The Norwegian Polio Study 1994: a nation-wide survey of problems in long-standing poliomyelitis

'The Norwegian Polio Study 1994' was performed to make a nation-wide survey of the medical and social situation, and of the needs of anterior poliomyelitis (polio). 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 persons (61%) answered. Sixty-six per cent were between 45 and 64 years of age, 25% were above 64 years and 9% were under 45 years. When specifying new health problems, 85% stated that they had experienced increased weakness in muscles affected by polio, while 58% had experienced increased weakness in previous non-affected muscles. Other health problems related to polio were fatigue during exercise (80%), general fatigue (57%), joint pain (58%), muscular pain (58%) and cold intolerance (62%). The participants indicated an increasing need of aids, but 80% were still independent of help from others and 57% were still employed, fully or part time. Only 17% were satisfied with the public health services for polio survivors, while 67% of those who had undergone comprehensive examination at some central hospital were satisfied. This study indicates an obvious need of building up expertise in multidisciplinary evaluation and treatment of post polio problems in countries where acute polio has been eliminated.

Poliomyelitis: long-time consequences for social life

In a study of 102 consecutive patients hospitalized for previous poliomyelitis, we found that 70 patients had continued education after elementary school and 18 were academics. This is a higher proportion than in the general Norwegian population. All 14 patients with paraparesis had continued education after elementary school, while as many as 12 of 18 patients with a university degree had widespread pareses in the acute phase. Of the patients 46 worked or had worked full-time up to 60 years of age. Only 29 patients were receiving a disabled pension. Another 9 patients had neither been employed nor received any pension, all housewives. Nine of 14 patients with paraparesis were working full-time, only 2 received disabled pension. Among the 35 patients with persisting widespread pareses, 11 were still in full-time work and 7 were working part-time. The employment rate among the patients in this study was nearly identical to the age-correlated general employment rate in Norway. Our conclusion is that polio patients are doing well in society; they have taken education, are working, and are generally self-supported. The degree of pareses does not seem to have been the most determining factor for their educational and professional activity.

[The Dutch poliomyelitis epidemic 1992/'93; invalidity and rehabilitation]

OBJECTIVE

To describe epidemiologic characteristics and neurological and functional recovery of the victims of the 1992/'93 Dutch poliomyelitis epidemic compared to the 1971 and 1978 epidemics.

DESIGN

Descriptive research.

SETTING

Rehabilitation Centre 'De Hoogstraat', Utrecht, The Netherlands.

METHODS

Two written questionnaires were sent out: one to the doctors attending the 71 registered patients five months after the end of the epidemic, the second 30 months after the end of the epidemic to the doctors of the patients with initial neurological impairments. Once every three months, muscular strength (MRC criteria), activities of daily life (ADL; using the Functional Independence Measure) and mobility (according to Hoffer) were assessed for 13 adult patients with moderately severe and severe disabilities.

RESULTS

The questionnaire response was 100%. The median age increased from 5-9 years in 1971 to 10-14 years in 1978 to 20 years old in 1992/'93. Due to the 1992/'93 epidemic adults ( > or = 20 years) had more moderately severe and severe sequelae than people below 20 years of age (p < 0.00I). In the 1978 epidemic these differences were not significant. Muscular strength improved until 30 months after the onset of the disease although no improvement was seen in 10/13 patients after 18 months. The ability to cope independently with the ADL improved until 18 months; ten patients became almost independent. Mobility improved until 12 months. Three patients remained wheelchair bound, 1 became an exercise walker, 5 household walkers and 4 community walkers.

CONCLUSION

Poliomyelitis is no longer a paediatric disease in the Netherlands. In future epidemics it should be borne in mind that most disablement probably will occur among adults. After an attack of acute poliomyelitis, muscular strength can continue to improve for up to two and a half years, while ADL usually remain stable after one and a half years and mobility after one year.

Rehabilitation of the handicapped child--what about the caregiver?

The mental health of caregivers of handicapped children (n = 68) and of caregivers of children with minor ailments (n = 40) was assessed using the General Health Questionnaire (GHQ). In the comparative study, the caregivers of handicapped children had a significantly higher mean score (6.8), which was above the threshold score of 4. This suggests that the task of caring for disabled children may have a stressful impact on the caregivers which may contribute to psychiatric morbidity. There is a need periodically to assess the mental health of the caregiver, even as the rehabilitation of the handicapped child progresses. Addressing the psychological disturbances in the caregiver should form part of the treatment of the handicapped child.

[Orthoses in patients with poliomyelitis]

Poliomyelitis, in spite of vaccination, is still a problem: in the third world as well as for the victims of the epidemics of the first half of this century, who now, becoming older, have growing difficulties to overcome their paralyses. They needed and still need orthoses for walking. How do they manage? And what can orthopedic technique offer them today?

Clinical observations on acute poliomyelitis

During the years of the polio epidemics, most patients with the poliovirus had little or no paralysis. In those with paralytic polio, the extent of involvement of the anterior horn cells was often underestimated. Thus, patients with post-polio syndrome now often report that a limb was uninvolved; however, the original record will show clear evidence of initial paralysis that improved so that the patient no longer recognized the weakness. The epidemics were associated with great anxiety involving the patients, their families and all of society. Treatment was for the most part ineffective and was sometimes confused or inappropriate. Patients developed coping techniques that have been singularly useful and effective. These coping techniques often include strategies that require maximal athletic development of little-used muscles. The coping techniques developed by post-polio patients would be of great benefit to patients with other forms of disability. Review of the medical histories, biographies, and autobiographies of patients who had severe disability because of poliomyelitis reveals that they adopted firm convictions about their disease and their recovery. We must be aware of these convictions if we are to treat their later disabilities. These convictions include the belief that their condition can only improve, that their improvement is related primarily to the willingness of the patient to engage in exercise, and that improvement is more a thing of the spirit than of medication. Associated with this conviction is denial--often concurred with by the family--of the extent of the disability. Furthermore, the confusion of physicians that patients witnessed during the great epidemics suggests to patients that physicians can be of little help to them now. Convictions that were invaluable to patients who were young and vigorous become a liability when aging and progressive weakness supervene. Patients who had adapted to muscle weakness through great physical and emotional effort are unable to continue functions they had regained. However, such patients cannot accept that they do not continue to improve. Some become depressed, but this is unusual.

National rehabilitation hospital limb classification for exercise, research, and clinical trials in post-polio patients

A need exists for an objective classification of polio patients for clinical and research purposes that takes into account the focal, asymmetric, and frequent subclinical nature of polio lesions. In order to prescribe a safe, effective exercise program, we developed a five-level (Classes I-V) limb-specific classification system based on remote and recent history, physical examination, and a four-extremity electrodiagnostic study (EMG/NCS). Class I limbs have no history of remote or recent weakness, normal strength, and a normal EMG. Class II limbs have no history of remote or recent weakness (or if remote history of weakness, full recovery occurred), normal strength and EMG evidence of prior anterior horn cell disease (AHCD). Class III limbs have a history of remote weakness with variable recovery, no new weakness, decreased strength, and EMG evidence of prior AHCD. Class IV limbs have a history of remote weakness with variable recovery, new clinical weakness, decreased strength, and EMG evidence of AHCD. Class V limbs have a history of severe weakness with little-to-no recovery, severely decreased strength and atrophy, and few-to-no motor units on EMG. In a prospective study of 400 limbs in 100 consecutive post-polio patients attending our clinic, 94 (23%) limbs were Class I, 88 (22%) were Class II, 95 (24%) were Class III, 75 (19%) were Class IV, and 48 (12%) were Class V. Guidelines for the use of this classification in a clinical/research setting are presented along with sample case histories and class-specific exercise recommendations.

[Walking in children after poliomyelitis]

Between 1983 and 1990 the authors examined 630 children who had suffered from poliomyelitis, mostly between the age of one and three, at an average age of 9 years 3 months. Half were unable to walk because of residual paralysis. Operation was carried out on 252 children. Most underwent soft tissue release at the hips, knees or tendo Achilles. Triple arthrodesis was carried out on 24. Calipers, produced locally, were used, and trunk bracing was not employed. The average duration of treatment was 3 months, with gradual achievement of correction. Vascular complications occurred in one leg, there were 5 paralyses of the sciatic nerve and 4 fractures of the upper tibia. One hundred children who were not able to walk before operation were reviewed. Sixty five were walking and able to go to school. The best results were achieved before the age of 12.

Toward the development of consumer-based criteria for the evaluation of assistive devices

The most important basis for evaluating an assistive device is whether it satisfies the needs of the disabled consumer. However, the factors that consumers consider in determining whether a device meets their needs are not well understood. This preliminary study applied a small focus group process to identify and prioritize factors used by long-term users of assistive technology in assessing their devices. A modified version of the Delphi Method was applied to two groups of long-term users--a Panel of Consumer Experts with Mobility Impairments and a Panel of Consumer Experts with Sensory Impairments. In total, the panels identified and prioritized 17 general factors for 11 types of assistive technologies. This study constitutes an initial step toward the development of design, engineering, and selection criteria based on the specific concerns of consumers.

A rejoinder to "Exercise Programs for Patients with Post-Polio Syndrome: a case report"--a short communication

This communication is in response to the article by Michael T Gross and Charles P Schuch entitled "Exercise Programs for Patients with Post-Polio Syndrome: A Case Report" published in the January 1989 issue of Physical Therapy. The investigators examined the effects of a rigorous isokinetic training program on peak torque of the knee flexor and extensor muscles of a post-polio patient. The literature on post-polio syndrome, however, does not support the use of either conventional muscle strengthening regimens or rigorous isokinetic exercise programs in the management of post-polio syndrome. In addition, based on the observation that there was no appreciable increase in muscle strength in either the affected or the apparently unaffected leg, the investigators concluded that their rigorous exercise program was not deleterious. The lack of a normal training response, however, is consistent with bilateral muscle fatigue secondary to overuse rather than muscle weakness secondary to disuse. This result is consistent with the need for a balance between rest and low-intensity exercise, which will help to maintain or enhance function while slowing rather than hastening further deterioration. We hope that this rejoinder clarifies some of the misconceptions that may arise from the Gross and Schuch article and that physical therapists consider very carefully the rationale for any type of exercise program for post-polio patients.

Paralytic poliomyelitis in Addis Ababa: follow-up survey of registered children

A survey was carried out of children resident in Addis Ababa with paralytic poliomyelitis who had been registered at a weekly-held multidisciplinary "polio clinic" at the Ethio-Swedish Children's Hospital. The children were physically examined and traced to their homes, where a questionnaire was completed yielding demographic data, initial disease presentation and subsequent treatment. A total of 557 (90%) children were traced, of whom 80% were between the ages of 5 and 16 years. The pattern of disease with predominantly lower limb involvement was similar to that in previous reports. Contractures were frequent, 50% having contractures both at initial presentation and on follow-up. Standard treatment protocols were offered. Initially, 70% of the patients required a walking aid. Follow-up showed poor compliance, with only half the children using the walking aid. Forty-seven per cent of the patients had not attended the clinic for over 2 years, those with moderate disability being more likely to attend. The survey suggested that poor compliance may be related to a poor understanding of the disease and benefits of rehabilitation, lack of transport and financial constraints. During the past 4 years a further 305 children from the city presented to the clinic with poliomyelitis. Rehabilitation of handicapped children is a problem in all developing countries and the lessons learned from this study may be useful to others planning rehabilitation programmes.

Influence of appropriate lower extremity orthotic management on ambulation, pain, and fatigue in a postpolio population

A major functional problem for the postpolio patient is the loss of ambulation ability. A retrospective study of lower extremity orthotic management for ambulation was made of 104 subjects with histories of paralytic poliomyelitis who received treatment and evaluation in a postpolio clinic. Thirty-six patients (35%) had a remote history of a surgical arthrodesis of the ankle. Fifty-six subjects (54%) reported using lower extremity orthoses after the onset of their polio. At initial postpolio clinic evaluation 19 subjects (18%) were using lower extremity orthoses, and all of these patients had a remote history of orthotic use. After clinical evaluation, a new lower extremity orthosis was recommended for 37 subjects (36%). Nine of these patients had never used orthotic devices. New orthoses for a previously braced limb or an additional orthosis for a previously unbraced limb were prescribed more frequently in previously braced patients (28 of 56 vs 9 of 48, p less than 0.02). Seventy-two percent of subjects with ankle fusion required new orthoses; 19% of those without fusion required one (p less than 0.001). A questionnaire returned by 81 subjects (78%) indicated that appropriate orthotic prescription significantly improved the ability to walk, increased perceived walking safety, and reduced knee and overall pain (p = 0.04 to 0.008).

Occupational therapy and the postpolio syndrome

Approximately 75,000 polio survivors are experiencing new weakness, pain, and fatigue that are related to their initial disease. These problems affect their functional ability; therefore, they are of concern to occupational therapists. Overwork of a weakened neuromuscular system is believed to be the cause of these late symptoms. This article reviews current writings on the late effects of poliomyelitis. An understanding of the symptoms, causality, and psychosocial ramifications of this phenomenon facilitates effective occupational therapy intervention. Guidelines for occupational therapy assessment and treatment are included.