Post Polio Syndrome

(PPS)

Phinoj K AbrahamIInd MOTh Student

All India Institute of Physical Medicine & Rehabilitation, (AIIPM&R) Mumbai

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Outline

Acute Paralytic Polio Stages

Post Polio Syndrome (PPS) Definition Epidemiology Causes Risk factors Path physiology Clinical Features Management Prognosis

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Virus [ Burnhilde, Lansing & Leon]

Contaminated water / food

Affinity for motor (muscle) nerves

Kills / Injures motor nerves

Results in weakness / paralysis

Acute Paralytic Polio

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Stages

There are four recognized stages:

Acute Paralysis and/or weakness Recovery and Rehabilitation Neurological Stability Post Polio Syndrome / Sequelae

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Post-Polio Syndrome (PPS)

A Neurological condition

New symptoms many years after acute

polio - typically 30-50 yrs.

New symptoms appear after a period of

neurological stability

Major sxs- New weakness, loss of function,

intense fatigue, pain in muscles / joints

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Halstead and Dalakas (1985) Definition Confirmed history of polio Partial or fairly complete neurological and

functional recovery after the acute episode. Period of at least 15 years with neurological and

functional stability Two or more of the following health problems

occurring after the stable period: Extensive fatigue Muscle and or joint pain New weakness in muscles previously affected or

unaffected New muscle atrophy Functional loss Cold intolerance

No other medical explanation foundHalstead LS. 1991

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Epidemiology of PPS The frequency of PPS ranges between

15%-80%,

Natural history data from post-polio clinic in Houston, Texas. A = birth; B = onset of polio; C = maximum recovery; D = onset of new health problems; E = time of evaluation; F = death. (Halstead, L. S. and Rossi, C. D 1987)

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Theorized Causes of PPS

The pathological changes that cause the symptoms of PPS are not well understood

There are four different theories on the cause of PPS:

Disintegration of overused motor units

Reactivation of Polio virus

Immune system dysfunction

Neural loss due to ageing

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Causes of PPS Accelerated natural ageing Falling nerve to muscle motor unit ratio Inflammation and active immune response Co-morbidity:

Orthopaedic problems Radiculopathy and entrapment neuropathy Respiratory failure General medical problems

PPS is more likely with Increasing age; The more severe the initial weakness was The more time that elapses after the attack

of polio

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Possible Causes of Late Complications of Polio

Halstead, L. S 1988

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Risk Factors for PPS

Higher age at onset of poliomyelitis The association with other diseases may

indicate that a chronic physical stress, particularly in already weak motor units, can contribute to the development of signs and symptoms of PPS

Poor Socio-economic conditions (Ragonese P et al)

Individuals who had polio exhibit "Type A" behavior and experience chronic stress (Richard L. Bruno et al)

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Pathophysiology

Theories: Remaining healthy

motor neurons can no longer maintain new sprouts

Decompensation / chronic denervation and reinervation process.

Denervation exceeds reinervation

Dalakas, M. C., et al 1985

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Theories (contd.)

Motor neuronal loss due to reactivation of a persistent latent virus.

Infection of the polio survivor’s motor neuron by a different enterovirus

Loss of strength associated with aging, in already weakened muscles

Dalakas, M. C., et al 1985

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Main Clinical Features of PPSCommon Fatigue New Weakness Decreased

endurance Muscle & joint pain Loss of function

Gait disturbance Climbing Stairs Dressing (Activities that

require repetitive muscular contraction)

Less common Muscle atrophy Respiratory

problems Swallowing

problems Cold intolerance Sleep apnoea

Julie K Silver, Anne C Gawne 2004

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Fatigue Post Polio Fatigue

Central (evolved from CNS)▪ Difficulty regarding cognition, concentration, memory

attention, maintaining wakefulness (because of the affectation of RAS, Basal Ganglia etc..)

Peripheral (evolving from the peripheral nerves i.e., the motor unit.)▪ Muscle weakness

According to Schanke and Stanghelle (2001), physical, peripheral fatigue was greater problem for the patients than mental, central Fatigue

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Muscle Pain

Extremely prevalent in PPS

Deep aching pain

Myofascial pain syndrome / Fibromyalgia

Small number of patients have muscle tenderness on palpation

Julie K Silver, Anne C Gawne 2004

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Differential Diagnosis Weakness and Functional Loss.

focal neurological disease such as a radiculopathy, focal compressive neuropathy, or spinal cord lesion and medical causes of neuropathy such as diabetes, thyroid disease, uremia, alcohol, toxins, and, uncommonly, hereditary neuromuscular disease.

Fatigue. anemia, chronic infections, collagen disorders,

thyroid disease, diabetes, cancer, depression . Pain.

osteoarthritis, bursitis, tendinitis, and myofascial pain polymyalgia rheumatica, fibromyalgia, polymyositis, and rheumatoid arthritis

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Management

Medical management Evaluation

Confirmation of previous Paralytic Polio Exclusion of other causes of new symptoms

Medications No well-proven pharmacologic treatment for this

▪ Pyridostigmine – fatigue (effectiveness ?)▪ Amantadine (Anti viral agent) effectiveness ?▪ High dose Prednisone (no significant improvement in

M Strength, however a trend to an increse in isometric strength)

Other symptomatic management

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Management cont..

Rehabilitative Interdisciplinary team

assessment▪ Physician, OT, PT,

SLP,P&O, SW, Respiratory Therapist

Goal setting Treat ment Planning &

intervention▪ Management of

Weakness▪ Management of Fatigue▪ Management of Pain

For the assessment of Fatigue

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Occupational Therapy

OT interventions are tasks or activities that promote health and improve occupational performance .

Role of OT in PPS Exercise program that involves the U/E Prevention of overuse injuries Treatment of any existing arm problems Education about the principles of energy

conservation

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Occupational therapy cont…

Interventions are Orthoses for the U/E (e.g. splints ) Assistive technology Modifications at home and work Lifestyle modification Exercise program Discharge and follow-up

MOYERS P et al .AJOT 53:251-289,1999

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Management of Fatigue

Energy conservation techniques

Life style changes

Regular rest periods or naps during the day

Pacing (rest periods during activity)

Improvement of sleep ( e. g relaxation

techniques)

Avoidance of excessive fatigue

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Management of pain

Most effective treatments for pain include: Heat Massage Gentle exercise Education Stretching Orthoses and Walking aids Re-education of Movement

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Prognosis

Post-polio syndrome is not life-threatening unless there is severe pulmonary involvement or a swallowing disorder.

The symptoms are manageable and with proper measures quality of life can remain good.

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Reference 1. Halstead LS. 1991. Assessment and differential diagnosis for

post-polio syndrome. Orthopedics. 14(11):1209.2. Halstead, L. S. and Rossi, C. D., Post-polio syndrome: clinical

experience with 132 consecutive outpatients, in Research and Clinical Aspects of the Late Effects of Poliomyelitis, Halstead, L. S. and Weichers, D. O., Eds., March of Dimes Birth Defects Foundation, 23(4), White Plains, NY, 1987, 13-26.

3. Halstead, L. S., Late complications of poliomyelitis, in Rehabilitation Medicine, Goodgold, J., Ed., CV. Mosby, Washington, D.C., 1988, 328-340.

4. Dalakas, M. C., Sever, J. L., Fletcher, M., Madden, D. L., Papadopoulos, N., Shekarchi, I., and Albrecht, P., Neuromuscular symptoms in patients with old poliomyelitis: clinical, virological and immunological studies, in Late Effects of Poliomyelitis, Halstead, L. S. and Weichers, D. O., Eds., Symposia Foundation, Miami, FL, 1985, 73-90.

5. Julie K Silver, Anne C Gawne 2004 Post Polio Syndrome p 5

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Reference

Ragonese P, Fierro B, Salemi G, Randisi G, Buffa D, D'Amelio M, Aloisio A, Savettieri G. Prevalence and risk factors of post-polio syndrome in a cohort of polio survivors. J Neurol Sci. 2005 Sep 15;236(1-2):31-5.

Stress and "Type A" Behavior as Precipitants of Post-Polio Sequelae: The Felician/Columbia Survey Richard L. Bruno, PhD, and Nancy M. Frick, MDiv, LhD

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