Disability and Rehabilitation
ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20
Long-standing poliomyelitis and psychological health Shimon Shiri, Irina Gartsman, Zeev Meiner & Isabella Schwartz To cite this article: Shimon Shiri, Irina Gartsman, Zeev Meiner & Isabella Schwartz (2015) Long-standing poliomyelitis and psychological health, Disability and Rehabilitation, 37:24, 2233-2237, DOI: 10.3109/09638288.2015.1019007 To link to this article: http://dx.doi.org/10.3109/09638288.2015.1019007
Published online: 27 Feb 2015.
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Date: 17 October 2015, At: 07:35
http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(24): 2233–2237 ! 2015 Informa UK Ltd. DOI: 10.3109/09638288.2015.1019007
RESEARCH PAPER
Long-standing poliomyelitis and psychological health Shimon Shiri, Irina Gartsman, Zeev Meiner, and Isabella Schwartz
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Department of Physical Medicine and Rehabilitation, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
Abstract
Keywords
Objective: To compare the psychological health of the individuals with long-standing poliomyelitis, with or without post-polio syndrome (PPS), to the general population and to identify the role of work as well as other variables with regard to their psychological health. Design: A cross-sectional study. Subjects: One hundred and ninety-five polio patients attending postpolio clinic in Jerusalem. Methods: Emotional distress (ED) was measured using the general health questionnaire (GHQ-12). Demographic, medical, social and functional data were recorded using a specific structured questionnaire. Each polio patient was compared to four age- and sex-matched controls. Results: ED was higher in the polio population as compared to the general population. Within the polio population ED was inversely correlated with work status. No correlation was found between ED and the functional level of polio participants and no difference was found in GHQ score between polio participants with or without post-polio. In addition, ED was less affected by subjective perception of physical health among polio patients as compared to the general population. Conclusions: Long-standing poliomyelitis is associated with decreased psychological health as compared to the general population. Yet, the resilience of polio survivors is manifested by their ability to block further decline of their psychological health in spite of deterioration in their physical health. Work appears as a significant source of resilience in the polio population.
Emotional distress, mental health, poliomyelitis, post-polio syndrome, work History Received 15 March 2014 Revised 3 February 2015 Accepted 10 February 2015 Published online 27 February 2015
ä Implications for Rehabilitation
Individuals with long-standing poliomyelitis often suffer from high emotional distress and may benefit from psychotherapy aimed at reducing distress. As active employment status is associated with increased mental health among polio survivors, encouraging participation at work needs to be a significant component of psychotherapeutic programs. Polio survivors, although physically disabled, may be relatively resilient, as their mental health is less affected by their negative health perception. This and other expressions of resilience may serve as a platform for increasing personal growth among them by implementing hopeoriented psychotherapy.
Introduction Despite successful efforts toward eradicating poliomyelitis, polio still represents a significant medical burden. It was estimated that there were 12–20 million people worldwide suffering from disabilities related to poliomyelitis [1]. A high rate of polio survivors develop new symptoms including new muscle weakness, exacerbating of previous weakness, muscle atrophy, cold intolerance and fatigue [2]. These new symptoms, comprising of the postpolio syndrome (PPS), have deleterious effect on the function and quality of life of the survivors [3,4]. PPS develops in 25–50% in patients with poliomyelitis and usually occurs 15–30 years after the initial infection with the poliovirus [5,6].
Address for correspondence: Shimon Shiri, Ph.D., Department of Physical and Medical Rehabilitation, Hadassah University Hospital – Mount Scopus, Jerusalem, Israel. Tel: +972 2 5610626. Fax: +972 2 5844885. E-mail: [email protected]
A considerable number of studies have attempted to examine the psychological health of polio survivors [7]. Many of these studies found polio survivors to suffer from greater degrees of psychological morbidity in the form of depression, anxiety disorders and other psychopathological characteristics such as Type A behavior [8]. More recent studies that followed the emergence of PPS have often found individuals with postpolio to have even greater degrees psychopathologies, low quality of life [9] and decreased satisfaction with life [4,10,11]. In these studies, individuals with postpolio experienced greater distressing symptoms such as depressive or hypochondrical symptoms than those with polio alone. Some of these studies found a correlation between levels of psychological distress and the physical deterioration of the patients [11,12]. Negative emotions were described as well, as individuals with postpolio experience pain, disability or other negative symptoms [13]. Correspondingly, we found that individuals with postpolio suffered from decreased mental and physical quality of life when compared to the general
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population [14]. Yet, it is still remains unclear whether the emergence of PPS is associated with further exacerbation in the psychological state of polio survivors and one aim of this study is to further examine this issue. Studies that used qualitative methods of research have presented different and more optimistic views of the experience of post-polio. In one study [15], it was found that symptoms of post-polio are associated with early traumatic memories associated with the emergence of polio. Yet, alongside with these painful experiences, participants reported that they had accomplished most of their ambitions in the areas of work and family life. Similarly, the majority of 39 participants with PPS reported a high level of psychosocial well-being and almost a quarter have that living with polio has meant personal development and strength [16]. In our search for processes that have the potential of increasing the well being of polio survivors, we found that when hope [17] is raised in the form of setting significant goals and finding channels of achieving these goals, quality of life of post-polio patients may improve significantly [14]. Recently, we conducted a large epidemiological study comparing the general situation of polio survivors with the general population in Jerusalem [18]. In this study, we aim to evaluate also the psychological state of polio survivors, with and without PPS, as compared to the general population. The relatively large number of participants allowed us to examine whether the psychological distress in this population is further exacerbated by the emergence of PPS. Another objective is to further explore the association of work and psychological health among polio survivors. Our earlier study [14] as well as other work has indicated that being active at work is associated with better quality of life among polio and other chronic illnesses sufferers [15,19–23]. In this study, we are able to compare the unique function of work, as in the polio population relatively to the general population. While in our previous study we have used a general quality of life questionnaire, in this study we decided to assess the psychological state of individuals with long-standing poliomyelitis using a questionnaire that is specifically aimed to measure psychological health, the general health questionnaire-12 (GHQ12) scale [22]. The GHQ-12 is measuring the emotional distress (ED), which serves as an efficient indicator of the psychological impact of adverse conditions present among specific community groups. It had been used frequently, both in clinical and community settings [23]. Our study is the first to use the GHQ in long-standing poliomyelitis survivors.
Methods Participants All the polio patients attended the postpolio clinic in the Physical Medicine and Rehabilitation Department in Hadassah Mount Scopus Medical Center in Jerusalem. The study was approved by the ethical committee of Hadassah Medical Center, and all of the patients who participated in the study signed an informed consent form. Two hundred and nine patients attending the post-polio clinic between 2010 and 2012 were offered to participate in the study, 14 refused or were unavailable and 195 patients were enrolled. Each participant was evaluated and interviewed by a rehabilitation physician experienced in polio patients’ care. Onehour structured interview took place in the post-polio clinic in the hospital (92%) or in the patient’s home (5%), 3% of the patients were interviewed by phone. The evaluation included a medical neurological and functional examination. Each patient was examined by a physiatrist with experience in management of polio and post-polio patients
Disabil Rehabil, 2015; 37(24): 2233–2237
and the diagnosis of PPS was made according to the March of Dimes criteria and the EFNS task force on PPS recommendations [24,25]. These criteria included: prior paralytic poliomyelitis with evidence of motor neuron loss as confirmed by history of the acute paralytic illness; signs of residual weakness and atrophy of muscles on neurological examination, and signs of denervation on electromyography; a period of partial or complete functional recovery after acute poliomyelitis, followed by an interval (usually 15 years or more) of stable neurological function; gradual or sudden onset of progressive and persistent new muscle weakness or abnormal fatigability (decreased endurance), with or without generalized fatigue, muscle atrophy or muscle and joint pain. Less commonly, symptoms attributed to PPS include new problems with breathing or swallowing; symptoms persist for at least a year; exclusion of other neurological, medical and orthopedic problems as causes of symptoms. The control group is a random stratified sample from the international health survey, conducted by the Central Bureau of Statistic of Israel in the years 2003/2004. All cases from the health survey were divided into 28 stratum by sex (male–female), religion (Jews–non-Jews) and age (45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75+). From each strata, a random sample of controls was selected. The number of controls selected was four times the number of cases in each strata, and the control group included 768 people with similar age, sex and religious distribution as the polio cases. The instruments (1) A survey questionnaire – The demographic, medical, social and functional data of polio patients had been evaluated using a specific questionnaire that was constructed using the relevant parts of the following surveys: the National Health Surveys conducted by the Central Bureau of Statistic of Israel at the years 2003/2004 and 2006/2007 [26] and the IsraeliEuropean SHARE study [27]. Demographic data included: age, age of polio infection, gender, ethnic origin and place of birth. Socioeconomic data contained: marital status, education and employment status. Answering the health selfassessment questionnaire, patients were asked to assess their physical, emotional and general (emotional and physical) health on a five-grade scale: excellent, very good, good, fair and poor. A self-reported questionnaire was used to identify difficulties in performing daily tasks (activities of daily living, ADL). The ADL questionnaire evaluated independency in bathing-showering, dressing, personal hygiene, eating and functional mobility. Functional mobility questionnaire assessed independency in bed mobility, sit to stand and transfers mobility, indoor and outdoor walking. Functional level was assessed on a five-grade scale: complete independence, independence with difficulties, independence with assistive aid, needs person assistance and fully dependent. In addition, polio patients were asked regarding the usage of walking aids and a wheelchair. (2) General health questionnaire-12 (GHQ-12) – This is a 12-item questionnaire assessing the current mental health by measuring ED [22]. Items of this instrument serve as measures for satisfaction and sense of general competence, six of which are positively phrased and six negatively phrased. Each item is rated on a four-point scale, very often, sometimes, rarely and never. To adjust between positively and negatively phrased items, the scale order has been adjusted and the scores were calculated as 49 minus the final score. Therefore the scores range between 1 and 37, with higher scores indicate increased distress. The GHQ-12 had
Polio and distress
DOI: 10.3109/09638288.2015.1019007
previously been used in Hebrew with good internal consistency of the instrument as measured by Cronbach’s of 0.88 for the entire sample [23].
Table 1. Demographic and social data of polio population in comparison with general population in Israel.
Statistical analyses Descriptive statistics were calculated for continuous variables: mean, and standard deviation, differences were assessed by t test. Percentages and rates were calculated for the categorical variables and differences were assessed by chi-square test. Adjusted means and standard error were computed using general linear models in order to asses the unique effect of each variable on GHQ score, while controlling for all other variables included in the model. To compare the effect of each variable on GHQ between polio survivors and general population interactions were add to the models. p Value50.05 was considered as significant.
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Mean age (years) Male (%) Married (%) Israeli born (%) Education412 years (%) Work (%)
Polio survivors (N ¼ 180)
General Israeli population (N ¼ 766)
p Value
57.6 ± 10.5 53.4 73.9 74.2 71.9 37
57.7 ± 11 52 81.1 40.1 61.6 47.9
0.88 0.72 0.029 50.001 0.026 0.007
Results
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Demographics One hundred and eighty of 195 polio participants filled the entire questionnaire including the GHQ. The mean age of polio survivors was 57.6 ± 10.5 (range ¼ 32–85); there were 53.4% men, 74.3% were Jews. In comparison with the general population, 73.9% versus 81.1% (p ¼ 0.029) were married, 74.2% versus 40.1% were born in Israel (p50.001) and 28.1% versus 38.4% (p ¼ 0.026) had 12 or less years of education. Only 37% of the polio patients were used as compared to 47.9% in the general population (p ¼ 0.007) (Table 1). Psychological health in polio population ED as measured in the GHQ was higher in the polio sample as compared to the general population (GHQ 13.00 versus 10.37, p ¼ 0.0004) representing reduced psychological health of polio participants. No difference was found in GHQ score between polio patients using walking aids or orthoses and/or restricted to a wheelchair and those who were not using these assistive devices (Figure 1). In the polio sample, 150 patients fulfilled the March of Dimes criteria of PPS [24] representing 78.9% of polio survivors. No difference was found in GHQ score between polio participants with or without PPS. Comparison of the association between demographic variables and psychological status between polio patients and the general population Two models of the association between ED and demographic parameters of polio participants in comparison to the general population are presented in Tables 2 and 3. The first model (Table 2) presents an association between demographic and employment parameters and psychological status of polio survivors in comparison to the general population. In this model, age has no effect on the psychological status in both populations, female gender, being unmarried and lower education were associated with higher ED among controls but not among polio participants. However, in all the examined parameters there were no significant differences between the general and polio populations. When the subjective perception of physical health was add to the model (model 2 – Table 3), most of these associations did not change. However, marital status became nonsignificant in both groups, whereas unemployment status showed significance only in the polio population. In both populations, negative perception of physical health was associated with higher ED; however, the psychological health of individuals with polio was significantly less affected by this factor than in the controls.
Figure 1. Comparison between GHQ-12 scores of polio survivors using walking aids or orthoses and/or restricted to a wheelchair and those not using these assistive devices as well as those with and without PPS. No significant difference in GHQ score was found between any of the presented groups.
Discussion The findings of this study indicate that the psychological health of individuals with long-standing poliomyelitis in Israel is lower than the general population. These findings are congruent with previous studies indicating that polio is associated with greater psychological vulnerability and depressive symptomatology [9,12,28–30]. Generally, these finding are consistent also with the general notion and findings that individuals with chronic illness are at increased risk for depression and deteriorated quality of life [31]. Interestingly, we found no differences between the psychological health of polio and post-polio survivors. Several studies showed that depressive symptoms are more common in patients with PPS as compared to polio survivors without PPS [11]. In our sample, almost 80% of the participants fulfilled the criteria of PPS. However, their psychological state was not significantly worse than polio survivors without PPS. In previous studies, risk factors for depression in polio population were their physical status linked to their polio sequelae [12,15,30]. In our study, however, we did not find association between worse physical characteristics or gait disabilities and worse ED. Taken together, these findings may reflect a resilient attitude of polio survivors toward their physical disabilities. Previous studies have shown that work is associated with higher quality of life among individuals with chronic illness such as poliomyelitis [32]. In our earlier study [14], we found work to be a factor that is positively associated with elevated quality of life among individuals with post-polio, but not among controls. Similarly, in this study, we found polio survivors who still work to be with less ED. This finding was significant only in polio population and not in the general population. The importance of work in the polio population was recently investigated in a study of 123 polio survivors in Israel [33]. Similarly to us, they found a
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Disabil Rehabil, 2015; 37(24): 2233–2237
Table 2. Association between demographic parameters and psychological status of polio survivors comparing to the general population- Model 1.
Adjusted mean
SE
p Value
N
Adjusted mean
SE
p Value
Comparison between polio and general population p Value
12.33 13.68
0.67 0.70
0.125
397 367
9.75 11.00
0.45 0.46
0.017
0.930
10.32 15.69
0.70 1.00
0.0001
581 183
9.06 11.69
0.44 0.67
0.002
0.143
14.82 11.86 12.33
1.09 0.83 0.92
0.134
135 306 323
10.12 10.61 10.40
0.70 0.55 0.60
0.839
0.223
12.71 13.30
0.57 0.83
0.546
620 144
9.36 11.38
0.31 0.63
0.002
0.279
13.11 13.89 12.02
0.81 0.80 0.83
0.183
294 211 259
12.00 9.93 9.18
0.47 0.55 0.53
0.00001
0.148
11.42 14.58
0.77 0.59
0.0004
366 398
8.96 11.79
0.49 0.44
Polio survivors (N ¼ 178)
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Characteristics
N
Model 1 Gender Male 95 Female 85 Ethnic origin Jews 134 Non-Jews 46 Age 550 34 50–60 70 60 76 Marital status Married 133 Not married 47 Education (years) 511 52 12–14 62 415 66 Employment Yes 66 No 114
General Israeli population (N ¼ 766)
50.0001
0.784
Table 3. Association between demographic parameters and psychological status of polio survivors comparing to the general population- Model 2: Including general health perception.
SE
p Value
N
Adjusted mean
SE
p Value
Comparison between polio and general population p Value
0.80 0.87
0.426
396 367
9.76 11.01
0.40 0.40
0.006
0.606
0.83 1.13
0.0003
580 183
9.14 11.63
0.38 0.58
0.001
0.128
1.17 0.91 1.09
0.172
135 306 322
11.23 10.20 9.73
0.62 0.48 0.53
0.240
0.677
0.74 0.96
0.324
619 144
9.90 10.87
0.28 0.55
0.093
0.979
0.97 0.96 0.90
0.482
294 211 258
11.29 10.36 9.50
0.41 0.48 0.46
0.004
0.313
0.90 0.78
0.004
365 398
10.07 10.70
0.43 0.39
0.221
0.070
1.70 0.71 0.67
0.006
235 282 246
6.61 8.98 15.56
0.46 0.44 0.47
50.0001
0.001
Polio survivors (N ¼ 178) Characteristics
N
Adjusted mean
Model 2: Including general health perception Gender Male 94 11.51 Female 84 12.21 Ethnic Origin Jews 134 9.32 Non-Jews 44 14.39 Age 550 33 13.66 50–60 69 11.04 60 76 10.87 Marital status Married 131 11.39 Not married 47 12.33 Education, years 511 51 11.60 12–14 61 12.55 415 66 11.42 Employment Yes 65 10.55 No 113 13.17 General health perception Very good or excellent 11 9.76 Good 65 11.70 Not so good or not good 102 14.12
significant correlation between higher disability and unemployment. Taken together, the findings of these studies emphasize the importance of work as a source that is associated with increased mental health and quality of life in polio patients. In this study, we used the GHQ-12 scale in order to evaluate the psychological state of the polio population. Using the GHQ, our study is the first to show that ED is increased in long-standing poliomyelitis survivors. This finding is similar to previous studies, which showed higher ED among other specific vulnerable populations, such as Holocaust survivors and elderly [34,35]. Similar to the Holocaust survivors, also our sample showed high resilience in spite of higher psychological distress.
General Israeli population (N ¼ 766)
Similar to our previous study [14], the current findings present several indicators of resilience among polio survivors. Resilience may be viewed as an ability to grow and develop in the face of stress and hardship [36]. The ability to maintain homeostasis when faced with stressful events is another basic feature of resilience [37,38]. In our study, no differences were found in the psychological health between individuals with various levels of polio sequelae, between those with or without PPS, between those with or without walking aids or between those who are restricted or not restricted to a wheelchair. Although negative assessment of their physical health condition affected their psychological condition, this effect has higher contribution to ED in the controls
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DOI: 10.3109/09638288.2015.1019007
as compared to the polio population. The ability of polio survivors to block the effect of their own pessimistic assessments with regard to their health more effectively than controls’ is another expression of resilience. Other studies found higher resilience in the polio population as compared to the general population [12,39]. Pierini and Stuifbergen [12] showed that more than half of the participants who had PPS rated their health as good or excellent. In another study, almost a quarter of the surveyed patients stated that living with polio helped them to achieve personal growth and increased strength [16]. In our previous study, we have shown that futureoriented coping strategies associated with hope were positively associated with higher physical and mental quality of life among individuals with PPS [14]. Our study, however, was not free of limitations, for example, polio survivors who participated in the study came only from one post-polio clinic and may not be representative of all polio survivors in Israel. The GHQ-12 has some limitations mainly due to response bias on the negative items, which may limit its utility as a screening instrument for psychiatric morbidity [40]. However, this is the first study comparing psychological health of a relatively large sample of polio survivors with the general population measuring many variables and therefore our results are pertinent to the general psychological and physical health of polio survivors.
Declaration of interest This research was supported by the 2011 award of the Post-Polio Health International (PHI) Organization St. Louis, Missouri, USA and the Lawrence and Anita Miller Los Angeles Jewish federation rehabilitation research Fund. The authors declare no conflicts of interests.
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ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20
Long-standing poliomyelitis and psychological health Shimon Shiri, Irina Gartsman, Zeev Meiner & Isabella Schwartz To cite this article: Shimon Shiri, Irina Gartsman, Zeev Meiner & Isabella Schwartz (2015) Long-standing poliomyelitis and psychological health, Disability and Rehabilitation, 37:24, 2233-2237, DOI: 10.3109/09638288.2015.1019007 To link to this article: http://dx.doi.org/10.3109/09638288.2015.1019007
Published online: 27 Feb 2015.
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Date: 17 October 2015, At: 07:35
http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(24): 2233–2237 ! 2015 Informa UK Ltd. DOI: 10.3109/09638288.2015.1019007
RESEARCH PAPER
Long-standing poliomyelitis and psychological health Shimon Shiri, Irina Gartsman, Zeev Meiner, and Isabella Schwartz
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Department of Physical Medicine and Rehabilitation, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
Abstract
Keywords
Objective: To compare the psychological health of the individuals with long-standing poliomyelitis, with or without post-polio syndrome (PPS), to the general population and to identify the role of work as well as other variables with regard to their psychological health. Design: A cross-sectional study. Subjects: One hundred and ninety-five polio patients attending postpolio clinic in Jerusalem. Methods: Emotional distress (ED) was measured using the general health questionnaire (GHQ-12). Demographic, medical, social and functional data were recorded using a specific structured questionnaire. Each polio patient was compared to four age- and sex-matched controls. Results: ED was higher in the polio population as compared to the general population. Within the polio population ED was inversely correlated with work status. No correlation was found between ED and the functional level of polio participants and no difference was found in GHQ score between polio participants with or without post-polio. In addition, ED was less affected by subjective perception of physical health among polio patients as compared to the general population. Conclusions: Long-standing poliomyelitis is associated with decreased psychological health as compared to the general population. Yet, the resilience of polio survivors is manifested by their ability to block further decline of their psychological health in spite of deterioration in their physical health. Work appears as a significant source of resilience in the polio population.
Emotional distress, mental health, poliomyelitis, post-polio syndrome, work History Received 15 March 2014 Revised 3 February 2015 Accepted 10 February 2015 Published online 27 February 2015
ä Implications for Rehabilitation
Individuals with long-standing poliomyelitis often suffer from high emotional distress and may benefit from psychotherapy aimed at reducing distress. As active employment status is associated with increased mental health among polio survivors, encouraging participation at work needs to be a significant component of psychotherapeutic programs. Polio survivors, although physically disabled, may be relatively resilient, as their mental health is less affected by their negative health perception. This and other expressions of resilience may serve as a platform for increasing personal growth among them by implementing hopeoriented psychotherapy.
Introduction Despite successful efforts toward eradicating poliomyelitis, polio still represents a significant medical burden. It was estimated that there were 12–20 million people worldwide suffering from disabilities related to poliomyelitis [1]. A high rate of polio survivors develop new symptoms including new muscle weakness, exacerbating of previous weakness, muscle atrophy, cold intolerance and fatigue [2]. These new symptoms, comprising of the postpolio syndrome (PPS), have deleterious effect on the function and quality of life of the survivors [3,4]. PPS develops in 25–50% in patients with poliomyelitis and usually occurs 15–30 years after the initial infection with the poliovirus [5,6].
Address for correspondence: Shimon Shiri, Ph.D., Department of Physical and Medical Rehabilitation, Hadassah University Hospital – Mount Scopus, Jerusalem, Israel. Tel: +972 2 5610626. Fax: +972 2 5844885. E-mail: [email protected]
A considerable number of studies have attempted to examine the psychological health of polio survivors [7]. Many of these studies found polio survivors to suffer from greater degrees of psychological morbidity in the form of depression, anxiety disorders and other psychopathological characteristics such as Type A behavior [8]. More recent studies that followed the emergence of PPS have often found individuals with postpolio to have even greater degrees psychopathologies, low quality of life [9] and decreased satisfaction with life [4,10,11]. In these studies, individuals with postpolio experienced greater distressing symptoms such as depressive or hypochondrical symptoms than those with polio alone. Some of these studies found a correlation between levels of psychological distress and the physical deterioration of the patients [11,12]. Negative emotions were described as well, as individuals with postpolio experience pain, disability or other negative symptoms [13]. Correspondingly, we found that individuals with postpolio suffered from decreased mental and physical quality of life when compared to the general
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population [14]. Yet, it is still remains unclear whether the emergence of PPS is associated with further exacerbation in the psychological state of polio survivors and one aim of this study is to further examine this issue. Studies that used qualitative methods of research have presented different and more optimistic views of the experience of post-polio. In one study [15], it was found that symptoms of post-polio are associated with early traumatic memories associated with the emergence of polio. Yet, alongside with these painful experiences, participants reported that they had accomplished most of their ambitions in the areas of work and family life. Similarly, the majority of 39 participants with PPS reported a high level of psychosocial well-being and almost a quarter have that living with polio has meant personal development and strength [16]. In our search for processes that have the potential of increasing the well being of polio survivors, we found that when hope [17] is raised in the form of setting significant goals and finding channels of achieving these goals, quality of life of post-polio patients may improve significantly [14]. Recently, we conducted a large epidemiological study comparing the general situation of polio survivors with the general population in Jerusalem [18]. In this study, we aim to evaluate also the psychological state of polio survivors, with and without PPS, as compared to the general population. The relatively large number of participants allowed us to examine whether the psychological distress in this population is further exacerbated by the emergence of PPS. Another objective is to further explore the association of work and psychological health among polio survivors. Our earlier study [14] as well as other work has indicated that being active at work is associated with better quality of life among polio and other chronic illnesses sufferers [15,19–23]. In this study, we are able to compare the unique function of work, as in the polio population relatively to the general population. While in our previous study we have used a general quality of life questionnaire, in this study we decided to assess the psychological state of individuals with long-standing poliomyelitis using a questionnaire that is specifically aimed to measure psychological health, the general health questionnaire-12 (GHQ12) scale [22]. The GHQ-12 is measuring the emotional distress (ED), which serves as an efficient indicator of the psychological impact of adverse conditions present among specific community groups. It had been used frequently, both in clinical and community settings [23]. Our study is the first to use the GHQ in long-standing poliomyelitis survivors.
Methods Participants All the polio patients attended the postpolio clinic in the Physical Medicine and Rehabilitation Department in Hadassah Mount Scopus Medical Center in Jerusalem. The study was approved by the ethical committee of Hadassah Medical Center, and all of the patients who participated in the study signed an informed consent form. Two hundred and nine patients attending the post-polio clinic between 2010 and 2012 were offered to participate in the study, 14 refused or were unavailable and 195 patients were enrolled. Each participant was evaluated and interviewed by a rehabilitation physician experienced in polio patients’ care. Onehour structured interview took place in the post-polio clinic in the hospital (92%) or in the patient’s home (5%), 3% of the patients were interviewed by phone. The evaluation included a medical neurological and functional examination. Each patient was examined by a physiatrist with experience in management of polio and post-polio patients
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and the diagnosis of PPS was made according to the March of Dimes criteria and the EFNS task force on PPS recommendations [24,25]. These criteria included: prior paralytic poliomyelitis with evidence of motor neuron loss as confirmed by history of the acute paralytic illness; signs of residual weakness and atrophy of muscles on neurological examination, and signs of denervation on electromyography; a period of partial or complete functional recovery after acute poliomyelitis, followed by an interval (usually 15 years or more) of stable neurological function; gradual or sudden onset of progressive and persistent new muscle weakness or abnormal fatigability (decreased endurance), with or without generalized fatigue, muscle atrophy or muscle and joint pain. Less commonly, symptoms attributed to PPS include new problems with breathing or swallowing; symptoms persist for at least a year; exclusion of other neurological, medical and orthopedic problems as causes of symptoms. The control group is a random stratified sample from the international health survey, conducted by the Central Bureau of Statistic of Israel in the years 2003/2004. All cases from the health survey were divided into 28 stratum by sex (male–female), religion (Jews–non-Jews) and age (45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75+). From each strata, a random sample of controls was selected. The number of controls selected was four times the number of cases in each strata, and the control group included 768 people with similar age, sex and religious distribution as the polio cases. The instruments (1) A survey questionnaire – The demographic, medical, social and functional data of polio patients had been evaluated using a specific questionnaire that was constructed using the relevant parts of the following surveys: the National Health Surveys conducted by the Central Bureau of Statistic of Israel at the years 2003/2004 and 2006/2007 [26] and the IsraeliEuropean SHARE study [27]. Demographic data included: age, age of polio infection, gender, ethnic origin and place of birth. Socioeconomic data contained: marital status, education and employment status. Answering the health selfassessment questionnaire, patients were asked to assess their physical, emotional and general (emotional and physical) health on a five-grade scale: excellent, very good, good, fair and poor. A self-reported questionnaire was used to identify difficulties in performing daily tasks (activities of daily living, ADL). The ADL questionnaire evaluated independency in bathing-showering, dressing, personal hygiene, eating and functional mobility. Functional mobility questionnaire assessed independency in bed mobility, sit to stand and transfers mobility, indoor and outdoor walking. Functional level was assessed on a five-grade scale: complete independence, independence with difficulties, independence with assistive aid, needs person assistance and fully dependent. In addition, polio patients were asked regarding the usage of walking aids and a wheelchair. (2) General health questionnaire-12 (GHQ-12) – This is a 12-item questionnaire assessing the current mental health by measuring ED [22]. Items of this instrument serve as measures for satisfaction and sense of general competence, six of which are positively phrased and six negatively phrased. Each item is rated on a four-point scale, very often, sometimes, rarely and never. To adjust between positively and negatively phrased items, the scale order has been adjusted and the scores were calculated as 49 minus the final score. Therefore the scores range between 1 and 37, with higher scores indicate increased distress. The GHQ-12 had
Polio and distress
DOI: 10.3109/09638288.2015.1019007
previously been used in Hebrew with good internal consistency of the instrument as measured by Cronbach’s of 0.88 for the entire sample [23].
Table 1. Demographic and social data of polio population in comparison with general population in Israel.
Statistical analyses Descriptive statistics were calculated for continuous variables: mean, and standard deviation, differences were assessed by t test. Percentages and rates were calculated for the categorical variables and differences were assessed by chi-square test. Adjusted means and standard error were computed using general linear models in order to asses the unique effect of each variable on GHQ score, while controlling for all other variables included in the model. To compare the effect of each variable on GHQ between polio survivors and general population interactions were add to the models. p Value50.05 was considered as significant.
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Mean age (years) Male (%) Married (%) Israeli born (%) Education412 years (%) Work (%)
Polio survivors (N ¼ 180)
General Israeli population (N ¼ 766)
p Value
57.6 ± 10.5 53.4 73.9 74.2 71.9 37
57.7 ± 11 52 81.1 40.1 61.6 47.9
0.88 0.72 0.029 50.001 0.026 0.007
Results
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Demographics One hundred and eighty of 195 polio participants filled the entire questionnaire including the GHQ. The mean age of polio survivors was 57.6 ± 10.5 (range ¼ 32–85); there were 53.4% men, 74.3% were Jews. In comparison with the general population, 73.9% versus 81.1% (p ¼ 0.029) were married, 74.2% versus 40.1% were born in Israel (p50.001) and 28.1% versus 38.4% (p ¼ 0.026) had 12 or less years of education. Only 37% of the polio patients were used as compared to 47.9% in the general population (p ¼ 0.007) (Table 1). Psychological health in polio population ED as measured in the GHQ was higher in the polio sample as compared to the general population (GHQ 13.00 versus 10.37, p ¼ 0.0004) representing reduced psychological health of polio participants. No difference was found in GHQ score between polio patients using walking aids or orthoses and/or restricted to a wheelchair and those who were not using these assistive devices (Figure 1). In the polio sample, 150 patients fulfilled the March of Dimes criteria of PPS [24] representing 78.9% of polio survivors. No difference was found in GHQ score between polio participants with or without PPS. Comparison of the association between demographic variables and psychological status between polio patients and the general population Two models of the association between ED and demographic parameters of polio participants in comparison to the general population are presented in Tables 2 and 3. The first model (Table 2) presents an association between demographic and employment parameters and psychological status of polio survivors in comparison to the general population. In this model, age has no effect on the psychological status in both populations, female gender, being unmarried and lower education were associated with higher ED among controls but not among polio participants. However, in all the examined parameters there were no significant differences between the general and polio populations. When the subjective perception of physical health was add to the model (model 2 – Table 3), most of these associations did not change. However, marital status became nonsignificant in both groups, whereas unemployment status showed significance only in the polio population. In both populations, negative perception of physical health was associated with higher ED; however, the psychological health of individuals with polio was significantly less affected by this factor than in the controls.
Figure 1. Comparison between GHQ-12 scores of polio survivors using walking aids or orthoses and/or restricted to a wheelchair and those not using these assistive devices as well as those with and without PPS. No significant difference in GHQ score was found between any of the presented groups.
Discussion The findings of this study indicate that the psychological health of individuals with long-standing poliomyelitis in Israel is lower than the general population. These findings are congruent with previous studies indicating that polio is associated with greater psychological vulnerability and depressive symptomatology [9,12,28–30]. Generally, these finding are consistent also with the general notion and findings that individuals with chronic illness are at increased risk for depression and deteriorated quality of life [31]. Interestingly, we found no differences between the psychological health of polio and post-polio survivors. Several studies showed that depressive symptoms are more common in patients with PPS as compared to polio survivors without PPS [11]. In our sample, almost 80% of the participants fulfilled the criteria of PPS. However, their psychological state was not significantly worse than polio survivors without PPS. In previous studies, risk factors for depression in polio population were their physical status linked to their polio sequelae [12,15,30]. In our study, however, we did not find association between worse physical characteristics or gait disabilities and worse ED. Taken together, these findings may reflect a resilient attitude of polio survivors toward their physical disabilities. Previous studies have shown that work is associated with higher quality of life among individuals with chronic illness such as poliomyelitis [32]. In our earlier study [14], we found work to be a factor that is positively associated with elevated quality of life among individuals with post-polio, but not among controls. Similarly, in this study, we found polio survivors who still work to be with less ED. This finding was significant only in polio population and not in the general population. The importance of work in the polio population was recently investigated in a study of 123 polio survivors in Israel [33]. Similarly to us, they found a
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Table 2. Association between demographic parameters and psychological status of polio survivors comparing to the general population- Model 1.
Adjusted mean
SE
p Value
N
Adjusted mean
SE
p Value
Comparison between polio and general population p Value
12.33 13.68
0.67 0.70
0.125
397 367
9.75 11.00
0.45 0.46
0.017
0.930
10.32 15.69
0.70 1.00
0.0001
581 183
9.06 11.69
0.44 0.67
0.002
0.143
14.82 11.86 12.33
1.09 0.83 0.92
0.134
135 306 323
10.12 10.61 10.40
0.70 0.55 0.60
0.839
0.223
12.71 13.30
0.57 0.83
0.546
620 144
9.36 11.38
0.31 0.63
0.002
0.279
13.11 13.89 12.02
0.81 0.80 0.83
0.183
294 211 259
12.00 9.93 9.18
0.47 0.55 0.53
0.00001
0.148
11.42 14.58
0.77 0.59
0.0004
366 398
8.96 11.79
0.49 0.44
Polio survivors (N ¼ 178)
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Characteristics
N
Model 1 Gender Male 95 Female 85 Ethnic origin Jews 134 Non-Jews 46 Age 550 34 50–60 70 60 76 Marital status Married 133 Not married 47 Education (years) 511 52 12–14 62 415 66 Employment Yes 66 No 114
General Israeli population (N ¼ 766)
50.0001
0.784
Table 3. Association between demographic parameters and psychological status of polio survivors comparing to the general population- Model 2: Including general health perception.
SE
p Value
N
Adjusted mean
SE
p Value
Comparison between polio and general population p Value
0.80 0.87
0.426
396 367
9.76 11.01
0.40 0.40
0.006
0.606
0.83 1.13
0.0003
580 183
9.14 11.63
0.38 0.58
0.001
0.128
1.17 0.91 1.09
0.172
135 306 322
11.23 10.20 9.73
0.62 0.48 0.53
0.240
0.677
0.74 0.96
0.324
619 144
9.90 10.87
0.28 0.55
0.093
0.979
0.97 0.96 0.90
0.482
294 211 258
11.29 10.36 9.50
0.41 0.48 0.46
0.004
0.313
0.90 0.78
0.004
365 398
10.07 10.70
0.43 0.39
0.221
0.070
1.70 0.71 0.67
0.006
235 282 246
6.61 8.98 15.56
0.46 0.44 0.47
50.0001
0.001
Polio survivors (N ¼ 178) Characteristics
N
Adjusted mean
Model 2: Including general health perception Gender Male 94 11.51 Female 84 12.21 Ethnic Origin Jews 134 9.32 Non-Jews 44 14.39 Age 550 33 13.66 50–60 69 11.04 60 76 10.87 Marital status Married 131 11.39 Not married 47 12.33 Education, years 511 51 11.60 12–14 61 12.55 415 66 11.42 Employment Yes 65 10.55 No 113 13.17 General health perception Very good or excellent 11 9.76 Good 65 11.70 Not so good or not good 102 14.12
significant correlation between higher disability and unemployment. Taken together, the findings of these studies emphasize the importance of work as a source that is associated with increased mental health and quality of life in polio patients. In this study, we used the GHQ-12 scale in order to evaluate the psychological state of the polio population. Using the GHQ, our study is the first to show that ED is increased in long-standing poliomyelitis survivors. This finding is similar to previous studies, which showed higher ED among other specific vulnerable populations, such as Holocaust survivors and elderly [34,35]. Similar to the Holocaust survivors, also our sample showed high resilience in spite of higher psychological distress.
General Israeli population (N ¼ 766)
Similar to our previous study [14], the current findings present several indicators of resilience among polio survivors. Resilience may be viewed as an ability to grow and develop in the face of stress and hardship [36]. The ability to maintain homeostasis when faced with stressful events is another basic feature of resilience [37,38]. In our study, no differences were found in the psychological health between individuals with various levels of polio sequelae, between those with or without PPS, between those with or without walking aids or between those who are restricted or not restricted to a wheelchair. Although negative assessment of their physical health condition affected their psychological condition, this effect has higher contribution to ED in the controls
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DOI: 10.3109/09638288.2015.1019007
as compared to the polio population. The ability of polio survivors to block the effect of their own pessimistic assessments with regard to their health more effectively than controls’ is another expression of resilience. Other studies found higher resilience in the polio population as compared to the general population [12,39]. Pierini and Stuifbergen [12] showed that more than half of the participants who had PPS rated their health as good or excellent. In another study, almost a quarter of the surveyed patients stated that living with polio helped them to achieve personal growth and increased strength [16]. In our previous study, we have shown that futureoriented coping strategies associated with hope were positively associated with higher physical and mental quality of life among individuals with PPS [14]. Our study, however, was not free of limitations, for example, polio survivors who participated in the study came only from one post-polio clinic and may not be representative of all polio survivors in Israel. The GHQ-12 has some limitations mainly due to response bias on the negative items, which may limit its utility as a screening instrument for psychiatric morbidity [40]. However, this is the first study comparing psychological health of a relatively large sample of polio survivors with the general population measuring many variables and therefore our results are pertinent to the general psychological and physical health of polio survivors.
Declaration of interest This research was supported by the 2011 award of the Post-Polio Health International (PHI) Organization St. Louis, Missouri, USA and the Lawrence and Anita Miller Los Angeles Jewish federation rehabilitation research Fund. The authors declare no conflicts of interests.
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