Joumol ~~Psychosomaric Prmted in Great Braam.
Research,
Vol. 35. No. 415. pp. 399-407.
0519-3999191 .$3.w+.oo Pergaman Press plc
1991
CARDIAC FAILURE: SYMPTOMS AND FUNCTIONAL
STATUS
RICHARD MAYOU,:~ ROGER BLACKWOOD,? BEIDGET BRYANT* and JOHN GARNHAM~ (Received
21 August
1990; accepted
17 October
1990)
Abstract-The associations between exercise capacity, symptoms and specific aspects of quality of life were examined in subjects participating in a trial of the treatment of heart failure. Patients were assessed on entry and after three months treatment. The principle symptoms were fatigue, breathlessness and chest pain. These limited the extent and speed of physical activities, restricted social, leisure and family life and were associated with emotional distress. There were associations between baseline exercise capacity and measures of quality of life. Change in exercise capacity during three months treatment was correlated with changes in measures of symptoms, limitation of activity and quality of life. The findings confirm the value of change in exercise capacity as a measure of functional status and suggest that it should be supported by a limited number of specific measures of quality of life.
INTRODUCTION
HEART failure affects at least 1% of the population in Western countries and its incidence is increasing. The commonest presenting symptoms are fatigue, breathlessness and chest pain [l--51. These impair exercise capacity and restrict ability to perform physical activities. There are consequences for work, leisure, social and sexual activities and for mood [l-61. However, there have been no detailed studies of symptoms or psychosocial disability or of their association with exercise capacity. Treatment aims to improve the expectation of life and reduce symptoms and disability. Successful treatment is associated with parallel, but poorly correlated, improvements in cardiac function, exercise capacity and functional class. There is less evidence about changes in quality of life. Tandon et al. 14, 51 reported findings from a treatment trial on 230 patients (67% NYHA Class III). The principal symptoms at baseline were fatigue, shortness of breath and sleeplessness. The main improvements as measured by the Sickness Impact Profile were in the areas of rehabilitation, home management, recreation and pastime, and sleep and rest. Improved exercise capacity during the trial was significantly correlated with improvements in only one of the SIP subscores, sleep and rest. We have reported a trial of three treatments of heart failure (xamoterol, digoxin, placebo) 171which found marked improvements in all three groups, but no significant differences in outcome for exercise capacity or quality of life between the two active treatment conditions and placebo control. This further paper concentrates on the whole group, ignoring treatment. We describe the clinical characteristics of the 123 subjects and examine the associations with exercise capacity, and changes in symptoms and quality of life over a three-month period. It is uncertain which are the most appropriate clinical and research measures of disability and quality of life [8-151. Simple overall measures of functional status,
*University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, U.K. iCardiac Research Unit, Wexham Park Hospital, Slough SL2 4HL, U.K. Address all correspondence to: Dr R. Mayou, University Department of Psychiatry, Hospital, Oxford OX3 7JX, U.K. 399
Warneford
R. MAYOU et al.
400
such as the New York Heart Association (NYHA) clinical classification are unsatisfactory 19, 10, 151. Exercise testing remains the preferred method of assessment but there is little association with haemodynamic measures. The relationship between exercise capacity in the laboratory and performance in everyday life is also uncertain. Guyatt et al. 1161 gave a 43-item questionnaire for quality of life to patients with cardio-respiratory disorders and found improvements in psychological and social function after treatment which were correlated with changes in physiological function. Rector et al. 131 found that there was only a weak association between peak oxygen consumption on exercise testing and the total score on a widely used measure of quality of life, the Sickness Impact Profile (SIP). Associations between other functional rating scales and a 6-min walk test are somewhat better but the scales lack sensitivity for general use 112, 131. We have preferred to select and adapt specific measures of those aspects of quality of life which a pilot study found to be of most relevance to patients and their families. They complained of fatigue and breathlessness, difficulty in performing everyday tasks at a normal speed, lack of confidence and impaired leisure and social life. Successful treatment was reported as improved morale, ability to carry out daily tasks with less anxiety or restriction, and a more satisfying everyday life. METHODS Putients The selection criteria were: breathlessness and/or fatigue, with or without angina pectoris during physical activity, in patients with mild to moderate cardiac failure (NYHA Class II-III) caused by ischaemic heart disease. idiopathic cardiomyopathy, hypertension or certain valvular disorders. The major exclusion criteria were: severe cardiac failure (NYHA Class IV), pulmonary disease, arrhythmias requiring therapy, aortic stenosis, hypertrophic obstructive cardiomyopathy and concurrent therapy with a cardiac glycoside, vasodilator, ACE inhibitor, calcium antagonist, anti-arrhythmic or large doses of loop diuretics (frusemide > 80 mg daily, or equivalent). Design There were five clinic visits: Visit 1 (entry), Visit 2 (end of I week placebo run-in) and Visits 3, 4 and 5 (1 week, 6 weeks and 13 weeks respectively, after commencing double-blind treatment). Patients attended a special research clinic by appointment where they were seen by the same doctor and interviewer at each visit.
Methods of assessment included a clinical history and chest X-ray at Visit 1 and clinical examinations at all visits focusing mainly on the cardiovascular system. At Visits 3 and 4 the patients were given a clinical examination for safety reasons only. Exercise and quality of life assessments were carried out at Visits 2 and 5.
A symptom-limited exercise test was conducted on a treadmill using the Balke protocol only in terms of the constant speed (5 km/h). Exercise duration and heart-rate at maximum recorded. Quality
1171 modified exercise were
of life
The assessment lasted for about 1 hr and was conducted by a trained interviewer. The following measures were included. Likut scales. The physician rated answers to questions about I1 variables on four- or live-point scales, where I always represented the ‘best’ and 5 the ‘worst’ assessment. The tiredness, breathlessness, chest pain, palpitations, difficulty walking, pace of walking, difficulty with daily tasks, pace of daily tasks, mood (weepy/miserable/low), confidence and sleep.
Cardiac
401
failure
Profile of Mood State (PO&IS). Patients completed a standard 41-item version of the Lorr-McNair self-report mood-scale [I81 about how they had felt during the previous week with respect to various types of mood. Sub-scores for anger, tension, fatigue, depression and lack of vigour were obtained. interview rurings. A semi-structured questionnaire developed and shown to be reliable in previous cardiac research [ 191 was adapted to provide the following ratings at baseline: physical component of job, dissatisfaction with work situation, amount of physical leisure, dissatisfaction with leisure, overall participation in leisure activities, frequency of sexual intercourse and limitation of activities. The interviews were tape recorded and replies were subsequently rated by the interviewer on four- or fivepoint scales according to previously agreed rules and case examples; in each case 1 was the ‘best’ and 5 the ‘worst’ rating. At Visit 5 the ratings were repeated and the interviewer also made ratings for changes in each area since the baseline, with 1 representing improvement and 5 deterioration. Diaries. Patients completed one week detailed diaries at baseline and at 3 months. They recorded the number of attempts at activities and the degree to which they were slowed or interrupted by pain or breathlessness. Duta unalysis The distribution of quality of life scores was examined for each parameter and found to be such that the data could be regarded as continuous and normal. Changes in Likert assessments were obtained by comparison of baseline and 3 month assessments; changes in scores potentially ranged from -4 (‘worse’ by 4 patients at 3 months) to +4 (‘better’ by 4 patients). The interview enabled direct ratings of change at the final assessment.
RESULTS
Symptoms
and disability
at baseline
The 123 patients were aged 37-79 yr (median age 60 yr), 61 were women and 62 men. One hundred and sixteen had cardiac failure which was classified as NYHA Class II and 7 had NYHA Class III. The aetiology of the cardiac failure was ischaemic heart disease in two thirds of the subjects and in the remainder valvular diseases, cardiomyopathy or hyperventilation. The principal physical symptoms were breathlessness and tiredness (Table I). Chest pain was a problem for a third of patients and many people reported difficulty in sleeping.
TABLE
I.-SYMPTOMS
AT
Never
Tiredness Breathlessness Chest pain Palpitations Miserable
TABLE
Anger Tension Depression Fatigue Lack of vigour
%
30 28 45 49 32
45 54 21 15 27
13 12 9 5 4
22 29 3.5
(POMS)
MEAN
OTHER
Cardiac
SCALES)
Good part of time
1
WITH
(LIKERT
Some of time
0
H-MOOD
BASELINE
Little
SCORES
CHRONIC
failure
3.0 8.4 4.0 7.4 12.4
AT
BASELINE
All/most of time 10 4
1 0 1
COMPARED
ILLNESSES
Type 2 diabetes
Angina
3.1 5.0 2.8 4.5 11.2
2.8 7.8 3.9 6.3 12.0
402
R. MAYOU et al. TABLE III.-IMPAIRMENT
OF
BASIC
ACTIVITIES
(%)
AT
Difficulty
Walking Daily tasks
Nil
Little
24 30
54 50
BASELINE LEVEL Speed
Noticeable
Great
18 18
3 1
Very auicklv 1 0
Quickly
4 8
Medium
Slowly
Very slowlv
51 66
34 22
3 3
A minority of patients were rated by the physician and rated themselves as being miserable and anxious. Mean POMS sub-scores were similar to those found in other chronic medical populations (Table II). Disturbances in mood were often associated with impaired concentration, irritability and pessimism about the future. Symptoms restricted ability to exercise, limiting the extent and speed of walking and ordinary daily tasks (Table III). Many patients reported that although their total daily activities were not greatly different from those before the onset of heart failure, the time spent doing them was greatly increased and associated with worry and discomfort. We rated 61% as slightly limited by their symptoms and 34% as severely disabled. The diaries confirmed self-report and interview ratings, and showed that the most basic activities such as dressing and washing were little affected, but that more demanding activities such as heavier household chores, gardening, shopping and lifting were impaired. Patients recorded that many activities were performed at reduced speed and noted frequent stops because of pain or breathlessness. Difficulty with basic physical activities was reflected in consequences for social functioning. The majority of patients were unable to work. Most reported their heart failure as causing changes for the worse in their leisure pursuits. This was evident in less intensive physical activity, reduced social leisure and diminished participation (i.e. time spent) in leisure activities. There was often considerable dissatisfaction with leisure which was attributed to the restrictions and frustrations of illness. Quality
of life and exercise
capacity
at baseline
We examined associations with treadmill measured exercise capacity by dichotomizing patients into two equal sized groups in terms of exercise duration (> or < 268 set). All individual quality of life measures showed numerical trends in favour of those who could exercise longer. There were a number of statistically significant differences (Table IV). Those who did least well on the treadmill suffered more tiredness but there was less difference in breathlessness or chest pain. They were much more likely to say that they had to walk very slowly and to perform daily tasks slowly. Their sleep was more disturbed, 40% reporting this as poor or very poor compared with 17% of those in the high exercise capacity group. They also reported more adverse effects on sex and leisure. There were no differences in any of the mood measures. We also examined the impairment of quality of life for those with cardiomegaly. Subjects with cardiomegaly reported more problems in walking @ < 0.05) and daily tasks (p < 0.05).
Cardiac TABLE
IV.-ASXKIATIONS
BETWEEN
EXERCISE
AT BASELINE N
Likert scales Tiredness Breathlessness Chest pain Palpitations Confidence Sleeping
268
set
Mean
(SD)
Probability of association
(~-TEST).
set
N
(SD)
59 59 59 59 59 59
3.3 3.0 2.3 2.0 2.5 3.1
(0.94) (0.82) (1.06) (0.90) (0.68) (1.20)
58 58 58 58 58 58
2.8 2.8 2.1 1.9 2.4 2.5
(0.82) (0.72) (0.76) (0.72) (0.96) (0.96)
Walking difficulty Pace of walking Difficulty with daily tasks Speed of daily tasks Weepy/miserable/low
59 59 59 59 59
2.0 3.5 2.0 3.4 2.2
(0.76) (0.60) (0.77) (0.64) (0.96)
58 58 58 58 58
1.9 3.1 1.8 3.1 1.9
(0.70) (0.62) (0.65) (0.59) (0.90)
Total
59
29.3
(5.53)
58
60 60 60 60 60 14 60 45
2.4 1.8 2.4 2.3 1.9 1.9 1.7
(0.58) (0.39) (0.74) (0.52) (0.85) (0.36) (0.87) 1.4 (0.78)
58 58 58 58 58 23 58 53
score
Quality of life interview Limitation of exercise Physical leisure Social leisure Leisure participation Leisure dissatisfaction Physical component job Work dissatisfaction Sexual intercourse
26.3 (4.18)
2.2 2.0 2.4 2.5 1.9 1.9 1.7 1.8
(0.52) (0.40) (0.64) (0.54) (0.80) (0.63) (0.91) (1.04)
< 0.005 -
< 0.005
Research,
Vol. 35. No. 415. pp. 399-407.
0519-3999191 .$3.w+.oo Pergaman Press plc
1991
CARDIAC FAILURE: SYMPTOMS AND FUNCTIONAL
STATUS
RICHARD MAYOU,:~ ROGER BLACKWOOD,? BEIDGET BRYANT* and JOHN GARNHAM~ (Received
21 August
1990; accepted
17 October
1990)
Abstract-The associations between exercise capacity, symptoms and specific aspects of quality of life were examined in subjects participating in a trial of the treatment of heart failure. Patients were assessed on entry and after three months treatment. The principle symptoms were fatigue, breathlessness and chest pain. These limited the extent and speed of physical activities, restricted social, leisure and family life and were associated with emotional distress. There were associations between baseline exercise capacity and measures of quality of life. Change in exercise capacity during three months treatment was correlated with changes in measures of symptoms, limitation of activity and quality of life. The findings confirm the value of change in exercise capacity as a measure of functional status and suggest that it should be supported by a limited number of specific measures of quality of life.
INTRODUCTION
HEART failure affects at least 1% of the population in Western countries and its incidence is increasing. The commonest presenting symptoms are fatigue, breathlessness and chest pain [l--51. These impair exercise capacity and restrict ability to perform physical activities. There are consequences for work, leisure, social and sexual activities and for mood [l-61. However, there have been no detailed studies of symptoms or psychosocial disability or of their association with exercise capacity. Treatment aims to improve the expectation of life and reduce symptoms and disability. Successful treatment is associated with parallel, but poorly correlated, improvements in cardiac function, exercise capacity and functional class. There is less evidence about changes in quality of life. Tandon et al. 14, 51 reported findings from a treatment trial on 230 patients (67% NYHA Class III). The principal symptoms at baseline were fatigue, shortness of breath and sleeplessness. The main improvements as measured by the Sickness Impact Profile were in the areas of rehabilitation, home management, recreation and pastime, and sleep and rest. Improved exercise capacity during the trial was significantly correlated with improvements in only one of the SIP subscores, sleep and rest. We have reported a trial of three treatments of heart failure (xamoterol, digoxin, placebo) 171which found marked improvements in all three groups, but no significant differences in outcome for exercise capacity or quality of life between the two active treatment conditions and placebo control. This further paper concentrates on the whole group, ignoring treatment. We describe the clinical characteristics of the 123 subjects and examine the associations with exercise capacity, and changes in symptoms and quality of life over a three-month period. It is uncertain which are the most appropriate clinical and research measures of disability and quality of life [8-151. Simple overall measures of functional status,
*University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, U.K. iCardiac Research Unit, Wexham Park Hospital, Slough SL2 4HL, U.K. Address all correspondence to: Dr R. Mayou, University Department of Psychiatry, Hospital, Oxford OX3 7JX, U.K. 399
Warneford
R. MAYOU et al.
400
such as the New York Heart Association (NYHA) clinical classification are unsatisfactory 19, 10, 151. Exercise testing remains the preferred method of assessment but there is little association with haemodynamic measures. The relationship between exercise capacity in the laboratory and performance in everyday life is also uncertain. Guyatt et al. 1161 gave a 43-item questionnaire for quality of life to patients with cardio-respiratory disorders and found improvements in psychological and social function after treatment which were correlated with changes in physiological function. Rector et al. 131 found that there was only a weak association between peak oxygen consumption on exercise testing and the total score on a widely used measure of quality of life, the Sickness Impact Profile (SIP). Associations between other functional rating scales and a 6-min walk test are somewhat better but the scales lack sensitivity for general use 112, 131. We have preferred to select and adapt specific measures of those aspects of quality of life which a pilot study found to be of most relevance to patients and their families. They complained of fatigue and breathlessness, difficulty in performing everyday tasks at a normal speed, lack of confidence and impaired leisure and social life. Successful treatment was reported as improved morale, ability to carry out daily tasks with less anxiety or restriction, and a more satisfying everyday life. METHODS Putients The selection criteria were: breathlessness and/or fatigue, with or without angina pectoris during physical activity, in patients with mild to moderate cardiac failure (NYHA Class II-III) caused by ischaemic heart disease. idiopathic cardiomyopathy, hypertension or certain valvular disorders. The major exclusion criteria were: severe cardiac failure (NYHA Class IV), pulmonary disease, arrhythmias requiring therapy, aortic stenosis, hypertrophic obstructive cardiomyopathy and concurrent therapy with a cardiac glycoside, vasodilator, ACE inhibitor, calcium antagonist, anti-arrhythmic or large doses of loop diuretics (frusemide > 80 mg daily, or equivalent). Design There were five clinic visits: Visit 1 (entry), Visit 2 (end of I week placebo run-in) and Visits 3, 4 and 5 (1 week, 6 weeks and 13 weeks respectively, after commencing double-blind treatment). Patients attended a special research clinic by appointment where they were seen by the same doctor and interviewer at each visit.
Methods of assessment included a clinical history and chest X-ray at Visit 1 and clinical examinations at all visits focusing mainly on the cardiovascular system. At Visits 3 and 4 the patients were given a clinical examination for safety reasons only. Exercise and quality of life assessments were carried out at Visits 2 and 5.
A symptom-limited exercise test was conducted on a treadmill using the Balke protocol only in terms of the constant speed (5 km/h). Exercise duration and heart-rate at maximum recorded. Quality
1171 modified exercise were
of life
The assessment lasted for about 1 hr and was conducted by a trained interviewer. The following measures were included. Likut scales. The physician rated answers to questions about I1 variables on four- or live-point scales, where I always represented the ‘best’ and 5 the ‘worst’ assessment. The tiredness, breathlessness, chest pain, palpitations, difficulty walking, pace of walking, difficulty with daily tasks, pace of daily tasks, mood (weepy/miserable/low), confidence and sleep.
Cardiac
401
failure
Profile of Mood State (PO&IS). Patients completed a standard 41-item version of the Lorr-McNair self-report mood-scale [I81 about how they had felt during the previous week with respect to various types of mood. Sub-scores for anger, tension, fatigue, depression and lack of vigour were obtained. interview rurings. A semi-structured questionnaire developed and shown to be reliable in previous cardiac research [ 191 was adapted to provide the following ratings at baseline: physical component of job, dissatisfaction with work situation, amount of physical leisure, dissatisfaction with leisure, overall participation in leisure activities, frequency of sexual intercourse and limitation of activities. The interviews were tape recorded and replies were subsequently rated by the interviewer on four- or fivepoint scales according to previously agreed rules and case examples; in each case 1 was the ‘best’ and 5 the ‘worst’ rating. At Visit 5 the ratings were repeated and the interviewer also made ratings for changes in each area since the baseline, with 1 representing improvement and 5 deterioration. Diaries. Patients completed one week detailed diaries at baseline and at 3 months. They recorded the number of attempts at activities and the degree to which they were slowed or interrupted by pain or breathlessness. Duta unalysis The distribution of quality of life scores was examined for each parameter and found to be such that the data could be regarded as continuous and normal. Changes in Likert assessments were obtained by comparison of baseline and 3 month assessments; changes in scores potentially ranged from -4 (‘worse’ by 4 patients at 3 months) to +4 (‘better’ by 4 patients). The interview enabled direct ratings of change at the final assessment.
RESULTS
Symptoms
and disability
at baseline
The 123 patients were aged 37-79 yr (median age 60 yr), 61 were women and 62 men. One hundred and sixteen had cardiac failure which was classified as NYHA Class II and 7 had NYHA Class III. The aetiology of the cardiac failure was ischaemic heart disease in two thirds of the subjects and in the remainder valvular diseases, cardiomyopathy or hyperventilation. The principal physical symptoms were breathlessness and tiredness (Table I). Chest pain was a problem for a third of patients and many people reported difficulty in sleeping.
TABLE
I.-SYMPTOMS
AT
Never
Tiredness Breathlessness Chest pain Palpitations Miserable
TABLE
Anger Tension Depression Fatigue Lack of vigour
%
30 28 45 49 32
45 54 21 15 27
13 12 9 5 4
22 29 3.5
(POMS)
MEAN
OTHER
Cardiac
SCALES)
Good part of time
1
WITH
(LIKERT
Some of time
0
H-MOOD
BASELINE
Little
SCORES
CHRONIC
failure
3.0 8.4 4.0 7.4 12.4
AT
BASELINE
All/most of time 10 4
1 0 1
COMPARED
ILLNESSES
Type 2 diabetes
Angina
3.1 5.0 2.8 4.5 11.2
2.8 7.8 3.9 6.3 12.0
402
R. MAYOU et al. TABLE III.-IMPAIRMENT
OF
BASIC
ACTIVITIES
(%)
AT
Difficulty
Walking Daily tasks
Nil
Little
24 30
54 50
BASELINE LEVEL Speed
Noticeable
Great
18 18
3 1
Very auicklv 1 0
Quickly
4 8
Medium
Slowly
Very slowlv
51 66
34 22
3 3
A minority of patients were rated by the physician and rated themselves as being miserable and anxious. Mean POMS sub-scores were similar to those found in other chronic medical populations (Table II). Disturbances in mood were often associated with impaired concentration, irritability and pessimism about the future. Symptoms restricted ability to exercise, limiting the extent and speed of walking and ordinary daily tasks (Table III). Many patients reported that although their total daily activities were not greatly different from those before the onset of heart failure, the time spent doing them was greatly increased and associated with worry and discomfort. We rated 61% as slightly limited by their symptoms and 34% as severely disabled. The diaries confirmed self-report and interview ratings, and showed that the most basic activities such as dressing and washing were little affected, but that more demanding activities such as heavier household chores, gardening, shopping and lifting were impaired. Patients recorded that many activities were performed at reduced speed and noted frequent stops because of pain or breathlessness. Difficulty with basic physical activities was reflected in consequences for social functioning. The majority of patients were unable to work. Most reported their heart failure as causing changes for the worse in their leisure pursuits. This was evident in less intensive physical activity, reduced social leisure and diminished participation (i.e. time spent) in leisure activities. There was often considerable dissatisfaction with leisure which was attributed to the restrictions and frustrations of illness. Quality
of life and exercise
capacity
at baseline
We examined associations with treadmill measured exercise capacity by dichotomizing patients into two equal sized groups in terms of exercise duration (> or < 268 set). All individual quality of life measures showed numerical trends in favour of those who could exercise longer. There were a number of statistically significant differences (Table IV). Those who did least well on the treadmill suffered more tiredness but there was less difference in breathlessness or chest pain. They were much more likely to say that they had to walk very slowly and to perform daily tasks slowly. Their sleep was more disturbed, 40% reporting this as poor or very poor compared with 17% of those in the high exercise capacity group. They also reported more adverse effects on sex and leisure. There were no differences in any of the mood measures. We also examined the impairment of quality of life for those with cardiomegaly. Subjects with cardiomegaly reported more problems in walking @ < 0.05) and daily tasks (p < 0.05).
Cardiac TABLE
IV.-ASXKIATIONS
BETWEEN
EXERCISE
AT BASELINE N
Likert scales Tiredness Breathlessness Chest pain Palpitations Confidence Sleeping
268
set
Mean
(SD)
Probability of association
(~-TEST).
set
N
(SD)
59 59 59 59 59 59
3.3 3.0 2.3 2.0 2.5 3.1
(0.94) (0.82) (1.06) (0.90) (0.68) (1.20)
58 58 58 58 58 58
2.8 2.8 2.1 1.9 2.4 2.5
(0.82) (0.72) (0.76) (0.72) (0.96) (0.96)
Walking difficulty Pace of walking Difficulty with daily tasks Speed of daily tasks Weepy/miserable/low
59 59 59 59 59
2.0 3.5 2.0 3.4 2.2
(0.76) (0.60) (0.77) (0.64) (0.96)
58 58 58 58 58
1.9 3.1 1.8 3.1 1.9
(0.70) (0.62) (0.65) (0.59) (0.90)
Total
59
29.3
(5.53)
58
60 60 60 60 60 14 60 45
2.4 1.8 2.4 2.3 1.9 1.9 1.7
(0.58) (0.39) (0.74) (0.52) (0.85) (0.36) (0.87) 1.4 (0.78)
58 58 58 58 58 23 58 53
score
Quality of life interview Limitation of exercise Physical leisure Social leisure Leisure participation Leisure dissatisfaction Physical component job Work dissatisfaction Sexual intercourse
26.3 (4.18)
2.2 2.0 2.4 2.5 1.9 1.9 1.7 1.8
(0.52) (0.40) (0.64) (0.54) (0.80) (0.63) (0.91) (1.04)
< 0.005 -
< 0.005
