Management of postpolio syndrome

Repeater F-waves are signs of motor unit pathology in polio survivors

INTRODUCTION

The purpose of this study was to determine whether F-waves reveal electrophysiological features of anterior horn cells in polio survivors.

METHODS

Forty-three polio survivors and 20 healthy controls underwent motor nerve conduction studies of the median and tibial nerves bilaterally, including sampling of F-waves elicited by 100 stimuli and the determination of motor unit number estimation (MUNE).

RESULTS

A significant increase in abnormally stereotyped ("repeater") F-waves and a reduction of F-wave persistence were observed in both nerves in the polio group as compared with the control group. Repeater F-waves had a negative correlation with MUNE.

CONCLUSIONS

These trends in F-wave persistence and repeater F-waves after motor unit loss are characteristic findings in polio survivors. Repeater F-waves are a sign of motor unit pathology.

Long-standing poliomyelitis and psychological health

OBJECTIVE

To compare the psychological health of the individuals with long-standing poliomyelitis, with or without post-polio syndrome (PPS), to the general population and to identify the role of work as well as other variables with regard to their psychological health.

DESIGN

A cross-sectional study.

SUBJECTS

One hundred and ninety-five polio patients attending postpolio clinic in Jerusalem.

METHODS

Emotional distress (ED) was measured using the general health questionnaire (GHQ-12). Demographic, medical, social and functional data were recorded using a specific structured questionnaire. Each polio patient was compared to four age- and sex-matched controls.

RESULTS

ED was higher in the polio population as compared to the general population. Within the polio population ED was inversely correlated with work status. No correlation was found between ED and the functional level of polio participants and no difference was found in GHQ score between polio participants with or without post-polio. In addition, ED was less affected by subjective perception of physical health among polio patients as compared to the general population.

CONCLUSIONS

Long-standing poliomyelitis is associated with decreased psychological health as compared to the general population. Yet, the resilience of polio survivors is manifested by their ability to block further decline of their psychological health in spite of deterioration in their physical health. Work appears as a significant source of resilience in the polio population. Implications for Rehabilitation Individuals with long-standing poliomyelitis often suffer from high emotional distress and may benefit from psychotherapy aimed at reducing distress. As active employment status is associated with increased mental health among polio survivors, encouraging participation at work needs to be a significant component of psychotherapeutic programs. Polio survivors, although physically disabled, may be relatively resilient, as their mental health is less affected by their negative health perception. This and other expressions of resilience may serve as a platform for increasing personal growth among them by implementing hope-oriented psychotherapy.

Complications and outcomes of complex spine reconstructions in poliomyelitis-associated spinal deformities: a single-institution experience

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To share our institutional experience with spinal reconstruction for deformity correction in patients with a history of poliomyelitis.

SUMMARY OF BACKGROUND DATA

Polio and postpolio syndrome are not uncommonly related to a paralytic spinal deformity. Limited modern data exist regarding outcomes and complications after spinal reconstruction in this population.

METHODS

A clinical database was reviewed for patients undergoing spinal reconstruction for polio-associated spinal deformity at our institution from 1985 to 2012. Relevant demographic, medical, surgical, and postoperative information were collected from medical records and analyzed. Preoperative and last follow-up Scoliosis Research Society-22 Questionnaire scores were recorded.

RESULTS

A total of 22 patients with polio who underwent surgical deformity correction were identified. Mean age was 49 years (range, 12-74 yr), and 15 patients (68%) were female. Preoperative motor deficit was present in 14 of 22 (64%) patients. All patients underwent instrumented spinal fusion (mean, 13 vertebral levels, range, 3-18). Ten (10/22, 45%) patients developed major complications, and 4 patients (4/22, 18%) developed new postoperative neurological deficits. Neurological monitoring yielded a 13% false-negative rate. At 2-year follow-up, 20 of 22 patients maintained an average coronal correction of 25° (33%, P = 0.001) and sagittal correction of 25° (34%, P = 0.003). Minimum 2-year follow-up data were available for 11 of 22 (50%) patients. At an average of 72 months of follow-up (range, 28-134 mo), the mean Scoliosis Research Society-22 Questionnaire pain subscore improved from a mean of 2.75 to 3.6 (P = 0.012); self-image from 2.8 to 3.7 (P = 0.041); function from 3.1 to 3.8 (P = 0.036); satisfaction from 2.1 to 3.9 (P = 0.08); and mental health from 3.7 to 4.5 (P = 0.115).

CONCLUSION

Spine reconstruction for poliomyelitis-associated deformity was associated with high complication rates (54%) and sometimes unreliable neurological monitoring data. Despite this, patients undergoing spine reconstructions had significantly improved outcome scores. These data may help surgeons to appropriately counsel this complicated patient population.

Normal serum levels of immune complexes in postpolio patients

OBJECTIVE

The pathophysiology of the postpolio syndrome is not fully understood. Increased cytokine levels in cerebrospinal fluid and peripheral blood indicate a systemic inflammatory process. Decreased cytokine levels and the clinical effect of intravenous immunoglobulin treatment further indicate an inflammatory/immunological pathogenesis. The aim of the present study was to evaluate whether an autoimmune process follows the initial infection, by means of analyzing immune complexes.

PATIENTS AND METHODS

Circulating immune complexes were analyzed from blood samples of 20 postpolio patients and 95 healthy controls. To compensate for differences in age between patients and controls, a sub-analysis was performed using only the 30 oldest controls. Tumor necrosis factor-inducing properties of polyethylene glycol-precipitated immune complexes were compared between the postpolio patients and 10 healthy controls.

RESULTS

When comparing levels in postpolio patients to the whole control group, including the 30 oldest investigated, there were no statistically significant differences. No difference was found in tumor necrosis factor levels induced by immune complexes when comparing patients and controls.

CONCLUSIONS

There was no increase in circulating immune complex or in tumor necrosis factor-inducing effects of circulating immune complex between postpolio patients and healthy controls, indicating that the postpolio syndrome is not due to an autoimmune reaction.

Age at spinal cord injury determines muscle strength

As individuals with spinal cord injury (SCI) age they report noticeable deficits in muscle strength, endurance and functional capacity when performing everyday tasks. These changes begin at ~45 years. Here we present a cross-sectional analysis of paralyzed thenar muscle and motor unit contractile properties in two datasets obtained from different subjects who sustained a cervical SCI at different ages (≤46 years) in relation to data from uninjured age-matched individuals. First, completely paralyzed thenar muscles were weaker when C6 SCI occurred at an older age. Muscles were also significantly weaker if the injury was closer to the thenar motor pools (C6 vs. C4). More muscles were strong (>50% uninjured) in those injured at a younger (≤25 years) vs. young age (>25 years), irrespective of SCI level. There was a reduction in motor unit numbers in all muscles tested. In each C6 SCI, only ~30 units survived vs. 144 units in uninjured subjects. Since intact axons only sprout 4-6 fold, the limits for muscle reinnervation have largely been met in these young individuals. Thus, any further reduction in motor unit numbers with time after these injuries will likely result in chronic denervation, and may explain the late-onset muscle weakness routinely described by people with SCI. In a second dataset, paralyzed thenar motor units were more fatigable than uninjured units. This gap widened with age and will reduce functional reserve. Force declines were not due to electromyographic decrements in either group so the site of failure was beyond excitation of the muscle membrane. Together, these results suggest that age at SCI is an important determinant of long-term muscle strength, and fatigability, both of which influence functional capacity.

Immunoglobulin g for the treatment of chronic pain: report of an expert workshop

BACKGROUND

The treatment of chronic pain is still unsatisfactory. Despite the availability of different drugs, most patients with chronic pain do not receive satisfactory pain relief or report side effects. Converging evidence implicates involvement of the immune system in the pathogenesis of different types of nociceptive and neuropathic chronic pain.

DESIGN

At a workshop in Liverpool, UK (October 2012), experts presented evidence suggesting immunological involvement in chronic pain and recent data supporting the concept that the established immune-modulating drug, polyvalent immunoglobulin G (IgG), either given intravenously (IVIg) or subcutaneously (SCIg), may reduce pain in some peripheral neuropathies and a range of other pain disorders. Workshop's attendees discussed the practicalities of using IVIg and SCIg in these disorders, including indications, cost-effectiveness, and side effects.

RESULTS

IgG may reduce pain in a range of nociceptive and neuropathic chronic pain conditions, including diabetes mellitus, Sjögren's syndrome, fibromyalgia, complex regional pain syndrome, post-polio syndrome, and pain secondary to pathological autoantibodies.

CONCLUSIONS

IgG is a promising treatment in several chronic pain conditions. IgG is a relatively safe therapeutic strategy, with uncommon and mild side effects but high costs. Randomized, controlled trials and predictive tests are needed to better support the use of IgG for refractory chronic pain.

Human spinal cord injury: motor unit properties and behaviour

Spinal cord injury (SCI) results in widespread variation in muscle function. Review of motor unit data shows that changes in the amount and balance of excitatory and inhibitory inputs after SCI alter management of motoneurons. Not only are units recruited up to higher than usual relative forces when SCI leaves few units under voluntary control, the force contribution from recruitment increases due to elevation of twitch/tetanic force ratios. Force gradation and precision are also coarser with reduced unit numbers. Maximal unit firing rates are low in hand muscles, limiting voluntary strength, but are low, normal or high in limb muscles. Unit firing rates during spasms can exceed voluntary rates, emphasizing that deficits in descending drive limit force production. SCI also changes muscle properties. Motor unit weakness and fatigability seem universal across muscles and species, increasing the muscle weakness that arises from paralysis of units, motoneuron death and sensory impairment. Motor axon conduction velocity decreases after human SCI. Muscle contractile speed is also reduced, which lowers the stimulation frequencies needed to grade force when paralysed muscles are activated with patterned electrical stimulation. This slowing does not necessarily occur in hind limb muscles after cord transection in cats and rats. The nature, duration and level of SCI underlie some of these species differences, as do variations in muscle function, daily usage, tract control and fibre-type composition. Exploring this diversity is important to promote recovery of the hand, bowel, bladder and locomotor function most wanted by people with SCI.

Triceps Brachii in Incomplete Tetraplegia: EMG and Dynamometer Evaluation of Residual Motor Resources and Capacity for Strengthening

BACKGROUND

Candidates for activity-based therapy after spinal cord injury (SCI) are often selected on the basis of manual muscle test scores and the classification of the injury as complete or incomplete. However, these scores may not adequately predict which individuals have sufficient residual motor resources for the therapy to be beneficial.

OBJECTIVE

We performed a preliminary study to see whether dynamometry and quantitative electromyography (EMG) can provide a more detailed assessment of residual motor resources.

METHODS

We measured elbow extension strength using a hand-held dynamometer and recorded fine-wire EMG from the triceps brachii muscles of 4 individuals with C5, C6, or C7 level SCI and 2 able-bodied controls. We used EMG decomposition to measure motor unit action potential (MUAP) amplitudes and motor unit (MU) recruitment and firing-rate profiles during constant and ramp contractions.

RESULTS

All 4 subjects with cervical SCI (cSCI) had increased MUAP amplitudes indicative of denervation. Two of the subjects with cSCI had very weak elbow extension strength (<4 kg), dramatically reduced recruitment, and excessive firing rates (>40 pps), suggesting profound loss of motoneurons. The other 2 subjects with cSCI had stronger elbow extension (>6 kg), more normal recruitment, and more normal firing rates, suggesting a substantial remaining motoneuron population.

CONCLUSIONS

Dynamometry and quantitative EMG may provide information about the extent of gray matter loss in cSCI to help guide rehabilitation strategies.

Poliomyelitis sequels in France and the clinical and social needs of survivors: a retrospective study of 200 patients

INTRODUCTION

Polio survivors in France are estimated at 50,000. This study aimed at describing their needs from their clinical and vocational conditions.

METHOD

A retrospective study of our physical and rehabilitation medicine (PRM) consultation activity.

RESULTS

One hundred and fifteen women/85 men, with a mean age of 51years±14.3 (17 to 82). Paralysis involved only one lower limb in 108 patients, the two lower limbs in 56 patients and only one upper limb in 4. At the time of the first consultation 137 patients had experienced functional worsening. The complaints were pain (105 subjects), fatigue (59) and new paresis (58). Only 25% had retired. Post-polio syndrome criteria were present in 46 subjects (23%). Patients who had contracted poliomyelitis in France (56%) differed from the other subjects with regard to age (58.4 versus 41.5), professional status and frequency of PPS (30.9% versus 12.6%).

CONCLUSION

These polio survivors were not particularly aged and they had often experienced functional worsening. The evolution of their disease shall represent a public health issue over the decades to come.

Circadian variation of fatigue in both patients with paralytic poliomyelitis and post-polio syndrome

ObjectiveIt was to evaluate the degree of fatigue in patients with paralytic poliomyelitis (PP) and with post-polio syndrome (PPS), and correlate it with parameters of sleep and the circadian cycle.MethodsThirty patients, 17 female (56.7%), participated in the study: they answered the Revised Piper Fatigue Scale and performed a nocturnal polysomnographic study. Eleven had PP (mean age±standard deviation of 47.9±6.4 years), and 19 had PPS (mean age±standard deviation of 46.4±5.6 years).ResultsOur study showed that fatigue was worse in the afternoon in the PP Group and had a progressive increase throughout the day in the PPS Group. We also observed compromised quality of sleep in both groups, but no statically significant difference was found in the sleep parameters measured by polysomnography.ConclusionFatigue has a well-defined circadian variation, especially in PPS Group. Poor sleep quality is associated with fatigue and, therefore, sleep disturbances should be evaluated and treated in this group of PPS.

Statin-induced myopathy in a patient with previous poliomyelitis

This report describes a patient with a history of poliomyelitis who developed new, progressive symptoms of muscle fatigue and weakness, suggestive of postpoliomyelitis syndrome. However, comprehensive investigations led to the diagnosis of statin-induced myopathy as the cause of the patient's symptoms. This case highlights the possibility of statin-induced myopathy in patients with a history of poliomyelitis and the differential diagnosis between postpoliomyelitis syndrome and statin-induced myopathy in these patients. The possibility of statin-induced myopathy should be considered when patients with previous poliomyelitis who take statin medication develop symptoms suggestive of postpoliomyelitis syndrome.

Infectious neuropathies

PURPOSE OF REVIEW

The purpose of this review is to address bacterial, viral, and other infectious causes of neuropathy or neuronopathy, with an emphasis on clinical manifestations and treatment.

RECENT FINDINGS

Most infectious neuropathies have been well described for some time and treatments are well established. An exception is HIV-associated distal symmetric polyneuropathy, which is an area of active research. Current work in this area focuses on epidemiology, risk factors, and underlying mechanisms.

SUMMARY

Infectious diseases are an important part of the differential diagnosis of peripheral nerve disorders because they are among the most amenable to treatment. However, diagnosis of infectious peripheral neuropathy may be challenging because of variability in a number of factors, including the pattern of deficits, geographic distribution of pathogens, length of time from the onset of infection to the development of neuropathy, and mechanism of nerve injury.

Intravenous immunoglobulin treatment of the post-polio syndrome: sustained effects on quality of life variables and cytokine expression after one year follow up

BACKGROUND

Expression of inflammatory cytokines in cerebrospinal fluid (CSF) has led to the hypothesis of intrathecal chronic inflammation to explain the denervation observed in post-polio syndrome (PPS). It has been shown that therapy with intravenous immunoglobulin (IVIG) improves physical performance and dampens down the inflammatory process at 6 months in PPS patients. We here examined the effects of IVIG on cytokine expression and clinical outcome one year after IVIG treatment.

METHODS

From a previous study with 135 PPS patients included, 41 patients were further evaluated before un-blinding for one year (21 placebo and 20 treated with IVIG, Xepol® 50 mg/ml), and were assessed for clinical variables by performing the Short Form-36 survey (SF-36) questionnaire assessment, the 6 minute walk distance test (6MWT) and registering pain level by Visual Analogue Scale (VAS) after IVIG treatment. A separate cohort of 37 PPS patients went through lumbar puncture (LP) at baseline and 20 patients, treated with IVIG, repeated the LP one year later. Thirty patients affected with other neurological diseases (OND) were used as control group. Inflammatory cytokines TNF, TGFβ, IFNγ, IL-23, IL-13 and IL-10 were measured in blood cells and CSF cells with RT-PCR.

RESULTS

Scores of the physical components of SF-36 were significantly higher at the one year follow up time-point in the IVIG-treated patients when compared to baseline as well as to the control subjects. Pain VAS score and 6MWT improved significantly in the IVIG-treated patients when compared with baseline Relative expression of TNF and IFN-γ in both PBMCs and CSF from PPS patients were increased compared to OND subjects at baseline (p < 0.05). One year after IVIG-treatment a decreased expression of IFN-γ and IL23 was found in CSF of PPS patients, while anti-inflammatory IL-13 was increased (p < 0.05).

CONCLUSIONS

IVIG has effects on relevant QoL variables and inflammatory cytokines up to one year in patients with PPS. This gives a basis for scheduling IVIG in upcoming trials with this therapy.

Poststroke Fatigue Is Still a Neglected Issue: Findings from an Internet-Based Study on the Need for Information and Treatment in The Netherlands

Objective. To evaluate the need for information and treatment of poststroke fatigue (PSF) in community-dwelling patients with stroke in The Netherlands. Methods. Data were obtained from a Dutch internet-based questionnaire. The amount of information received about PSF, self-management and other treatment options, and the perceived need for treatment were scored. PSF was assessed with two Visual Numerical Scales of fatigue severity (VNSF), the Fatigue Severity Scale (FSS7), and by scoring the nature (physical versus mental) and onset time of PSF. Results. Data were available of 538 stroke survivors (mean age 52 years, 45% men, and mean time since onset 2.7 years). Severe fatigue (both VNSF items ≥7; 48%) and severe fatigue impact (FSS7 > 5; 68%) were frequent. Most participants (57%) experienced both physical and mental fatigue. Only 17% of the respondents indicated to have had received sufficient information about PSF and 7% about treatment options, whereas 56% expressed a substantial need for treatment. The need for treatment was moderately associated with fatigue severity and fatigue impact, whereas information status was not related to any demographical, fatigue, or stroke characteristic. Conclusions. PSF is a significant symptom after stroke requiring medical attention and treatment. The results of this survey indicate that patients do not receive adequate information on PSF.

Cognitive and Graded Activity Training Can Alleviate Persistent Fatigue After Stroke

Background and Purpose—

Fatigue is a common, persistent consequence of stroke, and no evidence-based treatments are currently available to alleviate fatigue. A new treatment combining cognitive therapy (CO) with graded activity training (GRAT), called COGRAT, was developed to alleviate fatigue and fatigue-related symptoms. This study compared the effectiveness of the COGRAT intervention with a CO-only intervention after a 3-month qualification period without intervention.

Methods—

This randomized, controlled, assessor-blind clinical trial was conducted in 8 rehabilitation centers. Eighty-three stroke patients (>4 months after stroke) were randomly assigned to 12 weeks of CO or COGRAT after qualification. Seventy-three patients completed treatment and 68 were available at follow-up. Primary outcomes (Checklist Individual Strength–subscale Fatigue (CIS-f); self-observation list–fatigue (SOL-f)) and secondary outcomes (Hospital Anxiety and Depression Scale, Stroke-Adapted Sickness Impact Profile, SOL-pain, SOL-sleep-D, 6-minute walk test) were collected at baseline (before and after qualification period) and after treatment (immediate and 6-month follow-up).

Results—

The qualification period showed stable outcome measures. Both treatments showed significant beneficial effects on fatigue (CIS-f: η p 2 =0.48, P <0.001) and other outcomes (except pain and anxiety) with intention-to-treat analyses. Gains for the COGRAT group exceeded those in the CO group on number of individuals showing clinical improvement on the CIS-f (≥8 points: 58% versus 24%) and on physical endurance (η p 2 =0.20, P <0.001).

Conclusions—

A 12-week cognitive therapy program can alleviate persistent fatigue after stroke. The best results are obtained when cognitive therapy is augmented with graded activity training.

Clinical Trial Registration—

URL: http://www.trialregister.nl . Unique identifier: NTR2704.

Functional and environmental factors affecting work status in individuals with longstanding poliomyelitis

INTRODUCTION

Remunerative employment is a major concern of individuals with chronic disabilities, among them, those with longstanding poliomyelitis (LSP). Although LSP is not rare there are almost no data related to work participation.

PURPOSE

The aims of the current study were to determine the effects of a number of social and functional variables as barriers or facilitators to work participation in persons with LSP.

PATIENTS AND METHODS

Charts of 123 LSP patients of working age that were seen in the post-polio outpatient clinic, between the years 2000 and 2005 were reviewed for the study. Data on age, gender, family status, level of function in activities of daily living, basic, and extended (B-ADL and E-ADL), and mobility were then analyzed for correlation to the vocational status.

RESULTS

Seventy-two people (58.5%) were employed at the time of the survey. Gender and marital status were not found to significantly differ as regard to employment. Using assistive devices for mobility or being dependent for basic ADL were associated with lower levels of employment. Driving was positively associated with the employment status of the LSP individuals.

CONCLUSION

Persons with LSP encounter important barriers to work participation, particularly on the International Classification of Functioning, Disability, and Health (ICF) components of activity and environment.

Patients with severe poststroke fatigue show a psychosocial profile comparable to patients with other chronic disease: implications for diagnosis and treatment

Objective. To obtain a psychosocial profile of patients with poststroke fatigue (PSF), which could aid in optimizing treatment strategies. Methods. Eighty-eight outpatients with severe PSF measured with the Checklist Individual Strength-fatigue subscale (CIS-f) and the Fatigue Severity Scale (FSS) were selected. Depression and anxiety, psychological distress, coping, social support, and self-efficacy of this group were compared to reference groups of healthy controls and patients with other chronic diseases. Associations between psychosocial characteristics and fatigue were calculated. Results. Compared to healthy controls, patients with PSF reported more psychological distress, less problem-focused coping, and more positive social support. Minor or no differences were found in comparison with other chronic patients. The CIS-f correlated with somatic complaints and the FSS with cognitive complaints. Conclusion. Patients with PSF show a psychosocial profile comparable to patients with other chronic disease. Implications for diagnosis and treatment are discussed.

Post-stroke fatigue: a treatment protocol that is being evaluated

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is the neuropsychologist.

AbstractPurpose: Post-stroke fatigue is a common and debilitating complaint, which has only recently received attention in clinical rehabilitation. Until now, no evidence-based treatments have been available for the condition. Therefore, a new treatment was designed to reduce post-stroke fatigue complaints: Cognitive and Graded Activity Training (COGRAT).

Rationale: Following the premise that post-stroke fatigue is primarily caused by brain damage, the treatment aims to prevent fatigue and to manage existing fatigue symptoms. The purpose of the added graded activity programme is to reduce fatigue by changing cognitions and enhancing physical fitness.

Theory into practice: COGRAT consists of a cognitive treatment and graded activity programme in small groups over 12 weeks. In the cognitive treatment, patients receive education on post-stroke fatigue and register their activities and fatigue to gain insight into their daily agenda and fatigability. Patients are then taught several compensation strategies. Cognitive behavioural therapy is used to diminish anxiety, facilitate behavioural change and manage fatigue symptoms. The graded activity programme consists of walking on a treadmill, strength training and home work assignments. Maximum heart rate and strength are increased from 40% at the beginning of the training to a maximum of 70%.

Considerations for future improvements: COGRAT is currently being evaluated in outpatients with severe post-stroke fatigue in a multicentre randomized controlled trial. Preliminary data suggest both positive short- and long-term effects. Adaptations for other neurological patient groups suffering from fatigue are suggested.

Monomelic amyotrophy is not always benign: a case report

Monomelic amyotrophy (MA) is a variant of motor neuron disease (MND), characterized by muscle weakness and atrophy restricted to one limb. We describe the case of a 56-year-old Italian patient who developed a segmental muscular atrophy limited to the lower left limb. After 11 years of clinical stability he developed progressive spread of the disease to all limbs and to bulbar and respiratory muscles. The patient died from respiratory failure 15 years after disease onset. This case demonstrates that monomelic amyotrophy may rarely evolve to a diffuse fatal MND, even after more than a decade of clinical stability. Our findings support the idea that MA is part of the clinical continuum of MND.