A comparison of the effects of exercise and lifestyle modification on the resolution of overuse symptoms of the shoulder in polio survivors: a preliminary study

OBJECTIVE

To compare the effectiveness of exercise and lifestyle modification therapy in treating shoulder symptoms in polio survivors with lower-extremity weakness.

DESIGN

A randomized parallel group study.

SETTING

Research laboratory.

PARTICIPANTS

Twenty-three subjects recruited from a cohort of 194 polio survivors who had participated in a previous study had bilateral hip-extensor and knee-extensor weakness and reported experiencing shoulder pain on a regular basis with daily activity.

INTERVENTIONS

Subjects were randomly assigned to 1 of 3 treatment groups. Members of group 1 were placed on a home exercise program that focused on strengthening their hip and knee extensors. Members of group 2 were instructed in lifestyle modification techniques designed to avoid shoulder overuse. Members of group 3 received both interventions.

MAIN OUTCOME MEASURES

Shoulder symptoms were quantified in terms of number and severity. Isometric strength of bilateral hip and knee extensors was measured with a hand-held dynamometer.

RESULTS

Symptoms improved in all 3 groups. However, members of the exercise-only group (group 1) were the only ones to show a significant difference in both number and severity of symptoms when pre- and posttreatment values were compared.

CONCLUSIONS

Both exercise and lifestyle modification therapies that focus on reducing the stress related to lower-extremity weakness are effective in treating shoulder overuse symptoms in polio survivors. A trend toward greater improvement in shoulder symptoms in subjects who participated in the exercise program and who also showed a trend toward increased knee-extensor strength supports muscle strength and/or endurance as a key factor.

Long-term follow-up of patients with nonparalytic poliomyelitis

OBJECTIVE

To examine patients with previous nonparalytic poliomyelitis in search of muscle atrophy, weakness, and other late symptoms of poliomyelitis.

DESIGN

A mailed questionnaire followed up with neurologic and neurophysiologic examinations of respondents who reported symptoms possibly related to the late sequelae of polio.

SETTING

Neurology department at a university hospital.

PARTICIPANTS

Thirty-nine of 47 patients diagnosed with nonparalytic poliomyelitis and hospitalized at a Norwegian hospital between 1950 and 1954, during the Norwegian polio epidemic.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Electromyography to determine function of the anterior tibialis, vastus lateralis, and biceps brachii muscles; nerve conduction studies of the sural, peroneal, and tibial nerves; motor and sensory nerve conduction velocity, and compound muscle and sensory nerve action potentials, and distal latencies.

RESULTS

Twenty-five of 47 patients (53.2%) reported symptoms possibly related to the late sequelae of poliomyelitis. Eight of 20 examined symptomatic patients had normal neurologic and neurophysiologic findings, whereas 9 others had other medical conditions that could explain the symptoms. Three patients (6.7%) had neurologic and neurophysiologic findings and development of symptoms consistent with motoneuron damage.

CONCLUSION

Some nonparalytic patients may have subclinical acute motoneuron damage with subsequent development and manifestation of motor weakness and neuromuscular symptoms many years later. These symptoms should be considered a differential diagnosis in patients who have a history of nonparalytic poliomyelitis.

[The history of poliomyelitis in Norway--disease, society and patients]

The first epidemic of poliomyelitis in Norway was reported in 1868. Over the course of the 20th century, a total of 23,000 cases of acute poliomyelitis were registered, and the disease caused much suffering and fear before vaccination was introduced in 1956. After 1960, treatment and rehabilitation facilities for polio patients were gradually converted to other uses. Today there are 5,000-10,000 persons with sequelae poliomyelitis in Norway, many of them suffering from late effects of poliomyelitis, so-called postpolio syndrome. Thus there is still a need for multidisciplinary services for these patients, even though the poliovirus could be eradicated in a few years' time.

Submaximal exercise capacity and maximal power output in polio subjects

OBJECTIVES

To compare the submaximal exercise capacity of polio subjects with postpoliomyelitis syndrome (PPS) and without (non-PPS) with that of healthy control subjects, to investigate the relationship of this capacity with maximal short-term power and quadriceps strength, and to evaluate movement economy.

DESIGN

Cross-sectional survey.

SETTING

University hospital.

PARTICIPANTS

Forty-three polio subjects (25 PPS, 18 non-PPS) and 12 control subjects.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Power output, oxygen uptake, and heart rate were measured in an incremental submaximal cycle ergometry test. Maximal short-term power was measured in 5-second all-out efforts. Knee extensor strength was measured on a chair dynamometer.

RESULTS

The mean submaximal power +/- standard deviation at 80% of heart rate reserve of 83.8 +/- 29.9 watts in the polio subjects was significantly less than the mean submaximal power of 142.1 +/- 30.4 watts in the control group. However, expressed as a percentage of the maximal short-term power, submaximal power did not differ between the groups. Strength and maximal short-term power correlated significantly (p < .005) with submaximal power (r = .64 and .76, respectively). The oxygen uptake was higher than theoretically expected for the given submaximal power output in polio subjects, and appeared to increase with increasing asymmetry in strength and power between legs. No differences were found between PPS and non-PPS subjects.

CONCLUSION

The submaximal work capacity of polio subjects was severely reduced, mainly in association with the reduced muscle capacity. And, because of a reduced movement economy, their energy cost was elevated. Although muscle loads in activities such as walking and climbing stairs differ from cycling, they also may require elevated relative levels of effort, predisposing subjects to premature fatigue in sustained activity.

Physiological response to the ambulatory performance of hand-rim and arm-crank propulsion systems

Two types of propulsion systems-the hand rim (HR) and the arm crank (AC)-are commonly used in wheelchair ambulation. The purpose of this study was to investigate the physiological response of the two propulsion systems under actual locomotive condition by the actual users. The energetics of locomotion manual wheelchair (HR propulsion) and arm-propelled three-wheeled chairs (AC-propelled) at their free chosen speed (FCS) were studied and compared. Thirty-four male subjects with dysfunctioning lower limbs; 17 manual wheelchair users and 17 arm-propelled three-wheeled chairs regular users volunteered to participate in the study. Speed (m.min-1), oxygen uptake (1 x min(-1)) and heart rate (b x min(-1)) were monitored during steady-state ambulation at FCS for 5 min. Oxygen consumption (VO2, ml x kg(-1) min(-1)), oxygen cost (VO2, ml x kg(-1) m(-1)), net locomotive energy cost (kcal kg(-1) km(-1)) and physiological cost index (b x m(-1)) were derived. The FCS of the AC propelled device is remarkably higher than the HR system, and the magnitude of the physiological variables of the AC propulsion system was significantly lower (p<0.001) in relation to the HR propulsion system, as revealed from the results of t test for two sample means at a significance level p=0.001. It can be inferred from the result that the AC propulsion system could be used for long distance rides with a higher speed required for outdoor ambulation and that the HR propulsion system is suitable only for indoor use, because of its excellent maneuverability where short-duration low-velocity ambulation is required.

Dynamic water exercise in individuals with late poliomyelitis

OBJECTIVE

To evaluate the specific effects of general dynamic water exercise in individuals with late effects of poliomyelitis.

DESIGN

Before-after tests.

SETTING

A university hospital department.

PARTICIPANTS

Twenty-eight individuals with late effects of polio, 15 assigned to the training group (TG) and 13 to the control group (CG).

INTERVENTION

The TG completed a 40-minute general fitness training session in warm water twice weekly. Assessment instruments included the bicycle ergometer test, isokinetic muscle strength, a 30-meter walk indoors, Berg balance scale, a pain drawing, a visual analog scale, the Physical Activity Scale for the Elderly, and the Nottingham Health Profile (NHP).

MAIN OUTCOME MEASURES

Peak load, peak work load, peak oxygen uptake, peak heart rate (HR), muscle function in knee extensors and flexors, and pain dimension of the NHP.

RESULTS

The average training period was 5 months; compliance was 75% (range, 55-98). No negative effects were seen. The exercise did not influence the peak work load, peak oxygen uptake, or muscle function in knee extensors compared with the controls. However, a decreased HR at the same individual work load was seen, as well as a significantly lower distress in the dimension pain of the NHP. Qualitative aspects such as increased well-being, pain relief, and increased physical fitness were reported.

CONCLUSIONS

A program of nonswimming dynamic exercises in heated water has a positive impact on individuals with late effects of polio, with a decreased HR at exercise, less pain, and a subjective positive experience. The program was well tolerated (no adverse effects were reported) and can be recommended for this group of individuals.

The polio narratives: dialogues with FDR

As a group of accounts that span the decades from the mid-1940s to the present, the published polio narratives enable us to align their shifting perceptions of disability with social, cultural, and technological change. This paper identifies two distinct groups of narratives. Authors of the first group, writing between the mid-1930s and mid-1950s--a period of relative prosperity, conformity, and homogeneity--were uncomfortable with radical movements, diversity, and conflict; their narratives typically told of either full or substantial recovery. Beginning in the mid-1950s--the period of both McCarthy and the Civil Rights movement--a second wave of narratives begins to tell stories of partial to serious disability; typically, they reflect on a lifetime of coping with chronic disability. Both sets of narratives, however, represent a dialogue with Franklin Delano Roosevelt. Roosevelt himself, journalists, and the National Foundation for Infantile Paralysis all helped to create and promote a core polio narrative featuring FDR's triumph over disease and disability that would become a national myth. Yet while the early narratives reinforced the core elements of the Roosevelt myth, the later ones began to challenge them.

Appliances and surgery for poliomyelitis in developing countries

Death before maturity is the usual fate of the untreated crawling crippled child in developing countries. Most children with poliomyelitis, however, when upright and walking with supports or following surgery, are accepted by the community, educated by parents and relatives, and employable when they reach maturity. It is more economical to prevent 100 polio cases than to treat one hopelessly crippled child. It is often quicker to straighten 100 deformed limbs by simple subcutaneous surgeries than to treat a single patient with complicated procedures. It costs less for 100 crawling paralyzed children to walk in simple, locally made braces and clogs, than for 1 patient to be mobile in expensive imported appliances and boots. It is essential to educate or rehabilitate patients in addition to making them mobile. The final aim should be patients returned to their own village or town, accepted and integrated into their own communities, and earning their own living among their own friends. This chapter is discussed in further detail in both English and French in my Website, <www.worldortho.com>. This site also includes comprehensive information on both the manufacture of the simple appliances described and various surgical details. This information is also available on CD-ROM.

Physical activity for elderly persons with neurological impairment: a review

The paper reviews studies conducted on physical activities and exercise in elderly persons with neurological impairment due to stroke, Guillain-Barre syndrome, Parkinson's disease, multiple sclerosis or post-polio syndrome. The paper concludes: (i) it is not possible at present to draw conclusions regarding persons with Guillain-Barre syndrome and Parkinson's disease; (ii) individuals with multiple sclerosis and post-polio syndrome benefit from physical activity, but all studies have so far been conducted on those under 65 years of age, and its effect on elderly persons with these diseases is not known; (iii) exercise and customary activities (walking and swimming) should be encouraged and promoted in elderly persons after stroke.

Inspiratory muscle training in patients with prior polio who use part-time assisted ventilation

OBJECTIVE

To evaluate whether inspiratory muscle training in patients with prior poliomyelitis (and with symptoms and signs of hypoventilation) who use part-time assisted ventilation could improve symptoms and respiratory muscle function without adverse effects.

DESIGN

Intervention study with before-after trial.

SETTING

Training was performed in the patients' homes; assessments were performed at the hospital.

PATIENTS

Ten prior-polio patients were included. Three of them did not complete the trial, and their data were not included in results of training.

INTERVENTION

Ten weeks of daily inspiratory muscle training.

MAIN OUTCOME MEASURES

Spirometry, maximal inspiratory and expiratory pressures, inspiratory muscle endurance, and questions regarding activities of daily living were performed.

RESULTS

Inspiratory endurance capacity over 5 minutes improved from 10.7 to 16.7cm H2O (p < .05) assessed at 15 on the Borg scale, and most patients improved in activities of daily living. The whole-body endurance capacity remained stable over the studied period.

CONCLUSION

Inspiratory muscle training and close supervision can increase respiratory muscle endurance and improve well-being in patients with prior polio who use part-time assisted ventilation.

Neuromuscular rehabilitation and electrodiagnosis. 4. Specialized neuropathy

This self-directed learning module briefly highlights the differential diagnosis for acute weakness in patients with acute respiratory failure requiring prolonged mechanical ventilation. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article includes a discussion on the role of exercise in the treatment of patients with the late effects of poliomyelitis or with acute inflammatory demyelinating polyradiculoneuropathy.

An insole pressure measurement system: repeatability of postural data

This study analyzed the ability of an in-shoe plantar pressure measurement system to provide repeatable measurements of postural sway data for both healthy and clinical patients. Each participant's in-shoe pressure data were recorded for three trials during each test session during quiet stance. Healthy individuals (n = 9) participated on three consecutive days while clinical participants (n = 5) were tested on one day. Nine response variables were measured to assess their postural stability. Intrasubject measures were evaluated using the Kerlinger reliability procedure. Values provided directly by the Parotec System for a single day of testing yielded the following average coefficients: r = 0.95 (left), r = 0.97 (right) with mean coefficient values from the three day tests of: r = 0.98 (left), r = 0.98 (right). Variables calculated from raw data on a single day produced mean coefficients of: r = 0.77 (left), r = 0.76 (right) and over three days of: r = 0.65 (left), r = 0.66 (right). The ability to record highly reproducible data of postural sway parameters should assist clinicians to treat patients more confidently for balance deficiencies.

Depression in children with hemophilic arthropathy and poliomyelitis: a preliminary report

The aim of this study was to evaluate children with chronic disorders like hemophilia and poliomyelitis from the psychological perspective, to determine the frequency of depression, to identify the risk factors and to investigate the relation between disability and depression. Thirty-five patients with disability due to poliomyelitis and 12 patients with hemophilic arthropathy were included in the study. Thirty-six healthy children from the district schools served as controls. The Children's Depression Inventory (CDI) was used to assess the extent of depression. For the hemophilia group, joint scores proposed by the World Federation of Hemophilia were used to assess the degree of joint involvement. The poliomyelitis group was evaluated according to the level of ambulation and the need for orthoses. The CDI score was 10.57 +/- 5.87 in the poliomyelitis group, 11.00 +/- 5.64 in the hemophilic arthropathy group and 8.39 +/- 3.78 in the control group, but the difference was not statistically significant. Four of 35 patients with poliomyelitis (11.4%) and two of 12 hemophilic arthropathy patients (16%) exhibited depression. None of the children in the control group had depression. Since depression interferes with both medical compliance and rehabilitation potential, early diagnosis and treatment is important. Therefore, evaluation of the psychological status of chronically ill children must be a part of the rehabilitation program.

Prediction of walking possibility in crawling children in poliomyelitis

Crawling is one of the most common modes of ambulating in children with severe paralysis and deformities in poliomyelitis. Restoring upright posture and bipedal gait, although desirable, has its own limitations due to various factors. Fifty-three children below the age of 12 years (29 boys and 24 girls) crawling due to post-poliomyelitis residual paralysis were assessed for the genesis of crawling as a mode of ambulating. The patterns of crawling were classified according to Cross's classification. Paralyzed muscles and deformities in definite combinations were found responsible for each type of crawling. Trunk muscles, gluteus maximus, quadriceps, hamstrings, tibialis anterior, and triceps surae were identified as muscles crucial for walking in order of priority. At least antigravity power in these muscles was necessary for an upright posture and walking with support. Various combinations of treatment modalities were used to correct the deformities before fitting an orthosis and instituting gait training. Thirty-four children became outdoor walkers, 14 indoor walkers, and five remained nonwalkers. The most favorable patterns of crawling for restoration of upright posture were true quadruped progression (30 cases) and infant-like crawl (14 cases). Average follow-up was 17 months (range, 6 months to 5 years).

Managing occupations in everyday life to achieve adaptation

OBJECTIVE

The aim of this qualitative study was to gain a deeper understanding of how persons with poliomyelitis sequelae manage their daily occupations in order to adapt to environmental demands. This was a study of adaptive processes and capability in everyday life.

METHOD

Interviews with 22 persons with poliomyelitis sequelae were content analyzed according to grounded theory.

RESULTS

The analysis yielded 18 concepts describing adaptive strategies of participants. The strategies were arranged in six general groups: utilizing physical capability, influencing emotions, altering pattern of occupations, promoting concrete problem-solving, influencing relations, and facilitating future activities.

CONCLUSION

The strategies were interwoven, revealing different ways of reaching an adaptive balance in daily occupations for the present and the future.

The Norwegian Polio Study 1994 part II: early experiences of polio and later psychosocial well-being

STUDY DESIGN

The Norwegian Polio Study 1994 was a nation-wide survey of the medical and psychosocial situation of polio survivors.

METHOD

A questionnaire, consisting of 133 questions with sub-questions, was sent to a total of 2392 polio victims, most of them registered in 'The National Society of Polio Victims' in Norway. 1449 (61%) answered.

OBJECTIVES

To investigate the relationship between early polio experiences, such as duration of hospitalization and perceived support, and later psychosocial well-being.

RESULTS

Three hundred and ninety-one persons (27%) reported they had been psychologically harmed by the treatment received at the time they contracted polio (Harmed group), while 1053 persons (73%) did not (Non-Harmed group). Persons in the Harmed group were significantly younger at polio onset, were hospitalized for a longer period and had less parental visit and support. Today they use more medication, report more pain, general fatigue, sleep disturbance and concentration problems, more psychosocial distress, less satisfaction with life and less social support than persons in the Non-Harmed group.

CONCLUSIONS

The results demonstrate that a subgroup of polio survivors has been vulnerable from childhood, with possible consequences for their physical, psychological and social wellbeing later in life. Recommendations for long-life treatment of children with similar diseases should include follow-up not only of their physical disabilities, but also on psychological and psychosocial needs.