified in consultation with its
authors.
It was decided that all questionnaires would be scored by assigning 10
points to each "Type A" response, summing those responses, and dividing
by the total number of questions answered. This provided a
"Type
A" percentage on the basis of 10 questions, in persons who were
employed
full time, and on the basis of 7 questions (eliminating questions 2, 5,
and 8) in persons who were not employed full time. The
7-question
"Type A" score has been found by the authors of the questionnaire to
correlate
well with the IO-question score (Young, personal communication).
Documentation of psychophysiologic symptoms.
To document the occurrence of
psychophysiologic
symptoms that are recognized as concomitants of chronic stress,
subjects
were asked if they experienced frequent feelings of anxiety, headaches,
muscle & ,spasms, and "difficulty in failing asleep because the
mind
is racing." They were also asked if they had been diagnosed as having
asthma,
hypertension, coronary artery disease, ulcer, or colitis. In
addition,
subjects were asked if they were experiencing "generalized random
myoclonus"
(GRM), the slow contraction and rapid twitching that occur randomly in
limb and trunk muscles during sleep and especially at sleep onset
[9].
They were also asked if their sleep was disturbed by GRM. Psychologic
stress
and other precipitants of PPS. Subjects were asked whether
emotional
stress or "upset" precipitated or exacerbated the 3 most frequently
reported
and least well understood PPS-muscle weakness, muscle pain, and
unaccustomed
fatigue. They were also asked if these symptoms were
precipitated
or exacerbated by physical overexertion, exercise, or
exposure to
cold and hot ambient temperatures. Finally, the subjects were
asked
if PPS interfered with their ability to participate in social
activities,
complete or perform work, and perform self-care activities; they were
also
asked about their attitudes concerning their new symptoms and the
general
topic of disability. (Functional and attitudinal data will be presented
elsewhere.)
PROCEDURE
Distribution of the Survey
On April 1, 1985, 1,200 surveys were
mailed
to all self-identified post-polio clinics and support groups in the
continental
United States. Respondents were instructed to complete the survey after
April 15 and to return it by June 30, 1985. A copy of the
survey
was obtained by a national organization that provides services for
persons
with disabilities. The organization reproduced the
survey and
mailed it to their offices across the country for distribution without
our knowledge. While this unexpected distribution probably
increased
the number of persons who obtained the survey, control of the sample
was
lost and no meaningful response rate can be reported. Surveys that did
not include a completed "Type A" questionnaire or reported a
co-existing
medical condition that could cause muscle weakness, muscle pain, or
fatigue
(eg, arthritis, cancer, CVA, hyperthyroidism) were not included in the
analysis.
Data Analysis
Orthogonal analysis of variance and
independent
groups t-tests were applied to compare parametric variables between
groups.
The chi-squared statistic was applied to compare the frequency of
nonparametric
variables between groups. A value of P < 0.05 was
considered statistically
significant.
RESULTSDemographics, New Symptoms
and Level
of Functioning The respondents were remarkably similar to those in
other
surveys of persons who had polio (Table 2). The average
respondent
was a 52-year-old female, who had acute poliomyelitis in 1948 at age
10.5
years. She was experiencing unaccustomed fatigue, muscle
weakness
(in muscles originally affected by the polio), and muscle
pain. She
ambulated without orthotics or ambulatory aids prior to developing new
symptoms but required some assistive device (brace, cane or crutches)
with
the onset of PPS (Table 3). It should be noted that
the ability
to ambulate distinguishes these respondents from those in other
surveys.
The percentage of respondents who ambulated unassisted prior to PPS was
1.4 times greater than in other surveys. The percentage who
used
ambulatory aids or a wheelchair either prior to or following PPS onset
was at least 2 times less than in other surveys.
"Type A" Score in Post-Polio Subjects
The mean "Type A" score for all
respondents
was 53.2 (±2l.7). This score was significantly higher (t =
8.10.
P < .001) than the 35.6 (±14.0) reported by Young and
Barboriak
[8] for their nondisabled control sample. The "Type A" score in each
post-polio
subgroup, whether or not PPS were reported, was significantly higher
than
the control score of 35.6 (P < .001 (Figs. 1-4).
"Type A" Score, PPS and
Psychophysiologic
Symptoms
Between 88% and 91% of the
respondents reported
new decreases in muscle strength, increased muscle pain, or new or
increased
fatigue. The "Type A" score was significantly higher in
respondents
reporting muscle pain and fatigue (but not decreased muscle strength)
as
compared to subjects without
these symptoms (Figs.
1-3). Symptoms
pathognomonic of chronic stress were reported by 49% to 58% of the
respondents
(Fig. 4). The "Type A" score was significantly higher in
subjects
who reported these psychophysiologic symptoms than in those who did
not.
GRM was reported in 32.8% of the respondents and 29.9% reported both
GRM
and that their "sleep was disturbed by muscle twitching." It is
noteworthy
that there was no relationship
between GRM
or GRM-disturbed sleep and reports of daytime fatigue.
Stress and Other Precipitants of PPS
"Emotional stress" was the second
most frequently
reported cause of fatigue (6 1 % of respondents) and the third most
frequently
reported cause of decreased muscle strength and muscle pain (45% and 5
1 % of respondents, respectively) (Fig. 5). The "Type A"
score was
significantly higher in subjects reporting that their symptoms were
exacerbated
by emotional stress as compared to those who were unaffected by stress.
Exposure to cold ambient temperatures was the second most frequently
reported
cause of decreased muscle strength and muscle pain (62% and 60% of
respondents,
respectively). Exposure to cold or to heat was reported by
39% of
the respondents as the third most frequently reported cause of
fatigue.
As in all other studies, the most frequently reported cause of
decreased
muscle strength, muscle pain, and fatigue was physical overexertion or
exercise (reported by 92% to 95% of respondents).
DISCUSSION
The data indicate that both
hypotheses should
be accepted: 1) persons who had poliomyelitis demonstrate significantly
more "Type A" behavior than do nondisabled controls, and evidence
psychophysiologic
symptoms pathognomonic of chronic stress, and 2) PPS are initiated or
exacerbated
by stress. In
addition, there is an
interrelationship between
these 2 hypotheses. "Type A" scores are significantly higher
in respondents
who report that stress initiates or exacerbates PPS and in those
subjects
reporting psychophysiologic symptoms, new muscle pain, and unaccustomed
fatigue.
Genesis of "Type A" Behavior in Persons
Who Had Polio
There are a number of hypotheses as
to why
persons who had poliomyelitis exhibit "Type A" behavior and experience
symptoms of chronic stress. It is possible that adults and
even children
who exhibited "Type A" behavior and were experiencing stress were more
susceptible to infection by polio viruses because of stress-induced
immunosuppression.
It is also possible that to survive the acute polio infection and then
thrive despite paralysis in a totally inaccessible world, the special
drive
of the "Type A" personality was required. It might also be
the case
that persons with disabilities must learn "Type A" behavior in order to
succeed in a "barrier-full" society. For example, physical
limitations
might require one to become "time-conscious" to perform common tasks
that
require more time to complete than for persons who are not
disabled.
Social prejudice might require persons with disabilities to become
"hard-driving
overachievers"-personality, professionally, and especially
physically-to
be accepted by peers and employers. This last hypothesis raises the
question
as to whether orthopedically disabled persons in general, but
especially
those disabled early in life, exhibit "Type A" behavior, experience
chronic
stress, and may also have late-onset problems. A recently
completed
study has identified late-onset problems in adults with spina bifida
who,
although younger than the post-polio population, are similar in
educational
level and ambulatory ability (Table 4) (Gingher, personal
communication).
It is interesting to note that muscle weakness, joint pain, and
hypertension
were reported about half as frequently in the spina bifida sample as in
persons who had polio, while fatigue and muscle pain were not reported
at all. We arc presently conducting a survey of adults with
spina
bifida to document "Type A" behavior, psychophysiologic symptoms, and
late-onset
problems.
Stress and the Pathophysiology of PPS
The mechanism whereby stress induces
or exacerbates
PPS has not yet been described. Stress in animals has been
shown
to cause a variety of abnormalities that may contribute significantly
to
the pathophysiology of PPS. Stress has been shown to
accelerate the
onset of muscle fatigue and shorten life-span [5]. Stress has
also
been shown to augment age-related decreases in the number of terminal
axon
branches innervating both hind-limb and diaphragm muscles
[6]. A
decrease in the number of functional terminal axon branches may be
responsible
for the shrinkage of motor unit territories seen in persons who had
polio
(121 and has been implicated as a probable cause of post-polio muscle
weakness
( 1 3, 14]. Corticosterone secretion, a specific hormonal concomitant
of
stress, has been shown to have deleterious effect,,;- that directly
related
to the hypothesized pathophysiology of PPS. Elevated
corticosterone
levels have been associated with the inhibition of axonal sprouting in
aged animals with motor neuron denervation [I 51. Further,
stress-induced
hypersecretion of corticosterone has been shown to accelerate
age-related
losses of hippocampal neurons f 16]. This effect is thought
to result
from corticosterone-induced inhibition of neuronal glucose uptake and
the
impairment of neuronal energy metabolism in these .. metabolically
vulnerable"
neurons [7]. It has been suggested that polio-damaged and
extensively
sprouted anterior horn cells are also metabolically vulnerable, and
that
post-polio muscle weakness might occur as these neurons fail to
function
and even die because they "are just not able to keep pace with the
metabolic
demands of innervating all of their muscle fibers" [I 3]. Clearly,
research
needs to be conducted to document the relationship between the
physiologic
effects of stress and the pathophysiology of PPS.
Clinical Implications
This survey has documented the
deleterious
effects of physical overexertion and exposure to extremes in
temperature
in persons who were less severely affected by the original polio
infection
than were subjects in other studies [IO, 11, 171. It has also
documented
that GRM occurred in nearly two-thirds of this post-polio
sample.
However, the failure to find a relationship between GRM-induced sleep
disturbance
and daytime fatigue suggests that (GRM may not be a contributor to new
and unaccustomed fatigue. Most importantly, this survey demonstrated
that
emotional stress is a precipitant of PPS- Fortunately, it is a
precipitant
that can be treated. Post-polio clinics and support groups should
include
stress management as
an integral part of both therapeutic
and wellness
programs. We are presently studying combinations of cognitive
and
autonomic stress management techniques designed to reduce "Type A"
behavior,
counter the psychophysiologic symptoms of stress, and thereby decrease
the symptoms of post-polio sequelae.
ACKNOWLEDGMENTS
The authors thank the survey
participants,
John H. Zuck, Jr. for his labors in preparing and distributing the
survey,
Dr. Charles Rooney for his motivating logic, and Drs. Larry
Young,
Julie Rosenheimer, Bob Sapolsky, and Nan Gingher for their generous
assistance
in the preparation of the manuscript.
REFERENCES