SIGNS AND SYMPTOMS OF THE AUTONOMIC DYSFUNCTION IN TEACHERS Sinais e sintomas da disfunção autônoma em professores

(1) Centro de Estudos da Voz CEV, São Paulo, SP, Brazil. (2) São Paulo teachers’ union (Sindicato dos Professores de São Paulo SINPRO-SP), São Paulo, SP, Brazil. (3) Voice Specialization Course of Centro de Estudos da Voz CEV, São Paulo, SP, Brazil. Research performed in Centro de Estudos da Voz – CEV – São Paulo (SP), Brazil Conflict of interests: none teacher from São Paulo public schools showed relation between voice disorder and stress, due teachers in their own work environment to have a high psychic demand related to low control of their activities, which may make them susceptible to illness8. Emotional disorders frequently cause autonomic dysfunction9. The autonomic nervous system (ANS) is composed by two main types, sympathetic and parasympathetic, working coordinated and antagonistic in order to regulate involuntary functions10. It has central components as thalamus and limbic system, which are associated to emotions and visceral behavior. This system is responsible to homeostasis and for its response to external stimuli, as, for example, the “fight or flight” response that occurs when a threatening situation intensely stimulates the sympathetic nervous system which may cause increase in adrenalin, heartbeats and blood pressure11.  INTRODUCTION


INTRODUCTION
Teachers have higher risk to develop voice disturb when compared to general population 1 , which may influence the professional performance 2 and cause economic losses for these professionals and the educational system 3 .
The work environment in which the teacher acts may offer risk to development of voice disturbances [4][5][6][7] .Besides the environment influence, there is the emotional factor involving the professional coping to stress situations at work.A study with 83 teachers participated of the research, 60 women and 23 men, with mean age of 37.6 years, teaching at elementary or high schools of 6 schools (1 private and 5 public), from Rio de Janeiro city.A teacher of each school was previously trained to deliver the protocols of Vocal Signs and Symptoms (VSSQ) 1,17 and Autonomic Dysfunction (QAD) to the other teachers.All the subjects that accepted to participate of the research had to sign an informed consent term.
The sample was divided in two groups, according to the presence or absence of vocal complaint by the teacher.This division was done in two steps to evaluate the perception of the teacher to its own complaint.In the first step it was considered the self-reported complaints with a closed-question and two answer options ("yes" or "no"), regarding the presence or absence of vocal complaints at that moment.In the second step it was considered the number of vocal symptoms observed in VSSQ, translated/adapted to Brazilian Portuguese 17 .The mean of symptoms expected in Brazilian teachers is 3.7 17 .Therefore, subjects having until three vocal symptoms were included in the group without vocal complaint and the subjects with four or more symptoms were included in the group with vocal complaint.
With the purpose to observe the teacher´s perception regarding its own vocal complaint, selfreported complaint was compared to measured one (mean number of vocal symptoms presented at VSSQ).Statistical data were obtained based on measured complaint at VSSQ.After formatting the groups with and without vocal complaint, the focus of the research was to analyze QAD.
QAD is a list of 46 neurovegetative symptoms, with "yes" or "no" response options, 22 are related to ANS but without direct relation to voice, 16 are related to ANS and voice, 6 are not-relevant, that is, without relation with neurovegetative or voice aspects, and 2 are reliability questions, in order to evaluate the participant's consistence in answering the questions 15 (figure 1).
The statistical analysis was done using ANOVA Test and the Kappa concordance coefficient.The softwares used were SPSS V16, Minitab 15, and Excel Office 2007.The significance level adopted was 0.05 (5%).
Sympathetic system has the function to mobilize the body to activity and it acts to modulate the organs functions as heart, gastro intestinal tract, and sweat glands.Besides, it increases the body activities to assure the body may respond to stress.The parasympathetic system has the antagonist function, decreasing body activities, in order to restore energy 10 .Voice has the role to express emotion (barometer of emotion) and there for the voice disturbance may be interpreted as stress sign 12 .
Besides voice, mental and behavior disturbances, gastric and cardiovascular dysfunctions are related to organization factors 13 .Stress, anxiety, and depression may appear in patients with vocal folds lesions, paradoxical vocal fold disorder, and muscle-tension dysphonia 14 .In females, functional dysphonia may be a manifestation of stress and anxiety, with hyperactivity of ANS 11 .Patients with behavioral dysphonia have higher occurrence of neurovegetative symptoms 15 .
The Questionnaire of Autonomic Dysfunction (QAD) was used in some researches to quantify the number of neurovegetative symptoms in subjects with dysphonia compared to subjects without voice disturbances 11,15,16 , without reporting the profession of participants.The QAD was developed initially in a research performed in Utrecht University, Netherlands, in order to relate functional dysphonia and ANS dysfunction 11 .After, it was translated/ adapted to Brazilian Portuguese in the research relating behavioral dysphonia with nerovegetative symptoms 15 .
Considering teachers are professionals that have risks to develop voice disorders and stress, the purpose of this research is to compare the autonomic dysfunction signs in teacher with and without vocal complaints, defined by clinical investigation, using QAD.

This research was evaluated and approved by
Ethical in Research Committee of Centro de Estudos da Voz (CEV), under the protocol number 0417/09.
The inclusion criteria adopted for this study was the participant to be a teacher, working in classroom and without neurological or psychiatric diseases reported.
Name:_______________________________________________________date:_______________ Mark the symptoms or complaints that you have been feeling lately.There is no right or wrong answers.

RESULTS
Analyzing the perception of vocal complaint report by the teacher, it was observed that 42 subjects affi rmed to have vocal complaint and 41affi rmed not to have vocal complaint (p=0.877).But, when the sample was grouped according to the number of vocal symptoms, the group of teachers with vocal complaint increased up to 59 participants and the group without complaint decreased to 24 participants (p<0.001,fi gure 2).Both studied groups had nerovegetative symptoms with predominance in teachers with vocal complaint (table 1).In this group the mean of total neurovegetative symptoms was 13.7, while in the group without vocal complaint the mean was 7.7 (fi gure 3).Considering the mean of symptoms related to voice, the group with complaints had 4.7 symptoms against 1.8 in the group without vocal complaint (p<0.001,table 2).The teacher difficulty in perceiving itself as a voice professional may be an obstacle for the teacher to evaluate its own voice 6 .

Figure 3 -Mean of autonomic dysfunction signs and symptoms in groups with and without vocal complaint
The teachers participating of this research also had difficulty to perceive their own complaints, fact observed in the change in sample distribution.When composed from self-reported complaint (presence or absence of vocal complaint), the group with complaint had 42 teachers and without complaint 41.After counting the vocal symptoms marked in VSSQ, the group with vocal complaint increased to 59 and without complaint decreased to 24.This fact reinforce that it is insufficient to ask the teacher about the presence or absence of vocal complaint Comparing both sexes, women had higher number of neurovegetative symptoms with predominance in the group with vocal complaints (p=0.013,table 3).

DISCUSSION
Voice is a complex manifestation; depending on muscle actions and may suffer emotions and personality influence 18 .Although voice is the teacher's work instrument, the health-disease process related to voice is still little understood by this professional, having as consequence little perception of its own self-evaluation and its voice disturbs 6,[19][20][21] .There is a correlation between voice self-perception and temporomandibularjoint dysfunction (TJD) in women, considering that as severe the TJD, higher the vocal disturb perception 25 .The symptoms related to voice presented by the vocal complaint group showed that teachers of the present research may be susceptible to develop voice disturbances and autonomic dysfunction.Literature also points out studies relating the disturbances in ANS with QAD use, but in subjects with voice disorders from general population, without specifying the subjects' profession 11,15,16 .Other studies observe the relation between vocal complaint and ASN dysfunction symptoms with or without direct relation with voice in functional dysphonia, initially experienced only in female subjects 11 , and afterwards in both sexes, with predominance in women 16 .Although the current study did not evaluate whether the teachers with vocal complaint had deviated voices, it is worthy to point out that these data agree with a research with behavior dysphonia subjects 15 .
In table 3, comparing the symptoms according to sex, it is possible to observe that in vocal complaint group women had mean symptoms 14.8 while men had 8.6 (p=0.013).This higher number of symptoms in females may be explained by the accumulation of social roles played by women in social and work environment, which may generate an overload and increase in stress of these professionals.
The results points out the teachers from this study have risk to develop neurovegetative symptoms, mainly those direct related to voice.They also showed that the participants had little perception about their own vocal complaint, which reinforce the importance of using ADP in clinical help, as well as investment in vocal health programs, and guidance for teachers 20 .
It is worthy to highlight the importance of speechlanguage pathologist to pay attention the amount of neurovegetative symptoms that the teachers presents in ADP, mainly those related to vocal symptoms, in order to the teacher to be properly routed to the specialist, and the vocal rehabilitation may happen quickly.

CONCLUSION
The group of teachers with voice complaint had higher number of neurovegetative symptoms than the group without vocal complaint, mainly in issues related to voice, and predominantly in females.
(self-reported complaint), and it should be chosen to use a more detailed investigation, identifying possible vocal symptoms, with the help of specific tools, as VSSQ, and previous history, for example.
Teachers have higher risk to develop psychic illness when compared to other groups 22 .The interaction between subjects' characteristics and environment demands may generate disturbances in behavior, cognitive and physiological aspects.Stress and depression may be responses to environment demands 23 .When the subject can balance the stress situations and its environment, the ASN keep itself balanced, providing a better quality of life, and, therefore, of work.
The effects of environment demands in teachers' life may be understood in table 1, in which the most relevant neurovegetative symptoms without direct relation to voice in the vocal complaint group were: difficult concentration, disturbed sleep, nausea, palpitations, and dizziness.
The mean of symptoms related to voice in complaint group was 4.7 and in the group without vocal complaint was 1.8 (Table 2), which demonstrates that teachers with vocal complaint have more autonomic dysfunction than the ones without vocal complaint.Perhaps this occurs due to the fact that teachers with vocal problems have to change communication strategy in classroom, which may affect the stress and, as consequence, the number of symptoms 17 .
Analyzing the group without vocal complaint, the most frequent symptoms were (Table 1): Fluctuating nose obstruction (33.3%), difficulty breathing through the nose at rest (29.2%), and frequent sneezing (25%).Although these symptoms had occurred of the same way between groups, these data points out that the groups without vocal complaint also showed symptoms classifieds in QAD as related to voice.Research with teachers shows that as higher the time teaching, higher is the lack of air complaint.Other study points out teachers have more tendency to develop sore throats and breathing allergies than non-teachers.
In Table 1, the symptoms related to vice that were more frequent in vocal complaint group when compared to without vocal complaint one were: fatigability when speaking (p<0.001),need of constantly swallowing (p=0.014),sore throat (=0.001), neck pain while or after speaking (p=0.003),ATM pain or discomfort (p=0.017),constant need to yawn (p=0.003),constant hawk (p=0.010), and tension in head while speaking (=0.019).A research done with dysphonic teachers working in public schools in Mogi das Cruzes city (SP) showed a relation between dysphonia and vocal fatigue 24 .

Figure 2 -
Figure 2 -Relation between measured complaint (according to the numbers of symptoms marked in vocal sign and symptoms protocol) and the reported complaint.

Table 2 -Number of symptoms in autonomic dysfunction protocol (ADP) Real complaint Symptoms related to voice Symptoms not related to voice Not relevant Without complaint With complaint Without complaint With complaint Without complaint
* Statistic significant p-value (p≤0.05)Statistic test ANOVA Subtitles: SD = standard deviation; CV = coefficient of variation; N = number of subjects; CI = confidence interval

Table 3 -Comparison between sexes regarding number of neurovegetative symptoms in each group
* Statistic significant p-value (p≤0.05)Statistic test ANOVA Subtitles: SD = standard deviation; CV = coefficient of variation; N = number of subjects; CI = confidence interval