Journal of Neuroscience Nursing:
Development of the Activity Effort Scale for Women Aging With Paralytic Polio
Questions or comments about this article may be directed to Tracie Harrison, PhD RN FNP, at email@example.com. She is a an assistant professor at the School of Nursing, The University of Texas at Austin, Austin, TX.
The purpose of this study was to develop and psychometrically test the Activity Effort Scale among women aging with the affects of paralytic polio. On the basis of prior qualitative research, six items were generated. Two researchers with expertise in disability were consulted for examination of the items, which led to the addition of two more items to the scale. Next, a survey was sent to 500 women with a history of paralytic polio. Data from participants were subjected to psychometric testing: factor analysis, reliability testing, and correlation with existing measures. Useable surveys were returned by 299 women aged 49 to 75 years. Mean age of infection with polio was 7.6 years, and 54% had spinal polio. Principal component analysis of the 8-item scale resulted in one component with an eigenvalue above 1, explaining 74% of the variance. The Cronbach's alpha was .92. Correlations between variables supported content validity. Data suggest that the Activity Effort Scale is a valid and reliable tool consisting of one component measuring frequency of effort exerted beyond levels of discomfort, pain, and fatigue among women aging with paralytic polio.
Aging with the effects of paralytic polio is arguably an exemplar for the experience of aging with disability from an early age (Alexander, 1990). It has been hypothesized that aging with a disability from an early age is conceptually different than aging into a disability in later life. The impact of functional limitation on socialization, education, and overall role acquisition is often age related; therefore, the timing of functional limitations influences how it is interpreted by the individual and by the society (Verbrugge & Yang, 2002). Further, the longer one lives with a disabling condition, the more likely he or she will develop comorbidities (Jans & Stoddard, 1999). Women with paralytic polio have aged with various impairments and functional limitations that may include muscle paralysis leading to the inability to breathe without ventilator assistance or paralysis of extremities leading to the inability to walk or hold items with their arms (Koh, Williams, & Povlsen, 2002). Over time, women aging with paralytic polio, when compared with women in general, may be at higher risk for osteoporosis (Schrager, 2004), asthma, and hypertension (Campbell, Sheets, & Strong, 1999; Harrison & Stuifbergen, 2001). On average, the current polio survivors have been aging with varying degrees of functional limitations since the end of the polio epidemics, the 1950s to the early 1960s, and are at risk for developing comorbid conditions and an associated poorer quality of life (Harrison & Stuifbergen, 2001; McNaughton & McPherson, 2003).
As polio survivors have aged with early-onset impairment, many have also experienced new-onset fatigue, pain, and weakness in previously impaired muscles, which is called postpolio syndrome (PPS). Age-related changes experienced by polio survivors after years of living with a stable impairment have a multitude of effects on their lives (Harrison, 2004; Maynard, 1995; McNaughton & McPherson, 2003). Persons aging with polio have reported higher levels of depressive symptoms when compared with nondisabled age-matched controls (Kemp & Krause, 1999). Moreover, those who experienced pain, weakness, and fatigue have reported less satisfaction with their lives (Burger & Marincek, 2000) and a poorer quality of life (Kling, Persson, & Gardulf, 2000) than did those without pain, weakness, and fatigue. This may be because impairments that occur with increasing age hinder the ability to socially integrate (Farbu, Rekand, Aarli, & Gilhus, 2001).
In previous studies of polio survivors (Harrison & Stuifbergen, 2001, 2006), it was theorized that levels of comorbidity could be explained using the combined disablement (Verbrugge & Jette, 1994) and allostatic load (McEwen & Steller, 1993) models. In other words, the cumulative stress of living with a functional limitation increased susceptibility to illness over time. The combined models helped explain the increased levels of comorbidity, but the link between disablement and increased allostatic load needed further clarification. Albeit the link was thought to be the result of increased barriers to health, it was not conceptually clear. The mechanism for how disablement increased a person's allostatic load and their subsequent risk for comorbid conditions needed further work. From a previous qualitative study (Harrison, 2006) and a review of the extant literature, the frequency of "activity effort" is now theorized to be the necessary conceptual link between the two models that explains the increased comorbidity over time.
The purpose of this article was to introduce the concept of activity effort and the evidence in support of a newly developed questionnaire to measure the concept, the Activity Effort Scale. The allostatic load and the disablement process models are reviewed briefly as is the concept of activity effort. Next, the results of a study measuring the psychometric properties of the Activity Effort Scale among women with polio are presented and discussed.
Allostatic load is used to conceptualize the impact of living with high levels of biological stress with resultant wear and tear on the body (Seeman, McEwen, Rowe, & Singer, 2001). When people are able to adapt to challenges without developing high levels of physiological stress, they reach allostasis (Sterling & Eyer, 1988). When people live with high levels of stress over the life course but are not able to adapt, physiological damage occurs resulting in illness due to the long-term activation of neurohumoral mechanism meant only for short-term compensation (McEwen & Stellar, 1993). Biological markers have been proposed to measure allostatic load through physiological measurement of the body's function, which include measures of the "hypothalamic-pituitary-adrenal axis, sympathetic nervous system, cardiovascular system, and metabolic processes" (Seeman et al., 2001, p. 4770). Physiological measures have included various biomarkers such as cortisol levels, C-reactive protein, fibrinogen, creatinine clearance, epinephrine, homocysteine, blood pressure, dopamine, waist-to-hip ratio, and fasting glucose levels (Szanton, Gill, & Allen, 2005). The levels of allostatic load are calculated by "using a data driven partitioning of the sample" (Seeman et al., 2001, p. 4771). In other words, people are stratified based upon their relative risk by summing the number of measures that the individual scored at the top quartile or perhaps top 10% of risk (Szanton et al., 2005).
High levels of allostatic load have been associated with worse mortality, functional limitations, and mental health outcomes in primarily older populations (Gruenewalk, Seeman, Ryff, Karlamangla, & Singer, 2006; Seeman et al., 2001; Seplaki, Goldman, Weinstein, & Lin, 2004). In a population-based study of 2000 Taiwanese middle-aged and elderly people, measures of cortisol, epinephrine, no reprinephrine, dopamine, dehydroepiandrosterone sulfate (DHEA-S), growth hormone, immune system factors, blood pressure, cholesterol, glucose, and weight were compared based upon degree of functional limitations. Those people who were substantially impaired had significantly higher levels of cortisol, DHEA-S, and interleukin-6 than those of people who had no impairment. In addition, those who were substantially impaired had higher blood pressure, cholesterol, triglycerides, fasting glucose, and glycosylated hemoglobin. The authors asserted that there is an association between "profiles of functioning and physiological parameters of the stress response" (Seplaki et al., 2004, p. 210). Evidence also suggests that physiological adaptation to stress may be affected by early-life experiences, such as childhood trauma, which may lead to lasting and exaggerated stress responses (McEwen, 2003).
The disablement process model theorizes that disablement is due to the progression from pathology to impairment, from impairment to functional limitation, and from functional limitation to disability (Verbrugge & Jette, 1994). For instance, a woman with a history of pathology due to a poliomyelitis infection may have an impaired nerve that no longer innervates her leg muscles and subsequently be unable to move her legs due to that impairment. If the woman with the pathology, impairment, and functional limitation, for example, paralyzed legs, is unable to perform expected social roles such as work, marriage, or volunteering, she may be characterized as disabled. Being disabled, however, is not exclusively a result of the pathology, impairment, and/or functional limitation. Internal and external factors may influence her ability to maintain her social roles. For instance, if she uses a wheelchair and has access to ramps, she can continue to go to her place of employment. Of particular interest in this research is the relationship between the concepts of functional limitations and disability. These two concepts are reviewed below.
For women with polio, functional limitation is a result of impairment of nerves with subsequent muscle paralysis as a direct result of the pathological changes associated with poliomyelitis. Typically, polio survivors experienced initial paralysis then improved function during the first 10 to 20 years postinfection followed by a second decline 20 years later (Wenneberg & Ahlstrom, 2000). The most common type of decline includes muscle weakness, fatigue, and pain in previously affected muscles in PPS. In a study of 120 polio survivors, muscle deterioration was present in the flexor muscles of ankle, hip, and knee, and it was experienced at a rate greater than expected with normal aging (Klein, Whyte, Keenan, Esquenazi, & Polansky, 2000). In a study of 27 polio survivors, the rate of muscle decline averaged 1% per year. Their muscles showed evidence of chronic and new loss of neurons, with a slow disintegration of terminal nerve axons (Dalakas et al., 1986). This translated into a functional decline because many lost the ability to perform the physical activities they previously performed during the first 10 to 20 years after rehabilitation. In a study of 103 polio survivors, Nollet et al. (2001) reported that current functional limitations included problems with walking outside (46%) and climbing stairs (41%; Nollet et al., 2001).
Disability is the inability to perform social roles (Verbrugge & Jette, 1994). There are different dimensions of disability that can be operationalized when considering dimensions of the disablement process model (Verbrugge, Merrill, & Liu, 1999). For instance, one may be disabled in social interactions, job performance, self-care, and economic independence. For purposes of this study, disability is defined in a way consistent with Verbrugge and Jette (1994)-the inability to perform socially expected and/or desired roles, a definition which considers all dimensions of disability. The women in a previous qualitative study of polio survivors (Harrison, 2006; Harrison & Stuifbergen, 2005) described the interruption of multiple roles as functional impairment, which increased over time-ranging from family to occupational roles. The occupational roles, however, required the most activity effort from the women. This was because the women would lose multiple resources, from insurance to income to identity, if their occupational roles were lost. Hence, they worked hard to maintain their occupational roles.
The relationship between functional limitation and disability has been supported in multiple studies. For example, in one study of over 3,000 Mexican American, Anglo (Caucasian), and African American men and women older than 65 years (Rudkin, Markides, & Espino, 1997), it was reported that significantly higher levels of functional limitations were associated with lower income, lack of homeownership, and lack of private insurance. Those with greater degrees of functional limitations were more likely to be termed disabled and placed in a nursing home.
According to the disablement process model, intraindividual factors are descriptions of the ways people with functional limitations internally cope with their potentially disabling conditions. This can be in the form of lifestyle change, psychological coping styles, and/or personality characteristics (Verbrugge & Jette,1994). During previous qualitative work investigating the life-course experiences of 25 women aged 55 to 65 years with polio since childhood, it was reported that an important intraindividual factor needed to overcome disability was the amount of activity effort exerted despite pain, fatigue, or general discomfort (Harrison & Stuifbergen, 2005). Pushing the body to achieve was a way women with a variety of functional limitation levels overcame disability. Women with varying levels of functional limitations described increasing their activity effort to meet their social roles. The majority stated that, even if they did not feel the discomfort at the time they were exerting themselves, they would feel it the next day. The women stated that, although these efforts enabled them to remain socially active, it was maladaptive over time. If they continued to do activities despite increasing levels of fatigue, pain, or other discomforts, they experienced exhaustion, injuries, or further illness over time. This was, however, how they were taught to overcome physical barriers in their youth, so it was difficult to stop pushing themselves as they aged. The women stated that at midlife, when occupational and family demands were high, they had the highest demand on their physical reserves. With increasing age and retirement from the workforce, women were better able to preserve their energies and do activities without the high physical demands that worsened pain, fatigue, or overall discomfort. It is subsequently theorized that a high frequency of activity effort beyond pain, fatigue, or overall discomfort may increase woman's susceptibility to comorbid conditions by increasing her allostatic load; however, it would have the beneficial aspect of allowing her to overcome disability.
The literature supports the conceptualization of activity effort as an experience of prolonged effort in the context of varying degrees of pain, fatigue, and discomfort among persons with disabilities. People with disabilities due to arthritis have reported that social demands require that they keep moving despite high levels of pain and general discomfort (Rosenfeld & Faircloth, 2004). Indeed, Papadimitriou (2008) posited that activity effort is a learned strategy during rehabilitation. In an interesting ethnographic study of the rehabilitation experiences of persons with spinal cord injuries, Papadimitriou described how those with permanent disabilities were socialized to "work hard" to adjust to their new bodies. The physical therapists involved in their cases placed a higher value on those people who would "gracefully and stoically accept pain, discomfort and adversity" (p. 368) than on those who did not. This push toward "hard work" in the face of pain, fatigue, and discomfort was taught to people with disabilities during rehabilitation without insight into the long-term consequences of using this strategy for living with a permanent disability over time, and providers "unwittingly encourage clients to deny the lived reality of their bodies" (Papadimitriou, 2008, p. 369).
On the basis of prior qualitative work and existing literature, activity effort is theorized to be an intraindividual factor that may explain the connection between disablement and allostatic load. Figure 1 demonstrates the proposed relationships. On the basis of this, it is posited that, as women with functional limitations related to paralytic polio physically push themselves to overcome disability, despite levels of pain, fatigue, and general discomfort, they subsequently increase their allostatic load, which places them at risk for further comorbidities. Prior to testing this theory, however, it is necessary to examine and report the psychometric properties of the Activity Effort Scale among women with a history of paralytic polio.
After approval from the local institutional review board, 500 potential participants were selected from an existing national sample of polio survivors. These individuals had participated in a previous study of health promotion in people with polio and indicated a willingness to be contacted for future studies (Stuifbergen, Seraphine, Harrison, & Adachi, 2005). Potential participants were selected from the existing sample if they were women, older than 55 years, diagnosed with paralytic polio, and able to read and write English. Each woman received a letter explaining the study in detail along with a stamped return envelope and a survey questionnaire. A total of 303 surveys were returned; 299 were useable, for a response rate of 60%. No compensation was provided. All data were entered into Statistical Package for the Social Sciences 16.0 (Chicago, IL) for statistical analysis. Data were checked for accuracy, and any errors found in data entry were corrected.
The final sample included 299 women with a reported age ranging from 49 to 83 years (M = 65 years, SD = 5.8 years). Most were currently married (64%, n = 187) and had children (77%, n = 228). Twenty-four percent of the women lived alone, whereas 66% lived with one other person. Further, 47% (n = 137) reported that they were retired from the workforce; 17% (n = 49) reported that they were unemployed due to their disability. Twenty-four percent (n = 72) reported either working full- or part-time for pay. Another 10% stated that they worked as a full-time homemaker (n = 29). The hours worked each week ranged on average from 0 to 75 hours. Eight percent reported an income of $15,000.00/year or less, whereas 24% reported an income over $75,000.00/year. Ninety percent of the sample stated that they were Caucasian or of European ancestry, which included Scottish, Polish, German, Bohemian, Czechoslovakian, English, Italian, and Irish. Two women reported that they were of Asian ancestry, whereas four others identified themselves as African American (n = 1), Native American (n = 1), or Mexican American (n = 2). Twenty-five women did not report their race or ethnicity.
The women had contracted polio between 1931 and 1960. The average age at the time of infection was 8 years (SD = 5.7 years). It had been 35 to 74 years (M = 57 years, SD = 5.2 years) since their initial infection with poliomyelitis. At the time of infection, 84% (n = 248) were hospitalized for a period of about 1 week to 3.5 years. The women reported that 53% had spinal polio affecting primarily their extremities and skeletal muscles, 5% had bulbar polio affecting primarily their breathing and swallowing muscles, 18% had bulbar-spinal polio affecting both extremities and breathing muscles, and 23% were unsure of the type of polio. All of the women reported residual paralysis after their initial infection. Currently, 81% reported a diagnosis of PPS, which is made based upon a new onset of pain, fatigue, and/or weakness in muscles previously affected by poliomyelitis.
Demographic information on each woman included age, ethnicity, employment status, hours of weekly employment, age of impairment onset, year of initial polio, type of polio, diagnosis of PPS, marital status, and number of children.
Comorbidity was measured with the Self-Administered Comorbidity Questionnaire (Sangha, Stucki, Liang, Fossel, & Katz, 2003). This self-report questionnaire asks respondents to indicate if they have any of the 12 common health problems listed, such as heart disease, arthritis, chronic back pain, and kidney disease. The respondents may also indicate if they have other common problems by writing those in. Next, they are asked if they receive treatment and if their activity is limited by the problem. The responses are "yes" and "no" answers and scored 0 for "no" and 1 for "yes." The answers are summed; the maximum score is 45 points. Sangha et al. (2003) established the test-retest intraclass correlation coefficient (ICC) reliability and documented it as.90. Validity was established using the Charlson index (Sangha et al., 2003).
Functional limitation was measured with the revised version of the Health Assessment Questionnaire (Fries, Spitz, Kraines, & Holman, 1980). The Health Assessment Questionnaire uses 20 items to measure degree of difficulty with function in eight domains: dressing, standing, eating, walking, hygiene, reaching, grabbing, and being active. A score is calculated by summing the highest score in each domain and dividing it by 8 to reach a score from 0 to 3, with 3 indicating severe disability. The Cronbach's alpha in this sample of women with polio was.94.
Disability was measured with the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF; Mellick, Walker, Brooks, & Whiteneck, 1999; Whiteneck et al., 2004; Whiteneck, Charlifue, Gerhart, Overholser, & Richardson, 1987). The CHART-SF assesses the ability of people with impairments to fulfill social roles in six dimensions using 20 questions: physical independence, cognitive independence, mobility, occupation, social role participation, and economic independence (Whiteneck et al., 2004). This scale has been used to evaluate individuals who have a variety of impairments and disease processes including brain injury, spinal cord injury, stroke, and burns. Researchers have reported that the CHART-SF has demonstrated a high test-retest reliability ICC of.93 for the total score. Scores on the subscales range from 0 to 100, and the total score ranges from 0 to 600. A score of 100 on subscales indicates that the person has no difficulties with disability; they function in society at a performance level equivalent to a person without impairment. A score of less than 75 on a subscale and less than 450 on the total scale indicates disability (Whiteneck et al., 2004). The subscales measure physical independence, cognitive independence, mobility, occupation, social integration, and economic self-sufficiency. Overall, the higher the score, the less disability reported by the individual. Test-Retest reliability scores using one-way random ICC on the CHART-SF were found to be consistent with the original longer version (Walker, Mellick, Brooks, & Whiteneck, 2003). The test-retest reliability ICC was not calculated in this study because it was administered one time.
The Activity Effort Scale was created for this study and used to measure the frequency in which women expend effort beyond thresholds of pain, discomfort, and/or fatigue. Items were derived from preliminary qualitative research. Initially, six items were created to assess the concept of activity effort. The items were scored from 1 to 4 and assessed the frequency in which women exert themselves past points of comfort: never, seldom, often, or always. A score of 1 on an item indicated that they never did that act, whereas a score of 4 indicated that they always did that act. Items include statements such as, "I push myself to keep going when I feel increasing discomfort, pain or fatigue." The initial 6-item tool was expanded to include 8 items after an expert review panel suggested that two additional items be added. These two additional items, which were worded in an opposite direction from five of the other six items, assessed the frequency in which women rested instead of continuing to push past levels of pain, fatigue, or discomfort. By wording the items in opposite directions, the phenomenon were assessed from two perspectives-how frequently they exert themselves and how frequently they rest. These two items, Items 7 and 8, along with one other item, Item 5, were reverse scored before adding up the total scores. Reverse scoring was necessary so that items could be added, with a higher score indicating more exertion. The final 8-item scale assessed overall frequency of exertion beyond perceived comfort. The higher the summed scores were across all 8 items, the higher frequency of perceived exertion during activities. Scores may range from 0 to 32.
Data analysis was done to establish validity and reliability of the Activity Effort Scale (DeVellis, 1991). Cronbach's alpha was used to test internal consistency reliability of the Activity Effort Scale. This tests how well all the individual items pull together to measure the same latent construct of interest. According to DeVellis (1991), "if items have a strong relationship to their latent variable they will have a strong relationship to each other" (p. 25). Exploratory factor analysis was used to statistically analyze the scale items for the degree in which they measure a common factor, which supports construct validity. In other words, it is used to provide evidence that the scale measures what it is meant to measure. Items within a scale are examined to see if there are multiple dimensions of the construct and if all items contribute to the specified construct (DeVellis, 1991). Construct validity was also explored by performing Pearson correlations between variables considered theoretically related to the Activity Effort Scale.
Table 1 summarizes the means and standard deviations for all variables used in this study. This information is available to understand the range and mean of scores in this sample as compared with other samples using the same scales. It also provides evidence that the measures were used and performed as they were meant. Table 2 summarizes the relationships between the Activity Effort Scale and variables theoretically related to activity effort. This information is inspected to see if relationships among the variables are consistent with the developing theory. Statistically significant relationships were noted between the Activity Effort Scale and disability and between the Activity Effort Scale and comorbidity. There was also a statistically significant relationship between the Activity Effort Scale and chronological age and between the Activity Effort Scale and reported hours of weekly employment. The relationship between the Activity Effort Scale and functional limitations was not significant. These relationships between variables supported the developing theory.
Using the data from the 299 women with paralytic polio, items from the Activity Effort Scale were subject to factor analysis using principal component analysis (PCA) and Varimax rotation. The 8 items of the scale were assessed for the appropriateness of using PCA with correlations among items, a Bartlett's Test of Sphericity, and the Kaiser-Meyer-Oklin. The correlation matrix consisted of values all above .3, the Bartlett's Test of Sphericity was significant, and the Kaiser-Meyer-Oklin was .89, which exceeds the recommended value of .60 (Kaiser, 1970). After meeting the assumptions, the 8 items were subjected to PCA, which resulted in one component with an eigenvalue above 1, explaining 74% of the variance. The scree plot analysis showed a gradual drop, with a break after the first component. All questions loaded on the one component. The result of the Varimax rotation is presented in Table 3.
Internal consistency reliability was examined for the one-component Activity Effort Scale based upon the factor analysis. The Cronbach's alpha for the 8-item scale was.92. The reliability did not improve when any single item was removed from the analysis; therefore, all 8 items are recommended.
The purpose of this study was to test the psychometric properties of the Activity Effort Scale. The concept of activity effort, which is defined as the frequency of physically and psychologically pushing oneself to continue activities despite levels of fatigue, pain, and/or general discomfort, was derived from a qualitative study of women aging with early-onset disability related to paralytic polio (Harrison, 2006; Harrison & Stuifbergen, 2005). Findings from this study support the assertion that the Activity Effort Scale is a reliable and valid measure of activity effort.
In testing the validity of the scale, associations between variables were evaluated. The findings from this study support the assertion that the frequency of pushing to endure pain, discomfort, and fatigue is associated with comorbidity in the face of functional limitation. However, to understand the direction of the association, further longitudinal work is needed. It may be that, given any level of functional limitation, comorbid illnesses influence perceptions of activity effort, and no causal relationship between activity effort and the subsequent development of comorbid illness exists. The question for the next study is whether or not high levels of activity effort lead to the development of, or a heightened risk of the development of, further comorbid illness.
This study was limited to self-report, cross-sectional data. The next step in this research is to test the combined models of disablement and allostatic load using the concept of activity effort among women with paralytic polio. It is suggested that researchers could also use the biomarkers associated with severe impairment used in previous research (Seplaki et al., 2004), which included cortisol, DHEA-S, higher blood pressure, cholesterol, triglycerides, fasting glucose, glycosylated hemoglobin, and interleukin-6 as outcome variables. The combined use of self-report and biological measures using a longitudinal design would enhance knowledge and overcome the current limitation of this study.
Given that activity effort was also associated with less disability, it may be theorized that women increase their activity effort to overcome disability. In other words, one way of remaining socially engaged as a woman with a functional limitation may be to increase one's activity effort. Further validity for this was found when activity effort was noted to be associated with the number of hours a woman reportedly works and when it was found to be negatively associated with age. It may be considered that, by increasing activity effort to remain socially engaged, women may be increasing the likelihood that they develop further comorbid illnesses beyond the initial reason for their functional impairment. The implications of this for practice could be immense because recommendations could be developed to guide women on the degree of exertion that is actually beneficial versus harmful, but further studies are needed prior to making recommendations. At this juncture, nurses might become more aware that women aging with early-onset paralytic polio may be pushing themselves to overcome their impairment. This may be a strategy they have developed since childhood. It may be helpful to assist them to remain active in ways that do not exhaust their existing resources with advancing age.
The findings from this study are limited to women who are aging with paralytic polio. There is evidence, however, that the lived experiences of women aging with paralytic polio may be similar to women with other chronic disabling conditions (Stuifbergen, Harrison, Becker, & Carter, 2004; Stuifbergen et al., 2005). In a study of over 1,600 persons with PPS, a model developed to investigate quality of life and health-promoting behaviors in persons with multiple sclerosis was found to be similar for persons with PPS (Stuifbergen et al., 2005). The authors asserted that similarities in symptoms and role expectations while living with impairments create commonalities in women's experiences despite differences between the etiologies causing the impairments. On the basis of the evidence supporting commonalities in experiences between types of impairment, it is reasonable to expect that this scale, which is not disease specific, may be valid and reliable among other populations of women aging with disabilities. This is currently being assessed in groups of women aging with the affects of multiple sclerosis.
In conclusion, women aging with the affects of paralytic polio have lived with functional limitations since childhood. The ways they were taught to adapt to the impairment may have had adaptive advantages in that they were able to overcome disability to remain socially active. However, over time, the continued exertion beyond levels of pain, fatigue, and general discomfort may take its toll and lead to further illness. The Activity Effort Scale was developed so that this theory might be tested. Data suggest that the Activity Effort Scale is a valid and reliable tool consisting of one component measuring frequency of effort exerted beyond levels of discomfort, pain, and fatigue among women aging with paralytic polio. Further work is needed to test the relationships among variables using longitudinal designs and biological markers. This study provides evidence that the Activity Effort Scale may serve as a valid tool to begin further research on the lives of women aging with paralytic polio.
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